Informe del Comité de IFALPA de Investigación de Accidentes

 23  de  Mayo  de  2012  

     A:     Seccretario  de  Seguridad  Aérea  y  Desarrollo  Profesional,    

Alejandro  López  Camelo      INFORME   DE   LA   REUNIÓN   DEL   COMITÉ   DE   IFALPA   “ACCIDENT   ANALYSIS   &  PREVENTION  (AAP)”    Por  la  presente  hacemos  entrega  del  Informe  realizado  sobre  la  Reunión  del  Comité  de   IFALPA   “Accident   Analysis   &   Prevention   (AAP)”   llevada   a   cabo   en   Varsovia,  Polonia,  del  21  al  23  de  mayo  de  2012.      Saludamos  a  Ud.  atentamente,                            

  JOSÉ  NICOLÁS  PASCUAL  PAGANO  Investigador  de  Accidentes  Aéreos  

  GONZALO  MALDONADO  Investigador  de  Accidentes  Aéreos  

  2  ATTENDANCE LIST

IFALPA      

IFALPA  AAI  Juan  Carlos  Lozano   AAP  Chairman   [email protected]   x  

Peter  Beer   AAP  Vice-­‐Chairman   [email protected]   x  Ian  Whyte   AAP  Vice-­‐Chairman   [email protected]   x  

Arnaud  du  Bédat   Senior  Technical  Officer   [email protected]        AAP  MEMEBERS  

   IFALPA  AAI  

Gonzalo  Maldonado  Argentina  

[email protected]   x  Jose  Pagano   [email protected]      Bob  Fulton     Canada   [email protected]   x  Hans  Peter  Granhøj   Denmark   [email protected]   x  Antti  Rautiainen   Finland   [email protected]      Jean-­‐Félix  Barral       France   [email protected]      David  Schöne  

Germany  [email protected]      

Dieter  Spieß  gen.  Bongard   [email protected]   x  David  Ben  Shahar   Israel   [email protected]      Stefano  Zanoll   Italy   [email protected]   x  Hiroaki  Tateno   Japan   [email protected]   x  Alejandro  Peña  Dickinson   Mexico   [email protected]   x  Najib  Al  Ibrahimi       Morocco   [email protected]   x  Robin  Arenda   Netherlands   [email protected]   x  Stephen  van  Dijck   [email protected]   x  Andrzej  Cmil  

Poland  [email protected]      

Waclaw  Sieczkowski   [email protected]      António  Gomes   Portugal   [email protected]      Fatima  Jakoet  

South  Africa  [email protected]      

Gavin  McKellar   [email protected]   x  Cobus  Toerien   [email protected]   x  Ariel  Shocrón   Spain   [email protected]   x  Thomas  Steffen   Switzerland   [email protected]   x  Manasong  Pinthong   Thailand   [email protected]      Lloyd  Wragg   UK   [email protected]   x  Mike  "Elbow"  Bender   USA   [email protected]   x    OBSERVERS        Chris  McGregor   Airbus   [email protected]    Harry  Nelson     [email protected]    Terry  McVenes   Boeing   [email protected]        

  3  NON  ATTENDING  MEMBERS  AND  OBSERVERS  

 IFALPA  AAI  

Fanie  Coetzee   EVP  Professional  Affairs   [email protected]      Christoph  Mair   Austria   [email protected]   x  An  Schamp   Belgium   [email protected]      Henry  Chan   Hong-­‐Kong   [email protected]   x  Dave  Newbery   [email protected]   x  Linda  Gunnarsdóttir   Iceland   [email protected]      Eddie  Miller   Jamaica   [email protected]   x  Paul  Reuter  

Luxembourg  [email protected]   x  

Peter  Steensels   [email protected]   x  Low  Tuck  Loong   Malaysia   [email protected]   x  Carmel  Maniscalco   Malta   [email protected]   x  Hugh  Faris  

New  Zealand  [email protected]   x  

Gary  Parata   [email protected]   x  Johan  Glantz   Sweden   [email protected]   x  Wirush  Teparuck   Thailand   [email protected]   x  Malcolm  Terry   UK   [email protected]   x  Paul  Brady   USA   [email protected]   x  Vincenzo  Panico   ATR   [email protected]      Frédéric  Combes  

Airbus  [email protected]      

Jean  Daney   [email protected]      André  Tousignant   Bombardier   [email protected]      Pete  Kaumanns  

ECA  bpk-­‐[email protected]   x  

Loïc  Michel   [email protected]      Alexey  Morozov   MAK   [email protected]                                                          

  4  AGENDA  0   INTRODUCTION  0.1   Review  of  the  previous  meeting  minutes  0.2   Additions  to  the  Agenda  

   1   IFALPA  1.1   IFALPA  Annex  13  1.2   Implementation  of  Policy  (Flight  Data  Analysis,  Non-­‐Punitive  Culture,  etc)  

   2   ICAO  2.1   ICAO  Annex  13  2.2   ICAO  Annex  19  2.3   ICAO  Manuals  

   3   IFALPA  REPRESENTATION  IN  AIR  SAFETY  INVESTIGATION  BODIES/SAFETY  INITIATIVES  3.1   ICAO  Accident  Investigation  Methodology  Study  Group  (AIMSG)  3.2   ICAO  Flight  Recorder  Panel  (FLIRECP)  3.3   European  Civil  Aviation  Conference  (ECAC)  Group  of  Experts  on  Accident  Investigation  (ACC)  3.4   IATA  Accident  Classification  Task  Force  (ACTF)  3.5   Flight  Safety  Foundation  (FSF)  EASS/IASS  3.6   ECA  Flight  Data  WG  3.7   Regional  Aviation  Safety  Group  -­‐  Pan  American  3.8   Gulf  Flight  Safety  Committee  (GFSC)  3.9   Miscellaneous  other  representation  

