REVIEW OF PA RAST ACTION ITEMS AND OTHER RASG PA RELATED CONCLUSIONS. (Presented by the Secretariat) EXECUTIVE SUMMARY

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PA RAST/31 WP/02 19/02/18 Thirty First Pan America Regional Aviation Safety Team Meeting (PA RAST/31) of the Regional Aviation Safety Group Pan America (RASG PA) South Florida, United States, 20 to 22 February 2018 Agenda Item 2: Review of PA RAST Action Items REVIEW OF PA RAST ACTION ITEMS AND OTHER RASG PA RELATED CONCLUSIONS (Presented by the Secretariat) EXECUTIVE SUMMARY This working paper presents the RASG PA and ESC valid conclusions and decisions for the PA RAST review, updates and actions. The Regional Aviation Safety Group Pan America (RASG PA) and the Executive Steering Committee (ESC) record their activities as Conclusions and Decisions. Conclusions are RASG PA actions requiring communication and action by ICAO, States/Territories, and/or international organizations/industry. Decisions are RASG PA internal agreements. Appendix A1 and A2 presents the valid conclusions and decisions from PA RAST/30 Meetings. Appendix B presents the valid conclusions and decisions from the RASG PA/ESC/29 Meeting. Action: Take note of the valid conclusions and decisions of the RASG PA Meetings. Strategic Safety Objectives: References: Thirtieth Pan America Regional Aviation Safety Team Meeting, (PA RAST/30), Port of Spain, Trinidad and Tobago, from 14 to 16 November 2017 Twenty Ninth Regional Aviation Safety Group Pan America Executive Steering Committee Meeting (RASG PA ESC/29) Summary of Discussions, ICAO NACC Regional Office, Mexico City, Mexico, 29 30 November 2017

APPENDIX A1 Pan America Regional Aviation Safety Team (PA-RAST) Report

OVERVIEW Reports from PA-RAST/29 Ft. Lauderdale and PA- RAST/30 Port-of-Spain, Trinidad and Tobago Status of Detailed Implementation plans PA-RAST Deliverables to the ESC RASG-PA

PA-RAST/29 Meeting with the US Commercial Aviation Safety Team and GA Joint Steering Committee Ongoing work on Detailed Implementation Plans Discussions on ESC Deliverables RASG-PA

PA-RAST/30 Meeting with Trinidad and Tobago Industry Stakeholders and Regulators Closeout of activities: LOC-I and CFIT DIPs Final Discussions on ESC Deliverables November 2017 RASG-PA ESC/29

Pan America - Regional Aviation Safety Team Completed DIPs 2008-2014 PA-RAST CFIT DIPS LOC-I DIPs RE DIPs CFIT/02 CFIT/04 LOC-I/06 LOC-I/07 LOC-I/09 RE/04 RE/08 RE/09 RE/11 IATA IFALPA/IFATCA PA-RAST ALTA IFALPA ALTA ACI-LAC ALTA MEXICO RASG-PA

SUMMARY OF OUTPUTS Distributed RERR Toolkit to Operators and States Conducted Surveys on Go-around policies and unstable approach mitigation Provided advanced maneuvers manual to all operators Developed RASG-PA Aviation Safety Workshop s Developed and delivered Pilot Monitoring Toolkit Guidance for Runway Maintenance IAW Annex 14 Compiled and Published aviation safety tools and materials Standardized CFIT Training across operators Developed Safety Recommendation (RSR) Process RSR on Mode Awareness and Energy State Management Runway Safety Team in Mexico City, MX RASG-PA

Pan America - Regional Aviation Safety Team Active DIPs 2014 - Present PA-RAST BRAZIL & AIRBUS CFIT LOC-I RE MAC 1 5 4 4 RASG-PA

Detailed Implementation Status LOSS OF CONTROL IN FLIGHT LOC-I RASG-PA 8

Detailed Implementation Plan Status DIP 196: Effective Upset Prevention and Recovery Training (UPRT), Including Approach-to-Stall. Deliverable: Air Carriers conduct effective UPRT in realistic scenarios, and using qualified flight simulator training devices. Status: Checklist developed and distributed. RASG-PA 9

