Annual Safety Report 2011 - · PDF fileSRC ANNUAL SAfETy REPORT 2011 7 EUROCONTROL has developed and deployed a range of complementary systems to measure the state of ATM safety. These

Annual Safety Report2011

EUROCONTROL

Safety Regulation Commission

A situation requiring attention…

In this Report, the analysis of the achieved levels of safety shows that the ECAC safety objective continues to be met for accidents with ATM contribution. However, the analysis of ATM-related incidents reported to EUROCONTROL shows that the situation deteriorates in the assessment of safety occurrences. Data for 2010 shows an increase in the number of incidents reported in comparison with 2009, which reflects an improvement in the reporting culture. In addition, the lack of resources and qualified staff at national level dedicated to safety data collection and analysis is a factor of concern.

In parallel, the effectiveness of the safety oversight processes implemented by National Supervisory Authorities (NSAs) is again identified as a concern, which indicates a prime need for support to NSAs. Whereas States are seen to be perfor-ming well in areas related to the adoption and enactment of European legislation, the 2011 results from the ESIMS Audit Programme again confirm issues in the areas related to the implementation of the basic processes for safety oversight.

It must be borne in mind that the considerable effects of the global economic downturn have yet to be fully felt in the ATM safety field. Widespread budget cuts have been applied in ATM that can affect the availability of safety resources in the short term.

An example is the negative impact on improvement of resource levels in regulatory organisations, where effects on measured performance may be expected into the future. The resourcing of NSAs continues being a crucial factor. It has been observed that States and NSAs have difficulties in complying with the timelines given for their full range of activities. These activities, and the need to resource them, increase continuously in parallel to the new SES legislative developments.

Additional pressure on operating budgets for both Air Navigation Service Providers (ANSPs) and regulators is seen as inevi-table, and the industry will be relying on its previous investments in safety culture, resources and infrastructure to ensure that safety is allocated the correct place in the economic decision-making that will follow.

In this difficult context, the support to NSAs articulated at European level may become instrumental in mitigating this situation.

SRC ANNUAL SAFETY REPORT 2011

3SRC ANNUAL SAfETy REPORT 2011

5SRC AnnuAl sAfety report 2011

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ChAPTER 1 - INTROdUCTION

ChAPTER 2 - KEY SAFETY INdICATORS

ChAPTER 3 - SAFETY PERFORmANCE 2010

ChAPTER 4 - OPERATIONAL SAFETY ISSUES

ChAPTER 5 - SEvERITY CLASSIFICATION OF ATm-RELATEd INCIdENTS

ChAPTER 6 - REPORTINg LEvELS

APPENdIx A - ECAC ATm SAFETY PERFORmANCE INdICATORS FOR 2010

APPENdIx B - AddITIONAL INFORmATION FROm ThE ESImS AUdIT PROgRAmmE

TAble of CONTENTS

7SRC AnnuAl sAfety report 2011

EUROCONTROL has developed and deployed a range of complementary systems to measure the state of ATM safety. These enable the industry as a whole to track the progress made in implementing safety reforms and enhancements, as well as identifying aspects where performance is lacking, and intervention action is required.

Safety Occurrence Analysis

The Safety Analysis Function EUROCONTROL and associated Repository – SAFER - system is EUROCONTROL’s principal tool in its safety data analysis work, and consists of a European ATM Safety Data Repository, fed by a system of mandatory1 and voluntary data flows. Integrated analysis forms the basis for safety improvement measures and initiatives. The output of these activities plays a key role in safety improvement (both in safety regulation and safety management).

SAfER is designed to provide the ATM component of the EC’s aviation-wide reporting system, based on ECCAIRS. Accor-dingly, the system not only provides full inter-connectivity to other ECCAIRS-based systems, such as the data repositories held by EC and ICAO, but also shares a common taxonomy with those systems in respect of ATM occurrences.

ESImS Audits

The view described in this report, primarily based on the SAfER safety analysis system, is complemented with the results from the ESIMS Audit Programme implemented by the SRC in the period 2005-2011.

The ESIMS audits cover all applicable regulations related to the implementation of ATM safety oversight by a State, as well as the procedures, resourcing of functions and other implementing arrangements needed to implement, in respect to ATM, the Eight Critical Elements of a State’s Safety Oversight System defined in ICAO Document 9734-A.

ChApTeR 1 - INTROdUCTION

“SAFER” Outputsincluding

Safety Peformance IndicatorsSafety StatisticsKey Risk Area IdentificationCND Programmes Monitoring

SAFER

■

■

■

■

ATM -Repository

CommonSafety AnalysisFunction

Voluntary Data Flow(Airspace users/ ANSP’s)

Mandatory Data Flow(Member States)

SafetyRegulationCommission

EUROCONTROLAgency

Support toRulemaking

ESIMS

SRC Work Programme

Safety Analysis

Support toImplementation

SRC Eview ofSafety Deliverables

Maturity FrameworkSAFER (Safety Occurences reporting & analysis)

SAFREP Task Force (Safety KPIs)

NSA Training Initiative

Cooperative Work SRC/CND1 Mandatory under CN Decision No. 115, dated 02 September 2009, approving ESARR 2, Edition 3.0, for incorporation and implementation in the ATM regulatory

frameworks of EUROCONTROL Contracting Parties.

8

ATm-Related Incidents

Initial data for 2010 shows an increase of 42% in the total number of incidents reported in comparison with the same period of 2009. The updated data of 2009 now shows an increase of 29% when compared with 2008.

The increase in the number of occurrences reported is due to a number of factors:

n Increased reporting due to a successful implemen-tation of a just culture in ANSPs; we could see an increase of 1000 reports from one year to another, even starting from an already high level.

general Consideration

The analysis is based on the Annual Summary Template (AST) returns from 31 States which reported by end of March 2011. EUROCONTROL received one report presen-ting the preliminary data for 2010 and, whenever required, an update of the reporting year 2009. This is a record number of States reporting by the deadline and this could be only possible because of the work and dedi-cation of the nominated AST Focal Points and their advisors.

The severity assessment of some categories of ATM-related incidents applying the Risk Analysis Tool (RAT) is one of the Key Performance Indicators for safety in the first refe-rence period (2012-2014) in the context of the Performance Scheme Regulation (EC) No. 691/2010 and the associated Key Performance Indicators for Safety.

A number of ANSPs, Regulatory and Investigation Authorities have already started the implementation of the RAT methodology in 2010 and reporting the results through the AST. It is to be expected that there will be differences in the severity results in comparison with previous years, which will have an impact on the trend analysis, specifically for ‘Separation Minima Infringements’ and ‘Runway Incursions’ as well as the ATM specific occurrences.

Accidents with direct and IndirectContribution

Based on the AST returns and the data available from EASA/ICAO, in 2010 two non-fatal accidents (one runway excur-sion and another collision on the ground between aircraft and vehicle) was indicated as having an Indirect ATM Contribution. These initial assessments are in the process of being confirmed with the investigation authorities.

However, a significant number of accidents are still under investigation and updated results are expected in the next AST reporting round.

ChApTeR 2 - KEY SAFETY INdICATORS

02468

101214161820

0

4,000,000

8,000,000

12,000,000

16,000,000

20,000,000

Accidents with direct ATM contributionLinear (Accidents with direct + indirect ATM contribution

ECAC traffic levels (2005-20010)

Accidents with direct + indirect ATM contribution

2005 2006 2008 20092007

Number of accidents Flight Hours

2010

Accidents in ECAC with ATM contribution and traffic levels -aicraft above 2250 kg MTOM (2010 preliminary data)

0

20

40

60

80

100

120

140

0

200400600800100012001400160018002000

20032002 2004 2005 2006 2007 2008 2009 2010

ABTotal

0200400600800

100012001400160018002000

0

10

20

30

40

50

60

20032002 2004 2005 2006 2007 2008 2009

20032002 2004 2005 2006 2007 2008 2009

2010

2010

Total ATM Related IncidentsOccurrence per million flight hours and severity

SRC ANNUAL SAfETy REPORT 2010

With respect to the number of serious incidents (Severity A) and major incidents (Severity B), a considerable decrease is shown in the severity A (in absolute numbers 27 in 2009 and 16 in 2010), whereas for the major incidents (severity B) we see a considerable increase (see also the note about severity classification in general considerations).

Runway Incursions

Preliminary data for 2010 shows a considerable increase of 26% in total numbers of runway incursions reported. This is in line with the initial data reported in September 2010 covering the first part of 2010, when the increase was 20%. This increase is accounted for by increased reporting in general (see ATM-related incidents above) and by some Member States in particular.