   4   AIR  SAFETY  TRENDS  4.1   Trend  Analysis  System  4.1.1   Aviation  Safety  Reporting  Systems  (Airlines,  etc.)  4.2   REVIEW  OF  ACCIDENTS  (*  indicates  that  the  official  report  is  awaited)  4.2.1   Atlantic  Airways  BAe146,  Sørstokken,  Norway,  10  Oct  2006  4.2.2   Spanair  MD-­‐82,  Madrid,  Spain,  20Aug  2008  4.2.3   Qantas  A330-­‐300,  Western  Australia,  7  Oct  2008  4.2.4   Emirates  A340-­‐500,  Melbourne,  Australia,  20  Mar  2009  4.2.5   Fedex  MD-­‐11,  Tokyo  Narita,  Japan,  23  Mar  2009*  4.2.6   Air  France  A330,  South  Atlantic  Ocean,  1  Jun  2009*  4.2.7   Yemenia  Airways  A310-­‐300,  Moroni,  Comores,  30  Jun  2009*  4.2.8   American  Airlines  B737-­‐800,  Kingston,  Jamaica,  22  Dec  2009*  4.2.9   Ethiopian  Airlines  B737-­‐800,  off  Beirut,  Lebanon,  25  Jan  2010  4.2.10   Lufthansa  Cargo  MD-­‐11,  Riyadh,  Saudi  Arabia,  27  Jul  2010  4.2.11   Windjet  A319,  Palermo,  Italy,  24  Sep  2010*  4.2.12   Qantas  A380,  Singapore,  4  Nov  2010*  4.2.13   Miscellaneous  Recent  Accidents  4.3   REVIEW  OF  SERIOUS  INCIDENTS  &  INCIDENTS  4.3.1   Alrosa  Airlines  Tu-­‐154,  Russia,  7  Sep  2010  4.3.2   Miscellaneous  Recent  Serious  Incidents  and  Incidents  4.4   REVIEW  OF  HELICOPTER  ACCIDENTS,  SERIOUS  INCIDENTS  &  INCIDENTS  4.4.1   Miscellaneous  Recent  Helicopter  Accidents,  Serious  Incidents  and  Incidents  

   5   IFALPA  ACCREDITED  INVESTIGATOR  SCHEME  5.1   Recent  Accident  Investigator  Accreditation  Approvals  

  5  5.2   Investigator  Education  

   6   COMMUNICATIONS  6.1   Referrals  6.2   Checklist  of  actions  

   7   MISCELLANEOUS  7.1   Other  business          

  6  MINUTES 0 OPENING OF AAP MEETING, Monday 21 May 0.0.1 Captain Juan Carlos Lozano, Chairman of the AAP Committee, welcomed the

delegates and the observers, Captain Nelson and Mr. McGregor from Airbus, and Captain McVenes from Boeing. He thanked POLALPA for hosting the meeting. Captain Sieczkowski welcomed the Committee on behalf of POLALPA. The Chairman made a presentation on the role and goals of the Committee, and on the safety analysis work done at ICAO with emphasis on the results of the ICAO USOAP and accident statistics. He stressed that the AAP Committee should broaden its scope to safety management. He also expressed the Committee's best wishes to Captain Phillips from Boeing. Captain McVenes said that in all likeliness Captain Bob Aaron would be representing Boeing in future AAP meetings. The Chairman then gave the floor to individual introductions.

0.1 Review of the previous meeting minutes 0.1.1 The Chairman presented the report from the previous meeting in Haarlem and his

own annual report for 2011. There were no comments. He also explained the procedure implement by the Executive Board for the number of Committee meetings granted each year, directly related to the work to be done. The Senior Technical Officer made a presentation on the changes currently taking place in the IFALPA Secretariat and the headquarters' move to Montreal.

0.2 Additions to the agenda 0.2.1 The following late papers were added to the agenda:

- 13AAP006, Air Nostrum CRJ-200 Santander from Captain Shocrón, under item 4.3.2 - 13AAP007, Air Europa B737-800 Lanzarote from Captain Shocrón, under item 4.2.13 - 13AAP008, Luxembourg update from Captain Reuter, under item 4.2.13 - 13AAP009, Spanair MD-82 Madrid from Captain Shocrón, under item 4.2.2

1 IFALPA 1.1 IFALPA Annex 13 1.1.1 There had been no new version of this Annex. The Chairman mentioned the need

to regularly review the existing policies for currency and start drafting new policies on Safety Management policies. Committee members were encouraged to do such review.

1.1.2 The Chairman presented his paper suggesting new items for the AAP's agenda and a

change of name for the Committee to "Safety Investigation and Analysis", on the basis that "Accident Prevention" was only one part of the Committee's remit. There were extensive discussions and input on the proposals. On the first day of the meeting Captain Beer organized a survey of the Committee members and presented the results on the last day. There were about 10 different suggestions for a new name, but no consensus. Captain Wragg said that perhaps it wasn't so much the name that was important but the work done by the Committee members and their awareness of the role of the Committee. Captain Arenda said that the data available to the Committee (such as ADs, Safety Reports) were limited by essence, which might impair the capability of the Committee to fully encompass a role of Safety Management. Captain Beer summarized that the Committee clearly agreed that work was needed on Annex 19 and that the Committee's scope needed to be broadened towards SMS. The issue of a new name was left open, and a WG would be formed to do some more brainstorming.

1.2 Implementation of Policy

  7  There were no discussions under this agenda item.

2 ICAO 2.1 ICAO Annex 13 2.1.1 The Senior Technical Officer presented his paper. On 23 June 2011, ICAO's Air

Navigation Commission carried out a review of a proposal to amend Annex 13 on a definition for “contributing factors”, a direct consequence from the last ICAO AIG meeting and IFALPA's input. The relevant State Letter was then sent, dated 29 July 2011. 66 replies were received from 63 States and 3 international organizations, including IFALPA. The replies indicated unanimous support for the proposed amendments, and their applicability date was subsequently set to 14 November 2013. The Committee conducted a review the IFALPA policies affected by these amendments. Some rewording took place and is presented at Appendix 1. The Chairman and the Senior Technical Officer highlighted that this

2.2 ICAO Annex 19 2.2.1 The Chairman presented his report of the meeting of the ICAO SIP TF WG-3 that took

place in Cologne in December 2011. Captain Beer gave additional details on the work of the SIP TF and the interaction with the representatives from the Contracting States.

2.2.2 The Chairman presented his report on the SMP's activities. The SMP was established in March 2011 by the ICAO ANC to provide recommendations on the development of a new Annex on safety management responsibilities and processes, using a streamlined process. Two SMP meetings were subsequently held in Montreal, in November 2011 and February 2012.

2.2.3 This resulted in a draft Annex 19, which is in the process of being reviewed by the ANC. The final version is expected to be ready for publication during the first half of 2013 with a view to achieving an applicability date in November 2013. The Chairman then went through the draft Annex 19 included in his paper so the Committee could have a general idea of the content.

2.3 ICAO Manuals  

2.3.1 The Senior Technical Officer informed the Committee that, on 9 December 2011, ICAO had published Doc 9962 - Manual on Accident and Incident Investigation Policies and Procedures, which is available from the AAP section of the IFALPA website. The Manual provides guidance for States that do not have in place policies and procedures to meet the requirements of the provisions of Annex 13. It was developed in response to Recommendation 5/2 of AIG/08, which called for ICAO to develop guidance regarding policies and procedures for carrying out investigations.