Detailed Implementation Plan Status DIP 197: Flight Crew Training for Non-Normal Situations Deliverable: Air carriers clearly emphasize in policy and standard operating procedures (SOPs) and reinforce in training, the importance of establishing controlled and stabilized flight as the primary consideration during nonnormal situations, prior to troubleshooting or execution of checklists Status: Checklist completed and delivered RASG-PA 10

Detailed Implementation Plan Status DIP 198: ASA-Training Scenario-Based Training for Go- Around Maneuvers Deliverable: Air Carriers conduct effective, scenariobased go-around training that matches realistic situations Status: Implementation checklist complete and delivered RASG-PA 11

Detailed Implementation Plan Status DIP 199: Flight Crew Training ECRM Deliverable: Air carriers and other training providers as well as regulators enhance acceptance, utilization and effectiveness of crew resource management (CRM) principles on the flight deck by revising curriculum content and delivery. These principles should provide clear, unambiguous roles for the pilot flying (PF) and pilot monitoring (PM) in normal and non-normal operations. Status: Implementation Checklist complete and delivered RASG-PA 12

Detailed Implementation Status Controlled Flight Into Terrain (CFIT) RASG-PA 13

Detailed Implementation Plan Status DIP: Survey States to know if GPWS is a Regulatory Requirement Deliverable: Status: RASG-PA 14

Detailed Implementation Plan Status DIP: Produce a Checklist for CAA Inspectors to make sure Airlines comply with CFIT Regulations, training, SOPs and software and database updates Deliverable: Status: RASG-PA 15

Detailed Implementation Plan Status DIP: Vertical Guidance to replace circle to land approaches Deliverable: Status: RASG-PA 16

Detailed Implementation Plan Status DIP: Update Airport Obstacle Charts in accordance with WGS-84 Deliverable: Status: RASG-PA 17

Detailed Implementation Plan Status DIP: Survey States to know Obstacle and Terrain Implementation Area 1, 3 and 4 Status Deliverable: Status: RASG-PA 18

Detailed Implementation Status Runway Excursion (RE) RASG-PA 19

Detailed Implementation Plan Status DIP: RE Programme Session Deliverable: A facilitated training session between Pilots and Controllers to fun simulated flight execution Status: On-going activity for 2018 RASG-PA 20

Detailed Implementation Status Mid Air Collision (MAC) RASG-PA 21

Detailed Implementation Plan Status DIP: Incorporate Eurocontrol s Level Bust Toolkit Deliverable: Incorporate into flight crew and ATCO training programs Status: Translated to Portuguese and need for validation/translation to Spanish. Publish to RASG- PA Web site and work on marketing strategy RASG-PA 22

Detailed Implementation Plan Status DIP: Call Sign Designation Rules Deliverable: Update designation rules according to regional best practices to prevent communication flaws Status: On-going. Working to secure data on state level procedures for call sign designations RASG-PA 23

Detailed Implementation Plan DIP: FAA AC-980-48D Status Deliverable: Incorporate into the flight crew training programs Status: Review of survey to assess regional situation. Work with IATA to spread the word. Initiate studies of mitigation strategies and analyze data. RASG-PA 24

PA-RAST Deliverables to the ESC 1. RASG-PA Tactical Go-Team Concept 2. Assist CANSO with Strategic Review 3. Analyze Global and Regional Safety Targets 4. Coordination of RE Activity with the SRVSOP 5. Evaluation of Flight Safety Foundation Go- Around Decision Making and Execution Project RASG-PA 25

PA-RAST Deliverables to the ESC 1. Tactical Go-Team Concept Should be strongly considered for implementation Need for funding sources/deployment methods RASG-PA Support for National Safety Teams RASG-PA 26

Flow/Design of Teams 21 March 2017 RASG-PA Aviation Safety Seminar

PA-RAST Deliverables to the ESC 2. CANSO Strategic Review Brazil, Canada, USA, Embraer, IATA assisting Draft work initiated, however needs ESC input on long term strategic goals On-going Activity RASG-PA 28

PA-RAST Deliverables to the ESC 3. Global and Regional Safety Targets Can assist but PA-RAST not a implementing authority Need to retain strict analysis function Possibly expand use of the ARST for analysis on safety performance and included in future editions of the ASR IATA analyzing GASP-RASG programmes RASG-PA 29

PA-RAST Deliverables to the ESC 4. RE Activity with the SRVSOP On-going activity with between RE Team and the SRVSOP Work currently focused on. RASG-PA 30

