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Eurocontrol Runway Excursion Prevention Group – 20 January 2011 – Brussels Meeting

Runway Excursion (RE) Prevention Group Eurocontrol HQ, Brussels – 20 January 2011
CE Meeting Summary
Agenda

Introduction and Aims

  • Aim of the meeting is to bring together RE prevention strategies in Europe from Eurocontrol and ECAST and reach a common understanding on the current RE prevention plans in place
  • The aim of this group is to form a European Action Plan on REs for implementation across the European Community
  • Eurocontrol has been working with FSF and has generated a Report on REs.

ECAST RE Working Group – Bertrand de Courville

  • ECAST has formed an RE Working group
  • RE is one of a family of five significant safety issues being addressed by ECAST
    • ECAST has a set of other sub groups on Ground handling, SMS.
  • FAST is also associated with ECAST and the US CAST

ECAST and Eurocontrol Working Together

  • Important that all EC RE work is co-ordinated
  • Also important that expertise and outputs on RE is also widely distributed
  • Runway Incursion work is kept separate from RE – another gp is available for participation in RI
  • The Gp is sending out guidance – both internal and external generated
  • Wider co-ordination with the FAA and Australia will follow automatically

FSF Work

  • A FSF extensive report including a table of stabilised approach criteria is available on the FSF website.
  • There are numerous excellent and effective RE initiatives – getting the recommendations and advice to the frontline is the major challenge
  • The involvement of the ATC in forcing pilots into poor decision making by asking for expedites and runway changes, increasing speed or retaining height is another key contributor to potential RE incidents

Eurocontrol Study into Runway Excursions

  • Between 1980 – 2008, 1075 RE globally investigated of which 246 in Europe
  • 450 causal factors have been boiled down to prominent 18 factors
  • Sept 2010 situation is
    • 107 RE in 2010 – 20% of all accidents
    • 2 RE per week
    • 30 REs in Europe
    • 2 fatalities in Europe – 162 globally
    • 51% caused damage to aircraft
  • 11% take-off, 12% veer off, 43% overrun, 42% veer off
  • 45% wet/contam- 55% dry
  • The Gp discussed the final 200’ on the approach to the landing. Agreed the need to provide more capacity to the pilot to allow him time to make a sound decision to go-round or land
    • Currently many pilots are tunnel visioned on landing at this stage
  • FDM Users – the ECAST initiative to bring operators together within Europe to share best practice on FDM applications and algorithms for improved safety outcomes may be helpful on REs
  • Touchdown zone indications are not accurately available to many FDM recordings and this may have resulted in this part of the landing being poorly addressed in terms of advice
  • Veer offs – causal factors such as crosswind, wet runways, hard landings, nose-wheel steering problems, tyre failure
  • Proposed Recommendations on reducing REs required for the following stakeholders:
    • Aircraft manufacturers
    • Regulators
    • Aircraft operators
    • Aerodrome operators
    • Air navigation service providers

Consolidated View of Eurocontrol and FSF Way Ahead

  • Adoption of the recommendations in EAPRI is not mandated– voluntary only
  • This will equally apply to REs too
  • EASA is involved, but will use the RE Gp info and recommendations to influence rule making, not to dictate it
  •  Outstanding Actions from the last Eurocontrol RE Prevention WG was to produce advice targeted at specific stakeholders
    • Air operators
    • Manufacturers
    • Airports
    • ANSPs
  • This meeting then split into stakeholder groups outlined above in order to review the current recommendations from the Eurocontrol RE Study. The outcome of this review of the recommendations will be published once complete.
  • Each stakeholder sub Gp submitted their amended recommendations to Eurocontrol by 3 Feb 11.
  • The RE Group was asked to review the revised recommendations with 2 weeks of receiving the revision
  • RE Group to meet on 2 more occasions for this year – 16 May and then in Oct – to develop a final version of the recommendations for publication.
  • RE Gp were reminded of the ICAO Runway Safety Conference – Montreal 24-26 May 2011

Rich Jones
Chief Exec
UKFSC
10 Feb 2011

CAA Laser Working Group – 17 March 2011 – Gatwick Meeting

CAA Laser Working Group Meeting– 17 March 2011 – SRG Gatwick
CE Meeting Summary

Agenda

Key Issues

  • ATSIN and FODCOM providing advice and guidance were issued in 2008/9 by the CAA.
  • Both have been absorbed into CAP 493 – Section 2
  • Latest laser attack figures
    • Last year’s attacks doubled from 2009 with 1494 incidents
    • This year, the trend is going up again
  • Major spikes in Aug/Sep during warm weather and after overseas holidays when lasers are being bought and brought back to the UK
  • Birmingham Airport has the most effective reporting culture and is now the highest report numbers of attacks. Attack Locations
  • Overseas multi-targets have reduced
  • The CAA SDD analysts currently assess laser incidents as low risk
  • Most pilots are aware of the distraction danger and manage these attacks well but a high risk outcome cannot be ruled out
  • Advice on all aspects of laser attacks is widely available
    • CAP 493, FAA Video, numerous articles, a CAA package
    • A Credit card option was discussed – with medical advice to re-assure pilots of the improbability of any permanent damage to eyes but to recommend action in cases of medical concern
  • A draft Cranfield decision flow chart was provided by the UKFSC for consideration by the CAA
  • UKFSC concern expressed about malicious attacks on SAR helicopters including a hoax call out and subsequent serious attack on a night low level rescue mission
  • A rescue aids company had approached the CAA seeking dispensation from prosecution for attention getter for people in distress based on a bright red laser
    • This had been refused, but it was recommended that the CAA direct the company to include a warning notice on the dangers of illuminating rescue helicopters with this equipment.

Next Steps

  • A series of further actions would be considered by the CAA and discussed further by the Gp including:
    • Medical aspects of laser attacks
    • Co-ordination of responses – airport, flight crew and police
    • Continue to build prosecution evidence packs for police and judges
    • Monitor colour and increased power laser attacks and availability
    • Consider confiscation of lasers from ac luggage
    • Review advice to flight crew on attack mitigation in light of FAA video
    • Review the positive and negative consequences of publicising these attacks amongst the public and schools
      • Most considered that wider publicity should not be given

Rich Jones
Chief Exec
 UKFSC
25 March 2011

Eurocontrol Update – Post IATA IRM – 11 May 2011 – Geneva Meeting

Eurocontrol Update– Post IATA IRM Meeting – IATA HQ, Geneva – 11 May 2011
CE Summary

Stabilised Approach Awareness for ATC

  • Eurocontrol is developing an awareness package on stabilised approaches to train ATCOs
  • The package will be posted and promoted on Skybrary in due course

