Loss Of Control InflightAn Approach to Enhance Safety
Loss Of Control Inflight
TOP 3 HIGH-RISK OCCURRENCE CATEGORIES(TOT7)
R/W SAFETY RELATED
CONTROLLED FLIGHT INTO TERRAIN
LOSS OF CONTROL IN-FLIGHT
Loss Of Control Inflight
0% 10% 20% 30% 40% 50% 60% 70%
CFIT
LOCI
Rwy Safety Related
2%
3%
62%
13%
60%
6%
Fatalities Accidents
Observations from 2013 ICAO Safety Report 2014
Loss Of Control Inflight
0% 10% 20% 30% 40% 50% 60%
CFIT
LOCI
Rwy Safety Related
2%
2%
54%
5%
31%
0%
Fatalities Accidents
Observations from 2014 ICAO Safety Report 2015
Loss Of Control Inflight
LOCI9%
Others
Accidents %
LOCI
OTHERS
2010-2014 Fatal Accidents, IATA Reports
Loss Of Control Inflight
LOCI49%OTHERS
Fatality %
LOCI
OTHERS
2010-2014 Fatal Accidents, IATA Reports
Loss Of Control Inflight
LOCI49%
OTHERS
Fatality %
LOCI
LOCI9%
Others
Accidents %
LOCI
OTHERS
Loss Of Control Inflight
104
118
99
90
98
0
20
40
60
80
100
120
140
2010 2011 2012 2013 2014
Accidents
ICAO Safety Report 2015
Loss Of Control InflightLOC-I Threats:
Weather
ATC
CREW
Aircraft
Loss Of Control Inflight
Loss Of Control Inflight
Loss Of Control Inflight
Loss Of Control InflightCREW
Knowledge: Aircraft Limitations, Weather and its Avoidance
Proficiency: State of the Art Simulators Nowadays can Simulate every manoeuver required such as Stall Recovery, High Pitch Angles, Steep Bank Angles, Wind Shear, Collision Avoidance.
Situational Awareness: Crew should always be ahead of the Aircraft, and never be Complacent resulting from High Degree of Automation.
Loss Of Control Inflight
Loss Of Control Inflight
Thank You
Developing and Implementing
Regional LOC-I Safety Enhancements
George Rhodes
Assistant Director Infrastructure
IATA MENA
Fatal Accidents by Categories
18
Accident Frequency and Survivability
19
Loss of Control Inflight Accidents
2010 - 2014
There were a total of 415 commercial accidents
during this period:
38 of these accidents were LOC-I
37 were fatal accidents
Resulted in 1,242 out of 2,541 fatalities
20
LOC-I Accidents by Region
21
26% 13% 18% 8% 18% 5% 11% 0%0
2
4
6
8
10
12
AFI
ASP
AC
CIS
EUR
LATA
M
MEN
A
NA
M
NA
SIA
LOC
-I A
ccid
en
ts
LOC-I Accidents: Region of Operators10
5
7
3
7
2
4
Source: IATA GADM
LOC-I Fatal Accidents by Region
22
10
5
7
2
7
2
4
00
2
4
6
8
10
12
AFI
ASP
AC
CIS
EUR
LATA
M
MEN
A
NA
M
NA
SIA
LOC
-I A
ccid
en
ts
LOC-I Fatal Accidents: Region of Operators
Source: IATA GADM
Contributing
Factors
Latent Conditions (deficiencies in...) Errors (related to…)
