CAA Safety Plan 2011 To 2013

Civil Aviation Authority
Safety Plan
2011 to 2013
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FOREWORD
Safety Plan 2011/13
Foreword
The UK has an enviable safety record of which the industry is rightly proud. However, there is no doubt that civil aviation in the UK and in many other parts of the world continues to face unprecedented operational, economic and environmental pressures. The need to improve aviation safety in a proportionate and cost-effective way is therefore one of the great challenges faced by the CAA and our partners in the aviation community. The recently published CAA Strategic Plan refers to the UK State Safety Programme, which includes the CAA Safety Plan, as a key mechanism to drive improved safety performance across all sectors of the industry. This Plan has been developed by the CAA in partnership with industry because although the CAA has a safety oversight responsibility, industry has prime responsibility for managing their safety risk. Aviation safety is therefore a shared responsibility and this Plan shows our commitment to continuous improvement in safety performance. This Plan summarises the actions we and our industry partners are collectively taking to address safety issues. We are taking a proactive approach to safety and our Plan is outcome focussed with great emphasis on safety performance. We must deliver results that make a measurable difference, and ensure that we make the very best use of our available resources. The actions we are taking fall into two types. Firstly, we are taking action to address the factors behind the most significant worldwide accident types involving large airliners we call these the Significant Seven as well as actions for other sectors, such as business aviation, large public transport helicopters and general aviation. All actions target specific problems, and many of these relate to human performance. Much of this work will involve industry as well as various European and international partners. Secondly, we are taking action to address capability issues. We believe that enhancing our safety risk management process, promoting a just culture, industry implementation of safety management systems and adoption of a performancebased regulatory approach will improve the way the CAA regulates and will result in safety improvements of benefit to aviation and the public at large by focussing on the right risks. To achieve these benefits, we must ensure that the industry and the CAA have the right capabilities to deliver these improvements. The ultimate desire is to move towards a predictive approach to safety risk management. We believe that this Plan represents a great opportunity to make a difference in aviation safety. During the period of this Plan, we expect to see measurable improvements in safety performance.
Gretchen Burrett Group Director Safety Regulation
Significant Seven Safety Issues The CAA Significant Seven safety issues were identified following analyses of global fatal accidents and high-risk occurrences involving large UK commercial air transport (CAT) aeroplanes. For each of these issues, joint CAA/industry task forces were created to study the safety issue in-depth and make recommendations on how their risk could be mitigated. Task force outputs were consolidated, prioritised and then shared and debated with industry at a Safety Conference in 2010. The key outcome from this Conference was the clear prioritisation of loss of control and runway safety (primarily runway excursions) over the other safety issues. The key desired safety outcomes for each of the seven issues are detailed on the following pages. How to use this document Each of the summary sections on the following pages contains a link to the full description of the issue later in the document.
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OVERVIEW
Safety Plan 2011/13
Controlled Flight into Terrain (CFIT)

CFIT risk was found to be greatest during non-precision approaches (NPAs) and the most common causes were: descent below decision/safety heights without appropriate visual reference, inadequate monitoring and
Loss of Control
Whilst technology has played a significant part in mitigating the risk of other types of accident (e.g. GPWS for CFIT and ACAS for mid-air collision), advances in technology and automation may not have been fully supported by corresponding changes in training, and this may lead to an increased risk of loss of control events. Training and testing pilot competence currently focuses on their handling skills rather than monitoring skills. However, safe operation of complex and highly automated aircraft relies on each pilot effectively monitoring the aircraft systems, automation and the other pilots actions. Safety improvement activities to mitigate the risk of loss of control will therefore focus on the following three issues: n training and assessment of pilot monitoring skills; n use of aircraft automation; and n maintenance of manual flying skills. Desired Safety Outcome (1 of 3): Reduce the risk of loss of control occurrences and serious incidents in which inadequate or ineffective monitoring by the flight crew was a factor. more
lack of positional awareness. Terrain Awareness and Warning System warnings were an effective mitigation but relied on correct flight crew response, up-to-date terrain
Runway Excursion
The key factors in avoiding a runway overrun or excursion were found to be landing within the touchdown zone in the correct configuration and at the correct speed, and if this could not be ensured, then flying a go-around. Other factors that increased the risk included provision of incomplete runway contamination data to pilots, failure to provide compliant runway surface friction characteristics and inadequacy of safety areas surrounding the runway. Safety improvement activities to mitigate the risk of runway excursion will therefore focus on the following three issues: n reducing unstable/de-stabilised approaches; n improving information broadcast to pilots on expected braking action on contaminated runways; and n improving safety areas around runways. Desired Safety Outcome (1 of 3): Reduce the risk of runway excursions associated with unstable/de-stabilised approaches. more
databases and software, and the most accurate source of position information feeding into them. Desired Safety Outcome: Reduce the risk of serious incidents that occur during NPAs, through enhancements in technology and training. more
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OVERVIEW Airborne Conflict

Many of the risks associated with airborne conflict
Safety Plan 2011/13
Runway Incursion
Runway incursions are managed through the Runway Incursions Steering Group (RISG), a group that has been able to build an excellent working relationship with industry and stakeholders by working closely together. Continued engagement with industry will help to see a reduction in the number of runway incursions by UK registered aircraft, by ground vehicles and at UK aerodromes. The RISG is represented on the EUROCONTROL Runway Incursion Prevention Working Group and has contributed to the development of the revised European Action Plan for the Prevention of Runway Incursions version 2.0 (EAPPRI2). One of the key actions to mitigate the risk of runway incursions will be the promotion of recommendations from EAPPRI2 to industry. Desired Safety Outcome: Reduce the risk of runway incursions at UK licensed aerodromes.
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are already being addressed through working groups/initiatives and cover issues such as: level busts, airspace infringements and modelling of class G airspace utilisation. In addition to these issues, EUROCONTROL data suggests that a significant proportion of Airborne Collision Avoidance System Resolution Advisories (ACAS RAs) are not responded to correctly, which supports the need for a review of the effectiveness of flight crew training in this area. Desired Safety Outcome: Reduce the risk of midair collisions associated with incorrect responses to ACAS RA warnings. more
Ground Handling
Ground handling safety is managed through the Ground Handling Operations Safety Team (GHOST). GHOST is a group whose aim is to work with the UK aviation industry, organisations and groups worldwide to develop strategies to mitigate the safety risks from ground handling and ground support activities in the UK and elsewhere. With the exception of dangerous goods, ground handling activities are currently not directly regulated in the UK. Occurrences classified under the ground handling banner are numerous and varied. The majority are classified as low risk. However, those with the potential to cause the greatest harm to aircraft safety are loading errors and serious collisions between vehicles and aircraft with resulting damage that remains undetected prior to flight. Desired Safety Outcome: Reduce the risk associated with loading errors involving UK aircraft or at UK aerodromes.
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OVERVIEW
Safety Plan 2011/13
Key Capability Issues

One of the target outcomes from the CAA Strategic Plan is that, the UK aviation industry and the CAA will have measurably increased capability and performance in Safety Management, Human Factors and Just Culture, and demonstrated the benefits in terms of risk reduction. Improved CAA capability in these areas will translate to more effective, efficient and proportionate
Fire
The majority of aircraft fire incidents occurred in galleys, passenger and toilet areas but these were determined to be relatively low risk and unlikely to progress to a catastrophic accident. However, hidden area fires, although relatively infrequent, have a far greater potential for a catastrophic outcome. Most of the aircraft fires associated with fatal accidents occurred during the post-crash sequence and it would be more effective to address the causes of crashes (e.g. runway excursions) rather than make aircraft more tolerant to post-crash fire. Nevertheless, the CAA should maintain the focus on the effectiveness and efficiency of post-crash fire response whilst continuing to review new technologies and developments in emergency planning and enhanced fire-fighting. Desired Safety Outcome: Reduce the risk of hidden area fires occurring. more
oversight of the industry it regulates. The CAA will work with industry to help organisations embed, where appropriate, best practice in these capability areas into their own safety management processes. As an example, to most effectively identify and understand safety risks in the aviation system, the CAA will work with industry to extract the potential of data sources such as Flight Data Monitoring for flight operations related issues and Maintenance Error Management Systems for maintenance error.
Safety Management Systems (SMS)

Desired Capability Outcome: Improve the safety performance of organisations through the implementation of effective SMS and the CAAs capability to assess the effectiveness and safety performance of an organisations SMS. more
Integrated Safety Risk Management Process

Desired Capability Outcome: Develop a new Integrated Safety Risk Management Process to allow more effective monitoring and management of aviation safety risk by the CAA and industry. more
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OVERVIEW
Safety Plan 2011/13
Strategy for Human Factors (HF)

Specific HF-related actions are included throughout this Plan (e.g. pilot monitoring skills, HF aspects of airspace infringements and HF aspects of ground handling safety). However, a comprehensive review of human performance is underway to provide strategic direction for future HF work. This will include
Continuing Airworthiness
Desired Capability Outcome:
those factors that shape and support human performance on a day-to-day basis. Desired Capability Outcome: A better understanding of human performance, limitations, attitudes and behaviours to drive the practical application of Human Factors principles in reducing risk within the aviation safety system. more
Just Culture
Desired Capability Outcome: To achieve a balance between the interests of safety (e.g. protection of safety information) whilst not tolerating recklessness, and to achieve improvements in the open reporting of safety occurrences in parts of the industry where it is currently lacking. more
Improve the CAAs capability to extract intelligence from all sources of airworthiness-related safety data so that the associated risks are better understood and the most effective actions to mitigate them can be identified and implemented. more
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OVERVIEW
Safety Plan 2011/13
Fatigue Risk Management Systems (FRMS)

Desired Capability Outcome: Deliver effective regulatory oversight of fatigue management using FRMS techniques and metrics, proportionate to the size and complexity of the operational environment. To ensure that safety critical workers are able to operate at an effective level of alertness for all normal and abnormal circumstances. more
Total System Threats

