AAIB

Air Accidents Investigation Branch

Annual Safety Review

2017
 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

© Crown Copyright 2018

All rights reserved. Copies of this publication may be reproduced for personal use, or for use
within a company or organisation, but may not otherwise be reproduced for publication.

Extracts may be published without specific permission providing that the source is duly
acknowledged, the material is reproduced accurately and it is not used in a derogatory manner
or in a misleading context.

Published 14 March 2018

Enquiries regarding the content of this publication should be addressed to:

Air Accidents Investigation Branch

Farnborough House
Berkshire Copse Road
Aldershot
Hampshire
GU11 2HH.

This document is also available in electronic (pdf) format at www.aaib.gov.uk

 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Foreword

The AAIB’s purpose is to improve aviation safety

by determining the circumstances and causes

and Contents
Foreword
of air accidents and serious incidents, and
promoting action to prevent reoccurrence. I am
pleased to introduce the AAIB’s 2017 Annual
Safety Review which includes information on
our activity and progress on the status of Safety
Recommendations that were published in 2017.

The AAIB received 708 occurrence notifications

in 2017 and deployed 38 times to conduct
field investigations, 16 of which were fatal
accidents in the UK resulting in 28 deaths. A
further 204 investigations were conducted by
correspondence. Most of the fatal accidents
involved General Aviation with the dominant
causal factors again being loss of control in
flight and weather-related issues. In this Review, analysis has been presented of 72 fatal
accidents which occurred between 2010-2015 to highlight the most common causes and
draw attention to the extensive advice that is available to help pilots avoid the circumstances
that all too often lead to accidents.

In 2017 the AAIB deployed to 7 accidents overseas, including to Norway, Ireland, Holland,
the USA, the British Virgin Islands and the Turks and Caicos Islands, and participated in
98 other international investigations as the UK’s Accredited Representative or Expert.

2017 was notable as a year in which there were no fatal accidents involving a passenger
jet airliner anywhere in the world; a very welcome statistic. However, 2 passenger airliner
accidents in February 2018 unfortunately provides a reality check that such catastrophes
are not a thing of the past, and a forceful reminder of the human cost of such tragedies.
The need to learn from accidents is as pressing as ever. But so too is the need to learn
from serious incidents (which, by definition, were nearly accidents) to establish why safety
margins were compromised and promote action to address any weaknesses in the system.

AAIB published 3 Special Bulletins in 2017, which each related to occurrences where the
outcome was much less severe than it might have been, largely due to good fortune; two of
them involved Commercial Air Transport. The AAIB is investigating these occurrences with
as much rigour as if the outcome had been catastrophic to ensure the safety issues are fully
understood and addressed.

In March 2017, the AAIB published its Final Report on the accident involving the Hawker
Hunter aircraft which crashed on to the A27 Shoreham Bypass, while performing at the
Shoreham Airshow in 2015, fatally injuring 11 road users and bystanders. A further 35 Field
Investigations were concluded in 2017, and an update on the responses to all 29 Safety

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Recommendations made in 2017 is provided in this Review. This Review also summarises
99 significant Safety Actions undertaken by manufacturers, operators and regulators,
following close engagement with AAIB inspectors.

The AAIB must continually develop its capabilities and relationships to ensure it is ready for
current and future challenges. During 2017 the AAIB completed a major review of its strategy
and established priority areas for development. One example is the further strengthening of
the Branch’s human factors investigation capability by the recruitment of a specialist into the
newly established Inspector of Air Accidents (Human Factors) discipline, and an article on
this is included in this Review. Other ongoing measures include the further development of
techniques for investigating accidents involving unmanned air systems, and preparing the
AAIB for the advent of launches into space from the UK. In 2018 our new regulations will be
laid before Parliament and we will conduct a comprehensive survey of our stakeholders to
inform the further development of our working practices and our outputs. We look forward
to your feedback.

In the meantime, there is a lot of information in this Annual Safety Review which I trust you
will find informative and useful.

Crispin Orr
Chief Inspector of Air Accidents

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Contents

Foreword..............................................................................................................................i

and Contents
Foreword
AAIB General Aviation Fatal Accident Review................................................................3
Human Factors in Accident Investigation........................................................................9
CICTT Factors on Investigations by the AAIB in 2017..................................................13
Field investigations................................................................................................... 14
Correspondence investigations................................................................................ 15
Fatal investigations.................................................................................................. 16
Statistics for 2017.............................................................................................................17
Category Definition................................................................................................... 18
Notifications 2017..................................................................................................... 19
Notifications 2016..................................................................................................... 20
Notifications 2015..................................................................................................... 21
Safety Recommendations in 2017..................................................................................23
Safety Actions from investigations reported on in 2017..............................................32
Special Bulletin......................................................................................................... 32
Field Investigations.................................................................................................. 33
Correspondence Investigations................................................................................ 41
Appendix 1 - CICITT Occurrence Categories.................................................................48

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Boeing 737-4Q8, OE-IAG

Belfast International (Aldergrove) Airport
4 October 2016

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AAIB General Aviation Fatal Accident Review

Introduction / Overview

The AAIB has conducted a review of fatal General Aviation (GA) accident reports it published
between 2010 and 2015, inclusive. The total number of accidents was 72, resulting in
105 fatalities. Of these accidents, 63 involved fixed wing aircraft and 9 rotary wing. Almost
half the accidents were attributed to loss of control in flight.

This article is intended to provide pilots with a summary of the most common causes of GA
fatal accidents in the UK, so that lessons may be learnt and actions taken to prevent similar
accidents in the future.

Summary of events

AAIB General Aviation

Fatal Accident Review
Figure 1 shows a breakdown of the dominant causal factors in these accidents:

Dominant causal factors

8%
Loss of control in flight
14%
Weather related
46% Other
16% Struck object during takeoff / landing
Mid‐air collision
16%

Figure 1

Analysis and commentary

Loss of Control

The predominant causal factor was loss of control in flight, which accounted for
almost half of the accidents. Of these, most involved the aircraft entering an
inadvertent stall and/or spin following engine failure, or during aerobatics.

The UK CAA has published a Handling Sense Leaflet to increase stall/spin

awareness:

http://publicapps.caa.co.uk/docs/33/ga_srg_09webHSL02.pdf

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Where the accident involved a complete or partial engine failure, the loss of control was often
associated with inadequate airspeed, particularly whilst manoeuvring at low level (Figure 2).
AAIB General Aviation
Fatal Accident Review

Figure 2
Cessna 150F, G-ATKF
Hinton-in-the-Hedges Airfield, Northamptonshire
4 September 2015

Pilots are taught in the PPL syllabus how to handle a complete engine failure, but
the more insidious partial engine failure is not normally covered during training.
Avoi
dabl
e Ac
Man ciden
ts
take aging pa . 3
No
off in rt
sing ial powe

Recognising this, the Australian Transport Safety Bureau has published a safety
le-en r
gine loss aft
aircr e
aft r

leaflet on managing partial power loss after takeoff in single engine aircraft:

http://www.atsb.gov.au/publications/2010/avoidable-3-ar-2010-055/
Re
AR -20 search
10- 055

Common features of the aerobatic accidents were a lack of pilot training and experience in
aerobatics and insufficient height to recover when the planned manoeuvre was
unsuccessful.

The CAA has published a Safety Sense Leaflet that contains pertinent
information to consider before engaging in aerobatics:

http://publicapps.caa.co.uk/docs/33/20130121SSL19.pdf

Weather

A significant number of the accidents reviewed in this study were weather-related. Common
themes were: collision with terrain due to flying below the minimum safe altitude (MSA) in
IMC (Figure 3) and flying in IMC without the appropriate training and qualifications. Whilst
new technology has undoubtedly made the tasks of flight planning and navigation easier,
poor weather remains a constant threat to GA pilots and should not be underestimated.
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AAIB General Aviation

Fatal Accident Review
Figure 3
Piper PA-28-140 Cherokee, G-BHXK
Near Loch Etive, Oban, Argyll and Bute
4 April 2015

The ATSB has published a safety leaflet on Visual Flight Rules pilots who enter
Instrument Meteorological Conditions: Avoi

Accid
dabl
e Ac
nts N
cide
o. 4
Instr ents in
Con ument Mvolving
ditio eteo pilots
ns rolo
gica in

http://www.atsb.gov.au/publications/2011/avoidable-4-ar-2011-050/
l

Re
AR -20 search
11- 05
0

Collision with objects during takeoff or landing

The majority of accidents in this category involved collision with power cables or
trees, often at unlicensed airfields.

Operating to such airfields can be more challenging and the CAA has published
a Safety Sense Leaflet to highlight appropriate considerations when operating
from an unlicensed or private airstrip:

http://publicapps.caa.co.uk/docs/33/20130121SSL12.pdf

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Mid-air collisions

Of the six accidents in this category, three occurred whilst in the circuit and the others in
uncontrolled airspace.

The CAA has published a safety poster that aims to remind pilots of the standard overhead
join by means of a simple pictorial representation:

http://publicapps.caa.co.uk/docs/33/ga_srgwebStandardOverheadJoinPosterJan09.pdf

The CAA has also published a Safety Sense Leaflet providing an overview of the
principles of see-and-avoid and highlighting the importance of maintaining an
effective visual scan:
AAIB General Aviation
Fatal Accident Review

http://publicapps.caa.co.uk/docs/33/20130121SSL13.pdf

Other

In this category no specific trend was identified which could help prevent future accidents.

Other resources

In addition to the links already provided, further safety information is available from the
following sources:

Refresher or further training with an instructor

Flying skills are perishable. Flying instructors can provide knowledge on specific safety
issues and valuable training to help pilots improve their skills.

