ANNUAL SAFETY REVIEW. Samhæfingarsvið - Öryggisáætlanadeild Division of Coordination and facilitation Department of Safety and Promotion

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ANNUAL SAFETY REVIEW 2015 Samhæfingarsvið - Öryggisáætlanadeild Division of Coordination and facilitation Department of Safety and Promotion

Icelandic Transport Authority: Annual Safety Review for the year 2015 The Annual Safety Review gives a statistical overview of the past year as well as trends over a longer periods. This document is a part of the State Safety Program (SSP) in Iceland. Útgefandi: Icelandic Transport Authority Ármúli 2 108 Reykjavík Sími: +354 480 6000 Netfang: icetra@icetra.is Veffang: www.icetra.is June 2016 - Icelandic Transport Authority: Division of Coordination and facilitation, Department of Safety and Promotion. Acknowledgements The author wishes to acknowledge the contribution made by the ITSB, Icelandic aviation industry, Icelandic aviation community and Icetra personnel in the preparation of this report and thanks them for their support. Disclaimer The data presented in this document is strictly for information purposes only. It is obtained from a number of different sources and, whilst every care has been taken to ensure the accuracy of the data and to avoid errors in the content, Icetra makes no warranty as to the accuracy, completeness or currency of the content.

Foreword During 2015 the Icelandic Transport Authority reorganisation continued with a new organisational chart and continuing integration in various aspects, for example now there has been created one transport section instead of three one for each of the transport modes (aviation, maritime and roads). A great increase was in every transport mode last year and more new registrations of vehicles, aircrafts and vessels than for the past years. One contributing factor is the rapidly increasing tourism in Iceland. Transport safety does not come automatically but needs continuous maintenance especially in an upswing as well as at other times. Modern management of safety matters are based on safety plans, quality systems and continual responsibility of the organisation. Continuous monitoring relies upon e.g. registration of incidents, risk assessment, education and preventive measures, as well as change, if needed, in the regulatory framework. By using risk assessment, the continuous monitoring becomes more incisive and resources are allocated where they are needed. In this way, mutual trust between authority and organisations is built and those who excel are given flexibility and others get more focus to do better. Þórólfur Árnason, CEO and Director General The CEO is the head of the Icelandic Transport Authority which manages the administration of transport affairs and conducts oversight pertaining to aviation, maritime, traffic and safety oversight of transport structures and navigation. He has three deputy directors general of Civil Aviation working along his side. Mr. Þórólfur Árnason was appointed CEO/DG on August 1 st 2014. It is a challenge to uphold a high standard in transport safety according to international requirements. Employees are expected to maintain their specialisation and that has to be done by attending courses, seminars and other means for continuing education. 3

Contents Foreword...3 Table of Figures...5 1. Global Overview...6 2. European Overview...7 3. Iceland Overview...9 4. Safety Performance Indicators... 11 4.1 Tier 1 Safety Performance Indicators... 11 5. Safety Promotion... 12

Table of Figures Figure 1 The number of accidents and fatal accidents during the 2011-2015 period...6 Figure 2 Overview fatal accidents and fatalities 2015 vs 10 year average....8 Figure 3 The total number of reported occurrences in Iceland for the past 11 years....9 Figure 4 The total number of occurrence reports reported in Iceland and total flight hours in comparison....9 Figure 5 Number of accidents and serious incidents in Iceland.... 10 Figure 6 Number of fatal accidents and fatalities for the past ten years.... 10 Figure 7 Information letter on how to avert fuel deficiency.... 12 Figure 8 Information letter on grass landings.... 13 5