The volcanic ash crisis of 2010 was an example of a low probability but high-impact event that affected the total aviation system. A review of lessons learnt from this event revealed that one of the CAAs strengths during the crisis was its ability to draw upon internal expertise based on a long involvement in relevant issues and previous incidents. The need to retain such capability is reflected in the CAA Strategic Plan, together with the need for continued improvement in the CAAs expertise, plans and processes for crisis management, and the ability to better identify and prevent or prepare for rare but high-impact events that affect the total aviation system. more
Performance-Based Oversight
Desired Capability Outcome: Deliver effective regulation in a manner and at times which have the greatest impact on preventing significant aviation losses. Facilitation of proportionate, targeted and consistent regulation. more
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OVERVIEW
Safety Plan 2011/13
Business Aviation
The Business Aviation sector by its very scope and diversity of operations is different to commercial air transport and as a result there are specific challenges to be acknowledged. Thus the Business Aviation Safety Partnership (BASP) was established not because Business Aviation is deemed unsafe but
Large Public Transport Helicopters

The CAA has been actively involved with the offshore oil and gas industry in helicopter safety for over 30 years. The focal point for helicopter safety issues is the Helicopter Safety Steering Group (HSSG), which was formed in June 2010 with the aim of proactively identifying and addressing cross-industry issues around helicopter safety, related to helicopter operations in the UK offshore oil and gas industry. Desired Safety Outcome: Reduce the Large Public Transport Helicopter accident rate through improvements in helicopter airworthiness, operational safety and safety of offshore helidecks.
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because it was recognised that a more
General Aviation (GA)

Whilst the main focus of this Safety Plan is on large commercial air transport, the CAA remains committed to working with industry to improve GA safety in a proportionate manner. The CAA continues to discuss safety concerns on GA matters through the General Aviation Strategic Forum and the General Aviation Consultative Committee. The CAA has additionally committed to a wider review of the Regulatory Approach to Recreational Aviation. This will involve working closely with industry and EASA, to identify and act on opportunities to adopt a different, more proportionate approach, while ensuring that the key safety issues related to this community are addressed. Desired Safety Outcome (1 of 3): Reduce the risk of mid-air collisions involving GA aircraft.
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tailored approach to this sector was warranted. The BASP is a joint CAA/industry partnership that takes a holistic approach in seeking to incrementally improve business aviation safety and to reduce the involvement of business jet aircraft in serious events. The BASP Deliverables Document facilitates management of BASP work and details activity in terms of: regulatory work; direct engagement with aircraft operators, airfield operators and training providers; and the development and distribution of safety awareness and guidance material. BASP will ensure close links are maintained with the CAA Flight Operations Inspectorate when dealing with business aviation safety matters. Desired Safety Outcome (1 of 3): Reduce the number of and relative contribution to level busts in UK airspace by business jets. more
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1. OUTLINE
Safety Plan 2011/13
1. Outline
1.1 CAA Safety Plan and CAA Strategic Plan
The CAA Strategic Plans objective for enhancing aviation safety is: To enhance aviation safety performance by pursuing targeted and continuous improvements in systems, culture, processes and capability The CAA Strategic Plan describes the UK State Safety Programme (SSP), which will include the CAA Safety Plan, as the key mechanism to drive improved safety performance across all sectors of the industry. The SSP and CAA Safety Plan will: n focus on delivery of improved safety outcomes; n include clear high-level goals, co-developed with the aviation community; n utilise improved techniques and systems of safety data collection and risk analysis; n use appropriate leading and lagging indicators to ensure safety performance is measured. The indicators will be able to track both precursors to accidents and maturity (e.g. measures of the adoption of safety management and culture change); n include both continuous monitoring and horizon scanning to identify potential hazards from a State-wide perspective; and n include safety promotion as a key method for safety improvement.
1.2 CAA Safety Plan and Industry

This Plan has been developed in partnership with industry through earlier consultations and the Safety Conference in October 2010. Much work has already been done by the Significant Seven task forces for which industry has played an essential part. Whilst the Safety Conference focused primarily on commercial operations, the identification of safety risks within general aviation and other sectors of the industry, and the associated actions, have not been ignored. The work following on from the Strategic and Regulatory Reviews of General Aviation in 2006 has highlighted a number of safety issues. For the actions identified in this Plan to be progressed, industry involvement remains essential. For example, to produce best practice guidance for flight deck monitoring, the intention is to develop this with industry through the Loss of Control Action Group. The outcomes of actions contained in this Plan will be disseminated more widely through existing industry liaison groups. Throughout this process, the CAA will work with industry to determine what it can do, from a regulators point of view, to best help industry implement these outcomes as part of their own safety plans.
European level. The alignment between this Safety Plan and the EASP is shown for relevant Safety Actions in Sections 3 and 4. The CAA also remains committed to supporting the European Strategic Safety Initiative (ESSI), and specifically each of the three pillars: European Commercial Aviation Safety Team (ECAST), European Helicopter Safety Team (EHEST) and European General Aviation Safety Team (EGAST).
1.4 Way Forward

Although this Safety Plan covers the period 2011 to 2013, it will be reviewed annually and updated where necessary to ensure that the right risks have been identified and that the right actions are being taken to mitigate these risks.
1.3 European Aviation Safety Plan

Through this Safety Plan, the CAA aims to both support and influence the new European Aviation Safety Plan (EASP), so ensuring that the UK plays a significant part in safety planning at a
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2. SAFETY FRAMEWORK
Safety Plan 2011/13
2. Safety Framework
2.1 Significant Seven and Capability
The actions contained in this Safety Plan fall into two types: those to address the seven foremost aviation safety issues (Significant Seven Safety Issues), and those to improve capability in important individual subject areas such as Continuing Airworthiness and Human Factors (Key Capability Issues). The CAA Significant Seven safety issues were identified in 2009 following analyses of global fatal accidents and high-risk occurrences involving large UK commercial air transport (CAT) aeroplanes. The former involved the systematic analysis, by a multi-disciplinary team of experts, of more than 1,000 global fatal accidents dating back to 1980; identifying causal and circumstantial factors and accident consequences. The latter involved a similar indepth analysis of more than 100 high-risk Mandatory Occurrence Reports (MORs) specifically involving UK aircraft. For each of these issues, joint CAA/industry task forces were created to study the safety issue in-depth and make recommendations on how their risk could be mitigated. Further information on the output for each of the task forces can be seen in CAA Paper 2011/03 CAA 'Significant Seven' Task Force Reports, which is available for download on the CAA website. Task force outputs were consolidated and prioritised to identify the key desired safety outcomes, actions to achieve them, measures to track safety performance and effectiveness of the actions to be taken. The output was then shared with industry and debated at a Safety Conference in October 2010. The key outcome from this Conference was the clear prioritisation of loss of control and runway safety (primarily runway excursions) over the other safety issues. Also identified was the need to better understand human factors and particularly their contribution to the root causes of accidents, the importance of a good organisational culture as a prerequisite for a good safety culture and the need to join-up Safety Management Systems (SMS) across all aviation disciplines. These priorities are reflected in the actions contained in this Plan. The actions for large CAT aeroplanes are categorised in the framework, in Table 1, as the Significant Seven safety issues and the key capabilities that the CAA and industry need to possess to most effectively manage these safety issues. There are also actions to cover business aviation, large public transport helicopter operations and general aviation. More information on the associated actions, deliverables, timescales and performance indicators is contained in Section 3. The Significant Seven is, of course, just a starting point. The risks to the total aviation system in the UK need to be better understood, and each individual and organisation in the system has a unique risk profile based on the activity it or they undertake within the system. To continue to improve aviation safety in the UK, there will need to be a move to a performancebased oversight model that is able to address risks in a transparent way throughout the whole UK aviation system and is able to demonstrate that effective management is in place. At the system level, this is dealt with by the SSP. This document deals with those risks that can be managed directly by the CAA in partnership with industry.
2.2 Monitoring Safety Actions Table 1: Safety Framework Significant Seven Safety Issues (in priority order)
1. Loss of Control 2. Runway Excursion 3. Controlled Flight into Terrain 4. Runway Incursion 5. Airborne Conflict 6. Ground Handling 7. Airborne and Post-Crash Fire All Safety Plan action items have expected safety benefits and Safety Performance Indicators (SPIs) to enable the continuous monitoring of the impact of the action taken. It is crucial to the success of the Plan to monitor systematically and routinely the safety performance of the UK aviation system in close cooperation with industry. The following arrangements will provide this monitoring capability.
2.3 Governance of Safety Plan

A small high-level group of CAA, DfT and industry management will oversee, steer and challenge the progress of the SSP, including the Safety Plan, and ensure that it continues to deliver. The first meeting will be held in September 2011. A wider CAA/industry group will be invited to review progress and give feedback annually.
Key Capabilities Required for the Total Aviation System

n Integrated Safety Risk Management Process n Continuing Airworthiness n SMS n Just Culture n Human Factors n Performance-Based Oversight n Fatigue Risk Management Systems n Total System Threats
2.4 Communication with Stakeholders

The CAA will regularly use existing consultative committees/ liaison groups to keep industry updated with progress on actions and to maintain high levels of industry engagement, which is essential for the successful delivery of the Plan and enhancement of safety. The CAA may also periodically organise conferences to consider whether the current risks are still the priority, and the extent to which the actions are having the appropriate outcome, or to discuss subjects of specific interest.
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2. SAFETY FRAMEWORK
Safety Plan 2011/13
2.5 Safety Performance Indicators

