ANNUAL SAFETY REVIEW. Þróunar og greiningarstofa Division of Development and Analysis

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1 ANNUAL SAFETY REVIEW 2012 Þróunar og greiningarstofa Division of Development and Analysis

2 Flugmálastjórn Íslands: Annual Safety Review 2012 Útgefandi: Flugmálastjórn Íslands Skógarhlíð Reykjavík Sími: Fax: Netfang: Veffang: Flugmálastjórn Íslands: Þróunar- og greiningarstofa 2

3 Foreword The Icelandic Civil Aviation Administration will disband on June 30 th 2013 after 68 years. A new administrative and monitoring agency will be established with regards to all transport in air, on ground and at sea. On this significant turning point in the history of the ICAA, the first safety review is published. The aim is to make this an annual review were statistical analysis of the past year are presented as well as trends over a longer period. This document is a part of the State Safety Program (SSP) in Iceland. In many ways 2012 was a good year in aviation in Iceland. Sadly, there was one fatal accident involving a light aircraft where two pilots lost their lives. This accident is currently under investigation by the Icelandic Aircraft Accident Investigation Board and report will be issued in due course. There have only been two fatal accidents in Iceland in the past ten years. Dr. Pétur K. Maack, Director General The Director General is the senior officer of the Icelandic Civil Aviation Administration (ICAA) which is under the auspices of the Ministry of the Interior and, at the same time, the Minister of the Interior. Pétur K. Maack was appointed Director General on January First The daily management of the ICAA is in the hands of the Director General and the three directors of the Administration Division, Flight Safety Division, and Air Navigation and Aerodrome Division. The Director General supervises the administration of the ICAA, its communication with ministries and other institutions, as well as communication with various international institutions and organisations. This includes the participation of Iceland in the International Civil Aviation Organisation (ICAO), the Joint Aviation Authorities (JAA), and the European Aviation Safety Agency (EASA). The director generals of civil aviation in the Nordic Countries also collaborate and meet regularly. 3

4 Útdráttur Gróska í flutningaflugi hélt áfram árið 2011 og var vöxturinn um 3,5%. Fjöldi slysa jókst um 4,1% en hlutfall slysa á heimsvísu stóð í stað og var um það bil 4 slys fyrir hverja milljón brottfara. Í Evrópu var tíðni banaslysa ein sú lægsta í áratug. Slysatíðnin í flutningaflugi hjá aðildarríkjum EASA var einnig ein sú lægsta í heiminum eða 1,6 banaslys á hver 10 milljón fluga. Ómissandi þáttur í öryggismenningu fyrirtækis er góður tilkynningakúltúr. Með því að tilkynna, endurskoða og rýna í atvik þá er verið að sýna að skuldbinding til öryggisþróunar er stöðugt höfð að leiðarljósi, bæði hjá fyrirtækjum og í flugi almennt. Tilkynntum flugatvikum fjölgaði á Íslandi um 6 prósent á árinu 2012 eftir nokkra fækkun undanfarin tvö ár. Frá almannafluginu bárust 17 tilkynningar um flugatvik, þar af voru þrjú slys og eitt banaslys. Sex þessara slysa voru flokkuð sem alvarleg flugatvik. Frá flugvöllum og flugleiðsögu bárust 215 atvik þar af voru 11 brautarátroðningar; níu á Reykjavíkurflugvelli og tveir á Keflavíkurflugvelli. Árið 2012 bárust Flugmálastjórn Íslands átta tillögur til úrbóta frá Rannsóknarnefnd flugslysa (RNF); samþykktar voru fjórar af þessum átta tillögum. Abstract The growth in volume of commercial scheduled flights continued in 2011 at the rate of 3.5%. The number of accidents grew by 4.1% however the global accident rate remained unchanged at approximately four accidents per million departures. In Europe, the number of fatalities in 2011 was one of the lowest in the past decade. The accident rate in scheduled operations in EASA Member States (EASA MS) was one of the lowest in the world with 1.6 fatal accidents per 10 million flights. A vital element of any safety culture is a good reporting culture. Through which a commitment to continuously improve safety, in organisations and aviation, is shown by proactively reviewing events and ensuring safety hazards are addressed. In Iceland the occurrence reporting grew by six per cent in the last year after a decrease over the past two years. From the general aviation 17 occurrence reports were received in 2012, thereof three accidents and one fatal accident with two fatalities. Six of these occurrences were categorized as serious incidents. From Icelandic aerodromes and air traffic management 215 occurrences reports were received. There were 11 cases of runway incursions; nine were at BIRK and two at BIKF. In 2012 the Icelandic Civil Aviation Administration received eight safety recommendations form the Icelandic Aircraft Accident Investigation Board; four of these eight safety recommendations were accepted. 4

