Annual Safety Report 2012

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EUROCONTROL Aual Safety Report 212 Safety Regulatio Commissio

Table of Cotets Chapter 1 - Itroductio 6 Chapter 2 - Key Safety Idicators 9 Chapter 3 - Operatioal Safety Issues 12 Chapter 4 - Severity Classificatio of ATM Icidets 1 Appedix A - ECAC ATM Safety Performace Idicators for 211 SRC Aual safety report 212 3

Chapter 1 - Itroductio The aalysis of the ATM safety performace cotaied i this Report is based o the Aual Summary Templates (AST) reported by Member States to the EUROCONTROL SRC as part of their obligatios established uder the EUROCONTROL Covetio 1. Safety Occurrece Aalysis EUROCONTROL s safety data aalysis work cosists of a Europea ATM Safety Data Repository, fed by madatory ad volutary data flows, with its subsequet aalysis formig the basis for safety improvemet measures ad iitiatives. The output of these activities plays a key role i both safety regulatio ad safety maagemet. The AST reportig ad aalysis mechaism operated by the SRC represets the madatory elemet of this safety data aalysis work ad provides the primary basis for the SRC s advice to the EUROCONTROL goverig bodies o ATM safety-related issues. This work is desiged to provide the ATM compoet of the EC s aviatio-wide reportig system, based o ECCAIRS. Accordigly, the AST mechaism ot oly provides full iter-coectivity with other ECCAIRS-based systems, such as the data repositories held by the EC ad ICAO, but also shares a commo taxoomy with those systems i respect of ATM occurreces. Reportig Levels As part of their obligatios uder CN Decisio 11, thirty-three Member States reported to the EUROCONTROL SRC by the ed of March 212. This is yet aother record i respect of the umber of Member States who reported withi the deadlie. Such a achievemet was possible due to the cotiued hard work ad dedicatio of the omiated AST Focal Poits ad their advisors. The umbers of ATM-related icidets used i the aalysis is derived directly from the AST reports set by the States to EURO- CONTROL SRC. The umbers i the graph below show those States who have submitted AST reports ad for which exposure data is available. For each State, the level of reportig is measured by ormalisig the total umber of reported ATM-related icidets agaist the umber of flight hours i the State. The level of reportig ot oly measures the reportig maturity, but also the effectiveess of the atioal safety data flows which allow the AST Focal Poits to have all the atioal data available to report. It is for this reaso that EUROCONTROL cotiues to provide support to Member States i this field, icludig providig appropriate tools ad traiig, i order to improve the safety data flows. We cosider as the baselie the average reportig level of 23 ad the graph above measures how the idividual State s reportig level compares to that over the years. A idicatio of the progress made i reportig levels is measured by the umber of States reportig above the 23 baselie. The yellow lie i the graph measures this ad we ca see that improvemets are beig achieved, especially i the last years. This is i lie with the icrease i the overall umber of icidets at ECAC level, which shows the icrease is beig cotributed by a umber of States. The umber of States reportig above the baselie (22) i 211 was double the umber reportig uder the baselie (11). States per category 2 2 1 1 Less tha half of the baselie More tha half of the baselie Above Baselie 28 26 26 27 28 29 23 24 2 26 27 28 29 Level of reportig ATM related icidets Baselie 23 3 31 21 33 211 1 CN Decisio No. 11, dated 2 September 29, approvig ESARR 2, Editio 3., for icorporatio ad implemetatio i the ATM regulatory frameworks of EUROCONTROL Cotractig Parties. SRC Aual safety report 212

