International Civil Aviation Organization
European and North Atlantic Office
ICAO EUR HLSC Preparatory Seminar
9-11 February 2010
Baku, Azerbaijan
Theme 3: Other Safety Issues
Topic 3.2:Safety initiatives arising from recent accidents
1
Air France Flight AF447
ICAO
EUR/NAT Office
• Date of accident: 1st June 2009 at around 02:15
• Aircraft A330-203; Operator – Air France
• Airport of departure – Rio de Janeiro Galeao
• Destination – Paris Charles de Gaulle
Reference – Interim Report №2 dated 17 December 2009
Bureau d’Enquetes et d’Analyses pour la securite de l’aviation civile (BEA)
ICAO EUR High Level Safety Conference Preparatory Seminar
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Air France Flight AF447 - Findings
ICAO
EUR/NAT Office
• Site of accident: Near TASIL point, in international waters,
Atlantic Ocean;
• Was in contact with Brazilian ATLANTICO ATC on the
INTOL-SALPU-ORARO route at FL350; INTOL is an RNAV
waypoint located in the Atlantic Ocean, 565 km from Natal,
Brazil. The TASIL waypoint is located 1228 kilometers from
Natal. TASIL, the following waypoint, is at the border of the
Recife FIR and Dakar Oceanic FIR.
• The last radio exchange between the crew and Brazilian ATC
occurred at 01:35:15. The plane was arriving at the edge of
radar range of the Brazilian control centers;
•
ICAO EUR High Level Safety Conference Preparatory Seminar
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Air France Flight AF447 - Findings
ICAO
EUR/NAT Office
• At 02:01, the crew tried, without success for the third time , to
connect to the Dakar ATC ADS-C system;
• No further communications after passing INTOL;
•At 02:10 a position report and maintenance messages were
transmitted by ACARS;
•Up to the last automatic position point, received at 02:10:34,
the flight had followed the route indicated in the flight plan;
• The flight was not transferred between the Brazilian and
Senegalese control centers;
• Between 08:00 and 08:30, the first emergency alert messages
were sent by the Madrid and Brest control centers;
•
ICAO EUR High Level Safety Conference Preparatory Seminar
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Air France Flight AF447 - Findings
ICAO
EUR/NAT Office
•The first bodies and airplane parts were found on 6
June;
•At this stage, in the absence of any data from the
flight recorders, the main parts of the airplane and
any witness testimony on the flight, the precise
circumstances and causes of the accident are not yet
determined
•Consequences – 216 passenger +12 crew members –
all killed
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
Air France Flight AF447 Recommendations
NEED FOR IMPROVEMENTS -
 Recovery of accident data
 Air traffic management in oceanic and remote areas
 Search and Rescue
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
Air France Flight AF447 Recommendations
Recovery of accident data;
 Continuous or triggered transmission of FDR/CVR
 Deployable FDR/CVR/ELT
 Extra lightweight combination FDR/CVR located in
the vertical stabilizer: and
 Underwater location beacons (ULB) improvement,
with greater range and longer battery life.
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
Air France Flight AF447Recommendations
Air traffic management in oceanic and remote
areas Improve communications and surveillance by:
 Implementing ADS-C and CPDLC and FMC WPR
 Improved procedures for HF communications
Search and Rescue Guidance material supporting existing SAR alerting
SARPs
 Better coordination between ATS informing Rescue
Coordination Centers (RCC)
 Provisions on carriage of Emergency Locator
transmitters
ICAO EUR High Level Safety Conference Preparatory Seminar
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Issues to consider
ICAO
EUR/NAT Office
 Interdependencies
 Cost-benefit relationship
 Global perspective
ICAO EUR High Level Safety Conference Preparatory Seminar
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Spanair Flight JKK 5022
ICAO
EUR/NAT Office
• Date of accident: 20st August 2008 at 12:25 UTC
• Aircraft MD80; Operator – Spanair
• Airport of departure – Barajas, Madrid
• Destination – Gran Canaria
Reference – Interim Report dated 17 August 2009
By the Spanish Civil Aviation Accidents and Incidents Investigation
Commission (CIAIAC)
ICAO EUR High Level Safety Conference Preparatory Seminar
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Spanair Flight JKK 5022
ICAO
EUR/NAT Office
Injuries:
Of the 172 people on board,
- 154, including all crew
members, killed;
- 18 seriously injured
ICAO EUR High Level Safety Conference Preparatory Seminar
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Spanair Flight JKK 5022-Findings
ICAO
EUR/NAT Office
The takeoff manoeuvre was performed with the
flaps and slats retracted
 The following safety barriers were defeated:
 The checklist to confirm and verify the
airplane’s actual configuration; and
 Improper takeoff configuration warning system
(TOWS).
ICAO EUR High Level Safety Conference Preparatory Seminar
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A concept of accident causation
ICAO
EUR/NAT Office
Latent conditions trajectory
Actions or inactions by people (pilots, controllers, maintenance
Activities
Conditions
Factors
Resources
over
that
present
which
todirectly
protect
any
in the
influence
against
organization
system
thethe
before
risks
has
efficiency
athat
the
reasonable
accident,
organizations
of people
made
degree
in
engineers, aerodrome staff, etc.) that have an immediate
involved in production
evident
aviation
of
activities
by
direct
triggering
workplaces.
control
generate
factors.
and must control.
adverse
effect.
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
Errors and safety
A non linear relationship
Statistically, millions of
operational errors are
made before a major
safety breakdown occurs
Source:
Dedale
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
Accident investigation
Once in a million flights
Error
Deviation
ICAO EUR High Level Safety Conference Preparatory Seminar
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Amplification Degradation
breakdown
15
ICAO
EUR/NAT Office
Spanair Flight JKK 5022
Recommendations
 ICAO, FAA and EASA jointly hold an
international conference
 Objective - Draft directives on good practices
in the area of aviation operations in regard to
checklist design, personnel training and
improved procedures and cockpit work
methods so as to ensure that crews properly
configure aircraft for takeoffs and landings
 Attendance – Authorities, industry, academic
and research institutes, professional
association, etc.
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
ICAO provisions on Human-centered
flight deck interventions
•
Standard operating procedures (SOP);
•
Checklists; and
•
Flight crew briefings.
 Incorporated into the PANS-OPS Doc 8168
 Supported by ICAO Human Factors Training manual
(Doc 9683)
o Reflects the results of the practically-oriented Human
Factors research and industry best practices
 Annex 6 – Operation of Aircraft. Introduces a
requirement a human performance training within the
operators initial and recurrent flight crew training syllabi
 Crew Resource Management (CRM)
ICAO EUR High Level Safety Conference Preparatory Seminar
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Safety Management Principles
ICAO
EUR/NAT Office
 Safety Risk Management
 Safety Assurance
 Threat and Error Management (TEM) as an
early example of the safety management
principles integration to flight deck activities
 The TEM requirement was included in Annex 1
– Personnel Licensing and Annex 6 – Aircraft
Operation
ICAO EUR High Level Safety Conference Preparatory Seminar
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ICAO
EUR/NAT Office
Integration of Safety Management
Principles
 Broaden interventions to take operational
context into consideration
 Shift the micro view of pure Human Factors
Interventions to safety performance enabling
macro view
 A balanced approach
 The role of the State in the acceptance and
surveillance of the effectiveness of the
implementation
ICAO EUR High Level Safety Conference Preparatory Seminar
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Conclusions
ICAO
EUR/NAT Office
 Activities listed herewith provide the
foundation for reviewing ICAO Provisions and
guidance material
 ICAO to review relevant ICAO provisions and
propose within 18 months any amendment that
might be required
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