EVAIR Reporting System Feedback

  • From Summer 2008 to Summer 2010, EVAIR Stats showed:
    • 50% yearly increase in EVAIR Reports – 2010 saw 1133 total
    • Over 5000 reports altogether in EVAIR database
    • 78 airlines are contributing to the scheme
    • All European ANSPs provide feedback
  • Benefits of EVAIR Membership
    • Facilitates rapid responses from ATC to incidents and to getting problems fixed
    • Identifies causal factors and cross checks on ATM safety trends
    • Develops trust between ANSPs and Airlines
    • Uses ICAO taxonomy
    • Provides ATM safety bulletins
  • Incident Feedback on EVAIR Reports in 2009-2010
    • 61 stakeholders received feedback from ATC incidents
    • Feedback timing reduced from years to days
    • 11% of all EVAIR reports received feedback
    • 34% of feedback was initiated by EVAIR
  • Italian ANSP Feedback
    • Feedback is bi-directional
    • Only English is used for operational reporting
    • Narrative in reports require more detail
    • Lasers are a major growing problem
    • Stabilised approaches
    • Callsign confusion is being addressed – see next subject brief
    • Italian ANSP is encouraging famil flights for their ATCOs
    • Several regional airports have very poor infrastructure
  • Dutch ANSP Feedback
    • Stabilised approaches are the pilots responsibility
    • Go-rounds- send airline report to ATC
    • Different runway changes only accepted if safety involved
    • Airspace infringements by VFR traffic
    • Runway Incursion concerns
    • Giving way on taxiways
    • Laser attack increase
      • Lasers used at Amsterdam to scare birds
  • Actions By EVAIR Team based on EVAIR Data
    • Go-rounds and missed approaches review
    • TCAS events
    • Regular cross check of safety data and identify common safety concerns
    • Ensure transparency with the stakeholders
    • Support the feedback process and seek improvements
    • Use safety data and info for safety improvements only NOT to support legal cases

Eurocontrol Callsign Similarity Project

  • Eurocontrol started the initiative in 2006 to address callsign confusion
  • A pan European solution was necessary
  • CFMU manages flt plans across Europe and Eurocontrol manages safety for ATM, hence Eurocontrol undertook this work
  • The full Callsign confusion tool will be available from Spring 2013
    • It will be easily accessible through the NOP portal
    • A comprehensive city-pairs catalogue will be available
    • The system will be semi-manual initially but become fully automatic in due course
    • Its use will be covered by a CFMU agreement
    • The centralised service will be managed and maintained by the CSMC at Eurocontrol
  • SAim of the Tool is to reduce callsign confusion risk by 75%

Rich Jones
Chief Executive
UK FSC
23 June 2011

Draft State Safety Plan Launch – 5 July 2011 – Gatwick Meeting

Draft State Safety Plan Launch Meeting – CAA Aviation House – 5 July 2011
CE Meeting Summary

Agenda

Introduction – Gretchen Burrett

  • The State Safety Plan is part of the Safety Programme which ICAO requires each State to develop
  • The Plan lays down how the State Safety Programme will be delivered
  • The UK Safety Plan is aligned with the EASA European Safety Plan and uses the same priorities
  • Plan will evolve as a living document

Integrated Safety Performance – Tim Steads BA

  • BA uses assesses its safety performance using hazards and risk management
  • BA measures its hull loss rate with the rest of industry
  • The BA Corporate Safety Plan comprises:
    • Risk management
    • Aircraft accidents
    • Occupational risk
    • Ac damage
  • The BA Safety Plan incorporates a Safety Health Check
    • Incident and event trends are tested against BA Safety Plan targets and the level of risk is colour coded
    • A major risk is studied at each quarterly Safety Board meeting
    • Against each risk, a plan is developed and the resultant outcome measured
  • Risk management capability covers:
    • Reporting/Modelling/Forecasting
  • Risk controls are the key to stopping accidents
  • Impact of measures taken to reduce one type of risk needs to include analysis of the consequence for other user risk areas

CAA Safety Plan Contents – Joji Waites, CAA

  • Contents of the CAA Safety Plan are:
    • Plans to address the CAA’s Significant Seven Safety Concerns developed by joint Task Forces from the CAA and UK Industry.
    • These have been widely briefed to the UKFSC already.
  • Seven Key capabilities Requirements have also been identified in the Plan:
    • Integrated Safety Risk management process
    • Continued airworthiness
    • SMS
    • Just culture
    • Human factors
    • Performance based oversight
    • Total system threats
  • Other aviation sectors considered in the Plan:
    • Business aviation
    • Large public helicopters
    • General aviation
  • The Draft Safety Plan does not currently address some important aviation safety priorities and issues. A list has been drawn up by the CAA and the DfT to generate further ideas from the consultation for inclusion in the Plan.
  • This list has been developed by placing the safety of ‘UK Airline Industry Consumers’ at the heart of these priorities:
    • Review regulatory coverage – who is responsible for what between EASA and the UK CAA?
    • Foreign flights into UK airspace and Ops – when being used by UK consumers
    • Foreign destinations – when being used by UK airlines
    • Human performance
    • Class G for 21st century – is it fit for purpose when UK consumers are involved
    • Professional competence in key roles – regulator and service provider
    • Facilitate industry improvement – continuous improvement
    • Ground services – safety
  • Comments and views are invited on the Draft CAA State Safety Plan at http://www.caa.co.uk/SafetyPlanby 31 July 2011. Feedback form is available on the CAA website