2.3.2 The Senior Technical Officer further introduced his paper on a new group established by ICAO on 16 March 2012. This Group, the Assistance to Aircraft Accident Victims Policy Task Force (AVPTF) was tasked with developing a policy document for the provision of assistance to aircraft accident victims and their families. Invitations to make experts available for participation in the work of this task force have been sent to 15 Contracting States, IATA, IFALPA, IFATCA and the Air Crash Victims Families Group (ACVFG). The Committee reviewed the Terms of Reference of the AVPTF. Captain Beer gave an example of the psychological and legal problems associated with such assistance, and highlighted that expertise is needed to handle these situations with the necessary care. Captain Maldonado shared his experience with assistance to victims in Argentina. Captain Barral mentioned the on-going issues linked to the families of the victims of Air France 447. The AAP Committee reviewed and strongly supported the comments made on the draft document by Captain McCarthy. Captain van Dijck said he might be able to provide a volunteer from VNV to be the IFALPA contact point for the AVPTF. Due to the urgency of the answer a 2 week deadline was given.

3 IFALPA REPRESENTATION IN AIR SAFETY INVESTIGATION BODIES / SAFETY INITIATIVES

  8    

3.1 ICAO Accident Investigation Methodology Study Group (AIMSG)  

3.1.1 The Senior Technical Officer informed the Committee that the SG had now completed its work on Part II (Procedures and Checklists) of ICAO Doc 9756 (Manual of Accident and Incident Investigation), which provides guidelines for the conduct of accident investigations. Part II has just been released and is available for download from the AAP section of the IFALPA website. After consultation with Captain Glantz, it was agreed to remove this SG from the permanent agenda until further work requiring IFALPA input is undertaken.

3.2 ICAO Flight Recorder Panel (FLIRECP)  

There were no discussions under this agenda item.  

3.3 European Civil Aviation Conference (ECAC) Group of Experts on Accident Investigation (ACC)

3.3.1 The Chairman presented the official ECAC report of the ACC-36 meeting that took place in Dublin in November 2011. The Committee noted with interest agenda item 5, with the presentation that Captain Bosma from VNV made to the ACC on judicial and safety investigations, and agenda item 10 on recent ICAO activity. Captain Granhøj gave a verbal report of the ECAC workshop on ‘Treatment of Serious Incidents’ organised by the ECAC ACC in Denmark. Mr McGregor added a few words from a manufacturer's perspective, as Airbus had participated to the workshop. ACC/37 will take place next month in Tel Aviv. Captain Kaumanns is the new ECA representative and will attend along with Mr Michel.

3.4 IATA Accident Classification Task Force (ACTF)  

3.4.1 The Chairman presented Captain Mündel's report. He informed the Committee that Captain Mündel had left his airline CSA to fly A320s with HCA (Holidays Czech Airlines), a company which has no pilot representation. CZALPA's Executive Board is currently working on establishing relations with HCA pilots, and Captain Mündel is hoping to come back to technical work in the not so distant future. The Committee unanimously recognized the work of Captain Mündel over the past 12 years and agreed to suggest to the Executive Board that he be nominated for an award at the next IFALPA Conference. In the meantime, a new representative to the ACTF is needed. Captains Shocrón, Zanolli, Schöne and Barral all expressed an interest in taking over, pending their Association's approval.

3.5 Flight Safety Foundation (FSF) EASS/IASS  

3.5.1 The Chairman presented his report of the 64th IASS which took place in Singapore in November 2011, highlighting the "Professionalism" and "Go Around" projects. He expressed concerns on the current work done at the IASS, saying that for example the DVD produced by the FSF on Professionalism was of poor quality and content. There were extensive discussions on the Go Around project. Captain Barral mentioned that, in his airline, over 94% of non-stabilised approaches were not followed by a go-around. This was confirmed by the LOSA data presented at the IASS: only 3% of non-stabilised approaches result in a go-around. Captain Arenda pointed out that commercial pressure and cost was often the culprit in the unwillingness of pilots to go around, or the mindset that forces them to land. Captain Granhøj also mentioned that if all unstablised approaches resulted in a go- around, the handling of the traffic by ATC would be very different and in some cases pushed to its limits. Captain Nelson gave some details on the European Advisory Committee's newly launched Go-Around Safety Initiative. Captain Al Ibrahimi stressed that, in his airline and in most African airlines, only the Captain could initiate a go-around, and that this factor should be taken into account when analysing the data.

3.5.2 All the members went on sharing their experience in various situations normally requiring a go-around, and how their airline had identified the problem and acted (or not) upon it. The Chairman showed the presentation made at the IASS on the subject. The 65th IASS will take place in Santiago, Chile, from 23 to 25 October 2012. More

  9  information is available from the FSF website at the following address: http://flightsafety.org/aviation-safety-seminars/international-air-safety-seminar

3.6 ECA Flight Data WG  

3.6.1 The Chairman presented the report of the meeting that took place in Brussels on 31 Jan 2012. He stressed the importance of the revision of the EU Occurrence Reporting Directive. In April 2012 the European Commission had organised a workshop on just culture with the intention of coming up with a revision proposal by mid-2012. The Chairman then restated the need for European MAs to approach their national AIB in order to promote the Template for Advance Arrangements (TAA) and implement the obligations of the Accident Investigation Regulation. New WGs have been created in the framework of the European Operators FDM Forum, in which ECA will ensure pilot input. The Chairman also mentioned a presentation from EADS Astrium on airborne data streaming, a system which raises many safety and security concerns. Mr McGregor and Captain Nelson pointed out that, although part of the EADS group, Airbus had not been involved in the development of the system. Finally, the Chairman gave an update on the European Coordination Centre for Accident and Incident Reporting Systems (ECCAIRS), highlighting the deficiencies of the system. Captain Whyte pointed out that the ICAO ADREP 2000 taxonomy has been implemented in ECCAIRS and that ICAO was promoting the use of the software worldwide. The next ECA FD WG meeting will be held in Brussels on 14 June, under the chairmanship of Captain Bosma from VNV. European MAs were all invited to attend.

3.7 Regional Aviation Safety Group - Pan American  

3.7.1 The Chairman mentioned a few items that had been highlighted at the CAR-SAM meeting that took place during the annual IFALPA Conference in Paris. He said that the RASG was working very well in a collaborative approach, on projects like CFIT-related training, runway safety and ALAR toolkit.

3.8 Gulf Flight Safety Committee (GFSC)  

3.8.1 A joint meeting with the GFSC is still being considered, in order to raise the technical profile of IFALPA in the Gulf Region. Captain Lindsay Fenwick, former AAP member and Executive Board member, who now works in Dubai, will continue to act as contact point with the GFSC, along with the Lebanese Association. The Committee expressed its on-going interest in a joint meeting. Captain van Dijck shared the positive feedback he had received from the GFSC members when he made a presentation on behalf of IFALPA, and encouraged the Chairman to follow-up with the Executive Board.

