Experiencia Europeia Safety Analysis · Experiencia Europeia Safety Analysis John Vincent, Head...

Experiencia Europeia

Safety AnalysisSafety AnalysisJohn Vincent,

Head – Safety Analysis and Research,Executive Directorate

EASA

19 MarchHotel Windsor Guanabara

EASA in Cologne,Germany since 2004

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•• Independent legal statusIndependent legal status•• Operational since 28 September 2003Operational since 28 September 2003•• Offices in Cologne since 1st November 2004Offices in Cologne since 1st November 2004

FIN

IS

EE

LV

LT

UK

IR

DK

NO SE

RU

EASA Member States

EU 27 + 4

3

MD

CY

FR

BE

NL

DE

UK

RO

AL

MK

BG

EL

CH

IT

AHU

SB

EP

PL

CZ

MT

BA

L

SK

SICR

MC

Why a European Agency?

Uniform and legally binding rules

Common safety standards

Type certificates valid across Europe

A strong independent authority

4

A strong independent authority

First extension of scope adopted

Second extension – opinion issued

EASA Remit

Based on the Basic Regulation (EC) No 216/2008

Safety regulator, certification authority & advisory body

5

advisory body

Mission: to set & maintain the highest common safety & environmental standards

Method: part of the EU system with the EC and in partnership with the NAAs

EASA Remit

The new Basic Regulation

Airworthiness amendments

Pilot Licensing

Operations

6

Operations

Third country operators

Oversight and enforcement

Fines

Ultimately:

Aerodromes, ATM and ANS

Main tasks

Rulemaking

Standardisation inspections

7

Standardisation inspections

Type-certification & organisation

approvals

Safety Analysis

Structure

8

E2 Department – 2009

Head – Safety Analysis & Research

Administrator + 1 (CA)

9

Safety

Analysis

Manager

Accident

Investigation

Manager

Research

Project

Manager

4 (TA) + 1 (SNE)

4 + 1 (SNE)

Safety Team

Coordinator

+1 (TA)

Human

Factors

Expert

4Q 2009

Safety Risks Expert

2Q 2009

1 (TA)

2009-2013

Vision, Values, Mission

Strategic Priorities

Staff Policy Plan

Business Plan (MB 03/2008)

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Business Plan (MB 03/2008)

E2 Posts

22 posts by end of 2013

Planning for 2010-2014 underway

Key Performance Indicators

Safety Analysis

Safety Analysis: Conducts studies and provides reports concerning the safety of European and world-wide aviation

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wide aviation

Annual Safety Review

Developing safety policy

Building dependable repositories

Supporting a reporting with JRC

ESSIHistorical development of worldwide safety1945 - 2007

3,0

3,5

4,0

4,5

5,0

Passenger fatalities per 100 million passenger miles,

scheduled public transport operations, excluding acts of

unlawful interference

12

0,0

0,5

1,0

1,5

2,0

2,5

1945

1947

1949

1951

1953

1955

1957

1959

1961

1963

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

passenger fatalities rate 5 per. Mov. Avg. (passenger fatalities rate)

1968: 0.5After 1997: < 0.05

ESSIHistorical development of worldwide safety1988 - 2007

21

17

21

16

1416

1719

15

20

25

Rate of accidents involving passenger fatalities per 10 000 000 flights, scheduled operations, aeroplanes, excluding acts of

unlawful interference

13

7 7

5

3

10

13131416

4

6

8

10

4

0

5

10

15

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

fatal accident rate 5 per. Mov. Avg. (fatal accident rate)

ASR 2007

This document is published by EASA to inform the public of the general safety level in the field of civil aviation. The Agency provides this review on an annual

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Agency provides this review on an annual basis as required by Article 15(4) of Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 February 2008.http://www.easa.europa.eu/ws_prod/g/g_sir_review.php

2008 - preview

Fatal accidents - airline cargo/passenger operations, fixed wing

36

4645

33

37

35

40

45

50

15

20

16

14

16

11

25

16

10

13

15

26

22

2627

29

0

5

10

15

20

25

30

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

cargo operations passenger operations Linear (passenger operations) Linear (cargo operations)

2008 - previewCumulative number of fatalities by week

airline ops, fixed wing - week 47 2008

800

1000

1200

Kenya Airways

Douala

114

Tam

Sao Paulo

199

One-Two-

GO

Phuket

90

Atlasjet

Isparta

57

16

0

200

400

600

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

average 1998-2007 2008 2007

Adam Air

en-route

102

114

Santa Barbara Airlines

Llano de Hato - 46

Hewa Bora, Goma

48

Spanair

Madrid

153

Aeroflot-Nord

Perm

88

2008 - preview

Fatal accident - Air Transport ops

jet powered a/c over 5 700 kg

2008

AIRBUS

INDUSTRIESMCDONNELL-

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INDUSTRIES

15%

BOEING

38%BRITISH

AEROSPACE

8%

ILYUSHIN

8%

LEARJET

8%

MCDONNELL-

DOUGLAS

23%

General Aviation Fatal Accidents in Europe

Number of Fatal accidentsAerial Work

(A+H) 1,5%

GA >2250kg

4,9%

Commercial

2,8%

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GA <2250kg

90,8%

Commercial Aerial Work (A+H) GA >2250kg GA <2250kg

Fatalities Commercial

25,7%

GA >2250kg

5,7%

Aerial Work

(A+H) 1,5%

GA <2250kg

67,1%

Commercial Aerial Work (A+H) GA >2250kg GA <2250kg

Common Taxonomy

http://www.intlaviationstandards.org/

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Accident categories

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Measuring risk

Number of:

•Incidents

•Fatal accidents

•Fatalities

•Hull losses

PER

A. Period of time

B. Amount of aviation

activity:

Number of:

•Fatal accidents per year

•Passenger fatalities per

year

Examples

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activity:

B1. Number of

movements

•Aircraft

•Passengers

B2. Aggregated time or

distance flown:

•Aircraft

•Passengers

Number of fatal accidents

per:

•105 aircraft departures

•107 passenger journeys

Number of:

•Fatal accidents per 107

aircraft flying hours

•Fatalities per 108 passenger

km

•Incidents per 108 aircraft km

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Global Aviation Safety Roadmap

ICAO GASRM - 2006Frame of reference for stakeholders, including States, regulators, airline operators, airports, aircraft manufacturers,

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airports, aircraft manufacturers, pilot associations, safety organisations and air traffic service providers

To improve coordination and sharing

To minimise duplication

ESSI The European Strategic Safety Initiative

10 year programme (2006-2016)

aimed at improving aviation safety

in Europe, and for the European

citizen worldwide

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Partnership, with more than 150

organisations

Powered by industry and facilitated

by EASA

www.easa.europa.eu/essi

ECAST EHEST EGAST

COORDINATION GROUP

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ECASTCOMMERCIAL

AVIATION SAFETY TEAM

EHESTHELICOPTER SAFETY

TEAM

EGASTGENERAL AVIATIONSAFETY TEAM

International Partners

International Partners

WORKING GROUPS

WORKING GROUPS International

Partners

WORKING GROUPS

ECAST SMS WGTerms of Reference

Review reference SMS/Safety Culture materials, and ongoing initiatives

Identify best practices and examples of organisation for safety mgt

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of organisation for safety mgt

Compile / provide guidance materials on Safety Risk Management

Hazard identification

Risk assessment and analysis

Risk mitigation and control

Draft EASA RequirementsFor Safety Management

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Organisation Requirements (NPA 22-2008) will provide legal grounds for Safety Management

‘Golden Rules’

1. Full Safety Accountability at the Top

2. Supported by independent Safety Support Functionwith full authority from the Top

3. Individuals within the Safety Support Function

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3. Individuals within the Safety Support Function should have respect and influence

4. Formal communications from the Top to the Safety Support Function

5. Actions necessary to support the SMS should bemanaged throughout the organisation

6. Safety accountabilities and responsibilities should be documented and understood by the incumbents

Defining the Community Safety Programme

Collaboration between European Commission, EASA and Member States

Authority requirements provide a basis for a CSP

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basis for a CSP

Elements drafted by a small group, to be presented to all Member States

Means to share safety occurrences in place

Trust

General requirements for competent authorities

Safety promotion programmes

Mutual exchange of information

Collective oversight and enforcement

Mandatory safety information

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Mandatory safety information

Occurrence reportingOccurrence reporting

Authority management system:

Policy

Staff

Compliance monitoring

AccidentsAccidents

IncidentsIncidents

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IncidentsIncidents

AbnormalAbnormalVariationsVariations

Undesirable EventsUndesirable Events

EASA and investigation

Has the responsibility to ensure there is a safe European system;

Participates in AIB investigations, but NOT

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Participates in AIB investigations, but NOT in the determination of probable cause.

Determines if any of EASA’s responsibilities were involved;

If needed, initiates corrective action.

EASA and investigation

Has the responsibility to respond to facts learned in accident investigation with speed commensurate with the risk to continued operational safety;

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We use our Experts to assist in the investigation of accidents, in coordination with the AIB IIC;

Better training, more standardised participation.

ECCAIRSDatabase

(JRC central repository)

SafetyRecommendations

Database

Two separate systems linked by a n:n relation

Accident investigation:The European database

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Safety analysis

Thematic search by

• Descriptive factor

• Explanatory factor

• Text search / field

Notification

Updates

Reports

Process & reply to

Safety Recommendations

The End

John VincentEASA Head - Safety Analysis and Research

john.vincent@easa.europa.eu

Tel: + 49 221 89990 2012

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EASAOttoplatz 1D-50679 Köln PO Box 101253D-50452 Köln, GermanyTel: 49-221-89990000

Annex

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EASA / EC Rulemaking planning

AR/OR

Gen+FCL+MED

AR/OR

OPS

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Then EC Comitology Process (for the Implementing rules)

Publication expected from May 2010

Nov 08-Feb 09 Feb 09-May 09

Mar-May 2009 Jun-Aug 2009

Jun-Jul 2009 Sep-Oct 2009

Bow Tie representation

Safety Event 1

Barrier Hazard

Potential

Outcome

1. What is the hazard?3. What safety event could

release the hazard?

6. How do we recover if the event occurs? How can the potential

outcome likelihood or consequence severity of the outcome be limited?

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Undesirable

EventSafety Event 2

Safety Event 3

Potential

Outcome

Potential

Outcome

Mitigation

2. What happens when

hazard control is lost?

4. How can the accident scenario

develop?

What are the potential outcomes?

5. How do we avoid the undesirable event? How do we

keep control on the hazard?