Rich Jones
Chief Executive
UKFSC
11 July 2011

CAA Winter Wash up – 14 July 2011 – Gatwick Meeting

CAA Aerodrome Winter Wash Up Meeting – CAA, SRG Gatwick – 14 July 2011

CE Meeting Summary

Agenda

Item 2 – Review of the Heathrow Resilience Programme – post Begg Report

  • BAA has accepted and is in the process of addressing all 14 recommendations from the Begg Report
  • Improved snow resilience has already been introduced in 8 areas at Heathrow since Jan 11
  • Numerous other international airports have been consulted on their approach to winter ops resilience. Most of these airports often have more snow but invariably less traffic than Heathrow.
  • As a result the following lessons are being applied at LHR:
    • Aim to maintain one runway at all times
    • Ensure that demand and capacity is always being balanced
  • De-icing requirements and procedures vary significantly
    • Heathrow has 6 de-icers /17gnd handlers/96 airlines
    • The proposal to move away from stand and pan de-icing for ac to taxiway or holding point de-icing is yet undecided
  • BAA had the lone responsibility to clearing the stands – all other handling and service providers stay in their crew rooms
    • Health and Safety card is played extensively by gnd handlers to avoid snow clearance duties
    • After flying is finished – only BAA is left at Heathrow to clear snow.
  • Winter capability for vehicles is a problem – most airlines and ground handlers will not invest in tyres for snow usage
  • At least 319 personnel needed to clear stands of snow
  • BAA has gone from 50 vehicles to 195 specialist vehicles for snow handling and spent £10M to own them
  • Begg Recommendations – 14 in total- cover the following areas:
    • Preparation and planning
    • Command and control
    • Communications and passenger welfare
      • The Madrid airport plan is considered a good example to follow
        • Teams assigned to snow plan roles and trained to do them
        • Each airline and handler have signed a document detailing their responsibilities
    • Drills and testing of the plan
    • DfT will sign off the plan in due course
  • Collective Decision Making CDM is now being brought in at Heathrow which should help ( See AOA Seminar Summary on UKFSC website for more details)
  • In discussion, and the following points were made on behalf of the UKFSC:
    • Advantages of central de-icing versus stand de-icing was promoted
    • 16 different hold over times for 16 different de-icing fluids – a central de-icing point and consolidated de-icing company approach is required
  • Nomination of de-icer supplies as a strategic commodity which can be redistributed where it is needed was recommended but the DfT have decided against it.
  • One Gnd Handling company Rep stated ‘We don’t get paid to clear snow!’ – I challenged him by asking ‘How much business is lost with ac stuck on stand on the ground?’
    • A co-ordinated ‘all companies approach’ is needed to get the airport moving in everyone’s interests and retention of reputation
  • Sharing of Winter Ops Manual information between airline operators should be encouraged more
  • HSE prosecutions of ground handlers on ‘duty of care’ grounds during the winter snow were nil – but HSE issues and legal liabilities are oft used as rational for not getting involved in snow clearing
  • NVQ for de-icing qualification was advocated and needs promotion amongst de-icing companies and airlines to raise and maintain standards
  • Standards of de-icing still unacceptable according to numerous airline reports
  • Costs of de-icing fluids and procedures are reported to be highly variable which could lead cash-strapped business jet companies to avoid de-icing or see de-ice companies overcharge – no regulation of de-icing costs
  • Gatwick have offered BA the opportunity to remote de-ice certain ac types – under consideration by BA
  • Heathrow are offering BA temporary remote de-icing at Heathrow for the coming season
  • Advocated the Flybe approach of providing a pilot to supervise the de-icing at their bases – ensures standards and assists training for both parties
  • The need to check on the quality and that correct mixture of the fluids was being applied was discussed – some airports and handlers are regularly checking this, but others are not.
  • Cabin crew training on de-icing provides very useful additional eyes for the Captain to confirm adequate de-icing has been carried out

CAA Actions to be considered from the feedback

  • An Info Notice to address the HSE issues of snow clearing
  • Importance of engaging all stakeholders at the airport on the snow plan
  • Variety of de-icing products and procedures to be considered
  • Quality of products – effectiveness and consistency

Winter Information Group Report

  • WIG will review Winter Ops info and reissue Info Notices for the coming winter
  • Winter trial on runway friction measurement and reporting for selected UK airports established last season, but insufficient snow conditions meant it never actually happened
    • Therefore, outcome statistically void
  • The FAA TALPA ARC table was used as the basis for the trial information
  • The aim will be to repeat the trial on a wider basis at other airports in the UK for the coming winter
  • Meanwhile the ICAO friction task force continues to work up a co-ordinated approach encompassing FAA, EASA and ICAO groups.

Rich Jones
Chief Executive
21 July 2011

Flightglobal Safety Conference – 9 September 2011 – London

Flightglobal Flight Safety Conference – 9 September 2011 – London
Selected Presentations
CE Meeting Summary

REDUCING THE RISK OF LOSS OF CONTROL ACCIDENTS – Don Bateman – Honeywell

  • Loss of control is now the main focus for technology
  • Last 10 years – 37 accidents and 8000+ deaths
  • Various factors
    • Spatial disorientation
      • Go round manoeuvre issues
    • Eastern/western ADI confusion
    • Low airspeed and high AOA
  • Solutions
    • Simple direction of roll to the horizon on the ADI
    • FBW ac need tactile feedback
    • Limit go round thrust to minimise pitch-up
    • Use paddle switches rather than push buttons with lights
  • ‘No take-off flap’ configuration error take-offs
    • Add a virtual box to the EPGWS to say ‘check flaps’
  • Conclusions and recommendations
    • Simple practical technology is readily available
    • Use what already exists in the ac systems to better effect
    • Simple recovery aid to go for the nearest horizon
    • Add visual recovery arrows
    • Revisit the type of attitude display and include training
    • Fit AOA gauge
    • Add more clear back-up airspeed and attitude instruments
    • Re-visit pilot training in low cost manner
      • Improve instrument scan
      • Improve knowledge of partial system failure
      • Expand PC based tools to cascade failures
    • Virtual vortex icon on ADS-B display
    • On FBW ac, add a simple dive recovery protective envelope
    • Consider a lateral equivalent to a stick shaker

CHANGES IN TYPE RATING TRAINING – Lloyd Watson, Oxford Aviation

  • Major Safety Concerns
    • Loss of Control
    • Runway Excursion
    • Runway Incursions
    • Airborne Fires
    • CFIT
  • Defences
    • Good engineering
    • Training
  • Recurrent Training should address all these issues but?
    • Not regulated for in type ratings so not trained. Neither are:
      • PRNAV – MNPS airspace
      • Economic ops
      • LVO
      • EFBs
  • Other safety Initiatives available but not type training requirements
    • AQP
    • ATQP
    • ITQI
  • 5 different attitudes to type rating training:
    • Regulator
      • Sets the absolute standard
    • Self sponsored pilot
      • Pays and has limited resources
    • Airline Head of training
      • Sets what is expected for their airline
    • Accountant
      • Training is a cost
    • TRTO Head of training
      • Compliance and customer expectations
  • Conclusions
    • Type training is not fit for purpose
    • Such issues not on type rating need to be covered in line training
    • Evidence based training is being developed with ICAO
    • Answer is to download line training into type rating

MPL TRAINING AT FLYBE- Steve Deverell, Flybe

  • Experiences of an airline and a pilot will impact on the culture for training
  • Two MPL trg partners used by Flybe – Oxford and Jerez
  • Two intakes of 6 students so far
  • MPL course consists of 4 phases – Jerez
    • Ph1 is 105 hours flying initially
    • Ph2 B737 sim in MPL
    • Ph3 B737 sim
    • Advanced Q400 type training
  • MPL course at Oxford
    • Ph 1 Zlin 90 hours flying
    • Ph 2 CRJ200 sim
    • Ph3 Q400 intermediate sim – (now changed to B737)
    • Q400 advanced
  • Problem Areas
    • Intermediate Phase changed from Q400 to B737 sim
    • Scenario based training for Ph4 – new type training
    • Consistent competency based assessment
    • ATC environment is mandated in the sim but is unachievable so the TRTO is acting as the AT Controller
    • 12 Base training landings when Flybe consider 6 landings sufficient – if 12 remains the requirement, this is a stopper for MPL due to cost
    • Exemption required to the UK ANO to allow flying with one licensed pilot on the flight deck
  • Impact of MPL with the introduction of ATQP
    • New method of crew assessment
    • Scenario based training – task analysis needed for both
    • Training needs analysis
    • Colgan accident – input of stall training
    • Competency based assessment
      • Multiple crew is the major focus
      • Skill grading safety base
    • Threat and error management
    • Strong reporting culture
    • Correct data
    • FDM
    • Human factors
    • Educate the crews