Flight Operations 24% Manual Handling / Flight Controls 29%
Safety Management 24%
SOP Adherence / SOP Cross-verification
26%
Flight Ops: Training Systems 18% Intentional 16%
Regulatory Oversight 18% Unintentional 11%
Flight Ops: SOPs & Checking 13% Callouts 8%
Environmental Threats Undesired Aircraft States
Meteorology 37% Vertical / Lateral / Speed Deviation 21%
Icing Conditions 13%
Operation Outside Aircraft Limitations
16%
Poor visibility / IMC 13% Unnecessary Weather Penetration 16%
Thunderstorms 13% Unstable Approach 11%
Lack of Visual Reference 11% Abrupt Aircraft Control 5%
Airline Threats Countermeasures
Aircraft Malfunction 37% Overall Crew Performance 32%
Contained Engine Failure/Powerplant Malfunction
24%
Contingency Management 16%
Operational Pressure 8% Captain should show leadership 11%
Fire / Smoke (Cockpit/Cabin/Cargo) 5% Leadership 11%
Monitor / Cross-check 11%
23
24
Contributing
Factors –
Latent
Conditions
25
Contributing
Factors –
Undesired
Aircraft State
26
LOC-I Accidents in
MENA
Percentage
of
Commercial
Accidents
Versus
Total
Accidents -
MENA
27
LOC-I
Accidents
in MENA
per Year
28
Contributing Factors in LOC-I: MENA Region
29
Meteorology and Aircraft Malfunction were cited as contributing factors
30
5 W’s of RASG-MIDWhat is RASG-MID?
Regional Aviation Safety Group for the MID region
When & Where was it established? ICAO Council approval on 25 May 2010 to establish RASGs
RASG-MID kick off on 18 – 19 September 2011 in Cairo, Egypt
Why was is established? Develop an integrated data driven strategy, and implement a
work program that supports a regional performance framework
for the management of safety on the basis of the GASP
Who can participate? Members: Contracting states (ICAO MID region)
Observers: Non contracting states & Organizations
31
RASG-MID Contracting States…
MID Region
15 States…
Libya, Egypt, Sudan, Jordan, Syria, Lebanon,
Iraq, Kuwait, Qatar, Bahrain, UAE, Oman,
Saudi Arabia, Yemen, Iran
32
RASG-MID Permanent Observers
33
ICAO Council
Air Navigation Commission
RASG MID
RASG MID Steering
Committee
Annual Safety
Report Team
Regional
Aviation Safety
Team
Safety Support
Team
Runway &
Ground Safety
Working Group
RASG-MID
Structure
34
What we do Collect safety information from different
stakeholders Identify & address aviation safety risks in
the MID region Produce the annual safety report
1st Edition, Nov 2012 2nd Edition, Jan 2014 3rd Edition, March 2015 4th Edition, In progress
Data sources: States & Organizations
Annual Safety Report Team (ASRT)
35
What we do
Develop & implement SEIs and DIPs related to focus areas identified by the ASRT
SEIs & DIPs include: Development of training &
guidance material Holding regional workshops &
seminars Go teams
Regional Aviation Safety Team (RAST)
36
What we do
Support the RASG-MID steering committee with safety initiatives not directly related to key focus areas such as:State safety program (SSP)/Safety Management
Systems (SMS) implementationEstablishment of Regional safety oversight
organizations (RSOO)English language proficiency (ELP)…etc
Safety Support Team (SST)
37
Workflow for the three teams…
38
RASG-MID uses different types of
safety information
REACTIVE: safety analysis based on accidents and serious incidents in MID region
PROACTIVE: includes analysis of existing State conditions (ICAO SARPs implementation, traffic variations), IOSA, ISAGO audit results, and STEADES data
PREDICTIVE: based on analysis of Flight Operations Quality Assurance (FOQA) de-identified data, oriented towards identifying potential future hazards for initiating corresponding mitigation actions –an area for improvement!
39
Safety Data Analysis
Risk assessment based on:
FrequencySeverity (fatality)
Accident Category Frequency Severity Frequency*Severity
Runway/ Taxiway Excursion 1* 2 2
Ground Safety 1* 3 3
Gear up Landing / Gear Collapse 3 3 9
Hard Landing 4 3 12
Loss of Control In Flight 5 1 5
Controlled Flight Into Terrain 6 1 6
Top Risk Areas in the MID Region
Runway Safety
Loss of Control In-flight (LOC-I)
System Component Failure – NEW!