Chapter 2 - KEY SAFETY INDICATORS Accidets with Direct ad Idirect Cotributio I 211, the safety data received from Member States via the AST reportig mechaism, ad available iformatio from ICAO coverig ECAC States, showed there were a total of 71 accidets, out of which 11 were fatal. However, it is importat to ote that, with the traffic level icreasig by almost 4.8% compared to the previous year, oe of the reported accidets had either a direct or idirect ATM cotributio (for accidets ivolvig aircraft above 22kg MTOM). Note: a sigificat umber of accidets are still uder ivestigatio ad updated results are expected i the ext AST reportig roud. ATM-Related Icidets Followig the sigificat icrease i the total umber of icidets see over the previous two years, the data received for 211 idicates a icrease of 14.% i the total umber of ATM-related icidets. 2 This icrease could be iflueced by a umber of factors, such as: a cosiderable icrease i certai categories of ATM-related icidets i some Member States (e.g. airspace ifrigemets), the reportig of ew emergig cocers (e.g. laser iterferece) or icreased reportig of other types of potetial icidets (e.g. ustabilised approaches). 2 18 16 14 12 1 8 6 4 2 Number of accidets 3 ECAC traffic levels (2-211) Flight Hours 2 Accidets with direct + idirect ATM cotributio Accidets with direct ATM cotributio Liear (Accidets with direct + idirect ATM cotributio 4 2 2 2 26 27 28 29 21 211 Accidets i ECAC with ATM cotributio ad traffic levels - aicraft above 22 kg MTOM (211 prelimiary data) 16 12 8 4 The slight icrease i the umber of serious icidets is evidet i most of the ATM-related icidet categories we track i the SRC system: separatio miima ifrigemet, iadequate separatio, ear CFIT, uauthorised peetratio of airspace (airspace ifrigemet), deviatio from ATC clearace ad level bust. Aalysis of the reported data does ot idicate a apparet cause for the slight icrease i the umber of serious occurreces. A possible cause could be related to the more accurate ad objective severity classificatio as the result of the itroductio of the Risk Aalysis Tool (RAT) by a umber of Air Navigatio Service Providers from the begiig of 21. There is still a cosiderable shortage of resources available at atioal level to collect, classify ad aalyse all the data i time (which leads to a icreased backlog i codig data i databases at the ed of March 212 ot all 211 reports could be etered i some of the atioal databases) ad at a good quality level. This ot oly affects the completeess of the safety data i the 211 data set, but also the capabilities to udertake a timely safety aalysis at Europea ad atioal levels. I respect of the evolutio of the risk posed by the reported icidets o the ATM system, it is to be oted that, i absolute umbers, the serious icidets (severity class A) icreased by less tha 1%, whilst the major occurreces (severity class B) icreased by 2.1% whe compared with the 21 figures. 14 12 1 8 6 4 2 A B Total 22 23 24 2 26 27 28 29 21 Total ATM Related Icidets Occurrece per millio flight hours ad severity 211 2 18 16 14 12 1 8 6 4 2 2 See Appedix A, Icidets sectio for a explaatio o the Severity Classes for ATM related icidets. 6

Separatio Miima Ifrigemets Ruway Icursios The data reported for 211 shows a icrease of 12% i the umber of reported separatio miima ifrigemets compared with the previous year s figures. 14 12 1 4 2 As this icrease comes after a two-year decrease, the absolute umbers are still below the level of 28. However, i terms of the classificatio ad codig of losses of separatio, there is still room for improvemet, as a clear distictio shall be made betwee the separatio miima ifrigemets ad iadequate separatio. The correct classificatio is oly possible after havig coducted the full ivestigatio of such evets. Last but ot least, the atioal data flows should act as a process eabler. It is to be oted that work is o-goig i the SRC AST Focal Poits (AST-FP) Group, i cojuctio with the Actio Pla for the Improvemet of Severity Classificatio, to improve the situatio. I respect of the severity of the reported separatio miima ifrigemets, icreases are see i all severity categories from the previous year s figures. Cocerig the risk bearig separatio miima ifrigemets, the icrease show i 211 is quite substatial: 8 6 A B Total 1999 2 21 22 23 24 2 26 27 28 29 21 211 Separatio Miima Ifrigemets Occurrece per millio flight hours ad severity Serious icidets (severity class A) icreased i absolute umbers from 16 to 3, Major icidets (severity class B) icreased i absolute umbers from 178 to 217. For the first time i may years, prelimiary data for 211 shows a small decrease of 1%. However, this comes after two years of cosiderable icrease i the total umbers reported. The 211, SRC Aual Safety Report stated that, i respect to the cosiderable icrease: Ruway Icursios reported through the AST ow iclude ot oly those reported by ANSPs, but also by airlies ad aerodrome staff. These reports eed to be assessed/ ivestigated to ascertai if they are really ruway icursios (as per the defiitio), to collect all relevat data, determie the severity ad to avoid the itroductio i the database of duplicate reports. The SRC s AST-FP Group discussed typical scearios of ruwayrelated occurreces to better classify the reported ruway icursios as per the defiitio. Additioal effort was also made at atioal level to avoid duplicatio. These actios may explai the decrease compared to the cotiual icrease of ruway icursios reported over the last years. I absolute figures, the umber of serious ruway icursios i 211 slightly icreased (23) compared with the previous year (22), whilst a decrease is show for major evets (from 77 to 62). 14 13 12 11 1 9 8 7 6 4 3 2 1 A B Total 21 22 23 24 2 26 27 28 29 21 211 Ruway Icursios Occurrece per millio aircraft movemets ad severity 1 9 8 7 6 4 3 2 1 The percetage of icidets ot classified i this category has margially icreased from previous years to over 27% of the total occurreces. Therefore, it is vital that Member States esure that adequate resources are made available for the ivestigatio ad further aalysis of this type of key performace idicators for safety. I additio, Member States shall esure the quality ad completeess of the safety data both at atioal ad Europea level. SRC Aual safety report 212 7