FATIGUE MANAGEMENT AND FRMS – Nico Voorbach, ECA

  • ICAO SARPS on FRMS will apply at 15 December 2011
  • Guidance from Regulators & Operators available in the IATA FRMS manual
  • States must approve FRMS regs for operator to use and then  check & oversee
  • Operators FRMS should be based on scientific principles
  • Legal min regulation set for Ops to comply with Annex 8
  • FRMS US developments:
    • NTSB and IATA see fatigue as a priority
    • New US law foresees an FRMP- a Mandatory Plan to be regularly updated
    • An FRMS is a key component of fatigue management which can be used to justify deviations
  • EASA perspective of fatigue:
    • FRMS should be an integral part of an operator’s SMS
    • But EASA Regs do not mandate an FRMS – instead use soft-law regulation and variations + AMCs
    • ECA asks why ICAO uses hard law and EASA uses soft law?
    • New concepts need strong frameworks which facilitate oversight
    • Need to avoid unfair competition through FRMS “lite”
    • ECA Preferred Solution is use ICAO hard law to make EASA move to hard law on FRMS in Europe!

FRMS IMPLEMENTATION CASE STUDY – German Wings FRMS Manager

  • Why FRMS is valuable with current FTLS:
    • Max crew productivity is key to low cost model
    • Op experience demonstrates FTL are not enough
    • EU-Ops placed fatigue management to operators & crew
    • SMS – Fatigue management still ops responsibility
  • Alert Management process established at G Wings established on:
    • Science based
    • Shared responsibilities
    • Tailored to the company
    • Risk assessment & control dependent
  • Addresses Roster design / lifestyle & sleep / workload / workload – management
    • Company does roster & duty
    • Individual pilot does lifestyle & fatigue management
  • Collect data
    • Own ops
    • Reporting system
    • Survey
    • Scientific literature (IATA Volume covers it)
  • Fatigue Action Group
    • Undertakes Risk assessment – assess conditions – major high risk conclusion
    • Develops recommendations
      • Evidence based for specific ops based on scientific data
      • Consistent with business model
  • Approve Strategy by the Company SRB
  • Assign Responsibilities – Management has primary responsibility
  • Implement it – Promote it – document it – increases awareness – measure it – re-access performance
  • Results-based performance indicators
  • Continuous improvement – collect more data
  • Benefits
    • We know what we are doing
    • Specific causes of fatigue are known in the business
    • Scientific based – effective fatigue mitigation measures in place
    • Measurable fatigue risk
    • Crew have the tools & knowledge
    • No loss in crew productivity
    • Fulfilling the FRMS requirement

NEXT GENERATION OF FRMS – Jeppesen

  • 500 Jeppesen staff are studying and researching flightcrew rosters
  • Finnair requested a study due to their type of ops – Europe/Asia
  • Crew management process was developed at Finnair
  • Crew pairing & crew rostering are tied into flight schedule
    • Minimise cost/crew change/deadheads & layovers
    • Maximise crew performance
  • Predicted fatigue alertness is calculated out and applied
  • Calculations allow slippage if delays occur
  • Additional work on crew experience and route difficulty added to the fatigue is the next element of the work
  • Conclusion
    • Performance scoring required
    • Data collection & science needs to build trust
    • Finnair technically unaffected by change
    • Small positive results so far
    • SPIs established for trending

FDM CONTRIBUTION AND SAFETY MANAGEMENT Bertrand de Courville, Air France

  • Case 1 for FDM – involved a no flap t/o and low speed RTO. It was realised that this event was not being reported or measured
  • Pilot survey undertaken with 79 reports received of similar omissions
    • One response said it’s impossible due to so many checks
  • One fleet where the ac flap was taken during taxi had more events
    • SOP Change to always lower flap after engine start on all fleets
  • Case 2 for FDM – EASA Safety information Bulletin in June 2011:
    • Take off flap selection straight after engine start recommended
    • FDM event set to identify when the error takes place
  • Case 3 for FDM – Wrong response to TCAS RA event
    • Pilot reported it but couldn’t explain it
    • Realisation that TCAS in the opposite sense is a guaranteed collision
    • More reports were triggered by an awareness campaign
    • An FDM event to report incorrect action established
    • Introduced a safety awareness promotion
    • Current TCAS RA interface was poor – needle colour and ambiguous TCAS call out – no direction on adjust vertical speed
    • New software solution has been developed to address this ambiguity
    • Air France has the algorithms available for other airlines since 2003
  • Lessons from FDM reporting programmes:
    • No FDM events means none are reported
    • Absence of visibility for some events is a threat
    • Collecting data needs to be proactive
    • Internal safety surveys are easy and cheap
    • Sharing data and best practice is vital
  • Dedicated European Operators FDM Forum launched through ECAST
    • Pioneer Gp of 10 airline operators to discuss
      • Ops safety monitoring
      • Equipment
      • Programming
      • Data handling
      • ATQP
      • Organisation and management
      • Company culture
      • Disseminating the teachings of FDM
    • First FDM conference on 12 January 2012
  • Lessons from FDM programmes for safety management :
    • What to look for and where
    • Give sense to data collected
    • New software data tools design
    • Clarify priorities
    • Encourage a systematic proactive and efficient management of safety defences

FLIGHT DATA AUTOMATION BENEFITS- William Cecil, Teledyne

  • FDM data collection from ac on a routine basis offers
    • Track trends
    • Identify risk precursors
    • Take remedial action
  • Regulation exists broadly – should have a programme but no % set for collection from eligible ac fleet
  • ATQP specifies 60% of all sectors to qualify
  • Data recovery every turnround must be the goal
  • Auto downloads worldwide possible
  • Early identification of significant events easily deliverable
  • Early resolution of airworthiness issues
  • More rapid AOG support
  • Rapid detection of data loss and systems issues
  • Cheaper labour costs to maintain the system
  • Materials repairs
  • More reliability
  • Additional engine condition monitoring can be added
  • Fuel usage monitoring
  • Environmental control monitoring
  • Cost savings for none time critical information transfer rather than using much more expensive ACARS

RUNAWAY EXCURSIONS/INCURSIONS – Gideon Ewers

  • Runway Incursions
    • 966 in 2010 and over 1000 so far this year
    • Many methods to reduce RI numbers and risk
      • infrastructure
      • procedure
      • RWSL at 30 airports in US and at CDG
      • FAROS trial at Dallas starts today
      • 24 stop bars
      • Crossing at low energy points only
      • Mixed mode runway ops
  • Runway Excursions
    • 44 per year- 4 in the past 8 days
    • Most hull losses caused by REs
    • Unstable approaches
    • Mechanical failure
    • Incorrect techniques
    • Poor runway conditions
    • In the real world, data is consistent and ac flown by non-test pilots
    • Flight crews
      • Stabilised approach criteria
      • Proper understanding of landing techniques
      • Proper use of deceleration equipment
    • Ground crews
      • Accurate reporting conditions
    • RESA – for when other systems fail
    • EMAS