Runway Incursions reported through the AST now not only include those reported by ANSPs, but also by airlines and aerodrome staff. These reports need to be assessed/investigated to ascertain if they are really runway incur-sions (as per the definition), to collect all relevant data, determine the severity and to avoid the introduction in the database of duplicate reports. Resources dedicated to the safety analysis of the runway incursions are critical in ensuring good quality data at national and European level.

n Improvements in the collection of occurrence reports at national level, not only from the main ANSP but also from smaller ANSPs and other organisations such as airlines and aerodromes. This introduces new challenges in regard the collection of all the back-ground data required by ESARR 2, severity assessment and identification and elimination of possible dupli-cates. for example, the proportion of incidents not severity classified, or where the severity class is ‘Not determined’, had risen significantly in 2010. The AST focal Point (AST-fP) Group had developed an Action Plan for the improvement of severity classification and recommendations are made in the SRC Annual Safety Report for the Provisional Council’s meeting in December.

n This requires additional resources for safety analysis, which are not present today. A lack of resources for safety analysis becomes critical in many regulatory organisations. This issue is addressed in detailed in Section 4 of this report.

n The increase in the total number of incidents reported is propagated in some of the ESARR 2 categories of incidents, notably Runway Incursions. The same issues evident in the collection of overall incidents are also inherited in the runway incursion category.

n The permanent contact with the States’ Focal Point in reporting ASTs through the SRC AST-fP Group is paying off, as we can identify all the data sources and make appropriate arrangements so that the data is included in the AST. The work and dedication of the AST focal Point is key to these developments.

Separation minima Infringements

The initial data reported for 2010 show almost the same level of incidents when measured against traffic levels (3% increase in absolute numbers). However, as this type of occurrence usually take the longest time to be investi-gated, updates are likely to be submitted in the September reporting session.

9

0

20

40

60

80

100

120

140

20032002200120001999 2004 2005 2006 2007 2008 2009

ABTotal

0

20

40

60

80

100

120

140

0

5

10

15

20

25

30

35

40

200320021999 2000 2001 2004 2005 2006 2007 2008 2009

200320022001 2004 2005 2006 2007 2008 2009

2010

2010

2010

Separation Minima InfringementsOccurrence per million flight hours and severity

The increase is also reflected in the category of risk bearing occurrences - severities A and B compared to 2009, both in absolute and relative numbers. This shows that focus on the implementation of the second version of the European Action Plan for the Prevention of Runway Incursions (EAPPRI) is absolutely critical (EAPPRI 2). One of the elements highlighted in EAPPR 2 is the continuing need for effective Local Runway Safety Teams.

The increase is more evident in severity class B. While a number of States reported some increase in this seve-rity class, most of it is accounted for by reports from one Member State who showed a significant increase in total numbers reported and changes were made in the way severity of these incidents is determined and recorded (see also the note about severity classification in general considerations).

The percentage of incidents “not classified” in this cate-gory, at just over one quarter of the total occurrences, is at almost the same level as in 2009.

Performance Scheme Regulationand Associated Key PerformanceIndicators for Safety

Commission Regulation (EC) No. 691/2010 “laying down a performance scheme for air navigation services and network functions”, defines three Key Performance Indicators (KPI) for safety.

These safety KPIs were jointly developed by the EC, Member States, EASA and EUROCONTROL and were adopted by EC prior to the first reference period (2012-2014) – RP1, through Commission Implementing Regulation (EU) No. 1216/2011 amending Commission Regulation (EU) No. 691/2010. furthermore, a safety KPI metrics document, complemented by Guidance Material and Acceptable Means of Compliance, were developed and published in December 2011.

One of the safety KPIs is the application of the severity classification of the Risk Analysis Tool (RAT) methodology to allow harmonised reporting of severity assessment of Separation Minima Infringements, Runway Incursions and ATM-specific occurrences. This will allow the further deve-lopment of these indicators for the second reference period and the SRC’s Annual Safety Reports will therefore continue to monitor these occurrence categories throughout RP1.

The Performance Scheme Implementing Rule defines the Application of the Severity Classification methodo-logy of the Risk Analysis Tool as one of the Key Safety Indicators.

The “Metrics for Safety Key Performance Indicators for the Performance Scheme” defines measurement verification and mechanisms: “The measurement of the KPI will make use of existing safety data reporting mechanisms with enhancements where needed. It is proposed that the indi-cation of the application of the RAT severity classification methodology on individual occurrence level is included in the EUROCONTROL Annual Summary Template (AST) form.”

As a result, the AST focal Point Group is in the process of updating the AST template (i.e. EAM 2 / GUI 9 and EAM 2 / GUI 10) to indicate if the RAT severity classification metho-dology has been applied for the severity assessment of each reported occurrence

10

Runway IncursionsOccurrence per million aircraft movements and severity

0123456789

1011121314

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20

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60

70

80

90

100

200320022001 2004 2005 2006 2007 2008 2009 2010

ABTotal

ESImS Audits

The ESARR Implementation Monitoring and Support (ESIMS) Audit Programme was introduced in its present form in 2005 to assess, through a formal and detailed audit process, States’ ATM safety oversight arrangements and capabilities in parallel to the ICAO USOAP six-year audit cycle 2005-2011.

Audits cover all applicable regulations related to the imple-mentation of ATM safety oversight by a State, as well as the procedures, the resourcing of functions and other imple-menting arrangements needed to implement, in respect to ATM, the Eight Critical Elements of a State’s Safety Oversight System defined in ICAO Document 9734-A.

Specifically within those Member States where European Community law is applicable, ESIMS examines the

state of implementation of those SES requirements establishing safety oversight-related provisions, most notably Commission Regulation (EC) Nos. 1315/2007 and 2096/20052. In practical terms, the focus is placed on the NSA.

At the end of 2011, the whole six-year cycle of ESIMS audits will be concluded. from November 2005 to December

2011, 42 on-site audits and 8 follow-up audits have been completed. Thirty-three final reports had been published by September 2011.

There is a direct correspondence between the areas reviewed in an ESIMS audit and the Eight Critical Elements (CEs) of a State’s Safety Oversight System as defined in ICAO Doc 9734-Part A, ‘The Establishment and Management of a State’s Safety Oversight System’.

ChApTeR 3 - STATES’ SAFETY OvERSIghT ARRANgEmENTS


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FI

IS

GEAM

AZ

EE

UA

MD

TR

CY

FR

LV

LT

BE

NL

DE

GB

IE BY

RO

ALMK

BG

GR

CH

IT

AT HU

RS

ESPT

DK

NO SE

PL

CZ

MT

BA

MA TN

SY IQ

IR

KZ

RU

LU SK

SI HR

8 Follow up audits2010 - 2011

DZ

MC

42 ESIMS AuditsDec 05 - Sept 11

Extent of ESIMS audit activitiestill the end of October 2011

ME

EUROCONTROL

2 These were replaced in October 2011 by, respectively, Commission Implementating Regulation (EU) Nos. 1034/2011 and 1035/2011. It should also be noted that their provisions remain equivalent to the previous regulations.

The eight critical elements provide the basis used by IUSOAP to audit the safety oversight capabilities of a State. ESIMS audits use a series of protocol questions covering the whole scope of the audit. findings are raised against one or more protocol questions and each protocol ques-tion is associated with ICAO’s Critical Element.

ESImS Aggregated Results for2005-2011

The following charts are intended to map the compliance, expressed in percentage of compliance with the relevant requirements, for each one of the 8 critical elements of the ICAO Model. They present the results from the 31 ESIMS audits for which final Audit Reports have been released.

The aggregated scores obtained against the ICAO model are as follows:

12

ICAO ModelThe Eight Critical Elements of a State's Safety Oversight System

CE-6

CE-8

CE

-7

CE-1

CE

-2

CE-4

CE-5

CE-3

PrimaryAviation

Legislation

Specifi

c

Operat

ing

Regula

tions

Qua

lified

Tech

nica

lP

erso

nnel

and

Trai

ning

Licensing,

Certification,

Authorisation

and Approval

ObligationsResolution of

SafetyConcerns

Surve

illanc

e

Obliga

tions

Technical Guidance,

Tools & provision

of Safety

CriticalInfo

State Aviation

System and

Safety Oversight

Functions

ESTABLISH

IMPLEMENT

ESTABLISH

IMPLEMENT


CE-6

CE-8

CE

-7

CE-1

CE

-2

CE-4

CE-5

CE-3

PrimaryAviation

Legislation

Specifi

c

Operat

ing

Regula

tions

Qua

lified

Tech

nica

lP

erso

nnel

and

Trai

ning

Licensing,

Certification,

Authorisation

and Approval


SafetyConcerns

Surve

illanc

e

Obliga

tions

Technical Guidance,

Tools & provision

of Safety

CriticalInfo

State Aviation

System and

Safety Oversight

Functions

ESTABLISH

IMPLEMENT

ESTABLISH

IMPLEMENT

ICAO ModelThe Eight Critical Elements of a State’s Safety Oversight System

Level of compliance with RequirementsCompliance with mandatory provisions established at national or international level which relate to an ICAO Critical Element

(arithmetic mean for 31 audited Member States)

CE 1 - Primary Aviation Legislation

CE 2 - Speci�c Operating Regulations

CE 3 - State Civil Aviation System and Safety Oversight Fuctions

CE 4 - Technical Personnel, Quali�cations and Training

CE 5 - Technical Guidance, Tools and Provision of Safety Critical Information

CE 6 - Licensing, Certi�cation, Authorisation and/or Approval Obligations

CE 7 - Surveillance Obligations

CE 8 - Resolution of Safety Concerns

Percentage of audit protocol questions declared compliantICAO Critical Elements

Audits conducted from 2007 onwards showed significant progress over previous years, and it is evident that SES contributed very positively to these achievements, princi-pally by filling the gaps in the previously-existing National Primary Aviation Legislation (Critical Element 1 in the ICAO Model).