This is eve more importat i the cotext of the Performace Scheme for Air Navigatio Services ad Network Fuctios Commissio Regulatio (EU) No. 691/21 (updated by Commissio Implemetig Regulatio (EU) No. 1216/211) takig ito accout Member States resposibility to establish ad moitor the severity of these type of evets durig the first referece period (212-214). Performace Scheme Regulatio ad Associated Performace Idicators for Safety Commissio Regulatio (EU) No. 691/21 layig dow a performace scheme for air avigatio services ad etwork fuctios (updated by Commissio Implemetig Regulatio (EU) No. 1216/211), defies three Performace Idicators (PI) for safety. These safety PIs have bee developed by the EC, EASA ad EUROCONTROL, i cosultatio with Member States, ad adopted by the EC. Durig the first referece period, startig i 212, o targets have bee laid dow for these safety PIs. Oe of the safety PIs is the applicatio of the severity classificatio methodology of the Risk Aalysis Tool (RAT) to allow harmoised reportig of severity assessmet of separatio miima ifrigemets, ruway icursios ad ATM-specific occurreces at EU level. It has already bee proposed that, for the secod referece period startig from 21 (RP2 21-219), the use of the RAT methodology for the harmoised assessmet of severity for the ATM-related icidets is to be exteded to the evaluatio of the risk of recurrece. This will allow a more accurate ad Europea wide harmoised view o the risk posed by the reported occurreces o the ATM system. It is otable that the AST reportig mechaism was judged as the most appropriate vehicle for moitorig the applicatio of the RAT methodology by Member States. This represets a uequivocal recogitio of the overall maturity of the AST reportig system ad the excellet co-operatio with the AST-FP Group, which has bee developed over more tha a decade. 8

