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Transcript of IATA Incident Review Meeting IRM-09 - ukfsc.co.uk Meetings/IATA IRM/IATA IRM 09... · IATA Incident...
IRM-09 HKG Oct 26-27,2010 2
STEADES Current StatusWorld’s largest ASR database>105,000 ASRs annually With 4.5M annual sectors ,STEADES represents 28% of world’s western built jet traffic
STEADES Participation110+ airlines
Any languageOver 600 incident categories
Traffic STEADES Sectors (’09) % of world
A320 Family 734,000 12%
A330 138,000 27%
A340 55,000 28%
A380 8,600 100%
B777 129,000 37%
B737 828,000 23%
B747 163,000 26%
IRM-09 HKG Oct 26-27,20103
STEADES Analysis
STEADES data is comprised of Air Safety Reports collected from over 110 participating airlines and submitted to IATA quarterly.
DISCLAIMER: The information contained in this publication is subject to constant review in the light of changing government requirements and regulations. No subscriber or other reader should act on the basis of any such information without referring to applicable laws and regulations and/or without taking appropriate professional advice. Although every effort has been made to ensure accuracy, the International Air Transport Association shall not be held responsible for any loss or damage caused by errors, omissions, misprints or misinterpretation of the contents hereof. Furthermore, the International Air Transport Association expressly disclaims any and all liability to any person or entity, whether a purchaser of this publication or not, in respect of anything done or omitted, and the consequences of anything done or omitted, by any such person or entity in reliance on the contents of this publication.
© International Air Transport Association. All Rights Reserved. No part of this publication may be reproduced, recast, reformatted or transmitted in any form by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without the prior written permission from: Senior Vice President, Safety, Operations & Infrastructure
IRM-09 HKG Oct 26-27,2010 Cargo Smoke/Fire Warning - Preliminary Results4
STEADES Analysis: Cargo Smoke/FireDatabase Query Criteria
Date Range: Q1 2003 to Q1 2010 inclusive; AND
Descriptors/Categories:“Smoke/Fumes – Hold”,“Fire False Warning – Hold”,“Fire Detection System – Hold“Fire/Sparks – Hold”“Fire Protection System – Hold”
IRM-09 HKG Oct 26-27,20105
STEADES Analysis: Cargo Smoke/FireResults
718 reports matching criteria (7 year timeframe)Approx. 0.039 per 1,000 sectors OR 1 event per 25,400 flights
Industry (estimate): nearly 4 events each day (3 Ground, 1 Airborne) or 1,390/year
3% (20 events) confirmed actual presence of smoke or fire. (5 events airborne)
Approx 0.0011 per 1,000 sectors or 1 event per 880,000 flightsIndustry (estimate): 1 event every 9 days 4% (31 events) involved “non-normal” deplaning of passengers
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,20106
Cargo Smoke/Fire Events - Trend
Last reported Cargo Smoke/Fire event where the presence of smoke/fire was confirmed occurred in Q3 2007.
Reported Cargo Smoke / Fire Events
0
20
40
60
80
100
120
140
160
180
200
2003 2004 2005 2006 2007 2008 2009
Num
ber o
f Rep
orte
d E
vent
s
0.000
0.010
0.020
0.030
0.040
0.050
0.060
0.070
Repo
rted
Eve
nts
per
1000
Flig
hts
Actual Presence of Smoke/Fire Reported Events Events per 1000 Flights Linear (Events per 1000 Flights)
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,2010 7
Cargo Smoke/Fire Events - Risk
76% (546 events) included risk information
High: 16 events Medium: 94 eventsLow: 436 events
Note: The risk code assigned to an event is done at the airline. IATA does not validate incoming reports for risk assignment.
