subject annual report... · 2020. 5. 12. · 4.1) description 25 4.2) conclusion 25 5) case number...

2

Subject

Page Number

Forward

8

AIB Vision

9

AIB Mission

10

AIB Values

11

Introduction

12

Notifications

14

Introduction

15

Reporting Culture Rates

15

Notification Classes for 2016

17

1) Accident

17

2) Serious incident

17

3) Incident

18

4) Others

18

Reported Occurrences Categories

18

Investigations

20

Introduction

21

Full investigation annex 13 format report

21

Limited scope investigation report

21

Safety concern report

21

Investigation Status

21

Some selected cases of occurrences investigated in 2016

22

1) Case number AIB-2016-0272 (24/06/2016)

22

2) Case Number AIB-2015-0156 (31/07/2015)

22

2.1) Description

22

2.2) Conclusion

23

3

Subject

Page Number

3) Case number AIB-2014-0293 (02/12/2014)

23

3.1) Description

23

2.2) Conclusion

24

4) Case number AIB-2016-0067 (23/02/2016)

25

4.1) Description

25

4.2) Conclusion

25

5) Case number AIB-2014-0173 (06/07/2014)

25

5.1) Description

25

5.2) Conclusion

26

Recommendations

28

Introduction

29

Responding to Safety Recommendations

29

Issued Safety Recommendations

29

Engineering Lab.

40

Activities

41

Flight Recorder Laboratory (FRL) facilities’ work flow arrangements

42

Stage One: Receiving

42

Stage Two: Level two and three data recovery

43

Stage Three: Data Download

44

Stage Four: Cockpit Voice Recorder (CVR) Listening and transcribing

44

Equipment Maintenance

45

Equipment Inventory

45

Measuring Equipment Calibration Requirement

46

Capability Development

46

Frame Format Description Files (FFD)

46

4

Subject

Page Number

Layout File (LF)

47

Flight Analysis System (FAS)

47

Memory Access Retrieval system (M.A.R.S)

48

Characteristics of MARS

49

Safety Analysis

52

Safety Study

53

Scope of Work

53

1) Data Collection

53

2) Data Analysis

53

3) Team Formation

54

4) Result of Working Group

54

5) Standards' Assessment

54

6) Recommendations

54

6.1) Security and Air Transport (SSAT-GACA)

54

6.2) Saudia Ground Services (SGS)

55

6.3) Aviation Investigation Bureau (AIB)

55

6.4) GACA Airports

55

6.5) Operators (Saudia and Flynas)

55

Safety Concern and Issues

56

Bird Strike

57

Air Proximity

59

Financial & Admin Affairs

60

Introduction

61

1) Human Resources

61

1.1) Recruitment

61

5

Subject

Page Number

1.2) Employee Retention

61

1.3) Saudization

61

1.4) Policies and Procedures

61

1.5) Training and Development

61

1.6) Employee-Engagement Program

61

1.7) Leave Planning

61

1.8) Employee Database

61

1.9) Job Descriptions

61

1.10) Attendance

61

1.11) Forms

61

2) AIB’s Organizational Chart

62

3) Information Technology

63

3.1) AIB Website

63

3.2 FTP (File Transference Protocol)

63

3.3) Twitter

63

3.4) SharePoint System

63

3.5) AOMS (Aviation Occurrences Management System)

63

3.6) Network Wireless Access Point

63

3.7) Data Tracking System (DTS)

63

4.0) Public and Government Relations

63

4.1) Workshops, Conferences and Events

63

4.2) International Collaboration

64

4.3) Global Ministerial Aviation Summit

64

4.4) Employee Discount Program

64

Development

66

Introduction

67

6

Subject

Page Number

Cooperation and Collaboration Enhancement in Accident Investigations

67

MOU with the Interstate Aviation Committee of the Russian Federation

67

MOU with the Air Accident Investigation Bureau (AAIB) of Singapore

68

MOU with the Investigation Bureau of the Moroccan General Directorate of Civil Aviation

69

MOU with the Office of Aviation Safety of the Civil Aviation Administration of the Republic of China

69

Flight Data Analysis Workshop

69

Ministry of Interior communication program

70

Ministry of Defence communication program

71

Aviation Security communication program

71

Airports coordinators workshop

72

Workshop Objectives

72

Crash Landing Drill

73

Activities performed during the drill

73

National Disaster Plan Drill

75

Aviation Occurrence Management System (AOMS) Project

77

Project Vision

77

Process Scope

77

ECCAIRS (European Coordination Centre for Accidents and Incident Reporting Systems)