As part of the Integrated Safety Risk Management Process (ISRMP) project, a full suite of SPIs, utilising various data sources, will be developed by the CAA in partnership with industry. These SPIs will include both leading and lagging indicators (including precursor events), and will expand on the SPIs described in this document. SPI development will include measures required to monitor the performance of UK Air Navigation Services as part of the UK National Performance Plan (NPP). A Network of Analysts (NoA) is being created to facilitate development of these SPIs, and will comprise of safety analysts from the CAA and industry. The NoA will review the quality and consistency of data currently submitted as MORs, establish the necessary data streams and coordinate analyses of common interest across the industry.
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3. SAFETY ACTIONS [SIGNIFICANT SEVEN]
Safety Plan 2011/13
3. Safety Actions
3.1 Significant Seven Safety Issues
This section describes actions to mitigate specific safety risks to large CAT aeroplanes, which are considered to have the greatest potential for improving safety. They are the result of issues raised through detailed study of the key safety risks by the joint CAA/industry Significant Seven task forces and validated through consultation with industry. They also include other major projects that were underway prior to initiation of the task forces. Implementation of these actions and realisation of their benefits will involve a collaborative effort between the CAA and industry.
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Safety Plan 2011/13
3.1.1 Loss of Control
Whilst technology has played a significant part in mitigating the risk of other types of accident (e.g. GPWS for CFIT and ACAS
Actions to Achieve Desired Safety Outcome: 1. CAA, in partnership with industry, to commission independent research into current best practice in monitoring and associated training delivery methods, and to determine whether improvements are necessary. This research will cover UK and international aviation, and other industries, where appropriate. 2. If existing best practice is deemed to be insufficient, then CAA, in partnership with industry, to develop new best practice including a gap-analysis from the current to the new state, and guidance on the best way to deliver training and how to assess its effectiveness. 3. CAA to disseminate this best practice to industry, promote its use by EASA and educate its Flight Operations Inspectorate so that it can most effectively audit operators for compliance with this best practice where appropriate.
Deliverables and Dates: 1. Report produced on current best practice in monitoring and associated training delivery methods. Specific attention will be paid to monitoring of low airspeed as safety data highlights this as a particular issue. November 2011
Expected Safety Benefit:

An increased focus on the monitoring role within a multi-crew flight deck would be expected to improve the likelihood of the recognition and avoidance of potential loss of control events. Key Performance Indicators: Action success and overall loss of control risk will be tracked using the following key performance metrics:
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SIGNIFICANT for mid-air collision), advances

in technology and automation
may not have been fully supported by corresponding changes in training, and this may lead to an increased risk of loss of control events. Training and testing pilot competence currently focuses on their handling skills rather than monitoring skills. However, safe operation of complex and highly automated aircraft relies on each pilot effectively monitoring the aircraft systems, automation and the other pilots actions. Safety improvement activities to mitigate the risk of loss of control will therefore focus on the following three issues: n training and assessment of pilot monitoring skills; n use of aircraft automation; and n maintenance of manual flying skills. Desired Safety Outcome (LOC1): Reduce the risk of loss of control occurrences and serious incidents in which inadequate or ineffective monitoring by the flight crew was a factor. The safe operation of complex and highly automated aircraft relies on effective monitoring of the aircraft systems, automation and the other pilots actions. However, there is currently minimal guidance on the training and assessment of pilot monitoring skills.
2. a) Gap-analysis report produced. February 2012 b) CAA best practice guidance document produced on training and assessment of pilot monitoring skills. August 2012 3. a) Dissemination of best practice guidance document and education of CAA Flight Operations Inspectorate completed. November 2012 b) CAA Flight Operations to disseminate monitoring training and assessment best practice to industry, promote its use with EASA and undertake oversight activity to ensure that operators appropriately consider the principles of best practice in their own risk mitigation activities. January 2013
n Loss of control events. n Stick-shake and alpha floor events. n Take-off configuration warnings. n Low speed during approach events. n Low speed during cruise events. n Proportion of UK aircraft operators to have implemented and actively monitor loss of control precursor measures. n Proportion of UK AOC holders to have implemented pilot monitoring skills training as per new best practice guidance document. n Proportion of pilots employed by UK AOC holders that have received pilot monitoring skills training as per new best practice guidance document. Safety Outcome Owner: n CAA/Flight Operations Liaison Group (FOLG) Loss of Control Action Group for actions 1, 2 and 3a. n CAA Flight Operations Inspectorate (Aeroplanes) for action 3b. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER4.6 and 4.7.
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Safety Plan 2011/13
Desired Safety Outcome (LOC2): Reduce the risk of loss of control occurrences and serious incidents in which inadequate or ineffective use of aircraft automation by the flight crew was a factor. Analysis of accidents and high-severity occurrences identifies instances when the misuse, or inappropriate use, of automation has led, either directly or indirectly, to a loss of control condition.
Actions to Achieve Desired Safety Outcome: 1. CAA, in partnership with industry, to review the finalised FAA report on their study of crew interaction with flight deck automation and the Cranfield University research report into training for automation, distil the key issues, identify the key priorities for action and decide on the need for further research. 2. CAA, in partnership with industry, to act on the findings of the review.
Deliverables and Dates: 1. a) Report produced on review of FAA study and Cranfield University research. January 2012 b) Workshop held with industry to discuss findings of review and to identify the top-three key priorities for action. March 2012 2. Plan developed for the implementation of actions to mitigate the risk of the top-three findings from the review. May 2012
Expected Safety Benefit: A modified methodology for the training of automation in complex and highly automated aircraft would better equip pilots to identify and avoid loss of control situations. This training methodology would place an increased focus on the holistic use and management of the automation rather than training the individual functionality of the automation. Key Performance Indicators: Action success will be tracked using the following key performance metrics: n Loss of control events. n Stick-shake and alpha floor events. n Take-off configuration warnings. n Low speed during approach events. n Low speed during cruise events. Safety Outcome Owner: n CAA/FOLG Loss of Control Action Group. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER4.6 and 4.7.
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Safety Plan 2011/13
Desired Safety Outcome (LOC3): Reduce the risk of loss of control occurrences and serious incidents in which inadequate or ineffective manual flying skills by the flight crew was a factor. A lack of manual flying skill has been identified as a causal factor in a number of loss of control events that have led to an accident or high-severity occurrence. In particular, it has been identified that this lack of manual flying skill becomes critical when the use of automation is either inappropriate or not possible. Situations occur when manual flying skills are key to the safe recovery of an aircraft flight path disturbance which, without competent intervention, might otherwise become catastrophic.
Actions to Achieve Desired Safety Outcome: 1. CAA to disseminate the Jet Upset Recovery Training Aid Tool and its associated DVD to all UK commercial pilots.
Deliverables and Dates: 1. Jet Upset Recovery Training Aid Tool and associated DVD (once available) distributed to all UK commercial pilots. December 2011
Expected Safety Benefit: In situations where a pilot had inadvertently encountered a situation that could lead to a loss of control, it may be imperative for the pilot to possess the key manual flying skills necessary for recovery. These skills need to be taught and then practised on a regular basis such that they are April 2012 maintained to a competent and appropriate level. Key Performance Indicators: Action success will be tracked using the following key performance metrics: n Loss of control events. December 2012 n Stick-shake and alpha floor events. n Take-off configuration warnings. n Low speed during approach events. n Low speed during cruise events. n Proportion of UK AOC holders to have implemented training using the Jet Upset Recovery Training Aid. n Proportion of pilots employed by UK AOC holders that have received training based on the Jet Upset Recovery Training Aid. Safety Outcome Owner: n CAA Flight Crew Standards for action 1. n CAA Group Safety Services for action 2. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER4.6 and 4.7.
2. CAA to investigate the feasibility of incorporating the manual flying skills measuring methodology, developed through research with Cranfield University, into a Flight Data Monitoring (FDM) tool, and, if found practical, to then implement and exercise it in an airline trial. This methodology currently applies specifically to a simulator exercise to perform a singleengine ILS approach. However, if the trial is successful, then future work will investigate if extensions to the tool could be used for other scenarios.
2. a) Feasibility report produced.
b) If feasibility is positively demonstrated, then methodology incorporated into an FDM programme and trialled with at least one UK airline.
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Safety Plan 2011/13
3.1.2 Runway Excursion
The key factors in avoiding a runway overrun or excursion were found to be landing within the touchdown zone
Actions to Achieve Desired Safety Outcome: 1. CAA, in partnership with industry, to develop, implement and monitor measures of unstable/destabilised approaches as part of a wider suite of runway excursion precursor measures. 2. CAA, through the Flight Operations Inspectorate operator oversight programme, to check that UK operators monitor for unstable/destabilised approaches and, where appropriate, mitigate their risk. 3. CAA, in partnership with industry, to review air traffic control (ATC) procedures and improve ATC Officer (ATCO) training, to minimise the likelihood of ATC contributing to unstable approaches. This will involve liaison with the NATS Safety Partnership Agreement work on unstable approaches.
Deliverables and Dates: 1. Unstable/de-stabilised approach measures developed and implemented. April 2012
Expected Safety Benefit: Reduction in the number of unstable/de-stabilised approaches that continue to a landing will reduce the risk of aircraft touching down at the incorrect speed and/or position with a corresponding reduction in the risk of running off the side or end of the runway.
SEVEN
SIGNIFICANT in the correct configuration