High2% Medium
13%
Low61%
Insufficient Information
24%
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,20108
Cargo Smoke/Fire Events – Sampling of High Risk Events
Translated: “Very heavy rain at BKO. Decided to hold at GATAM to calculate landing distance for wet runway. While waiting, FWD CARGO SMOKE alarm and LAND ASAP. Emergency checklist performed and declared MAYDAY. Immediate ILS 06. Visual at about 500 ft AGL. As soon as we vacated the runway, the airport fire service performed a visual inspection, nothing to report. Passengers deplaned. Inspection by a mechanic who explained that this is recurring item on this aircraft due to sensitivity of the smoke detectors.”
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,20109
Cargo Smoke/Fire Events – Sampling of High Risk Events
B777 - “During cruise, the crew received a smoke warning indication for the bulk cargo hold. The fire extinguisher bottles were discharged and the fire indication went out, but returned after 5 minutes. The aircraft was diverted to an enroute airport where a safe overweight landing was performed. Inspection carried out found a smoking passenger bag.”
Cargo Smoke/Fire Warning - Preliminary Results
0.000
0.020
0.040
0.060
0.080
0.100
0.120
0.140
0.160
0.180
0.200
PUSH-BACK
TAXI-OUT
TAKE-OFF
INITIAL C
LIMB
CLIMB
CRUISEDESCENT
HOLDIN
GAPPROACH
LANDIN
G
TAXI-INPARKED
NONE
SEVERAL PHASES
Even
ts p
er 1
000
Flig
hts 2003 2004 2005 2006 2007 2008 2009
Cargo Smoke/Fire Events – Flight Phase
61% (437 events) occurred during Parked Phase7% (30 events) due to exhaust fumes from ground equipment vehicles66% (287 events) due to insecticide spray
IRM-09 HKG Oct 26-27,201012
Cargo Smoke/Fire Events –
Cargo Smoke/Fire Warning - Preliminary Results
All Events
Benign89%
Insufficient Information19%
Insecticide Spray50%
Hazard Report1%
Insufficient Information6%
Confirmed Smoke/Fire3%
Dangerous Goods1%
Humidity / Perishables7%
Ground Equipment Exhaust Fumes
4%Fire Detection System
Problem9%
IRM-09 HKG Oct 26-27,201013
Cargo Smoke/Fire Events – Actual Smoke/Fire Events
Actual Smoke/Fire Events: 20 eventsPower Drive Unit (PDU): 6 eventsPassenger Bag or Courier Material: 6 eventsWires: 2 events
Found wire bundle damagedFound wires cut and shorting-out, circuit breaker tripped
Failed electronic system: 1 eventEntertainment System: 1 eventLeaking Heat Exchanger: 1 eventLeaking oil pipe: 1 eventInsufficient Information: 2 events
Last Actual Smoke/Fire Event reported in Q3 2007
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,201015
Cargo Smoke/Fire Events – Airborne
166 events during airborne phasesApprox. 0.0089 per 1,000 sectors OR 1 event per 112,000 flightsIndustry (estimate):
Roughly 1 event per day somewhere in the world
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,2010 16
Airborne Events
Benign84%
Hazard Report1%
Dangerous Goods2%
Confirmed Smoke/Fire
3%
Insufficient Information
10%
Cargo Smoke/Fire Events – Airborne
Confirmed Cargo Smoke / Fire events:
3% (5 events) involved confirmed smoke or fire during airborne phases
166 benign events mainly false warnings, problems with Smoke/Fire detection equipment, or humidity / perishables
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,201017
Cargo Smoke/Fire Events – Airborne
Sample narrative
B777- “On arrival and during unloading of the bulk cargo bay, a courier bag was found to have suffered heat damage. The outer cover was melted through and the cardboard box contents showed signs of scorching. Ground staff stated that the bag was located above the marked limit and was found in contact with the hold ceiling, covering a hold lighting unit. Engineering have completed installation of modification kits to adapt the hold lighting to a lower wattage system…”
Cargo Smoke/Fire Warning - Preliminary Results
IRM-09 HKG Oct 26-27,2010 Published October 201018
STEADES Analysis for IRMGoal: introduce each section (accident category) at IRM with high level analysis of accident category precursors found in STEADES.
IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 20
Mid-Air Collision Extract from Safety Report 2009:
None in Safety Report 2009
IRM-09 HKG Oct 26-27,2010 Published October 201021
Mid-Air Collision Precursors from STEADES:
UAS: TCASAltitude DeviationLateral Deviation
Errors:Flight Crew Manual HandlingFlight Crew Auto HandlingFlight Crew Mis-selectionChecklist / SOP useInsufficient crew rest
Threats: Auto Flight (defects / failures with autopilot, uncommanded pitch/roll, roll/pitch exceedence…)Instrument failuresLoss of CommsPressurization failures / problemsNavigation System failuresMeteorological (fog…)
Drill down
Drill down
Drill down
IRM-09 HKG Oct 26-27,2010 Published October 201022
Mid-Air Collision Precursors from STEADES:Mid-Air Collision Precursors
0
0.2
0.4
0.6
0.8
1
1.2
2003 2004 2005 2006 2007 2008 2009
Rat
e (E
vent
s pe
r 10
00 fl
ts)
TCAS Altitude Deviations Loss of Comms Index Linear (Index)
IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 24
Loss of Control In-flight Extract from Safety Report 2009:
IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 25
Loss of Control In-flight Precursors from STEADES:
UAS: Aircraft Limit ExceedenceUnstable ApproachTemporary Loss of ControlAvoidance ManoeuvreStall Warning/Alpha protection Fuel imbalanceAircraft out of trim
Errors:Flight Crew Manual HandlingFlight Crew Auto HandlingConfiguration warnings (Flaps)
Threats: Flight Controls (defects with Trim, Flaps, Rudder…)Auto Flight (defects / failures with autopilot, uncommanded pitch/roll, roll/pitch exceedence…)BidstrikeEnvironmental (volcanic ash, animal strike…) Meteorological (turbulence, windshear, crosswind…)Fuel (failure of crossfeeds, booster pumps, contamination…)Ice / Rain Protection (failure of anti/de icing)Instrument failuresDamage to structures (wings, fuselage, fin…)Documentation (error with fuel plan)
Drill down
Drill down
Drill down
IRM-09 HKG Oct 26-27,2010 Published October 201026
Loss of Control Precursors from STEADES:Loss of Control Precursors
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
2003 2004 2005 2006 2007 2008 2009
Rat
e (E
vent
s pe
r 100
0 flt
s)
Aircraft Limit Exceedence Stall Warning / Alpha Protection Configuration Warnings (all)Index Linear (Index)
IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 28
CFIT Extract from Safety Report 2009:
IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 29
CFIT Precursors from STEADES:
UAS: Unstable ApproachAircraft out of trimEGPWS warnings
Errors:Flight Crew Manual HandlingFlight Crew Auto HandlingFlight Crew Mis-selectionChecklist / SOP useInsufficient crew rest
Threats: Auto Flight (defects / failures with autopilot, uncommanded pitch/roll, roll/pitch exceedence…)Instrument failuresPressurization failures / problemsNavigation System failuresMeteorological (fog…)Windshear
Drill down
Drill down
Drill down
Drill down
IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 30
CFIT Precursors from STEADES:
CFIT Precursors
0
0.2
0.4
0.6
0.8
1
1.2
2003 2004 2005 2006 2007 2008 2009
Rate
(Eve
nts
per 1
000
flts)
Ustable Approach EGPWS Warnings Flight Crew Mis-SelectionsWindshear Warning Index Linear (Index)
IRM-09 HKG Oct 26-27,2010 31
5 CFIT Accidents classified by ACTF (193 fatalities) in 2010
Aviastar-TU (0) Mar 22Pamir Airways (38) May 17Aero Service (Congo Brazzaville) (9) June 19Air Blue (146) July 28National Air Cargo (0) Oct 12