5 Efnisyfirlit Foreword...3 Útdráttur...4 Abstract...4 Table of Figures Global overview European Overview ECCAIRS Commercial Air Transport General Aviation Aerodromes and Air Traffic Management (ATM) SSP State Safety Programme Icelandic Aircraft Accident Investigation Board (IAAIB) Division of Development and Analysis

6 Table of Figures Figure 1 Global rate of accidents involving passenger fatalities per 10 million flights, scheduled commercial air transport operations, excluding acts of unlawful inference. (Source: EASA Annual Safety Review 2011)... 7 Figure 2 Rate of fatal accidents per 10 million flights per world region ( , scheduled passanger and cargo operations). (Source: EASA Annual Safety Review 2011)... 8 Figure 3 Global Accident Rate per million departures. (Source: ICAO Safety Report 2012)... 8 Figure 4 Rate of fatal accidents in scheduled passenger operations in EASA MS and third country operated aeroplanes (fatal accidents per 10 million flights). (Source: EASA Annual Safety Review 2011) Figure 5 Accident catgories for fatal and non-fatal accidents (number of accidents by EASA MS operated aeroplanes ) Figure 6 Total number of occurrence reports in Iceland for the past 5 years Figure 7 Overview of total number of occurrence reports in Iceland per month in Figure 8 - Most commonly reported occurrences in Figure 9 Most commonly reported occurrences from Icelandic aerodromes and air traffic management

7 1. Global overview The growth in volume of commercial scheduled flights continued in 2011 at the rate of 3.5%. The number of accidents grew by 4.1% however the global accident rate remained unchanged at approximately four accidents per million departures. The year 2011 was the safest since 2004 with regard to fatalities. The fatality rate decreased by 41.4% and was improved runway safety the key element for this decrease. The decreasing global rate for accidents over the last 20 years involving passenger fatalities per 10 million flights is depicted in figure 1.1. In recent years this accident rate has not improved significantly, averaging between 4 and 5 fatal accidents per 10 million flights. Figure 1 Global rate of accidents involving passenger fatalities per 10 million flights, scheduled commercial air transport operations, excluding acts of unlawful inference. (Source: EASA Annual Safety Review 2011) The 5 year moving average rate (thin blue line in figure 1.1) has remained almost constant since On figure 1.2 the rate of fatal accidents per 10 million flights per world region is drawn up. Regional variations are considerable and four regions are below the world average (North America, EASA MS, East Asia, Australia and New Zealand. It is noteworthy that the accident rate is the same in North America as in Europe. ICAO ICAO The International Civil Aviation Organisation is a specialized agency of the United Nations which was founded in 1944 to promote the safe and orderly development of international civil aviation throughout the world. ICAO sets the standards and recommended practices necessary for aviation safety, security, efficiency and environmental protection on global basis. It serves as the primary forum for cooperation in all fields of civil aviation among its 191 Member States. The 2012 Safety Report introduces accident statistics and trends. The year 2011 is analysed as well as a 7 year trends. It is noted that the number of accidents experienced annually in commercial scheduled flights has been more or less stable since 2005 at approximately 120 events or 4 accidents per million departures. 7

8 Figure 2 Rate of fatal accidents per 10 million flights per world region ( , scheduled passanger and cargo operations). (Source: EASA Annual Safety Review 2011) ICAO studies the accident rate based on scheduled commercial air traffic with a Maximum Take-Off Weight (MTOW) above 2250 kg per million departures. Aircraft accidents are categorized using the definition provided in Annex 13 to the Chicago Convention. Figure 3 shows the change in the accident rate since 2005, with 2011 having an accident rate of 4.2 accidents per million departures. Figure 3 Global Accident Rate per million departures. (Source: ICAO Safety Report 2012) The accidents of the year 2011 send a contradictory signal: on the one hand, the number of accidents involving passenger fatalities in scheduled operations worldwide remained high at 16, but the related number of fatalities to passengers dropped from 658 in 2010 to 330 in The drop in the number of passenger fatalities can be mainly attributed to the involvement of smaller aircraft in fatal accidents as well as to a lower proportion of fatalities of persons on board when compared to the previous year. 8