4 AIR SAFETY TRENDS  

4.1.0 Trend Analysis System  

4.1.1 Aviation Safety Reporting Systems (Airlines, etc.)  

There were no discussions under this agenda item  

4.2 REVIEW OF ACCIDENTS (* indicates that the report is awaited)  

4.2.0 Captain Whyte explained the purpose of putting specific accidents on the agenda, ie that their investigation is likely to bring lessons and/or referrals.

4.2.1 Atlantic Airways BAe146, Stord, Norway, 10 Oct 2006  

4.2.1.1 Following a non-precision approach, the aircraft overran on landing and fell down a steep, wooded slope. It caught fire and was destroyed. The final report was recently released by the AIBN and can be downloaded from www.aibn.no/Aviation/Reports/2012-04-eng or from the AAP section of the IFALPA website. Captain Granhøj presented the final report, the sequence of events, the conclusions and the safety recommendations. He highlighted paragraph 1.7.5.4 which mentions the IFALPA Runway Safety Manual, and para. 2.6.3.4, which states "Based on a safety perspective the AIBN also supports the proposal from IFALPA that a damp runway should be reported as wet". Overall Captain

  10  Granhøj was satisfied with the report. He would report on the training issues at the next HUPER meeting in Munich, and write a referral to ADO and AGE on other relevant issues. It was agreed to remove this accident from the agenda.

4.2.2 Spanair MD-82, Madrid, Spain, 20 Aug 2008  

4.2.2.1 The aircraft got briefly airborne before hitting the ground tail first, and then bouncing 3 times across the area adjacent to runway 36L. It finally overran the runway and fell into a ditch. Captain Shocrón presented his paper. The final report was published in Spanish on 27 July 2011, and later in English. It can be downloaded at: www.fomento.gob.es/NR/rdonlyres/EC47A855-B098-409E-B4C8- 9A6DD0D0969F/107087/2008_032_A_ENG.pdf or from the AAP section of the IFALPA website. Captain Shocrón presented the outstanding issues not properly addressed in the report, and went through the take-off sequence and the stall warning system. It was agreed to keep this accident on the agenda.

4.2.3 Qantas A330-300, Western Australia, 7 Oct 2008  

4.2.3.1 Whilst cruising at FL370, the aircraft experienced two severe pitch down movements, which led to 14 injuries. There were several master warnings, and series of high Angle of Attack spikes. The aircraft was diverted to Learmonth. The ATSB’s final report can be downloaded at: www.atsb.gov.au/publications/investigation_reports/2008/aair/ao-2008-070.aspx or from the AAP section of the IFALPA website.

4.2.3.2 Captain Whyte made a presentation to support his paper, explaining the sequence of events. He highlighted the essential safety role played by seatbelts during cruise, as those passengers whose belts hat had not been tightened enough or not worn sustained the worst injuries, in particular to the head. Captain Whyte then went through a few issues including the weather phenomenon called "Single Event Effect" that might have played a role in the disturbance of airborne systems, ECAM and crew workload. He also said that there had not been any update for 2 years, whereas ICAO Annex 13 requires a 12-monthly update. Captain Shocrón highlighted the good airmanship of the flight crew, facing an unexpected situation, a comment supported by Mr McGregor from Airbus. It was agreeed that Captain Whyte would write the relevant referrals for HUPER and ADO. It was agreed to remove this accident from the agenda.

4.2.4 Emirates A340-500, Melbourne, Australia, 20 Mar 2009  

4.2.4.1 On take-off, a first attempt to rotate the aircraft was unsuccessful. Following greater nose-up command, the aircraft suffered a tailstrike, damaged some of the ground equipment, and did not begin to climb until TOGA was selected. The crew returned to Melbourne. It was found that a TOW of 100 tonnes below the actual TOW had been used for take-off performance calculations. The ATSB's final report, released on 18 December 2011, can be downloaded at: www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-012.aspx or from the AAP section of the IFALPA website. Captain Whyte made a presentation to support his paper. He mentioned the distraction that the presence of two additional flight crew members in the cockpit had created during the pre-flight, and called it an "important lesson on the need to focus your attention". On this topic, Captain Beer mentioned an excellent study called "The Multitasking Myth", conducted by Loukia Loukopoulos (who had previously made a presentation to the AAP Committee in Barcelona), Key Dismukes and Immanuel Barshi. Captain Whyte also highlighted the safety actions and recommendations, including increased resilience and certification issues. One of the concerns was the time taken to complete the final report, published nearly three years after the occurrence. The ATSB had not issued an update of the investigation status on the second anniversary of the accident. The research report "Take-off performance calculation and entry errors: A global perspective" was released in January 2011.

  11  4.2.4.2 Answering the Chairman, Captain Whyte said that a significant number of

similar occurrences involving miscalculations had been listed in the report and provided a useful source of reference. Captain Zanolli mentioned the presence of a system in the F/E Panel on B747 classics that gave the "weight on wheels" information, and that was quite accurate and very useful for double-checking calculations. It was agreed that Captain Shocrón would raise the distraction issue with the HUPER Committee, and that the accident should be removed from the agenda.

4.2.4.3 As a complement to the above issues, Mr McGregor made a presentation on 3 Airbus projects designed to secure take-off and provide a "safety net" within avionics regarding erroneous take-off parameters/operations and degraded aircraft performance, and to prevent risks of tailstrike, overrun and take-off from wrong runways. These projects, carried out in partnership with Honeywell and Thales, are known as TOS1 (partly available on SA, LR and A380), TOS2 (launched on A350) and TOM (feasibility study).

4.2.5 FedEx MD-11, Tokyo Narita, Japan, 23 Mar 2009*  

4.2.5.1 On landing on Runway 34L, the aircraft bounced in a nose-high attitude, then pitched down and struck the runway nose first. It rolled to the left, broke into several parts and came to rest on the grass whilst a fire erupted. An interim report was released on 16 April 2010 and can be downloaded at www.mlit.go.jp/jtsb/eng-air_report/N526FE.pdf or from the AAP section of the IFALPA website. Captain Bender said he had no update on the progress of the final report, and that the composition of the Japanese TSB had changed 3 times since the accident. There was a second "progress meeting" in Long Beach CA in November 2011, during which the JTSB said the final report would be available at the end of 2012. Captain Tateno said that the relations between ALPA Japan and the JTSB were still difficult, although he had had an opportunity to present the Association's views. It was agreed to keep this accident on the agenda.

4.2.6 Air France A330, South Atlantic Ocean, 1 Jun 2009*  

4.2.6.1 While cruising at FL350 through the ITCZ, the aircraft sent a series of ACARS messages regarding systems malfunctions and erroneous indications, including speed information lost or erroneous; Autopilot, Flight Director and autothrottle off; alternate law; limit speeds lost, etc. Captain Barral made a presentation on the sequence of events. After a long series of search and recovery operations, both the FDR and the CVR were eventually recovered in early May 2011, and the BEA was able to access the data a few days afterwards. A third interim report followed and was published in French on 29 July, with the English translation a few days later. It can be downloaded at:

www.bea.aero/en/enquetes/flight.af.447/flight.af.447.php. or from the AAP section of the IFALPA website.