1. Global Overview The ICAO s primary indicator of safety in the global air transport system is the accident rate based on scheduled commercial operations involving aircraft with an MTOW above 5700 kg. Aircraft accidents are reviewed by the ICAO SISG and categorized using the definition provided in Annex 13 to the Chicago Convention Aircraft Accident and Incident Investigation. The reduction in accident rate to 2.8 accidents per million departures, a 7% decrease compared to 2014, represents the lowest rate in recent history. Extremely notable was that the Regional Avation Safety Group - Africa (RASG- AFI) region did not have any fatal accidents in 2015 and three of the five RASG regions each experienced only a single fatal accident in 2015. The year-over-year accident statistics indicate a decrease in the overall number of accidents as well as the accident rate. Compared to 2014, the number of accidents ecreased by 5% in 2015 to 92. Furthermore, the global accident rate involving scheduled commercial operations decreased by 7%, from 3.0 accidents per million departures in 2014 to 2.8 accidents per million departures in 2015. The 474 fatalities in 2015 represent a substantial decrease from the 904 fatalities in 2014, despite the tragic events of the Germanwings and Metrojet accidents which caused significant loss of life. The number of fatal accidents decreased in 2015 to just 6, the lowest in the past five years. The annual number of accidents has been generally declining between 2011 and 2015, from 125 in 2011 to 92 in 2015. 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 co-operation in all fields of civil aviation among its 191 Member States. In all of its coordinated safety activities, ICAO strives to achieve a balance between assessed risk and the requirements of practical, achievable and effective risk mitigation strategies Figure 1 The number of accidents and fatal accidents on scheduled commercial flights during the 2011-2015 period (Source: ICAO Safety Report 2015). The 2016 Safety Report introduces accident statistics and trends. The year 2015 is analysed as well as a 7 year trends.

2. European Overview The top 5 operational domains in terms of the number of fatalities in 2015 were: CAT Aeroplanes: In 2015 the domain with the highest number of fatalities was CAT Aeroplanes. This involved a single fatal accident, which was the Germanwings accident that occurred on 24 March 2015. In 2014, there were 2 fatal accidents and there has not been more than 2 fatal accidents in CAT Aeroplanes since 2005. This operational domain is the greatest focus of EASA s safety activities and the reorganisation of the collaborative groups and advisory bodies will help the Agency to learn more about the safety challenges faced by airlines and manufacturers. Non Commercial Aeroplanes: In terms of fatal accidents, the second highest number occurred in non commercial operations with aeroplanes. This domain also had the second highest number of fatalities with 65, which is less than the 10-year annual average of 79. The General Aviation Roadmap is key to the Agency s strategy for non commercial aeroplanes and the establishment of a Collaborative Analysis Group (CAG) in this area to support the work of the current General Aviation Sub Safety Consultative Committee will help to identify the most effective safety actions. Gliders/Sailplanes: The domain of glider/sailplane operations had the 3rd highest number of fatalities with 27 and the 2nd highest number of fatal accidents, of which there were 24. Both the number of fatalities and the number of fatal accidents were slightly higher than the 10-year annual average. Aerial Work/Part SPO Aeroplanes: In 2015, there were 2 major accidents involving aerial work/part SPO operations with aeroplanes. They were an airborne collision between 2 LET-410 aircraft taking part in parachuting operations in Slovakia, which led to 7 fatalities, and the Shoreham Airshow accident in the United Kingdom where there were 11 ground fatalities. These 2 accidents led to a much higher number of fatalities compared with the 10-year annual average despite there being the same number of fatal accidents. Following the Shoreham accident, the UK CAA completed a review of public air display arrangements and produced an associated actions report. In addition, EASA is currently performing specific analysis on parachuting operations to understand more about the risks and consider how improvements can be made with experts from this domain. EASA 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 2016 provides a detailed safety analysis based on the data that were available to the Agency on the 1 st of April 2016. The full report may be accessed on the EASA website at: http://www.easa.europa.eu Non Commercial Helicopters: non commercial helicopter operations had the 5th highest number of fatalities, which was a reduction of more than 50% when compared with the 10-year annual average. 7

Figure 2 Overview fatal accidents and fatalities 2015 vs 10 year average (Source: EASA Annual Safety Review 2016).