Chapter 3 - Operatioal Safety Issues This chapter provides a aalysis ad progress report o a umber of operatioal safety issues that are curretly uder the focus of the SRC ad its specialised workig groups (SRC Coordiatio Group [SRCCG] ad AST-FP Group). A full aalysis of all Europea Key Risk Areas is preseted i this Report. Uauthorised Peetratio of Airspace/Airspace Ifrigemets At the 34th meetig of the EUROCONTROL Provisioal Coucil, agreemet was reached o the acceptace of the SRC s 21 Aual Safety Report which icluded a recommedatio o the subject, i.e. States to urgetly implemet, as a matter of priority, the provisios of the Europea Actio Pla for Airspace Ifrigemet Risk Reductio. I additio, at the 3th Provisioal Coucil meetig, the SRC s 211 Itermediate Safety Report was oted ad a ew recommedatio with respect to uauthorised peetratio of airspace/airspace ifrigemets was accepted, i.e. for the PC to: I 211, additioal meetigs were scheduled ad two workshops coducted. Member States have bee approached to support ad orgaise similar workshops to implemet the required actios. Support activities have cotiued i 212, icludig a umber of preparatory meetigs ad workshops. The objective of havig all Member States ivolved i the implemetatio of the EAPAIRR remais, with EUROCONTROL cotiuig to provide support ad moitorig its implemetatio up to 213. However, i order to meet this objective, cotiued commitmet from the SRC ad the Provisioal Coucil remais vital. The iitial data for 211 shows a very sigificat icrease of over 32% i the umber of Uauthorised Peetratios of Airspace (UPA) compared with last year. The icrease is more promiet i a few States. For example, oe State, followig the actios decided at atioal level for the implemetatio of the EAPAIRR, made arragemets for the improvemet of the reportig system by which Flight Iformatio Ceter (FIC) staff will report all airspace ifrigemets. The icrease from oe year to aother was dramatic. These actios to improve reportig will allow more accurate measuremet of the extet, severity ad associated risk of the problem. Urge all remaiig Member States to start the implemetatio of the agreed Europea Actio Pla for Airspace Ifrigemet Risk Reductio, before the ed of 211. DSS/OVS/SAF, i cojuctio with DNM/Operatios/Safety, udertook actios to icrease the awareess of the Europea Actio Pla for Airspace Ifrigemet Risk Reductio (EAPAIRR) with Member States regulatory/oversight authorities ad ANSPs. Overall, EUROCONTROL provided support to 18 Member States durig 21-211, icludig: 3 3 2 2 1 1 A - Serious Icidet B - Major Icidet C - Sigificat Icidet E - No sigificat safety effect D - Not determied Not classified 22 23 24 2 26 27 28 29 21 211 Durig 21, sixtee Member States reacted o the activities take, with a umber of atioal workshops takig place o the developmet of atioal/local implemetatio plas for the risk reductio of airspace ifrigemets (Estoia, Norway, Demark, Switzerlad, Slovakia, Hugary ad Italy). Several preparatory meetigs were also held (Swede, Netherlads, Croatia, Turkey, Greece, Austria, Czech Republic, Polad ad Spai). Uauthorised Peetratio of Airspace Occurrece per millio flight hours ad severity Although the percetage of airspace ifrigemets ot severity classified decreased to some extet (aroud 1%) compared to the 21 level, there is a substatial icrease i this category (from 83 i 21 to 118 i 211) i absolute umbers. SRC Aual safety report 212 9

The percetage of serious icidets (severity class A) amouts to.3% of the total umber of reported evets. This represets a small icrease (.2% i the 21 data). However, i terms of absolute umbers of occurreces, 211 shows a cosiderable icrease from 4 to 12 evets. The umber of major airspace ifrigemets decreased, i absolute figures, from 79 i 21 to 68 i 211. The safety risk posed by airspace ifrigemets/upas is evidet whe a aircraft peetrates cotrolled airspace ad comes too close to aother aircraft. Depedig o the airspace ifriged, such ecouters are classified as Separatio Miima Ifrigemets or Iadequate Separatio, which are collectively called Losses of Separatio (LoS). The chart shows the umber ad percetage of UPAs which resulted i a LoS. 2 18 16 14 12 1 8 6 4 2 Number of LoS i UPA Percetage of LoS i UPA 2 26 27 28 29 21 Uauthorised Peetratio of Airspace (UPA) as Losses of Separatio (LoS) 211 8 7 6 4 3 2 1 The percetage of LoS i the overall umber of UPAs reported i 211 amouts of 3.6% of the total umber of reported Separatio Miima Ifrigemets. However, i absolute umbers, there is a slight decrease i the umber of UPAs where a loss of separatio also occurred (from 178 i 21 to 172 i 211). There is a close lik betwee the risk associated with the UPAs ad the umber of those edig up i a LoS (i.e. the opportuities that the ifrigig aircraft eters ito coflict with aother aircraft). Therefore, the SRC will cotiue to moitor the relatioship betwee UPAs ad LoS. This lik is illustrated i the graph, where the proportio of LoS i the UPAs which are Serious icidets (Severity A) ad Major icidets (severity B) is much higher tha for the overall umbers. Laser Iterferece I 211, the SRC cotiued to moitor the issues related to the malicious use of high powered lasers, as this has bee idetified as a global cocer. This type of icidet is a possible hazard to aircraft safety, especially i the fial approach stage. Both the AST-FP Group ad the SRCCG follow ad support the developmets, activities ad iitiatives i this area. The EUROCONTROL Agecy, with the support of the SRC, hosted a multidiscipliary semiar i October 211, which ivolved regulatory ad oversight authorities of the Member States, Air Navigatio Service Providers, pilots, pilots associatios, police, represetatives of the judicial system ad other stakeholders. 8 7 6 4 3 2 1 2 26 27 28 29 21 A B Total 211 The regulatory iput of the Agecy durig this evet was largely based o the feedback provided by Member States i the AST-FP Group meetigs. The coclusios of the semiar ca be summarised as follows: Losses of Separatio i UPA (Percetage of umber of UPAs) Laser iterferece is cofirmed as a global safety ad security threat ad ot just a aviatio issue. Therefore, a pro-active multidiscipliary approach is eeded to respod to the threat; Need for a overall framework establishig what is a legitimate use of lasers (ic. developmet of ICAO stadards); Techology is developig rapidly for both laser devices ad protectio measures; 1