CAA Publications

CAA safety information for recreational flying can be found at the following link:

https://www.caa.co.uk/General-aviation/Safety-information/Safety-information/

CAA Handling and Safety Sense Leaflets cover a wide range of topics summarising key
safety points and techniques relevant to GA pilots. Leaflets are available to download here:

http://publicapps.caa.co.uk/modalapplication.aspx?appid=11&mode=list&type=sercat&id=21

The CAA ‘Skyway Code’ provides private pilots with practical guidance on operational,
safety and regulatory issues related to their flying:

https://www.caa.co.uk/General-aviation/Safety-information/The-Skyway-Code/

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General Aviation Safety Council (GASCo) Safety Evenings

These are designed to provide an opportunity for pilots to reflect on GA safety as it affects
them and the people they fly with. The aim is to facilitate an exchange of views on how to
improve flight safety by sharing information, thoughts and ideas.

The title of GASCo’s current presentation is ‘Aware Today, Alive Tomorrow’. It addresses
maintaining situational awareness and the use of threat and error management to prevent
loss of control accidents, mid-air collisions and airspace infringements.

GASCo website : http://www.gasco.org.uk/

Safety evenings : http://www.gasco.org.uk/safety-evenings.aspx

AAIB General Aviation

Fatal Accident Review

Sud-Aviation SE-313B Alouette II, HA-PPC

Breighton Aerodrome, Yorkshire
17 July 2016

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Boeing 737-476(SF), EI-STD

East Midlands Airport
29 April 2014

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Human Factors in Accident Investigation

Introduction

As air accident investigators our job can often be as much about trying to understand the
human contribution to an accident or incident, as it is about trying to understand the technical
contribution. It can be a common misconception to think that the human involvement
lies only with those most recently involved in the moments leading up to an accident, for
example the pilot who happens to be at the controls at the time of the accident, the air
traffic controller who issued the last clearance or the
engineer or who last worked on the aircraft. However,
people in operational roles often inherit decisions,
policies and procedures that may have been made

in Accident Investigation
or implemented many years before. And they may
have to carry out complex tasks involving competing

Human Factors
priorities and variable threats in a constantly changing
work environment. It is important therefore that an
accident or incident investigation explores all of the
aspects which have the potential to influence how an
individual executes a task on any given day. Slingsby T67M Mk II Firefly, G-BNSO
Whitwell-on-the-Hill, North Yorkshire
30 April 2016
Human factors v human error

Human error, in isolation, is not an acceptable conclusion for accident investigation. Instead,
identifying the presence of human error, or human performance that was not as expected,
should be the starting point for an investigation. As investigators we need to look at all the
human interactions and organisational influences that may have contributed to an accident,
whether those be in the immediate lead-up to an accident or further back in time. When
examining these issues we have the gift of hindsight, which is not something those involved
at the time of an accident possess. It is therefore vital that rather than looking back in time,
scrutinising someone’s actions and trying to understand them based on
what we now know, we instead need to put ourselves in their shoes and
understand how the situation unfolded in their eyes - what information did
A AIB
they have available to them at the time, what threats were they managing,
Air Acc
idents
Invest
igation
Branch

how had they been trained, what condition was the equipment in? Only Annual
Safety
Review
in this way can we attempt to work out why an individual’s thoughts, 2017

actions and behaviours may have made perfect sense to them at the
time. It is only when we gain proper insight into these issues that
we can identify the areas that will deliver the most meaningful safety
improvements.

What is ‘normal’?

We must also strive to understand what ‘normal’ looks like. People may routinely employ
work-arounds and adaptations to facilitate the smooth running of an operation, however
if we only consider these in the context of the circumstances of an accident we might fail
to appreciate how such actions form a normal part of the operation and routinely deliver
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a safe outcome. Understanding how such tasks are normally executed by the
individuals involved, and by other individuals, can provide relevant context to the
investigation. And of course, it is also equally important to understand what went
right as well as what went wrong, for example, what safety features worked as Opera
tor
intended or what human interventions prevented the outcome from being even Manua
worse. l

Historically

Historically the AAIB has often relied on external human factors expertise to
support its investigations on a case-by-case basis. However, in recent years the
AAIB has been taking steps to enhance its capability in the field of investigating human
factors and human performance, including the establishment of an internal human factors
working group in 2013. Included in the working group’s activities were a review of how other
in Accident Invesigation

safety investigation agencies are resourced to investigate human performance aspects,

Human Factors

identification of suitable human factors training provision for AAIB inspectors and creation
of a database of external HF expertise in specialist areas. Inspectors come to the AAIB with
a wide range of aviation industry experience, and this includes
some with a wealth of human factors knowledge and others
with less knowledge in this area. The training identified by the
working group has served to update and refresh inspectors’
knowledge on the investigation of human factors and human
performance issues, as well as bringing the inspectorate to a
common baseline on current thinking in this field. By March
2017 all AAIB inspectors had undertaken this training and it is
a mandatory requirement for all new joiners.

Human factors today

In late 2017 the AAIB embarked upon a campaign to recruit its first dedicated in-house
human factors specialist. This involved the creation of a new investigation discipline within
the AAIB, adding to the established disciplines of operations, engineering and flight data
recording. The new Inspector of Air Accidents (Human Factors) will take up post in April
2018 and the AAIB is looking forward to integrating this new capability into our existing
investigation activities and to the new opportunities that this will bring. There will still of
course be a need for assistance from external specialist human factors expertise from time
to time to support AAIB investigations – the field of human factors is vast and it would
be impossible for any human factors practitioner to be expert in all of the many different
facets of human factors. The AAIB will therefore continue to seek external expertise as
appropriate under the direction of the Human Factors Inspector.

Accident Investigation Branch collaboration

In addition, over the last few years the AAIB has been working closely with colleagues from
the Rail and Marine Accident Investigation Branches (RAIB and MAIB) via a tri-Branch
human factors working group. While technology, procedures and operating environment
can differ greatly between the transport modes, the fundamentals of human performance
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AAIB
in a complex or safety-critical operational environment remain
the same. The cross-branch working group therefore strives
to exchange experiences, learning and expertise relevant to Air Accidents Investigation Branch

the investigation of human factors and human performance

aspects, consider ways in which human factors capability can be
developed across and within the three Branches and to explore
ways of developing the competence of inspectors to investigate
human factors aspects. The RAIB has recruited an Investigation
Support Officer who will carry out human factors research in
support of investigations across the three Branches.

Conclusion

Truly getting to grips with the human performance and organisational aspects of an air

in Accident Investigation
accident is an integral part of the AAIB’s role and the AAIB has been taking steps to enhance

Human Factors
its capability in these areas over recent years. Recruitment of a dedicated Inspector of Air
Accidents (Human Factors) is an important and defining step on this journey, and we look
forward to reporting further on our progress in this field in future Annual Reports, as we
continue to shape and develop this evolving capability.

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SZD-24-4A Foka 4, G-DBZZ

Bicester Airfield, Oxfordshire
8 August 2010

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CICTT Factors on Investigations by the AAIB in 2017

Every occurrence in the UK is recorded on the European Central Repository (ECCAIRS) and
is coded using the occurrence taxonomy defined by the CAST/ICAO Common Taxonomy
Team (CICTT). This is a worldwide standard taxonomy to permit analysis of data in support
of safety initiatives. In the UK the coding of occurrences is carried out by the CAA. It
should be noted that they are recorded as multiple factors, for example turbulence (TURB)
leading to loss of control in flight (LOC-I). Similarly, other (OTHER) is also used and may
include maintenance manual errors or human factors, aspects that do not have specific
classifications.

CICTT Factors on Investigations

L... RAMP
A...
MAC
BI...

by the AAIB in 2017


MED
91

NAV
LOC-I
50
SCF-NP
WSTR...
55

5
F-POST
FUEL
LOC-G
38
ADRM

UNK
OTHR ARC
91 67

ICE

SCF-PP
35
CFIT

GCOL
11 F-NI
TURB
11
RE CTOL
31 18

See Appendix 1 for

category descriptions


Factors for all investigations reported on by AAIB in 2017

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Field investigations

14

SCF-PP SCF-NP
4 10

F-NI
3
UNK
CICTT Factors on Investigations

RE
by the AAIB in 2017

ICE LOC-I OTHR

3
14 11

MAC

F-POST
LOC-G
2

CFIT MED
2
TURB CTOL
2 ARC 2
2
See Appendix 1 for
category descriptions


Factors for field investigations reported on by AAIB in 2017

In 2017 the AAIB reported on 38 field investigations, 16 of which were fatal accidents in
the UK and 22 were non-fatal accidents or serious incidents. The analysis of the CICTT
factors for each of these reveal that the overall major factor in fatal accidents reported on
in 2017 was LOC-I.

The 22 non-fatal field investigations that were reported on in 2017 were mostly on
serious incidents to commercial air transport (CAT) aircraft. The majority of CAT serious
incidents were attributed to other followed by system/component failure or malfunction
non powerplant (SCF-NP). However, in general aviation (GA) private flying, the statistics
show the most prolific cause of accidents and serious incidents was again LOC-I.

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Correspondence investigations

MAC BIRD
AM...


M...

80 LA...

LOC-G F-...
37
SCF-NP
45 RAMP

ICE
5 NAV
LOC-I
36 CFIT

CICTT Factors on Investigations

WSTRW

by the AAIB in 2017

OTHR ARC
80 65 UNK

SCF-PP
FUEL
31

F-NI
GCOL
11 ADRM
TURB
9
RE CTOL
30 16

See Appendix 1 for

category descriptions

Factors for correspondence investigations reported on by AAIB in 2017

Correspondence investigations are usually conducted on non-fatal accidents on GA

aircraft and to some serious incidents on CAT aircraft. The factors most predominant
in these occurrences were classified as other followed by abnormal contact with the
ground (ARC).

