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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
8/3/2019 CAA Safety Plan 2011 to 2013
http://slidepdf.com/reader/full/caa-safety-plan-2011-to-2013 2/46
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
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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
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4PAGE OVERVIEW Civil Aviation Authority Safety Plan 2011/13
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
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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.
5PAGE OVERVIEW Civil Aviation Authority Safety Plan 2011/13
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
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6PAGE OVERVIEW Civil Aviation Authority Safety Plan 2011/13
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
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. moremoremore
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7PAGE OVERVIEW Civil Aviation Authority Safety Plan 2011/13
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
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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.
8PAGE OVERVIEW Civil Aviation Authority Safety Plan 2011/13
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
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.
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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
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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.
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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
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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.
13PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
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
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Desired Safety Outcome (LOC2): Reduce the
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.
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success 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.
Safety Outcome Owner:
n CAA/FOLG Loss of Control Action Group.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER4.6 and 4.7.
3.1.1 Loss of Control
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3.1.1 Loss of Control
Desired Safety Outcome (LOC3): Reduce the
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.
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success 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 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.
Safety Outcome Owner:
n CAA Flight Crew Standards for action 1.
n CAA Group Safety Services for action 2.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER4.6 and 4.7.
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Deliverables and Dates:
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
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
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.
Key Performance Indicators:
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.
n Proportion of UK aircraft operators to have
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.
Safety Outcome Owner:
n CAA Group Safety Services for action 1.
n CAA Flight Operations Inspectorate (Aeroplanes) for
action 2.
n CAA Air Traffic Standards for action 3.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER1.5 and 1.6.
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
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Desired Safety Outcome (RE2): Introduce
capability for aerodrome operators to provide meaningful data to pilots concerning expected
braking action on contaminated runways.
Deliverables and Dates:
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
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
n Consistent and relevant informationpromulgated to enable flight crews to be better
equipped to anticipate the braking action
expected on contaminated runways.
Key Performance Indicators:
Action success will be tracked using the
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.
Safety Outcome Owner:
n CAA Aerodrome Standards.
Alignment with European Aviation Safety Plan:
nReference: Safety Actions AER1.2, 1.3, 1.5 and 1.6.
3.1.2 Runway Excursion
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Desired Safety Outcome (RE3): Improve the
safety areas around runways.
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
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.
Safety Outcome Owner:
n CAA Aerodrome Standards.
Alignment with European Aviation Safety Plan:
nReference: Safety Actions AER1.2, 1.3, 1.5 and 1.6.
3.1.2 Runway Excursion
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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.
19PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
SIGNIFICANT
SEVEN
3.1.3 Controlled Flight into Terrain (CFIT)
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
Reduction in the high proportion of CFIT-relatedincidents/accidents that occur during NPAs.
Key Performance Indicators:
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.
n Proportion of UK aircraft operators to have
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.
Safety Outcome Owner:
n CFIT Task Force.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER3.4 and 3.5.
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20PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
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.
Desired Safety Outcome: Reduce the risk of
runway incursions at UK licensed
aerodromes.
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
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.
Safety Outcome Owner:
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).
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER5.1, 5.2, 5.4
and 5.5.
SIGNIFICANT
SEVEN
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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
Actions to Achieve Desired Safety Outcome:
Continued
Deliverables and Dates:
Continued
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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
22PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
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.
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Desired Safety Outcome: Reduce the risk of
mid-air collisions associated with incorrect responses to ACAS RA warnings.
Deliverables and Dates:
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
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
Reduced risk of collision resulting from incorrectuse of ACAS and enhancement of the final
safety barrier to mid-air collision (other than
providence).
Key Performance Indicators:
Action success and overall airborne conflict
risk will be tracked using the following key
performance indicators:
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.
n Proportion of UK aircraft operators to have
implemented and actively monitor mid-air
collision precursor measures.
Safety Outcome Owner:
n CAA Flight Operations ACAS Focal Point
(with close liaison with the ASI ACAS Working
Group).
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER2.8 and 2.9
(plus AER2.1 for work carried out by the AIWG).
3.1.5 Airborne Conflict
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24PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
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.
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success and overall ground handling
risk will be tracked using the following key
performance indicators:
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.
Safety Outcome Owner:
n GHOST for actions 1 to 4.
n CAA Dangerous Goods Office for action 5.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions AER5.9 and 5.10.
SIGNIFICANT
SEVEN
3.1.6 Ground Handling
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25PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
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.
Actions to Achieve Desired Safety Outcome:
Continued
Deliverables and Dates:
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
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26PAGE 3. SAFETY ACTIONS [SIGNIFICANT SEVEN] Civil Aviation Authority Safety Plan 2011/13
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/ .
Desired Safety Outcome: Reduce the risk of
hidden area fires occurring.
Actions to Achieve Desired Safety Outcome:
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.
Deliverables and Dates:
1. DVD/Internet training aid produced.April 2012
Expected Safety Benefit:
Improved workmanship will reduce thelikelihood of poor maintenance practices causing
hidden fires.
Key Performance Indicators:
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.
Safety Outcome Owner:
n CAA Airworthiness.
3.1.7 Fire
SIGNIFICANT
SEVEN
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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
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28PAGE 3. SAFETY ACTIONS [KEY CAPABILITY ISSUES] Civil Aviation Authority Safety Plan 2011/13
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).
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
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.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions SYS3.2, 3.4, 3.5,
3.6 and EME1.1.
