CAA Safety Plan 2011 to 2013

8/3/2019 CAA Safety Plan 2011 to 2013

http://slidepdf.com/reader/full/caa-safety-plan-2011-to-2013 1/46

2011 to 2013Safet

y Plan

Civil Aviation Authority



2PAGE FOREWORD Civil Aviation Authority Safety Plan 2011/13

The UK has an enviable safety record of

which the industry is rightly proud. However,

there is no doubt that civil aviation in the UK

and in many other parts of the world continues

to face unprecedented operational, economic

and environmental pressures. The need to

improve aviation safety in a proportionate and

cost-effective way is therefore one of the

great challenges faced by the CAA and our

partners in the aviation community.

The recently published CAA Strategic Plan

refers to the UK State Safety Programme,

which includes the CAA Safety Plan, as a keymechanism to drive improved safety

performance across all sectors of the

industry. This Plan has been developed by

the CAA in partnership with industry because

although the CAA has a safety oversight

responsibility, industry has prime

responsibility for managing their safety risk.

Aviation safety is therefore a shared

responsibility and this Plan shows our

commitment to continuous improvement in

safety performance.

This Plan summarises the actions we and

our industry partners are collectively taking

to address safety issues. We are taking a

proactive approach to safety and our Plan is

outcome focussed with great emphasis on

safety performance. We must deliver

results that make a measurable difference,

and ensure that we make the very best use

of our available resources. The actions we

are taking fall into two types.

Firstly, we are taking action to address the

factors behind the most significant

worldwide accident types involving large

airliners – we call these the ‘Significant

Seven’ – as well as actions for other sectors,

such as business aviation, large public

transport helicopters and general aviation. All

actions target specific problems, and many of

these relate to human performance. Much

of this work will involve industry as well as

various European and international partners.

Secondly, we are taking action to address‘capability issues’. We believe that

enhancing our safety risk management

process, promoting a ‘just culture’, industry

implementation of safety management

systems and adoption of a performance-

based regulatory approach will improve the

way the CAA regulates and will result in

safety improvements of benefit to aviation

and the public at large by focussing on the

right risks. To achieve these benefits, we

must ensure that the industry and the CAA

have the right capabilities to deliver these

improvements. The ultimate desire is to

move towards a predictive approach to

safety risk management.

We believe that this Plan represents a

great opportunity to make a difference in

aviation safety. During the period of this

Plan, we expect to see measurable

improvements in safety performance.

Gretchen Burrett

Group Director

Safety Regulation

How to use this document

Each of the summary sections on the

following pages contains a link to the full

description of the issue later in the

document.

‘Significant Seven’ Safety Issues

The CAA ‘Significant Seven’ safety issues

were identified following analyses ofglobal fatal accidents and high-risk

occurrences involving large UK

commercial air transport (CAT)

aeroplanes. For each of these issues, joint

CAA/industry task forces were created to

study the safety issue in-depth and make

recommendations on how their risk could

be mitigated. Task force outputs were

consolidated, prioritised and then shared

and debated with industry at a Safety

Conference in 2010. The key outcome

from this Conference was the clear

prioritisation of loss of control and runway

safety (primarily runway excursions) over

the other safety issues. The key desired

safety outcomes for each of the seven

issues are detailed on the following pages.

Foreword



CFIT risk was found to be greatest

during non-precision approaches

(NPAs) and the most common causes

were: descent below decision/safety

heights without appropriate visual

reference, inadequate monitoring and

lack of positional awareness. Terrain

Awareness and Warning System

warnings were an effective

mitigation but relied on correct flight

crew response, up-to-date terrain

databases and software, and the

most accurate source of position

information feeding into them.Desired Safety Outcome: Reduce the

risk of serious incidents that occur

during NPAs, through enhancements

in technology and training.

Runway Excursion

The key factors in avoiding a runway overrun or

excursion were found to be landing within thetouchdown zone in the correct configuration

and at the correct speed, and if this could not be

ensured, then flying a go-around. Other factors

that increased the risk included provision of

incomplete runway contamination data to

pilots, failure to provide compliant runway

surface friction characteristics and inadequacy

of safety areas surrounding the runway.

Safety improvement activities to mitigate the

risk of runway excursion will therefore focus on

the following three issues:

n reducing unstable/de-stabilised approaches;

n improving information broadcast to pilots on

expected braking action on contaminated

runways; and

n improving safety areas around runways.

Desired Safety Outcome (1 of 3): Reduce the

risk of runway excursions associated with

unstable/de-stabilised approaches.

Loss of Control

Whilst technology has played a significant

part in mitigating the risk of other types of

accident (e.g. GPWS for CFIT and ACAS for

mid-air collision), advances in technology and

automation may not have been fully

supported by corresponding changes in

training, and this may lead to an increased riskof loss of control events. Training and testing

pilot competence currently focuses on their

handling skills rather than monitoring skills.

However, safe operation of complex and

highly automated aircraft relies on each pilot

effectively monitoring the aircraft systems,

automation and the other pilot’s actions.

Safety improvement activities to

mitigate the risk of loss of control will

therefore focus on the following three

issues:

n training and assessment of pilot monitoring

skills;

n use of aircraft automation; and

nmaintenance of manual flying skills.

Desired Safety Outcome (1 of 3): Reduce the

risk of loss of control occurrences and

serious incidents in which inadequate or

ineffective monitoring by the flight crew

was a factor.

3PAGE OVERVIEW Civil Aviation Authority Safety Plan 2011/13

Controlled Flight into Terrain (CFIT)

more

more

more




Runway Incursion

Runway incursions are managed through the Runway Incursions Steering Group

(RISG), a group that has been able to build an excellent working relationship with

industry and stakeholders by working closely together. Continued engagement

with industry will help to see a reduction in the number of runway incursions by UK

registered aircraft, by ground vehicles and at UK aerodromes.

The RISG is represented on the EUROCONTROL Runway

Incursion Prevention Working Group and has contributed to the

development of the revised European Action Plan for the

Prevention of Runway Incursions version 2.0 (EAPPRI2). One

of the key actions to mitigate the risk of runway incursions will

be the promotion of recommendations from EAPPRI2 to

industry.

Desired Safety Outcome: Reduce the risk of

runway incursions at UK licensed aerodromes. Ground Handling

Ground handling safety is managed through

the Ground Handling Operations Safety

Team (GHOST). GHOST is a group whoseaim is to work with the UK aviation industry,

organisations and groups worldwide to

develop strategies to mitigate the safety

risks from ground handling and ground

support activities in the UK and elsewhere.

With the exception of dangerous goods,

ground handling activities are currently not

directly regulated in the UK. Occurrences

classified under the ground handling banner

are numerous and varied. The majority are

classified as low risk. However, those with

the potential to cause the greatest harm to

aircraft safety are loading errors and serious

collisions between vehicles and aircraft

with resulting damage that remains

undetected prior to flight.

Desired Safety Outcome: Reduce the

risk associated with loading errors

involving UK aircraft or at UK aerodromes.

Airborne Conflict

Many of the risks associated with airborne conflict

are already being addressed through working

groups/initiatives and cover issues such as: level

busts, airspace infringements and modelling of

class G airspace utilisation. In addition to these

issues, EUROCONTROL data suggests that a

significant proportion of Airborne Collision

Avoidance System Resolution Advisories (ACAS

RAs) are not responded to correctly, which

supports the need for a review of the effectiveness

of flight crew training in this area.

Desired Safety Outcome: Reduce the risk of mid-

air collisions associated with incorrect responses

to ACAS RA warnings.

more

more

more



One of the target

outcomes from the

CAA Strategic Plan is

that, “the UK aviation

industry and the CAA

will have measurably

increased capability

and performance in

Safety Management,

Human Factors and

Just Culture, and

demonstrated the

benefits in terms of

risk reduction”.

Improved CAAcapability in these

areas will translate to

more effective,

efficient and

proportionate

oversight of the

industry it regulates.

The CAA will work

with industry to help

organisations embed,

where appropriate, best practice in these capability areas into their own safety

management processes. As an example, to most effectively identify and understand

safety risks in the aviation system, the CAA will work with industry to extract the

potential of data sources such as Flight Data Monitoring for fl ight operations related

issues and Maintenance Error Management Systems for maintenance error.

Integrated Safety Risk Management Process

Desired Capability Outcome: Develop a new Integrated Safety Risk

Management Process to allow more effective monitoring and management of

aviation safety risk by the CAA and industry.


Fire

The majority of aircraft fire incidents occurred in galleys, passenger

and toilet areas but these were determined to be relatively low risk

and unlikely to progress to a catastrophic accident. However,

hidden area fires, although relatively infrequent, have a far greater

potential for a catastrophic outcome. Most of the aircraft fires

associated with fatal accidents occurred during the post-crash

sequence and it would be more effective to address the causes of

crashes (e.g. runway excursions) rather than make aircraft more

tolerant to post-crash fire. Nevertheless, the CAA should maintain

the focus on the effectiveness and efficiency of post-crash fire

response whilst continuing to review new technologies and

developments in emergency planning and enhanced fire-fighting.

Desired Safety Outcome: Reduce the risk of hidden area fires

occurring.

Safety Management Systems (SMS)

Desired Capability Outcome: Improve

the safety performance of organisations

through the implementation of effective

SMS and the CAA’s capability to assess

the effectiveness and safety performance

of an organisation’s SMS.

KeyCapabilityIssues

more moremore




Strategy for Human Factors (HF)

Specific HF-related actions are

included throughout this Plan (e.g.

pilot monitoring skills, HF aspects of

airspace infringements and HF

aspects of ground handling safety).

However, a comprehensive review

of human performance is underway

to provide strategic direction for

future HF work. This will include

those factors that shape and

support human performance on a

day-to-day basis.