9 2. European Overview In Europe, the number of fatalities in 2011 was one of the lowest in the past decade. The accident rate in scheduled operations in EASA Member States (EASA MS) is, as above mentioned, one of the lowest in the world with 1.6 fatal accidents per 10 million flights. The Air Traffic Management (ATM) domain has a small contribution, either direct or indirect, to accident and incidents in the overall aviation system. EASA Figure 4 Rate of fatal accidents in scheduled passenger operations in EASA MS and third country operated aeroplanes (fatal accidents per 10 million flights). (Source: EASA Annual Safety Review 2011). The European Aviation Safety Agency (EASA) publishes the Annual Safety Review each year as required by Article 15(4) of Regulation (EC) No 216/2008. The Annual Safety Review (ASR) presents statistics on European and worldwide civil aviation safety. The statistics are grouped according to the type of operation, for instance commercial air transport and aircraft category, such as aeroplanes, helicopters and gliders. The ASR 2011 provides a detailed safety analysis based on the data that were available to the Agency and Eurocontrol on 1 st of April The full report may be accessed on the EASA website at: Figure 5 Accident catgories for fatal and non-fatal accidents (number of accidents by EASA MS operated aeroplanes ). 9

10 3. ECCAIRS ECCAIRS stands for the European Coordination Centre for Accident and Incident Reporting System. The mission of ECCAIRS is to assist national and European transport authorities and accident investigation bodies in collecting, sharing and analysing their safety information in order to improve public transport safety. Directive 2003/42/EC on Occurrence Reporting in Civil Aviation obliges Member States to collect and exchange the information about incidents and accidents since July Analysts from the National Aviation Authorities in the Member States, Investigation Authorities as well as from the European Institutes form a Network of Analysts (NoA). The NoA will focus on the following areas: Understanding what barriers exist to the provision of the best possible safety data and developing ways to improve safety data across Europe. Agreeing the classification of aircraft accidents in EASA MS. Carrying out analysis of safety data to support the European Aviation Safety Plan (EASp) and State Safety Plans, as well as identifying emerging issues for possible inclusion in the future. Sharing experiences, good practice and developing safety analysis projects across Europe to enable the European Aviation Community to exploit the ECCAIRS European Central Repository for the benefit of all. Providing analysis support to existing EASA groups such as the European Strategic Safety Initiative (ESSI) and the European Human Factors Advisory Group (EHFAG). ECCAIRS helps to cope with the implementation of the legislation. It offers a standard and flexible accident and incident data collection, representation, exchange and analysis tools. European Coordination Centre for Accident and Incident Reporting Systems The European Commission has established a software platform for ICAO s ADREP * taxonomy which is known as the European Coordination Centre for Accident and Incident Reporting System (ECCAIRS). The ECCAIRS reporting system allows the EU authorities to collect and exchange information on transport incidents and accidents in a standardised way. Under this system, all safety occurrences form EASA Member States are collected in a centralised database: the European Central Repository (ECR). Following the successful example in the aviation domain, in the next future ECCAIRS will be applied in similar way in two other transport domains: maritime and railways. 10

11 Mandatory Occurrence Reporting Aviation Occurrence is defined as an operational interruption, defect, fault or other irregular circumstance that has or may have, influenced flight safety and that has not resulted in an accident or serious incident. Occurrence reports are of great value and when identifying possible areas of safety concerns it is not the individual reports but the aggregated data that gives you the fuller picture. 3. Commercial Air Transport A vital element of any safety culture is a good reporting culture. Through which a commitment to continuously improve safety, in organisations and aviation, is shown by proactively reviewing events and ensuring safety hazards are addressed. Commercial Air Transport (CAT) is defined as all civil aircraft operations, with maximum take-off mass (MTOM) over 2250 kg, that involve transportation of passengers, cargo and mail for remuneration or hire. In 2012 the ICAA received 866 occurrence reports from the Icelandic Flight Industry, on average 72 occurrences per month. Submitted occurrence reports in 2012 grew by six per cent between years. It is worth noting that later in the year 2013 a new legislation on Occurrence Reporting in Civil Aviation will be in effect. This legislation will repeal Directive No 2003/42/EC, Commission Regulation (EC) No 1321/2007 and Commission regulation (EC) No 1330/2007. Furthermore, it will amend Regulation (EU) No 996/2010. Figure 6 Total number of occurrence reports in Iceland for the past 5 years. 11

