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Experiencia Europeia
Safety AnalysisSafety AnalysisJohn Vincent,
Head – Safety Analysis and Research,Executive Directorate
EASA
19 MarchHotel Windsor Guanabara
EASA in Cologne,Germany since 2004
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•• Independent legal statusIndependent legal status•• Operational since 28 September 2003Operational since 28 September 2003•• Offices in Cologne since 1st November 2004Offices in Cologne since 1st November 2004
FIN
IS
EE
LV
LT
UK
IR
DK
NO SE
RU
EASA Member States
EU 27 + 4
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MD
CY
FR
BE
NL
DE
UK
RO
AL
MK
BG
EL
CH
IT
AHU
SB
EP
PL
CZ
MT
BA
L
SK
SICR
MC
Why a European Agency?
Uniform and legally binding rules
Common safety standards
Type certificates valid across Europe
A strong independent authority
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A strong independent authority
First extension of scope adopted
Second extension – opinion issued
EASA Remit
Based on the Basic Regulation (EC) No 216/2008
Safety regulator, certification authority & advisory body
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advisory body
Mission: to set & maintain the highest common safety & environmental standards
Method: part of the EU system with the EC and in partnership with the NAAs
EASA Remit
The new Basic Regulation
Airworthiness amendments
Pilot Licensing
Operations
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Operations
Third country operators
Oversight and enforcement
Fines
Ultimately:
Aerodromes, ATM and ANS
Main tasks
Rulemaking
Standardisation inspections
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Standardisation inspections
Type-certification & organisation
approvals
Safety Analysis
Structure
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E2 Department – 2009
Head – Safety Analysis & Research
Administrator + 1 (CA)
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Safety
Analysis
Manager
Accident
Investigation
Manager
Research
Project
Manager
4 (TA) + 1 (SNE)
4 + 1 (SNE)
Safety Team
Coordinator
+1 (TA)
Human
Factors
Expert
4Q 2009
Safety Risks Expert
2Q 2009
1 (TA)
2009-2013
Vision, Values, Mission
Strategic Priorities
Staff Policy Plan
Business Plan (MB 03/2008)
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Business Plan (MB 03/2008)
E2 Posts
22 posts by end of 2013
Planning for 2010-2014 underway
Key Performance Indicators
Safety Analysis
Safety Analysis: Conducts studies and provides reports concerning the safety of European and world-wide aviation
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wide aviation
Annual Safety Review
Developing safety policy
Building dependable repositories
Supporting a reporting with JRC
ESSIHistorical development of worldwide safety1945 - 2007
3,0
3,5
4,0
4,5
5,0
Passenger fatalities per 100 million passenger miles,
scheduled public transport operations, excluding acts of
unlawful interference
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0,0
0,5
1,0
1,5
2,0
2,5
1945
1947
1949
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
passenger fatalities rate 5 per. Mov. Avg. (passenger fatalities rate)
1968: 0.5After 1997: < 0.05
ESSIHistorical development of worldwide safety1988 - 2007
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17
21
16
1416
1719
15
20
25
Rate of accidents involving passenger fatalities per 10 000 000 flights, scheduled operations, aeroplanes, excluding acts of
unlawful interference
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7 7
5
3
10
13131416
4
6
8
10
4
0
5
10
15
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
fatal accident rate 5 per. Mov. Avg. (fatal accident rate)
ASR 2007
This document is published by EASA to inform the public of the general safety level in the field of civil aviation. The Agency provides this review on an annual
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Agency provides this review on an annual basis as required by Article 15(4) of Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 February 2008.http://www.easa.europa.eu/ws_prod/g/g_sir_review.php
2008 - preview
Fatal accidents - airline cargo/passenger operations, fixed wing
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4645
33
37
35
40
45
50
15
20
16
14
16
11
25
16
10
13
15
26
22
2627
29
0
5
10
15
20
25
30
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
cargo operations passenger operations Linear (passenger operations) Linear (cargo operations)
2008 - previewCumulative number of fatalities by week
airline ops, fixed wing - week 47 2008
800
1000
1200
Kenya Airways
Douala
114
Tam
Sao Paulo
199
One-Two-
GO
Phuket
90
Atlasjet
Isparta
57
16
0
200
400
600
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
average 1998-2007 2008 2007
Adam Air
en-route
102
114
Santa Barbara Airlines
Llano de Hato - 46
Hewa Bora, Goma
48
Spanair
Madrid
153
Aeroflot-Nord
Perm
88
2008 - preview
Fatal accident - Air Transport ops
jet powered a/c over 5 700 kg
2008
AIRBUS
INDUSTRIESMCDONNELL-
17
INDUSTRIES
15%
BOEING
38%BRITISH
AEROSPACE
8%
ILYUSHIN
8%
LEARJET
8%
MCDONNELL-
DOUGLAS
23%
General Aviation Fatal Accidents in Europe
Number of Fatal accidentsAerial Work
(A+H) 1,5%
GA >2250kg
4,9%
Commercial
2,8%
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GA <2250kg
90,8%
Commercial Aerial Work (A+H) GA >2250kg GA <2250kg
Fatalities Commercial
25,7%
GA >2250kg
5,7%
Aerial Work
(A+H) 1,5%
GA <2250kg
67,1%
Commercial Aerial Work (A+H) GA >2250kg GA <2250kg
Common Taxonomy
http://www.intlaviationstandards.org/
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Accident categories
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Measuring risk
Number of:
•Incidents
•Fatal accidents
•Fatalities
•Hull losses
PER
A. Period of time
B. Amount of aviation
activity:
Number of:
•Fatal accidents per year