PA-RAST Deliverables to the ESC 5. FSF Go-Around Project Noted that many organizations providing separate input A timely project and raised interesting questions Outcomes and conclusions raised in the report may not be acceptable to industry and operators RASG-PA 31

New Framework for ASIAS and FDX Data LOC Loss of Control ALL ASIAS Part 121 Includes Stall Warnings and Overbanks ALAR Unstable Approach Part 121 RASG-PA Severity Levels: 1000 500 ft., <500 ft. HAT, Egregious CFIT TAWS - Part 121 RASG-PA Available in Mode 1, Mode 2 and EGPWS Midair Collision TCAS - Part 121 RASG-PA Compares FOQA and Simulation data Measuring the effectiveness to metroplex airspace redesign OAPM 32

Define Overbank Classification for > 45⁰ All Overbanks Subthreshold Roll Not Subthreshold Roll Roll Command into the Bank Roll Altitude > 45⁰ for 2 seconds or more Max Roll Rate from 35⁰ to Max Roll Angle < 5⁰ per second Max roll command into roll < max normal load factor into the roll (35⁰ to M ~ Max to 35⁰). Max Normal Load Factor: out of the roll > into the roll. Vertical speed decreases > 1,000 fpm between entry bank angle of 30⁰ to end of overbank at 45⁰ Max Roll Rate: out of the roll > into the roll. Max Normal Load Factor from 35⁰ to max roll angle < 1.2g. Roll angle is within 2⁰ of max roll angle for < 5 seconds. TCAS RA alert is not present within 15 seconds. GPWS alert is not present within 15 seconds. Roll Altitude > 45⁰ when at least 1 of the Subthreshold Roll criteria is not met. (This is All Overbanks Subthreshold Rolls.) Roll Command > 5⁰ in the direction of bank when bank angle > 45⁰ resulting in bank angle of 50⁰ or more. 33

Define Must exceed at least 3 criteria UA rate = Go - Around rate = # of Unstable Approaches # of all Approaches # of Go - Arounds proceeding an Unstable Approach # of Unstable Approaches Category Criteria Standard Egregious Above Glideslope > 1 dot > 2 dot ILS Below Glideslope < -1 dot < -2 dot Localizer Deviation > 1 dot L/R > 2 dot L/R Airspeed High Speed Vref + 20 kts Vref + 35 kts Low Speed Below Vref -3 below Vref Descent Rate High Decent Rate 1000 ft./min 1500 ft./min Thrust Low Thrust Decent N1 35% Below approach power limit 1000 to 500 ft. HAT Descent Rate Airspeed Attitude Configuration Thrust GPWS GPWS Alert Any Alert < 1000 ft. Late Flaps > 2 degrees < 300 ft. Configuration Late Gear Any < 1000 ft. Speed Brakes Any - Unstable Pitch On - Attitude Unstable Roll On - <500 ft. HAT GPWS ILS Unstable Yaw On - 34

Metrics ASIAS RASG-PA Airport coverage 35

High Level Trends 36

Visual Display 37

PA-RAST Plan 2018-2019 Assist RASG-PA to align work programme with GASP Mitigate RE and MAC Monitor/proactive to Regional safety issues Coordinate work with RSOOs Increase participation of States and Stakeholders Collect safety information for ICAO RASG-PA 38

Summary Committed to improving aviation safety and enabling seamless Technical co-operation and communication between States and Stakeholders The PA-RAST shall continue to expand its collaboration with safety organizations to expand its data analysis reach, in order to promote aviation safety and support activities necessary to address emerging safety issues RASG-PA 39

Thank you! RASG-PA

APPENDIX A2 REVIEW OF ALL PA-RAST DECISIONS CONCLUSION ACTION ITEMS November 2017 PA-RAST/30 1

PA RAST OUTREACH EFFORTS: That, for promoting recognized safety standards/management practices, the PA RAST: a) Discuss with the ASRT the issue of expanding data analysis for Part 129 and Part 91 carriers for inclusion into the 2018 RASG PA Annual Safety Report; b) promote the benefits of ISSAs; and c) begin outreach efforts aimed at Part 129 and Part 91 carriers to participate in RASG activities and at implementing continuous training activities 23 June 2016 RASG-PA/9 2