and at the correct speed,
and if this could not be ensured, then flying a go-around. Other factors that increased the risk included provision of incomplete runway contamination data to pilots, failure to provide compliant runway surface friction characteristics and inadequacy of safety areas surrounding the runway. Safety improvement activities to mitigate the risk of runway excursion will therefore focus on the following three issues: n reducing unstable/de-stabilised approaches; n improving information broadcast to pilots on expected braking action on contaminated runways; and n improving safety areas around runways. As well as implementing the following actions, the CAA will also support the development of the European Action Plan on the Prevention of Runway Excursions (EAPPRE), a task led by EUROCONTROL in cooperation with the European Commercial Aviation Safety Team (ECAST). Desired Safety Outcome (RE1): Reduce the risk of runway excursions associated with unstable/de-stabilised approaches.
2. Monitoring of unstable/de-stabilised approaches and, where appropriate, implementation of risk mitigation checked for UK operators. Ongoing 3. a) Unstable approach awareness included in ATCO Training for Unusual Circumstances and Emergencies (TRUCE). Ongoing b) Pilots attending TRUCE training. Ongoing c) Repository of information on flight deck awareness for controllers developed in partnership with industry. December 2011 Key Performance Indicators: Action success and overall runway excursion risk will be tracked using the following key performance indicators: n Runway excursion and overrun events. n Unstable/de-stabilised approaches: all and proportion that continue to landing. n Deep landing events. n High-speed touchdown events. n High-speed rejected take-off events. n Proportion of UK aircraft operators to have implemented and actively monitor runway excursion precursor measures. n Proportion of air traffic controllers to have completed unstable approach awareness training through TRUCE. n Number of pilots to have attended a TRUCE training session. Safety Outcome Owner: n CAA Group Safety Services for action 1. n CAA Flight Operations Inspectorate (Aeroplanes) for action 2. n CAA Air Traffic Standards for action 3. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER1.5 and 1.6.
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Safety Plan 2011/13
Desired Safety Outcome (RE2): Introduce capability for aerodrome operators to provide meaningful data to pilots concerning expected braking action on contaminated runways.
Actions to Achieve Desired Safety Outcome: 1. CAA to support and influence efforts to standardise International (ICAO) and European (EASA) standards and recommended practices associated with both runway braking action and aircraft performance so that unambiguous and easy to use information is passed to flight crew. This will be used to enhance the pilots decisionmaking process when calculating take-off and landing distances required.
Deliverables and Dates: 1. a) Updated policy and guidance on winter operations disseminated to UK industry, and used to influence EASA aerodrome requirements and guidance. October 2011 b) Winter Information Group (WIG) Winter Runway Assessment Trial: report and recommendations produced. September 2012
Expected Safety Benefit: n Consistent and relevant information promulgated to enable flight crews to be better equipped to anticipate the braking action expected on contaminated runways. Key Performance Indicators: Action success will be tracked using the following key performance indicators: n Runway excursion and overrun events with runway contamination as a contributory or causal factor. n Take-off/landing events involving loss of aircraft directional control caused by contaminated runway surface. n Proportion of UK licensed aerodromes using new reporting criteria for runway surface condition. n Proportion of UK licensed aerodromes correctly carrying out an agreed runway maintenance friction testing regime as per CAP 683. Safety Outcome Owner: n CAA Aerodrome Standards. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER1.2, 1.3, 1.5 and 1.6.
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Safety Plan 2011/13
Desired Safety Outcome (RE3): Improve the safety areas around runways.
Actions to Achieve Desired Safety Outcome: 1. CAA to encourage UK licensed aerodromes with the minimum compliant Runway End Safety Area (RESA) to review runway excursion risk factors regularly and consider alternative and additional mitigation measures.
Deliverables and Dates: 1. RESA risk assessments conducted by UK licensed aerodromes with minimum compliant RESAs. December 2012
Expected Safety Benefit: In moving away from compliance-based thinking, licensed aerodromes will have fully considered the risks of runway excursion and taken appropriate actions to mitigate such risks. Key Performance Indicators:
2. CAA to work to influence appropriate drafting of objective-based requirements in EASA and ICAO aerodrome regulations.
2. Objective-based requirements and associated guidance material for overrun safety areas included within EASA and ICAO aerodrome requirements. March 2012
Action success will be tracked using the following key performance indicators: n Proportion of UK licensed aerodromes with minimum compliant RESAs that have implemented additional mitigation measures. Safety Outcome Owner: n CAA Aerodrome Standards. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER1.2, 1.3, 1.5 and 1.6.
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Safety Plan 2011/13
3.1.3 Controlled Flight into Terrain (CFIT)
CFIT risk was found to be greatest during nonprecision approaches (NPAs) and the most common
Actions to Achieve Desired Safety Outcome: 1. CAA to run an education campaign aimed at operators, highlighting the safety and cost benefits of Approach with Vertical Guidance (APV) type approaches. 2. CAA to investigate implementation of APVtype approaches in USA to identify factors that could help accelerate implementation in UK/Europe and feed this back to the ongoing European work in this area. 3. CAA to simplify the process for APV approval. 4. CAA to encourage operators to become APV approved and aerodrome operators to make provisions.
Deliverables and Dates: 1. Information brochure jointly produced by CAA and NATS and disseminated to all aircraft and aerodrome operators. September 2011 2. Report presented to EASA/EUROCONTROL. December 2011
Expected Safety Benefit: Reduction in the high proportion of CFIT-related incidents/accidents that occur during NPAs. Key Performance Indicators: Action success and overall CFIT risk will be tracked using the following key performance indicators: n (E)GPWS warnings (by mode and whether genuine, nuisance or false). n Unstable/de-stabilised approaches: all and proportion that continue to landing. n Significant deviation below glideslope events.
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SIGNIFICANT causes were: descent below

decision/safety heights
without appropriate visual reference, inadequate monitoring and lack of positional awareness. Terrain Awareness and Warning System warnings were an effective mitigation but relied on correct flight crew response, upto-date terrain databases and software, and the most accurate source of position information feeding into them. Desired Safety Outcome: Reduce the risk of serious incidents that occur during NPAs, through enhancements in technology and training.
3. Simplified approval process developed. December 2011 4. Programme of safety promotion road-shows to aircraft and aerodrome operators implemented. March 2012
n Gross position error events. n Deviation below minimum safety altitude events. n Proportion of UK aircraft operators to have implemented and actively monitor CFIT precursor measures. n Number of APV-type approaches published in the UK AIP compared with traditional NPAs. n Number of APV-type approaches at EU and thirdcountry aerodromes, which are UK operator destinations. n Proportion of relevant UK fleet approved for APVtype approaches. n Proportion of approaches flown by UK operators, which have some form of vertical guidance. Safety Outcome Owner: n CFIT Task Force. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER3.4 and 3.5.
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Safety Plan 2011/13
3.1.4 Runway Incursion
Runway incursions are managed through the Runway Incursions Steering Group (RISG), a group that
Actions to Achieve Desired Safety Outcome: 1. CAA to audit and support all UK licensed aerodromes to, through their Local Runway Safety Team (LRSTs), review, identify and address infrastructure and communication issues such as taxi patterns, signage and complex RT procedures; and that they develop appropriate mitigations where appropriate (e.g. publication of runway hotspots). 2. CAA, in cooperation with EUROCONTROL, EASA and ICAO, to promote the development and implementation of technologies designed to prevent runway incursions.
Deliverables and Dates: 1. LRSTs in place, where appropriate, and working effectively with based and visiting operators to manage the runway incursion risk. Improved and more effective communication between local stakeholders on runway incursion issues. April 2012
Expected Safety Benefit: n Will enable all parties to gain a better understanding of the issues that affect each other, and this will enable a partnership approach to robust resolution of the issues. n Will ensure that LRSTs are providing meaningful and useful output based on local risks. Key Performance Indicators: Action success and overall runway incursion
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SIGNIFICANT has been able to build an

excellent working relationship
with industry and stakeholders by working closely together. Continued engagement with industry will help to see a reduction in the number of runway incursions by UK registered aircraft, by ground vehicles and at UK aerodromes. The RISG is represented on the EUROCONTROL Runway Incursion Prevention Working Group and has contributed to the development of the revised European Action Plan for the Prevention of Runway Incursions version 2.0 (EAPPRI2). One of the key actions to mitigate the risk of runway incursions will be the promotion of recommendations from EAPPRI2 to industry. Desired Safety Outcome: Reduce the risk of runway incursions at UK licensed aerodromes.
2. a) Proposal tabled at ICAO Runway Safety Symposium that ICAO should ensure coordinated development of requirements for runway safety technologies to ensure a globally consistent service to aerodrome users, interoperability and avoid duplication of effort. May 2011 Action Completed: This was raised and tabled for further discussion by ICAO. b) Work commissioned to define a workable runway incursion prevention technology, with a view to promoting its development to the international community. April 2012 c) Investigation of new runway incursion prevention procedures completed. April 2012
risk will be tracked using the following key performance indicators: n Runway incursions at UK aerodromes or involving UK operators broken down by severity grade. n Proportion of UK licensed aerodromes that have implemented recommendations from and/or audited themselves against EAPPRI2. n Proportion of UK licensed aerodromes with an LRST that have been audited for success. Safety Outcome Owner: n CAA Aerodrome Standards for actions 1, 3 (aerodrome part) and 4. n RISG for action 2. n CAA Air Traffic Standards for action 3 (ANSP part). n CAA Flight Operations for action 3 (AOC part). Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER5.1, 5.2, 5.4 and 5.5.
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Safety Plan 2011/13
3.1.4 Runway Incursion
Actions to Achieve Desired Safety Outcome: Continued 3. CAA to promote recommendations from the EUROCONTROL work on EAPPRI2 to UK industry.
Deliverables and Dates: Continued 3. a) Information Notice on EAPPRI2 disseminated to all UK licensed aerodromes, UK ANSPs and UK AOC holders. June 2011 Action Completed: Information Notice IN 2011/51 issued on 17 June 2011. b) Implementation of EAPPRI2 recommendations by UK licensed aerodromes, UK ANSPs and UK AOC holders, where appropriate, checked at subsequent audits. June 2012
4. CAA, in cooperation with industry, to implement new standards and provide guidance on airside driver training.
4. Strategy, standards and guidance for airside driver training developed and implemented in conjunction with industry. December 2011
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Safety Plan 2011/13
3.1.5 Airborne Conflict
Many of the risks associated with airborne conflict were already subject to ongoing work by groups/initiatives
operations. Safety improvement work on infringements is carried out under the auspices of the Airspace Infringement Working Group (AIWG), some of whose key activities are described below, followed by those for airspace. AIWG n Provide guidance to flying instructors on navigation training priorities within training syllabi if there is no scope for syllabus change. n Improve understanding of Human Factors aspects of infringements. n Train pilots what to do if they infringe (i.e. pilot responsibilities at the moment when they believe they have infringed). n Develop guidance on the content of instructor seminars. n Explore the possibility of greater electronic conspicuity of aircraft.
demand, balances the needs of all users and mitigates the impact of aviation on the environment (see http://www.caa.co.uk/fas). Implementation of the FAS by the UK aviation industry will enable, amongst other things, the following safety outcomes: n Performance based navigation that allows routes to be flown more accurately and consistently. n Building flexibility and resilience into the system reduces the occurrence of pinch points and high-risk situations. n New communications, navigation and surveillance technology awareness of users and controllers. n Simplification of the airspace structure and classification reduces potential for errors, infringements and level busts. Delivery of the Strategy, including its safety benefits, will be ensured through continued
focussed on safety issues that were not already covered. One of their main conclusions was that the most effective barrier in resolving airborne conflicts was the correct following of ACAS Resolution Advisories (RAs). However, EUROCONTROL data suggests that a significant proportion of ACAS RAs are not responded to correctly, which supports the need for a review of the effectiveness of flight crew training in this area. The following actions address this issue.
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SIGNIFICANT prior to the task force