Desired Capability Outcome:

A better understanding of human

performance, limitations, attitudes

and behaviours to drive the practical

application of Human Factors

principles in reducing risk within the

aviation safety system.

Just Culture

Desired Capability Outcome: To achieve a

balance between the interests of safety (e.g.

protection of safety information) whilst not

tolerating recklessness, and to achieve

improvements in the open reporting of safety

occurrences in parts of the industry where it is

currently lacking.

Continuing Airworthiness


Improve the CAA’s capability to

extract intelligence from all

sources of airworthiness-related

safety data so that the associated

risks are better understood and

the most effective actions to

mitigate them can be identified

and implemented. moremoremore




Total System Threats

The volcanic ash crisis of

2010 was an example of a low

probability but high-impact event

that affected the total aviation

system. A review of lessons learnt

from this event revealed that one of

the CAA’s strengths during the crisis

was its ability to draw upon internal

expertise based on a long

involvement in relevant issues and

previous incidents. The need to retain

such capability is reflected in the CAA

Strategic Plan, together with the need

for continued improvement in theCAA’s expertise, plans and processes

for crisis management, and the

ability to better identify and prevent

or prepare for rare but high-impact

events that affect the total

aviation system.

Performance-Based Oversight

Desired Capability Outcome: Deliver effective

regulation in a manner and at times which have

the greatest impact on preventing significant

aviation losses. Facilitation of proportionate,

targeted and consistent regulation. more

more

Fatigue Risk Management Systems (FRMS)

Desired Capability Outcome: Deliver effective

regulatory oversight of fatigue management

using FRMS techniques and metrics,

proportionate to the size and complexity of the

operational environment. To ensure that safety

critical workers are able to operate at an

effective level of alertness for all normal and

abnormal circumstances. more



Business Aviation

The Business Aviation

sector by its very scope

and diversity of

operations is different to

commercial air transport

and as a result there are

specific challenges to be

acknowledged. Thus the

Business Aviation Safety

Partnership (BASP) was

established not because

Business Aviation is

deemed unsafe but

because it was

recognised that a more

‘tailored approach’ to this

sector was warranted.The BASP is a joint

CAA/industry partnership

that takes a holistic

approach in seeking to

incrementally improve

business aviation safety

and to reduce the

involvement of business

jet aircraft in serious

events. The BASP

Deliverables Document

facilitates management of

BASP work and details

activity in terms of: regulatory work; direct engagement with aircraft operators,

airfield operators and training providers; and the development and distribution of

safety awareness and guidance material. BASP will ensure close links are

maintained with the CAA Flight Operations Inspectorate when dealing with business

aviation safety matters.

Desired Safety Outcome (1 of 3): Reduce the number of and relative contribution

to level busts in UK airspace by business jets.


General Aviation (GA)

Whilst the main focus of this Safety Planis on large commercial air transport, the

CAA remains committed to working

with industry to improve GA safety in a

proportionate manner. The CAA

continues to discuss safety concerns on

GA matters through the General Aviation

Strategic Forum and the General

Aviation Consultative Committee. The

CAA has additionally committed to a

wider review of the Regulatory

Approach to Recreational Aviation. This

will involve working closely with industry

and EASA, to identify and act on

opportunities to adopt a different, more

proportionate approach, while ensuring

that the key safety issues related to this

community are addressed.

Desired Safety Outcome (1 of 3):

Reduce the risk of mid-air collisions

involving GA aircraft.

Large Public Transport

Helicopters

The CAA has been actively

involved with the offshore oil andgas industry in helicopter safety

for over 30 years. The focal point

for helicopter safety issues is the

Helicopter Safety Steering Group

(HSSG), which was formed in

June 2010 with the aim of

proactively identifying and

addressing cross-industry issues

around helicopter safety, related

to helicopter operations in the UK

offshore oil and gas industry.

Desired Safety Outcome:

Reduce the Large Public Transport

Helicopter accident rate through

improvements in helicopter

airworthiness, operational safety

and safety of offshore helidecks.

more more

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9PAGE 1. OUTLINE Civil Aviation Authority Safety Plan 2011/13

1.1 CAA Safety Plan and CAA Strategic Plan

The CAA Strategic Plan’s objective for

enhancing aviation safety is:

To enhance aviation safety performance by

pursuing targeted and continuous

improvements in systems, culture, processes

and capability

The CAA Strategic Plan describes the UK

State Safety Programme (SSP), which will

include the CAA Safety Plan, as the key

mechanism to drive improved safetyperformance across all sectors of the industry.

The SSP and CAA Safety Plan will:

n focus on delivery of improved safety outcomes;

n include clear high-level goals, co-developed

with the aviation community;

n utilise improved techniques and systems of

safety data collection and risk analysis;

n use appropriate leading and lagging indicators

to ensure safety performance is measured. The

indicators will be able to track both precursors to

accidents and maturity (e.g. measures of the

adoption of safety management and culture

change);

n include both continuous monitoring and horizon

scanning to identify potential hazards from a

State-wide perspective; and

n include safety promotion as a key method for

safety improvement.

1.2 CAA Safety Plan and Industry

This Plan has been developed in partnership with

industry through earlier consultations and the

Safety Conference in October 2010. Much work

has already been done by the ‘Significant Seven’

task forces for which industry has played an

essential part. Whilst the Safety Conference

focused primarily on commercial operations, the

identification of safety risks within general

aviation and other sectors of the industry, and

the associated actions, have not been ignored.

The work following on from the Strategic and

Regulatory Reviews of General Aviation in 2006has highlighted a number of safety issues.

For the actions identified in this Plan to be

progressed, industry involvement remains

essential. For example, to produce best practice

guidance for flight deck monitoring, the intention

is to develop this with industry through the Loss

of Control Action Group. The outcomes of

actions contained in this Plan will be

disseminated more widely through existing

industry liaison groups. Throughout this process,

the CAA will work with industry to determine

what it can do, from a regulators point of view,

to best help industry implement these outcomes

as part of their own safety plans.

1.3 European Aviation Safety Plan

Through this Safety Plan, the CAA aims to both

support and influence the new European

Aviation Safety Plan (EASP), so ensuring that the

UK plays a significant part in safety planning at a

1. Outline

European level. The alignment between this

Safety Plan and the EASP is shown for relevant

Safety Actions in Sections 3 and 4. The CAA also

remains committed to supporting the European

Strategic Safety Initiative (ESSI), and specifically

each of the three pillars: European Commercial

Aviation Safety Team (ECAST), European

Helicopter Safety Team (EHEST) and European

General Aviation Safety Team (EGAST).

1.4 Way Forward

Although this Safety Plan covers the period 2011

to 2013, it will be reviewed annually and updated

where necessary to ensure that the right risks

have been identified and that the right actions

are being taken to mitigate these risks.



based oversight model that is able to address

risks in a transparent way throughout the whole

UK aviation system and is able to demonstrate

that effective management is in place. At the

system level, this is dealt with by the SSP. This

document deals with those risks that can be

managed directly by the CAA in partnership with

industry.

2.2 Monitoring Safety Actions

All Safety Plan action items have expected safety

benefits and Safety Performance Indicators

(SPIs) to enable the continuous monitoring of the

impact of the action taken. It is crucial to the

success of the Plan to monitor systematically

and routinely the safety performance of the UK

aviation system in close cooperation with

industry. The following arrangements will

provide this monitoring capability.

2.3 Governance of Safety Plan

A small high-level group of CAA, DfT andindustry management will oversee, steer and

challenge the progress of the SSP, including the

Safety Plan, and ensure that it continues to

deliver. The first meeting will be held in

September 2011. A wider CAA/industry group

will be invited to review progress and give

feedback annually.

2.4 Communication with Stakeholders

The CAA will regularly use existing consultative

committees/ liaison groups to keep industry

updated with progress on actions and to

maintain high levels of industry engagement,

which is essential for the successful delivery of

the Plan and enhancement of safety. The CAA

may also periodically organise conferences to

consider whether the current risks are still the

priority, and the extent to which the actions are

having the appropriate outcome, or to discuss

subjects of specific interest.

10PAGE 2. SAFETY FRAMEWORK Civil Aviation Authority Safety Plan 2011/13

2.1 ‘Significant Seven’ and Capability

The actions contained in this Safety Plan fall

into two types: those to address the seven

foremost aviation safety issues (‘Significant

Seven’ Safety Issues), and those to improve

capability in important individual subject areas

such as Continuing Airworthiness and Human

Factors (Key Capability Issues).

The CAA ‘Significant Seven’ safety issues

were identified in 2009 following analyses of

global fatal accidents and high-risk occurrences

involving large UK commercial air transport

(CAT) aeroplanes. The former involved thesystematic analysis, by a multi-disciplinary team

of experts, of more than 1,000 global fatal

accidents dating back to 1980; identifying

causal and circumstantial factors and accident

consequences. The latter involved a similar in-

depth analysis of more than 100 high-risk

Mandatory Occurrence Reports (MORs)

specifically involving UK aircraft.

For each of these issues, joint CAA/industry

task forces were created to study the safety

issue in-depth and make recommendations on

how their risk could be mitigated. Further

information on the output for each of the task

forces can be seen in CAA Paper 2011/03 – CAA

'Significant Seven' Task Force Reports, which is

available for download on the CAA website.

Task force outputs were consolidated and

prioritised to identify the key desired safety

outcomes, actions to achieve them, measures to

track safety performance and effectiveness of

the actions to be taken. The output was then

shared with industry and debated at a Safety

Conference in October 2010. The key outcome

from this Conference was the clear prioritisation

of loss of control and runway safety (primarily

runway excursions) over the other safety issues.