12 Figure 7 Overview of total number of occurrence reports in Iceland per month in Figure 8 - Most commonly reported occurrences in Depicted in figure seven are the most commonly reported occurrences during Non-power plant failures of components in various aircraft systems (SCF-NP) are most frequently reported. These are followed by aircraft operation general occurrences which are flight crew related. Security occurrences are quite common but usually do not pose a risk to the overall safety of the aircraft. In the year 2012, no accidents occurred in Commercial Air Transport in Iceland. There were five serious incidents, thereof three runway incursions. 12

13 4. General Aviation General Aviation is defined as all civil aircraft operations with MTOM over 2250 kg other than commercial air transport and aerial work operation. Due to few occurrences in this category light aircrafts with MTOM below 2250 kg are also included. From the general aviation 17 occurrence reports were received in 2012, thereof three accidents and one fatal accident with two fatalities. Six of these occurrences were categorized as serious incidents. 5. Aerodromes and Air Traffic Management (ATM) In the year 2012 there were 215 occurrences reported from Icelandic aerodromes and air traffic management. There has been an increase in runway incursions in Europe for the past three years and therefore it has been targeted a priority by EASA. Runway incursions are defined as any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and take-off of aircraft. There were 11 cases of runway incursions in Iceland in 2012; nine were at BIRK and two at BIKF. In figure 8 the most commonly reported occurrences from Icelandic aerodromes and air traffic management are shown. Figure 9 Most commonly reported occurrences from Icelandic aerodromes and air traffic management. in

14 7. SSP State Safety Programme To further enhance the level of safety in aviation ICAO has encouraged the member states to incorporate the principles of safety management Those principles evolve around the implementation of - Safety Management System (SMS) in the industry on one hand and a State Safety Programme (SSP) within the state on the other hand. ICAA must establish and maintain a SSP by involving all sections/departments within the organization. At the same time the programmes and plans put forward by EASA are part of the SSP i.e; European Aviation Safety Programme (EASP) and European Aviation Safety Plan (EASp). By doing so Eurpoe is uniting the combined knowledge and concentrating at the same time on the european projects deeemed to need special attention. The origin of those pojects is a result of the huge data gathering eithin the ECCAIRS Ocurrence Reporting system that is eventually combined in ECR (European Common Repository). ECR is then used as a basis for analysis work the results are but forward in the EASp projects. Examples of such projects are: The development of SPI- Safety Performance Indicators and the associated procedures for analysis work. Methods for risk based oversight. Runway Excursions actions (EAPPRE) Helicopter operational safety (EHEST) Ground operations manual (ECAST) Improve data gathering and analysis in general aviation. For few years ICAA has been using the methodology to monitor organisations in aviation and enhance further the oversight i.e; risk based oversight approach. 14

