WELCOME

ACAC/ICAO AIG Workshop (Jeddah, Saudi Arabia, 25-27 April 2017)

GCAA OVERVIEW

ACCIDENT INVESTIGATION (AAIS)

LEGISLATION AND STANDARDS

EXAMPLES OF INVESTIGATIONS

MAIN PROCESSES

CAPABILITIES

FUTURE

GCAA OVERVIEW

Overview

• Established in 1996 under the Federal Law No. 4 • Financially and administratively independent funded by fees imposed on the aviation sector for its services

The most important functions of the body: • Organize and monitor the safety, security and environment of civil aviation • Provide air navigation services • Facilitate air connectivity and international cooperation in civil aviation • It is the only authority responsible for the various aspects of regulation and legislation to the civil aviation

sector in the UAE.

HE Engr Sultan Bin Saeed Al Mansoori Minister of Economy and Chairman of GCAA

HE Saif Mohammed Al Suwaidi Director General of GCAA

ACCIDENT INVESTIGATION (AAIS)

LEVEL 1 – AIR ACCIDENT INVESTIGATION

Director General

Air Navigation

Service Provider

Safety Affairs

Security Affairs

Strategy and Internal

Affairs Support Services

Audit, Quality and Risk Mgmt

Air Accident

Investigation ICAO Office Commercial

Services

LEVE

L 0

LEVE

L 1

Mission

To improve aviation safety by providing effective safety recommendations based on the application of world leading investigation methods.

Vision

To be an international recognised and respected centre of excellence in the science of air safety investigation.

Message from AAIS ADG

AAIS STRUCTURE

Ismaeil Al Hosani AGS- AAIS

Ibrahim Al Addasi Chief Air Accident Investigator

Elias Nikolaidis Chief Air Accident Investigator

Fazal AliBaksh Sr Investigator

Abdelati Al Fadil Sr Investigator

Mohamed Al Kayat Sr Investigator

Hans Meyer Investigator

Naser Al Messabi Technical Assistant

Thomas Curran Chief Air Accident Investigator

Khalid Al Raisi Director AAI

Jeremias Malaihollo Sr Investigator

Usman Karappath Administration Officer

LEGISLATION AND STANDARDS

LEGISLATION TIERS Civil Aviation Law No. 20 of 1991 Ch. 7- ‘Aircraft Accidents’

Civil Aviation Regulations CAR Part VI, Ch. 3

Publications (Annex13)

AAIS’s Procedures

EXAMPLES OF INVESTIGATIONS

FOKKER F27 MK.050, EP-LCA Date: 10 February 2004

Location: 2.6 nm final to runway 12 of Sharjah International Airport, UAE.

Probable Cause: The power levers were moved by a pilot from the flight idle position into the ground control range, which led to an irreversible loss of flight control.

Injuries: There were a total of 43 fatalities and 3 survivors.

Nature of Damage: Totally destroyed on impact and only the tail section was relatively intact.

AUGUSTA WESTLAND AB139, A6-BBB Date: 3 June 2008

Location: Near Al Futaisi Island, Abu Dhabi, UAE.

Probable Cause: The most probable cause of the accident was human factor due to crew disorientation following an unusual attitude.

Nature of Damage: Totally destroyed and its wreckage scattered over the shallow water.

Injuries: Injuries: All crew members including the three passengers were fatally injured (2 Crew+ 3 Passenger = 5).

BELL 212, A6-ALV Date: 3 September 2008

Location: Rashid Drilling Rig, Maersk Resilient, Dubai, UAE

Probable Cause: The most probable cause was loss of situational awareness due to loss of visual reference and the inability to determine the correct attitude of the Helicopter and react to this condition.

Nature of Damage: Totally destroyed as a result of significant impact forces and subsequent fire.

Injuries: Injuries: All crew members including the three passengers were fatally injured (2 Crew+ 3 Passenger = 5).

BOEING 707-300C, ST-AKW Date: 21 October 2009 Location: 1.6 kilometers from the end of runway 30 (threshold of RWY12), Sharjah International Airport, UAE. Probable Cause: The departure of the No. 4 engine core cowls; the consequent disconnection of No. 4 engine EPR Pt7 flex line; the probable inappropriate crew response to the perceived No. 4 engine power loss; the Aircraft entering into a stall after the published maximum bank angle was exceeded; and the Aircraft LOC that was not recoverable.

Nature of Damage: Totally destroyed as a result of significant impact forces and subsequent fire.

Injuries: All 6 crew members were fatally injured.

BOEING 747-44AF, N571UP Date: 3 September 2010 Location: nine nautical miles south west of Dubai International Airport,Dubai.

› Probable Cause: The uncontained cargo fire directly affected : the control cables and toxic smoke into the cockpit area, affecting the visibility in the cockpit, obscuring the view of the primary flight displays, audio control panels, and the view outside the cockpit which prevented the pilots from seeing anything, including the checklists , flight display warnings and the radio panels. the crew oxygen system, leading to an over heat failure which caused the Captain to be incapacitated due to toxic smoke poisoning.

Nature of Damage: Totally destroyed as a result of significant impact forces and subsequent fire.

Injuries: The two crew members were fatally injured.

PARAMOTOR Date: 26 January 2011

Location: Ajman, UAE.

› Probable Cause: The pilot entered into a spiral maneuver which who could not recover due to insufficient altitude and limited experience. The paramotor fell into the sea and the weight of the engine dragged the pilot to sub-surface leading to his drown.

Nature of Damage: Minor damage due to salt water submerse.

Injuries: The pilot was fatally injured.