Also identified was the need to better understand

human factors and particularly their contribution

to the root causes of accidents, the importance

of a good organisational culture as a prerequisite

for a good safety culture and the need to join-up

Safety Management Systems (SMS) across all

aviation disciplines. These priorities are reflectedin the actions contained in this Plan.

The actions for large CAT aeroplanes are

categorised in the framework, in Table 1, as the

‘Significant Seven’ safety issues and the key

capabilities that the CAA and industry need to

possess to most effectively manage these

safety issues. There are also actions to cover

business aviation, large public transport

helicopter operations and general aviation.

More information on the associated actions,

deliverables, timescales and performance

indicators is contained in Section 3.

The ‘Significant Seven’ is, of course, just a

starting point. The risks to the total aviation

system in the UK need to be better understood,

and each individual and organisation in the

system has a unique risk profile based on the

activity it or they undertake within the system. To

continue to improve aviation safety in the UK,

there will need to be a move to a performance-

2. Safety Framework

Table 1: Safety Framework

‘Significant Seven’ Safety Issues

(in priority order)

1. Loss of Control

2. Runway Excursion

3. Controlled Flight into Terrain

4. Runway Incursion

5. Airborne Conflict

6. Ground Handling

7. Airborne and Post-Crash Fire

Key Capabilities Required for theTotal Aviation System

n Integrated Safety Risk Management

Process

n Continuing Airworthiness

n SMS

n Just Culture

n Human Factors

n Performance-Based Oversight

n Fatigue Risk Management Systems

n Total System Threats



11PAGE 2. SAFETY FRAMEWORK Civil Aviation Authority Safety Plan 2011/13

2.5 Safety Performance IndicatorsAs part of the Integrated Safety Risk

Management Process (ISRMP) project, a full

suite of SPIs, utilising various data sources, will

be developed by the CAA in partnership with

industry. These SPIs will include both leading

and lagging indicators (including precursor

events), and will expand on the SPIs described in

this document. SPI development will include

measures required to monitor the performance

of UK Air Navigation Services as part of the UK

National Performance Plan (NPP).A Network of Analysts (NoA) is being created

to facilitate development of these SPIs, and will

comprise of safety analysts from the CAA and

industry. The NoA will review the quality and

consistency of data currently submitted as

MORs, establish the necessary data streams and

coordinate analyses of common interest across

the industry.



12PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13

3.1 ‘Significant Seven’ Safety Issues

This section describes actions to mitigate

specific safety risks to large CAT aeroplanes,

which are considered to have the greatest

potential for improving safety. They are the

result of issues raised through detailed study of

the key safety risks by the joint CAA/industry

‘Significant Seven’ task forces and validated

through consultation with industry. They also

include other major projects that were

underway prior to initiation of the task forces.

Implementation of these actions and realisation

of their benefits will involve a collaborativeeffort between the CAA and industry.

3. Safety Actions



Whilst technology has played a

significant part in mitigating therisk of other types of accident

(e.g. GPWS for CFIT and ACAS

for mid-air collision), advances

in technology and automation

may not have been fully supported by

corresponding changes in training, and this may

lead to an increased risk of loss of control events.

Training and testing pilot competence currently

focuses on their handling skills rather than

monitoring skills. However, safe operation of

complex and highly automated aircraft relies oneach pilot effectively monitoring the aircraft

systems, automation and the other pilot’s actions.

Safety improvement activities to mitigate the

risk of loss of control will therefore focus on the

following three issues:

n training and assessment of pilot monitoring skills;

n use of aircraft automation; and

nmaintenance of manual flying skills.

Desired Safety Outcome (LOC1): Reduce the

risk of loss of control occurrences and serious

incidents in which inadequate or ineffective

monitoring by the flight crew was a factor.

The safe operation of complex and highly

automated aircraft relies on effective monitoring of

the aircraft systems, automation and the other

pilot’s actions. However, there is currently minimal

guidance on the training and assessment of pilot

monitoring skills.


SIGNIFICANT

SEVEN

Deliverables and Dates:

1. Report produced on current best practice inmonitoring and associated training delivery

methods. Specific attention will be paid to

monitoring of low airspeed as safety data high-

lights this as a particular issue.

November 2011

2. a) Gap-analysis report produced.

February 2012

b) CAA best practice guidance documentproduced on training and assessment of pilot

monitoring skills.

August 2012

3. a) Dissemination of best practice guidance

document and education of CAA Flight

Operations Inspectorate completed.

November 2012

b) CAA Flight Operations to disseminate

monitoring training and assessment best

practice to industry, promote its use with EASA

and undertake oversight activity to ensure that

operators appropriately consider the principles

of best practice in their own risk mitigation

activities.

January 2013

Expected Safety Benefit:

An increased focus on the monitoring role within amulti-crew flight deck would be expected to

improve the likelihood of the recognition and

avoidance of potential loss of control events.

Key Performance Indicators:

Action success and overall loss of control risk will

be tracked using the following key performance

metrics:

n Loss of control events.

n Stick-shake and alpha floor events.

n

Take-off configuration warnings.n Low speed during approach events.

n Low speed during cruise events.

n Proportion of UK aircraft operators to have

implemented and actively monitor loss of control

precursor measures.

n Proportion of UK AOC holders to have

implemented pilot monitoring skills training as per

new best practice guidance document.

n Proportion of pilots employed by UK AOC holders

that have received pilot monitoring skills training as

per new best practice guidance document.

Safety Outcome Owner:

n CAA/Flight Operations Liaison Group (FOLG)

Loss of Control Action Group for actions 1, 2 and 3a.

n CAA Flight Operations Inspectorate (Aeroplanes)

for action 3b.

Alignment with European Aviation Safety Plan:

n Reference: Safety Actions AER4.6 and 4.7.

Actions to Achieve Desired Safety Outcome:

1. CAA, in partnership with industry, tocommission independent research into current

best practice in monitoring and associated

training delivery methods, and to determine

whether improvements are necessary. This

research will cover UK and international

aviation, and other industries, where

appropriate.

2. If existing best practice is deemed to be

insufficient, then CAA, in partnership with

industry, to develop new best practice includinga gap-analysis from the current to the new

state, and guidance on the best way to deliver

training and how to assess its effectiveness.

3. CAA to disseminate this best practice to

industry, promote its use by EASA and educate

its Flight Operations Inspectorate so that it can

most effectively audit operators for compliance

with this best practice where appropriate.

3.1.1 Loss of Control





risk of loss of control occurrences and serious incidents in which inadequate or

ineffective use of aircraft automation by the

flight crew was a factor.

Analysis of accidents and high-severity

occurrences identifies instances when the

misuse, or inappropriate use, of automation has

led, either directly or indirectly, to a loss of

control condition.


1. CAA, in partnership with industry, to reviewthe finalised FAA report on their study of crew

interaction with flight deck automation and the

Cranfield University research report into training

for automation, distil the key issues, i dentify the

key priorities for action and decide on the need

for further research.

2. CAA, in partnership with industry, to act on

the findings of the review.


1. a) Report produced on review of FAA studyand Cranfield University research.

January 2012

b) Workshop held with industry to discuss

findings of review and to identify the top-three

key priorities for action.

March 2012

2. Plan developed for the implementation of

actions to mitigate the risk of the top-three

findings from the review.

May 2012


A modified methodology for the training ofautomation in complex and highly automated

aircraft would better equip pilots to identify and

avoid loss of control situations. This training

methodology would place an increased focus on

the holistic use and management of the

automation rather than training the individual

functionality of the automation.


Action success will be tracked using the

following key performance metrics:



n Take-off configuration warnings.

n Low speed during approach events.



n CAA/FOLG Loss of Control Action Group.









risk of loss of control occurrences and serious incidents in which inadequate or

ineffective manual flying skills by the flight

crew was a factor.

A lack of manual flying skill has been

identified as a causal factor in a number of loss

of control events that have led to an accident or

high-severity occurrence. In particular, it has

been identified that this lack of manual flying

skill becomes critical when the use of

automation is either inappropriate or not

possible. Situations occur when manual flying

skills are key to the safe recovery of an aircraft

flight path disturbance which, without

competent intervention, might otherwise

become catastrophic.


1. CAA to disseminate the Jet Upset RecoveryTraining Aid Tool and its associated DVD to all

UK commercial pilots.

2. CAA to investigate the feasibility of

incorporating the manual flying skills measuring

methodology, developed through research with

Cranfield University, into a Flight Data

Monitoring (FDM) tool, and, if found practical, to

then implement and exercise it in an airline trial.

This methodology currently applies specifically

to a simulator exercise to perform a single-

engine ILS approach. However, if the trial is

successful, then future work will investigate if

extensions to the tool could be used for other

scenarios.


1. Jet Upset Recovery Training Aid Tool andassociated DVD (once available) distributed to all

UK commercial pilots.

December 2011

2. a) Feasibility report produced.

April 2012

b) If feasibility is positively demonstrated,

then methodology incorporated into an FDM

programme and trialled with at least one UK

airline.

December 2012


In situations where a pilot had inadvertentlyencountered a situation that could lead to a loss of

control, it may be imperative for the pilot to

possess the key manual flying skills necessary for

recovery. These skills need to be taught and then

practised on a regular basis such that they are

maintained to a competent and appropriate level.



following key performance metrics:



n Take-off configuration warnings.

n Low speed during approach events.


n Proportion of UK AOC holders to have

implemented training using the Jet Upset

Recovery Training Aid.

n Proportion of pilots employed by UK AOC

holders that have received training based on the

Jet Upset Recovery Training Aid.


n CAA Flight Crew Standards for action 1.

n CAA Group Safety Services for action 2.