79

Post-Accident Communication Strategy

79

Introduction

79

Objectives

81

Main Successes and achievements of the communication Strategy

82

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The AIB team is committed to aviation safety and will continue its mission in conducting its function to the highest standards to promote aviation safety. I am honored to present to His Excellency the Minister of Transport Chairman of the Board of Directors of the General Authority of Civil Aviation the 2016 Annual report of the Aviation Investigation Bureau. This is the third annual report since the establishment of the AIB in November 2013. It is without a doubt, that the continuous support of His Excellency has enabled the AIB to pursue ambitious initiatives and to achieve major accomplishments during 2016, in various areas of AIB functions. There was a 70% increase in the number of received notifications of occurrences compared to 2015. This is perceived as a significant enhancement in the reporting culture, and as a result of an extensive outreach program in 2015, which included KSA service providers and operators. The AIB has successfully engaged the aviation industry and stakeholders in the development of a National Post Accident Communication Strategy. This effort has also triggered among other initiatives, the development and enhancement of Family Assistance plans within the aviation sector of KSA.

Director General

Abdulelah Othman Felemban

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AIB

Vision

To be recognized as an

international leader in

advancing global

aviation safety.

10

AIB

Mission

To advance aviation

safety through

independent occurrence

investigations and safety

studies, promote an

effective and

comprehensive safety

reporting system and

communicate risks and

safety recommendations.

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AIB

Values

Respect: Fostering an environment that allows

staff to contribute, innovate and excel.

Integrity and impartiality: In all activities.

Competence: Continual professional and technical

development.

Transparency: Exchange information to enhance

aviation safety.

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The Aviation Investigation Bureau “AIB” of the Kingdom of Saudi Arabia investigates accidents and other occurrences involving civil aircraft. It analyses data on all notified accidents and incidents. It conducts research into specific matters of concern that emerge from data analysis and specific incidents, or matters that may be referred to by other organizations. It does so in a manner consistent with the Aircraft Accident and Incident Investigation Convention on International Civil Aviation that was signed in Chicago in the year of 1944 (Annex 13). The AIB may also investigate serious accidents or incidents involving Saudi registered aircraft overseas, or assist with overseas investigations involving Saudi registered or foreign aircraft if an overseas investigative authority seeks assistance and the AIB has the suitable resources available. The AIB may also have observer status in important overseas investigations, which provides valuable opportunities to learn from overseas organizations and to benchmark its knowledge and procedures against other organizations. The AIB cooperates with the following organizations: The General Authority of Civil Aviation (GACA) of the Kingdom of Saudi Arabia. Operators in Saudi Arabia. Aircraft manufacturers. Other safety agencies to assist the government in implementing aviation safety

initiatives.

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Introduction: The AIB has an Operation Control Center “OCC” that maintains a 24/7 notification service. It receives all notifications such as; telephone calls, emails, facsimiles and web forms that are utilized to notify the AIB of the aviation occurrences. A single occurrence can generate multiple notifications from different sources, it is common that duplicate notifications occur. The number of occurrences has increased up to 606 occurrences in 2016, where it was 338 in 2015, with an increase rate of 79%. Once a notification is received by an OCC duty officer, it’s logged into a database called the Aviation Occurrence Tracking System “AOTS”. AOTS helps track occurrences from initiation, to investigation, to closure. This process is consistent with the AIB Regulation and Annex 13 of the International Civil Aviation Organization “ICAO”. The graph below shows the comparison between 2015 and 2016 on a monthly basis.

Notifications on a monthly basis

Reporting Culture Rates: 2016 shows a significant improvement in the occurrence reporting culture in airports. The outreach program that AIB conducted with airports has played a major role in emphasizing the importance of occurrence reporting. Yet, one of the biggest challenges identified by the AIB is addressing the un-reported occurrences. The graph below shows a comparison of occurrence notifications in the four major airports in KSA.

0

10

20

30

40

50

60

70

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

20 26

19 21 27

23

16

27

54

40 36

29

36 42

47

67

37

54 59

57

45

66

41

55


2015 20 26 19 21 27 23 16 27 54 40 36 29

2016 36 42 47 67 37 54 59 57 45 66 41 55

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Reporting Rate Chart

The graph below shows notifications by airports in KSA.