4.2.6.2 Captain Barral presented the BEA recommendations to the company, including the use of a Class C Airborne Image Recorder (AIR) to show the information available to the pilots from the displays. Discussions followed on the various initiatives to install AIRs in the flight deck, and associated efforts from IFALPA to guarantee pilot privacy. The Senior Technical Officer gave some more background on these efforts and reminded the Committee of the 3 Classes of AIRs currently defined in ICAO Annex 6: - Class A AIRs capture the general cockpit area - Class B AIRs capture data link message displays. - Class C AIRs capture instruments and control panels

4.2.6.3 The Committee continued to support the current IFALPA policy opposing the installation of AIRs in commercial transport aircraft, but acknowledged that some countries were already planning to install them.

4.2.6.4 Captain Barral also presented the actions taken by SNPL following the publication of the report, in which two of the initial recommendations were left out, apparently for political reasons. SNPL subsequently produced its own leaflet raising questions on the technical issues related to these missing recommendations. This leaflet is available (in French only) from the SNPL website at the following address:

  12  www.snpl.com/download.php?id=2181. It was

sent in April 2012 to all Air France pilots. Mr McGregor said that the final report is expected in mid-June. It was agreed to keep this accident on the agenda.

4.2.7 Yemenia Airways A310, Moroni, Comores, 30 Jun 2009*  

4.2.7.1 The aircraft was destroyed when it crashed into the sea while on approach to Moroni, about 20nm from the airport. Captain Barral gave a few details on the investigation, which is on-going. The Investigator In Charge is from the Comores, the flight recorders have been decoded and read, but there are some political issues with the Yemeni Authorities, which seem to slow down the publication of the final report. Mr McGregor and Captain Nelson made a presentation on the sequence of events and the trajectory of the aircraft. Both recorders were recovered after 60 days in the sea, which led to some reading difficulties, in particular for the CVR, due to corrosion. Operational considerations so far include loss of situational awareness and stall recovery. Updates will be made available on the BEA website: www.bea.aero/en/enquetes/flight.iy.626/flight.iy.626.php It was agreed to keep this accident on the agenda.

4.2.8 American Airlines B737-800, Kingston, Jamaica, 22 Dec 2009*  

4.2.8.1 Following an ILS approach at night, in heavy rain and poor visibility, the aircraft overran runway 12, continued through the airport perimeter fence and across the sea wall onto the shore, before eventually coming to rest. The aircraft touched down 4200' down the 8900' runway 12, which was wet at the time following a heavy downpour, and subject to a 15kt tailwind: the pilots had elected to fly the ILS approach to 12 rather than the RNP/RNAV approach to runway 30. The aircraft departed the end of the runway at 60kt and broke into three parts. The crew had not violated any procedure, had filed a report on ASAP and are flying again. A 5th press release was issued by the Jamaican CAA on 31 August 2010 and can be downloaded at: www.jcaa.gov.jm/NEWS_UPDATES/News%20Release%20ACCIDE NT%20INVESTIGATION%20August%2031%202010.pdf Captain McVenes advised that the draft report had been released for comments, that Boeing had sent their comments and that the final report would be released in the coming months. Captain Beer said it was unlikely that the report was unlikely to bring any new lesson learned, and it was agreed to remove this accident from the agenda.

4.2.9 Ethiopian Airlines B737-800, off Beirut, Lebanon, 25 Jan 2010  

4.2.9.1 The aircraft crashed into the sea shortly after take-off from Beirut, by night and in poor weather with heavy rain associated with local thunderstorm activity. The investigation was carried out by Capt. Abdel-Aziz Aziz from the Lebanese Association. The final report was published on 17 January 2012 and can be downloaded from the Lebanese CAA website: www.lebcaa.com, or from the AAP section of the IFALPA website. Captain McVenes presented the sequence of events and showed the trajectory of the flight. The Chairman then presented the conclusions and went through the safety recommendations. The report states that the probable causes were:

- the flight crew's mismanagement of the aircraft's speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control, and

- the flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.

Captain Ben Shahar mentioned the lack of response from the F/O and the usually high cockpit gradient typical to some countries. It was agreed to remove this accident from the agenda.

4.2.10 Lufthansa Cargo MD-11, Riyadh, Saudi Arabia, 27 Jul 2010  

4.2.10.1 The aircraft touched down on runway 33L (wind 320/14) at just over 2g, bounced, touched down again at 3g, bounced again and touched down again at 4.3g. The nose-gear collapsed, the fuselage broke in two major sections, rupturing the fuel lines,

  13  which is likely to have initiated the subsequent fire. The two crew members (the only people on board) survived, both recorders were recovered but in poor condition. Captain McVenes made a presentation on the investigation. The final report was approved by the Board of Directors of the GACA on 21 January 2012 and can be downloaded at www.bfu.de or from the AAP section of the IFALPA website. It contains 9 safety recommendations including:

- the revision by Boeing of the MD-11 Flight Crew Operating Manual to reemphasize high sink rate awareness during landing, the importance of momentarily maintaining landing pitch attitude after touchdown and using proper pitch attitude and power to cushion excess sink rate in the flare, and to go around in the event of a bounced landing. Subsequent action was taken by Boeing. Captain Bender said that the change had already taken place in his airline.

- the installation of HUDs on Lufthansa's MD-11F aircraft.  

- and a number of actions for Riyadh airport's infrastructure and emergency response plan (cameras, vehicles, equipment, etc.).

Interestingly, the final report does not have a specific paragraph on "causes" but instead "cause related findings". Captain Rautiainen shared his experience in flying the type, in particular in a "nose heavy" configuration. It was agreed to remove this accident from the agenda.

4.2.11 Windjet A319, Palermo, Italy, 24 Sep 2010*  

4.2.11.1 Following a night approach to runway 07 in reported wind shear and heavy rain conditions, the aircraft touched down about 1,300 feet short of the runway, impacted the localizer antenna for the ILS runway 25 embedding parts of the antenna in its nose and came to a stop to the left of the runway. A successful evacuation was initiated. Captain Zanolli made a presentation on the sequence of events that led to the accident. He said that issues related to human factors and training had been left out. Mr McGregor said that, during the approach, the aircraft had not maintained the glideslope, with multiple inputs from the Captain, and agreed with Captain Zanolli that there were many human factor issues involved. It was agreed to keep this accident on the agenda.