15 8. Icelandic Aircraft Accident Investigation Board (IAAIB) In 2012 the Icelandic Civil Aviation Administration received eight safety recommendations form the Icelandic Aircraft Accident Investigation Board. As listed in the table below, the ICAA did not accept four of these eight safety recommendations. IAAIB Reference M-01510/AIG-15 M-01009/AIG-07 Safety Recommendation Rannsóknarnefnd flugslysa leggur til við Flugmálastjórn Íslands og Innanríkisráðuneytið að þau endurskoði reglugerð 770/2010 og Flugmálahandbók Íslands þannig að fyrir allt flug á Íslandi verði krafist að gerðar séu flugáætlanir. ICAA action: FMS tekur ekki undir þessa tillögu í öryggisátt. IRR verður sent bréf um afstöðu FMS varðandi framkvæmd og þjónustu vegna flugáætlana. Að FMS endurbæti reglugerð 780/2006 um fis (með breytingum 779/2007) með tilliti til orðskýringa og starfsrækslu á fisum án hreyfils svo ekki verði um villst að um svifvængi/svifdreka sé að ræða. RNF beinir því til FMS að kanna hvort mögulegt sé að stækka og/eða hækka tilgreind hættu-eða haftasvæði svo sem KAMBAR og SANDSKEID. RNF beinir því til FMS að kanna hvort mögulegt sé að færa haftasvæði frá leiðum til og frá Reykjavíkur-og Keflavíkurflugvöllum. ICAA action: Þetta er eitt einstakt tilvik og snéri öðruvísi við ef þetta væri ítrekað að gerast. Þessi tillaga er sett í farveg með flugmálafélaginu. Ekki er ástæða til að bregðast við þessari tillögu. Tengist tillögu 1 og verður unnið ásamt henni. The Icelandic Aircraft Accident Investigation Board (IAAIB) investigates aircraft accidents, serious incidents and air traffic incidents investigations in accordance with International Civil Aviation Organisations s Annex 13. The jurisdiction of the IAAIB is the Icelandic territory, as well as the air traffic control and flight information service areas serviced by Iceland with respect to air traffic incidents. The goal of an aircraft accident investigation shall be to increase aviation safety without apportioning blame or liability. The AAIB shall in its investigations be independent of other investigating agencies such as the police or judicial. The Board determines when there is reason to investigate an aircraft accident. Further information on the IAAIB and specific reports can be found on their website at: 15

16 IAAIB Reference M-00909/AIG-08 M-05608/AIG-16 Safety Recommendation RNF beinir því til FMS að hún: Sjái til þess að reglum sé fylgt eftir varðandi notkun ratsjárvara innan flugstjórnarsvæða þar sem þeirra er krafist og í samráði við ISAVIA setji sérstakt verklag í flugstjórn ef undanþágur eru veittar fyrir flug án ratsjársvara innan flugstjórnarsvæðis FAXI. Setji skilyrði um gerð flugáætlana í öllum flugum. Sjái til þess að endurskoða upplýsingar til flugmanna og flugumferðastjóra til aukins skilnings á loftrýmum. ICAA action: Tekið er undir þessa tillögu. Haft verður samband við Isavia um verklag við undanþágur. Senda þarf einnig nótu til flugmálafélagsins. Ekki er ástæða til að bregðast við þessari tillögu. Tekið er undir þessa tillögu. IAAIB places emphasis on proper rest period before all flights. In this respect, IAAIB recommends that the ICAA, in co-ordination with the Canadian and Danish authorities, inform ferry flight pilots of the importance of proper rest prior to long ferry flights. ICAA action: The ICAA does not accept this safety recommendation. It is not the ICAA s role to inform ferry flight pilots of the importance of proper rest prior long ferry flights. However, ICAA should have general instructions regarding ferry flights and they can be found on ICAA s website. 16

17 Division of Development and Analysis The Division of Development and Analysis (DDA) was set up to lead and manage projects. DDA purpose is to develop, assist and coordinate and then let the projects go their way. DDA is working closely with other departments and sometimes provides guidance for the customers. The main tasks are: The State Safety Programme (SSP) Occurrence reporting entry into ECCAIRS and analysis QMS and SMS knowledge and assistance Environmental issues in aviation The projects of the DDA pertain to entry and statistical analysis of mandatory reported occurrences that involve Icelandic aircrafts, airports and airspace. Occurrences on board aircrafts can be variable from the smallest failures to accidents. The aim with the registration of these occurrences is to find trend in the data that could cause an incident or even accident. DDA handles communication with international agencies with regards to registration and analysis of occurrences and reporting of conclusions to appropriate entities. Sveinn V. Ólafsson is the head of the division. Sveinn has M.Sc. in Systems Engineering from Virginia Polytechnic Institute & State University in USA 1990, M.Sc. in Aerospace Engineering form the same university 1988 and Final Exam in Mechanical Engineering 1986 from University of Iceland. Sólveig Ragnarsdóttir is a safety analyst at the Division of Development and Analysis. Sólveig is a psychologist from the University Iceland and has a licence to practice as such from the Ministry of Health and Insurance. She graduated with a MSc in Human Factors and Safety Assessment in Aeronautics from Cranfield University in England (2008). Skógarhlíð Reykjavík Ísland Sími Fax Netfang fms@caa.is Veffang 17

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