Rich Jones
Chief Executive
UKFSC
17 October 2011

CAA Winter Wash up – 14 July 2011 – Gatwick Meeting

CAA Aerodrome Winter Wash Up Meeting – CAA, SRG Gatwick – 14 July 2011

CE Meeting Summary

Agenda

Item 2 – Review of the Heathrow Resilience Programme – post Begg Report

  • BAA has accepted and is in the process of addressing all 14 recommendations from the Begg Report
  • Improved snow resilience has already been introduced in 8 areas at Heathrow since Jan 11
  • Numerous other international airports have been consulted on their approach to winter ops resilience. Most of these airports often have more snow but invariably less traffic than Heathrow.
  • As a result the following lessons are being applied at LHR:
    • Aim to maintain one runway at all times
    • Ensure that demand and capacity is always being balanced
  • De-icing requirements and procedures vary significantly
    • Heathrow has 6 de-icers /17gnd handlers/96 airlines
    • The proposal to move away from stand and pan de-icing for ac to taxiway or holding point de-icing is yet undecided
  • BAA had the lone responsibility to clearing the stands – all other handling and service providers stay in their crew rooms
    • Health and Safety card is played extensively by gnd handlers to avoid snow clearance duties
    • After flying is finished – only BAA is left at Heathrow to clear snow.
  • Winter capability for vehicles is a problem – most airlines and ground handlers will not invest in tyres for snow usage
  • At least 319 personnel needed to clear stands of snow
  • BAA has gone from 50 vehicles to 195 specialist vehicles for snow handling and spent £10M to own them
  • Begg Recommendations – 14 in total- cover the following areas:
    • Preparation and planning
    • Command and control
    • Communications and passenger welfare
      • The Madrid airport plan is considered a good example to follow
        • Teams assigned to snow plan roles and trained to do them
        • Each airline and handler have signed a document detailing their responsibilities
    • Drills and testing of the plan
    • DfT will sign off the plan in due course
  • Collective Decision Making CDM is now being brought in at Heathrow which should help ( See AOA Seminar Summary on UKFSC website for more details)
  • In discussion, and the following points were made on behalf of the UKFSC:
    • Advantages of central de-icing versus stand de-icing was promoted
    • 16 different hold over times for 16 different de-icing fluids – a central de-icing point and consolidated de-icing company approach is required
  • Nomination of de-icer supplies as a strategic commodity which can be redistributed where it is needed was recommended but the DfT have decided against it.
  • One Gnd Handling company Rep stated ‘We don’t get paid to clear snow!’ – I challenged him by asking ‘How much business is lost with ac stuck on stand on the ground?’
    • A co-ordinated ‘all companies approach’ is needed to get the airport moving in everyone’s interests and retention of reputation
  • Sharing of Winter Ops Manual information between airline operators should be encouraged more
  • HSE prosecutions of ground handlers on ‘duty of care’ grounds during the winter snow were nil – but HSE issues and legal liabilities are oft used as rational for not getting involved in snow clearing
  • NVQ for de-icing qualification was advocated and needs promotion amongst de-icing companies and airlines to raise and maintain standards
  • Standards of de-icing still unacceptable according to numerous airline reports
  • Costs of de-icing fluids and procedures are reported to be highly variable which could lead cash-strapped business jet companies to avoid de-icing or see de-ice companies overcharge – no regulation of de-icing costs
  • Gatwick have offered BA the opportunity to remote de-ice certain ac types – under consideration by BA
  • Heathrow are offering BA temporary remote de-icing at Heathrow for the coming season
  • Advocated the Flybe approach of providing a pilot to supervise the de-icing at their bases – ensures standards and assists training for both parties
  • The need to check on the quality and that correct mixture of the fluids was being applied was discussed – some airports and handlers are regularly checking this, but others are not.
  • Cabin crew training on de-icing provides very useful additional eyes for the Captain to confirm adequate de-icing has been carried out

CAA Actions to be considered from the feedback

  • An Info Notice to address the HSE issues of snow clearing
  • Importance of engaging all stakeholders at the airport on the snow plan
  • Variety of de-icing products and procedures to be considered
  • Quality of products – effectiveness and consistency

Winter Information Group Report

  • WIG will review Winter Ops info and reissue Info Notices for the coming winter
  • Winter trial on runway friction measurement and reporting for selected UK airports established last season, but insufficient snow conditions meant it never actually happened
    • Therefore, outcome statistically void
  • The FAA TALPA ARC table was used as the basis for the trial information
  • The aim will be to repeat the trial on a wider basis at other airports in the UK for the coming winter
  • Meanwhile the ICAO friction task force continues to work up a co-ordinated approach encompassing FAA, EASA and ICAO groups.

Rich Jones
Chief Executive
21 July 2011

Flightglobal Safety Conference – 9 September 2011 – London

Flightglobal Flight Safety Conference – 9 September 2011 – London
Selected Presentations
CE Meeting Summary

REDUCING THE RISK OF LOSS OF CONTROL ACCIDENTS – Don Bateman – Honeywell

  • Loss of control is now the main focus for technology
  • Last 10 years – 37 accidents and 8000+ deaths
  • Various factors
    • Spatial disorientation
      • Go round manoeuvre issues
    • Eastern/westernADI confusion
    • Low airspeed and high AOA
  • Solutions
    • Simple direction of roll to the horizon on the ADI
    • FBW ac need tactile feedback
    • Limit go round thrust to minimise pitch-up
    • Use paddle switches rather than push buttons with lights
  • ‘No take-off flap’ configuration error take-offs
    • Add a virtual box to the EPGWS to say ‘check flaps’
  • Conclusions and recommendations
    • Simple practical technology is readily available
    • Use what already exists in the ac systems to better effect
    • Simple recovery aid to go for the nearest horizon
    • Add visual recovery arrows
    • Revisit the type of attitude display and include training
    • Fit AOA gauge
    • Add more clear back-up airspeed and attitude instruments
    • Re-visit pilot training in low cost manner
      • Improve instrument scan
      • Improve knowledge of partial system failure
      • Expand PC based tools to cascade failures
    • Virtual vortex icon on ADS-B display
    • On FBW ac, add a simple dive recovery protective envelope
    • Consider a lateral equivalent to a stick shaker