Need for harmoised measures at Europea/global level: Timely ad effective i-flight ad post-flight procedures, Alertig procedures, i.e. to law eforcemet authorities, Traiig for pilots ad ATCOs i how to deal with, ad protect from, the iterferece, Legislative, regulatory ad other legal measures (absece of EU legislatio [purchase, carriage ad use of lasers]. Curretly there are oly idividual States regulatory ad legal/judicial activities), Awareess campaigs, Guidace material for use at decisio-makig level. 4 3 3 2 2 1 1 2716 1288 22 28 29 21 368 211 I additio to the coclusios of the semiar, a umber of actios ad iitiatives related to a possible way forward have bee idetified: Laser iterfereces reports by Member States via the AST mechaism Short-Term Actios ( quick wis ) Review i-flight ad post-flight reportig procedures (e.g. warigs through NOTAMs, ATIS, R/T messages, etc.); Traiig for pilots ad air traffic cotrollers; Awareess campaigs with idustry ad society; Curret techologies for the protectio from laser iterferece; Ulawful iterferece to be addressed at ICAO level. Medium Term Actios EU legislatio (productio, distributio, purchase, carriage ad use of certai type of laser), icludig o-itetioal iterfereces (crimial offece, prosecutio, licesig), Research for future techologies for the protectio from laser iterferece. For the last two years, AST-FP Group members have preseted the iformatio gathered i their States o activities ad actios developed ad take with respect to laser iterferece, as well as the umbers of this type of icidet, both domestic ad abroad. The iformatio provided by Member States is show i the graph, which clearly shows the rapid icrease i the reported umber of laser iterfereces. The SRC (through the AST-FP Group ad SRCCG) ad the EUROCONTROL Network Maagemet will cotiue to moitor laser iterferece-related developmets, through the followig mechaisms, ad co-ordiate with the EC ad EASA: AST-FP Group Gatherig of laser iterferece data from atioal represetatives cotiuous moitorig gatherig of best practices ad its dissemiatio coordiate ad iform SRCCG ad SRC. DNM/Ops/Safety Safety Warig Messages Cotiuous moitorig through the volutary reportig mechaism of EVAIR. SRC Aual safety report 212 11