1. Unstable/de-stabilised approach measuresdeveloped and implemented.

April 2012

2. Monitoring of unstable/de-stabilised

approaches and, where appropriate,

implementation of risk mitigation checked for UK

operators.

Ongoing

3. a) Unstable approach awareness included in

ATCO Training for Unusual Circumstances and

Emergencies (TRUCE).

Ongoing

b) Pilots attending TRUCE training.

Ongoing

c) Repository of information on flight deck

awareness for controllers developed in

partnership with industry.

December 2011


1. CAA, in partnership with industry, to develop,implement and monitor measures of unstable/de-

stabilised approaches as part of a wider suite of

runway excursion precursor measures.

2. CAA, through the Flight Operations

Inspectorate operator oversight programme, to

check that UK operators monitor for unstable/de-

stabilised approaches and, where appropriate,

mitigate their risk.

3. CAA, in partnership with industry, to review air

traffic control (ATC) procedures and improve ATC

Officer (ATCO) training, to minimise the likelihood

of ATC contributing to unstable approaches. This

will involve liaison with the NATS Safety

Partnership Agreement work on unstable

approaches.


Reduction in the number of unstable/de-stabilisedapproaches that continue to a landing will reduce the

risk of aircraft touching down at the incorrect speed

and/or position with a corresponding reduction in the

risk of running off the side or end of the runway.


Action success and overall runway excursionrisk will

be tracked using the following key performance

indicators:

n Runway excursion and overrun events.

nUnstable/de-stabilised approaches: all and

proportion that continue to landing.

nDeep landing events.

nHigh-speed touchdown events.

nHigh-speed rejected take-off events.


implemented and actively monitor runway excursion

precursor measures.

n Proportion of air traffic controllers to have

completed unstable approach awareness training

through TRUCE.

nNumber of pilots to have attended a TRUCE training

session.



n CAA Flight Operations Inspectorate (Aeroplanes) for

action 2.

n CAA Air Traffic Standards for action 3.



The key factors in avoiding a

runway overrun or excursionwere found to be landing

within the touchdown zone

in the correct configuration

and at the correct speed,

and if this could not be ensured, then flying a

go-around. Other factors that increased the

risk included provision of incomplete runway

contamination data to pilots, failure to provide

compliant runway surface friction

characteristics and inadequacy of safety areas

surrounding the runway.

Safety improvement activities to mitigate

the risk of runway excursion will therefore

focus on the following three issues:

n reducing unstable/de-stabilised approaches;

n improving information broadcast to pilots on

expected braking action on contaminated

runways; and

n improving safety areas around runways.

As well as implementing the following

actions, the CAA will also support the

development of the European Action Plan on

the Prevention of Runway Excursions

(EAPPRE), a task led by EUROCONTROL in

cooperation with the European Commercial

Aviation Safety Team (ECAST).

Desired Safety Outcome (RE1): Reduce the

risk of runway excursions associated with

unstable/de-stabilised approaches.

SIGNIFICANT

SEVEN

3.1.2 Runway Excursion




Desired Safety Outcome (RE2): Introduce

capability for aerodrome operators to provide meaningful data to pilots concerning expected

braking action on contaminated runways.


1. a) Updated policy and guidance on winteroperations disseminated to UK industry, and used

to influence EASA aerodrome requirements and

guidance.

October 2011

b) Winter Information Group (WIG) Winter

Runway Assessment Trial: report and

recommendations produced.

September 2012


1. CAA to support and influence efforts tostandardise International (ICAO) and European

(EASA) standards and recommended practices

associated with both runway braking action and

aircraft performance so that unambiguous and

easy to use information is passed to flight crew.

This will be used to enhance the pilot’s decision-

making process when calculating take-off and

landing distances required.


n Consistent and relevant informationpromulgated to enable flight crews to be better

equipped to anticipate the braking action

expected on contaminated runways.



following key performance indicators:

n Runway excursion and overrun events with

runway contamination as a contributory or

causal factor.

n Take-off/landing events involving loss of

aircraft directional control caused by

contaminated runway surface.

n Proportion of UK licensed aerodromes using

‘new reporting criteria’ for runway surface

condition.

n Proportion of UK licensed aerodromes correctly

carrying out an agreed runway maintenance

friction testing regime as per CAP 683.


n CAA Aerodrome Standards.


nReference: Safety Actions AER1.2, 1.3, 1.5 and 1.6.





Desired Safety Outcome (RE3): Improve the

safety areas around runways.


1. CAA to encourage UK licensed aerodromeswith the minimum compliant Runway End

Safety Area (RESA) to review runway excursion

risk factors regularly and consider alternative

and additional mitigation measures.

2. CAA to work to influence appropriate drafting

of objective-based requirements in EASA and

ICAO aerodrome regulations.


1. RESA risk assessments conducted by UKlicensed aerodromes with minimum compliant

RESAs.

December 2012

2. Objective-based requirements and

associated guidance material for overrun safety

areas included within EASA and ICAO

aerodrome requirements.

March 2012


In moving away from compliance-based thinking,licensed aerodromes will have fully considered

the risks of runway excursion and taken

appropriate actions to mitigate such risks.


Action success will be tracked using the following

key performance indicators:

n Proportion of UK licensed aerodromes with

minimum compliant RESAs that have

implemented additional mitigation measures.


n CAA Aerodrome Standards.


nReference: Safety Actions AER1.2, 1.3, 1.5 and 1.6.




CFIT risk was found to be

greatest during non-precision approaches (NPAs)

and the most common

causes were: descent below

decision/safety heights

without appropriate visual reference,

inadequate monitoring and lack of positional

awareness. Terrain Awareness and Warning

System warnings were an effective mitigation

but relied on correct flight crew response, up-

to-date terrain databases and software, and the

most accurate source of position information

feeding into them.


serious incidents that occur during NPAs,

through enhancements in technology and

training.


SIGNIFICANT

SEVEN

3.1.3 Controlled Flight into Terrain (CFIT)


1. CAA to run an education campaign aimed atoperators, highlighting the safety and cost

benefits of Approach with Vertical Guidance

(APV) type approaches.

2. CAA to investigate implementation of APV-

type approaches in USA to identify factors that

could help accelerate implementation in

UK/Europe and feed this back to the ongoing

European work in this area.

3. CAA to simplify the process for APV

approval.

4. CAA to encourage operators to become APV

approved and aerodrome operators to make

provisions.


1. Information brochure jointly produced byCAA and NATS and disseminated to all aircraft

and aerodrome operators.

September 2011

2. Report presented to EASA/EUROCONTROL.

December 2011

3. Simplified approval process developed.

December 2011

4. Programme of safety promotion road-shows

to aircraft and aerodrome operators

implemented.

March 2012


Reduction in the high proportion of CFIT-relatedincidents/accidents that occur during NPAs.


Action success and overall CFIT risk will be tracked

using the following key performance indicators:

n (E)GPWS warnings (by mode and whether

genuine, nuisance or false).

nUnstable/de-stabilised approaches: all and

proportion that continue to landing.

n Significant deviation below glideslope events.

nGross position error events.

n Deviation below minimum safety altitude events.


implemented and actively monitor CFIT precursor

measures.

nNumber of APV-type approaches published in the

UK AIP compared with traditional NPAs.

nNumber of APV-type approaches at EU and third-

country aerodromes, which are UK operator

destinations.

n Proportion of relevant UK fleet approved for APV-

type approaches.

n Proportion of approaches flown by UK operators,

which have some form of vertical guidance.


n CFIT Task Force.






3.1.4 Runway Incursion

Runway incursions are

managed through theRunway Incursions Steering

Group (RISG), a group that

has been able to build an

excellent working relationship

with industry and stakeholders by working

closely together. Continued engagement with

industry will help to see a reduction in the

number of runway incursions by UK registered

aircraft, by ground vehicles and at UK

aerodromes.

The RISG is represented on the

EUROCONTROL Runway Incursion Prevention

Working Group and has contributed to the

development of the revised European Action

Plan for the Prevention of Runway Incursions

version 2.0 (EAPPRI2). One of the key actions

to mitigate the risk of runway incursions will be

the promotion of recommendations from

EAPPRI2 to industry.


runway incursions at UK licensed

aerodromes.


1. CAA to audit and support all UK licensedaerodromes to, through their Local Runway

Safety Team (LRSTs), review, identify and

address infrastructure and communication

issues such as taxi patterns, signage and

complex RT procedures; and that they develop

appropriate mitigations where appropriate (e.g.

publication of runway hotspots).

2. CAA, in cooperation with EUROCONTROL,

EASA and ICAO, to promote the development

and implementation of technologies designed to

prevent runway incursions.


1. LRSTs in place, where appropriate, andworking effectively with based and visiting

operators to manage the runway incursion risk.

Improved and more effective communication

between local stakeholders on runway incursion

issues.

April 2012

2. a) Proposal tabled at ICAO Runway Safety

Symposium that ICAO should ensure coordinated

development of requirements for runway safety

technologies to ensure a globally consistent

service to aerodrome users, interoperability and

avoid duplication of effort.

May 2011

Action Completed: This was raised and tabled

for further discussion by ICAO.

b) Work commissioned to define a workable

runway incursion prevention technology, with a

view to promoting its development to the

international community.

April 2012

c) Investigation of new runway incursion

prevention procedures completed.

April 2012


n Will enable all parties to gain a betterunderstanding of the issues that affect each

other, and this will enable a partnership

approach to robust resolution of the issues.

nWill ensure that LRSTs are providing meaningful

and useful output based on local risks.