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eID
Fatal investigations

F-POST
2

CTOL
2
SCF-PP
3
CICTT Factors on Investigations

MED
1
by the AAIB in 2017

LOC-I OTHR
9 4
ARC
1

CFIT
1
SCF-NP
1
RE
ICE 1
1
MAC
1
See Appendix 1 for
category descriptions

Factors for fatal investigations reported on by AAIB in 2017

The predominant cause of fatal accidents in general aviation, in common with previous
years, was loss of control in flight (LOC-I). The article at the beginning of this Annual
Safety Review explores the reasons behind this in more detail.

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Statistics for 2017

An overview of what we were involved with during 2017 can be seen below:
99
Number
of Safety
Actions
noted 3
220 1 Number 35
of Special
Number of Number Number of
Bulletins
Correspondence of Formal Field Reports
published
Investigation Reports published
Reports published published

38
UK Field
Investigations
2.3 17.4 opened 8.9
Average months Average months Average months
to publication for a to publication to publication
Correspondence for a Formal for a Field
Investigation Investigation 16 Investigation
UK Fatal
Accidents

204 29
Correspondence Number of
(AARF) 28 Safety

Investigation
Investigations Number of Recommendations

Statistics
opened Deaths

52 708
Referred 0
to Sporting Total Number
of Notifications Number of
Associations Safety Studies
received by the
published
AAIB

298 1 0
No further 9 Military Joint Military
AAIB action Overseas (AAIB & Civil
(Civil) (no AAIB assistance) Aircraft
involvement)
61
44 1
Foreign
Registered UK Military
Overseas Registered (no AAIB
Overseas involvement)

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Introduction

The following pages provide the statistics for 2017, 2016 and 2015, for accidents and
serious incidents involving the Air Accidents Investigation Branch.

An explanation of the categories is as follows:

Category Definition

UK Aircraft overseas Investigations involving UK registered aircraft, or aircraft

registered in one of the UK Overseas Territories or Crown
Dependencies, occurring in a Foreign State where the
AAIB has participated in the capacity as the Accredited
Representative in accordance with ICAO Annex 13.

Foreign Aircraft overseas Accidents and serious incident investigations to Foreign

registered aircraft occurring in a Foreign State where the
AAIB has participated in the capacity as the Accredited
Representative or Expert in accordance with ICAO Annex 13.

UK Field Investigations Investigations involving the deployment of a ‘Field’ team within

the UK or to one of the UK Overseas Territories or Crown
Dependencies and those investigations where a team has
not deployed but Safety Recommendations are made. Also
includes investigations which have been delegated to the
AAIB by another State.

Military with AAIB Assistance Where an MoD Service Inquiry is convened following an
accident / serious incident to a Military aircraft and an AAIB
Investigation

Inspector is appointed to assist.

Statistics

AARF Investigations Investigations conducted by correspondence only using

an Aircraft Accident Report Form (AARF) completed by the
aircraft commander.

Overseas (no AAIB) Notifications to the AAIB of an overseas event which has no
AAIB involvement.

Referrals to Sporting Investigations referred to the relevant UK Sporting Associations.

Associations

No further AAIB action (Civil) Occurrences notified to the AAIB involving civil registered
aircraft which do not satisfy the criteria of an accident or
serious incident in accordance with the Regulations.

Military (no AAIB inv) Notifications to the AAIB concerning Military aircraft with no
AAIB involvement.

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Notifications 2017

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
UK Registered
5 4 3 4 5 4 6 2 5 4 2 0 44
Overseas
Foreign Reg
3 3 4 9 6 7 8 4 5 2 3 7 61
Overseas
UK Field
2 3 4 2 6 3 2 4 5 1 2 4 38
Investigations
Military (AAIB
0 0 0 0 0 1 0 0 0 0 0 0 1
Assistance)
Correspondence
9 7 15 15 36 29 24 25 17 11 10 6 204
Investigations (AARF)
Overseas (no AAIB
2 1 0 1 0 0 1 1 1 1 0 1 9
involvement)
Referred to the
appropriate Aviation 4 2 1 5 9 9 4 9 3 2 2 2 52
Sporting Association
No further AAIB
15 19 24 22 22 29 33 27 32 34 18 23 298
action (civil)
Military (no AAIB
0 1 0 0 0 0 0 0 0 0 0 0 1
involvement)
Total 40 40 51 58 84 82 78 72 69 55 37 43 708

UK Fatal accidents 1 0 1 1 3 2 1 1 3 0 1 2 16

Number of deaths 1 0 5 1 4 2 2 2 4 0 4 3 28

Investigation
Statistics
Non‐reportable (Military) UK Registered Overseas Foreign Reg Overseas
0% 6% 9%
UK Field Investigation
Non‐reportable (Civil) 6%
42%
Military (AAIB assist)
0%

Correspondence Investigation
(AARF)
29%

Referred to the appropriate Aviation

Sporting Association Overseas (no AAIB involvement)
7% 1%

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Notifications 2016

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
UK Registered
5 3 5 6 6 4 6 4 2 4 3 2 50
Overseas
Foreign Reg
1 5 4 7 4 9 3 5 18 8 6 4 74
Overseas
UK Field
3 2 2 2 1 3 8 3 3 4 2 5 38
Investigations
Military (AAIB
0 0 0 0 0 0 0 1 0 0 0 0 1
Assistance)
Correspondence
9 15 10 16 19 25 27 31 22 16 8 10 208
Investigations (AARF)
Overseas (no AAIB
1 2 1 1 0 0 0 0 0 2 0 0 7
involvement)
Referred to the
appropriate Aviation 1 2 3 4 4 3 5 9 8 4 0 1 44
Sporting Association
No further AAIB
18 12 19 20 22 27 29 23 21 11 15 14 231
action (civil)
Military (no AAIB
0 0 0 1 0 0 0 1 0 0 0 1 3
involvement)
Total 38 41 44 57 56 71 78 77 74 49 34 37 656

UK Fatal accidents 0 0 1 1 1 1 4 1 1 2 0 2 14

Number of deaths 0 0 1 2 2 2 4 1 2 2 0 2 18
Investigation
Statistics

Non‐reportable (Military) UK Registered Overseas

0% 8% Foreign Reg Overseas
11%
Non‐reportable (Civil)
35%
UK Field Investigation
6%

Military (AAIB assist)

0%

Referred to the appropriate Aviation

Sporting Association Correspondence Investigation
7% (AARF)
32%
Overseas (no AAIB involvement)
1%

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Notifications 2015

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
UK Registered
4 1 0 1 6 4 10 4 4 1 1 3 39
Overseas
Foreign Reg
5 2 4 3 5 4 8 6 4 3 4 3 51
Overseas
UK Field
3 1 1 5 1 5 5 4 2 3 3 1 32
Investigations
Military (AAIB
1 0 0 0 0 0 0 0 0 1 0 0 2
Assistance)
Correspondence
11 7 12 24 16 29 24 20 27 12 7 5 194
Investigations (AARF)
Overseas (no AAIB
1 3 0 0 1 0 0 1 1 1 0 0 8
involvement)
Referred to the
appropriate Aviation 0 5 2 1 7 3 11 11 8 2 0 0 50
Sporting Association
No further AAIB
24 15 15 24 15 13 21 15 26 16 17 13 214
action (civil)
Military (no AAIB
0 0 1 0 0 2 0 0 1 2 0 0 6
involvement)
Total 49 34 35 58 51 58 79 61 73 41 32 25 596

UK Fatal accidents 1 0 0 3 1 3 2 3 1 2 1 1 18

Number of deaths 2 0 0 4 2 3 6 13 1 3 4 1 39

Investigation
Statistics
Non‐reportable (Military) UK Registered Overseas
1% 7% Foreign Reg Overseas
9%
Non‐reportable (Civil)
36% UK Field Investigation
5%

Military (AAIB assist)

0%

Referred to the appropriate

Aviation Sporting Association
8%
Correspondence Investigation
Overseas (no AAIB
(AARF)
involvement)
33%
1%

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

AAIB Inspector at accident site of Boeing 737-500, VQ-BBN

Kazan International Airport, Kazan, Russia
17 November 2013

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 AAIB
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Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Recommendations in 2017

In 2017 the AAIB issued 29 Safety Recommendations from 8 investigations.

160

150
140 146
139

120 128

114
109 109
100
103
98
95 95
80
82 82
76 76
68 69
60 66
58 58 57 57
55
40 47
42
38 40 39 39 37 39
32 32
28 29
20 26 26
23
17 19 20 17
13 9 10
0
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Each Safety Recommendation is classified using the SR Topic taxonomy defined by the
European Network of Safety Investigation Authorities (ENCASIA) Working Group 6 (WG6)
which the AAIB is a member. The majority of the Safety Recommendations were dealing
with safety issues relating to aircraft operations and safety risk management.

Each addressee to a Safety Recommendation has to respond within 90 days in accordance

with European Regulation EU 996/2010 Article 18 and detail what actions have been taken
or are under consideration and the time taken for their completion. If no actions are being
considered by the addressee they have to provide their reasoning for the decision.

On receipt the AAIB has 60 days in which to assess the response and to inform the addressee
on whether it is adequate. If the reply is not adequate or partially adequate then to provide
justification to the addressee. and Safety Action Overview

The responsibility to monitor the progress of action taken in response to a recommendation

Safety Recommednation

lies with the addressee including the authorities responsible for civil aviation safety.

The AAIB will keep open Safety Recommendations where it expects to receive responses
from the addressee. If no further response is expected the recommendation is closed. A
closed status does not necessarily mean the actions for a Safety Recommendation are
complete, nor that the Safety Issue has been addressed.