Notifications by airport in KSA

0

20

40

60

80

100

120

140

160

KAIA KKIA KFIA PMIA

89

66

26

11

157

114

61

19

2015

2016

9 8 1 3 3 3

89

3

26

66

1 11

2 1 0 0 4 7 5 2 2 1 2 2

22 8 1 1 3 6

157

5

61

114

2 19

7 0 1 1 1 6 4 5 0 0 1 4

0

20

40

60

80

100

120

140

160

180 2015 2016

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Number of occurrences for the year 2016 (Airports Vs Aerospace comparison)

Notification Classes for 2016: The four basic occurrence classes are as follows:

Occurrence Classes for 2016

1) Accident: An occurrence associated with the operation of an aircraft which a person is fatally or seriously injured, or the aircraft sustains substantial damage.

2) Serious incident: An incident involving circumstances indicating that an accident nearly occurred.

0

50

100

150

200

250

300

350

400

450

Airports Aerospace

432

56

102

16

In-Kingdom

Out-Of_Kingdom

1

35

374

197

Accidents

Serious Incidents

Incidents

Others

32.45% 5.76%

61.61%

0.16%

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3) Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.

4) Others: A reported event that does not classify as an accident or incident. The reported occurrences are identified based on severity and impact for both, passengers and flight operations as noted in the graph below. Some minor events could be non-significant in nature, but still recorded for data collection purposes and safety analysis. Reported Occurrences Categories: All of the occurrences reported to AIB are categorized in accordance with the ICAO categorization taxonomy. The ICAO Accident/Incident Data Reporting (ADREP) system is based on the ADREP taxonomy to allow for international data sharing. The ADREP taxonomy is a set of definitions and descriptions used during the gathering and reporting of accident and incident data that is forwarded to ICAO. This taxonomy is maintained by the ICAO Accident Investigation Group. Some occurrences are categorized in more than one category.

Occurrence Categories Comparison

3

1

2

11

60

5

0

14

5

6

1

5

48

48

0

0

6

48

17

3

3

8

1

43

14

1

5

38

74

39

3

22

14

2

0

1

34

70

1

1

5

110

40

19

4

57

4

48

0 20 40 60 80 100 120

ADRM: Aerodrome

AMAN: Abrupt maneuvre

ARC: Abnormal runway contact

ATM: ATM/CNS

BIRD: Birdstrike

CABIN: Cabin safety events

CTOL: Collisions with obstacle

F-NI: Fire/Smoke (non-impact)

FUEL: Fuel related

GCOL: Ground collision

LOC-G: Loss of control ground

LOC-I: Loss of control inflight

MAC: AIRPROX/near miss/midair collsion

RAMP: Ground handling

RI-A: Runway incursion animal

RI-VA: Runway incursion vehicle

RI-VAP: Runway incursion vehicle

SCF-NP: System/component failure

SCF-PP: Powerplant failure or malfunction

SEC: Seurity related

TURB: Turbulence encounter

WSTRW: Windshear or thunderstorm

UNK: Unknown

OTHR: Other

2016 2015

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Introduction: The purpose of an investigation is to determine the facts, conditions, and circumstances in order to arrive at findings that will identify causal factors. The sole objective of the investigation of an aviation occurrence shall be the prevention of aviation occurrences. It is not the purpose of this activity to apportion blame or liability. The AIB, in carrying out investigations, usually publishes three kinds of reports for aviation occurrences depending on its safety significance. The reports differ in size and scope, but they all follow the basic ICAO annex 13 concept in its structure. All reports present facts, analysis, findings and when necessary safety recommendations. It’s important to state that this is only for the sake of practicality. Certain circumstances may require AIB to deviate from this practice. The three kinds of reports are as follows: Full investigation annex 13 format report: This is for investigated Accidents and serious incidents that involve international interested parties. Limited scope investigation report: for incidents that involve domestic interested parties only, such as ground incidents or ATC incidents. Safety concern report: for safety critical observations and standalone recommendations addressing specific safety matters. Investigation Status: In 2016, 65 occurrences were investigated, 14 cases were completed, and 51 are On-Going investigations. The graph below shows the number of investigated occurrences and the status of the investigation.

2016 Investigations Status

0

10

20

30

40

50

60

70

On-Going Completed Total

51

14

65

On-Going

Completed

Total

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Some selected cases of occurrences investigated in 2016: 1) Case number AIB-2016-0272 (24/06/2016): This aviation occurrence is categorized as “Accident”. It occurred to a private powered parachute aircraft with Rotax 912 engine that crashed into a swamp at As Suwadirah, 70 km east of Medina. A pilot and one passenger were on board and the passenger died in this accident.

