Loss Of Control Inflight. An Approach to Enhance Safety

Loss Of Control Inflight An Approach to Enhance Safety

Loss Of Control Inflight TOP 3 HIGH-RISK OCCURRENCE CATEGORIES(TOT7) R/W SAFETY RELATED CONTROLLED FLIGHT INTO TERRAIN LOSS OF CONTROL IN-FLIGHT

Loss Of Control Inflight Rwy Safety Related 6% 62% LOCI 3% 60% CFIT 2% 13% 0% 10% 20% 30% 40% 50% 60% 70% Fatalities Accidents Observations from 2013 ICAO Safety Report 2014

Loss Of Control Inflight Rwy Safety Related 0% 54% LOCI 2% 31% CFIT 2% 5% 0% 10% 20% 30% 40% 50% 60% Fatalities Accidents Observations from 2014 ICAO Safety Report 2015

Loss Of Control Inflight Accidents % LOCI 9% Others LOCI OTHERS 2010-2014 Fatal Accidents, IATA Reports

Loss Of Control Inflight Fatality % OTHERS LOCI 49% LOCI OTHER S 2010-2014 Fatal Accidents, IATA Reports

Loss Of Control Inflight Fatality % Accidents % LOCI 9% OTHE RS LOCI 49% LO CI Others LOCI OTHERS

Loss Of Control Inflight 140 120 118 100 104 99 90 98 80 60 40 20 0 2010 2011 2012 2013 2014 Accidents ICAO Safety Report 2015

Loss Of Control Inflight LOC-I Threats: Weather ATC CREW Aircraft

Loss Of Control Inflight

Loss Of Control Inflight

Loss Of Control Inflight

Loss Of Control Inflight CREW Knowledge: Aircraft Limitations, Weather and its Avoidance Proficiency: State of the Art Simulators Nowadays can Simulate every manoeuver required such as Stall Recovery, High Pitch Angles, Steep Bank Angles, Wind Shear, Collision Avoidance. Situational Awareness: Crew should always be ahead of the Aircraft, and never be Complacent resulting from High Degree of Automation.

Loss Of Control Inflight

Loss Of Control Inflight Thank You

Developing and Implementing Regional LOC-I Safety Enhancements George Rhodes Assistant Director Infrastructure IATA MENA

Fatal Accidents by Categories 18

Accident Frequency and Survivability 19

Loss of Control Inflight Accidents 2010-2014 There were a total of 415 commercial accidents during this period: 38 of these accidents were LOC-I 37 were fatal accidents Resulted in 1,242 out of 2,541 fatalities 20

AFI ASPAC CIS EUR LATAM MENA NAM NASIA LOC-I Accidents LOC-I Accidents by Region 12 10 10 LOC-I Accidents: Region of Operators 8 7 7 6 4 2 5 3 2 4 0 26% 13% 18% 8% 18% 5% 11% 0% Source: IATA GADM 21

AFI ASPAC CIS EUR LATAM MENA NAM NASIA LOC-I Accidents LOC-I Fatal Accidents by Region 12 10 10 LOC-I Fatal Accidents: Region of Operators 8 7 7 6 4 5 4 2 2 2 0 0 Source: IATA GADM 22

Latent Conditions (deficiencies in...) Errors (related to ) Contributing Factors Flight Operations 24% Manual Handling / Flight Controls 29% Safety Management 24% SOP Adherence / SOP Crossverification Flight Ops: Training Systems 18% Intentional 16% Regulatory Oversight 18% Unintentional 11% Flight Ops: SOPs & Checking 13% Callouts 8% 26% Environmental Threats Undesired Aircraft States Meteorology 37% Vertical / Lateral / Speed Deviation 21% Icing Conditions 13% Operation Outside Aircraft Limitations Poor visibility / IMC 13% Unnecessary Weather Penetration 16% Thunderstorms 13% Unstable Approach 11% Lack of Visual Reference 11% Abrupt Aircraft Control 5% 16% Airline Threats Countermeasures Aircraft Malfunction 37% Overall Crew Performance 32% Contained Engine Failure/Powerplant Malfunction 24% Contingency Management 16% Operational Pressure 8% Captain should show leadership 11% Fire / Smoke (Cockpit/Cabin/Cargo) 5% Leadership 11% 23 Monitor / Cross-check 11%