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 AAIB
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Safety Recommendation Topics Topics

Safety Recommendation
0 5 10 15 20 25
0 5 10 15 20 25
Procedures / Regulations - Aircraft operations 22

Personnel - Training / proficiency / check 7

Aircraft / Equipment / Facilities - Aircraft equipment - Aircraft systems 6

QMS/SMS/SSP - Safety assurance 4

Aircraft / Equipment / Facilities - Aircraft equipment - Powerplant 3

Aircraft / Equipment / Facilities - Aircraft equipment - Safety equipment 3

Personnel - Medical / Human Factors 3

QMS/SMS/SSP - Safety risk management 3

Procedures / Regulations - Aircraft maintenance/inspection 3

QMS/SMS/SSP - Safety policy and objectives 2

Procedures / Regulations - Oversight/Auditing 2

Personnel - Other 1

Procedures / Regulations - Aircraft dispatch 1

Aircraft / Equipment / Facilities - Aircraft equipment 1

Procedures / Regulations - Aircraft certification 1

Procedures / Regulations - Design/Production/Manufacturing 1

Procedures / Regulations - Rescue Fire Fighting Services 1

Procedures / Regulations - Search and Rescue 1

QMS/SMS/SSP - Safety promotion 1

The chart above shows the recommendation topics. It should be noted that a recommendation
can encompass several topics within the classification system.

A ‘Not adequate’ assessment means that the response does not address the intent of
the Safety Recommendation nor does it address the safety issue concerned.
A ‘Partially adequate’ assessment means the response goes someway to meeting the
intent of the Safety Recommendation and the action will address the safety issue to a
certain extent, but further action would be required to fully address the issue identified.
An ‘Adequate’ assessment means that the response fully meets the intent of the Safety
Recommendation and the action is expected to address the safety issue.

Of the 29 Safety Recommendations issued in 2017, as of the end of February 2018,

responses have been received for 21. In assessing the responses, 15 were adequate and
closed, 5 were partially adequate and 1 was not adequate. Following the assessment,
16 Safety Recommendations from 2017 were closed, 11 remain open. The AAIB is awaiting
and Safety Action Overview

responses from addressees for 5 of the open Safety Recommendations. Responses have
Safety Recommendation

recently been received for two Recommendations and are pending AAIB classification.

Each Safety Recommendation is also defined as to whether it is a Safety Recommendation

of European Union Wide Relevance (SRUR) or a Safety Recommendation of Global
Concern (SRGC). Of those issued in 2017, 6 were SRUR and 3 were SRGC.

The AAIB, as well as all EU Member States, is required to record on the European Central
Repository Safety Recommendation Information System (SRIS) all recommendations it
raises and the response that are received. Data from SRIS is available to view publically at:
http://eccairsportal.jrc.ec.europa.eu/index.php?id=114&no_cache=1
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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Recommendations issued in 2017

Notes: Safety Recommendation classification correct at time of publication.

Safety Recommendations can also be made through AAIB Special Bulletins and
are then also reflected in the final report.
Reflects the situation with Safety Recommendatations at 28 February 2018.

Safety Recommendation 2017-001 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority amend CAP 403 to clarify the point at
which an aerobatic manoeuvre is considered to have been entered and the minimum height
at which any part of it may be flown.

Adequate - Closed

Safety Recommendation 2017-002 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority require

pilots intending to conduct aerobatics at flying displays to
be trained in performing relevant escape manoeuvres and
require that their knowledge and ability to perform such
manoeuvres should be assessed as part of the display
authorisation process.

Adequate - Closed

Safety Recommendation 2017-003 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority review the grouping of aircraft types in
display authorisations to account for handling and performance differences it considers
significant. and Safety Action Overview
Adequate - Closed
Safety Recommednation

Safety Recommendation 2017-004 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority remind operators, whose activities are
subject to the guidance published in Civil Aviation Publication 632, of the need to maintain
detailed training records for pilots and check their compliance during inspections it carries
out.

Adequate - Closed

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Recommendation 2017-005 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority specify that the flight demonstration
requirement of a display authorisation evaluation, other than to assess formation following,
cannot be satisfied by the pilot following another aircraft during the evaluation.

Adequate - Closed

Safety Recommendation 2017-006 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority undertake a study of error paths that
lead to flying display accidents and integrate its findings into the human factors training it
requires the holders of display authorisations to undertake.

Response Received - pending AAIB classification

Safety Recommendation 2017-007 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority

review the arrangements for safety regulation and
oversight of intermediate and complex ex-military
aircraft operated in accordance with Civil Aviation
Publication 632, to ensure that they are consistent
and appropriate.

Partially Adequate - Open

Safety Recommendation 2017-008 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority consider implementing the changes
outlined in Health and Safety Laboratory report MSU/2016/13 ‘Review of the risk assessment
and Safety Action Overview

sections of CAP 403’.

Safety Recommendation

Adequate - Closed

Safety Recommendation 2017-009 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority require operators of aircraft used for
flying displays to identify, and where practicable remove, any hazardous materials.

Adequate - Closed

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Recommendation 2017-010 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Civil Aviation Authority prohibit the use of phenolic asbestos
drop tanks on civil registered aircraft.

Partially Adequate - Open

Safety Recommendation 2017-011 made on 24 February 2017

G-BXFI Hawker Hunter T7 on 22 August 2015

It is recommended that the Department for Transport commission, and report the findings
of, an independent review of the governance of flying display activity in the United Kingdom,
to determine the form of governance that will achieve the level of safety it requires.

Partially Adequate - Open

Safety Recommendation 2017-012 made on 2 June 2017

G-KAXT Westland Wasp HAS1 on 23 September 2016

It is recommended that, for ex-military aircraft on the UK civil register, the Civil Aviation
Authority requires maintenance and overhaul tasks to be reviewed in the light of the
expected aircraft utilisation and calendar-based time limits introduced where appropriate.
Where such calendar-based time limits already exist, these should be reviewed to ensure
that they are appropriate for the aircraft utilisation.

Adequate - Closed

Safety Recommendation 2017-013 made on 7 September 2017

G-BDZC Reims Cessna F150M on 17 October 2016

It is recommended that the Civil Aviation Authority

promulgates to flying instructors the need for
specific training to highlight the differences Flap selector
between the C150 and C152 flap switch designs. switch

Training should also include the effect on aircraft

and Safety Action Overview
Safety Recommednation

performance and handling of Flap 40°.

Adequate - Closed

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 AAIB
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Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Recommendation 2017-014 made on 8 September 2017

G-PRPC DHC-8-402 on 14 December 2016

It is recommended that Flybe Ltd introduces defined

and consistently delivered flight crew training on
pre‑departure inspections for the DHC-8-402 (Q400),
compliant with the inspection procedure documented
in its Operations Manual. This should include a
practical element on the aircraft and a demonstration
of correctly secured main engine access panels.

Adequate - Closed

Safety Recommendation 2017-015 made on 8 September 2017

G-PRPC DHC-8-402 on 14 December 2016

It is recommended that Flybe Ltd considers introducing a means of disseminating pertinent

safety information to ground operations staff in an appropriate format.

Adequate - Closed

Safety Recommendation 2017-016 made on 20 September 2017

C-FWGH Boeing 737-86J on 21 July 2017

It is recommended that the Federal Aviation

Administration, mandate the use of Flight
Management Computer software revision U12.0,
or later revision incorporating the outside air
temperature crosscheck, for operators of Boeing 737
Next Generation aircraft.

Partially Adequate - Open 1

2

Safety Recommendation 2017-017 made on 20 September 2017

C-FWGH Boeing 737-86J on 21 July 2017
and Safety Action Overview
Safety Recommendation

It is recommended that The Boeing Company promulgates to all 737 operators the
information contained within this Special Bulletin and reminds them of previous similar
occurrences reported in the Boeing 737 Flight Crew Operations Manual Bulletin dated
December 2014.

Response Received - pending AAIB classification

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 AAIB
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Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Recommendation 2017-018 made on 25 September 2017

G-GSGS Glasflugel 304 ES on 10 August 2017

It is recommended that the European Aviation Safety Agency

(EASA) requires that all powered sailplanes, operating under
either an EASA Restricted Type Certificate, or an EASA
Permit to Fly, and fitted with a Front Electric Sustainer (FES)
system, are equipped with a warning system to alert the pilot
to the presence of a fire or other hazardous condition in the
FES battery compartment.

Adequate - Closed

Safety Recommendation 2017-019 made on 25 September 2017

G-GSGS Glasflugel 304 ES on 10 August 2017

It is recommended that Alisport Srl modifies the Silent 2 Electro microlight to incorporate a
warning system to alert the pilot to the presence of a fire or other hazardous condition in the
Front Electric Sustainer (FES) battery compartment.

Adequate - Closed

Safety Recommendation 2017-020 made on 25 September 2017

G-GSGS Glasflugel 304 ES on 10 August 2017

It is recommended that Albastar d.o.o. modifies the AS13.5m Front Electric Sustainer (FES)
microlight to incorporate a warning system to alert the pilot to the presence of a fire or other
hazardous condition in the FES battery compartment.

Partially Adequate - Open

Safety Recommendation 2017-021 made on 9 November 2017

G-YAKB YAK-52 on 8 July 2016

The Civil Aviation Authority should review

the maintenance requirements for seat belts
and Safety Action Overview
Safety Recommednation

and harnesses, and, if necessary, revise the

maintenance requirements to ensure that seat
belts and harnesses remain in a condition
with an acceptable residual strength.

Adequate - Closed

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 AAIB
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Safety Recommendation 2017-022 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the Federal Aviation Administration mandate Service Bulletin

GTCP331-49-7936 to add a system that shuts down the APU automatically if there is
contamination of the lubricating oil.