In those Member States where European Community law is applicable, SES has also ensured a common benchmark for safety oversight, notably through the transposition of ESARR 1 into Community legislation by means of Commission Regulation (EC) No. 1315/2007, which is now replaced with the equivalent Commission Implementating Regulation (EU) No. 1034/2011 deve-loped as part of the EASA regulatory system.

Evolution of the Level ofCompliance in the Last Year

The implementation of corrective actions continues in accordance with the reports received from the States audited so far. However, the effectiveness of the over-sight processes implemented by NSAs is still a key area for improvement. States are seen to be performing well in areas related to the adoption and enactment of European legislation, but less well in implementing safety oversight processes.

Indeed, when compared with the data available a year ago, the 2011 results indicate a decrease in all of the Critical Elements (CEs) with the biggest change in CE-7 (surveillance obligations) and CE-8 (resolution of safety concerns).

Critical Element 7 (CE-7, Surveillance Obligations) concerns those mechanisms required in a State Safety Oversight system to detect safety deficiencies in a proactive manner. This includes the audits and reviews of safety arguments required in ESARR 1 and its corresponding EU law. Critical Element 8 (CE-8, Resolution of Safety Concerns) includes the arrangements established to deal with safety issues in a reactive manner. This includes the analysis of safety occurrences, the use of safety directives.

The results confirm again that the main area for impro-vement detected relates to the effective implementation of all those mechanisms and processes and their effec-tiveness. This also continues indicating a prime need for support to NSA’s.

If we take into account that the aggregated figures include results from audits conducted before the entry into force in 2007 of the provisions of ESARR 1 and its equivalent Commission Regulation (EC) No. 1315/2007, the real gap which exists for those critical elements related to the safety oversight processes could indeed be larger than the one shown in the aggregated results.


0102030405060708090

100

0102030405060708090

100

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 CE-8

2010 Report2011 Report

50556065707580859095

100




Compliance with mandatory provisions per ICAO criticalelement (CE) - 2011 (31 audited States)

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100

0102030405060708090

100



50556065707580859095

100




2010-2011 Change in Level of Compliance with Requirements per ICAO CE

For example, compliance in relation to

«surveillance obligations» (CE-7)decreases from 72% to 68%


CE-6

CE-8

CE

-7

CE-1

CE

-2

CE-4

CE-5

CE-3

PrimaryAviation

Legislation

Specifi

c

Operat

ing

Regula

tions

Qua

lified

Tech

nica

lP

erso

nnel

and

Trai

ning

Licensing,

Certification,

Authorisation

and Approval


SafetyConcerns

Surve

illanc

e

Obliga

tions

Technical Guidance,

Tools & provision

of Safety

CriticalInfo

State Aviation

System and

Safety Oversight

Functions

ESTABLISH

IMPLEMENT

ESTABLISH

IMPLEMENT


CE-6

CE-8

CE

-7

CE-1

CE

-2CE

-4

CE-5

CE-3

PrimaryAviation

Legislation

Specifi

c

Operat

ing

Regula

tions

Qua

lified

Tech

nica

lP

erso

nnel

and

Trai

ning

Licensing,

Certification,

Authorisation

and Approval


SafetyConcerns

Surve

illanc

e

Obliga

tions

Technical Guidance,

Tools & provision

of Safety

CriticalInfo

State Aviation

System and

Safety Oversight

Functions

ESTABLISH

IMPLEMENT

ESTABLISH

IMPLEMENT

Main area forimprovement andNeeds for support

to NSAs

Only 7 out of the 19 Member States that provided their updated Corrective Action Plans during the summer of 2011 reported full or nearly full (above 90%) implemen-tation of the corrective actions intended to address the findings from the ESIMS audits performed between 2006 and 2010.

Clearly, in some cases where there are still significant imple-mentation deficiencies, there is the risk that safety oversight applied by NSAs remains a system which exists on paper, but offering no meaningful contribution to ATM safety.

The resourcing of NSAs continues being a crucial factor and remains a serious concern requiring proactive attention by States and European bodies to ensure the implementation of effective oversight processes. It has been observed that States and NSAs have difficulties in complying with the timelines given for their full range of activities, not only those checked by the ESIMS audits. These activities, and the need for resourcing them, increase continuously in parallel to the new SES legislative developments.

As per the Report on the SES Legislation Implementation for 20103 , only 8 NSAs out of 31 reported no significant staff shortages. In total, 16 NSAs reported a significant lack of qualified resources, although in 6, recruitment plans had been approved and were on-going. In 5 NSAs, recruit-ment plans were awaiting Ministerial/Governmental approval, and 3 reported that recruitment plans were on hold, mainly due to budgetary constraints resulting from economic difficulties.

In at least 4 of the 5 NSAs which reported at not having conducted an assessment of human resources, there are indications through their SES Annual Reports showing a severe shortage of staff. The situation regarding resources can be considered as jeopardising their ability to fulfil their oversight obligations.

Analysis of “Top Non-compliances” in the Sample of Audits Conducted

The analysis of “top non-compliances” in the sample of audits conducted (31 States) revealed the following signi-ficant overall features:

n The areas of primary aviation legislation and technical personnel qualification and training remain with the highest level of compliance with the regulatory requi-rements, at levels reaching respectively 88% and 82%. It should be emphasised that percentages reflect the compliance with the relevant mandatory provisions in

force at the time of the audit, and not the maturity of the safety oversight system. findings raised in the form of observations indicating areas for improvement do not count in these percentages.

n ICAO Critical Element 7, that is to say, the implemen-tation of ‘surveillance obligations’ by means of audits, inspections and other activities, obtains the lowest score and reaches now 66%. This is the only Critical Element below 70% compliance.

n A significant factor in the States’ performance is that ESARR 1 and its equivalent EC rule, Commission Regulation (EC) No. 1315/20074, became applicable in November 2007, after which ESIMS audit findings relating to these requirements were no longer obser-vations but non-conformities, thus emphasising States’ and NSAs’ problems in establishing and implementing ICAO Critical Elements 4, 5, 6, 7 and 8.

n 24 States did not take sufficient actions to establish a safety baseline defining acceptable levels of safety. 22 States have not kept acceptable levels of safety under review and 21 NSAs did not monitor and assess the levels of safety achieved against the safety regulatory requirements applicable in the airspace under their supervision as required in ICAO Annex 11, 2.27 and Article 5 of Commission Implementating Regulation (EU) No. 1304/2011.

n Nearly 60% of States have not issued appropriate safety rules for engineering and technical personnel underta-king safety-related tasks as required in ESARR 5, Section 5.3.2.1 and the equivalent Article 9 of Commission Implementating Regulation (EU) No. 1035/2011 nor have 65% of the States ensured adequate and appro-priate safety oversight of such personnel.

n In 19 States safety recommendations, interventions and corrective actions were not properly developed or recorded, and their implementation was not moni-tored as required by the EC Directives relating to Safety Occurrence Reporting.

n 60% of States had not verified that the new or modi-fied regulations related to ESARR 4, ESARR 5 (Section 5.1 and 5.2) and ESARR 6 were being applied by the ANSPs. These provisions have been incorporated into EU legislation as a result of the transposition of ESARRs into Community law.

n 18 NSAs have not received notifications of all planned safety related changes to the ATM systems.

14 3 See Chapter 2 of the Report on the SES Legislation Implementation for 2010, Edition 1.1, dated 27 June 2011.4 This was replaced in October 2011 by Commission Implementing Regulation (EU) No. 1034/2011. It should also be noted that the provisions remain equivalent to

the previous regulation.

Progress on Corrective Action Plans

A key feature of the ESIMS process is the development and implementation of Corrective Action Plans (CAPs) by States. CAPs address the deficiencies revealed in the audit process, and are incorporated into the final audit report, which also includes an evaluation of their effectiveness by DSS/OVS.

In accordance with the provisions of SRC Document 21 and the decisions made by SRC33 regarding the disse-mination of ESIMS audit information, DSS/OVS requests, (one year after the closing meeting of the on-site audit) from the Member States an update on the progress made by the State regarding the actions taken to address the findings resulting from the ESIMS audits.

The updated CAPs are used to prepare a graph depicting the level of implementation of the ICAO critical elements at the time of the audit together with the progress reported regarding the implementation of corrective actions. This graph is added to the State’s Audit Results Summary Sheet to show the progress made by the State and published on the official SRC website and OneSky Team. The following figure is based on the reports received from the 22 States previously audited under ESIMS, and shows the aggregated progress made in the implementation of corrective actions.

7 out of 22 States that sent the updated corrective actions plan in 2011 have reported having fully or almost fully closed the actions for the ESIMS findings and reached a nearly 100% level of compliance. All of them have been audited between 2005 and beginning of 2008 which would indicate that the States need at least 3 years to deal with the major problems discovered during the audit and to implement effectively most of the corrective actions.

The total of 20 States have reported to have reached between 89% and 98% level of compliance in all of the ICAO CE with CE7 scoring the lowest level and CE4 the highest level of compliance.

The reports forwarded by States are based on their self-assessment, but between 2010 and 2011 six follow-up audits were arranged to double-check this aspect. Three additional follow-up audits are foreseen before the end of 2011.

The results of the follow-ups performed so far, even though only 4 States are at this moment taken as a sample for analysis, reveal the following issues:

n Significant progress can be observed in the imple-mentation of the corrective actions, especially in the areas of CE5 - CE8. The 3 to 5 years that passed since the original ESIMS audit seemed to be enough time for the States to implement effective safety oversight of ATM.

