annualsafetyreviewand regulation(eu) 376/2014...regulation (eu) no 376/2014 is complemented by the...

Agencija za civilno letalstvo Slovenija

Civil Aviation Agency Slovenija

Posvet na področju začetne in stalne plovnosti, 24.03.2017

Nataša Bešter, nadzornik I, CSMJerneja Šifrer, nadzornik I

Annual Safety Review andRegulation (EU) 376/2014

Agencija za civilno letalstvo RS, Kotnikova ulica 19a, 1000 Ljubljana

STATE SAFETY PROGRAMME(SSP)

ANNUAL SAFETY REVIEW

OCCURRENCE REPORTING

Content


Each State shall establish an SSP for themanagement of safety in the State, inorder to achieve an acceptable level ofsafety performance in civil aviation. TheSSP shall include the following components:

1. State safety policy and objectives;2. State safety risk management;3. State safety assurance; and4. State safety promotion.

STATE SAFETY PROGRAMME (SSP)

28.07.2016 SSP in the

Republic of Slovenia

was adopted, by the

government.

SSP is a standard not a recommended

practice.

Legal framework:

- Annex 19

- Safety Management

Manual (Doc 9859)

http://www.caa

.si/index.php?i

d=508


4

SAFETY MANAGEMENT SYSTEM (SMS)


Tier 1 SPI – data about number of accidents and seriousincidents in certain time period which provide generaloverview about trends and level of safety.Tier 2 SPI – data about number of occurrencescategorized as incidents in certain time period.Tier 3 SPI are indicators categorized according certaincategories which might represent risk for a safety butwithout outcome. These occurrences are the precursorswhich might lead to incidents in case that certain barriersfalls. Knowing that precursors we can take preventivemeasures and reduce the outcome (incident).

CAA Annual Aviation Safety Reviews

STATE SAFETY PROGRAMME – SAFETY PERFORMANCE INDICATORS

http://www.caa.si/index.php?id=508

Runway excursion

Runway incursion –

vehicle, a/c or person

AIRPROX/near miss/

mid-air collision

Controlled flight into/

towards terrain

Loss of control in flight

Ground safety(ground collision

ground handling)

Fire, smoke and fumes

GA safety

Risk, connected

with civil/military

operations

Helicopter safety

events

A/c design and

maintenance

risk

Loss of radar

detection


6

ANNUAL SAFETY REVIEW 2016

Number of occurrences in 2016

600

6 20

Number of occurrences regarding class - year2016

Incident

SeriousIncident

Accident


7


Reporters in 2016

1

1

1

1

1

1

1

2

2

2

3

3

3

4

4

5

6

6

6

6

7

7

9

16

24

87

212

269

0 50 100 150 200 250 300

Ω

Σ

Z

Y

X

W

V

U

T

S

R

Q

P

O

N

M

L

K

J

I

H

G

F

E

D

C

B

A

Number of reports regarding reporters – year 2016


8


Reporters in 2016

1

1

1

1

1

1

1

2

2

2

3

3

3

4

4

5

6

6

6

6

7

7

9

16

24

87

212

269

0 50 100 150 200 250 300

Ω

Σ

Z

Y

X

W

V

U

T

S

R

Q

P

O

N

M

L

K

J

I

H

G

F

E

D

C

B

A

Number of reports regarding reporters – year 2016 (maintenance)


Highlights – Data Overview 2016

23

312

Number of fatal, non-fatal accidents -year 2016

Aeroplane (MTOM < 2250)Ultralight planeSailplane (MTOM < 2250)Paraglider

2 fatalities

7 fatalities

1 fatality

8

2

2

Number of accidents regarding

State of licensing - year 2016

SI

No licence

PL

1 fatality

1 fatality

Paragliders

7

1

Number of accidents regarding

State of licensing - year 2016

SI

DE

4 fatalities

4 fatalities

Aeroplanes (MTOM < 2250)Ultralight planesSailplanes (MTOM < 2250)