CHANGES IN TYPE RATING TRAINING – Lloyd Watson, Oxford Aviation

  • Major Safety Concerns
    • Loss of Control
    • Runway Excursion
    • Runway Incursions
    • Airborne Fires
    • CFIT
  • Defences
    • Good engineering
    • Training
  • Recurrent Training should address all these issues but?
    • Not regulated for in type ratings so not trained. Neither are:
      • PRNAV – MNPS airspace
      • Economic ops
      • LVO
      • EFBs
  • Other safety Initiatives available but not type training requirements
    • AQP
    • ATQP
    • ITQI
  • 5 different attitudes to type rating training:
    • Regulator
      • Sets the absolute standard
    • Self sponsored pilot
      • Pays and has limited resources
    • Airline Head of training
      • Sets what is expected for their airline
    • Accountant
      • Training is a cost
    • TRTO Head of training
      • Compliance and customer expectations
  • Conclusions
    • Type training is not fit for purpose
    • Such issues not on type rating need to be covered in line training
    • Evidence based training is being developed with ICAO
    • Answer is to download line training into type rating

MPL TRAINING AT FLYBE- Steve Deverell, Flybe

  • Experiences of an airline and a pilot will impact on the culture for training
  • Two MPL trg partners used by Flybe – Oxford and Jerez
  • Two intakes of 6 students so far
  • MPL course consists of 4 phases – Jerez
    • Ph1 is 105 hours flying initially
    • Ph2 B737 sim in MPL
    • Ph3 B737 sim
    • Advanced Q400 type training
  • MPL course at Oxford
    • Ph 1 Zlin 90 hours flying
    • Ph 2 CRJ200 sim
    • Ph3 Q400 intermediate sim – (now changed to B737)
    • Q400 advanced
  • Problem Areas
    • Intermediate Phase changed from Q400 to B737 sim
    • Scenario based training for Ph4 – new type training
    • Consistent competency based assessment
    • ATC environment is mandated in the sim but is unachievable so the TRTO is acting as the AT Controller
    • 12 Base training landings when Flybe consider 6 landings sufficient – if 12 remains the requirement, this is a stopper for MPL due to cost
    • Exemption required to the UK ANO to allow flying with one licensed pilot on the flight deck
  • Impact of MPL with the introduction of ATQP
    • New method of crew assessment
    • Scenario based training – task analysis needed for both
    • Training needs analysis
    • Colgan accident – input of stall training
    • Competency based assessment
      • Multiple crew is the major focus
      • Skill grading safety base
    • Threat and error management
    • Strong reporting culture
    • Correct data
    • FDM
    • Human factors
    • Educate the crews

FATIGUE MANAGEMENT AND FRMS – Nico Voorbach, ECA

  • ICAO SARPS on FRMS will apply at 15 December 2011
  • Guidance from Regulators & Operators available in the IATA FRMS manual
  • States must approve FRMS regs for operator to use and then check & oversee
  • Operators FRMS should be based on scientific principles
  • Legal min regulation set for Ops to comply with Annex 8
  • FRMS US developments:
    • NTSB and IATA see fatigue as a priority
    • New US law foresees an FRMP- a Mandatory Plan to be regularly updated
    • An FRMS is a key component of fatigue management which can be used to justify deviations
  • EASA perspective of fatigue:
    • FRMS should be an integral part of an operator’s SMS
    • But EASA Regs do not mandate an FRMS – instead use soft-law regulation and variations + AMCs
    • ECA asks why ICAO uses hard law and EASA uses soft law?
    • New concepts need strong frameworks which facilitate oversight
    • Need to avoid unfair competition through FRMS “lite”
    • ECA Preferred Solution is use ICAO hard law to make EASA move to hard law on FRMS in Europe!

FRMS IMPLEMENTATION CASE STUDY – German Wings FRMS Manager

  • Why FRMS is valuable with current FTLS:
    • Max crew productivity is key to low cost model
    • Op experience demonstrates FTL are not enough
    • EU-Ops placed fatigue management to operators & crew
    • SMS – Fatigue management still ops responsibility
  • Alert Management process established at G Wings established on:
    • Science based
    • Shared responsibilities
    • Tailored to the company
    • Risk assessment & control dependent
  • Addresses Roster design / lifestyle & sleep / workload / workload – management
    • Company does roster & duty
    • Individual pilot does lifestyle & fatigue management
  • Collect data
    • Own ops
    • Reporting system
    • Survey
    • Scientific literature (IATA Volume covers it)
  • Fatigue Action Group
    • Undertakes Risk assessment – assess conditions – major high risk conclusion
    • Develops recommendations
      • Evidence based for specific ops based on scientific data
      • Consistent with business model
  • Approve Strategy by the Company SRB
  • Assign Responsibilities – Management has primary responsibility
  • Implement it – Promote it – document it – increases awareness – measure it – re-access performance
  • Results-based performance indicators
  • Continuous improvement – collect more data
  • Benefits
    • We know what we are doing
    • Specific causes of fatigue are known in the business
    • Scientific based – effective fatigue mitigation measures in place
    • Measurable fatigue risk
    • Crew have the tools & knowledge
    • No loss in crew productivity
    • Fulfilling the FRMS requirement

NEXT GENERATION OF FRMS – Jeppesen

  • 500 Jeppesen staff are studying and researching flightcrew rosters
  • Finnair requested a study due to their type of ops – Europe/Asia
  • Crew management process was developed at Finnair
  • Crew pairing & crew rostering are tied into flight schedule
    • Minimise cost/crew change/deadheads & layovers
    • Maximise crew performance
  • Predicted fatigue alertness is calculated out and applied
  • Calculations allow slippage if delays occur
  • Additional work on crew experience and route difficulty added to the fatigue is the next element of the work
  • Conclusion
    • Performance scoring required
    • Data collection & science needs to build trust
    • Finnair technically unaffected by change
    • Small positive results so far
    • SPIs established for trending

FDM CONTRIBUTION AND SAFETY MANAGEMENT Bertrand de Courville, Air France

  • Case 1 for FDM – involved a no flap t/o and low speed RTO. It was realised that this event was not being reported or measured
  • Pilot survey undertaken with 79 reports received of similar omissions
    • One response said it’s impossible due to so many checks
  • One fleet where the ac flap was taken during taxi had more events
    • SOP Change to always lower flap after engine start on all fleets
  • Case 2 for FDM – EASA Safety information Bulletin in June 2011:
    • Take off flap selection straight after engine start recommended
    • FDM event set to identify when the error takes place
  • Case 3 for FDM – Wrong response to TCAS RA event
    • Pilot reported it but couldn’t explain it
    • Realisation that TCAS in the opposite sense is a guaranteed collision
    • More reports were triggered by an awareness campaign
    • An FDM event to report incorrect action established
    • Introduced a safety awareness promotion
    • Current TCAS RA interface was poor – needle colour and ambiguous TCAS call out – no direction on adjust vertical speed
    • New software solution has been developed to address this ambiguity
    • Air France has the algorithms available for other airlines since 2003
  • Lessons from FDM reporting programmes:
    • No FDM events means none are reported
    • Absence of visibility for some events is a threat
    • Collecting data needs to be proactive
    • Internal safety surveys are easy and cheap
    • Sharing data and best practice is vital
  • Dedicated European Operators FDM Forum launched through ECAST
    • Pioneer Gp of 10 airline operators to discuss
      • Ops safety monitoring
      • Equipment
      • Programming
      • Data handling
      • ATQP
      • Organisation and management
      • Company culture
      • Disseminating the teachings of FDM
    • First FDM conference on 12 January 2012
  • Lessons from FDM programmes for safety management :
    • What to look for and where
    • Give sense to data collected
    • New software data tools design
    • Clarify priorities
    • Encourage a systematic proactive and efficient management of safety defences