Note: the graph depicting the level of factual implemen-tation of corrective actions in each of the ICAO CE takes as a reference the results of the audits for both States if ESARR 1 had been applicable at the time of the original audit (ESARR 1 related observations at the time of the audit were marked as non-conformities for the purposes of the analysis).


2011 Progress in implementation of Corrective Actions as reported by States

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100


Implementation of CAP as reported by State

After follow-up audit

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100


Level of compliance with mandatory provisions in force at the time of the audit

Progress of implementation of corrective actions reported by States in 2011

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100


Results at the time of the audit (ESARR 1 applicable)

Results after follow-up adit

Level of compliance with ICAO Critical Elements at the time of the original audit and after follow-up audit

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100




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100




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100




n Some of the issues originating from the first ESIMS audits were still open during the follow-up audits, mainly due to the problems with double regulation.

n Additionally it was found out that the States had overestimated their implementation of corrective actions when sending the updated CAPs to the DSS/OVS (formerly the SRU) in the years following the original audits, mainly in the areas of CE-3, CE-6, CE-7 and CE-8. The results of the follow-up audits clearly indicate that those States still have major issues with the effective implementation of the safety oversight activities.

detailed Audit Results per State

In November 2006, the EUROCONTROL Permanent Commission decided to align its approach on the public dissemination of ESIMS audit information with that of ICAO/USOAP (CN Decision No. 108).

The ICAO-based approach, using a chart to depict the implementation status of each of the eight critical elements, has been adapted in the form of an ‘Audit Results Summary Sheet’ for each audited Member State. The Summary Sheet depicts the level of compliance with the mandatory provisions related to the implementation of each ICAO critical element at the time of the audit.

To make the information more up-to-date and to show the progress made by States since the audit, the updated Corrective Action Plans submitted by States is used to update the information presented.

The Audit Results Summary Sheets available can be consulted at:

http://www.eurocontrol.int/articles/esarr-implementation- monitoring-and-support-esims-programme

16

Implementation of CAP as reported by State and after follow-up

0102030405060708090

100




0102030405060708090

100




0102030405060708090

100




This chapter provides an analysis and progress report of some operational safety issues that are currently under the focus of the SRC and its specialised working groups (SRC Coordination Group and AST focal Point Group).5

Unauthorised Penetration ofAirspace / Airspace Infringements

At its 34th meeting, the Provisional Council (PC) was presented with the SRC’s 2010 Annual Safety Report, which included an analysis of, and highlights related to, Unauthorised Penetrations of Airspace / Airspace Infringements. The PC agreed with the SRC Annual Safety Report, including a SRC recommendation on the subject, i.e.

“States to urgently implement, as a matter of priority, the provisions of the European Action Plan for Airspace Infringement Risk Reduction”.

A brief outline is provided below on the actions and acti-vities undertaken so far by DSS/OVS/SAf, in conjunction with DNM/Operations/Safety, to increase the awareness of the Action Plan for this key risk area with Member States’ regulatory/oversight authorities and ANSPs. It was initiated with the view to commencing the urgent imple-mentation of recommended actions, and where possible and feasible, the proposed actions, for all stakeholders involved, at national and local level.

During 2010, sixteen Member States reacted on the activities and related actions taken, resulting in a mix of preparatory meetings and actual national workshops on the development of national / local implementation plans for the risk reduction of airspace infringements (preparatory meetings held in Sweden, Netherlands, Croatia, Turkey, Greece, Austria, Czech Republic, Poland and Spain. National/local workshops were held in Estonia, Norway, Denmark, Switzerland, Slovakia, Hungary and Italy).

for 2011, a number of preparatory meetings have been scheduled and two workshops have been conducted in the first quarter. Member States are being actively approa-ched to react on the proposals to support and organise similar national workshops to urgently implement the required actions. The SRC’s 2011 Intermediate Safety Report to PC35 included a recommendation on the issue which was adopted.

Consequently, the Provisional Council urged all Member States, who had not already done so, to start the imple-mentation, at national level, of the agreed European Action Plan for Airspace Infringement Risk Reduction before the end of 2011. In addition, EUROCONTROL will continue its support to States for the implementation.

The initial data for 2010 shows almost the same number of airspace infringements reported compared to 2009 (compared to an increase of 20% in 2009) The number of occurrences not being severity classified in this category has risen to almost 25%.

In this category, an increase in risk bearing incidents (severity A and B) is noted, which is totally accounted for by a rise in the severity B (major) occurrences, which is at the highest level since reporting began. In absolute numbers, serious incidents (severity A) decreased from 6 to 4 compared to 2009.

In this area, the implementation of the European Action Plan for the Reduction of Airspace Infringements started in 2010 in a number of States and future analysis will entail the possible impact of the implementation efforts on the recommended and proposed actions by all stakeholders involved.

ChApTeR 4 - OPERATIONAL SAFETY ISSUES


5 The EUROCONTROL European Safety Programme ESP+ and the EASA European Aviation Safety Plan (EASp) contain additional information on safety measures in regard to safety issues in ATM.

0

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20032002 2004 2005 2006 2007 2008 2009 2010

ABCED

Not classified

0

1

2

3

4

5

6

7

20032002 2004 2005 2006 2007 2008 2009

A - Serious Incident

B - Major Incident

C - Significant Incident

E - No significant safety effect

D - Not determined

Not classified

AA - Total inability to provide safe ATM service

A - Serious inability to provide safe ATM service

B - Partial inability to provide safe ATM service

C - Ability to provide safe but degrated ATM service

E - No effect on ATM service

D - Not determined

Not classified

Unauthorised Penetration of AirspaceOccurrence per million flight hours and severity

The safety risk posed by airspace infringements/unau-thorised penetration of airspace (UPAs) is evident when an aircraft penetrating the controlled airspace comes too close to another aircraft. Depending on the airspace infringed, such encounters are classified as Separation Minima Infringements or Inadequate Separation, which collectively are called Losses of Separation (LoS).

The graph below shows the number and percentage of UPAs which resulted in a LoS.

After a reduction of LoS in 2006 and 2008, the numbers in 2009 and 2010 increased in comparison with previous years.

There is a close link between the risk associated with UPAs and the number of those resulting in a LoS (i.e. the oppor-tunities that the infringing aircraft enters into conflict with another aircraft). Therefore, the SRC will continue to monitor the relationship between UPAs and LoS.

The analysis of the UPAs also looks at the distribution of UPAs on the class of airspace infringed, the type of flight/operations involved and the phase of flight.

According to the 2009 safety data, over 80% of UPAs occurred in classes A, C and D airspace.

The vast majority of aircraft involved in such occurrences were flying en-route. It is to be noted that this class of airspace was filled in for almost 96% of the reported occurrences, which gives a good view regarding the kind of airspace infringed.

It is to be noted that only 2% of the reported UPAs are attributed to civil-military encounters. This figure consi-ders the military flights operating as ‘OAT’. In 11% of the incidents, the type of operation is not provided by the reporting State.

18

Unauthorised Penetration of Airspace (UPA)as Losses of Separation (LoS)

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20032002 2004 2005 2006 2007 2008 2009 2010

020406080

100120140160

180200

2005 2006 2007 2008 2009 20100%

2%

4%

6%

8%

10%

12%Number of LoS in UPAPercentage of LoS in UPA

Losses pf Separation in UPA(Percentage of number of UPAs)

0%

10%

20%

30%

40%

50%

60%

70%

80%

2005 2006 2007 2008 2009 2010

ABTotal

2009 UAP Distribution by Class of Airspace

11%

33%40%

4%

6%6%

87%

2%

11%GAT/GATGAT/OATNot categorised

0

500

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3000

3500

Taxi DEP En-route ARR

ABCDEFGNot categorised

2009 UAP Distribution by Phase of flight

11%

33%40%

4%

6%6%

87%

2%


0

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1000

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3500



It is of interest to note that in 27% of the reported UPAs, the aircraft involved were flying IfR. In such cases, either the information concerning the other aircraft involved was not available or the IfR flight was the subject of the unau-thorised airspace penetration.

As such, 50% of the UPAs involved aircraft flying visual flight rules. Just 6% of the reported UPAs account for occurrences where the aircraft involved operated IfR and VfR. The percentage of UPAs where the flight rules are unknown/not indicated is quite high, showing that not always the infor-mation on the infringing aircraft is available.

Looking at the type of flight, we find a similar distribution, for example 57% of the aircraft where general aviation, 23% with missing information. The number of occur-rences concerning commercial or general aviation with other flights probably count for the number of UPAs that involved civil and military traffic flying OAT.

Laser Interference

The malicious use of (high) powered lasers has been indicated as a global concern, as this type of incident is a possible hazard to aircraft safety, especially when it concerns aircraft in the final approach phase of their flight. Although a number of such events have been indicated as being of relatively low severity, the increasing number of purposely directed lasers that interfere with aircraft (and potentially ATC) operations pose a potential threat to aircraft and its occupants. In some countries, an increase in the number of attackers who have been convicted by the judicial system, especially in cases when the attacks were oriented against military or police helicopters, is noted. In a number of countries, the identification of the attackers was made using the exact GPS location as identified by the pilot and transmitted to the police.

Discussions on the subject emphasise the problems encountered by different Member States in dealing with this type of occurrence and the different solutions envi-saged at national level.

