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JAA Safety Strategy Initiative Issues in relation with the CPS study

JAA Safety Strategy Initiative Issues in relation with the CPS study. Y. Morier - JAA Regulation Director. Contents of the Presentation. The two activities in relation with CPS: The Design-related ad-hoc group The Future Aviation Safety Team Proposals for further co-operation.

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JAA Safety Strategy Initiative Issues in relation with the CPS study

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  1. JAA Safety Strategy InitiativeIssues in relation with the CPS study Y. Morier - JAA Regulation Director

  2. Contents of the Presentation • The two activities in relation with CPS: • The Design-related ad-hoc group • The Future Aviation Safety Team • Proposals for further co-operation

  3. JSSI Design Related Ad-Hoc GroupFinal Report (1) • Problem statement • Identified by UK CAA, ref CAP 681, that, although rarely identified as primary cause of accidents (2,2 % of the significant 589 accidents) design related issues were frequently mentioned among the contributing factors in accidents occurring to JAA & North American ops. • Frequency depends on chosen criteria & accident sample

  4. JSSI Design Related Ad-Hoc Group Final Report (2) • Tasks: • Check how issue has been addressed by JSAT’s (CFIT, ALAR, Loss of control, Runway incursions) and by the Harmonisation Work Programme • Validate “Design related” to remain a focus area of JSSI • Based on above, develop a scope of work for a Design related analysis team. This should include a provisional list of accidents to be reviewed • Input: • CAA Accident Investigation Group process & system • 23 accidents selected by the CAA as design related

  5. JSSI Design Related Ad-Hoc Group Final Report (3)

  6. JSSI Design Related Ad-Hoc Group Final Report (4) • General Conclusion • 20 out of the 23 accidents are or have been covered in other groups as follows: • CAST Joint Safety Analysis Teams (JSAT): CFIT, Approach & landing, Weather, Turbulence, Runway Incursion • FAA/JAA Harmonisation (HWP) • ATSRAC: Ageing Transport Systems Rulemaking Advisory Committee • PSM + ICR team

  7. JSSI Design Related Ad-Hoc Group Final Report (5) • Tire burst issue • One accident among the 23 due to tire burst • Different burst models are used in certification • CAA-UK did a study following BAC 1-11 incidents • Concorde accident • No activity under CAST of the FAA/JAA Harmonisation Work Programme • Recommendation to start an Harmonisation Activity

  8. PSM+ICR vs Loss of Control

  9. Power plant System Malfunction + Inappropriate Crew Response (1) • Every year, approximately 5 such accidents still happen • Except for items A, B and G no further action is proposed by the CAST Loss of Control Team

  10. Power plant System Malfunction + Inappropriate Crew Response (2) • Request the JSSI Steering Group for guidance how to proceed on: • more realistic simulations • turbo prop flight idle potential to Loss of Control • Human Factors and negative transfer from previous training

  11. Certification Maintenance issue (1) • AAG Ref: 95/17: MANUFACTURERS/AIRLINES - MAINTENANCE • No defined overhaul standard applicable to artificial horizons • AAG Ref: 89/20: MANUFACTURERS/AIRLINES - MAINTENANCE • Inadequate inspection procedures at engine overhaul resulted in failure to detect fatigue cracking.

  12. Certification Maintenance issue (2) • AAG Ref: 92/19: MANUFACTURERS/AIRLINES - MAINTENANCE • No inspection or functional test to verify condition/serviceability of propeller Beta Blocking Device. • AAG Ref: 95/27: MANUFACTURERS/AIRLINES - MAINTENANCE • Inadequate and ineffective inspection and repair techniques allowed fatigue crack development from multiple corrosion pits at taper bore hole

  13. Certification Maintenance issue (3) • Apart from above accidents, one member of JSSI/FAST, (from Bombardier) has raised the issue of shortfalls in the 25.1309 SSA- CMR - MRB process • These concerns have been adequately addressed in the problem statement as attached to the final report