Chapter 4 - Severity Classificatio of ATM Icidets Ay safety aalysis at atioal or Europea level is depedet upo a complete ad cosistet severity assessmet i order to give full visibility of the real levels of risk. Previous, aalysis of the level of the severity assessmet of the ATM-related icidets reported through the AST mechaism to EUROCONTROL showed that severity assessmet was deterioratig. Cosequetly, the AST-FP Group prepared a umber of recommedatios ad a Actio Pla was agreed by the SRC ad approved by the Provisioal Coucil. 12 1 8 6 4 2 SMI RWY IS UAP CLR Part of the actios is the cotiuous moitorig of the completeess of the severity assessmet. This sectio presets the latest update based o the data received i March 212. 2 26 27 28 29 Number of occurreces severity ot classified 21 211 The chart shows the umber of ATM-related icidets ot severity classified for differet categories of icidets. Ufortuately, we see a icrease i most areas, especially i Uauthorised Peetratios of Airspace ad Separatio Miima Ifrigemets. The percetage of icidets ot severity classified i 211 varies betwee 27% ad 4% of the total umber for each category. The situatio is better for Separatio Miima Ifrigemets, where the percetage of occurreces ot severity classified icreased 12% compared with the previous year s data. If we add the icidets where the severity is classified as ot determied (i.e. some data provided but ot eough to fully assess it), the percetages rise to betwee 17% ad 47%. O average, the percetage of Ruway Icursios where the severity is either abset or ot determied averaged more tha 2% i the period represeted i the graph ad rose to 3% accordig to the 211 data reported. As the applicatio of the Risk Aalysis Tool methodology for the severity assessmet of ruway icursios is a key performace idicator for safety i RP1 (212-214), cocrete actio is eeded to esure this gap is closed. 6% % 4% 3% 2% 1% % SMI RWY IS UAP CLR 2 26 27 28 29 21 Percetage of occurreces severity ot classified or ot determied 211 I coclusio, the umber of icidets reported through the AST mechaism that are ot severity classified is icreasig. This situatio is of cocer, ot oly for the outcome of the aalysis made at Europea level, but also for the atioal safety aalysis, as this outcome is idicative for the results of aalysis ad ivestigatio performed at atioal level. Each Member State will receive the situatio o o-classified icidet reports i order to help to improve this situatio. Therefore, the full implemetatio of the agreed Recommedatios ad Actio Pla is paramout to improvig the curret situatio. 12

APPENDIx

Appedix a - ECAC ATM SAFETY PERFORMANCE INDICATORS FOR 211 Accidets Overall Numbers Based o the AST returs for 33 Member States ad the data available from ICAO (coverig all ECAC States), there was o accidet with a ATM cotributio i 211 (for accidets ivolvig aircraft above 22kg MTOM). However, a sigificat umber of accidets are still uder ivestigatio ad updated results are expected i the ext AST reportig roud. Accidet Categories 2 18 16 14 12 1 8 6 4 2 Number of accidets 3 Flight Hours 2 Accidets with direct + idirect ATM cotributio Accidets with direct ATM cotributio Liear (Accidets with direct + idirect ATM cotributio 4 ECAC traffic levels (2-211) 2 2 2 26 27 28 29 21 211 Accidets i ECAC with ATM cotributio ad traffic levels - aicraft above 22 kg MTOM (211 prelimiary data) 16 12 8 4 The graph presets the umber of accidets i the categories that are specifically tracked i the AST system. The data for 211 shows that the most sigificat accidet category was agai collisio betwee aircraft ad vehicle/perso/obstructio(s) with 9 accidets, followed by a collisio betwee two aircraft o the groud. I additio, ad similar to the previous year, two fatal accidets were reported: a Mid-Air Collisio ad a CFIT. 12 1 8 6 26 27 28 29 21 211 Total 26 = 99 (fatal 1) Total27 = 78 (fatal 6) Total28 = 73 (fatal 14) Total 29 = 66 (fatal 12) Total 21 = 63 (fatal 9) Total 211 = 76 (fatal 12) Overall, 12 accidets were idicated as beig fatal. No accidet has bee idicated as havig ay ATM cotributio. However, as may accidets are still uder ivestigatio, chages may surface whe further results become available to AST Focal Poits. 4 2 Mid-Air CFIT GND acft-acft Airboe- Groud GND acft-other Number of accidets per category aircraft with MTOW above 22 kg SRC Aual safety report 212 1