initiative starting. These key
groups/initiatives and their associated activities are listed below. Level Bust Working Group (LBWG) The LBWG is co-chaired by the CAA and NATS and key activities include: n Roll-out of the Barometric Pressure Setting Advisory Tool (BAT) at London Terminal Control Centre to allow controllers to highlight incorrect altimeter setting to pilots. n Engagement and awareness activities with the business aviation community (see section 4.1 for specific actions). n Work with a UK operator on day-to-day flight deck measures (e.g. observations of detailed flight deck behaviours associated with altimeter setting) to monitor level bust risk. Airspace & Safety Initiative (ASI) The ASI is a joint CAA, NATS, Airport Operators Association, GA and Ministry of Defence effort to investigate and tackle the major safety risks in UK airspace (see http://www.airspacesafety.com). The ASI has working groups on Air Traffic Services Outside Controlled Airspace (ATSOCAS), infringements, airspace design and classification, equipment carriage, and off-route commercial
Airspace n Study and modelling of Class G airspace utilisation to better inform knowledge of airspace hotspots. n Replacement of Class F airspace (UK Advisory Routes). Future Airspace Strategy (FAS) The FAS aims to provide a policy structure to enable a modernised air traffic management system that provides safe, efficient airspace, that has the capacity to meet reasonable
support of the FAS work via the FAS Programme Board and partnership with the FAS Implementation Group. In addition to continuing to support these initiatives, the CAA will work more closely with ANSPs in the implementation of their safety plans, where relevant, particularly in areas of responsibility where the CAA has the ability to facilitate progress. Given the existence of many ongoing initiatives, the Airborne Conflict Task Force
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Safety Plan 2011/13
3.1.5 Airborne Conflict
Desired Safety Outcome: Reduce the risk of mid-air collisions associated with incorrect responses to ACAS RA warnings.
Actions to Achieve Desired Safety Outcome: 1. a) CAA to update its guidance material on ACAS training. b) CAA to liaise with ICAO to amend ICAO Doc 8168 Aircraft Operations to better cover ACAS training. 2. CAA to investigate and promote, where appropriate, the use of part-task/desktop additional training aids for ACAS training. 3. CAA to sample the quality of ACAS simulator training, establish the range of capabilities of devices to simulate realistic ACAS event scenarios and ensure that operators are aware of the potential of each simulator in this regard.
Deliverables and Dates: 1. a) AIC on ACAS training updated and published. December 2011 b) Recommendations to amend Doc 8168 submitted to ICAO. January 2012 2. Investigation report completed and promotion plan implemented. December 2011 3. Report on ACAS simulator training devices completed and advice disseminated to industry via the Senior Examiners Newsletter and the Type Rating Examiner Newsletter. March 2012
Expected Safety Benefit: Reduced risk of collision resulting from incorrect use of ACAS and enhancement of the final safety barrier to mid-air collision (other than providence). Key Performance Indicators: Action success and overall airborne conflict risk will be tracked using the following key performance indicators: n Loss of separation in UK controlled airspace. n Risk-bearing UK AIRPROX outside of controlled airspace. n Risk-bearing foreign AIRPROX involving UK aircraft. n ACAS RAs: all genuine RAs and proportion involving incorrect pilot response. n Level busts in UK airspace. n UK airspace infringements. n Proportion of UK aircraft operators to have implemented and actively monitor mid-air collision precursor measures. Safety Outcome Owner: n CAA Flight Operations ACAS Focal Point (with close liaison with the ASI ACAS Working Group). Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER2.8 and 2.9 (plus AER2.1 for work carried out by the AIWG).
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Safety Plan 2011/13
3.1.6 Ground Handling
Ground handling safety is managed through the Ground Handling Operations Safety Team (GHOST). GHOST is a
Actions to Achieve Desired Safety Outcome: 1. CAA, in partnership with industry, to develop loading error education material for promulgation to Ground Service Providers and airlines.
Deliverables and Dates: 1. DVD containing educational material promulgated to Ground Service Providers, airlines, pilots. The intended audience is anyone who may have an impact on the safe loading of aircraft and the intent is to raise awareness of the consequences of errors or in-attention. June 2011 Action Completed: Safety in the Balance DVD narrated by Captain Bruce Dickinson is available for download from the GHOST website and is also being distributed free of charge within the UK and overseas industry stakeholders. There is no copyright, so further copies can be made.
Expected Safety Benefit: n Increased awareness and competence leading to a reduction in human factors-related errors. n Increased industry cooperation and shared ownership of risks. n Increased internal monitoring, supervision and auditing to monitor and correct unsafe behaviours. Key Performance Indicators: Action success and overall ground handling risk will be tracked using the following key performance indicators: n Ramp occurrences broken down by process during which they occurred and their outcome. n Collisions involving vehicles and parked aircraft at UK reporting aerodromes. March 2011 n Collisions, near-collisions and conflicts involving vehicles and taxiing aircraft at UK reporting aerodromes. n Loading errors: all reported and those resolved before departure. n Late aircraft type changes. n Late turn-arounds or turn-arounds in less than the minimum scheduled time. Safety Outcome Owner: n GHOST for actions 1 to 4. December 2011 n CAA Dangerous Goods Office for action 5. Alignment with European Aviation Safety Plan: n Reference: Safety Actions AER5.9 and 5.10.
SEVEN
SIGNIFICANT group whose aim is to work

with the UK aviation industry,
organisations and groups worldwide to develop strategies to mitigate the safety risks from ground handling and ground support activities in the UK and elsewhere. With the exception of dangerous goods, ground handling activities are currently not directly regulated in the UK. Occurrences classified under the ground handling banner are numerous and varied. The majority are classified as low risk. However, those with the potential to cause the greatest harm to aircraft safety are loading errors and serious collisions between vehicles and aircraft with resulting damage that remains undetected prior to flight. Desired Safety Outcome: Reduce the risk associated with loading errors involving UK aircraft or at UK aerodromes. 2. CAA, in partnership with industry, to explore the human factors aspects of ground handling safety in depth.
2. a) UK Ground Handling (GH) Human Factors forum established. Action Completed: The GH forum was established in March 2011. Deliverables of the group are as outlined in the GHOST TORs for 2011, also available on the GHOST website. b) Recommendations presented to GHOST on how to promote internal open reporting systems, and how to improve awareness of and subsequent reporting of relevant ground handling incidents.
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Safety Plan 2011/13
3.1.6 Ground Handling
Actions to Achieve Desired Safety Outcome: Continued 3. CAA to act on outcome of review of internal auditing standards as well as airline and aerodrome oversight of third parties to determine whether enhanced or direct oversight of UK ground handling activities is necessary to significantly reduce GH incidents, and if so, how best it might be achieved. 4. CAA, in partnership with industry, to establish detailed scope for specific industry self-monitoring activities (initially aircraft loading) to provide an effective method for industry to identify organisational drift, including guidelines for establishing policy and procedure. Furthermore, establish investigative guidelines so that root cause can be truly determined. The following action is being run by the CAA Dangerous Goods Office: 5. CAA, in partnership with industry, to increase awareness and education with regards to the correct loading of electric mobility aids.
Deliverables and Dates: Continued 3. Paper presented to GHOST outlining key findings of the review and recommending an appropriate course of action. September 2011
4. Draft self-monitoring checklist produced for endorsement by GHOST and subsequent promulgation to industry. December 2011
5. a) Guidance published for industry stakeholders. September 2011 b) Liaise with Disabled Persons Transport Advisory Committee and guidance published for passengers. September 2011 c) UK experience shared with the Dangerous Goods European Liaison Group. December 2011
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Safety Plan 2011/13
3.1.7 Fire
The majority of aircraft fire incidents occurred in galleys, passenger and toilet areas but these were determined to be
Actions to Achieve Desired Safety Outcome: 1. CAA to raise fire safety awareness through a DVD/Internet training campaign to engineering and associated groups on the effects of fire/smoke events on aircraft caused by poor quality control/workmanship.
Deliverables and Dates: 1. DVD/Internet training aid produced. April 2012
Expected Safety Benefit: Improved workmanship will reduce the likelihood of poor maintenance practices causing hidden fires. Key Performance Indicators: Action success and overall fire risk will be tracked using the following key performance indicators: n Aircraft fires. n Aircraft smoke events. n Maintenance-related events involving aircraft wiring. n Number of viewings of Internet training material. Safety Outcome Owner: n CAA Airworthiness.
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SIGNIFICANT relatively low risk and unlikely