Response Awaited – Open

Safety Recommendation 2017-023 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the European Aviation

Safety Agency mandate Service Bulletin
GTCP331-49-7936 to add a system that
shuts down the APU automatically if there is
contamination of the lubricating oil.

Not Adequate - Open

Safety Recommendation 2017-024 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the Federal Aviation Administration regulate the operation of

interphone handsets, including during emergency communications, so that it is standardised
irrespective of aircraft type.

Response Awaited - Open

Safety Recommendation 2017-025 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the European Aviation Safety Agency regulate the operation of
interphone handsets, including during emergency communications, so that it is standardised
irrespective of aircraft type.
and Safety Action Overview

Partially Adequate - Closed

Safety Recommendation

Safety Recommendation 2017-026 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the Federal Aviation Administration reconsider the requirements for
briefings given to passengers seated at exits, to ensure they offer appropriate guidance on
exiting the aircraft rapidly in an emergency without implying undue responsibility for opening
the exits.

Response Awaited - Open

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 AAIB
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Safety Recommendation 2017-027 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the Federal Aviation

Administration require cabin crew on aircraft that are
parked, and with passengers on-board who are neither
boarding nor deplaning, to be evenly distributed
throughout the cabin and in the vicinity of floor-level
exits in order to provide the most effective assistance
in the event of an emergency.

Response Awaited - Open

Safety Recommendation 2017-028 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the European Aviation Safety Agency require cabin crew on aircraft
that are parked and with passengers on-board to be evenly distributed throughout the cabin
and in the vicinity of floor-level exits, in order to provide the most effective assistance in the
event of an emergency.

Adequate - Closed

Safety Recommendation 2017-029 made on 7 December 2017

N276AY Airbus A330-323 on 26 June 2016

It is recommended that the Federal Aviation Administration require that flight and cabin crew
participate in joint training to enhance their co-ordination when dealing with emergencies.

Response Awaited - Open

and Safety Action Overview

Safety Recommednation

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

Safety Actions from investigations reported on in 2017

Early in an investigation the AAIB will engage with authorities and organisations which
are directly involved and have the ability to act upon any identified safety issues. The
intention is to prevent recurrence and to that end to encourage proactive action whilst the
investigation is ongoing and not for those involved to wait for the issue of official Safety
Recommendations.

When safety action is taken, it may mean there is no need to raise a Safety Recommendation
as the safety issue may have been addressed. However, if the issue remains then a Safety
Recommendation will be raised. The published report details the safety issues and the
safety action that has taken place, usually with a green highlight. In 2017 safety actions
directly as a result of AAIB investigations were recorded on two formal investigations,
eighteen field investigations and seventeen correspondence investigations.

SPECIAL BULLETIN

Sikorsky S-92A, G-WNSR on 28 December 2016

Safety issue – HUMS procedures, component failure, airworthiness

The operator

The operator has subsequently introduced a number of measures to further strengthen

the ability to detect impending bearing degradation. These include: a review of all HUMS
data to ensure no anomalies, fleet-wide borescope inspections, a requirement for HUMS
to be serviceable before flight and the time between HUMS download/analysis reduced
to a maximum of 5 hours. The operator has also reviewed their HUMS processes and
analytical procedures and introduced a requirement to carry out an additional assurance
check.

The helicopter manufacturer

On 31 December 2016, the helicopter manufacturer

issued to all operators an ‘All Operators Letter’ (AOL),
CCS-92-AOL-16-0019, which described the event.
It emphasises the use of the HUMS Tail Gearbox
and Safety Action Overview
Safety Recommendation

Bearing Energy Tool, provided on the ground station,

which will detect a TRPCS bearing that is experiencing
degradation, and recommends that this Tool should be
utilised as often as reasonably possible.

This was followed by an Alert Service Bulletin (ASB)

issued by the manufacturer on 10 January 2017. ASB 92-64-011 introduces a one-
time inspection of the TRPCS and bearing assembly for ratcheting, binding, or rough
turning. The manufacturer has recommended that compliance is essential and is to be
accomplished prior to the next flight from a maintenance facility; three flight hours are

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 AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

allowed in order to return directly to a maintenance facility. Concurrent with the release
of ASB 92-64-011, the manufacturer published Temporary Revision 45-03 to require
operators to use S-92 HUMS ground station software to review Tail Rotor Gearbox
energy analysis Condition Indicators for alert conditions on a reduced flight hour interval.
Records in excess of published alert levels require inspection of the pitch change shaft
and bearing.

FIELD INVESTIGATIONS

Hawker Sea Fury T Mk 20, G-RNHF on 31 July 2014

Safety issue – Historic aircraft airworthiness and maintenance

Various marks of the Centaurus engine are still in use in a small number of aircraft but
findings in this case could equally apply to other radial and inline aero-engine types. Based
on this, the CAA has undertaken to publish a Safety Notice aimed at the historic aircraft
community, to draw attention to the issues and difficulties of maintaining airworthiness of
aging aircraft engines and their associated components.

Saab 2000, G-LGNR on 6 November 2015

Safety issue – checklist unintended result, reduced control

The manufacturer stated that it intended to add the following to the ‘Aileron system open
failure’ section of the malfunction checklist at the next AOM revision: “NOTE: Verify an
open failure by visually observing that one of the ailerons do not follow control wheel input.”

ATR 72-212 A, G-COBO on 4 March 2016

Safety issue – effects of icing, pre-flight inspection and training

The ATO responsible for the pilot’s type conversion training is adjusting its conversion
course to align with the EASA Operational Suitability Data report. This is being achieved
by incorporating the manufacturer’s simulator profile for a badly de-iced tailplane.

The operator has enhanced its winter awareness training for pilots by purchasing a
and Safety Action Overview

computer-based training module. All pilots will complete this before each winter season
Safety Recommednation

and their knowledge will be tested as part of the process.

The operator’s conversion courses are being

extended through the inclusion of a ground training
day, with a training captain, prior to the start of Line
Flying Under Supervision. This is to ensure time is
spent discussing, in detail, technical issues relating to
line operations. Winter operations and de-icing/anti-
icing will be among the topics covered.

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 AAIB
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The operator provided the co-pilot with additional training before he was allowed to
resume line flying duties.

The operator is reviewing its requirements for aircraft inspections following use of
thickened de-icing fluids.

The operator intends to provide better guidance for the aftermath of a serious incident
by making changes to its Operations Manual (Part A). This is likely to include a
recommendation for a group debrief to take place as a matter of course, so the crew can
discuss what happened and what they have learnt.

The manufacturer has stated it will contact all operators prior to the start of the next
European winter, to promote awareness of the circumstances which led to this serious
incident.

Airbus A319-111, G-EZFJ on 14 April 2016

Safety issue – EFB software anomaly, potential cockpit display confusion

●● The operator sent an email to all pilots on 22 April 2016 highlighting this specific
anomaly.

●● The MRC function was disabled across the operator’s fleet in May 2016.

●● The operator has reviewed and proposed further modification to their SOPs.

●● In the L6.x versions of FlySmart, it has been verified by the manufacturer that the
MRC function is not affected by this anomaly.

●● The manufacturer has sent Flysmart Runway

‘CONDITIONS’ selection area
Communication reference X46D16018565 entry area

to operators highlighting the anomaly

discovered during this investigation and
recommending that the affected operators Dropdown box for
single runway
selection
disable the MRC option.

●● The manufacturer sent Flight Operations

Transmission (FOT) 999.0095/16 to
all operators reminding them of the
and Safety Action Overview
Safety Recommendation

manufacturer’s recommended procedures for EFB use. This involves each crew
member performing their own independent calculations, the results of which are
then cross-checked.

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 AAIB
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Rans S6-ESD (Modified) Coyote II, G-MYES on 30 May 2016

Safety issue – Low speed handling, pilot information and airfield markings

As a result of the rate of stall/spin accidents involving Rans S6 aircraft in the UK, the LAA
has undertaken to conduct a safety review encompassing the following aspects:

●● ‘Complete a review of accident data with the type to date, including consideration
of the aircraft configuration, weights and cg positions, mission and pilot profiles of
those involved, including a comparison with the accident data for similar types of
microlight

●● Carry out a flight test program on at least two representative examples, to

investigate possible handling, performance or other factors that might contribute to
an elevated accident rate, including:

• Longitudinal stability
• Ability to trim (in pitch)
• Longitudinal and lateral/directional trim changes with changes in power and
configuration (i.e. flap position)
• Directional stability and control, including contributing effects of adverse yaw
with aileron input, and any contributing ergonomic aspects
• Pre-stall warning
• Stall characteristics
• Ease of operation of controls
Throttle valve
(not visible)
• Adequacy of low-speed stall recovery/
Mounting

climb performance at different weights and bracket

centre of gravity positions Throttle valve

actuation

• Behaviour in a simulated engine failure Throttle cable

(note 90o bend)

• Instrumentation, in particular, adequacy of

indication of airspeed and slip’

The LAA has advised that the applicable paragraphs of BCAR Section S, both current
and extant at the time the type was introduced to the UK, are being used as the basis
for this evaluation. The results of the safety review will be communicated to all Rans S6
and Safety Action Overview

pilots within the LAA membership

Safety Recommednation

The LAA has also undertaken to produce a series of pilot’s notes for the Rans S6, tailored
to each airframe/engine combination on the UK fleet, on completion of the flight tests.
The relevant Rans S6 TADS will be updated accordingly.

Flying club

Recognising the possibility of future confusion, the flying club at Shifnal Airfield reported
that it had removed the landing T and signal square, to prevent incorrect signals being
displayed.