4.2.12 Qantas A380, Singapore, 4 Nov 2010*  

4.2.12.1 The aircraft suffered an uncontained failure of its No. 2 engine shortly after take-off from Singapore, which led to structural damage to the airframe. Several homes and cars on the Indonesian island of Batam suffered damage from bits of engine and cowling which fell from the aircraft. The crew returned to Singapore and landed safely. Updates on the investigation are available from the ASTB at the following address: www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-089.aspx An interim factual report was published in May 2011 but Captain Whyte said there had been no update since. Mr McGregor said Airbus had not seen a draft final report yet. It was agreed to keep this accident on the agenda.

4.2.13 Miscellaneous Recent Accidents  

4.2.13.1 Chairing the third day, Captain Beer asked the Committee whether they had any addition to the agenda from the Airclaims papers.

Captain McVenes made a presentation on the Asiana B747-400F accident off the Korean Coast near Jeju island (28 Jul 2011). Captain Whyte stressed the need to study this accident alongside the UPS B747-400 accident in Dubai (3 Sep 2010), as both of them had a similar cargo including Li batteries. Comments were made on the lack of appropriate fire suppression systems in freight aircraft. The Chairman also commented on the oxygen protection available to the crew in the accident aircraft. It was agreed to add these 2 accidents on the agenda, under the same item.

  14  Captain van Dijck mentioned the Sky Airlines B737-400 accident in Antalya (10 Oct 2011). The Senior Technical Officer would ask Captain Hakan Yurdakul from Turkish ALPA whether he could find more information on this accident.

Captain McVenes said a few words on the LOT B767 gear-up landing in Warsaw (1 Nov 2011). The investigation is completed and the final report is nearing completion. There were discussions on the procedures related to circuit breaker protection.

4.2.13.2 The Chairman presented the conclusions and safety recommendations included in the final report of the AirBlue A321 accident in Islamabad (28 Jul 2010), which had been identified as Controlled Flight into Terrain (CFIT) resulting from a number of human factors. Captain Nelson highlighted the decreasing number of airlines that were still doing circling approaches. Captain Whyte said Qantas had already stopped circling approaches in the B747-400 and that it would be the same for the B767 once the RNP certification program gets further, although installation cost has been identified as an obstacle for some airlines. The Technical Officer mentioned IFALPA's position paper 09POS05 which addresses the subject, and Captain Rivas's extensive work on RNP on behalf of IFALPA.

4.2.13.3 Captain Maldonado presented his paper on investigation into the Sol Líneas Aéreas accident which took place in Prahuaniyeu, Argentina, on 18 May 2011. He said APLA had not been allowed to participate to the investigation and express their concerns. It was agreed to add this accident to the agenda.

4.2.13.4 Captain Whyte presented his paper on the Airlines PNG DHC-8 that took place in Madang, Papua New Guinea, on 13 October 2011. The aircraft force-landed on sparsely timbered terrain. During the impact sequence, it was severely damaged while colliding with trees and the ground, and an intense fuel-fed fire began. 28 passengers were fatally injured while the 3 crew and 1 passenger survived. The PNG Accident Investigation Commission (AIC) is investigating the accident with technical assistance from the ATSB. The PNG AIC is very small and will need to rely heavily on outside expertise for many aspects of the investigation. Both the CVR and FDR were recovered and contain useable information. A preliminary report containing brief factual information on the accident can be downloaded at: www.atsb.gov.au/publications/investigation_reports/2011/aair/ae-2011-132.aspx Captain Whyte presented the AOMs issued by Bombardier following the accident, and Captain Fulton gave additional details on the ground idle system in the DHC-8. Captain Whyte mentioned a Qantas incident in which the F/O inadvertently activated the ground idle trigger. Both engines entered ground idle for 2s but the crew quickly recovered. It was agreed to put the accident on the agenda.

4.2.13.5 Captain Miller from JALPA had sent a note to the Senior Technical Officer, expressing his thanks to Captain Brady and his US ALPA colleagues for all the help provided in the aftermath of the Caribbean Airlines B737-800 accident in Georgetown, Guyana, on 30 July 2011. The aircraft overran runway 06 at night, in rainy weather, went over a road and broke into two sections. There were some injuries amongst the passengers. Captain Miller, who's also an IFALPA-Accredited Accident Investigator, has been part of the CVR team. A factual report from the Guyana CAA is still awaited. Captain Bender said he would relay Captain Miller's comments to his ALPA colleagues.

4.2.13.6 Captain Shocrón presented his paper on the final report of the Air Europa B737-800 accident in Lanzarote on 31 Oct 2008. After a long flare, the aircraft touched down about half-way down runway 21, ran off the end at 51kt, travelled over the 60m of stopway and came to a stop on soft ground. There were no injuries. The final report can be downloaded at www.fomento.gob.es/NR/rdonlyres/054C08A8-398E-43BB- AC54-635409583282/109460/2008_041_IN_ENG.pdf or from the AAP section of the IFALPA website. It states the cause of the accident as being a high-energy unstabilized approach followed by a landing with excessive speed on a wet runway, in conjunction with inefficient use of autobrake and reversers. It also mentions as

  15  contributing factor a combination of deficiencies involving several aspects of CRM. Captain Shocron highlighted some concerns expressed by SEPLA, in particular with regards to fatigue as a contributing factor to the accident.

4.2.13.7 The Senior Technical Officer presented Captain Reuter's paper. The Committee noted the update provided on the three accidents mentioned.

4.2.13.8 Captain Fulton said a few words on the First Air B737-200 accident near Resolute Bay, Nunavut, on 20 August 2011. The investigation is in the "post field phase" with a preliminary report expected within 6 months. It was agreed to add this accident to the agenda.

4.3 REVIEW OF SERIOUS INCIDENTS AND INCIDENTS  

4.3.1 Alrosa Airlines Tu-154, Russia, 7 Sep 2010  

4.3.1.1 Whilst cruising on a flight at 30,000 ft from Irkutsk to Moscow, the electrical generating system failed, disabling the plane's entire electric system, including navigation and radio systems, fuel pumps and air brakes. The crew managed to steer the aircraft to an abandoned military helicopter airfield but due the short runway the plane rolled off 200 metres into the woods before coming to a stop. Mr Morozov said that this occurrence had been classified as "serious incident" rather than "accident", and that MAK had therefore not carried out an investigation. The Russian CAA had released a report, which Mr Morozov had presented at the Haarlem meeting, explaining the electric system of the Tu-154 and the origin of the failure. This incident was considered an example of good airmanship. It was agreed to remove it from the agenda.

4.3.2 Miscellaneous Recent Serious Incidents and Incidents  

4.3.2.1 Captain Shocrón presented his paper on an Air Nostrum CRJ-200ER incident that took place in Santander on 24 February 2009. As the aircraft was passing through FL200 in the descent, both engines flamed out. Within one minute, the ADG popped out, and the Captain set the Continuous Ignition to ON, getting both engines re-started at the same time. After some minutes, a company CRJ Captain entered the cockpit and told the flight crew to declare the emergency. The approach and landing were uneventful.