3.2.1 Integrated Safety Risk Management Process
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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
Deliverables and Dates:
Continued
3.2.1 Integrated Safety Risk Management Process
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30PAGE 3. SAFETY ACTIONS [KEY CAPABILITY ISSUES] Civil Aviation Authority Safety Plan 2011/16
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
Deliverables and Dates:
Continued
3.2.1 Integrated Safety Risk Management Process
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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.
Actions to Achieve Desired Capability Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
n Repeat audit findings (reduction in their
number).
n Industry requests for their performance
against the national distribution.
Capability Outcome Owner:
n CAA Airworthiness for actions 1 to 3.
n CAA Group Safety Services for action 4.
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32PAGE 3. SAFETY ACTIONS [KEY CAPABILITY ISSUES] Civil Aviation Authority Safety Plan 2011/13
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.
Actions to Achieve Desired Capability Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
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.
Capability Outcome Owner:
n CAA Group Safety Services.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions SYS2.5, 2.6, 2.7,
2.8, 2.9 and 2.10.
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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.
Actions to Achieve Desired Capability Outcome:
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.
Deliverables and Dates:
1. Review of Human Factors in Civil Aviationcompleted.
December 2011
2. UK Strategy for Human Factors in Civil
Aviation published.
February 2012
Expected Safety Benefit:
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.
Key Performance Indicators:
Objective competency-based standards for
training and proportionate performance-based
assurance assessment, together with maturity
indices for Safety Management Systems.
Capability Outcome Owner:
n CAA Group Safety Services.
Alignment with European Aviation Safety Plan:
n Reference: Safety Actions HFP1.1 and 1.2.
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3.2.6 Performance-Based Oversight
Desired Capability Outcome:
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.
Actions to Achieve Desired Capability Outcome:
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.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
n ‘Significant Seven’ precursor events.
n Resource deployed on regulating non-critical
activity.
Capability Outcome Owner:
n CAA Group Safety Services.
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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.
Actions to Achieve Desired Capability Outcome:
1. FRMS training to be developed for allappropriate CAA staff.
2. Develop a consistent SRG approach to
fatigue in aviation safety critical environments.
Deliverables and Dates:
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
Expected Safety Benefit:
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.
Key Performance Indicators:
n Proportion of relevant CAA staff appropriately
trained and skilled in the assessment and
practical implementation of FRMS.
Capability Outcome Owner:
n CAA Flight Operations Policy.
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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).
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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
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39PAGE 4. OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13
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.
Deliverables and Dates:
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
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success will be tracked using the
following key performance indicators:
n Level busts in UK airspace involving business
jets (broken down by number and rate for G-
registered and foreign registered aircraft).
Safety Outcome Owner:
n BASP.
4.1 Business Aviation
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40PAGE 4. OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13
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.
Deliverables and Dates:
1. BASP Safety Notice on appropriate
response to ACAS warnings, and associated
training advice, produced and distributed.
March 2012
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success will be tracked using the
following key performance indicators:
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.
Safety Outcome Owner:
n BASP.
4.1 Business Aviation
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41PAGE 4. OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13
4.1 Business Aviation
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.
Deliverables and Dates:
1. Recommendations for implementation of
ATQP for business jet operations produced.
April 2012
Actions to Achieve Desired Safety Outcome:
1. BASP Chair together with CAA Flight
Operations ATQP Focal Point to investigate
implementation of ATQP for business jet
operations.
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success will be tracked using the
following key performance indicators:
n Number of UK business jet operators running
ATQPs.
Safety Outcome Owner:
n BASP.
C S f
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42PAGE 4. OTHER AVIATION SECTORS Civil Aviation Authority Safety Plan 2011/13
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.
Expected Safety Benefit:
Reduction in the Large Public Transport
Helicopter accident rate.
Key Performance Indicators:
Action success and overall risk to offshore
helicopter operations will be tracked using the
following key performance indicators:
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.
Safety Outcome Owner:
n CAA Flight Operations Inspectorate
(Helicopters).
Actions to Achieve Desired Safety Outcome:
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).
Deliverables and Dates:
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
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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.
Actions to Achieve Desired Safety Outcome:
Continued
Deliverables and Dates:
Continued
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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.
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Deliverables and Dates:
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
Expected Safety Benefit:
Reduction in the likelihood of mid-air collisions
involving GA aircraft.
Key Performance Indicators:
Action success will be tracked using the
following key performance indicators:
n Actual mid-air collisions involving GA aircraft.
n AIRPROX involving GA aircraft.
Safety Outcome Owner:
n CAA Flight Operations Inspectorate (General
Aviation).
Alignment with European Aviation Safety Plan:
n Reference: Safety Action GA1.3.
Actions to Achieve Desired Safety Outcome:
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
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Desired Safety Outcome (GA2): Reduce the
risk of accidents due to pilots making wrong
decisions over the conduct of a flight.
Deliverables and Dates:
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
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
Reduction in the number of accidents involving
poor decision-making by pilots.
Key Performance Indicators:
Action success will be tracked using the
following key performance indicators:
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.
Safety Outcome Owner:
n CAA Flight Operations Inspectorate (General
Aviation).
4.3 General Aviation
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Desired Safety Outcome (GA3): Reduce the
risk of accidents due to the effects of
helicopter and wind turbine induced wake
turbulence on light aircraft.
Deliverables and Dates:
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
Actions to Achieve Desired Safety Outcome:
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.
Expected Safety Benefit:
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.
Key Performance Indicators:
Action success will be tracked using the
following key performance indicators:
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’.
Safety Outcome Owner:
n CAA Flight Operations Inspectorate (GeneralAviation).
4.3 General Aviation