Action success and overall runway incursion

risk will be tracked using the following key

performance indicators:

n Runway incursions at UK aerodromes or

involving UK operators broken down by severity

grade.

n Proportion of UK licensed aerodromes that

have implemented recommendations from

and/or audited themselves against EAPPRI2.

n Proportion of UK licensed aerodromes with an

LRST that have been audited for success.


n CAA Aerodrome Standards for actions 1, 3

(aerodrome part) and 4.

n RISG for action 2.

n CAA Air Traffic Standards for action 3 (ANSP

part).

n CAA Flight Operations for action 3 (AOC part).


n Reference: Safety Actions AER5.1, 5.2, 5.4

and 5.5.

SIGNIFICANT

SEVEN




3. a) Information Notice on EAPPRI2

disseminated to all UK licensed aerodromes, UK

ANSPs and UK AOC holders.

June 2011

Action Completed: Information Notice IN

2011/51 issued on 17 June 2011.

b) Implementation of EAPPRI2

recommendations by UK licensed aerodromes,

UK ANSPs and UK AOC holders, where

appropriate, checked at subsequent audits.

June 2012

4. Strategy, standards and guidance for airside

driver training developed and implemented in

conjunction with industry.

December 2011

3. CAA to promote recommendations from the

EUROCONTROL work on EAPPRI2 to UK

industry.

4. CAA, in cooperation with industry, to

implement new standards and provide guidance

on airside driver training.

3.1.4 Runway Incursion


Continued


Continued



Many of the risks associated

with airborne conflict werealready subject to ongoing

work by groups/initiatives

prior to the task force

initiative starting. These key

groups/initiatives and their associated activities

are listed below.

Level Bust Working Group (LBWG)

The LBWG is co-chaired by the CAA and NATS

and key activities include:

n Roll-out of the Barometric Pressure Setting

Advisory Tool (BAT) at London Terminal Control

Centre to allow controllers to highlight incorrect

altimeter setting to pilots.

n Engagement and awareness activities with

the business aviation community (see section

4.1 for specific actions).

n Work with a UK operator on ‘day-to-day flight

deck measures’ (e.g. observations of detailed

flight deck behaviours associated with altimeter

setting) to monitor level bust risk.

Airspace & Safety Initiative (ASI)

The ASI is a joint CAA, NATS, Airport Operators

Association, GA and Ministry of Defence effort to

investigate and tackle the major safety risks in UK

airspace (see http://www.airspacesafety.com).

The ASI has working groups on Air Traffic

Services Outside Controlled Airspace (ATSOCAS),

infringements, airspace design and classification,

equipment carriage, and off-route commercial


SIGNIFICANT

SEVEN

3.1.5 Airborne Conflict

demand, balances the needs of all users and

mitigates the impact of aviation on theenvironment (see http://www.caa.co.uk/fas).

Implementation of the FAS by the UK aviation

industry will enable, amongst other things, the

following safety outcomes:

n Performance based navigation that allows

routes to be flown more accurately and

consistently.

n Building flexibility and resilience into the

system reduces the occurrence of pinch points

and high-risk situations.

n New communications, navigation and

surveillance technology awareness of users and

controllers.

n Simplification of the airspace structure and

classification reduces potential for errors,

infringements and level busts.

Delivery of the Strategy, including its safety

benefits, will be ensured through continued

support of the FAS work via the FAS Programme

Board and partnership with the FAS

Implementation Group.

In addition to continuing to support these

initiatives, the CAA will work more closely with

ANSPs in the implementation of their safety

plans, where relevant, particularly in areas of

responsibility where the CAA has the ability to

facilitate progress.

Given the existence of many ongoing

initiatives, the Airborne Conflict Task Force

operations. Safety improvement work on

infringements is carried out under the auspices ofthe Airspace Infringement Working Group

(AIWG), some of whose key activities are

described below, followed by those for airspace.

AIWG

n Provide guidance to flying instructors on

navigation training priorities within training

syllabi if there is no scope for syllabus change.

n Improve understanding of Human Factors

aspects of infringements.

n Train pilots what to do if they infringe (i.e. pilot

responsibilities at the moment when they

believe they have infringed).

n Develop guidance on the content of instructor

seminars.

n Explore the possibility of greater electronic

conspicuity of aircraft.

Airspace

n Study and modelling of Class G airspace

utilisation to better inform knowledge of

airspace ‘hotspots’.

n Replacement of Class F airspace (UK Advisory

Routes).

Future Airspace Strategy (FAS)

The FAS aims to provide a policy structure to

enable a modernised air traffic management

system that provides safe, efficient airspace,

that has the capacity to meet reasonable

focussed on safety issues that were not already

covered. One of their main conclusions wasthat the most effective barrier in resolving

airborne conflicts was the correct following of

ACAS Resolution Advisories (RAs). However,

EUROCONTROL data suggests that a significant

proportion of ACAS RAs are not responded to

correctly, which supports the need for a review

of the effectiveness of flight crew training in this

area. The following actions address this issue.





mid-air collisions associated with incorrect responses to ACAS RA warnings.


1. a) AIC on ACAS training updated andpublished.

December 2011

b) Recommendations to amend Doc 8168

submitted to ICAO.

January 2012

2. Investigation report completed and

promotion plan implemented.

December 2011

3. Report on ACAS simulator training devices

completed and advice disseminated to industry

via the Senior Examiners Newsletter and the

Type Rating Examiner Newsletter.

March 2012


1. a) CAA to update its guidance material onACAS training.

b) CAA to liaise with ICAO to amend ICAO

Doc 8168 – Aircraft Operations to better cover

ACAS training.

2. CAA to investigate and promote, where

appropriate, the use of part-task/desktop

additional training aids for ACAS training.

3. CAA to sample the quality of ACAS simulator

training, establish the range of capabilities of

devices to simulate realistic ACAS event

scenarios and ensure that operators are aware

of the potential of each simulator in this regard.


Reduced risk of collision resulting from incorrectuse of ACAS and enhancement of the final

safety barrier to mid-air collision (other than

providence).


Action success and overall airborne conflict



n Loss of separation in UK controlled airspace.

n Risk-bearing UK AIRPROX outside of

controlled airspace.

n Risk-bearing foreign AIRPROX involving UK

aircraft.

n ACAS RAs: all genuine RAs and proportion

involving incorrect pilot response.

n Level busts in UK airspace.

n UK airspace infringements.


implemented and actively monitor mid-air

collision precursor measures.


n CAA Flight Operations ACAS Focal Point

(with close liaison with the ASI ACAS Working

Group).


n Reference: Safety Actions AER2.8 and 2.9

(plus AER2.1 for work carried out by the AIWG).

3.1.5 Airborne Conflict




Ground handling safety is

managed through the GroundHandling Operations Safety

Team (GHOST). GHOST is a

group whose aim is to work

with the UK aviation industry,

organisations and groups worldwide to develop

strategies to mitigate the safety risks from

ground handling and ground support activities in

the UK and elsewhere. With the exception of

dangerous goods, ground handling activities are

currently not directly regulated in the UK.

Occurrences classified under the ground

handling banner are numerous and varied. The

majority are classified as low risk. However,

those with the potential to cause the greatest

harm to aircraft safety are loading errors and

serious collisions between vehicles and aircraft

with resulting damage that remains undetected

prior to flight.

Desired Safety Outcome: Reduce the risk

associated with loading errors involving UK

aircraft or at UK aerodromes.


1. CAA, in partnership with industry, to developloading error education material for promulgation

to Ground Service Providers and airlines.

2. CAA, in partnership with industry, to explore

the human factors aspects of ground handling

safety in depth.


1. DVD containing educational materialpromulgated to Ground Service Providers,

airlines, pilots. The intended audience is anyone

who may have an impact on the safe loading of

aircraft and the intent is to raise awareness of

the consequences of errors or in-attention.

June 2011

Action Completed: ‘Safety in the Balance’ DVD

narrated by Captain Bruce Dickinson is available

for download from the GHOST website and is

also being distributed free of charge within the

UK and overseas industry stakeholders. There

is no copyright, so further copies can be made.

2. a) UK Ground Handling (GH) Human Factors

forum established.

March 2011

Action Completed: The GH forum was

established in March 2011. Deliverables of the

group are as outlined in the GHOST TORs for

2011, also available on the GHOST website.

b) Recommendations presented to GHOST

on how to promote internal open reporting

systems, and how to improve awareness of and

subsequent reporting of relevant ground

handling incidents.

December 2011


n Increased awareness and competenceleading to a reduction in human factors-related

errors.

n Increased industry cooperation and shared

ownership of risks.

n Increased internal monitoring, supervision and

auditing to monitor and correct unsafe behaviours.


Action success and overall ground handling



n Ramp occurrences broken down by process

during which they occurred and their outcome.

n Collisions involving vehicles and parked

aircraft at UK reporting aerodromes.

n Collisions, near-collisions and conflicts

involving vehicles and taxiing aircraft at UK

reporting aerodromes.

n Loading errors: all reported and those

resolved before departure.

n Late aircraft type changes.

n Late turn-arounds or turn-arounds in less than

the minimum scheduled time.


n GHOST for actions 1 to 4.

n CAA Dangerous Goods Office for action 5.



SIGNIFICANT

SEVEN

3.1.6 Ground Handling




3.1.6 Ground Handling

3. CAA to act on outcome of review of internal

auditing standards as well as airline and

aerodrome oversight of third parties to

determine whether enhanced or direct oversight

of UK ground handling activities is necessary to

significantly reduce GH incidents, and if so, how

best it might be achieved.

4. CAA, in partnership with industry, to

establish detailed scope for specific industry

self-monitoring activities (initially aircraft loading)

to provide an effective method for industry to

identify organisational drift, including guidelines

for establishing policy and procedure.

Furthermore, establish investigative guidelines

so that root cause can be truly determined.

The following action is being run by the CAA

Dangerous Goods Office:

5. CAA, in partnership with industry, to increase

awareness and education with regards to the

correct loading of electric mobility aids.