The SRC tasked the SRC Co-ordination Group (SRCCG) to come up with a position concerning this risk area after several Member States expressed their concerns regar-ding the increasing number of reports received and were looking for a global solution to address this type of occurrence.

The AST-fP Group has also been involved in gathering the latest developments on this issue from in their respective States, with a view to updating the SRC and SRCCG on recent activities and initiatives in this area and to enable the preparation of a formal SRC position on this matter. The graph presents the trend for 13 Member States


2009 UAP Distribution by Phase of flight

11%

33%40%

4%

6%6%

87%

2%


0

500

1000

1500

2000

2500

3000

3500



2009 UAP Distribution by flight Rulesof the Aircraft Involved

16%

3%

17%

41%

Ca/GaCA-GA/OtherNot indicated/UnknonCA OnlyGA Only

23%

IFR OnlyIFR/VFRVFR OnlyNot indicated/Unknon

27%

5%

45%

23%

2009 UAP Distribution by Type of flight

16%

3%

17%

41%

Ca/GaCA-GA/OtherNot indicated/UnknonCA OnlyGA Only

23%

IFR OnlyIFR/VFRVFR OnlyNot indicated/Unknon

27%

5%

45%

23%

reporting in AST-fP Group for the period 2008-2010. If we add data from other sources, the number of reported Laser Interferences in 2010 will be in excess of 4000.

for the last two years, AST-fP Group members have pres-ented the information gathered in their States on activities and actions developed and taken with respect to laser interference as well as the numbers of this type of inci-dents, both domestic and abroad.

The information as provided by the Member States is shown in the graph below, which clearly shows the fast increase in the reported laser interference.

Activities/Actions Related to LaserInterference

The number of reported laser interference occurrences is increasing. This is possibly due to a growing awareness, as well as counter effects having been indicated because of more public attention given to this safety issue.

Generally, incidents involve individuals directing powerful laser beams towards aircraft during (final) approach and aircraft flying at low level (inc. police, rescue helicopters). Some incidents occurred with respect to pointing lasers at local ATC tower facilities.

To highlight a number of activities and actions related to the subject, the following list (not exhaustive) indicates examples which have been taken and/or initiated to address this safety issue from different perspectives and in a number of settings.

Air Navigation Service Providers

Investigations following reports – resulted in Safety Bulletin and research of Legal Situation (e.g. Norway and Sweden).

Pilots Associations

IfALPA – Briefing Leaflet – Effects of Laser Illumination of Aircraft

National (Aviation) Authorities

n CAA revised issue of ATSIN on malicious use of lasers against aircraft and ATS personnel,

n Re-issue of CAP 736 in UK, feb 2011 – re-emphasizes the issue and cooperation with Judicial authorities,

n UK CAA proposed to amend the Air Navigation Order;

(PROPOSED AMENDMENT TO ARTICLE 135 - Dangerous lights;

135(A) A person shall not direct or shine any light in the United Kingdom at any aircraft in flight so as to dazzle or distract the pilot of the aircraft.)

n Austrian Law prohibits ownership of powerful lasers unless approved by authorities,

n Some Member States have issued awareness mate-rial and increased liaison with Police,

n Some Member States have created Stakeholder groups to find the best mitigation measures and started related rulemaking actions.

SRC/EUROCONTROL

AST-FP groupn Gathering of laser interference data from national

representatives – continuous monitoring – gathering of best practice information and its dissemination – coordinate and inform SRCCG and SRC.

dNm/Ops/Safetyn Safety Warning Message – Laser Illumination of

Aircraft and ATC Towers – Impact, Suggested solu-tions, Pilot and Controller Actions, feedback from ANSPs, IATA, Airlines. Coordination and information through SISG and Safety Team.

20

Laser interferences reports

0

500

1000

1500

2000

2500

3000

2008 2009 2010

252

1288

2708

EUROCONTROL hosted a multidisciplinary seminar on 10/11 October 2011, which involved parties such as: States’ regulatory and oversight authorities, ANSPs, pilots and associations, police authorities and repre-sentatives of the judicial system, EUROCONTROL and stakeholders.

Laser interference is confirmed being a global safety and security risk/threat (not just an aviation issue) and a multi-disciplinary pro-active approach is needed to counter the threat. The need for harmonised measures at European/global level was identified, both as short term actions at operational level (reporting procedures, training for pilots and controllers, awareness material, protection measures against lasers) and medium/long term actions (EU Legislation (production, distribution, purchase, carriage and use of certain type of laser) including non-intentional interferences (criminal offence, prosecution, licensing) as well as research for future technologies for the protection of laser interference.

Use of the Term ‘AIRPROx’

In 2003 and 2004, the SRC/SRU participated in a review of the status of the reporting and investigation of Airproxes in EUROCONTROL Member States. It was found that, across Europe the extent to which the processes dealing with reporting and assessment of Airproxes at the time, was at best very limited. The review revealed that, apart from the UK Airprox Board, similar bodies and/or mecha-nisms existed in practically all the States with the notion that in a range of States this only existed and functioned in theory. In addition the definition of AIRPROX used was different in the several states that had an Airprox board or body/mechanism handling reported Airproxes.

A small survey, at the time, observed that comparisons cannot be made based on the figures published by these States Airprox Boards and it was decided that from 2006 onwards no reference to Airproxes were used in SRC reporting and the tracking of Airprox reports was halted. furthermore the usage of Airproxes as a performance indi-cator was stopped. In line with this decision, the PRU/PRC decided to drop the use of Airproxes in their PRR reports for the same reasons as the SRC.

Last year, on request, the SRC and DSS/OVS (the former SRU) conducted another survey with the aim of determi-ning the state of play with respect to Airproxes. The results of that survey show that:

n AIPROXES are dealt with at national level through different arrangements (AIRPROX Board, AAIB, CAA, etc.),

n The situation with respect to the use of the term AIRPROX and harmonised use of the definition has not changed (in comparison with 2003/2004 review by SRC/SRU).

The outcome of the last AST-fP Group meeting in March 2011 showed that: “The definition of the term ‘AIRPROX’ lacks harmonisation and the arrangements put in place at national level in order to deal with such reports differ from one state to another. Furthermore, the usage of AIRPROXs as a performance indicator has been discontinued. Nevertheless, it is assumed that, irrespective of the national arrangements in place, all occurrences that are subject to an Air Proximity Report (separation minima infringement or inadequate sepa-ration) are investigated at national level and their severity is determined (including IFR/VFR encounters where no separa-tion minima is defined, or outside the controlled airspace).”

further monitoring of the AIRPROX subject through the AST reporting mechanism will be ensured by the AST-fP Group. In addition the Group will continue to report on the issue to SRC, through the SRCCG.


Analysis of 2005-2010 SeverityClassification of ATm Incidents

Risk is a factor that exists in every human endeavour, inclu-ding operations involving aircraft, whether in the air or on the ground. Each aircraft movement involves some level of risk because the system, being human-based, is fallible. Identifying and mitigating risk is critical to increasing the level of safety.

To this end, ESARR 2 requires that States shall ensure “that the severity of occurrences is determined, the risk posed by occurrences classified, and the results recorded” (see ESARR 2 – section 5.1.6). It also states that “The assessment/inves-tigation of the occurrence shall enable the determination of the severity level of the occurrence” (ESARR 2, Appendix A, §A-3.1).

The determination of the risk posed by a safety occur-rence is crucial in any safety analysis.

An increase in the number of ATM safety occurrences reported does not necessarily show an increase in the level of risk. An increase in the total number is in itself an impro-vement in safety, giving more visibility of the underlying safety issues.

In order to be able to assess the improvement or deteriora-tion of the risk levels posed by the ATM safety occurrences, they have to be investigated to a level which enables an assessment of the severity and risk. ESARR 2 severity schemes define the severity and risk levels to be assessed and the Risk Analysis Tools (RAT) methodology provides a method for consistent and coherent identification of the risk elements in order to assess the severity and risk. Significantly, the Commission Regulation on the so-called Performance Scheme (EU) 691/2010 identifies the appli-cation of the RAT methodology as a Key Performance Indicator for Safety.

Any safety analysis at the European level is therefore dependent on a complete and consistent severity assess-ment, to give full visibility of the real levels of risk.

However, an analysis of the ATM related incidents reported through the AST mechanism to EUROCONTROL shows that severity assessment situation is deteriorating.

The graph shows the number of ATM related incidents not severity classified for different types of incidents (including a number of already identified key risk areas).

In the area of Unauthorised Penetrations of Airspace, Separation Minima Infringements and Deviation from ATC Clearance, the increase in the last three years is very significant.

ChApTeR 5 - SEvERITY CLASSIFICATION OF ATm RELATEd OCCURRENCES

22

0

100

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700

800

900

2005 2006 2007 2008 2009

SMIRWYISUAPCLR

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35%

40%

45%

0%

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40%

50%

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2010

SMIRWYISUAPCLR

2005 2006 2007 2008 2009 2010

2005 2006 2007 2008 2009 2010

SMIRWYISUAPCLR

Number of occurrencesseverity not classified

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100

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400

500

600

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800

900

2005 2006 2007 2008 2009

SMIRWYISUAPCLR

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2010

SMIRWYISUAPCLR

2005 2006 2007 2008 2009 2010

2005 2006 2007 2008 2009 2010

SMIRWYISUAPCLR

Percentage of occurrencesseverity not classified

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2005 2006 2007 2008 2009

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SMIRWYISUAPCLR

2005 2006 2007 2008 2009 2010

2005 2006 2007 2008 2009 2010

SMIRWYISUAPCLR

Percentage of occurrencesseverity not classified or not determined

The percentage of incidents not severity classified in 2010 varies between 10% and 30% of the total number for each category. If we add the incidents where the severity is clas-sified as “not determined” (i.e. some data provided but not enough to fully assess the severity), the percentages rise to values between 15% and 35%.

