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LOSS OF CONTROL STATUS REPORT

LOSS OF CONTROL STATUS REPORT. OST 05-3, 20 TH September 2005 Presented by Maria Algar Ruiz (CJAA, Technical Assistant to Operations Director). SUMMARY.  Project Presentation/Analysis methods  Accidents Groups Classification  Preliminary Conclusions  Actions Plan list.

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LOSS OF CONTROL STATUS REPORT

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  1. LOSS OF CONTROL STATUS REPORT OST 05-3, 20TH September 2005 Presented by Maria Algar Ruiz (CJAA, Technical Assistant to Operations Director) LoC Ad Hoc WG

  2. SUMMARY Project Presentation/Analysis methods Accidents Groups Classification Preliminary Conclusions Actions Plan list LoC Ad Hoc WG

  3. PROJECT PRESENTATION/ANALYSIS METHODS • Deep study of fatal accidents (1988-2004) and many incidents, potential accidents due to loss of control.Involving JAA Operators. • Group classification based on similar scenarios and look for similar events into the available data base (UK CAA MORS database) • Preliminary actions plan list coming from this study to mitigate the perceived risks. • Classification of these actions plan list into the responsible parties. LoC Ad Hoc WG

  4. FATAL ACCIDENTS LIST (1988-2004) LoC Ad Hoc WG

  5. ACCIDENTS GROUP CLASSIFICATION • Loss of control following lightning strike and/or total loss of electrical power • Loss of control following an instrument failure or malfunction (attitude/air speed indicator) • Loss of control due to cargo loading errors • Loss of control following air intake icing on turboprop aircraft engines • Loss of control due to spatial disorientation (resulting in spiral dives) • Loss of control due to the use in-flight of reverse beta range •  Others, not included in any of the above categories LoC Ad Hoc WG

  6. PRELIMINARY CONCLUSIONS (I) • Aircraft airworthiness protection against lightening strike • Pilot training for recovery from total loss of electrical power • AFM procedures including unreliable airspeed indications • Pilot training requirements for scenarios in which airspeed indications are unreliable. Is it possible to simulate unreliable airspeed indication? • Need to install an additional standby attitude indicator (artificial horizon) for aircraft with MTOM less than 5,700 kg (EQSG)? • Quality audit on the loading instruction given to the cargo dispatchers (SWSG) LoC Ad Hoc WG

  7. PRELIMINARY CONCLUSIONS (II) • Is JAR-OPS 1 robust enough to avoid loading related accidents(JAR-OPS 1.205 ‘Competences of Operations Personnel’)? • AMM recommendation for parking in icing conditions? • The ‘auto-relight’ modification. Human factors’ aspect? • SIC (CJAA Operations Division Safety Information Communications) for operators to recommend the NOTAC issued to aircrew to inspect the air intakes(coordination with EASA needed) • Training awareness programme focussed on pilots with an Eastern Europe/Russian training background • Installation of an aural ‘bank angle’ warning. LoC Ad Hoc WG

  8. PRELIMINARY CONCLUSIONS (III) • To issue an recommendation for an OD (Operational Directive) to highlight to the operators that it is not permitted to use the beta-range in-flight on turboprop aircraft. • New aircraft should be fitted with a device to prevent the use of beta range in-flight • Possible lack of training and/or awareness of the implications of allowing approach speed to fall below Vmcl on turbo-prop aircraft (especially during single-engine approaches, for example with an engine out). • Certification requirements that only requires an engine-out go-around to be performed from the approach configuration. What about one-engine out, go-around from landing configuration case? LoC Ad Hoc WG

  9. ACTION PLAN LIST (I)

  10. ACTION PLAN LIST (II)

  11. ACTION PLAN LIST (III)

  12. ACTION PLAN LIST (IV)

  13. YOUR VIEWS AND INPUTS ARE WELCOME! LoC Ad Hoc WG

  14. THANK YOU FOR YOUR ATTENTION! LoC Ad Hoc WG

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