Continued


Continued

3. Paper presented to GHOST outlining key

findings of the review and recommending an

appropriate course of action.

September 2011

4. Draft self-monitoring checklist produced for

endorsement by GHOST and subsequent

promulgation to industry.

December 2011

5. a) Guidance published for industry

stakeholders.

September 2011

b) Liaise with Disabled Persons Transport

Advisory Committee and guidance published for

passengers.

September 2011

c) UK experience shared with the Dangerous

Goods European Liaison Group.

December 2011




The majority of aircraft fire

incidents occurred in galleys,passenger and toilet areas but

these were determined to be

relatively low risk and unlikely

to progress to a catastrophic

accident. However, hidden area fires, although

relatively infrequent, have a far greater potential

for a catastrophic outcome. Most of the aircraft

fires associated with fatal accidents occurred

during the post-crash sequence and it would be

more effective to address the causes of crashes

(e.g. runway excursions) rather than make

aircraft more tolerant to post-crash fire.

Nevertheless, the CAA should maintain the

focus on the effectiveness and efficiency of

post-crash fire response whilst continuing to

review new technologies and developments in

emergency planning and enhanced fire-fighting.

In addition to the action described below to

address the risk of hidden area fires, the CAA

collaborates extensively with the FAA and

Transport Canada, together with EASA, on fire

and cabin safety issues. Through formal

agreements, both the FAA and Transport Canada

support fire research studies in the UK, which

focus on areas of mutual concern. The work is

reported in international specialist meetings for

materials flammability, fire systems and cabin

safety detailed at http://www.fire.tc.faa.gov/ .


hidden area fires occurring.


1. CAA to raise fire safety awareness through aDVD/Internet training campaign to engineering

and associated groups on the effects of

fire/smoke events on aircraft caused by poor

quality control/workmanship.


1. DVD/Internet training aid produced.April 2012


Improved workmanship will reduce thelikelihood of poor maintenance practices causing

hidden fires.


Action success and overall fire risk will be

tracked using the following key performance

indicators:

n Aircraft fires.

n Aircraft smoke events.

n Maintenance-related events involving aircraft

wiring.

n Number of viewings of Internet training

material.


n CAA Airworthiness.

3.1.7 Fire

SIGNIFICANT

SEVEN

http://www.fire.tc.faa.gov/

http://www.fire.tc.faa.gov/



27PAGE 3. SAFETY ACTIONS [KEY CAPABILITY ISSUES] Civil Aviation Authority Safety Plan 2011/13

One of the target outcomes

from the CAA Strategic Planis that, “the UK aviation

industry and the CAA will

have measurably increased

capability and performance in

Safety Management, Human Factors and Just

Culture, and demonstrated the benefits in terms

of risk reduction”. Improved CAA capability in

these areas will translate to more effective,

efficient and proportionate oversight of the

industry it regulates. The CAA will work with

industry to help organisations embed, where

appropriate, best practice in these capability

areas into their own safety management

processes. As an example, to most effectively

identify and understand safety risks in the

aviation system, the CAA will work with industry

to extract the potential of data sources such as

FDM for flight operations related issues and

Maintenance Error Management Systems

(MEMS) for maintenance error.

3.2 Key Capability Issues




Desired Capability Outcome: Develop a new

Integrated Safety Risk Management Process to allow more effective monitoring and

management of aviation safety risk by the

CAA and industry.

Actions to Achieve Desired Capability Outcome:

1. Safety Risk PolicyTo review issues concerning practice, principles

and priority:

a) Develop safety risk policies and clarify the

concept of an ‘acceptable level of safety’.

b) Define ‘safety risk’ as applicable for the CAA

and UK.

2. Evidence Base

To improve safety data and information

collection/sharing:

Evidence Base 1 – MORS Database

a) Complete the CAA’s transition to the

ECCAIRS occurrence reporting software.

b) Define with CAA Safety Data and industry

the level of reporting to MORS and agree the

coding of occurrences (using the ECCAIRS

taxonomy).

Evidence Base 2 – Data Streams

c) Develop with industry a range of

standardised FDM-based precursor measures

and how they might be used to drive priorities.

d) Develop with industry a range of safety

performance indicators and how they might be

used to drive priorities.

e) Capture results from oversight audits,

industry trends and alternative data sources (e.g.

MEMS).

Evidence Base 3 – Exposure Data

f) Maintain and improve utilisation data.

g) Gather new measures of exposure (e.g.

exposure to contaminated runways).


1. Safety Risk PolicySafety risk policy defined and implemented.

October 2011

2. Evidence Base

The most effective way to collect and share

safety data/information established.

April 2012


Improvements in the monitoring of UK safetyperformance so that intelligence can be

provided to enable proportionate and timely

action to be taken, to continuously improve

safety.


n Common risk classification framework used

by the CAA and industry.

n Data streams and indicators established for all

key safety issues.

Capability Outcome Owner:

n CAA Group Safety Services.


n Reference: Safety Actions SYS3.2, 3.4, 3.5,

3.6 and EME1.1.

3.2.1 Integrated Safety Risk Management Process




Evidence Base 4 – Industry Networks

h) Establish with industry a UK ‘Network of

Analysts’ to support the development of new

data streams and performance indicators and to

improve reporting standards/quality.

3. Safety Risk Processing and Assessment of

Current Risks

To improve the risk classification and analysis of

aviation safety events, and the identification and

assessment of current safety issues:

a) Conclude the European/industry work in

developing a common risk classification

framework for aviation safety events and

promote its use.

b) Propose revisions to the ECCAIRS risk

grading scheme.

c) Develop risk modelling techniques based on

the common risk classification framework.

d) Develop The High Risk Events Analysis Team

(THREAT) and Accident Analysis Group (AAG) to

identify current safety issues.

e) Further explore the potential of FDM and

MEMS data to better identify current safety issues

and to assess safety risk in the aviation system.

3. Safety Risk Processing and Assessment of

Current Risks

Common framework for the risk classification of

aviation safety events, and a process to identify

and assess current safety issues developed.

April 2012

Actions to Achieve Desired Capability

Outcome: Continued


Continued





4. Safety Performance Monitoring and

Identification of Future Risks

To improve the identification of future/emerging

safety issues, and to provide an improved safety

performance monitoring function for CAA senior

management, CAA technical divisions and industry:

a) Further develop quarterly safety performance

monitoring function.

b) Develop new measures to continuously

monitor safety trends.

c) Define how to analyse results from oversight

audits, industry trends, alternative data sources

and horizon scanning.

d) Establish a Statistics Group to review safety

performance monitoring results.

e) Improve the quantification and forecasting of

safety risks.

4. Safety Performance Monitoring and

Identification of Future Risks

Full suite of SPIs to monitor safety performance for

all key safety issues established and a process to

identify future/emerging safety issues developed.

June 2012

Actions to Achieve Desired Capability

Outcome: Continued


Continued





3.2.2 Continuing Airworthiness

Desired Capability

Outcome: Improve the CAA’s capability to extract

intelligence from all

sources of airworthiness-

related safety data so that

the associated risks are better understood

and the most effective actions to mitigate

them can be identified and implemented.

Inherent in more effective regulatory

oversight will be an improved understanding of

priorities and spending regulator time in

proportion with the risk to safety. This means

obtaining the best possible intelligence about the

nature and extent of risks in all areas including

airworthiness. It may include better sharing of

data and intelligence between companies and

the regulator, and within the regulator, deeper

analysis of available data (including identification

of the root causes of airworthiness-related

incidents), better prioritisation of findings

according to safety relevance, better feedback to

industry of generic issues and the ability to feed

back the position of an individual company

against the national distribution.


1. CAA to develop, in partnership with industry,methods to identify and implement analysis,

prioritisation and data exchange on findings from

CAA and industry audits to improve overall

intelligence. This will focus on Continuing

Airworthiness and, if successful, similar

methods may be developed in other areas at a

later date.

2. To enhance the sharing of continuing

airworthiness information by improving the

interface and working procedures with EASA.

This will facilitate a performance-based approach

to Type Liaison/Design Liaison activities.

3. Review Maintenance Error Management

System (MEMS) policy and related application.

4. As part of the ISRMP project (see 3.2.1),

further explore the potential of MEMS data to

better identify airworthiness-related safety

issues, particularly the HF aspects, and to assess

their contribution to safety risk in the aviation

system.


1. a) Partnership meeting held withrepresentatives of the UK Operators Technical

Group (OTG).

November 2011

b) Plan implemented for Improved Safety

Intelligence on Continuing Airworthiness.

December 2011

2. Establishment of a functional performance-

based Type Liaison/Design Liaison process. This

will streamline the areas covered and simplify/

standardise the reporting system.

March 2012

3. a) Current MEMS requirements revised as

required (following engagement with the UK

MEMS Group).

January 2012

b) Civil Aircraft Airworthiness Information

and Procedures (CAAIP) updated and published

to reflect the revisions to MEMS requirements.

April 2012

4. Plan implemented to make best use of

MEMS data as part of the process for identifying

and acting on safety risks.

April 2012


Improvements in the analysis of airworthiness-related issues so that intelligence can be

provided to enable proportionate and timely

action to be taken, to improve safety.


n Repeat audit findings (reduction in their

number).

n Industry requests for their performance

against the national distribution.


n CAA Airworthiness for actions 1 to 3.





3.2.3 SMS

Desired Capability

Outcome: Improve the safety performance

of organisations through

the implementation of

effective SMS and the

CAA’s capability to assess the effectiveness

and safety performance of an

organisation’s SMS.


1. Hold industry workshops to help organisationsunderstand SMS and implement effective systems.

2. Develop an assessment methodology that

will assess the performance and the

effectiveness of an SMS.