As an example, the percentage of Runway Incursions where the severity is either absent or “not determined” remained between 20-30% in the last 6 years which represents almost a quarter of all incidents. This situation renders very difficult an analysis that takes into account all risks posed by this key risk area, as well as the corresponding measurement of the effectiveness of the related Action Plan’s implementation.

The increase in the number of incidents not severity clas-sified is more significant in areas where a major increase in reporting of such occurrences has occurred in recent years, as in the case of Unauthorised Penetration of Airspace.

According to the feed-back received from the AST-fP Group, there is no direct correlation between the number of reported incidents and the resources available to process and analyse the safety related data. Unfortunately in many States the tendency is to reduce even more the available resources. Such measures will continue to nega-tively impact the AST reporting in the future.

Therefore, EUROCONTROL is ready to continue to provide support to the Member States to streamline their processes in respect of reporting and analysis of occurrences, inclu-ding the assessment of the risk posed by such occurrence on the ATM system.

In this context, the Agency has already started to organise training sessions in Member States in respect of the use of RAT, which is now the second key performance indicator for safety, in line with the provisions of the Commission Regulation (EC) No. 691/2010.

Action Plan and Recommendations

This section presents a number of Recommendations prepared by the AST focal Point Group, agreed by SRC and submitted to the Provisional Council for approval. In addition, an Action Plan is presented to SRC for approval to improve the situation at the national level.

Increase in reporting does not lead to an increase in resources available for investigation and safety analysis.

In accordance with the charts given in section above, the increase in the absolute number of incidents not severity classified is much higher than the proportion of incidents not classified. This shows that some of the additional inci-dents reported were “absorbed” and severity classified but a significant number were not.

This lack of resources available for investigation and safety analysis is arguably one of the most difficult areas to mitigate. The AST-fP Group, as a technical body, is not in a position to take effective action on this matter, action is necessary at the higher level. The recommendations should address all the stakeholders involved in the severity classification (Regulatory Authorities, ANSPs, Investigation Authorities, etc.).

Recommendation

Member States shall ensure that sufficient capabilities are available to deal with the reporting, investigation, storing and analysis of ATM safety occurrences.

The severity is not classified at all

This is closely related to the previous point, but also includes cases where the reporting and investigation process does not include such a step, or the severity classes are not compliant with ESARR 2 (e.g. the “severity” is always “Incident”)

The lack of severity assessment could arise in Member States where the transposition of ESARR 2 has not been fully achieved. One solution is that Member States ensure national regulations and/or regulatory procedures include, as a specific step, the severity and risk assessment of ATM safety occurrences and that the result is recorded. Another, more effective, way is to include this requirement in the revision of Directive 2003/42/EC, thus replacing a rulema-king activity in all the States where the EC law applies. The lack of action at this level could also influence the national safety data flows, as there is no legal basis for the regulator to ask for additional data from the ANSPs.

Recommendations

1. Member States to support the inclusion in the revision of Directive 2003/42/EC of the severity and risk assessment of ATM safety occurrences and the result is recorded.

2. Member States to ensure that at the national level the assessment of the severity and risk of ATM safety occur-rences is carried out, including through appropriate procedures and processes, and the results are recorded.


The AST-fP Group Members shall support the improve-ment by submitting to DSS/OVS the cases where the;

n severity and risk assessment of ATM safety occurrences is not required at national level;

n lack of requirements/arrangements prevents the regu-lator or the national focal Point getting the required ESARR 2 / AST data.

National data flows do not ensure that severity is recorded in the national/ regulator database

The full compliance by ESARR 2 / AST requires data collec-tion from both reporting and investigation of safety occurrences. If the latter is not available, for whatever reason, the severity may not be present in the national database and subsequently in the AST report or European Central Repository (or is not as per ESARR 2). Quality assu-rance in the national data flows and the AST reporting is essential for an effective and trustworthy Safety monito-ring process.

To improve the situation, the following Action Plan is pres-ented based on the actions agreed at AST-fP #20:

n identify cases where the severity assessed by an inves-tigation Organisation (e.g. ANSP/ Commission/ Body etc) are not arriving in the national database(s);

n establish bilateral contacts AST-fP with DSS/OVS/SAf to find possible solutions;

n based on the above, define solutions and best prac-tices to be applied at national level;

n continue co-ordination with the SAfREP Tf and SAfREP Ad-Hoc Group for the definition of best prac-tices, link with the RAT methodology implementation, the monitoring of the RAT usage (including by means of AST reporting), input to the RAT User Group.

following the implementation of these technical measures, the AST focal Point group and SRC will address the need for further actions at a higher and mandatory level.

24

for each State, the level of reporting is measured by normalising the total number of reported ATM-related incidents against the number of flight hours in the State.

The numbers of ATm-related incidents used in the analysis are derived directly from the AST report sent by the State to EUROCONTROL SRC. The numbers in the graph below show those States who have submitted AST reports and for which exposure data is available.

The ‘level of reporting’ measures not only the reporting maturity but also the effectiveness of the national safety data flows which allow the AST focal Points to have all the data available to report. It is for this reason that EUROCONTROL continues to provide support to Member States in this field, including by providing appropriate tools and training, for improving the safety data flow.

Initial data for 2010 shows a significant increase of 42% in the total number of incidents reported in comparison with the same period of 2009. The updated data for 2009 now shows an increase of 29% when compared with 2008. The number of States reporting also increased to a record level of 31.

This increase is also evident in the graph, where the number of States reporting above the baseline – 19, is well above the number of States reporting under the baseline – 11. One State from the total number of 31 reporting 2010 data is not included in the graph, as there are no available data regarding the number of flight hours.

Under-Reporting

In terms of the difference in reporting levels between the States, while many States increased their reporting levels in comparison with previous years, they maintain the same gap when comparing with the States reporting at the highest levels. Even by not taking into account the State with the highest number of incidents reported, the average of the next best 3 reporters is still at three times the ECAC average. This situation happens because the best reporters also saw their reporting levels increased at the same rate with the rest of the States.

The good news is that the average reporting level in 2010 (the brown dashed line on the graph) is above the 2003 reporting level of the best in class, which shows that progress has been achieved in the last 7 years. But in the meantime the reporting level of the best in class has also risen and in 2010, applying this rate to all ECAC States, the possible number of incidents that could have been reported in addition (the “Area of improvement” depicted in the graph) translates to more than 50000 ATM related incidents that affect or could affect safety (had all ECAC States reported at the level of the “best” reporters).

ChApTeR 6 - REPORTINg LEvELS


02468

101214161820

2003 2004 2005 2006 2007 20092008

Less than half of the baselineMore than half of the baselineAbove Baseline

States per category

2010

Level of reporting ATM related incidentsBaseline 2003

2002 2003 2004 2005 2006 2008 20092001 20070

1000

2000

3000

4000

5000

6000Average best 3 reporters (2001-2010)Average ECAC rate

2010

Area

of

impr

ovem

ent

Current reporting levels and possible reporting levelsNumber of incidents per million flight hours


APPENdICES

Accidents - Overall Numbers

Based on the AST returns for 31 Member States and the data available from ICAO (covering all ECAC States), in 2010 two non-fatal accidents (runway excursion and another collision on the ground between aircraft and vehicle) were indicated as having an Indirect ATM Contribution. This is an initial assessment, as the accidents are still under investigation.

However, a significant number of accidents are still under investigation and updated results are expected in the next AST reporting round.

Appendix A - ECAC ATm SAFETY PERFORmANCE INdICATORS FOR 2010


02468

101214161820

0

4,000,000

8,000,000

12,000,000

16,000,000

20,000,000

Accidents with direct ATM contributionLinear (Accidents with direct + indirect ATM contribution

ECAC traffic levels (2005-20010)

Accidents with direct + indirect ATM contribution

2005 2006 2008 20092007

Number of accidents Flight Hours

2010

Accidents in ECAC with ATM contribution and traffic levels -aicraft above 2250 kg MTOM (2010 preliminary data)

0

2

4

6

8

10

12

CFIT GNDcollisionacft-acft

Collisionacft-ground

object

Mid-Air

Total 2006 = 99 (fatal 15)Total2007 = 78 (fatal 6)Total2008 = 73 (fatal 14)Total 2009= 66 (fatal 10)Provisionnally 2010 Total= 61

0

12

3

4

56

78

CFIT GNDcollisionacft-acft

Airborne-Ground

GNDacft-other

Mid-Air

Total FatalTotalTotal ATM Contribution

2006 2007 2008 2009 2010

Accident Categories

Initial data for 2010 shows that the most significant acci-dent category was again ‘collision between aircraft and vehicle/person/obstruction(s)’, with 9 accidents indicated, which is about the average of the 2005-2010 interval. Two Mid-air collision and two CfIT accidents were reported.