10


2

80

1

1

1

2

2

2

1

5

6

7

7

10

12

14

17

17

23

27

28

46

58

70

77

86

1

1

2

1

0 10 20 30 40 50 60 70 80 90 100

UNK

OTHR

AMAN

FUEL

GCOL

ICE

GTOW

LOLI

RE

WILD

ARC

RI

LOC-I

MED

SCF-PP

TURB

ADRM

SEC

WSTRW

CFIT

MAC

RAMP

ATM

NAV

BIRD

SCF-NP

Number of serious incidents/incidents regarding category - year 2016

Incidents

Serious incidents

Main Areas of Concern / Safety Issues



Number of incidents /serious incidents SCF-NP

Month

– year

2016

Number

of FH

No. of

incidents

SCF-NP

No. of

incidents

SCF-NP (per

1000 FH)

JAN 2524,30 7 2,77

FEB 2742,72 8 2,92

MAR 3167,88 5 1,58

APR 3290,58 2 0,61

MAJ 3475,27 4 1,15

JUN 3923,03 10 2,55

JUL 4611,38 11 2,39

AVG 4520,20 7 1,55

SEP 4034,18 1 0,25

OKT 3791,83 5 1,32

NOV 2972,43 3 1,01

DEC 3098,03 3 0,97

AVERAGE 1,59

SD 0,84

AVERAGE + 1SD 2,43

AVERAGE + 2SD 3,27

AVERAGE + 3SD 4,11

0,00

0,50

1,00

1,50

2,00

2,50

3,00

3,50

4,00

4,50

JAN FEB MAR APR MAJ JUN JUL AVG SEP OKT NOV DEC

Number of incidents SCF-NP -

2016

AVG + 3SD

AVG + 2SD

AVG + 1SD

AVG

An alert (abnormal, unacceptable trend) is indicated if any of the conditions below are met for the current monitoring period (current year):• any single point is above the 3 SD line;• 2 consecutive points are above the 2 SD line;• 3 consecutive points are above 1 SD line.


Key Safety Actions/Initiatives 2016-2017

• Done in 2016 • Scheduled for 2017

• Adoption of national Decree on unmanned aircraft system

• Safety promotion campaign on DRONES -www.dronbonton.si

• Promotion of occurrence reporting according to Reg. 376/2014

• Operational and technical requirements for the designation of transponder mandatory zones

• ECCAIRS 5

• SSP implementation activities

• Review of SPIs in organizations under our oversight

• Promotion of occurrence reporting in the area of general aviation

• Promotion of data quality in the occurrence reports

• Safety conference for CAMO and maintenanceorganisations

• Safety workshops for examiners


OCCURRENCE REPORTING

Occurrence reporting is one of the safety tools that enablesthe management of safety for aviation organisations andStates.


• in force since May/2014,applicable since 15.11.2015

• direct applicability in the MS• complements the EU Occurrence

Reporting framework and further develops the standards for reporting, collecting, storing, protecting and disseminating the relevant safety information.

Regulation (EU) No. 376/2014 on thereporting, analysis and follow‐up of

occurrences in civil aviation

Legal framework

Its main objectives:

• to prevent accidents through

reporting, analysis and follow-

up of relevant safety

information at industry,

national and EU level

• to increase information

exchange between aviation

stakeholders by mean of the

European Central Repository

• to ensure continued

availability of safety

information by enhancing Just

Culture


15

Regulation (EU) No 376/2014 is

complemented by the Commission

Implementing Regulation (EU)

2015/1018 laying down a list

classifying occurrences in civil

aviation to be mandatorily reported.

The European Aviation Safety

Reporting Portal provides information

and guidance material on the

Regulation (EU) No 376/2014 and its

practical implementation.

http://www.aviationreporting.eu/index.

php?id=208

Legal framework


Para 1:

Occurrences which may represent a significant risk to aviation safety andwhich fall into the following categories shall be reported by the persons listedin paragraph 6 through the mandatory occurrence reporting systems pursuantto this Article:(b) occurrences related to technical conditions, maintenance andrepair of aircraft, such as:

(i) Structural defects;(ii) System malfunctions;(iii) Maintenance and repair problems;(iv) Propulsion problems (including engines, propellers and rotor systems) and auxiliary power unit

problems;

16

Regulation (EU) 376/2014

Article 4

Para 2:„Each organisation established in aMember State shall establish a mandatoryreporting system to facilitate the collectionof details of occurrences.“


Para 6:

The following natural persons shall report the occurrences referred to in paragraph 1through the system established in accordance with paragraph 2 by the organisation whichemploys, contracts or uses the services of the reporter or, failing that, through the systemestablished in accordance with paragraph 3 by the Member State of establishment of theirorganisation, or by the State which issued, validated or converted the pilot's licence, orthrough the system established in accordance with paragraph 4 by the Agency:(a)the pilot in command, or, in cases where the pilot in command is unable to report the occurrence, any

other crew member next in the chain of command of an aircraft registered in a Member State or anaircraft registered outside the Union but used by an operator for which a Member State ensuresoversight of operations or an operator established in the Union;

(b)a person engaged in designing, manufacturing, continuous airworthiness monitoring, maintaining ormodifying an aircraft, or any equipment or part thereof, under the oversight of a Member State or ofthe Agency;

(c)a person who signs an airworthiness review certificate, or a release to service in respect of an aircraftor any equipment or part thereof, under the oversight of a Member State or of the Agency;

(d)a person who performs a function which requires him or her to be authorised by a Member State as astaff member of an air traffic service provider entrusted with responsibilities related to air navigationservices or as a flight information service officer;

(e)a person who performs a function connected with the safety management of an airport to whichRegulation (EC) No 1008/2008 of the European Parliament and of the Council applies;

(f) a person who performs a function connected with the installation, modification, maintenance, repair,overhaul, flight-checking or inspection of air navigation facilities for which a Member State ensuresthe oversight;

(g)a person who performs a function connected with the ground handling of aircraft, including fuelling,loadsheet preparation, loading, de-icing and towing at an airport covered by Regulation (EC) No1008/2008.