Icidets The classificatio of ATM-related icidets is based o the severity of their effect o the safe operatio of aircraft ad occupats as show i this table (refer also to EAM 2 / GUI 1 ad EAM 2 / GUI for more details). A - Serious Icidet B - Major Icidet C - Sigificat Icidet E - No sigificat safety effect D - Not determied Not classified The tred aalysis is based o the AST data reported by 33 Member States. To ease iterpretatio, icidet-related performace idicators (the treds up to 211) are ormalised based o millios of flight hours, except for ruway icursios which are ormalised based o millios of aircraft movemets (departure ad arrivals). There was a 4.8% icrease i the umber of flight hours i ECAC States ad about a 3% icrease i the umber of arrivals/departures. Oe icidet ca be subcategorised ito more tha oe type of icidet. For example, oe icidet ca be categorised as a Deviatio from ATC Clearace, a Level Bust ad a Separatio Miima Ifrigemet. As opposed to accidet aalysis, there is o MTOM limit for ATM-related icidets. Geeral Treds Safety data for 211 shows a 14.% icrease i the total umber of icidets reported i compariso with the same period of 21. Whe measured agaist traffic levels, the icrease i 211 is 7.9%. A icrease of over 26% i the absolute umber of serious icidets (severity A) is observed i 211, while the umber of serious icidets, as a percetage of the total umber of occurreces, raised from.6% to.7%. There is a decrease of 1.8% i the absolute umber of major icidets (severity B). Separatio Miima Ifrigemets Compared with the previous year s data, the data reported for 211 shows a 12.1% icrease i absolute umbers ad a.6% icrease whe measured agaist traffic levels. With respect to the umber of serious icidets (Severity A) ad major icidets (Severity B), a cosiderable icrease is show i both severity A (i absolute umbers 16 i 21 ad 3 i 211) ad severity B icidets (i absolute umbers 178 i 21 ad 217 i 211). 2 18 16 14 12 1 8 6 4 2 6 4 3 2 1 14 12 1 8 6 4 2 4 3 3 2 2 1 1 22 23 24 2 26 27 28 29 21 211 22 23 24 2 26 27 28 29 21 211 Total ATM Related Icidets Occurrece per millio flight hours ad severity 21 22 23 24 2 26 27 28 29 21 211 21 22 23 24 2 26 27 28 29 21 211 Separatio Miima Ifrigemets Occurrece per millio flight hours ad severity 16

Near Cotrolled Flight ito Terrai (Near CFIT) The data reported for 211 idicates a icrease i absolute umbers (72 ear-cfits reported i 211 vs 1 i 21), which represets the highest figure reported durig the last decade. I the risk bearig icidets, oly 3 serious icidets (severity A) are reported (as i 21), whilst the major icidets (severity B) showed a decrease compared to 21 (8 ear CFITs reported i 211 ad 9 i 21). 6 4 3 2 1 21 22 23 24 2 26 27 28 29 21 211 Ruway Icursios Near Cotrolled Flight Ito Terrai Occurrece per millio flights hours ad severity The umber of serious ruway icursios saw a small icrease i absolute figures compared with the previous year (23 i 211 compared with 22 i 21). It is to be oted that the umber of major evets decreased from 77 i 21 to 62 i 211. 12 1 8 6 4 2 2 26 27 28 29 21 211 7 6 4 3 2 1 23 24 2 26 27 28 29 21 211 Ruway Icursios Occurrece per millio aircraft movemets ad severity Uauthorised Peetratio of Airspace The data for 211 shows a sigificat icrease of over 4% i this category. The umber of occurreces ot beig severity classified amouts to over 23%. This percetage represets a small decrease of almost 1% compared to the level of 21. I this category, a sigificat icrease i the umber of serious icidets (severity A) is oted (12 i 211 from 4 i 21), whilst the umber of major icidets decreased from 79 i 21 to 68 i 211. 3 3 2 2 1 1 7 6 22 23 24 2 26 27 28 29 21 211 Ruway Icursios Occurrece per millio aircraft movemets ad severity The percetage of icidets ot severity classified i this category represets over 27% of the total occurreces ad is almost at the same level as i 21. I additio, 8% of the reported Ruway Icursios were categorised D from a severity view poit. The apparet lack of progress i the severity classificatio of this category of occurrece represets a serious cause for cocer. 4 3 2 1 22 23 24 2 26 27 28 29 21 211 Uauthorised peetratio of Airspace Occurrece per millio flight hours ad severity SRC Aual safety report 212 17