3. Iceland Overview In 2015 the ICAA received approximately 1200 occurrence reports from the Icelandic Flight Industry, on average 100 occurrences per month. Submitted occurrence reports in 2015 decreased between years for the first time since 2010. However, the occurrence-reporting rate per 1000 flight hours has been constant for the past three years at 7 reports per 1000 flight hours, therefore this is not a decrease though the number of reports are lower between years. Figure 3 A steady growth has been in the total number of reported occurrences in Iceland for the past 11 years. Figure 4 Overview of the total number of occurrence reports reported in Iceland per year for the past eight years and total flight hours in comparison. 9

Sadly, in 2015 there were two fatal accidents, where three men lost their lives. These accidents are currently under investigation by the Icelandic Transportation Safety Board (ITSB) and reports will be issued in due course. There have been four fatal accidents in Iceland in the past ten years with eight fatalities. On figure five, accidents and serious incidents investigated by the Transport Accident Investigation Board can be seen with a moving average of 4 years. Figure 5 Number of accidents and serious incidents investigated by the Icelandic Transportation Safety Board (ITSB) and a moving average of 4 years. Figure 6 Number of fatal accidents and fatalities for the past ten years.

4. Safety Performance Indicators Safety Performance Indicators (SPIs) are grouped into three levels or tiers. The European Aviation Safety Programme describes the tiers and the reasoning behind the classification as follows: First tier SPIs refer to the number of accidents and serious incidents. This is mainly intended for the general public and describes the final result of the safety level visible to the public. The same first tier SPIs are monitored in Iceland, at EU level and globally. Second tier SPIs measure the functionality of the system and focus on certain crucial issues identified as the most common or serious accident types, including at international level, and which therefore require monitoring and safety enhancement measures. These incident types have been defined in accordance with international definitions (e.g. those of the ICAO). Third tier SPIs were developed by reflecting on the causal factors of second tier incident types. After identifying causal factors, the incident types and indicators expressing these factors were determined. By monitoring the third tier SPIs, defining the relevant safety performance targets for national operators and following up on how these targets are achieved, we seek to prevent second tier incidents. At the same time, the follow-up of third tier SPIs assists in measuring the functionality of the targets defined. Third tier SPIs may be contributing factors in more than one type of second tier incident. The titles of third tier SPIs given are followed by a reference in parentheses to the second tier SPI considered being the closest related. 4.1 Tier 1 Safety Performance Indicators Tier 1 SPI s refer to the number of accidents, serious incidents and fatalities; the prevention and reduction of these must be the most important goal of all aviation safety work. 1. Commercial Air Transport a. Accidents b. Serious Incidents One. c. Fatalities 3. Commercial Light Helicopters a. Accidents b. Serious Incidents c. Fatalities 2. Commercial Large Helicopters a. Accidents b. Serious Incidents c. Fatalities 4. General Aviation a. Accidents There were six accidents, including two fatal accidents. b. Serious Incidents Ten. c. Fatalities There were three fatalities in two accidents. 11

5. Safety Promotion To further enhance the level of safety in aviation in Iceland as part of the State Safety Program the Icleandic transport Authority has published the following information letters one regarding ways to avert fuel deficiency and another one on grass landings. See below (only in Icelandic). These information letters can be found here: https://www.samgongustofa.is/flug/oryggi-og-fraedsla/fraedsluefni Figure 7 Information letter on how to avert fuel deficiency.

Figure 8 Information letter on grass landings. 13

Department of Safety Analysis and Promotion (ICETRA) The Division of Coordination and Facilitation works on diverse projects involving aviation, maritime and road traffic. The role of the division is to ensure that transportation prosper, with emphasis on transportation safety and awareness, their efficiency and environmental issues. Within the division there are three sections: legal; transportation facilitation; safety analysis and also special projects like education and awareness in relation to safety programs and supervision of research and developments. Department of Safety analysis and promotion works on projects in aviation safety, road traffic safety, and Maritime safety. Incident and accident registration and analysis is processed within the section with statistical and analysis outputs for strategic decision processes on transportation matters. Ármúli 2 108 Reykjavík Ísland Sími +354 480 6000 Fax +354 480 6003 Netfang icetra@icetra.is Veffang www.icetra.is