4.3.2.2 The CIAIAC initiated an investigation into the incident but then focused on the words spoken by both pilots regarding the shutting down of the engines. Captain Shocrón went through the 4 recommendations. The draft final report is nearing completion. It was agreed to add this serious incident to the agenda.

4.4 REVIEW OF HELICOPTER ACCIDENTS & INCIDENTS  

4.4.1 Miscellaneous Recent Helicopter Serious Incidents and Incidents  

4.4.1.1 There were no papers or presentation on this agenda item. The Committee discussed the relevancy of keeping this item on the agenda, in view of IPHPA having joined IFALPA and providing new human resources to the HEL Committee. It was agreed that the Chairman would discuss this with the HEL Chairman at the 2012 IFALPA Committee Chairmen's meeting which will take place in Montreal in July. The Chairman would then give his feedback to the Committee.

5 ACCREDITED ACCIDENT INVESTIGATOR SCHEME  

5.1 Recent Accreditation Approvals.  

5.1.1 The Senior Technical Officer made a presentation on the new accreditations that were granted since the last AAP meeting: Captain Richard Tainsh and F/O Stuart Lomas from Australia, Captain Julian Pinzon from Colombia, Captain Dave Goddard from Hong-Kong, Captain Paul Cullen from Ireland, F/Os Keigo Hisamoto, Kazuma Kanai, Tsuyoshi Satoh and Manabu Suzuki from Japan, Captain Andre Grey from Leeward Islands, Captain Carmel Maniscalco from Malta, Captains Carlos Arroyo Landero, Germán Diaz Barriga, Juan Carlos Gonzalez Curzio, Mario Herrera Jimenez, Fermin Leon and Heriberto Salazar Eguiluz from Mexico, F/O Marcus Tan from

  16  Singapore, F/O Cobus Toerien from South Africa and Captain Martin Rommen from Sweden. The Chairmen expressed his satisfaction with the scheme but said that more investigators needed to be trained, in particular in the AFI region. Captain Al Ibrahimi shared his experience with the neighbouring MAs.

5.1.2 Local response plans for 25 countries have already been uploaded on the IFALPA Intranet under AAP/Accident and Serious Incident Response Plan/Local guidelines: Australia, Austria, Belgium, Czech Republic, Finland, France, Germany, Hong-Kong, Iceland, Ireland, Italy, Japan, Malaysia, Mexico, Morocco, Netherlands, New Zealand, Norway, Portugal, South Africa, Spain, Switzerland, UK, US/Canada. Committee members representing an Association that has not provided a response plan yet were requested to address the issue.

5.2 Investigator Education  

5.2.1 Captain Whyte presented Captain Lomas's report of the UNSW accident investigation course he had attended in June 2011. This course is recognized by IFALPA for accreditation.

5.2.2 The Chairman presented his paper on a proposed procedure to allow the AAP Committee to track the final reports discussed in the Committee meetings as well as provide an expert opinion to the investigation authority/authorities when needed or advised. It is expected that the new format would help and focus the discussions on accident reports. Captain Granhøj suggested that any report should perhaps be read by two Committee members to see whether views concurred on the content and conclusions. The Chairman said that, whilst ideal, this would probably not be feasible from a resources viewpoint. The Committee supported the concept of the paper. The final version will be put in the AAP section for further reference.

5.2.3 Captain Tateno said that ALPA Japan was planning to organize an IFALPA Safety School (ISS) in Japan, and that he would liaise with Captain Meyer, IFALPA's Technical Officer in charge of training, to assess the feasibility of such course from an IFALPA's viewpoint.

5.2.2 Captain Beer presented the results of the IFALPA survey on SMS (available from the IFALPA website. The plan is to publish these results in a detailed publication, possibly with the participation of ICAO and IATA A second survey might take place in 2013/2014 for comparison purposes.

6 COMMUNICATIONS  

6.1 Referrals  

6.1.1 There were no discussions under this agenda item.  

6.2 Checklist of actions for next meeting  

6.2.1 The Senior Technical Officer updated the Committee on the actions agreed during the meeting.

7 MISCELLANEOUS  

7.1 Election of Vice-Chairman  

7.1.1 Elections to the position of Vice-Chairman were held in accordance with the IFALPA Constitution and By-Laws, para. 2.9.5. As there were only two candidates, elections were conducted by acclamation. Captains Beer and Whyte were unanimously re-elected.

7.2 Any Other Business  

7.2.1 The Committee discussed the next meeting. A number of members expressed the wish to have the meeting later in the year to reach a better time balance between 2 annual Conferences. The Committee noted the invitation from HKALPA and agreed to suggest to the Executive Board that the 2013 AAP meeting took place in Hong-Kong in Fall, the

  17  exact date to be determined after looking at the IFALPA Calendar and other industry meetings.

CLOSING OF THE MEETING

The Chairman thanked Captains Cmil and Sieczkowski for the warm hospitality from POLALPA, and Captain Nelson and Mr McGregor from Airbus for kindly sponsoring the Monday dinner in the Arkadia restaurant (www.arkadia-restauracja.pl) on Rynek Starego Miasta, in the old town market place. He thanked all the observers for their welcome contributions to the debates. Finally, he thanked the Committee Members for their hard work and looked forward to seeing them at the next meeting. The meeting was subsequently closed.    

  18  CHECKLIST OF ACTIONS

 Agenda  Item   Action   Responsibility  

     2.1.1   To  consider  the  policy  proposal  presented  at  Appendix  1  for  inclusion  on  the  2013  Conference  agenda.  

Executive  Board  

2.3.2   To  provide  a  possible  IFALPA  contact  point  for  the  AVPTF  within  2  weeks  of  the  end  of  the  Warsaw  meeting  

Capt.  van  Dijck  

3.1.1   To  remove  the  AIMSG  from  the  agenda.   Senior  Tech  Officer  3.4.1   To  consider  the  nomination  of  Captain  Karel  Mündel  for  an  

award  at  the  2013  annual  Conference.  Executive  Board  

    To  inform  the  Senior  Technical  Officer  of  their  availability  to  succeed  to  Captain  Mündel  as  IFALPA  representative  to  the  IATA  ACTF.  

Captain  Shocrón       Captain  Zanolli       Captain  Schöne       Captain  Barral  3.8.1   To  note  the  on-­‐going  interest  of  the  AAP  Committee  to  hold  a  

joint  meeting  with  the  GFSC  in  the  Gulf  Region.  Executive  Board  

4.2.1   To  report  on  the  training  issues  identified  in  the  Atlantic  Airways  accident  at  the  next  HUPER  meeting  in  Munich,  and  write  a  referral  to  ADO  and  AGE  on  other  relevant  issues.  