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Airbus A330-323, N276AY on 26 June 2016

Safety issue – Emergency evacuation procedures, master minimum equipment list

(MMEL) guidance and component maintenance policy

Operator

All pilots were informed that an evacuation should only be halted by the
commander if he ‘has clear information that continuation of the evacuation would
cause greater injury’.

Studies of the interphone equipment on different

aircraft types confirmed a need to refine the
communication process on certain types. On the
Airbus A319, A320, A321 or A330-300, FAs should
now press the emer call button once to contact the
flight deck in an emergency. On the Airbus A330‑200
they should press the prio capt button and on the
Embraer E190 the emer pilot button.

A video was produced with the co-operation of the

crew involved in this occurrence, to highlight the issues they experienced. This
video is being used as an educational tool for all pilots during their recurrent Human
Factors (HF) training, for the nine month cycle commencing 1 February 2017. It
may also become possible to use this video during FA training.

A type-specific ’Emergency Deplaning’ drill has been developed for use by pilots on
each of the operator’s aircraft types and incorporated into the OM and the appropriate
QRH. This drill is relevant to parked aircraft that are using a jetbridge or steps.
Details were promulgated to all crews and pilots received relevant simulator training.

As there is no commonality between the cabin interphone handsets on different

aircraft types, a physical training aid is being developed for use during initial and
recurrent FA training. This is intended to give FAs a better understanding of the
differences they will encounter and to help them adapt to any of the 14 aircraft
types or variants on which they can be qualified.
and Safety Action Overview
Safety Recommendation

Recurrent HF training for the aircraft operator’s 12,000 pilots takes place on a 9
month cycle. The 27,000 FAs are on a 12 month cycle. This makes it difficult to
conduct joint evacuation training with entire crews, so the operator is considering
having pilot representatives participate in FA training and vice-versa. Future
recurrent training for both pilots and FAs will focus on unplanned cabin evacuations
when the aircraft is not on the runway.

The Continuing Qualification training given to all FAs between April 2017 and
March 2018 includes a review of an ‘Emergency Deplaning’ and it is likely attendees
will hear the specific aural alert signals for each aircraft type.

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The operator expects a company safety investigator to contact the commander

by telephone as soon as its ‘Dispatch’ department has been advised of a serious
incident or accident. The safety investigator is now required to remind the
commander during this contact that action be taken to ensure the circuit breaker
for the CVR is pulled without delay.

Training procedures were developed for the aircraft operator’s ramp personnel, to
ensure they know how best to react if a slide evacuation occurs while an aircraft
is parked.

Twice a year, US operators, along with some foreign airlines that operate to the US,
share experiences at a safety forum. The operator intends to discuss issues raised by
this event at such a forum; to raise the industry’s awareness of the challenges that can
be created by a cabin evacuation from a parked aircraft.

Aircraft manufacturer

The aircraft manufacturer has reviewed and amended the MMEL section 24-23-01,
for the dispatch of an aircraft with APU AC auxiliary generation unserviceable and a
summary of these changes is as follows:

MMEL item 24-23-01A ‘APU not used’:

No change, as not relevant to the event.

MMEL item 24-23-01B ‘Electrical failure’:

To insure a more robust detection of a

mechanical failure, a review has been
conducted with the APU Generator supplier
and the following 4 failure messages
will be added to the list from the AMM
task 24‑23‑00‑040-803.

GEN APU (8XS)

GEN APU (8XS) EX FLD / GAPCU (40XG)
GAPCU (40XG) EX FLD / GEN APU (8XS)
and Safety Action Overview

GEN APU (8XS) EX FLD / GAPCU (40XG)

Safety Recommednation

If any of these messages is present in the PFR when doing the interactive APU
test, then the MMEL 24-23-01C must be applied.

MMEL item 24-23-01C ‘AC auxiliary generation deactivated or removed

(mechanical failure)’:

An update of the related AMM tasks (e.g. 24-23-00-040-801 and -802) has been
decided, to prevent oil cross-contamination from the APU Gen to the APU. The
AMM TASK 49-91-41-210-802-A “Check of the APU Oil System for APU Generator

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Debris” has been added at the end of those tasks, and must be carried out prior to
aircraft dispatch. This AMM task includes a physical check of the APU oil system
(inlet screens of the scavenge-oil, inspection of the magnetic chip detectors and
the mechanical differential pressure indicator, check of the lubrication oil supply
and generator scavenge filters).

Yak-52, G-YAKB on 8 July 2016

Safety issue – Smaller (less than 400 hp) historic engines overhaul policy

The CAA have stated that they are conducting a review of engine maintenance to
determine if Leaflet 70-80 should be extended to all piston engines and whether any
Alternative Means (Methods) of Compliance arising from Leaflet 70-80 should be made
mandatory by means of a Mandatory Permit Directive (MPD). This will also include a
review of Generic Requirement No. 24 in CAP 747.

Druine D.31 Turbulent, G-ARNZ on 14 August 2016

Safety issue – Aircraft system design

The operators of the aircraft developed a modification to fit a

Landing gear description

screen to the engine’s carburettor intake, withThethe landingintention ofMk IX is operated by two hydraulic actuators, one for each
gear of the Spitfire
landing gear. In both the extended and retracted position each landing gear is held in position
preventing the ingress of similar debris to the balloon fragment.
by a spring-actuated chamfered locking pin which engages in either the down-lock lug or the
up-lock lug on each landing gear.
Should this screen become blocked, air can still be supplied
Extension of the landing gear requires the pilot to move the selector lever out of its detent.
to the carburettor via the alternative hot air Thissupply,
energises thethereby
hydraulic system and actuator, removing the load from the locking pin, it
also rotates the locking pin 180 . Movement of the selector lever to the
o
detent retracts
allowing the engine to operate normally. After the landingsatisfactory
DOWN
gear actuator, moving the landing gear past the chamfer of the landing gear
locking pin. While the landing gear is in motion appears in the landing gear status
testing, the modification was approved by the windowLight Aircraft
DOWN
on the landing gear selector. When each landing gear is fully extended the increase

Association. in hydraulic system pressure operates a pressure switch which causes to be displayed
in the landing gear status window. In addition, when the landing gear locking pin has engaged
IDLE

in the down-lock lug of the landing gear, the indication circuit for that landing gear is
completed.

Spitfire IXT, G-LFIX on 15 September 2016 Landing gear position indication

The Spitfire Mk IX is fitted with a landing gear position indicator on the left side of the

Safety issue – Cockpit indicator visibility instrument panel. The indicator consists of two black, back-illuminated panels. When the
bulbs behind the panels light up the word UP is displayed in the upper panel and the word
DOWN in the lower panel, Figure 2.

In order to prevent the illumination of the

complete word “DOWN” in the landing gear
position indicator in the event that one landing
gear has not achieved the fully locked position,
and Safety Action Overview
Safety Recommendation

the maintenance organisation modified the

landing gear indicator to prevent light from
either of the indicator bulbs illuminating the
complete down caption. Indicator panel windows Bulb positions (panel cover removed)

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Westland Wasp HAS1, G-KAXT on 23 September 2016

Safety issue – Continued airworthiness of historic aircraft and servicing policy

The investigation findings were highlighted to the CAA at

an early stage. The CAA took urgent action to ensure the
continued airworthiness of Westland Wasp and Scout
helicopters on the UK register by issuing Emergency
Mandatory Permit Directive (EMPD) No 2017‑002‑E.
(http://publicapps.caa.co.uk/modalapplication.
aspx?appid=11&mode=detail&id=7759)

The EMPD requires operators to perform a visual check

of the condition of the universal joint and conduct periodic
lubrication of the joint.

Airbus A319-131, G-EUPM on 19 October 2016

Safety issue – CVR/FDR data preservation

Following this event, the operator of G-EUPM made changes to its procedures to ensure
that the commander is aware of his responsibility to ensure that the recordings are
preserved.

Airbus A320-214, G-EZWX on 28 November 2016

Safety issue - Component malfunction, OEM information and crew awareness

●● By 9 December 2016, the operator of G-EZWX had removed all affected static
inverters from its fleet and those that were held as spares.

●● The operator’s engineering department is now reviewing all

TFUs on a routine basis.

Further safety action

●● The aircraft manufacturer has advised that, later in 2017, it will

release an Inspection Service Bulletin (ISB) to assist operators
and Safety Action Overview

in identifying and rectifying any of the affected static inverters.

Safety Recommednation

●● The aircraft manufacturer has also advised that it will provide

additional information to operators on the operation of the
emergency interphone system.

●● The operator has advised that, following the provision of the additional information
of the emergency interphone system from the aircraft manufacturer, it will include
this as part of crew training and update the appropriate internal manuals.

●● The operator has also advised that it intends to conduct a review of its processes
that relate to VSBs.
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ATR 72-212 A, 500 Version, G-COBO on 21 December 2016

Safety issue – Operating procedures, crew response

Operator

The operator reviewed its ATR procedures and amended them to improve safeguards
against similar occurrences. Flight crews were reminded of the required response to
APM cautions, and the operator now replicates this incident, and APM messages, during
pilots’ flight simulator training. Several internal recommendations were made, addressing
non-normal situation handling in general.

The following FLYING STAFF INSTRUCTION – ATR was issued on 28 December 2016,
with an amendment to the ATR Operations Manual Part B, Section 2.4:

‘2.4.16.2 Climb Speed

Standard Climb Speed is 170 kt IAS or Red Bug + 10 kt, whichever is the higher,
achieved using AFCS [Automatic Flight Control System] IAS mode.

Climb speed may only be reduced below 170 knots if required for terrain clearance
or mandatory ATC requirements. Under these circumstances the minimum IAS is
White Bug + 10 kt in Normal Conditions and Red Bug + 10 kt in Icing Conditions.
…
If during climb at Standard Climb Speed the average rate of climb falls below 500
feet per minute, crews should request to stop climb at the next available level
or advise ATC of the reduced climb capability. Speed must not be reduced to
maintain a given rate of climb.’

