ICAO EUR HLSC Preparatory Seminar

1. 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

2. Air France Flight AF447 • 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’aviationcivile (BEA) ICAO EUR High Level Safety Conference Preparatory Seminar

3. Air France Flight AF447 - Findings • 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

4. Air France Flight AF447 - Findings • 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

5. Air France Flight AF447 - Findings • 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

6. 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

7. 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

8. Air France Flight AF447- Recommendations • 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

9. Issues to consider Interdependencies Cost-benefit relationship Global perspective ICAO EUR High Level Safety Conference Preparatory Seminar

10. Spanair Flight JKK 5022 • Date of accident: 20st August 2008 at 12:25 UTC • Aircraft MD80; Operator – Spanair • Airport of departure – Barajas, Madrid • Destination – Gran Canaria Reference – Interim Reportdated 17 August 2009 By the Spanish Civil Aviation Accidents and Incidents Investigation Commission (CIAIAC) ICAO EUR High Level Safety Conference Preparatory Seminar

11. Spanair Flight JKK 5022 Injuries: Of the 172 people on board, - 154, including all crew members, killed; - 18 seriously injured ICAO EUR High Level Safety Conference Preparatory Seminar

12. Spanair Flight JKK 5022-Findings 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

13. A concept of accident causation Organization People Defences Workplace Management decisions and organizational processes Working conditions Errors and violations Regulations Training ORGANIZATION Technology Resources to protect against the risks that organizations involved in production activities generate and must control. Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect. Factors that directly influence the efficiency of people in aviation workplaces. Activities over which any organization has a reasonable degree of directcontrol Conditions present in the system before the accident, made evident by triggering factors. Latent conditions trajectory ICAO EUR High Level Safety Conference Preparatory Seminar

14. 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

15. Accident investigation Once in a million flights Flaps omitted Checklist failure Unheeded warning Incident / accident Error Deviation Amplification Degradation / breakdown ICAO EUR High Level Safety Conference Preparatory Seminar

16. Spanair Flight JKK 5022Recommendations 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

17. 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) • 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

18. Safety Management Principles • 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

19. 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

20. Conclusions 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 ICAO EUR High Level Safety Conference Preparatory Seminar