Captain  Granhøj       Senior  Tech  Officer  

4.2.3   To  write  the  relevant  referrals  to  HUPER  and  ADO  concerning  the  Qantas  A330  accident.  

Captain  Whyte  

4.2   To  remove  the  following  accidents  from  the  agenda:   Senior  Tech  Officer       -­‐  Atlantic  Airways  BAe146,  Stord,  Norway,  10  Oct  2006           -­‐  Qantas  A330-­‐300,  Western  Australia,  7  Oct  2008           -­‐  Emirates  A340-­‐500,  Melbourne,  Australia,  20  Mar  2009           -­‐  American  Airlines  B737-­‐800,  Kingston,  22  Dec  2009           -­‐  Ethiopian  Airlines  B737-­‐800,  off  Beirut,  25  Jan  2010           -­‐  Lufthansa  Cargo  MD-­‐11,  Riyadh,  Saudi  Arabia,  27  Jul  2010           To  add  the  following  accidents  to  the  agenda:           -­‐  Sol  Líneas  Aéreas,  Prahuaniyeu,  Argentina,  18  May  2011           -­‐  Airlines  PNG  DHC-­‐8,  Madang,  PNG,  13  October  2011           -­‐  Asiana  B747-­‐400F  off  near  Jeju  island,  28  Jul  2011  and  UPS  

B747-­‐400  Dubai  (3  Sep  2010),  as  one  agenda  item      

4.2.13.1   To  contact  Captain  Hakan  Yurdakul  from  Turkish  ALPA  whether  he  could  find  more  information  on  the  Sky  Airlines  B737-­‐400  accident  in  Antalya  (10  Oct  2011).  

Senior  Tech  Officer  

4.3.2.1   To  add  the  Air  Nostrum  CRJ-­‐200ER  incident  in  Santander  (24  Feb  2009)  to  the  agenda.  

Senior  Tech  Officer  

5.2.2   To  upload  on  the  AAP  section  of  the  IFALPA  website  the  template  of  the  accident  report  as  presented  in  12AAP028.  

Senior  Tech  Officer  

7.1   To  note  that  Captains  Beer  and  Whyte  were  re-­‐elected  as  Vice-­‐Chairmen  of  the  AAP  Committee.  

Executive  Board  

7.2   To  consider  the  recommendation  of  the  AAP  Committee  that  the  2013  meeting  be  held  in  Hong-­‐Kong  in  Fall  and  to  determine  a  date  

Executive  Board  

  19    

INTRODUCTORY PAPER 68th IFALPA CONFERENCE

DUBLIN, IRELAND, 12-15 APRIL 2013        1. ITEM

NO. SUBJECT STATUS

C1.2 CAUSES AND FACTORS  

2. SOURCE AND DATE SUBMITTED  

The Chairman of the AAP Committee, on behalf of the Committee, May 2012.

3. ICAO POLICY  

3.1 ICAO Annex 13  

ICAO Annex 13 gives the following definitions:

Causes. Actions, omissions, events, conditions, or a combination thereof, which led to the accident or incident. The identification of causes does not imply the assignment of fault or the determination of administrative, civil or criminal liability.

Contributing factors. Actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The identification of contributing factors does not imply the assignment of fault or the determination of administrative, civil or criminal liability.

IFALPA POLICY

The word "causes" should be replaced with "factors" and defined as follows:

Factors. Actions, omissions, events, conditions, or a combination thereof, which contributed to or influenced the outcome of a result or circumstance.

Participation

ICAO paragraph 5.25 states that "participation in the investigation shall confer entitlement to participate in all aspects of the investigation, under the control of the investigator-in-change, in particular to: (...) h) participate in investigation progress meetings including

deliberations related to analysis, findings, causes, contributing factors and safety recommendations; and

(...)"

                         Ax. 13, 10th Ed (Jul 2010)                          POL-STAT 2008                Ax. 13, 10th Ed (Jul 2010)

  20    

IFALPA POLICY

IFALPA believes that sub paragraph h) should be amended to read as follows:

"h) participate in investigation progress meetings including deliberations related to analysis, findings, contributing factors and safety recommendations; and"

ICAO Annex 13, Appendix, details the format of the final report as follows:

3. CONCLUSIONS

List the findings, causes and/or contributing factors established in the investigation. The list of causes and/or contributing factors should include both the immediate and the deeper systemic causes and/or contributing factors.

Note.— As stated in 6.1, the Final Report format presented in this Appendix may be adapted to the circumstances of the accident or incident. Thus, States may use either “causes” or “contributing factors”, or both, in the Conclusions.

IFALPA POLICY

IFALPA believes that the above paragraph should be amended to read as follows:

3. CONCLUSIONS

List the findings and contributing factors established in the investigation. The list of factors should include both the immediate and systemic factors that contributed to the accident or incident, or that either adversely or positively affected the safety of the flight.

4. PROPOSED IFALPA POLICY  

4.1 AMEND the above policies as follows:  

The word "causes" should be replaced with "factors" and defined as follows:

Factors. Actions, omissions, events, conditions, or a combination thereof, which contributed to or influenced the outcome of a result or circumstance.

IFALPA believes that the word “causes” will always have the potential of being confused with liability, and subsequent attribution of blame and possibly legal compensation, which is contrary to the objectives of ICAO Annex 13. The Federation therefore argues that the word "causes" must be removed from this Annex and, replaced with " safety factors", with "safety factors defined as follows:

   POL-STAT 2008            Ax. 13, 10th Ed (Jul 2010)                                POL-STAT 2011                          POL-STAT

  21  Safety factors.

An act, event or condition that either positively or negatively affects safety. Safety Factors should be identified as:

a) Contributing Safety Factors. Actions, events, conditions, omissions or a combination thereof, which can be established to have either enhanced or mitigated the severity of an occurrence and/or contributed to or influenced the safety of the occurrence.

b) Additional Safety Factors. Safety factors identified during the occurrence investigation which while not meeting the definition of contributing safety factors, could, if present in the future, affect the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence.

IFALPA believes that sub paragraph h) should be amended to read as follows:  

"h) participate in investigation progress meetings including deliberations related to analysis, findings, contributing factors and safety recommendations; and"

With regards to sub paragraph h), IFALPA reiterates the statement on causes and safety factors made in Chapter 1 of this Annex.

IFALPA believes that the above paragraph should be amended to read as follows:  

3. CONCLUSIONS  

List the findings and contributing factors established in the investigation. The list of factors should include both the immediate and systemic factors that contributed to the accident or incident, or that either adversely or positively affected the safety of the flight.

IFALPA reiterates the statement on causes and safety factors" made in Chapter 1 of this Annex.

5. COMMENTS FROM THE PROPOSERS  

5.1 The above amendments were necessary to address the new ICAO definition of "contributing factors" and its use throughout ICAO Annex 13.

6. COMMENTS FROM THE EXECUTIVE BOARD  

6.1