FLIGHT DATA AUTOMATION BENEFITS- William Cecil, Teledyne

  • FDM data collection from ac on a routine basis offers
    • Track trends
    • Identify risk precursors
    • Take remedial action
  • Regulation exists broadly – should have a programme but no % set for collection from eligible ac fleet
  • ATQP specifies 60% of all sectors to qualify
  • Data recovery every turnround must be the goal
  • Auto downloads worldwide possible
  • Early identification of significant events easily deliverable
  • Early resolution of airworthiness issues
  • More rapid AOG support
  • Rapid detection of data loss and systems issues
  • Cheaper labour costs to maintain the system
  • Materials repairs
  • More reliability
  • Additional engine condition monitoring can be added
  • Fuel usage monitoring
  • Environmental control monitoring
  • Cost savings for none time critical information transfer rather than using much more expensive ACARS

RUNAWAY EXCURSIONS/INCURSIONS – Gideon Ewers

  • Runway Incursions
    • 966 in 2010 and over 1000 so far this year
    • Many methods to reduce RI numbers and risk
      • infrastructure
      • procedure
      • RWSL at 30 airports in US and at CDG
      • FAROS trial at Dallas starts today
      • 24 stop bars
      • Crossing at low energy points only
      • Mixed mode runway ops
  • Runway Excursions
    • 44 per year- 4 in the past 8 days
    • Most hull losses caused by REs
    • Unstable approaches
    • Mechanical failure
    • Incorrect techniques
    • Poor runway conditions
    • In the real world, data is consistent and ac flown by non-test pilots
    • Flight crews
      • Stabilised approach criteria
      • Proper understanding of landing techniques
      • Proper use of deceleration equipment
    • Ground crews
      • Accurate reporting conditions
    • RESA – for when other systems fail
    • EMAS

Rich Jones
Chief Executive
UKFSC
17 October 2011

GNSS Vulnerability Meeting – 13th September 2011 – CAA House, Kingsway London Meeting

GNSS Vulnerability Meeting – CAA Kingsway 13 September 2011
CE Meeting Summary

Agenda

Opening Remarks and Responses to UKFSC/GAPAN Concerns

  • CAA consider ac unlikely to have significantly different or improved nav kit in the next 9 years despite increasing exploitation of GNSS capability
    • Implementation plan for the intro of PBN is being undertaken by the CAA FAS Implementation Team which includes industry
    • GNSS environment will not change in the next 10 years
    • SESAR work packages are under way to look at the shape of airspace and the nav infrastructure to support it
  • CAT1 performance based on space based kit is being researched currently
  • GNSS benefits have been slow to be introduced
  • En route phase of flight now benefits from the GNSS using PBN, which is mandated
  • However, Terminal Area use of PBN/GNSS is not mandated at this stage
  • Any future use of GNSS will require safety cases for system outage and ac outage to be considered carefully in its planning
  • System outage in the terminal area has been simulated by NATS and controllers found it manageable
  • It is considered that sufficient ground based and IRS cover remains available in the Terminal Area to address any GNSS outage
  • With a GNSS outage, RNP capability is regarded as good on Boeing but not on Airbus

UK Airspace Position

  • North Atlantic region is not seriously affected by space weather
    • NATS looking at the North Atlantic now in case of GNSS loss and are likely to suspend reduced lateral separation in such a situation
  • En route domestic – no documented failures caused by interference in MORs over 13 years – although 2 suspect reports were unproven
    • MORs are reviewed regularly by NATS to identify any GPS related interference
    • Integrity in the ac is expected by NATS which means no drift without an indication to the crew of a GNSS problem
  • Terminal Airspace
    • The threat from Space weather maybe slightly increase risk
    • However, PBN will be flyable and available with GNSS off
  • Approach Phase
    • Ground Based System vulnerabilities to jamming and interference remain
    • An ILS back up will be needed for the time being for any space based approach aid
    • Cost may be a stopper to wider deployment of GBAS
  • SESAR is developing the debate on PBN but the vulnerabilities are not being fully addressed at this stage
    • The UK CAA could push these up the agenda in ICAO and Europe
  • CAA could address this into Europe, but an effective business case will be needed for the airlines to agree to funding additional equipment for their ac
  • GNSS vulnerability to the new ‘Litesquared’ and power grid cable broadband projects are known
    • CAA will provide a short report on these vulnerability issues

Way Ahead

  • The CAA is keen to exploit the GNSS advantages
  • Vulnerabilities are recognised but are expected to be considered carefully in the safety case
  • ICAO Nav panel is looking at GNSS vulnerabilities and 2 Papers are being considered for placement on the high level ICAO agenda
    • One 2006 paper which looked at space weather vulnerabilities is being refreshed.
      • Japan is at the centre of these types of vulnerabilities and is closely involved
    • The second Paper is on the Vulnerabilities of GNSS written in 2003 which is also being reviewed.
      • The original paper failed to quantify the effects
      • Canada expert is reviewing the paper which also looks at States institutional and military planned jamming
    • Recommendations from these Paper reviews go to the ICAO Air Navigation Conference next Year and will include:
      • Requires States to undertake studies on GNSS vulnerability
      • Requires States to identify alternates to compliment GNSS exploitation
  • US has started this work but others need to be encouraged
  • SESAR is researching future Nav aids – but not vulnerabilities
  • Stanford Uni are looking at an alternate source using a DME piggy back system – but not a complete solution for those with no current DME availability
  • CAA will review IRUs specification as a back up for GNSS and may move them towards a mandatory fit – but an radio solution may be No 1 back up

Other Work on GNSS Issues

  • A Paper on nav aid decommissioning is being written for the ICAO Air Nav Conference by NATS – could be used as an awareness builder for GPS vulnerability
  • This paper to be circulated for thoughts to see if this paper could be developed
  • PBN Imp Rules are under development at EASA in which the CAA is involved
  • The back up requirement in an RMP environment to counter/mitigate GNSS vulnerabilities should be included in this work
  • A short assessment of threats associated with GNSS Vulnerability and mitigation for time periods and from individual ac and multi ac impacts will be required in due course
  • A initial assessment of threats associated with GNSS vulnerabilities was discussed
  • ELoran discussed as another back up – UK still funding its LORAN station with 3 others in France, Germany and Norway but it has a test bed status only
  • ELoran ac equipment is none existent
  • ELoran Kicked into touch by the CAA and Eurocontrol a few years ago
  • ELoran is more vulnerable to space weather than GPS