I this area, the implemetatio of the Europea Actio Pla o Airspace Ifrigemet Risk Reductio started i 21 ad 211 i a large umber of Member States. Future aalysis will etail the possible impact of the implemetatio efforts o the recommeded ad proposed actios by all atioal stakeholders ivolved. The icrease i the umber of this type of occurrece might very well be attributed to the awareess of the aviatio commuity (ic. Geeral Aviatio GA) made i some Member States as part of the activities related to the implemetatio of the Europea Actio Pla i order to esure risk reductio i this area. Aircraft Deviatio from ATC Clearace The data reported for 211 idicates a slight icrease i total umbers of 7.3%, followig the sigificat icrease (over 3%) see i 21. For the umber of risk bearig icidets (severity A ad B) a decrease is oted for major icidets ( i 211 ad 89 i 21). However, for serious icidets a slight icrease is idicated for 211: 11 compared to 7 i 21. This is at the level of 28 ad below the level of the previous two years. 2 2 1 1 21 22 23 24 2 26 27 28 29 21 211 Level Busts The data for 211 shows a icrease of almost 11% compared to the total umber of icidets reported i this category i the previous year. This follows a substatial icrease of over 2% last year. 12 1 8 6 4 2 2 26 27 28 29 21 211 Level Busts Number of occureces per severity I 211, the umber of Level Busts ot severity classified reached over 44% of the total umber of occurreces reported Europea-wide. It is to be oted that 19.% of the reported level busts were also associated with a loss of separatio. Oly 1.4% of those evets reported i 211 had ot bee severity assessed. I respect to the risk bearig icidets (severity A ad B), this followed the overall tred where there was a icrease i Severity A there is oe more serious icidet compared to 21 ( istead of 4), whilst we see a decrease i major icidets (severity B) whe compared to 21 (21: 19 ad 29: 23). 9 8 7 6 4 3 2 1 21 22 23 24 2 26 27 28 29 21 211 Aircraft Deviatio from ATC Clearace Occurrece per millio flight hours ad severity 3 2 2 1 1 2 26 27 28 29 21 211 Level Busts Number of occureces per severity 18

ATM Specific Occurreces After a sigificat icrease i 21, the iitial data for 211 shows a decrease of 7%, although this is still higher tha the level reached i 29. The umber of States reportig these types of occurreces through the AST agai icreased from 29 States i 21 to 33 i 211. I absolute umbers 14,76 occurreces were reported i 211, with 1,668 reported i 21 ad 12,2 i 29. The severity classificatio of the results is show i the followig table; 16 14 12 1 AA - Total iability to provide safe ATM service A - Serious iability to provide safe ATM service B - Partial iability to provide safe ATM service C - Ability to provide safe but degrated ATM service E - No effect o ATM service D - Not determied Not classified 7 6 4 3 2 1 22 23 24 2 26 27 28 29 21 211 Total ATM Specific Occurreces High risk occureces per millio flight hours & severity Occurreces Related to ATM Support Fuctios The decrease observed i total umbers is also oticed i most of the sub-categories; with the highest umber of occurreces reported i 211 beig i the area of Data Processig (as it was the case i 21) followed by the Commuicatio ad Surveillace fuctios. 8 6 4 2 7 22 23 24 2 26 27 28 29 21 211 Total ATM Specific Occurreces Number of occureces per severity The umbers of the highest risk categories have either remaied at the 212 level as i 21, or show a small decrease: AA total iability to provide ATM services - recorded as 18 occurreces, the same as i 21; A - serious iability - 49 i 211 ad i 21; B partial iability to provide ATM Services - from 89 i 21 to 799 evets i 211. 22 2 18 16 14 12 1 8 6 4 2 24 2 26 27 28 29 21 211 Commuicatio Surveillace Data Processig Navigatio Iformatio Occurreces related to the ATM Support Fuctios Occurreces per millio flight hours SRC Aual safety report 212 19

Notes

EUROCONTROL Jauary 213 - Europea Orgaisatio for the Safety of Air Navigatio (EUROCONTROL) This documet is published by EUROCONTROL for iformatio purposes. It may be copied i whole or i part, provided that EUROCONTROL is metioed as the source ad it is ot used for commercial purposes (i.e. for fiacial gai). The iformatio i this documet may ot be modified without prior writte permissio from EUROCONTROL. www.eurocotrol.it SRC Documet 2, Editio 1.