The following memo was sent to all ATR pilots:

‘APM / Reduced Performance

Crews are also reminded that Severe Icing may be encountered without the
presence of the normally associated visual cues, and reduced rate of climb or
cruise airspeed are sometimes the only indication of significant ice accretion.
Whenever crews encounter or suspect severe icing, the full checklist at QRH page
and Safety Action Overview

1.09 [Severe Icing] must be completed.

Safety Recommendation

Aircraft manufacturer

The aircraft manufacturer stated that it is working

to improve the APM to avoid the illumination of
cautions that are perceived as spurious.

As a result of this occurrence and that investigated

by the AIBN the manufacturer has amended the
DEGRADED PERF and SEVERE ICING procedures.

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The amended DEGRADED PERF procedure will state that the SEVERE ICING
procedure should be actioned if the aircraft is unable to maintain a climb rate greater
than 100 ft/min, when climbing at red bug +10 kt. The SEVERE ICING procedure will
have fewer memory items and will state that, after IAS and engine power are increased
and the autopilot is disconnected, a descent is to be initiated to escape the severe icing
conditions.

The amendments, in the appropriate documents, are due to be distributed to all operators
in January 2018.

The manufacturer of this aircraft, together with other aircraft manufacturers, has
contributed to the update of the Airplane Upset Prevention and Recovery Training
Aid (AUPRTA), Revision 3, which is available on ICAO website. This update includes
information specific to turboprop aircraft.

Boeing 737-36E Freighter, TF-BBF on 3 February 2017

Safety issue - Component failure

The operator is replacing the V-band clamps at the failure

location on TF-BBF across its fleet of 737-300 and 737-400
aircraft. This is being carried out on a rolling programme,
as the aircraft undergo scheduled C-check maintenance
inspections. The operator is also considering replacement
of other V-band clamps on their aircraft where the release of
bleed air may create a hazard.

Europa, G-NDOL on 28 May 2017

Safety issue – Modification standard, system integrity

On 19 July 2017, the LAA issued Airworthiness Information Leaflet LAA/MOD/247/010.

This required a mandatory inspection, before next flight, of all Europa aircraft operating
under an LAA administered Permit to Fly. The inspection was to check for the correct
installation of a fuel vapour return line. Details can be found on the LAA website.
and Safety Action Overview
Safety Recommednation

CORRESPONDENCE INVESTIGATIONS

Robinson R44 II, G-SAIG and Spitfire IXT, G-CCCA on 15 June 2016

Safety issue – airfield movements deconfliction

After the accident, the Aerodrome Safety Manager issued a safety notice to the
helicopter operator based at the airfield, requiring helicopters to hold short of the
active runway and request clearance to cross. The A/G radio operator will then
inform the helicopter pilot of any known traffic and the pilot, having checked it is
safe to do so, may then cross the runway.
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Europa XS, G-BYSA on 10 August 2016

Safety issue – Airfield information

The airfield operator has informed the publishers of

various flight guides that the runway width is now 10 m
and requested that they include a warning to ‘Beware
cliffs on the east side of the airfield’.

The Light Aircraft Association included this accident in

their October 2016 ‘Safety Spot’ feature to advise their
members of the circumstances.

Flight Design CTSW, G-CGVG on 8 October 2016

Safety issue – Airworthiness and NDT servicing policy

In response to this accident the UK agent

intends to issue Service Bulletin CT145,
which requires removal and dye penetrant
crack inspection of the main landing gear legs
of all CT2K and CTSW aircraft at intervals of
300 flying hours. Service Bulletin CT145 will
supersede SB CT123. Service Bulletin CT145
will also introduce modification M309, in which
the edges of the main attachment hole in the
legs are peened, leaving residual compression
stress at the hole edges intended to supress fatigue crack initiation. Service Bulletin
CT145 continues to include the requirement to inspect the legs for cracks and straightness
following heavy landing events.

Eurofox 912(LS), G-ODGC on 15 October 2016

Safety issue – Component fatigue, lifing policy and airworthiness

As a result of the incident and discussions with the LAA, on 1 November 2016 the aircraft
manufacturer issued Mandatory Service Bulletin, EuroFOX SB 03/2016 LAA (v2). This
and Safety Action Overview
Safety Recommendation

required the replacement of the landing gear mounting bolts within 20 flying hours of
the release date of the Bulletin and introduced a 500 flying-hour mandatory life on the
bolts. On 4 November 2016, the LAA published Airworthiness Alert LAA/AWA/16/07
which detailed the failure and alerted operators of the aircraft to the requirements of the
Mandatory Service Bulletin. The incident was also publicised in the LAA’s November 2016
Safety Sense article.

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UAS Schiebel Camcopter S-100 (unregistered) on 18 October 2016

Safety issue – Human factors, workload and control logic

The manufacturer has implemented a software change to reduce operator workload

during takeoff. If the UA is on the ground and the trim mode has been selected:

●● Operator thumb rocker climb-rate inputs between -50% and +50% produce an
automatic climb rate command of +50% until the trim becomes active, and

●● All cyclic joystick inputs are ignored until the trim becomes active.

Dassault Falcon 7X, VQ-BSO on 24 November 2016

Safety issue – Aircraft ground handling and observation

London City Airport identified the following safety actions:

1. The parking positions for the Falcon 7X should be identified and the position of
their main and nose wheels marked on the apron surface.
2. All the Jet Centre’s marshallers should receive refresher training on the correct
ICAO marshalling signals.
3. Marshalling wands must be used for all
manoeuvring not just at night or in reduced
visibility.
4. Initially, marshallers and ‘wing walkers’ would
be equipped with belt mounted horns to
provide an audio STOP signal. This would
subsequently be replaced providing digital
radios on a dedicated frequency.
5. A new supervisory level appointment would be
created to oversee all parking.’

Robin DR400/180 Regent, G-ETIV on 7 December 2016 and Safety Action Overview
Safety issue – CRM, spatial awareness and airfield knowledge
Safety Recommednation

Following an investigation, a safety action was

taken at the airfield to ensure pilots are told the
runway in use when they call on the radio prior
to arrival.

In May 2017, the CAA published CAP 1535,

‘The Skyway Code’ which is intended to
provide General Aviation pilots involved in
non‑commercial and flight training operations

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with practical guidance on the operational, safety and regulatory issues relevant to
their flying. ‘The Skyway Code’ includes a section on the responsibilities of the Pilot
in Command in a format which is intended to be more accessible than from regulatory
documents.

To further clarify the term ‘Safety Pilot’ when used with an ‘Operational Safety Pilot
Limitation (OSL)’ placed on a Medical Certificate, the CAA will produce an article for
‘Clued Up’, its magazine for the general aviation community. Additionally, the CAA will
also ask the General Aviation Safety Council (GASCO) to publish the same article in its
Flight Safety Bulletin.

DHC-8-402, Dash 8, G-FLBB on 8 December 2016

Safety issue – Component history and reliability

The operator has expressed concerns over the reliability of the outflow valve and has
initiated a reliability investigation involving the spare part provider and the OEM. At the
time of writing the results of the reliability investigation are not known.

Piper PA-28-181 Cherokee Archer II, G-BPAY on 29 December 2016

Safety issue – Ground movements, parking and observation

Since the accident the airfield operator has changed its procedures to reduce the need
for parallel rows of parked aircraft and therefore lessen the risk of ground collisions.

Agusta AW139, G-VINB on 20 January 2017

Safety issue – Flight planning and CRM

The operator carried out a prompt internal investigation into the incident and identified a
number of potential safety actions. The following are of relevance to this report:

Carry out a Flight Planning Software review for The remaining sectors were completed without incident.

robustness and ease of use.

Carry out a review of the destination nomenclatures

and Safety Action Overview

used for planning applications and software.

Safety Recommendation

Reiterate to all crews the importance of clear and

unambiguous communications.

Reiterate to crews the importance of re-briefing all

aspects of the flight when a significant change has been applied.’

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Bell 206B Jet Ranger III, G-BTHY on 19 February 2017

Safety issue – Air space use and NOTAM requirements

The operator has advised its pilots of the potential hazard of high flying kites and the
need to avoid areas where they suspect the activity is taking place.

The CAA has been advised of the activity and an investigation is being conducted. The
incident has also been reviewed by the CAA Safety Risk Panel.

Airbus A320-214, G-EZTV on 3 March 2017

Safety issue – Aircraft ground handling procedures and equipment knowledge

There have been several safety actions made by three organisations as a result of this
accident. These are outlined below.

The ground handling company has instigated several changes to its procedures
and to personnel training, including:

Improvements to towbar maintenance

and inspection procedures.

A training aid has been developed to

help ground crew recognise when
shear pins are unserviceable.

A standard fault-finding procedure

has been introduced for ground crews
when they hear an unusual sound or
suspect a shear pin has broken while
pushing or pulling an aircraft.

Improvements have been made to ground crew training to ensure that correct
procedures for aircraft engine start are followed for each stand at Manchester.

The airfield operator has issued safety alerts to airfield users regarding inspections
and maintenance of pushback equipment and regarding stand-specific pushback
and Safety Action Overview
Safety Recommednation

procedures.

The aircraft operator has reviewed its pushback procedures in response to the
aircraft manufacturer’s comments.

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Airbus A320-214, G-EZTM on 26 March 2017

Safety issue – Aircraft ground movements and support procedures

The operator’s engineering department is reviewing the AMM task (324200710001-A

Rev.55) and will make recommendations to the aircraft manufacturer to amend the AMM
accordingly.