IL-76TD, RA76799 Date: 5 February 2012

Location: Sharjah International Airport, UAE.

Probable Cause: Mechanical damage of No. 2 engine turbine which started with a dismantled part that departed the 2nd stage NGVs due to heat stress. The subsequent turbine parts failed mechanically by the domestic dismantled object. The heat stress was caused by the malfunctioning FCU and flame torch coming out of one of the twelve fuel nozzles followed by uncontrolled gas temperature. The FCU malfunction was caused by beyond-limits contaminants.

Nature of Damage: Minor damage due to salt water submerse.

Injuries: The pilot was fatally injured.

BOEING 737-800, A6-FEB Date: 6 December 2013

Location: Dubai International Airport, UAE. . Probable Cause: The causes of carriage of chemical oxygen generators onboard passenger aircraft were: No label in the PSU or by the AMO; the STC EO did not contain the appropriate reference to ATA 35 – Oxygen; the Operator and AMO personnel were unaware that the PSU assemblies contained dangerous material; and the contract agreed between the Operator and the AMO did not differentiate between normal and dangerous goods when returning removed parts.

Nature of Damage: None.

Injuries: None.

HAWKER BEECHCRAFT 400XP, AP-RBA Date: 23 May 2014

Location: Al Maktoum Airport, UAE.

Probable Cause: The cause of the takeoff attempt from a taxiway was the flight crew tiredness due to operational factors and exposure to elevated temperature and humidity conditions leading to the crew paying inadequate attention to positively verifying that they had lined up on the designated runway. Contributing Factor was that the Tower Controller did not maintain a continuous visual watch on the Aircraft ground movement.

Nature of Damage: None.

Injuries: None.

GYROCOPTER, A6-GY0 Date: 9 December 2015

Location: Skydive Drop Zone, Palm Jumeirah, Dubai , UAE. .

Probable Cause: TBD

› Nature of Damage: None.

Injuries: None.

Narration: Gyrocopter participating in an air race held as part of the Fédération Aéronautique Internationale (FAI), 2015 World Air Games (WAG), suffered loss of control and impacted the sea upon passing the final race course pylon. The Pilot was submerged in the water for a period of approximately ten minutes before being rescued in an unconscious condition by safety and rescue divers. The Pilot did not regain consciousness and succumbed to his injuries ten days after the Accident.

BOEING 777-31H, A6-EMW Date: 3 August 2016

Location: Dubai International Airport,Dubai

Probable Cause: TBD

Nature of Damage: : Totally destroyed as a result of significant impact forces and subsequent fire.

Injuries: 23 minor and 1 serious.

Narration: Flight EK521 departed Trivandrum International Airport (VOTV), India, for Dubai International Airport (OMDB). The Aircraft impacted the runway during an attempted go-around at Dubai.

BOEING 777-31H, A6-EMW Date: 14 January 2017

Location: Dubai International Airport,Dubai

Probable Cause: TBD

› Nature of Damage: Ssignificant damage due to fire.

Injuries: 1 (pilot) serious Narration: After the balloon landed, and the basket came to a complete stop in normal position, the envelope moved slightly upward and pushed the burner/burner frame backward towards the basket. The initial observations indicated that there were no upright intact to prevent this from happening. The envelope ‘scoop’ deflected the flame of the burner, which was still active at that time, towards the basket and the pilot who sustained severe burns and was transported to the hospital.

MAIN PROCESSES

Step 1

Step 2

Step 3

AAIS MAIN PROCESSES • DI Notification

• Initial Investigation

• Case Opening Decision-making

• Investigation

• Report Making

• Safety Recommendations

IMMEDIATE NOTIFICATION DUTY INVESTIGATOR – 24HRS

0506414667

DI NOTIFICATION PROCESS

30:00

01:00

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The DI receives a call or the ROSI Reviewer finds a trend

The DI classifies the occurrence

The DI/Reviewer files form 035

Accident

Serious incident/ Incident

Require detailed investigation

Require safety study

Evaluate the occurrence following the below guidelines- •Anticipated safety value? •A6- registered •UAE operator? •Potential impact on public? •Trend as per ROSI? •Large or small aircraft? •Commercial or private use? •Relevance safety program? •Have enough available resources? •No opportunity for investigation by others? •Happened recent to the notification? •Training benefits for the AAIS investigators? No

Yes Does the evaluation result in a high

score subject to the DI review?

INVESTIGATION OPENING DECISION-MAKING

Require safety study

Pass to other agencies for further action

Recordkeeping for future research and statistical analysis

Recordkeeping: Unlikely to result in safety benefit

REPORTS’ APPROVAL PROCESS

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Send/forward to

GCAA SA

Organization All SRs entered and followed-up

via Q-Pulse

The State AAIA or NAA or ICAO

SR issued by AAIS or received

from a foreign authority

The addressee provides his

response

The IIC makes his decision on the response and

status

Update the Q-Pulse

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SR PROCESS

CAPABILITIES Software

Hardware

Human

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FLIGHT RECORDERS LAB

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ACCIDENT SITE BIOLOGICAL HAZARDS

On each 100-passengers flight: 1 passenger carries HIV 6 passengers carry Hepatitis B 3 passengers carry Hepatitis C

IMMEDIATE NOTIFICATION

SR PROCESS IN Q-PULSE

FUTURE

AAIS RECENT ACTIVITIES › Independence (end of 2017)

› Inflight explosion and underwater flight recorders and wreckage recovery exercise (Q4 2017)

› Safety Information Protection Law (draft by end of 2017)

› ISASI (2018)

› Innovation (continuous)

THANK YOU