Conclusions and Actions

  • Litesquared and national grid proposals to be reviewed by CAA
  • Draft NSP paper circulated – on close hold but invite comments by end of October to participants
  • Secretariat Paper on GNSS vulnerabilities for conference circulated for ideas
    • European position needs to be addressed/appreciated
  • Consider making a UK paper for the conference on GNSS
  • CAA to attend the UKFSC in January to brief on the latest PBN position
    • Helpful to get a balanced view on this issue into other forums
  • CAA/NATS will produce an enhanced GNSS vulnerability position paper to better understand the issues

Full List of Actions

Rich Jones
Chief Exec
UKFSC
18 September 11

MAST – 14th October 2009 – Heathrow Meeting

MAST Meeting – Heathrow BAA Compass Centre – 14 October 2009
CE Meeting Summary

Agenda

Item 2 –Review Actions

  • AGMS link to EFPS as a RI prevention tool is being investigated but will be expensive and take some time. Progress will be reported to the MAST.
  • No incursions reported in past 2 months
  • Driver training with police now has significant price tag and will be more selective
  • Top 3 Issues from user companies still being sought by the MAST.
  • Runway Ahead Signage – The CAA did not undertake a formal HF analysis on positioning of Runway Ahead Signage before issuing guidance but did take CAA expert soundings from Ops and ATC. NATS will now seek to arrange an HF assessment.
  • Two van runs coming up – Drivers on 11 Dec 09. Pilots in Feb 2010. Contact for participation in both is Jane Gothard at NATS Heathrow.
  • Runway status lights meeting held with Eurocontrol on the possible trial of RWSL at Heathrow. NATS are now liaising on the CDG RWSL installation.
  • NATS are now Costing of options on various incursion prevention measures including the introduction of 24 hour stop bars and ‘ring of steel’ stop bars.
  • NATS are undertaking a roadshow amongst LHR airline operators briefing examples of driver and pilot incursions at LHR to increase awareness.
  • Pushback Procedure Review A clearer statement is needed in the Air Pilot doc (AIP) on the pushback approval procedure and responsibilities. A revision of the CAA Cap and Air pilot to be drawn up by MAST Members

Item 3 – Feedback

  • Methods to improve WIP information transfer to LHR operators continue to be considered. Gatwick examples and Navtech solutions were discussed.
  • Gatwick example had been provided by the UKFSC for this process.

Item 4 – Safety Reports

  • Two vehicles got lost at night, 3 am in the morning and ended up alongside the runway; they were intercepted by stopped by an Ops vehicle. These large load vehicles had been allowed on the manoeuvre area unescorted to return back to the control post but got lost. In the process, they started to cross the runway, which was not active at the time. Under investigation.
  • A Libyan aircraft taxied in error towards 09R when it was active. He was instructed to take the 2nd taxiway on the right, but got confused by the WIP at the first turn off and continued beyond his intended turn off taxiway.
  • The Libyan ac continued on towards the active runway with aircraft taking off at the time but the Libyan ac was stopped before reaching the runway
    • An abort by the rotating aircraft would not have been possible however, analysis of the FDM data and the airfield tapes indicate that had the Libyan entered 09R, the rotating aircraft would have cleared above it.

Item 5 – Safety KPIs – Nothing further to report

Item 6 – Cat 1 and Cat III Debate

  • At the previous MAST Meeting it had been suggested that LHR NATS were about to proceed on a plan to combine Cat1 and Cat III holds as a safety measure.
  • Some MAST Members had expressed concern that this had been decided without sufficient consultation or consideration of the commercial impact on capacity
  • Subsequently, it had been discovered that NATS were not actively discussing the combination of Cat1 and Cat III at LHR at this stage
  • Nonetheless, a broader strategy is being considered currently by NATS to decrease runway incursion risk. Outcome will be known in 3 months. No realistic debate on Cat holds was possible until the outcome is known
  • However, in consequent MAST discussion of the procedures for use of Cat I and III holds at LHR, it became apparent that the AIP is not clear on the procedure for take-off at Heathrow and MAST Members would seek to clarify the AIP accordingly.

Item 7 – Brief on the CAA Significant Seven Safety Task Forces – Rich Jones

Agenda

  • Two vehicles got lost at night, 3 am in the morning and ended up alongside the runway; they were intercepted by stopped by an Ops vehicle. These large load vehicles had been allowed on the manoeuvre area unescorted to return back to the control post but got lost. In the process, they started to cross the runway, which was not active at the time. Under investigation.
  • At the previous MAST Meeting it had been suggested that LHR NATS were about to proceed on a plan to combine Cat1 and Cat III holds as a safety measure.
  • Some MAST Members had expressed concern that this had been decided without sufficient consultation or consideration of the commercial impact on capacity
  • Subsequently, it had been discovered that NATS were not actively discussing the combination of Cat1 and Cat III at LHR at this stage
  • Nonetheless, a broader strategy is being considered currently by NATS to decrease runway incursion risk. Outcome will be known in 3 months. No realistic debate on Cat holds was possible until the outcome is known
  • However, in consequent MAST discussion of the procedures for use of Cat I and III holds at LHR, it became apparent that the AIP is not clear on the procedure for take-off at Heathrow and MAST Members would seek to clarify the AIP accordingly.

Item 7 – Brief on the CAA Significant Seven Safety Task Forces – Rich Jones
Brief attached 

Item 8 – HAL LHR Website Contents Update

  • Website went live on 31 July 2009
  • Airport map is the most popular page so far
  • Aerodrome manual next most popular
  • International hits on the website is also growing
  • Website includes Heathrow facts and figures
  • Potential future content includes:
    • Full animation of taxi patterns for the entire LHR Manoeuvre area
    • Incident replay
    • Pushback transmissions and procedures examples
    • Taxi procedure examples with sound – including R/T transmission
  • Regular Email updates can be made available to registered interested parties

MAST Pages Input To Hal Website

  • Latest published airfield map will always be the start page
  • The A380 taxiway map – (code F aircraft)
  • B747 taxi restriction map
  • Guide for GA biz jet users
  • Helicopter page is under development
  • A pilots question area – called ‘Ask ATC’ – NOT a chat forum but Q and A will be posted.
    • A series of questions and answers will be built up for information.
  • Individual Error hotspot pages will be posted complete with runway incursion hotspot pictures and a map.

Items 9 and 10 – Nil Report

Item 10 – AOB

  • New Airside Works Approval Process
    • Long term project to establish an IT based works approval process to tie down the works ongoing and future plans for LHR
    • Aim is to have all stakeholders on an all-informed net
  • Bird-strike Remains Identification – The BAA will pay for bird remain identification since they have the responsibility to manage the bird population effectively
  • A meeting to discuss A380 Operations at Heathrow will be held at the old tower at LHR between 1pm – 3pm on 3 Nov 09. Contact Jane Gothard to get a seat.

Next Meetings
16 Dec 2009, 10 Feb 2010, 21 April 2010

Rich Jones
Chief Exec
UKFSC
15 Oct 2009

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