IRM-09 HKG Oct 26-27,201033
05
101520253035
2004 2005 2006 2007 2008 2009
Runway Excursions 2004 - 2009
Excu
rsio
ns a
s ra
tio to
# o
f ac
cide
nts
The % is relative to the total number of accidents during that year
33%24%
27% 24%27%
Actual R
unway
Excursions
32%
29 2924212734
IRM-09 HKG Oct 26-27,201034
34
Runway Excursions (Rates) 2004-2009 per Million Sectors
NAM0.33
LATAM1.33
EUR0.41
CIS0.71
MENA3.39
AFI3.76 ASPAC
1.30
NASIA0.16
Based on region of operator
IRM-09 HKG Oct 26-27,201035
Runway Excursions - Regional Occurrences 2004-2009 accident count
2
43
23 2320
4
2623
05
101520253035404550
NASIA ASPAC AFI MENA EUR CIS NAM LATAM
IRM-09 HKG Oct 26-27,201036
Runway Excursions - Regional Occurrences Region of Operator Vs. Occurrence
1%
26%
14% 14%12%
2%
16%14%
1%4%
18%
12%12%13%13%
27%
0%
5%
10%
15%
20%
25%
30%
NASIA ASPAC AFI MENA EUR CIS NAM LATAM
Region of Operator Region of Occurrence
IRM-09 HKG Oct 26-27,201037
Take off vs. Landing
Overrun vs. Veer off
75
89
65
70
75
80
85
90
95
Overrun Veer off
Excursion Take of f17%
Excursion Landing83%
IRM-09 HKG Oct 26-27,201038
Turboprops vs. Jets Substantial Damage and Hull Loss
Substantial Damage
52%
Hull Loss48%
Turboprops
Hull Loss55%
Substant ial Damage45%
Jets
IRM-09 HKG Oct 26-27,201039
2010 Runway Excursion Accidents (Till Sep 2010) accident data
Year to September, there have been 77 events
26 Accidents200 fatalities
51 other Runway Excursion Incidents (known)Ratio is 26/77 (34 %)
22
11
14
9
16
1314
0
5
10
15
20
25
2004 2005 2006 2007 2008 2009 2010
IRM-09 HKG Oct 26-27,201040
EMAS Arrests vs. Overrun Accidents (2004-2010) accident data
1613
11 1214
9
11
1
10
02468
1012141618
2004 2005 2006 2007 2008 2009 2010
Overrun accidents EMAS Saves
To date, there have been five incidents where the technology has worked successfully to arrest aircraft which overrun the runway and in several cases has prevented injury to passengers and damage to the aircraft
From 2004- Sep 2010, a total of 3 accidents were arrested by EMAS
IRM-09 HKG Oct 26-27,2010© International Air Transport Association 2011. All
Rights Reserved. Extract from the Runway Excursion Risk Reduction (RERR) Toolkit Second Edition 2011
and subject to the disclaimer contained therein. 41
Incidents
Accidents
2010 Runway Excursion (thru Sept 2010)
IRM-09 HKG Oct 26-27,201042
2010 STEADES Analysis publishedTopic Origin of Request Type Timeline Status
1. Airport Markings Deficiencies IRM/SG 2009 Mini May 2010 Published
2. South Atlantic ATM Events Airline requests Mini May 2010 Published
3. ATM Events at Toronto Airline requests Mini July 2010 Published
4. ATM Events in Philippines Airline requests Mini Sept 2010 Published
5. Anti/De Icing Events Airline requests Mini Oct 2010 Published
IRM-09 HKG Oct 26-27,201043
2010 Analysis scheduledTopic Origin of Request Type Timeline Status
6. Turbulence Injuries Cabin Safety TF Mini Oct 2010 In progress
7. Medical Diversions Cabin Safety TF Mini Oct 2010 In progress
8. Cargo Door Indications Airline requests Mini Nov 2010 In progress
9. Airport Markings/construction IRM/SG 2010 In-depth Nov 2010 In progress
10. Cargo Smoke/Fire Warnings Airline Requests In-depth Oct 2010 In progress
11. Foreign Object Damage Airline Request In-depth Oct 2010 In progress
12. NOTAM Issues IRM/SG 2010 In-depth Nov 2010 In progress
13. Unstable approach Customer survey In-depth Dec 2010 In progress