  14. Accident pre-warnings, pre-cursors • The AEA rep in the JSSI StG suggested that there were accident pre cursors in the list of 23 accidents • The team listed following accidents with “prior warnings”: • AAG 89/07 B747 Pacific Cargo door • AAG 89/10 DC-9 Saginaw Cargo door • AAG 91/08 DC-9 Hopkins Intl Ground ice • AAG 92/02 A320 Mt St Odile CFIT • AAG 94/24 B737 Pittsburg LofC • AAG 94/34 ATR72 Roselawn LofC/Ice • AAG 97/02 EMB120 near Detroit LofC/Ice

  15. Accident pre-warnings, pre-cursors (2) • Boeing problem statement: • Several accident/incident investigations have revealed that information about a potential hazard was available to industry but not recognized.

  16. Accident pre-warnings, pre-cursors (3) • During the Nov 15, 2001 Design related team meeting 5 presentations were given to set the stage: • Airbus-Systematic incident & accident analysis • Boeing-Continued Operations Safety Process • Deep Treatment analysis (Independent Expert) • 1st Occurrence treatment experiment (Fokker) • CAA-UK Safety Intervention Program

  17. Accident pre-warnings, pre-cursors (4) • Discussion • Industry/Authority Deep Treatment (DTA) Analysis group most likely output to be a “system template” which is: • Aircraft type specific • Operator specific • Sift out the non relevant items. • Incorporate DTA into CAST enhancement 27: improve aviation safety through use of risk management and risk analysis methods

  18. Accident pre-warnings, pre-cursors (5) • Discussion (Cont’d) • The EU Commission has established ECCAIRS • based in ICAO ADREP 2000; link to BASIS in progress • database controlled by Authorities --> NEEDS AUTHORITY INITIATIVE FOR ACCIDENT PRE-CURSOR DEVELOPMENT • Direct inspections --> audits --> ECCAIRS initiative required

  19. Accident pre-warnings, pre-cursors (6) • JAA revision to JAR 21: encourage: tool development/use, safety culture

  20. Design-Related Ad-Hoc Group recommendations (1) • Accept Certification-Maintenance problem statement and develop it into Terms of Reference to review JAR/FAR 25.1529 and Appendix H for improvement: this one element of the general issue of Certification/Operations/Maintenance interfaces • That the proposed FAA/JAA harmonisation on protection from tire/wheel burst be implemented • The JSSI StG group provides direction for the remaining PSM + ICR interventions

  21. Design-Related Ad-Hoc Group recommendations (2) • The JSSI to establish a new working group with the objective “to implement an effective process for the “deep treatment of anomalies” (DTA) that would better enable prevention of accidents through systematic analysis of incidents and other service data • Discharge the ad-hoc group

  22. JSSI Steering Group Conclusions • Design RelatedFinal report was delivered on January 17 and the JSSI Steering Group agreed to the following: • 2 Terms of Reference for Harmonisation: • Tire/wheel burst • Certification/Maintenance Interface • One proposal to further investigate the concept of “Deep Treatment of Anomalies/Precursors”

  23. Future Aviation Safety Team • Why FAST ? • Complement methodology based on accidents/ incidents analysis • Future may not be a direct extrapolation of the past: Changes • Many accidents are related to situations not envisaged by the assumptions made when designing: this is in-line with CPS finding 2

  24. Proposals • The follow-up of the two issue identified by the Design-Related ad-Hoc Group: • Certification/Maintenance Interface • Deep Treatment of Anomalies/Precursors • Should be performed jointly by JAA and FAA

  25. JSSI: Abbreviations • CAST: Commercial Aviation Safety Team (US) • FSF: Flight Safety Foundation • ICAO: International Civil Aviation Organisation • AHP: Analytical Hierarchy Process • CPS: Commercial Airplane Certification Process Study • AOC: Area of Change • CRM: Crew Resources Management

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