3. All appropriately selected CAA staff to have

an appropriate level of competence to assess

SMS and Human Factors Programmes within

regulated organisations.


1. Programme for industry workshops agreed.October 2011

2. a) SMS assessment methodology developed.

December 2011

b) SMS maturity assessment model defined.

December 2011

c) Methodology to evaluate risk

assessments defined.

December 2011

3. All appropriately selected CAA staff to have

received training in the assessment and practical

implementation of SMS.

April 2012


Effective implementation of SMS will increasethe safety performance of organisations leading

to an increase in the overall safety performance

of the aviation system in the UK, and this needs

to be matched by the CAA’s ability to assess the

performance and effectiveness of an SMS.


n Number of organisations that have fully

implemented SMS before final transitional dates

allowed by EASA regulations.

n SMS maturity and effectiveness indices.

n Proportion of relevant CAA staff appropriately

trained, skilled and assessed against a

competency framework.




n Reference: Safety Actions SYS2.5, 2.6, 2.7,

2.8, 2.9 and 2.10.






3.2.5 Strategy for Human Factors (HF)

Specific HF-related actions

are included throughout thisPlan (e.g. pilot monitoring

skills, HF aspects of airspace

infringements and HF aspects

of ground handling safety).

However, a comprehensive review of human

performance is underway to provide strategic

direction for future HF work. This will include

those factors that shape and support human

performance on a day-to-day basis.

Desired Capability Outcome: A better

understanding of human performance,

limitations, attitudes and behaviours to

drive the practical application of Human

Factors principles in reducing risk within the

aviation safety system.

Increasing complexity in aircraft design,

operation and maintenance, including the

integration of Air Traffic Management changes

within the Single European Sky, may increase

the risk of human error, which continues to be

cited as the main cause or contributory factor(s)

in at least 75% of all safety occurrences.Challenging commercial environments and a

desire to reduce regulation expose people,

processes and performance within the aviation

safety system to even greater cumulative risk.


1. Carry out a comprehensive Review ofHuman Factors in Civil Aviation.

2. Develop a UK Strategy for Human Factors in

Civil Aviation, which will be offered to the

European Human Factors Action Group (EHFAG)

as the basis for a European Union equivalent.


1. Review of Human Factors in Civil Aviationcompleted.

December 2011

2. UK Strategy for Human Factors in Civil

Aviation published.

February 2012


A commonly held understanding of HumanFactors across the aviation community, specifically

applied to mitigate individual and cumulative

risks associated with a particular operation or

environment within the aviation safety system.


Objective competency-based standards for

training and proportionate performance-based

assurance assessment, together with maturity

indices for Safety Management Systems.




n Reference: Safety Actions HFP1.1 and 1.2.




3.2.6 Performance-Based Oversight


Deliver effective regulationin a manner and at times

which have the greatest

impact on preventing

significant aviation losses.

Facilitation of proportionate, targeted and

consistent regulation.

This means regulating on the basis that

people, organisations and sectors of civil

aviation must accurately identify their risks and

the risks to consumers, that they manage them

effectively whilst still complying with applicable

prescriptive rules. SMS, Human Factors and

proportionate compliance assurance are

embedded into the regulatory approach.


1. Concepts of SMS maturity and risk profilingof regulated organisations developed.

2. Regulatory oversight behaviours and

methodologies fully developed and individually

tailored according to risk profile.

3. Regulatory capabilities matched to the risk

management capabilities of those being

regulated.


1. New Performance-Based Oversight Modelrefined and delivered for external consultation.

December 2011

2. Oversight Model processes defined,

management arrangements and training

prepared.

April 2012

3. Performance-Based Oversight Model adopted

as CAA safety oversight methodology according

to an implementation plan.

June 2012


nGreater focus on risks to consumer welfare,

regulatory desired outcomes and the control of

risk by regulated entities.

n Risks to consumers identified early and

controlled in proportionate and effective ways.

n Regulatory capacity and capability in line with

desired outcomes.


n ‘Significant Seven’ precursor events.

n Resource deployed on regulating non-critical

activity.






3.2.7 Fatigue Risk Management Systems

As aviation is a continuous

and global activity, fatigue ofindividuals working in this

environment has to be

considered as a hazard. The

benefits of Fatigue Risk

Management Systems (FRMS) have been

recognised in all modes of transportation and

safety critical environments. The application of

assessment, assurance and education

techniques can be readily applied and integrated

into regulatory oversight. ICAO has

strengthened its fatigue management

requirements for aircrew to include the ability to

apply to FRMS either in combination with

prescriptive rules sets or as the primary method

of fatigue management. ICAO is planning to

extend these techniques into other aviation

safety critical areas.

Desired Capability Outcome: To deliver

effective regulatory oversight of fatigue

management using FRMS techniques and

metrics, proportionate to the size and

complexity of the operational environment.To ensure that safety critical workers are

able to operate at an effective level of

alertness for all normal and abnormal

circumstances.


1. FRMS training to be developed for allappropriate CAA staff.

2. Develop a consistent SRG approach to

fatigue in aviation safety critical environments.


1. All appropriately selected CAA staff to havereceived training in the assessment and practical

implementation of FRMS.

January 2013

2. Cross-departmental working group

established with a relevant fatigue safety

promotion plan developed.

March 2012


nRegulatory oversight capacity and capability in

line with desired safety outcomes.

n Consistent approach to the impact of fatigue

risk in the operational environment through the

promotion of fatigue awareness leading to

effective monitoring and application of

appropriate mitigations.


n Proportion of relevant CAA staff appropriately

trained and skilled in the assessment and

practical implementation of FRMS.


n CAA Flight Operations Policy.




3.2.8 Total System Threats

The volcanic ash crisis of

2010 was an example of alow probability but high-

impact event that affected

the total aviation system. A

review of lessons learnt from

this event revealed that one of the CAA’s

strengths during the crisis was its ability to

draw upon internal expertise based on a long

involvement in relevant issues and previous

incidents. The need to retain such capability is

reflected in the CAA Strategic Plan, together

with the need for continued improvement in

the CAA’s expertise, plans and processes for

crisis management, and the ability to better

identify and prevent or prepare for rare but

high-impact events that affect the total aviation

system. Key activities that support these

needs and that address total system threats,

such as volcanic ash, are listed below.

n Through the Integrated Safety Risk

Management Process project (see section

3.2.1), improve the identification of current,

emerging and future safety issues (includinghow to capture and analyse results from

industry trends and horizon scanning).

n Providing a leading role in the International

Volcanic Ash Task Force including the

development and adoption of an international

risk assessment framework for volcanic ash.

n Contribution to the EU seventh framework

Weather Hazards for Aeronautics (WEZARD)

project, which will include a review of the

current knowledge on volcanic ash, mineraldust and ice crystals as potential threats to

aviation.

n Investigation of the risk posed by the next

solar maximum through the CAA’s Space

Weather Working Group.

n Identification and mitigation of potential

common mode failure points in the aviation

system (e.g. reliance on Global Navigation

Satellite Systems).

n Preparations for a safe 2012 London

Olympics and Paralympics through the CAA

Olympic and Paralympics Steering Group

(COPSG - see http://www.caa.co.uk/olympics).

n Creation of a CAA Crisis Information

Management Team to support the command

and control teams that lead the crisis

management response on behalf of the CAA.

n Support for the European Aviation Crisis

Coordination Cell (EACCC) to ensure timely

response to any future pan-European crisis

severely affecting aviation (reference: EASP

Safety Action SYS4.2).



38PAGE 4. OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13

Whilst the focus of this Safety Plan is on actions

to mitigate the key risks to large fixed-wingcommercial air transport operations, the CAA

remains committed to working with industry to

improve safety in all aviation sectors. This

includes supporting international collaborative

partnerships such as the European Helicopter

Safety Team (EHEST) and the European General

Aviation Safety Team (EGAST), and working with

individual organisations to target specific risks.

This section of the Plan describes actions to

address safety risks associated with business

aviation, large public transport helicopter

operations and general aviation.

4. Other Aviation Sectors




The Business Aviation sector

by its very scope and diversityof operations is different to

CAT and as a result there are

specific challenges to be

acknowledged. Thus the

Business Aviation Safety Partnership (BASP)

was established not because Business Aviation

is deemed unsafe but because it was

recognised that a more ‘tailored approach’ to

this sector was warranted.

The BASP is a joint CAA/industry partnership

that takes a holistic approach in seeking to

incrementally improve business aviation safety

and to reduce the involvement of business jet

aircraft in serious events. The BASP

Deliverables Document facilitates management

of BASP work and details activity in terms of:

regulatory work; direct engagement with aircraft

operators, airfield operators and training

providers; and the development and distribution

of safety awareness and guidance material.

BASP will ensure close links are maintained with

the CAA Flight Operations Inspectorate when

dealing with business aviation safety matters.Key work focussed on level busts, ACAS

response and Alternative Training and Qualification

Programmes (ATQPs) are described below.

Desired Safety Outcome (BA1): Reduce the

number of, and relative contribution to level

busts in UK airspace by business jets.


1. Programme of safety briefings for the period1st April 2011 to 31st March 2012 completed.

March 2012

2. One-page pilot guides for operations in

airspace and at airports of particular relevance

to business aviation produced and distributed.

March 2012


1. BASP Chair to co-ordinate, facilitate anddeliver ongoing safety briefings/events both

domestically and internationally to ensure

effective engagement with the business aviation

community on numerous safety issues, and on

level busts particularly.

2. BASP endorsed safety promotional material

distributed to business aviation associations,

operators and training organisations.