Contributing Factors Latent Conditions 24

Contributing Factors Undesired Aircraft State 25

LOC-I Accidents in MENA 26

Percentage of Commercial Accidents Versus Total Accidents - MENA 27

LOC-I Accidents in MENA per Year 28

Contributing Factors in LOC-I: MENA Region Meteorology and Aircraft Malfunction were cited as contributing factors 29

5 W s of RASG-MID What is RASG-MID? Regional Aviation Safety Group for the MID region When & Where was it established? ICAO Council approval on 25 May 2010 to establish RASGs RASG-MID kick off on 18 19 September 2011 in Cairo, Egypt Why was is established? Develop an integrated data driven strategy, and implement a work program that supports a regional performance framework for the management of safety on the basis of the GASP Who can participate? Members: Contracting states (ICAO MID region) Observers: Non contracting states & Organizations 30

RASG-MID Contracting States MID Region 15 States Libya, Egypt, Sudan, Jordan, Syria, Lebanon, Iraq, Kuwait, Qatar, Bahrain, UAE, Oman, Saudi Arabia, Yemen, Iran 31

RASG-MID Permanent Observers 32

RASG-MID Structure ICAO Council Air Navigation Commission RASG MID RASG MID Steering Committee Annual Safety Report Team Regional Aviation Safety Team Runway & Ground Safety Working Group Safety Support Team 33

Annual Safety Report Team (ASRT) What we do Collect safety information from different stakeholders Identify & address aviation safety risks in the MID region Produce the annual safety report 1 st Edition, Nov 2012 2 nd Edition, Jan 2014 3 rd Edition, March 2015 4 th Edition, In progress Data sources: States & Organizations 34

Regional Aviation Safety Team (RAST) What we do Develop & implement SEIs and DIPs related to focus areas identified by the ASRT SEIs & DIPs include: Development of training & guidance material Holding regional workshops & seminars Go teams 35

Safety Support Team (SST) What we do Support the RASG-MID steering committee with safety initiatives not directly related to key focus areas such as: State safety program (SSP)/Safety Management Systems (SMS) implementation Establishment of Regional safety oversight organizations (RSOO) English language proficiency (ELP) etc 36

Workflow for the three teams 37

RASG-MID uses different types of safety information REACTIVE: safety analysis based on accidents and serious incidents in MID region PROACTIVE: includes analysis of existing State conditions (ICAO SARPs implementation, traffic variations), IOSA, ISAGO audit results, and STEADES data PREDICTIVE: based on analysis of Flight Operations Quality Assurance (FOQA) de-identified data, oriented towards identifying potential future hazards for initiating corresponding mitigation actions an area for improvement! 38

Safety Data Analysis Risk assessment based on: Frequency Severity (fatality) Accident Category Frequency Severity Frequency*Severity Runway/ Taxiway Excursion 1* 2 2 Ground Safety 1* 3 3 Gear up Landing / Gear Collapse 3 3 9 Hard Landing 4 3 12 Loss of Control In Flight 5 1 5 Controlled Flight Into Terrain 6 1 6 39

Top Risk Areas in the MID Region Runway Safety Loss of Control In-flight (LOC-I) System Component Failure NEW! 40

Loss of Control Inflight (LOC-I) MID- Regional Aviation Safety Team (RAST)