CREATION OF ANALYSIS TEAM That the PA RAST consider dedicating a team to hot spot analysis. IATA will develop new analysis tools to assist in this effort and report its findings at the August 2017 PA RAST meeting. 23 June 2016 RASG-PA/9 3

PRESENTATION OF ASIAS DATA That, in order to increase the quality of the data to be presented at PA RAST meetings: a) the ASIAS and FDX data be presented twice a year at PA RAST Meetings. Preferably, it will be combined with development and review of safety enhancements at each of the three day sessions (every six months); and b) ongoing review of this data allows previewing precursors (predictive information) in the CAR and SAM Regions for Runway Excursion (RE), Loss of Control Inflight (LOC I), Controlled Flight Into Terrain (CFIT), and Mid Air Collision (MAC) occurrences 23 June 2016 RASG-PA/9 4

DEVELOPMENT OF KEY PERFORMANCE INDICATORS (KPIs) That, in order to assist the Data Analysis Team with its activities a) the Safety Enhancement Teams discuss and develop Key Performance Indicators (KPI s) for each of the groups in order to assist the Data Analysis Team in focusing its analysis; and b) The newly created safety analysis team provide feedback to the PA RAST by the August 2017 meeting 23 June 2016 RASG-PA/9 5

PA RAST SAFETY DATA That the PA RAST, intercessionally, shall form a small working group via web conferences to discuss and propose possible solutions on the use of more harmonized data sets, with streamlined analysis, for use by the PA RAST and Member States, for future PA RAST meetings 23 June 2016 RASG-PA/9 6

RE Training Session Programme session with the assistance of a facilitator between pilots and air traffic controllers, in order to discuss the simulated flight execution presented in the RASG PA Runway Excursion (RE) Prevention Video (RREPV) 23 June 2016 RASG-PA/9 7

The need for the PA-RAST to create a small Ad hoc group to provide recommendations and possible proposals on a RASG- PA Tactical Go-Team Concept at the next RASG-PA ESC Meeting to be held in October 2017 Collaborative Safety Teams should continue to be considered Consider other funding sources/deployment methods RASG support of National Safety Teams Thorough Project Management type review Create a product for States use Design a flow chart to design concept August 2017 PA-RAST 29 8

Meeting s Secretariat to call for volunteers to form a group led by CANSO, to discuss and review RASG-PA strategic documents, safety targets and other relevant information. IATA Brazil Canada Embraer Secretariat 19 June 2017 8 th Pan American Safety Summit 9

The need for the PA-RAST to discuss, review and analyze the global and regional Safety target information contained in RASG-PA/ESC/28 WP12, Regional Safety Targets. (Ref: Decision RASG-PA ESC/28/2 - Review of Corresponding Regional Safety Targets). Stay the course Use ASRT for data on Safety Performance The PA-RAST RE SET should coordinate with the SRVSOP working group regarding the stabilized approach initiatives. Ongoing 19 June 2017 8 th Pan American Safety Summit 10

The PA-RAST RE SET should coordinate with the SRVSOP working group regarding the stabilized approach initiatives. Ongoing 19 June 2017 8 th Pan American Safety Summit 11

The PA-RAST should discuss the issues concerning the Flight Safety Foundation (FSF) Go-Around Decision Making and Execution project, provide feedback, and coordinate its analysis with GREPECAS regarding any AGA and ATM issues raised. Organizations may/may not provide their own recommendations to FSF Good report/some outcomes not acceptable Discussions ongoing outside of the RASG Comments from meeting minutes of PA-RAST 28 and 29 19 June 2017 8 th Pan American Safety Summit 12

RASG-PIRG Map out objectives What the GASP does What the PA-RAST does 19 June 2017 8 th Pan American Safety Summit 13

Program Management For PA-RAST Activities Add clear timelines/deliverables when able Quick turn of meeting minutes With assistance!!! Share the load! Revamp the Website Create a safety calendar 19 June 2017 8 th Pan American Safety Summit 14