Overall, seven accidents were indicated as being fatal. As many accidents are still under investigation, changes may surface when further results become available to AST focal Points.

Number of accidents per categoryaircraft with MTOW above 2250 kg

30

0

20

40

60

80

100

120

140

0

200400600800100012001400160018002000

20032002 2004 2005 2006 2007 2008 2009 2010

ABTotal

0200400600800

100012001400160018002000

0

10

20

30

40

50

60

20032002 2004 2005 2006 2007 2008 2009

20032002 2004 2005 2006 2007 2008 2009

2010

2010

0

20

40

60

80

100

120

140

0

200400600800100012001400160018002000

20032002 2004 2005 2006 2007 2008 2009 2010

ABTotal

0200400600800

100012001400160018002000

0

10

20

30

40

50

60

20032002 2004 2005 2006 2007 2008 2009

20032002 2004 2005 2006 2007 2008 2009

2010

2010

Total ATM Related IncidentsOccurrence per million flight hours and severity

Incidents

The classification of ATM-related incidents is based on the severity of their effect on the safe operation of aircraft and occupants as shown in this table (refer also to EAM 2 / GUI 1 and EAM 2 / GUI 5 for more details).

The trend analysis is based on AST data reported by 31 Member States. To ease interpre-tation, incident-related performance indicators (the trends up to 2010) are normalised based on millions of flight

hours, except for runway incursions which are normalised based on millions of aircraft movements (departure and arrivals). There was a 2.9% increase in the number of flight hours of ECAC States and almost no change in the number of arrivals/departures.

general Trends

Initial data for 2010 shows a significant increase of 42% in the total number of incidents reported in comparison with the same period of 2009. The updated data of 2009 now shows an increase of 29% when compared with 2008. See the section ‘Key Safety Indicators’ for an explanation of the increase. When measured against traffic levels, the increase in 2010 is 37.7%.

Most of the increase in newly reported incidents are not severity classified, or the severity class is ‘Not Determined’. This remains a cause of concern and actions are taken to improve the situation (see Section 4 of the report).

An increase in serious incidents (severity A) is observed, but less than the overall increase as their proportion in overall numbers had decreased. The increase in major inci-dents (severity B) is in line with the overall increase.


B - Major Incident



D - Not determined

Not classified






D - Not determined

Not classified

Separation minima Infringements

The initial data reported for 2010 show almost the same level of incidents when measured against traffic levels (3% increase in absolute numbers). However, as this type of occurrence usually take the longest time to be investi-gated, updates are likely to be submitted in the September reporting session.

With respect to the number of serious incidents (Severity A) and major incidents (Severity B), a considerable decrease is shown in severity A (in absolute numbers 27 in 2009 and 17 in 2010), whereas for the major incidents (severity B) a considerable increase is observed.

Near Controlled Flight into Terrain (Near CFIT)

The preliminary data reported for 2010 indicates an increase in absolute numbers (31 near-CfITs reported in 2009 versus 50 for 2010, which is higher than the reported level in 2008). In the risk bearing incidents, there are 4 reported serious incidents (severity A) (nil in 2009, 4 in 2008) and for the major incidents (severity B) an increase is noted compared to 2009 (9 near CfITs reported in 2010, 2 in 2009) and 15 in 2008.


0

20

40

60

80

100

120

140

20032002200120001999 2004 2005 2006 2007 2008 2009

ABTotal

0

20

40

60

80

100

120

140

0

5

10

15

20

25

30

35

40

200320021999 2000 2001 2004 2005 2006 2007 2008 2009

200320022001 2004 2005 2006 2007 2008 2009

2010

2010

2010Separation Minima Infringements

Occurrence per million flight hours and severity

0

20

40

60

80

100

120

140

20032002200120001999 2004 2005 2006 2007 2008 2009

ABTotal

0

20

40

60

80

100

120

140

0

5

10

15

20

25

30

35

40

200320021999 2000 2001 2004 2005 2006 2007 2008 2009

200320022001 2004 2005 2006 2007 2008 2009

2010

2010

2010

0

5

10

15

20

25

30

35

40

45

50

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

2003 2004 2005 2006 2007 2008 2009

Proportion Severity AProportion Severity BProportion Severities A&B

200320022001 2004 2005 2006 2007 2008 2009 2010

Near Controlled Flight Into TerrainOccurrence per million flights hours and severity

Runway Incursions

Preliminary data for 2010 shows a considerable increase of 26% in total numbers of runway incursions reported. This increase is accounted for by increased reporting in general and by some Member States in particular.

The increase is also reflected in the category of risk bearing occurrences - severities A and B, compared to 2009, both in absolute and relative numbers. The increase is more evident in severity class B. While a number of States reported some increase in this severity class, most of it is accounted for by reports from one Member State who showed a similar increase in total number reported.

The percentage of incidents “not classified” in this cate-gory at just over one quarter of the total occurrences is at almost the same level as in 2009.

Unauthorised Penetration of Airspace

The initial data for 2010 show almost the same number of airspace infringements reported compared to 2009 (compared to an increase of 20% in 2009) The number of occurrences not being severity classified in this category has risen to almost 25%.

Within this category, an increase in risk bearing incidents (severity A and B) is noted, which is fully accounted for by a rise in the severity B (major) occurrences, which are at the highest level since we track this category. In absolute numbers, serious incidents (severity A) decreased from 6 to 4 compared to 2009.

In this area, the implementation of the European Action Plan for the Reduction of Airspace Infringements has started in 2010 in a number of States and future analysis will entail the possible impact of the implementation efforts on the recommended and proposed actions by all stakeholders involved.

32

0102030405060708090

0

1

2

3

4

5

6

7

2003 2004 2005 2006 2007 2008 2009 2010

2003 2004 2005 2006 2007 2008 2009 2010

0102030405060708090

0

1

2

3

4

5

6

7

2003 2004 2005 2006 2007 2008 2009 2010

2003 2004 2005 2006 2007 2008 2009 2010

Runway IncursionsOccurrence per million aircraft movements and severity

0

50

100

150

200

250

300

0

1

2

3

4

5

6

7

200420032002 2005 2006 2007 2008 2009 2010

200420032002 2005 2006 2007 2008 2009 2010

0

50

100

150

200

250

300

0

1

2

3

4

5

6

7

200420032002 2005 2006 2007 2008 2009 2010

200420032002 2005 2006 2007 2008 2009 2010

Unauthorised penetration of AirspaceOccurrence per million flight hours and severity

Aircraft deviation from ATC Clearance

The preliminary data reported for 2010 indicates a signifi-cant increase in total numbers for this type of occurrences of almost 34, in line with the increase in overall number of ATM-related incidents. The level of reported incidents remained at almost the same level in a number of States. However, in some other Member States, the numbers have risen considerably compared to the previous year.

for the number of risk bearing incidents (severity A and B), a decrease is noted for serious incidents (severity A) - 11 in 2009 and 8 in 2010. However, for major incidents (severity B), a considerable increase is indicated for 2010: 91 compared to 38 in 2009. This is above the 2007 highest level so far.

Level Busts

The preliminary data for 2010 show an increase of almost 22% compared to the total number of incidents reported in this category in the previous year, and is noted as an all time high. This is not surprising, as this is a sub-cate-gory of ‘Deviation from ATC clearance’ where the increase is 30%. for risk bearing incidents (severity A and B), there is one more serious incident compared to 2009 (5 instead of 4). However, in the major incidents (severity B), a noted increase is indicated compared to 2009 (24 in 2010 as opposed to 15 in 2009), which is at the same level as reported in 2006/2007.

33

0

50

100

150

200

250

20022001 2003 2004 2005 2006 2007 2008 2009

01234

56789

2010

20022001 2003 2004 2005 2006 2007 2008 2009 2010

0

50

100

150

200

250

20022001 2003 2004 2005 2006 2007 2008 2009

01234

56789

2010

20022001 2003 2004 2005 2006 2007 2008 2009 2010

Aircraft Deviation from ATC ClearanceOccurrence per million flight hours and severity

0102030405060708090

100

0100200300400500600700800900

1000

2005 2006 2007 2010

2005 2006 2007 2008 2009

2008 2009

2010

0102030405060708090

100

0100200300400500600700800900

1000

2005 2006 2007 2010

2005 2006 2007 2008 2009

2008 2009

2010

Level Busts resulting in Loss of SeparationPercentage for severy categories A and B

Level BustsNumber of occurrences per severity

ATm Specific Occurrences

Initial data for 2010 shows a significant increase of 29%. This is in line with the increase in the number of incidents reported. The number of States reporting this type of occurrences through the AST also increased from 26 States in 2009 to 29.

In absolute numbers, 15,769 occurrences were reported in 2010, 12,200 in 2009 and 11,993 in 2008.

Severity classification of the results is according to the table below.

The increase in total numbers is also evident in the numbers of the highest risk categories: AA – total inability to provide ATM services - recorded is 14 occurrences (12 in 2009); A - serious inability - 39 in 2010 and 29 in 2009; B – partial inability to provide ATM Services - from 677 events in 2010 and 398 in 2009.

Occurrences Related to ATm Support Functions

An increase is evident in most of the sub-categories; with the highest number of occurrences reported in 2010 being in the area of ‘Data Processing’ followed by the ‘Communication’ and ‘Surveillance’ functions.