40
Loss of Control – Inflight (LOC-I)
MID- Regional Aviation Safety Team (RAST)
MID-RAST Process 1. Develop short and medium term regional safety priorities
based on identified Focus Areas (FAs)
2. Develop SEIs for the identified FAs;
3. Provide recommended actions through the development
of Detailed Implementation Plans (DIPs)
4. Monitor the implementation of DIPs and provide feedback
to the RSC; and
5. Review DIPs with MID-RSC & RASG-MID
6. Approval of DIPs by RASG-MID
7. Implementation & Monitor progress (IATA MENA + stake
holders
42
Loss of Control In-Flight (LOC-I)
LOC-I/1: Airplane State awareness (ASA) -Low
airspeed alerting
LOC-I/2: Standard Operating Procedures
effectiveness and adherence ;and
LOC-I/3: ASA-Training-Flight Crew Training
Verification and Validation
43
LOC-I/1 :Airplane State awareness (ASA)-
Low airspeed alerting
Compiled statistical data to identify the number
of operators and their fleet in MID region.
1481 aircraft registered in the MID Region.
Consulted with manufacturers of aircraft to
determine the status of their fleet.
44
ASA MID fleet Status (1)
949 New Generation aircraft with glass cockpit having
the provision of low speed alert. Represents 64%
compliance rate
217 Classic western built aircraft representing 15 % of
the total fleet in Mid Region
123 Regional Jets representing 8%
124 Eastern built aircraft representing 8%, mainly in Iran,
Libya and Sudan
68 Turbo Prop aircraft representing 5 %
45
ASA fleet Status (2) Basic on Boeing 787, 777, 747-8, 767-400 {with the
Large Format Display Systems (LFDS)} and 747-400.
Optional on Boeing 737-600/700/800/900 (service
bulletin available (SB 737-34A2292).
No Option on Boeing 757, 727, MD-90, MD-80, 737-
100/200/300/400/500 or the 767.
Basic on Airbus A320 family, A330, A340, A350 and
A380
Not basic on A300 & A310.
46
LOC-I/1 :Airplane State awareness
(ASA)-Low airspeed alerting
The ICAO ANC highlighted that the work on Low Airspeed
Alerting provisions was excellent material and the ANC
should consider referring this work to the AIRP for further
review.
47
LOC-I/2 :SOPs effectiveness and adherence
Many aviation safety organizations recently reaffirmed the
importance of SOPs.
identified deficiencies in SOPs as contributing causal factors in
aviation accidents.
commonly cited deficiencies involving flight crews non-compliance
with established procedures; or the non-existence of established
procedures in some manuals.
Airlines should consult with manufacturers to check that
SOPs are consistent with current manufacturer
recommendations with regards to LOC-I and CIFT.
48
LOC-I/3 :Flight Crew Training (1)
Upset prevention and recovery training, including
the following:
1. Qualification of flight simulators to satisfactorily
represent aircraft characteristics for proposed scenarios
Coordinate with airplane and simulator manufacturers
to ensure that simulators satisfactorily represent
aircraft characteristics for proposed scenarios
2. Approach-to-stall training in realistic scenarios
3. Upset prevention and recovery training (UPRT) realistic
scenarios
49
LOC-I/3 :Flight Crew Training (2)
Approach-to-stall training in realistic scenarios.
(i.e., up to the stall warning activation):
approach-to-stall with the autopilot engaged (including
auto-throttles disengaged, inoperative or not installed
a demonstration of recognition and recovery from initial
improper response to approach-to-stall.
high-altitude approach-to-stall (service ceiling for the
weight)
low-altitude approach-to-stall (terrain critical) and recovery
with ground proximity warning system (GWPS) alerts
air data system failures that can lead to stall
50
LOC-I/3 :Flight Crew Training (3)
Upset prevention and recovery training (UPRT)
realistic scenarios including but not limited to:
Upsets encountered with and without auto-flight
engaged.
Upsets occurring in instrument meteorological
conditions (IMC)
Sub-threshold roll (imperceptible roll rate) in IMC
Pilot-induced upsets
Air data system failures (e.g., unreliable airspeed)
51
Ref. Documentations
IATA Guidance Material and Best Practices for the
Implementation of Upset Prevention and Recovery
Training (First edition effective June 2015)
ICAO Doc.10011 Manual on Aeroplane Upset Prevention
and Recovery Training
Annex 6 ;ICAO AMENDMENT 38 on UPRT
52
Q&ATHANK YOU