Thank You! Gracias! Obrigado! 19 June 2017 8 th Pan American Safety Summit 15

APPENDIX B CONCLUSION RASG PA ESC/29/1 ENHANCEMENT OF SAFETY DATA ANALYSIS BY GREPECAS AND RASG PA That, in order to enhance the safety performance analysis in the CAR/SAM Regions, and considering the existing work conducted by the PA RAST MAC Group and the GREPECAS GTE; and to strengthen the coordination between RASG PA and GREPECAS: a) the Secretariat coordinate with both groups to ensure a review of the data analysis work being conducted by each of them, identifying synergies and strengthening their work programme and outcomes; and b) report the results and findings to the RASG PA ESC/30 Meeting. CONCLUSION RASG PA ESC/29/2 FLIGHT DATA ANALYSIS PROGRAMME (FDMP)/ FLIGHT DATA ANALYSIS PROGRAMME FDAP IMPLEMENTATION IN THE NACC AND SAM REGIONS That, in order to broaden FDMP/FDAP throughout the NACC and SAM Regions: a) States take note of the results of the CBA developed by RASG PA FDAP Ad hoc working group for the implementation of FDAP on airplanes over 5 700 kg; b) States and RSOOs encourage operator s review of the CBA document for them to decide their own implementation c) States and RSOOs analyze the aviation safety benefits if an amendment to the aviation regulations is incorporated to request FDAP on aeroplanes above 5,700 Mass Take off Weight (MTOW); and d) RASG PA request the ICAO ANC to take note of the results of the CBA document and consider an amendment to Annex 6 Part I, FDAP Recommendation 3.3.1 and Standard 3.3.2 of Section 3.3, as follows: 3.3.1 Recommendation All aeroplanes of a maximum certificated take off mass over 5 700 kg should be equipped with a Quick Access Recorder (QAR). This QAR should record at a minimum the parameters recorded by the Flight Data Recorder and the operator should establish and maintain a flight data analysis programme as part of its safety management system. 3.3.2 All aeroplanes of a maximum certificated take off mass over 5 700kg for which the individual certificate of airworthiness has been first issued on or after 1 January 2005 shall be equipped with a Quick Access Recorder (QAR). This QAR shall record at a minimum the parameters recorded by the Flight Data Recorder and the operator shall establish and maintain a flight data analysis programme as part of its safety management system.

B2 CONCLUSION RASG PA/ESC/29/3 ENHANCEMENT OF DATA COLLECTION That, in order to enhance data collection, the Flight Safety Foundation: a) work with the PA RAST co chairs to determine the gaps in data collection that will serve the PA RAST processes, b) identify and prioritize desired information to be shared for effective safety improvements, and c) report the results of this task to the RASG PA/ESC/31 Meeting. CONCLUSION RASG PA ESC/29/4 PA RAST DELIVERABLES That, in order to make available and visible the deliverables accomplished by the RASG PA PA RAST: a) the PA RAST shall prepare information packages on the accomplishments of PA RAST DIPs for States awareness, as well as for DCA Meetings and Safety Directors Meetings; b) the PA RAST to follow up on the actions agreed by the ESC, as detailed in paragraph 5.6; c) the Secretariat shall publish all PA RAST deliverables and DIP information in the RASG PA website, and d) PA RAST and Secretariat to report the results of these tasks to the RASG PA/ESC/30 meeting.

B3 CONCLUSION RASG PA/ESC/29/05 FEEDBACK ON THE IMPLEMENTATION OF GLOBAL AVIATION SAFETY PLAN GASP AND RASG PA That, in order to seek feedback from States and Industry to identify actionable gaps in the implementation of ICAO Global Plans, following a more client oriented and performance based approach by the RASG PA, the RASG PA Secretariat (NACC and SAM Regional ICAO Offices): a) conduct a survey on the level of satisfaction and the performance results provided by RASG PA; b) in consultation and agreement with the ESC Members, develop an action plan based on the survey results; and c) present the survey results and respective action plan to the RASG PA Members by 30 June 2018 and inform them to the ICAO ANC. CONCLUSION RASG PA ESC/29/6 RASG PA PREPARATION FOR PIRG RASG MEETING That, in order to organize a common position and ideas for the RASG PIRG coordination Meeting on 13 December, the PIRG RASG Preparation Ad hoc Group (Brazil, Canada, United States, IATA and ICAO (NACC and SVRSOP) prepare a paper to include RASG PA s achievements, evolution/strengths and Coordination with GREPECAS, for the RASG PA representative to present at the meeting by 7 December 2017. END