to progress to a catastrophic
accident. However, hidden area fires, although relatively infrequent, have a far greater potential for a catastrophic outcome. Most of the aircraft fires associated with fatal accidents occurred during the post-crash sequence and it would be more effective to address the causes of crashes (e.g. runway excursions) rather than make aircraft more tolerant to post-crash fire. Nevertheless, the CAA should maintain the focus on the effectiveness and efficiency of post-crash fire response whilst continuing to review new technologies and developments in emergency planning and enhanced fire-fighting. In addition to the action described below to address the risk of hidden area fires, the CAA collaborates extensively with the FAA and Transport Canada, together with EASA, on fire and cabin safety issues. Through formal agreements, both the FAA and Transport Canada support fire research studies in the UK, which focus on areas of mutual concern. The work is reported in international specialist meetings for materials flammability, fire systems and cabin safety detailed at http://www.fire.tc.faa.gov/. Desired Safety Outcome: Reduce the risk of hidden area fires occurring.
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3. SAFETY ACTIONS [KEY CAPABILITY ISSUES]
Safety Plan 2011/13
3.2 Key Capability Issues
One of the target outcomes from the CAA Strategic Plan is that, the UK aviation industry and the CAA will have measurably increased capability and performance in Safety Management, Human Factors and Just Culture, and demonstrated the benefits in terms of risk reduction. Improved CAA capability in these areas will translate to more effective, efficient and proportionate oversight of the industry it regulates. The CAA will work with industry to help organisations embed, where appropriate, best practice in these capability areas into their own safety management processes. As an example, to most effectively identify and understand safety risks in the aviation system, the CAA will work with industry to extract the potential of data sources such as FDM for flight operations related issues and Maintenance Error Management Systems (MEMS) for maintenance error.
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Safety Plan 2011/13
3.2.1 Integrated Safety Risk Management Process
Desired Capability Outcome: Develop a new Integrated Safety Risk Management Process to allow more effective monitoring and management of aviation safety risk by the CAA and industry.
Actions to Achieve Desired Capability Outcome: 1. Safety Risk Policy To review issues concerning practice, principles and priority: a) Develop safety risk policies and clarify the concept of an acceptable level of safety. b) Define safety risk as applicable for the CAA and UK. 2. Evidence Base To improve safety data and information collection/sharing: Evidence Base 1 MORS Database a) Complete the CAAs transition to the ECCAIRS occurrence reporting software. b) Define with CAA Safety Data and industry the level of reporting to MORS and agree the coding of occurrences (using the ECCAIRS taxonomy). Evidence Base 2 Data Streams c) Develop with industry a range of standardised FDM-based precursor measures and how they might be used to drive priorities. d) Develop with industry a range of safety performance indicators and how they might be used to drive priorities. e) Capture results from oversight audits, industry trends and alternative data sources (e.g. MEMS). Evidence Base 3 Exposure Data f) Maintain and improve utilisation data. g) Gather new measures of exposure (e.g. exposure to contaminated runways).
Deliverables and Dates: 1. Safety Risk Policy Safety risk policy defined and implemented. October 2011
Expected Safety Benefit: Improvements in the monitoring of UK safety performance so that intelligence can be provided to enable proportionate and timely action to be taken, to continuously improve safety. Key Performance Indicators: n Common risk classification framework used
2. Evidence Base The most effective way to collect and share safety data/information established. April 2012
by the CAA and industry. n Data streams and indicators established for all key safety issues. Capability Outcome Owner: n CAA Group Safety Services. Alignment with European Aviation Safety Plan: n Reference: Safety Actions SYS3.2, 3.4, 3.5, 3.6 and EME1.1.
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Safety Plan 2011/13
Actions to Achieve Desired Capability Outcome: Continued Evidence Base 4 Industry Networks h) Establish with industry a UK Network of Analysts to support the development of new data streams and performance indicators and to improve reporting standards/quality. 3. Safety Risk Processing and Assessment of Current Risks To improve the risk classification and analysis of aviation safety events, and the identification and assessment of current safety issues: a) Conclude the European/industry work in developing a common risk classification framework for aviation safety events and promote its use. b) Propose revisions to the ECCAIRS risk grading scheme. c) Develop risk modelling techniques based on the common risk classification framework. d) Develop The High Risk Events Analysis Team (THREAT) and Accident Analysis Group (AAG) to identify current safety issues. e) Further explore the potential of FDM and MEMS data to better identify current safety issues and to assess safety risk in the aviation system.
Deliverables and Dates: Continued
3. Safety Risk Processing and Assessment of Current Risks Common framework for the risk classification of aviation safety events, and a process to identify and assess current safety issues developed. April 2012
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Safety Plan 2011/16
Actions to Achieve Desired Capability Outcome: Continued 4. Safety Performance Monitoring and Identification of Future Risks To improve the identification of future/emerging safety issues, and to provide an improved safety performance monitoring function for CAA senior management, CAA technical divisions and industry: a) Further develop quarterly safety performance monitoring function. b) Develop new measures to continuously monitor safety trends. c) Define how to analyse results from oversight audits, industry trends, alternative data sources and horizon scanning. d) Establish a Statistics Group to review safety performance monitoring results. e) Improve the quantification and forecasting of safety risks.
Deliverables and Dates: Continued 4. Safety Performance Monitoring and Identification of Future Risks Full suite of SPIs to monitor safety performance for all key safety issues established and a process to identify future/emerging safety issues developed. June 2012
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Safety Plan 2011/13
3.2.2 Continuing Airworthiness
Desired Capability Outcome: Improve the CAAs capability to extract intelligence from all sources of airworthinessrelated safety data so that the associated risks are better understood and the most effective actions to mitigate them can be identified and implemented. Inherent in more effective regulatory oversight will be an improved understanding of priorities and spending regulator time in proportion with the risk to safety. This means obtaining the best possible intelligence about the nature and extent of risks in all areas including airworthiness. It may include better sharing of data and intelligence between companies and the regulator, and within the regulator, deeper analysis of available data (including identification of the root causes of airworthiness-related incidents), better prioritisation of findings according to safety relevance, better feedback to industry of generic issues and the ability to feed back the position of an individual company against the national distribution.
Actions to Achieve Desired Capability Outcome: 1. CAA to develop, in partnership with industry, methods to identify and implement analysis, prioritisation and data exchange on findings from CAA and industry audits to improve overall intelligence. This will focus on Continuing Airworthiness and, if successful, similar methods may be developed in other areas at a later date. 2. To enhance the sharing of continuing airworthiness information by improving the interface and working procedures with EASA. This will facilitate a performance-based approach to Type Liaison/Design Liaison activities. 3. Review Maintenance Error Management System (MEMS) policy and related application.
Deliverables and Dates: 1. a) Partnership meeting held with representatives of the UK Operators Technical Group (OTG). November 2011 b) Plan implemented for Improved Safety Intelligence on Continuing Airworthiness. December 2011 2. Establishment of a functional performancebased Type Liaison/Design Liaison process. This will streamline the areas covered and simplify/ standardise the reporting system. March 2012 3. a) Current MEMS requirements revised as required (following engagement with the UK MEMS Group). January 2012 b) Civil Aircraft Airworthiness Information and Procedures (CAAIP) updated and published to reflect the revisions to MEMS requirements. April 2012
Expected Safety Benefit: Improvements in the analysis of airworthinessrelated issues so that intelligence can be provided to enable proportionate and timely action to be taken, to improve safety. Key Performance Indicators: n Repeat audit findings (reduction in their number). n Industry requests for their performance against the national distribution. Capability Outcome Owner: n CAA Airworthiness for actions 1 to 3. n CAA Group Safety Services for action 4.
4. As part of the ISRMP project (see 3.2.1), further explore the potential of MEMS data to better identify airworthiness-related safety issues, particularly the HF aspects, and to assess their contribution to safety risk in the aviation system.
4. Plan implemented to make best use of MEMS data as part of the process for identifying and acting on safety risks. April 2012
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Safety Plan 2011/13
3.2.3 SMS
Desired Capability Outcome: Improve the safety performance of organisations through the implementation of effective SMS and the CAAs capability to assess the effectiveness and safety performance of an organisations SMS.
Actions to Achieve Desired Capability Outcome: 1. Hold industry workshops to help organisations understand SMS and implement effective systems. 2. Develop an assessment methodology that will assess the performance and the effectiveness of an SMS.
Deliverables and Dates: 1. Programme for industry workshops agreed. October 2011 2. a) SMS assessment methodology developed. December 2011 b) SMS maturity assessment model defined. December 2011 c) Methodology to evaluate risk assessments defined. December 2011
Expected Safety Benefit: Effective implementation of SMS will increase the safety performance of organisations leading to an increase in the overall safety performance of the aviation system in the UK, and this needs to be matched by the CAAs ability to assess the performance and effectiveness of an SMS. Key Performance Indicators: n Number of organisations that have fully implemented SMS before final transitional dates allowed by EASA regulations. n SMS maturity and effectiveness indices. n Proportion of relevant CAA staff appropriately trained, skilled and assessed against a April 2012 competency framework. Capability Outcome Owner: n CAA Group Safety Services. Alignment with European Aviation Safety Plan: n Reference: Safety Actions SYS2.5, 2.6, 2.7, 2.8, 2.9 and 2.10.
3. All appropriately selected CAA staff to have an appropriate level of competence to assess SMS and Human Factors Programmes within regulated organisations.
3. All appropriately selected CAA staff to have received training in the assessment and practical implementation of SMS.
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Safety Plan 2011/13
3.2.4 Just Culture
Desired Capability Outcome: To achieve a balance between the interests of safety (e.g. protection of safety information) whilst not tolerating recklessness, and to achieve improvements in the open reporting of safety occurrences in parts of the industry where it is currently lacking.
Actions to Achieve Desired Capability Outcome: 1. CAA to measure itself against the Just Culture metrics defined by the EC, EASA and EUROCONTROL (E3) Just Culture Task Force, and to act on any shortcomings.
Deliverables and Dates: 1. CAA to have measured itself against the Just Culture metrics defined by the E3 group and formulated a plan to address any shortcomings. December 2011
Expected Safety Benefit: To improve the safety reporting culture in industry so that more comprehensive safety data is available to enable a more reliable assessment of the safety risk to be made. This is essential for an effective SMS. Key Performance Indicators: n Effective Just Culture metrics developed. April 2012 n Improved occurrence reporting rates for organisations (including ratio of high-risk to lowrisk occurrences). April 2012 Capability Outcome Owner: n CAA Group Safety Services. Alignment with European Aviation Safety Plan: n Reference: Safety Action SYS3.3.
2. Develop a method of measuring Just Culture as part of the maturity of an organisations SMS.
2. Suitable method developed for use by the CAA.
3. Raise Just Culture awareness within CAA and with industry Accountable Managers emphasising the benefits to business of open reporting.
3. Just Culture awareness raised.
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Safety Plan 2011/13
3.2.5 Strategy for Human Factors (HF)
Specific HF-related actions are included throughout this Plan (e.g. pilot monitoring skills, HF aspects of airspace infringements and HF aspects of ground handling safety). However, a comprehensive review of human performance is underway to provide strategic direction for future HF work. This will include those factors that shape and support human performance on a day-to-day basis. Desired Capability Outcome: A better understanding of human performance, limitations, attitudes and behaviours to drive the practical application of Human Factors principles in reducing risk within the aviation safety system. Increasing complexity in aircraft design, operation and maintenance, including the integration of Air Traffic Management changes within the Single European Sky, may increase the risk of human error, which continues to be cited as the main cause or contributory factor(s) in at least 75% of all safety occurrences. Challenging commercial environments and a desire to reduce regulation expose people, processes and performance within the aviation safety system to even greater cumulative risk.
Actions to Achieve Desired Capability Outcome: 1. Carry out a comprehensive Review of Human Factors in Civil Aviation.
Deliverables and Dates: 1. Review of Human Factors in Civil Aviation completed. December 2011
Expected Safety Benefit: A commonly held understanding of Human Factors across the aviation community, specifically applied to mitigate individual and cumulative risks associated with a particular operation or environment within the aviation safety system. Key Performance Indicators: Objective competency-based standards for training and proportionate performance-based assurance assessment, together with maturity indices for Safety Management Systems. Capability Outcome Owner: n CAA Group Safety Services. Alignment with European Aviation Safety Plan: n Reference: Safety Actions HFP1.1 and 1.2.
2. Develop a UK Strategy for Human Factors in Civil Aviation, which will be offered to the European Human Factors Action Group (EHFAG) as the basis for a European Union equivalent.
2. UK Strategy for Human Factors in Civil Aviation published. February 2012
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Safety Plan 2011/13
3.2.6 Performance-Based Oversight
Desired Capability Outcome: Deliver effective regulation in a manner and at times which have the greatest impact on preventing significant aviation losses. Facilitation of proportionate, targeted and consistent regulation. This means regulating on the basis that people, organisations and sectors of civil aviation must accurately identify their risks and the risks to consumers, that they manage them effectively whilst still complying with applicable prescriptive rules. SMS, Human Factors and proportionate compliance assurance are embedded into the regulatory approach.
Actions to Achieve Desired Capability Outcome: 1. Concepts of SMS maturity and risk profiling of regulated organisations developed.
Deliverables and Dates: 1. New Performance-Based Oversight Model refined and delivered for external consultation. December 2011
Expected Safety Benefit: n Greater focus on risks to consumer welfare, regulatory desired outcomes and the control of risk by regulated entities. n Risks to consumers identified early and controlled in proportionate and effective ways. n Regulatory capacity and capability in line with desired outcomes. April 2012 Key Performance Indicators:
2. Regulatory oversight behaviours and methodologies fully developed and individually tailored according to risk profile.
2. Oversight Model processes defined, management arrangements and training prepared.
3. Regulatory capabilities matched to the risk management capabilities of those being regulated.
3. Performance-Based Oversight Model adopted as CAA safety oversight methodology according to an implementation plan. June 2012
n Significant Seven precursor events. n Resource deployed on regulating non-critical activity. Capability Outcome Owner: n CAA Group Safety Services.
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Safety Plan 2011/13
3.2.7 Fatigue Risk Management Systems
As aviation is a continuous and global activity, fatigue of individuals working in this environment has to be considered as a hazard. The benefits of Fatigue Risk Management Systems (FRMS) have been recognised in all modes of transportation and safety critical environments. The application of assessment, assurance and education techniques can be readily applied and integrated into regulatory oversight. ICAO has strengthened its fatigue management requirements for aircrew to include the ability to apply to FRMS either in combination with prescriptive rules sets or as the primary method of fatigue management. ICAO is planning to extend these techniques into other aviation safety critical areas. Desired Capability Outcome: To deliver effective regulatory oversight of fatigue management using FRMS techniques and metrics, proportionate to the size and complexity of the operational environment. To ensure that safety critical workers are able to operate at an effective level of alertness for all normal and abnormal circumstances.
Actions to Achieve Desired Capability Outcome: 1. FRMS training to be developed for all appropriate CAA staff.
Deliverables and Dates: 1. All appropriately selected CAA staff to have received training in the assessment and practical implementation of FRMS. January 2013
Expected Safety Benefit: n Regulatory oversight capacity and capability in line with desired safety outcomes. n Consistent approach to the impact of fatigue risk in the operational environment through the promotion of fatigue awareness leading to effective monitoring and application of appropriate mitigations.
2. Develop a consistent SRG approach to fatigue in aviation safety critical environments.
2. Cross-departmental working group established with a relevant fatigue safety promotion plan developed. March 2012
Key Performance Indicators: n Proportion of relevant CAA staff appropriately trained and skilled in the assessment and practical implementation of FRMS. Capability Outcome Owner: n CAA Flight Operations Policy.
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Safety Plan 2011/13
3.2.8 Total System Threats
The volcanic ash crisis of 2010 was an example of a low probability but highimpact event that affected the total aviation system. A review of lessons learnt from this event revealed that one of the CAAs strengths during the crisis was its ability to draw upon internal expertise based on a long involvement in relevant issues and previous incidents. The need to retain such capability is reflected in the CAA Strategic Plan, together with the need for continued improvement in the CAAs expertise, plans and processes for crisis management, and the ability to better identify and prevent or prepare for rare but high-impact events that affect the total aviation system. Key activities that support these needs and that address total system threats, such as volcanic ash, are listed below. n Through the Integrated Safety Risk Management Process project (see section 3.2.1), improve the identification of current, emerging and future safety issues (including how to capture and analyse results from industry trends and horizon scanning). n Providing a leading role in the International Volcanic Ash Task Force including the development and adoption of an international risk assessment framework for volcanic ash. n Contribution to the EU seventh framework Weather Hazards for Aeronautics (WEZARD)
project, which will include a review of the current knowledge on volcanic ash, mineral dust and ice crystals as potential threats to aviation. n Investigation of the risk posed by the next solar maximum through the CAAs Space Weather Working Group. n Identification and mitigation of potential common mode failure points in the aviation system (e.g. reliance on Global Navigation Satellite Systems). n Preparations for a safe 2012 London Olympics and Paralympics through the CAA Olympic and Paralympics Steering Group (COPSG - see http://www.caa.co.uk/olympics). n Creation of a CAA Crisis Information Management Team to support the command and control teams that lead the crisis management response on behalf of the CAA. n Support for the European Aviation Crisis Coordination Cell (EACCC) to ensure timely response to any future pan-European crisis severely affecting aviation (reference: EASP Safety Action SYS4.2).
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4. OTHER AVIATION SECTORS
Safety Plan 2011/13
4. Other Aviation Sectors