•Passenger fatalities per
year
Examples
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activity:
B1. Number of
movements
•Aircraft
•Passengers
B2. Aggregated time or
distance flown:
•Aircraft
•Passengers
Number of fatal accidents
per:
•105 aircraft departures
•107 passenger journeys
Number of:
•Fatal accidents per 107
aircraft flying hours
•Fatalities per 108 passenger
km
•Incidents per 108 aircraft km
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Global Aviation Safety Roadmap
ICAO GASRM - 2006Frame of reference for stakeholders, including States, regulators, airline operators, airports, aircraft manufacturers,
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airports, aircraft manufacturers, pilot associations, safety organisations and air traffic service providers
To improve coordination and sharing
To minimise duplication
ESSI The European Strategic Safety Initiative
10 year programme (2006-2016)
aimed at improving aviation safety
in Europe, and for the European
citizen worldwide
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Partnership, with more than 150
organisations
Powered by industry and facilitated
by EASA
www.easa.europa.eu/essi
ECAST EHEST EGAST
COORDINATION GROUP
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ECASTCOMMERCIAL
AVIATION SAFETY TEAM
EHESTHELICOPTER SAFETY
TEAM
EGASTGENERAL AVIATIONSAFETY TEAM
International Partners
International Partners
WORKING GROUPS
WORKING GROUPS International
Partners
WORKING GROUPS
ECAST SMS WGTerms of Reference
Review reference SMS/Safety Culture materials, and ongoing initiatives
Identify best practices and examples of organisation for safety mgt
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of organisation for safety mgt
Compile / provide guidance materials on Safety Risk Management
Hazard identification
Risk assessment and analysis
Risk mitigation and control
Draft EASA RequirementsFor Safety Management
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Organisation Requirements (NPA 22-2008) will provide legal grounds for Safety Management
‘Golden Rules’
1. Full Safety Accountability at the Top
2. Supported by independent Safety Support Functionwith full authority from the Top
3. Individuals within the Safety Support Function
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3. Individuals within the Safety Support Function should have respect and influence
4. Formal communications from the Top to the Safety Support Function
5. Actions necessary to support the SMS should bemanaged throughout the organisation
6. Safety accountabilities and responsibilities should be documented and understood by the incumbents
Defining the Community Safety Programme
Collaboration between European Commission, EASA and Member States
Authority requirements provide a basis for a CSP
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basis for a CSP
Elements drafted by a small group, to be presented to all Member States
Means to share safety occurrences in place
Trust
General requirements for competent authorities
Safety promotion programmes
Mutual exchange of information
Collective oversight and enforcement
Mandatory safety information
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Mandatory safety information
Occurrence reportingOccurrence reporting
Authority management system:
Policy
Staff
Compliance monitoring
AccidentsAccidents
IncidentsIncidents
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IncidentsIncidents
AbnormalAbnormalVariationsVariations
Undesirable EventsUndesirable Events
EASA and investigation
Has the responsibility to ensure there is a safe European system;
Participates in AIB investigations, but NOT
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Participates in AIB investigations, but NOT in the determination of probable cause.
Determines if any of EASA’s responsibilities were involved;
If needed, initiates corrective action.
EASA and investigation
Has the responsibility to respond to facts learned in accident investigation with speed commensurate with the risk to continued operational safety;
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We use our Experts to assist in the investigation of accidents, in coordination with the AIB IIC;
Better training, more standardised participation.
ECCAIRSDatabase
(JRC central repository)
SafetyRecommendations
Database
Two separate systems linked by a n:n relation
Accident investigation:The European database
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Safety analysis
Thematic search by
• Descriptive factor
• Explanatory factor
• Text search / field
Notification
Updates
Reports
Process & reply to
Safety Recommendations
The End
John VincentEASA Head - Safety Analysis and Research
Tel: + 49 221 89990 2012
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EASAOttoplatz 1D-50679 Köln PO Box 101253D-50452 Köln, GermanyTel: 49-221-89990000
Annex
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EASA / EC Rulemaking planning
AR/OR
Gen+FCL+MED
AR/OR
OPS
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Then EC Comitology Process (for the Implementing rules)
Publication expected from May 2010
Nov 08-Feb 09 Feb 09-May 09
Mar-May 2009 Jun-Aug 2009
Jun-Jul 2009 Sep-Oct 2009
Bow Tie representation
Safety Event 1
Barrier Hazard
Potential
Outcome
1. What is the hazard?3. What safety event could
release the hazard?
6. How do we recover if the event occurs? How can the potential
outcome likelihood or consequence severity of the outcome be limited?
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Undesirable
EventSafety Event 2
Safety Event 3
Potential
Outcome
Potential
Outcome
Mitigation
2. What happens when
hazard control is lost?
4. How can the accident scenario
develop?
What are the potential outcomes?
5. How do we avoid the undesirable event? How do we
keep control on the hazard?