Article 4


Key principle

The occurrences to be reported in the context of mandatoryreporting systems are those listed in Regulation 2015/1018.

18


What to report ?

Occurrences in civil aviation to be mandatorily reported – IR (EU) 2015/1018:• occurrences related to the operation of the aircraft,• occurrences related to technical conditions, maintenance and repair of

aircraft• occurrences related to air navigation services and facilities• occurrences related to aerodromes and ground services• occurrences related to aircraft other than complex motor-powered aircraft,

including sailplanes and lighter than air vehicles

Key principleIn situations where the reporter is aware about an occurrence andsuspects it is reportable but cannot determine it with certainty,he/she is expected to report it.


19



20



Key principle

Occurrence reports contained in an organisation databaseand sent to the competent authority shall comply withformat specifications that include:• the compatibility with the ECCAIRS software and the

ADREP taxonomy• the use of standardised formats• the provision of mandatory data fields.

ECCAIRS/ADREP/RISK CLASSIFICATION

How to report?

Key principleUsing tools and methods provided by the European Commission ensurescompliance with format related legal requirements.

Key principleMandatory data fields cannot be left blank when they are relevant to theoccurrence. They should always be filled with a value (Annex I).


How to report?

22

EuropeanReportingPortal

On-line reporting

Report a newoccurrence

- [email protected]

- .e5y

Update a reported

occurrence


23

When to report?


Article 15

(Reg 376/2014) - Confidentiality and appropriate use of information

Member States, the Agency and organisations shall not make available or usethe information on occurrences:(a) in order to attribute blame or liability; or(b) for any purpose other than the maintenance or improvement of aviationsafety.

Just‐Culture


Article 16

(Reg 376/2014) ‐ Protection of the information sourceWithout prejudice to applicable national criminal law, Member States shall refrain frominstituting proceedings in respect of unpremeditated or inadvertent infringements of thelaw which come to their attention only because they have been reported pursuant toArticles 4 and 5.

If disciplinary or administrative proceedings are instituted under national law,information contained in occurrence reports shall not be used against:(a) the reporters; or

(b)the persons mentioned in occurrence reports.

The protection shall not apply to any of the following situations:(a) in cases of willful misconduct;

(b)where there has been a manifest, severe and serious disregard of an obviousrisk and profound failure of professional responsibility to take such care asis evidently required in the circumstances, causing foreseeable damage to aperson or property, or which seriously compromises the level of aviationsafety.

Just‐Culture


The following classes are used:

• Accident - classification by AIB• Serious Incident ‐ classification by AIB• Incident ‐ OK !!

– Major Incident ‐ only for ANS– Significant Incident ‐ only for ANS

• Occurrence without safety effect ‐ only for ANS• Observation ‐ not for mandatory events• Occurrence with no flight intended ‐ Maintenance, production• Not determined ‐ OK!

Occurrence class


• ADRM Aerodrome• AMAN Abrupt Maneuver• ARC Abnormal runway contact• ATM ATM/CNS• BIRD Birdstrike• CABIN Cabin safety events• CFIT Controlled flight into towards terrain• CTOL Collision with obstacle(s) during take-off and landing• EVAC Evacuation• EXTL External load related occurrences• F-NI Fire/Smoke (non-impact)• F-POST Fire/Smoke (post impact)• FUEL Fuel related• ICE Icing• GCOL Ground Collision• GTOW Glider towing related events• LALT Low altitude operations• LOC-G Loss of control – ground• LOC-I Loss of control – Inflight

Occurrence categories


• LOLI Loss of lifting conditions En‐Route• MAC Airprox / ACAS alert / loss of separation / (near) midair collisions• MED Medical• NAV Navigation error• RAMP Ground handling• RE Runway excursion • RI Runway incursion – vehicle, aircraft or person• SCF-NP System component failure or malfunction [non‐powerplant]• SCF-PP Powerplant failure or malfunction• SEC Security related• TURB Turbulence encounter• UIMC Unintended flight in IMC• UNK Unknown or undetermined• USOS Undershoot/Overshoot• WILD Collision Wildlife• WSTRW Windshear or thunderstorm• OTHR Other

Occurrence categories – con‘t


THANK YOU FOR YOUR ATTENTION

Thank you for your attention!

[email protected]

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