34


B - Major Incident



D - Not determined

Not classified






D - Not determined

Not classified

0200

400

600

800

1000

1200

1400

1600

0

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009 2010

2002 2003 2004 2005 2006 2007 2008 2009 2010

Total ATM Specific OccurrencesPer million flight hours & severity

0200

400

600

800

1000

1200

1400

1600

0

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009 2010

2002 2003 2004 2005 2006 2007 2008 2009 2010

Total ATM Specific OccurrencesHigh risk occurences per million flight hours & severity

020406080

100120140160180200

SurveillanceCommunication Data Processing Navigation Information

0

2

4

6

8

10

12

14

SurveillanceCommunication Data Processing Navigation Information

2005 2006 20072004 2008 2009

2005 2006 20072004 2008 2009 2009

Occurrences related to the ATM Support FunctionsOccurrences per million flight hours

Non-Compliances per Critical Area

A more detailed analysis of the audit findings related to each ICAO Critical Element leads to the following summary:

n CE1 (Primary Aviation Legislation) - The level of implementation remains high with 63% of the protocol questions (PQs) relating to the overall legislative framework and organisational arrangements found to be non-compliant. The most problematic aspect remains the determination of sanctions for infringe-ments of SES requirements, required by Regulation (EC) No. 549/2004. Additionally arrangements related to the safety oversight of organisations providing cross border services or functions is one of the key issues when it comes to ATM framework.

n CE2 (Specific Operating Regulations) - In this area, the level of compliance remains unchanged since 2010 report. It is worth noting that 33% of all defi-ciencies found in this critical element related to States’ progress in the publication and implementation of regulations compliant with ESARRs 3, 4 and 5, while 23% of all deficiencies found related to States’ progress in the publication and implementation of regulations compliant with ESARR 2. In addition, 12% of the defi-ciencies found related to the lack of establishment of a safety baseline defining acceptable levels of safety.

n CE3 (State Aviation System and Safety Oversight Functions) - A significant (4%) drop in non-compliances can be observed in the CE when comparing the results of 2011 to the results of 2010. The results show that 29% of all non-compliances discovered in CE3 concerned the arrangements for the establishment of the national supervisory authority exercising effectively the safety oversight activities in ATM matters. 28% of the non-conformities found in this area related to the insufficient identification and establishment of appropriate arrangements as regards the responsibilities, interfaces and coordination neces-sary for the implementation of ESARRs, with ESARR 2 being the most problematic.

Additionally, a high number of PQs found not-satisfac-tory regarding the institutional arrangements related to the lack of appropriate arrangements for close co-opera-tion with other NSAs to ensure adequate supervision of ANSPs holding a valid certificate from one Member State that also provide services relating to the airspace falling under the responsibility of another Member State.

n CE4 (Qualified Technical Personnel and Training) - 50% of deficiencies found in this area relate to safety oversight capabilities, and specifically personnel compe-tency. The main difficulty for States appears to be their ability to employ sufficient technical staff to carry out safety oversight tasks and functions, establish qualifica-tion criteria for oversight personnel and to adequately train such personnel (in 30% of the audited States). Moreover, it is still problematic for States to ensure that the audits are conducted by auditors qualified in accor-dance with ESARR1-related requirements.

n CE5 (Technical guidance, Tools and Provision of Safety Critical Information) - The majority of issues in this CE related to the required conditions for granting licences/certificates, especially the requirements for the operational ATC units to have approved unit trai-ning plans and the initial ATC training courses to satisfy, as a minimum, the ECAC guidelines for Common Core Content training (33% of all the deficiencies found). 30% were related to the lack of appropriate proce-dures for the verification of compliance with safety regulatory requirements. Additionally lack of guidance documentation supporting the review of changes was found to be an issue with 22% of all of the non-confor-mities found for this CE.

n CE6 (Licensing, Certification, Authorisation and Approval Obligations) - 35% of non-compliances raised in this CE were related to the safety oversight of changes to the ATM system, with the majority of problems found in the area of the process for the review of changes. 21% of the deficiencies found in this CE related to the NSAs’ processes to verify the implemen-tation by ANSPs of the on-going ATCOs competency assessment. Significant problems exist as well with regards to the processes of verification of implemen-tation of safety-related conditions identified to allow the proposed operation of new system and verification processes of the implementation of safety objectives, safety requirements and other safety-related condi-tions identified in EC declarations of verification of technical systems (in 30% of the audited States).

n CE7 (Surveillance Obligations) - for this critical element the highest year-on-year drop in the level of implementation of CE7 requirements can be observed (6%). This is due to the greater number of States being audited after ESARR 1 became applicable and the corresponding greater number of non-conformities related to ESARR 1 requirements.

Appendix b - AddITIONAL INFORmATION FROm ThE ESImS AUdIT PROgRAmmE


27% of the deficiencies found in the CE related to inappropriate, or lack of, oversight of changes in the on-going oversight performed by the NSAs. 23% of the non-compliances referred to safety regulatory auditing issues (more especially, programmes of audits and management of audit findings). In addition 14% of the non-compliances related to the process of verification of compliance with safety regulatory requi-rements and 13% to the lack of on-going verification of the implementation by ANSPs of ESARRs 2-6, or their corresponding EC rules where applicable.

n CE8 (Resolution of Safety Concerns) - 26% of all non-compliances related to the lack, or inappro-priate use, of the analysis of ATM safety occurrences to improve regulatory decision-making and other safety regulatory processes. Nearly 23% of the defi-ciencies found referred to the enforcement of safety directives as per ESARR 1 and Commission Regulation (EC) No. 1315/2007, and to the implementation of appropriate enforcement measures in accordance with Article 7(7) of Regulation (EC) No. 550/2004 and Article 9 of Regulation (EC) No. 549/2004. 20% of the non-compliances in this CE were related to the process of the findings management, especially with regards to the proper follow-up of the implementation of the corrective actions (for 30% of the audited States).

36

Sub section of each Critical Element with the highest number of non-conformities found

0 10 20 30 40 50 60 70 80 90 100

CE 1 - Legislative framework & organisational arrangemets

CE 2 - Progress in publication of regulations compliante with ESARR3, ESARR4, ESARR5 and ESARR6

CE 3 - National safety regulator

CE 4 - Safety oversight Capabilities - personnel competency

CE 5 - Required conditions for granting licences/certi�cates

CE 6 - Safety oversight of changes to the ATM system

CE 7 - Safety oversight of changes to the ATM system

CE 8 - Use of reporting and analysis of ATM safety occurences for safety regulatory matters

Top percentage of the de�ciencies found for each Critical Element

Schedule of Audits


State On-site Audit Final Audit Report

DENMARK November 2005 Released April 2006HUNGARY December 2005 Released April 2006MALTA March 2006 Released September 2006SPAIN April 2006 Released November 2006THE NETHERLANDS April 2006 Released December 2006PORTUGAL June 2006 Released November 2006SLOVAKIA October 2006 Released May 2007SLOVENIA November 2006 Released May 2007FRANCE February 2007 Released September 2007FINLAND March 2007 Released September 2007ICELAND June 2007 Released January 2008 UNITED KINGDOM July 2007 Released January 2008AUSTRIA September 2007 Released March 2008ROMANIA October 2007 Released May 2008SWEDEN November 2007 Released June 2008SWITZERLAND December 2007 Released September 2008LITHUANIA February 2008 Released December 2008IRELAND March 2008 Released September 2008LATVIA April 2008 Released November 2008THE FORMER YUGOSLAV REPUBLIC OF MACEDONIA July 2008 Released May 2009BULGARIA October 2008 Released March 2009SERBIA November 2008 Released June 2009CROATIA November 2008 Released August 2009CYPRUS February 2009 Released January 2010ESTONIA March 2009 Released October 2009NORWAY June 2009 Released January 2010BOSNIA&HERZEGOVINA July 2009 Released November 2010POLAND September 2009 Released November 2010MONACO October 2009 Released April 2011CZECH REPUBLIC December 2009 Released May 2011ARMENIA February 2010 Released March 2011GERMANY October 2010 Under developmentUKRAINE December 2010 Under developmentGREECE December 2010 Under developmentAZERBAIJAN February 2011 Under developmentBELGIUM March 2011 Under developmentLUXEMBOURG March 2011 Under developmentITALY April 2011 Under developmentTURKEY May 2011 Under developmentALBANIA June 2011 Under developmentMOLDOVA October 2011 Under developmentMONTENEGRO October 2011 Under developmentMALTA March 2010 Under developmentHUNGARY March 2010 Released December 2010SLOVAKIA November 2010 Released June 2011SERBIA December 2010 Released September 2011LITHUANIA June 2011 Under developmentPORTUGAL September 2011 Under developmentLatvia November 2011 Under developmentSlovenia December 2011 Under development

noTeS

EUROCONTROL

February 2012 - © European Organisation for the Safety of Air Navigation (EUROCONTROL)

This document is published by EUROCONTROL for information purposes. It may be copied in

whole or in part, provided that EUROCONTROL is mentioned as the source and it is not used for

commercial purposes (i.e. for financial gain). The information in this document may not be modified

without prior written permission from EUROCONTROL.

www.eurocontrol.int

SRC Document 50 - Edition 1.0

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Annual Safety Report 2011 - · PDF fileSRC ANNUAL SAfETy REPORT 2011 7 EUROCONTROL has developed and deployed a range of complementary systems to measure the state of ATM safety. These