The ground handling company has undertaken the following actions to prevent a
recurrence:

1. Raised awareness of the event;

2. Retrained the staff involved concerning the correct chocking procedures;

3. The defective equipment local operating procedure has been re-issued to all
staff to prevent inoperative equipment being available for use.

Agusta A109S Grand, G-PBWR on 5 May 2017

Safety issue – Airworthiness, left horizontal stabiliser failure

Prompted by this event, the manufacturer issued a Service

Bulletin providing new instructions for a one-time inspection
and new repetitive inspections at a reduced inspection
threshold and interval. As a result of this and its own safety
assessment, EASA issued Emergency Airworthiness
Directive AD 2017-0085-E, on 12 May 2017, to mandate
these instructions.

Reims Cessna F406 Caravan II, G-RVLX on 1 June 2017

Safety issue – Hatch and door security, crew aircraft knowledge

The operator is taking the following safety actions:

An email was sent to all crew to notify them of the event and to highlight correct
and Safety Action Overview
Safety Recommendation

door operation and security

A fleet check of aircraft fitted with a similar door was carried out to ensure that both
primary and secondary locks operated correctly.

Placarding of the secondary handle will be improved to clearly identify when it is

the locked position.

A strap will be fitted to the emergency exit main handle to minimise the likelihood
of it being inadvertently disturbed.

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Cessna 510 Citation Mustang, OE-FHK on 15 June 2017

Safety issue – Aircraft system knowledge

The aircraft operator has taken the following Safety Actions;

A ‘Safety Bulletin’ to flight crew was circulated

which stated that the parking brake is only to be
set with the battery switch in the batt position
and that the appropriate checklists are always
to be followed. This notice also warns crew not
to remove chocks if there are obstacles such as
a fuel bowser nearby and states that trainee pilots are always to be accompanied
by an experienced crew member while operating the aircraft.

The SOPs were modified and additional guidance on operation of the parking
brake and the use of wheel chocks was placed in the OM.

Pilot training was revised to try to ensure a comprehensive understanding of the

hydraulic system and the aircraft brakes.

Quest Q-200 UAS on 12 July 2017

Safety issue - Commercial UAV operating procedures

The operator has made the following procedural changes to minimise the probability of
collisions with high obstacles on this and other construction sites:

Construction site staff will be contacted, prior

to launch, to check the height of the highest
structure to ensure that sufficient clearance
can be met. If this cannot be achieved that
part of the site will not be overflown.

Any flights that have the potential to overfly

the construction site will be flown at 400 ft. and Safety Action Overview
Manual corrective action will be taken to manoeuvre the UA in the event of
Safety Recommednation

deviations from the flight plan.

AW109SP Grand New, G-HLCM on 2 August 2017

Safety issue - Rotor blade integrity and airworthiness

The manufacturer identified the main rotor blades that were potentially affected and
issued Service Bulletin 109SP-116 to introduce a periodic inspection.

The EASA issued Emergency Airworthiness Directive 2017-0176-E to mandate the

requirements of the Service Bulletin.
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Appendix 1 - CICITT Occurrence Categories

CODE DESCRIPTION
ARC ABNORMAL RUNWAY CONTACT
AMAN ABRUPT MANEUVER
ADRM AERODROME
MAC AIRPROX/TCAS ALERT/LOSS OF SEPARATION/NEAR MIDAIR
COLLISIONS/MIDAIR COLLISIONS
ATM ATM/CNS
BIRD BIRD
CABIN CABIN SAFETY EVENTS
CTOL COLLISION WITH OBSTACLE(S) DURING TAKEOFF AND LANDING
CFIT CONTROLLED FLIGHT INTO OR TOWARD TERRAIN
EVAC EVACUATION
EXTL EXTERNAL LOAD RELATED OCCURRENCES
F–NI FIRE/SMOKE (NON-IMPACT)
F–POST FIRE/SMOKE (POST-IMPACT)
FUEL FUEL RELATED
GTOW GLIDER TOWING RELATED EVENTS
GCOL GROUND COLLISION
RAMP GROUND HANDLING
ICE ICING
LOC–G LOSS OF CONTROL–GROUND
LOC–I LOSS OF CONTROL–INFLIGHT
LOLI LOSS OF LIFTING CONDITIONS EN ROUTE
LALT LOW ALTITUDE OPERATIONS
MED MEDICAL
NAV NAVIGATION ERRORS
OTHR OTHER
RE RUNWAY EXCURSION
RI RUNWAY INCURSION
SEC SECURITY RELATED
SCF–NP SYSTEM/COMPONENT FAILURE OR MALFUNCTION (NON-POWERPLANT)
SCF–PP SYSTEM/COMPONENT FAILURE OR MALFUNCTION (POWERPLANT)
TURB TURBULENCE ENCOUNTER
USOS UNDERSHOOT/OVERSHOOT
UIMC UNINTENDED FLIGHT IN IMC
UNK UNKNOWN OR UNDETERMINED
WILD WILDLIFE
WSTRW WIND SHEAR OR THUNDERSTORM

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 AAIB
Air Accidents Investigation Branch
AAIB
Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch
Annual Safety Review 2017 Air Accidents Investigation Branch

GLOSSARY OF ABBREVIATIONS
© Crown Copyright 2018 aal above airfield level lb pound(s)
ACAS Airborne Collision Avoidance System LP low pressure
ACARS Automatic Communications And Reporting System LAA Light Aircraft Association
ADF Automatic Direction Finding equipment LDA Landing Distance Available
AFIS(O) Aerodrome Flight Information Service (Officer) LPC Licence Proficiency Check
agl above ground level m metre(s)
All rights reserved. Copies of this publication may be reproduced for personal use, or for use AIC Aeronautical Information Circular MDA Minimum Descent Altitude
within a company or organisation, but may not otherwise be reproduced for publication. amsl above mean sea level METAR a timed aerodrome meteorological report
AOM Aerodrome Operating Minima min minutes
APU Auxiliary Power Unit mm millimetre(s)
Extracts may be published without specific permission providing that the source is duly ASI airspeed indicator mph miles per hour
acknowledged, the material is reproduced accurately and it is not used in a derogatory manner ATC(C)(O) Air Traffic Control (Centre)( Officer) MTWA Maximum Total Weight Authorised
or in a misleading context. ATIS Automatic Terminal Information Service N Newtons
ATPL Airline Transport Pilot’s Licence NR Main rotor rotation speed (rotorcraft)
BMAA British Microlight Aircraft Association Ng Gas generator rotation speed (rotorcraft)
BGA British Gliding Association N1 engine fan or LP compressor speed
BBAC British Balloon and Airship Club NDB Non-Directional radio Beacon
BHPA British Hang Gliding & Paragliding Association nm nautical mile(s)
Published 14 March 2018
CAA Civil Aviation Authority NOTAM Notice to Airmen
CAVOK Ceiling And Visibility OK (for VFR flight) OAT Outside Air Temperature
CAS calibrated airspeed OPC Operator Proficiency Check
cc cubic centimetres PAPI Precision Approach Path Indicator
CG Centre of Gravity PF Pilot Flying
cm centimetre(s) PIC Pilot in Command
CPL Commercial Pilot’s Licence PNF Pilot Not Flying
°C,F,M,T Celsius, Fahrenheit, magnetic, true POH Pilot’s Operating Handbook
CVR Cockpit Voice Recorder PPL Private Pilot’s Licence
DME Distance Measuring Equipment psi pounds per square inch
EAS equivalent airspeed QFE altimeter pressure setting to indicate height
EASA European Aviation Safety Agency above aerodrome
ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate
EGPWS Enhanced GPWS elevation amsl
EGT Exhaust Gas Temperature RA Resolution Advisory
EICAS Engine Indication and Crew Alerting System RFFS Rescue and Fire Fighting Service
EPR Engine Pressure Ratio rpm revolutions per minute
ETA Estimated Time of Arrival RTF radiotelephony
ETD Estimated Time of Departure RVR Runway Visual Range
FAA Federal Aviation Administration (USA) SAR Search and Rescue
FDR Flight Data Recorder SB Service Bulletin
FIR Flight Information Region SSR Secondary Surveillance Radar
FL Flight Level TA Traffic Advisory
ft feet TAF Terminal Aerodrome Forecast
ft/min feet per minute TAS true airspeed
g acceleration due to Earth’s gravity TAWS Terrain Awareness and Warning System
GPS Global Positioning System TCAS Traffic Collision Avoidance System
GPWS Ground Proximity Warning System TGT Turbine Gas Temperature
Enquiries regarding the content of this publication should be addressed to: hrs hours (clock time as in 1200 hrs) TODA Takeoff Distance Available
HP high pressure UAS Unmanned Aircraft System
Air Accidents Investigation Branch hPa hectopascal (equivalent unit to mb) UHF Ultra High Frequency
Farnborough House IAS indicated airspeed USG US gallons
Berkshire Copse Road IFR Instrument Flight Rules UTC Co-ordinated Universal Time (GMT)
ILS Instrument Landing System V Volt(s)
Aldershot IMC Instrument Meteorological Conditions V1 Takeoff decision speed
Hampshire IP Intermediate Pressure V2 Takeoff safety speed
GU11 2HH. IR Instrument Rating VR Rotation speed
ISA International Standard Atmosphere VREF Reference airspeed (approach)
kg kilogram(s) VNE Never Exceed airspeed
KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator
KIAS knots indicated airspeed VFR Visual Flight Rules
KTAS knots true airspeed VHF Very High Frequency
This document is also available in electronic (pdf) format at www.aaib.gov.uk km kilometre(s) VMC Visual Meteorological Conditions
kt knot(s) VOR VHF Omnidirectional radio Range
 AAIB
Air Accidents Investigation Branch

Annual Safety Review

2017

Air Accidents Investigation Branch

Annual Safety Review
2017