Whilst the focus of this Safety Plan is on actions to mitigate the key risks to large fixed-wing commercial air transport operations, the CAA remains committed to working with industry to improve safety in all aviation sectors. This includes supporting international collaborative partnerships such as the European Helicopter Safety Team (EHEST) and the European General Aviation Safety Team (EGAST), and working with individual organisations to target specific risks. This section of the Plan describes actions to address safety risks associated with business aviation, large public transport helicopter operations and general aviation.
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Safety Plan 2011/13
4.1 Business Aviation
The Business Aviation sector by its very scope and diversity of operations is different to CAT and as a result there are specific challenges to be acknowledged. Thus the Business Aviation Safety Partnership (BASP) was established not because Business Aviation is deemed unsafe but because it was recognised that a more tailored approach to this sector was warranted. The BASP is a joint CAA/industry partnership that takes a holistic approach in seeking to incrementally improve business aviation safety and to reduce the involvement of business jet aircraft in serious events. The BASP Deliverables Document facilitates management of BASP work and details activity in terms of: regulatory work; direct engagement with aircraft operators, airfield operators and training providers; and the development and distribution of safety awareness and guidance material. BASP will ensure close links are maintained with the CAA Flight Operations Inspectorate when dealing with business aviation safety matters. Key work focussed on level busts, ACAS response and Alternative Training and Qualification Programmes (ATQPs) are described below. Desired Safety Outcome (BA1): Reduce the number of, and relative contribution to level busts in UK airspace by business jets.
Actions to Achieve Desired Safety Outcome: 1. BASP Chair to co-ordinate, facilitate and deliver ongoing safety briefings/events both domestically and internationally to ensure effective engagement with the business aviation community on numerous safety issues, and on level busts particularly.
Deliverables and Dates: 1. Programme of safety briefings for the period 1st April 2011 to 31st March 2012 completed. March 2012
Expected Safety Benefit: Increased awareness by UK and particularly foreign-based business aviation pilots of level busts and associated airspace issues resulting in a reduction in the number / rate of occurrence and associated risk. Key Performance Indicators:
2. BASP endorsed safety promotional material distributed to business aviation associations, operators and training organisations.
2. One-page pilot guides for operations in airspace and at airports of particular relevance to business aviation produced and distributed. March 2012
Action success will be tracked using the following key performance indicators: n Level busts in UK airspace involving business jets (broken down by number and rate for Gregistered and foreign registered aircraft). Safety Outcome Owner: n BASP.
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Safety Plan 2011/13
Desired Safety Outcome (BA2): Reduce the proportion of incorrect response to ACAS RA warnings by business jet pilots. This work is largely driven by EUROCONTROL data, which suggests that a significant proportion of ACAS RAs are not responded to correctly. The output of the ACAS-related work carried out for CAT aeroplanes (described in section 3.1.5 Significant Seven Airborne Conflict) will be reviewed for its relevance to business aviation.
Actions to Achieve Desired Safety Outcome: 1. a) BASP-endorsed safety promotional material distributed to business aviation associations, operators and training organisations. b) Direct engagement with CAA Flight Crew Standards, senior trainers in industry, training organisations and operators focussed on enhancing the provision of realistic and effective ACAS training.
Deliverables and Dates: 1. BASP Safety Notice on appropriate response to ACAS warnings, and associated training advice, produced and distributed. March 2012
Expected Safety Benefit: Increased awareness by business jet pilots of the correct response required for ACAS warnings and a reduction in the associated risk of level busts and mid-air collision. Key Performance Indicators: Action success will be tracked using the following key performance indicators: n ACAS RAs involving all business jets in UK airspace and G-registered business jets worldwide: all genuine RAs and proportion involving incorrect pilot response. Safety Outcome Owner: n BASP.
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Safety Plan 2011/13
Desired Safety Outcome (BA3): Extend Alternative Training and Qualification Programmes (ATQPs) into business jet operations. This work will liaise closely with the ongoing oversight of ATQP implementation by larger CAT operators.
Actions to Achieve Desired Safety Outcome: 1. BASP Chair together with CAA Flight Operations ATQP Focal Point to investigate implementation of ATQP for business jet operations.
Deliverables and Dates: 1. Recommendations for implementation of ATQP for business jet operations produced. April 2012
Expected Safety Benefit: ATQP offers the operator the opportunity to develop a recurrent training programme that is bespoke and tailored to their needs, and has been unanimously hailed a great success by the UK airlines that have adopted such programmes. ATQP has been welcomed for its effectiveness by trainers and line crews alike, and has produced measured improvement in operating standards. Key Performance Indicators: Action success will be tracked using the following key performance indicators: n Number of UK business jet operators running ATQPs. Safety Outcome Owner: n BASP.
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Safety Plan 2011/13
4.2 Large Public Transport Helicopters
The CAA has been actively involved with the offshore oil and gas industry in helicopter safety for over 30 years. The focal point for helicopter safety issues is the Helicopter Safety Steering Group (HSSG), which was formed in June 2010 with the aim of proactively identifying and addressing cross-industry issues around helicopter safety, related to helicopter operations in the UK offshore oil and gas industry. The following research activities are being managed by CAA on behalf of industry.
Actions to Achieve Desired Safety Outcome: 1. Improvement in helicopter airworthiness: a) enhancement of Health & Usage Monitoring System (HUMS) vibration health monitoring (VHM) data analysis. b) extension of HUMS to rotors.
Deliverables and Dates: 1. Improvement in helicopter airworthiness: a) publication of final report on advanced anomaly detection (AAD). September 2011 b) publication of final report on application of AAD to tail rotor HUMS VHM data. March 2012 c) participation in Rotorcraft Technology Validation Programme (RTVP) joint industry project. December 2013
Expected Safety Benefit: Reduction in the Large Public Transport Helicopter accident rate. Key Performance Indicators: Action success and overall risk to offshore helicopter operations will be tracked using the following key performance indicators: n Accidents and high-risk occurrences. n Proportion of UK helicopter flights monitored by AAD (advanced HUMS). n Proportion of the UK offshore helicopter fleet equipped for GPS-guided approaches. n Proportion of UK Continental Shelf Helidecks fitted with the new lighting system. Safety Outcome Owner: n CAA Flight Operations Inspectorate June 2012 (Helicopters).
2. Improvement in helicopter operational safety: Desired Safety Outcome: Reduce the Large Public Transport Helicopter accident rate through improvements in helicopter airworthiness, operational safety and safety of offshore helidecks. a) development and introduction of GPSguided offshore approaches.
2. Improvement in helicopter operational safety: a) completion and reporting of demonstration trials of GPS-guided offshore approaches. completion and reporting of in-service trials of GPS-guided offshore approaches. March 2014
b) production of a performance specification for emergency breathing systems. c) development of a measure of low airspeed for helicopter Flight Data Monitoring (FDM) systems. d) development of offshore helicopter specific warning envelopes for Enhanced Ground Proximity Warning Systems (EGPWS).
b) publication of a performance specification for emergency breathing systems. December 2011 c) development and publication of helicopter low airspeed measure. March 2013 d) development and publication of improved EGPWS warning envelopes. June 2012
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Safety Plan 2011/13
4.2 Large Public Transport Helicopters
Actions to Achieve Desired Safety Outcome: Continued e) development of a prediction/forecasting system for helicopter triggered lightning strikes.
Deliverables and Dates: Continued e) development, demonstration and reporting of a system for predicting helicopter triggered lightning strikes. March 2012
3. Improvement in offshore helideck safety: a) development of improved helicopter moving deck landing criteria.
3. Improvement in offshore helideck safety: a) development, demonstration and publication of improved helicopter moving deck landing criteria. December 2013
b) development of improved helideck lighting system. c) development of a resistance to sliding criterion for aluminium helidecks.
b) development, demonstration and publication of improved helideck lighting system. December 2011 c) development, demonstration and publication of a resistance to sliding criterion for aluminium helidecks. June 2012
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Safety Plan 2011/13
4.3 General Aviation
Whilst the main focus of this Safety Plan is on large commercial air transport, the CAA remains committed to working with industry to improve GA safety in a proportionate manner. The CAA continues to discuss safety concerns on GA matters through the General Aviation Strategic Forum and the General Aviation Consultative Committee. The CAA has additionally committed to a wider review of the Regulatory Approach to Recreational Aviation. This will involve working closely with industry and EASA, to identify and act on opportunities to adopt a different, more proportionate approach, while ensuring that the key safety issues related to this community are addressed. As well as continuing to support and influence the European General Aviation Safety Team (EGAST), the CAA is undertaking the following actions. Desired Safety Outcome (GA1): Reduce the risk of mid-air collisions involving GA aircraft.
Actions to Achieve Desired Safety Outcome: 1. Improve visual conspicuity of gliders and other light aircraft with small cross-sectional profiles. 2. Improve understanding of Class G airspace utilisation to better inform knowledge of airspace hotspots. 3. Provide real-time information to pilots on events involving large numbers of GA aircraft.
Deliverables and Dates: 1. Investigation report produced on the use of reflective foil on control surfaces. December 2011
Expected Safety Benefit: Reduction in the likelihood of mid-air collisions involving GA aircraft. Key Performance Indicators:
2. Modelling of Class G airspace utilisation completed. December 2011 3. IT-based solutions (building on work completed with the British Gliding Association for glider events) developed in conjunction with NATS and GA representative bodies. December 2011
Action success will be tracked using the following key performance indicators: n Actual mid-air collisions involving GA aircraft. n AIRPROX involving GA aircraft. Safety Outcome Owner: n CAA Flight Operations Inspectorate (General Aviation). Alignment with European Aviation Safety Plan: n Reference: Safety Action GA1.3.
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Safety Plan 2011/13
Desired Safety Outcome (GA2): Reduce the risk of accidents due to pilots making wrong decisions over the conduct of a flight.
Actions to Achieve Desired Safety Outcome: 1. Research project into Human Factors in decision-making process.
Deliverables and Dates: 1. Background HF research project by Cranfield University completed. Complete
Expected Safety Benefit: Reduction in the number of accidents involving poor decision-making by pilots. Key Performance Indicators:
2. Translate results into a proof of concept turnkey DVD product for pilot education.
2. Tender bids from potential commercial providers evaluated. Complete
Action success will be tracked using the following key performance indicators: n Volume of sales of commercially available decision making tuition product. n Analysis of data from results achieved by users. n Accidents attributed to poor decision making. Safety Outcome Owner: n CAA Flight Operations Inspectorate (General Aviation).
3. Provide commercially available product at a realistic price for pilots to practice outside the cockpit.
3. Production of interactive tuition tool for improvement of pilot decision-making with a commercial partner (subject to validation of proof of concept product). December 2012
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Safety Plan 2011/13
Desired Safety Outcome (GA3): Reduce the risk of accidents due to the effects of helicopter and wind turbine induced wake turbulence on light aircraft.
Actions to Achieve Desired Safety Outcome: 1. Research project on an Integrated Simulation of a Light Aircraft Encounter with Helicopter and Wind Turbine Wakes. The helicopter case covers both in ground effect rotor wash whilst in the hover and induced wake whilst in forward flight. 2. Translate research results into avoidance guidelines regarding safe operation of light aircraft in relation to helicopter and wind turbine wake encounters.
Deliverables and Dates: 1. Background research project completed on impacts of wakes on light aircraft. August 2014
Expected Safety Benefit: n Reduction in the number of accidents and incidents involving light aircraft attributed to wake turbulence from helicopters and wind turbines. n Improved knowledge of the hazard posed to aviation from wind turbine wake vortices and education material for the GA community in
2. Guidance disseminated on wake vortex avoidance distances for pilots and ATCOs associated with helicopters operating in hover and forward flight. December 2014
relation to the avoidance of this type of hazard. Key Performance Indicators: Action success will be tracked using the following key performance indicators: n Accidents or serious incidents involving light aircraft attributed to helicopter and wind turbine wake turbulence encounters both nationally and across Europe. n Requests from aviation stakeholders on information on the effects of wind turbine wake turbulence on flight operations. n Feedback from pilots at General Aviation Safety Council (GASCo) Safety Evenings. Safety Outcome Owner: n CAA Flight Operations Inspectorate (General Aviation).
3. Disseminate results to UK ANSPs, the GA community, and European (EASA and EUROCONTROL) and international (ICAO) stakeholders.
3. Guidance disseminated on wake vortex avoidance distances for aviation stakeholders, wind energy developers and local authorities associated with wind turbine wake turbulence effects on light aircraft. December 2014