Increased awareness by UK and particularlyforeign-based business aviation pilots of level

busts and associated airspace issues resulting

in a reduction in the number / rate of occurrence

and associated risk.




n Level busts in UK airspace involving business

jets (broken down by number and rate for G-

registered and foreign registered aircraft).


n BASP.

4.1 Business Aviation




Desired Safety Outcome (BA2): Reduce the

proportion of incorrect response to ACAS RA

warnings by business jet pilots.

This work is largely driven by

EUROCONTROL data, which suggests that a

significant proportion of ACAS RAs are not

responded to correctly. The output of the

ACAS-related work carried out for CAT

aeroplanes (described in section 3.1.5

‘Significant Seven’ – Airborne Conflict) will be

reviewed for its relevance to business aviation.


1. BASP Safety Notice on appropriate

response to ACAS warnings, and associated

training advice, produced and distributed.

March 2012


1. a) BASP-endorsed safety promotional

material distributed to business aviation

associations, operators and training

organisations.

b) Direct engagement with CAA Flight Crew

Standards, senior trainers in industry, training

organisations and operators focussed on

enhancing the provision of realistic and effective

ACAS training.


Increased awareness by business jet pilots of

the correct response required for ACAS

warnings and a reduction in the associated risk

of level busts and mid-air collision.




n ACAS RAs involving all business jets in UK

airspace and G-registered business jets

worldwide: all genuine RAs and proportion

involving incorrect pilot response.


n BASP.






Desired Safety Outcome (BA3): Extend

Alternative Training and Qualification

Programmes (ATQPs) into business jet

operations.

This work will liaise closely with the ongoing

oversight of ATQP implementation by larger CAT

operators.


1. Recommendations for implementation of

ATQP for business jet operations produced.

April 2012


1. BASP Chair together with CAA Flight

Operations ATQP Focal Point to investigate

implementation of ATQP for business jet

operations.


ATQP offers the operator the opportunity to

develop a recurrent training programme that is

bespoke and tailored to their needs, and has

been unanimously hailed a great success by the

UK airlines that have adopted such

programmes. ATQP has been welcomed for its

effectiveness by trainers and line crews alike,

and has produced measured improvement in

operating standards.




n Number of UK business jet operators running

ATQPs.


n BASP.

C S f




4.2 Large Public Transport Helicopters

The CAA has been actively

involved with the offshore oil

and gas industry in helicopter

safety for over 30 years. The

focal point for helicopter

safety issues is the Helicopter

Safety Steering Group (HSSG), which was

formed in June 2010 with the aim of proactively

identifying and addressing cross-industry issues

around helicopter safety, related to helicopter

operations in the UK offshore oil and gas

industry. The following research activities are

being managed by CAA on behalf of industry.

Desired Safety Outcome: Reduce the Large

Public Transport Helicopter accident rate

through improvements in helicopter

airworthiness, operational safety and safety

of offshore helidecks.


Reduction in the Large Public Transport

Helicopter accident rate.


Action success and overall risk to offshore

helicopter operations will be tracked using the


n Accidents and high-risk occurrences.

n Proportion of UK helicopter flights monitored

by AAD (advanced HUMS).

n Proportion of the UK offshore helicopter fleet

equipped for GPS-guided approaches.

n Proportion of UK Continental Shelf Helidecks

fitted with the new lighting system.


n CAA Flight Operations Inspectorate

(Helicopters).


1. Improvement in helicopter airworthiness:

a) enhancement of Health & Usage

Monitoring System (HUMS) vibration health

monitoring (VHM) data analysis.

b) extension of HUMS to rotors.

2. Improvement in helicopter operational safety:

a) development and introduction of GPS-

guided offshore approaches.

b) production of a performance specification

for emergency breathing systems.

c) development of a measure of low

airspeed for helicopter Flight Data Monitoring

(FDM) systems.

d) development of offshore helicopter

specific warning envelopes for Enhanced

Ground Proximity Warning Systems (EGPWS).


1. Improvement in helicopter airworthiness:

a) publication of final report on advanced

anomaly detection (AAD).

September 2011

b) publication of final report on application of

AAD to tail rotor HUMS VHM data.

March 2012

c) participation in Rotorcraft Technology

Validation Programme (RTVP) joint industry

project.

December 2013

2. Improvement in helicopter operational

safety:

a) completion and reporting of

demonstration trials of GPS-guided offshore

approaches.

June 2012

completion and reporting of in-service trials

of GPS-guided offshore approaches.

March 2014

b) publication of a performance specification

for emergency breathing systems.

December 2011 c) development and publication of helicopter

low airspeed measure.

March 2013

d) development and publication of improved

EGPWS warning envelopes.

June 2012

43PAGE 4 OTHER AVIATION SECTORS Ci il A i ti A th it S f Pl 2011/13




4.2 Large Public Transport Helicopters

e) development, demonstration and reporting of

a system for predicting helicopter ‘triggered’

lightning strikes.

March 2012

3. Improvement in offshore helideck safety:

a) development, demonstration and

publication of improved helicopter moving deck

landing criteria.

December 2013

b) development, demonstration and

publication of improved helideck lighting system.

December 2011

c) development, demonstration and

publication of a resistance to sliding criterion for

aluminium helidecks.

June 2012

e) development of a prediction/forecasting

system for helicopter ‘triggered’ lightning strikes.

3. Improvement in offshore helideck safety:

a) development of improved helicopter

moving deck landing criteria.

b) development of improved helideck

lighting system.

c) development of a resistance to sliding

criterion for aluminium helidecks.


Continued


Continued

44PAGE 4 OTHER AVIATION SECTORS Ci il A i ti A th it S f t Pl 2011/13



Whilst the main focus of this

Safety Plan is on large

commercial air transport, the

CAA remains committed to

working with industry to

improve GA safety in a

proportionate manner.

The CAA continues to discuss safety

concerns on GA matters through the General

Aviation Strategic Forum and the General

Aviation Consultative Committee. The CAA has

additionally committed to a wider review of the

Regulatory Approach to Recreational Aviation.

This will involve working closely with industry

and EASA, to identify and act on opportunities to

adopt a different, more proportionate approach,

while ensuring that the key safety issues related

to this community are addressed.

As well as continuing to support and

influence the European General Aviation Safety

Team (EGAST), the CAA is undertaking the

following actions.

Desired Safety Outcome (GA1): Reduce the

risk of mid-air collisions involving GA aircraft.



1. Investigation report produced on the use of

reflective foil on control surfaces.

December 2011

2. Modelling of Class G airspace utilisation

completed.

December 2011

3. IT-based solutions (building on work

completed with the British Gliding Association

for glider events) developed in conjunction with

NATS and GA representative bodies.

December 2011


Reduction in the likelihood of mid-air collisions

involving GA aircraft.




n Actual mid-air collisions involving GA aircraft.

n AIRPROX involving GA aircraft.


n CAA Flight Operations Inspectorate (General

Aviation).


n Reference: Safety Action GA1.3.


1. Improve visual conspicuity of gliders and

other light aircraft with small cross-sectional

profiles.

2. Improve understanding of Class G airspace

utilisation to better inform knowledge of

airspace ‘hotspots’.

3. Provide real-time information to pilots on

events involving large numbers of GA aircraft.

4.3 General Aviation

45PAGE 4 OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13





risk of accidents due to pilots making wrong

decisions over the conduct of a flight.


1. Background HF research project by

Cranfield University completed.

Complete

2. Tender bids from potential commercial

providers evaluated.

Complete

3. Production of interactive tuition tool for

improvement of pilot decision-making with a

commercial partner (subject to validation of

proof of concept product).

December 2012


1. Research project into Human Factors in

decision-making process.

2. Translate results into a “proof of concept”

turnkey DVD product for pilot education.

3. Provide commercially available product at a

realistic price for pilots to practice outside the

cockpit.


Reduction in the number of accidents involving

poor decision-making by pilots.




n Volume of sales of commercially available

decision making tuition product.

n Analysis of data from results achieved by

users.

n Accidents attributed to poor decision making.


n CAA Flight Operations Inspectorate (General

Aviation).


46PAGE 4 OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13





risk of accidents due to the effects of

helicopter and wind turbine induced wake

turbulence on light aircraft.


1. Background research project completed on

impacts of wakes on light aircraft.

August 2014

2. Guidance disseminated on wake vortex

avoidance distances for pilots and ATCOs

associated with helicopters operating in hover

and forward flight.

December 2014

3. Guidance disseminated on wake vortex

avoidance distances for aviation stakeholders,

wind energy developers and local authorities

associated with wind turbine wake turbulence

effects on light aircraft.

December 2014


1. Research project on an Integrated

Simulation of a Light Aircraft Encounter with

Helicopter and Wind Turbine Wakes. The

helicopter case covers both in ground effect

rotor wash whilst in the hover and induced wake

whilst in forward flight.

2. Translate research results into avoidance

guidelines regarding safe operation of l ight

aircraft in relation to helicopter and wind turbine

wake encounters.

3. Disseminate results to UK ANSPs, the GA

community, and European (EASA and

EUROCONTROL) and international (ICAO)

stakeholders.


n Reduction in the number of accidents and

incidents involving light aircraft attributed to

wake turbulence from helicopters and wind

turbines.

n Improved knowledge of the hazard posed to

aviation from wind turbine wake vortices and

education material for the GA community in

relation to the avoidance of this type of hazard.




n Accidents or serious incidents involving light

aircraft attributed to helicopter and wind turbine

wake turbulence encounters both nationally and

across Europe.

n Requests from aviation stakeholders on

information on the effects of wind turbine wake

turbulence on flight operations.

n Feedback from pilots at General Aviation

Safety Council (GASCo) ‘Safety Evenings’.


n CAA Flight Operations Inspectorate (GeneralAviation).


Documents

CAA Safety Plan 2011 to 2013