MID-RAST Process 1. Develop short and medium term regional safety priorities based on identified Focus Areas (FAs) 2. Develop SEIs for the identified FAs; 3. Provide recommended actions through the development of Detailed Implementation Plans (DIPs) 4. Monitor the implementation of DIPs and provide feedback to the RSC; and 5. Review DIPs with MID-RSC & RASG-MID 6. Approval of DIPs by RASG-MID 7. Implementation & Monitor progress (IATA MENA + stake holders 42

Loss of Control In-Flight (LOC-I) LOC-I/1: Airplane State awareness (ASA) -Low airspeed alerting LOC-I/2: Standard Operating Procedures effectiveness and adherence ;and LOC-I/3: ASA-Training-Flight Crew Training Verification and Validation 43

LOC-I/1 :Airplane State awareness (ASA)- Low airspeed alerting Compiled statistical data to identify the number of operators and their fleet in MID region. 1481 aircraft registered in the MID Region. Consulted with manufacturers of aircraft to determine the status of their fleet. 44

ASA MID fleet Status (1) 949 New Generation aircraft with glass cockpit having the provision of low speed alert. Represents 64% compliance rate 217 Classic western built aircraft representing 15 % of the total fleet in Mid Region 123 Regional Jets representing 8% 124 Eastern built aircraft representing 8%, mainly in Iran, Libya and Sudan 68 Turbo Prop aircraft representing 5 % 45

ASA fleet Status (2) Basic on Boeing 787, 777, 747-8, 767-400 {with the Large Format Display Systems (LFDS)} and 747-400. Optional on Boeing 737-600/700/800/900 (service bulletin available (SB 737-34A2292). No Option on Boeing 757, 727, MD-90, MD-80, 737-100/200/300/400/500 or the 767. Basic on Airbus A320 family, A330, A340, A350 and A380 Not basic on A300 & A310. 46

LOC-I/1 :Airplane State awareness (ASA)-Low airspeed alerting The ICAO ANC highlighted that the work on Low Airspeed Alerting provisions was excellent material and the ANC should consider referring this work to the AIRP for further review. 47

LOC-I/2 :SOPs effectiveness and adherence Many aviation safety organizations recently reaffirmed the importance of SOPs. identified deficiencies in SOPs as contributing causal factors in aviation accidents. commonly cited deficiencies involving flight crews non-compliance with established procedures; or the non-existence of established procedures in some manuals. Airlines should consult with manufacturers to check that SOPs are consistent with current manufacturer recommendations with regards to LOC-I and CIFT. 48

LOC-I/3 :Flight Crew Training (1) Upset prevention and recovery training, including the following: 1. Qualification of flight simulators to satisfactorily represent aircraft characteristics for proposed scenarios Coordinate with airplane and simulator manufacturers to ensure that simulators satisfactorily represent aircraft characteristics for proposed scenarios 2. Approach-to-stall training in realistic scenarios 3. Upset prevention and recovery training (UPRT) realistic scenarios 49

LOC-I/3 :Flight Crew Training (2) Approach-to-stall training in realistic scenarios. (i.e., up to the stall warning activation): approach-to-stall with the autopilot engaged (including auto-throttles disengaged, inoperative or not installed a demonstration of recognition and recovery from initial improper response to approach-to-stall. high-altitude approach-to-stall (service ceiling for the weight) low-altitude approach-to-stall (terrain critical) and recovery with ground proximity warning system (GWPS) alerts air data system failures that can lead to stall 50

LOC-I/3 :Flight Crew Training (3) Upset prevention and recovery training (UPRT) realistic scenarios including but not limited to: Upsets encountered with and without auto-flight engaged. Upsets occurring in instrument meteorological conditions (IMC) Sub-threshold roll (imperceptible roll rate) in IMC Pilot-induced upsets Air data system failures (e.g., unreliable airspeed) 51

Ref. Documentations IATA Guidance Material and Best Practices for the Implementation of Upset Prevention and Recovery Training (First edition effective June 2015) ICAO Doc.10011 Manual on Aeroplane Upset Prevention and Recovery Training Annex 6 ;ICAO AMENDMENT 38 on UPRT 52

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