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CAA Safety Plan 2011 To 2013

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Civil Aviation Authority

Civil Aviation Authority

Safety Plan 2011/13

Civil Aviation Authority

Safety Plan 2011/13

Controlled Flight into Terrain (CFIT)

OVERVIEW Airborne Conflict

Civil Aviation Authority

Safety Plan 2011/13

Civil Aviation Authority

Safety Plan 2011/13

Key Capability Issues

Safety Management Systems (SMS)

Integrated Safety Risk Management Process

Civil Aviation Authority

Safety Plan 2011/13

Strategy for Human Factors (HF)

Civil Aviation Authority

Safety Plan 2011/13

Fatigue Risk Management Systems (FRMS)

Total System Threats

Civil Aviation Authority

Safety Plan 2011/13

Large Public Transport Helicopters

because it was recognised that a more

General Aviation (GA)

Civil Aviation Authority

Safety Plan 2011/13

1.2 CAA Safety Plan and Industry

1.4 Way Forward

1.3 European Aviation Safety Plan

Civil Aviation Authority

Safety Plan 2011/13

2.3 Governance of Safety Plan

Key Capabilities Required for the Total Aviation System

2.4 Communication with Stakeholders

Civil Aviation Authority

Safety Plan 2011/13

2.5 Safety Performance Indicators

3. SAFETY ACTIONS [SIGNIFICANT SEVEN]

Civil Aviation Authority

Safety Plan 2011/13

3. SAFETY ACTIONS [SIGNIFICANT SEVEN]

Civil Aviation Authority

Safety Plan 2011/13

3.1.1 Loss of Control

Expected Safety Benefit:

SIGNIFICANT for mid-air collision), advances

3. SAFETY ACTIONS [SIGNIFICANT SEVEN]

Civil Aviation Authority

Safety Plan 2011/13

3.1.1 Loss of Control

3. SAFETY ACTIONS [SIGNIFICANT SEVEN]

Civil Aviation Authority

Safety Plan 2011/13

3.1.1 Loss of Control

2. a) Feasibility report produced.

3. SAFETY ACTIONS [SIGNIFICANT SEVEN]

Civil Aviation Authority

Safety Plan 2011/13

3.1.2 Runway Excursion

SIGNIFICANT in the correct configuration