Powered Parachute

2) Case Number AIB-2015-0156 (31/07/2015): 2.1) Description: At the end of a routine flight, aircraft HZ-IBN entered the visual circuit to land on Runway 25 at Blackbushe airport in UK. A number of TCAS alerts occurred while flying in the circuit, and the pilot maneuvered the aircraft until it was significantly higher and faster than normal for a visual approach. Following several TAWS alerts, the aircraft crossed the runway threshold 43 kt above the target threshold speed1.

Aircraft HZ-IBN

The aircraft floated before touching down and overran the runway end. It collided with an earth bank, and then cars in a car park, causing the wing to separate and a fire to start. The four occupants were fatally injured. Several factors combined to create a very high workload

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for the pilot. This may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model, leading him to become fixated on continuing the approach. 2.2) Conclusion: Aircraft HZ-IBN joined the circuit at a speed and height which would have been consistent with the pilot’s stated plan to extend downwind in order that the microlight could land first. The subsequent positioning of HZ-IBN and the microlight involved HZ-IBN maneuvering across the microlight’s path, in the course of which the first of several TCAS warnings was generated. After maneuvering to cross the microlight’s path, HZ-IBN arrived on the final approach significantly above the normal profile but appropriately configured for landing. In the ensuing steep descent, the pilot selected the speed brakes out but they remained stowed because they are inhibited when the flaps are deployed. The aircraft’s speed increased and it crossed the threshold at the appropriate height, but 43 KIAS above the applicable target threshold speed. The excessive speed contributed to a touchdown 710 m beyond the threshold, with only 438 m of paved surface remaining. From touchdown, at 134 KIAS, it was no longer possible for the aircraft to stop within the remaining runway length. The brakes were applied almost immediately after touchdown and the aircraft’s subsequent deceleration slightly exceeded the value used in the aircraft manufacturer’s landing performance model. The aircraft departed the paved surface at the end of Runway 25 at a groundspeed of 83 kt. The aircraft collided with an earth bank and cars in a car park beyond it, causing the wing to separate and a fire to start. Although the aircraft occupants survived these impacts, they died from the effects of fire. Towards the end of the flight, a number of factors came together to create a very high workload situation for the pilot, to the extent that his mental capacity could have become saturated; His ability to take on new and critical information, and adapt his situational awareness,

would have been impeded. In conjunction with audio overload and the mental stressors this can invoke, this may

have lead him to become fixated on continuing the approach towards a short runway. 3) Case number AIB-2014-0293 (02/12/2014): 3.1) Description: A Cessna 340 twin-engine airplane was on final approach to land at King Khalid International Airport (OERK) – Riyadh, Kingdom of Saudi Arabia (KSA). At approximately 600 feet altitude, the left engine sputtered and quit and ten (10) seconds later the right engine quit. The pilot quickly notified the Air Traffic Control Tower of the emergency due to the loss of power in both engines. The airplane touched down on the desert like terrain outside the perimeter fence of the airport, skidding and then hit a pile of rocky earthen rubble. A Cessna 340, Registration N340JC, was in the process of being sold to a buyer in Malaysia. For this purpose, N340JC was being ferried / operated by a professional aviation ferrying company. The ferry trip was from the Yoakum County Airport, Plains, Texas, and United States to the Sultan Abdul Aziz Shah Airport, Subang International Airport, Kuala Lumpur, Malaysia (see

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image on figure 10). The entire ferry trip was divided into many segments which were mainly limited by the availability of fuel for each segment. It should be noted the aircraft’s flight plan routing deviated from its flight plan noted in the aircraft’s ferry insurance policy.

Route of Aircraft N340JC

This accident occurred at 1457 UTC (1757 local time), in the hours of darkness, 1.25 nm from the threshold of runway 33R at the King Khalid International Airport-Riyadh, KSA. The aircraft landed on desert like terrain, skidding into a pile of earthen rubble and sustained serious damages.

Extent of serious damages on aircraft N340JC

3.2) Conclusion: The Pilot-In-Command (PIC) did not adequately prepare the aircraft for this international ferry flight. The PIC did not accurately calculate the required fuel necessary to complete the flight from Hurghada to Riyadh.

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It is likely the Flight Crew’s flight plan estimate included the flight time en-route from Hurghada International Airport to King Khalid International Airport in Riyadh without any consideration for additional fuel consumption for starting, taxi, takeoff, climb and vectoring or maneuvering for a landing approach when arriving into Riyadh. The aircraft was carrying an additional non-essential cargo that likely derogated the aircraft’s performance. Neither Flight Crew member notified ATC of the fuel shortage. The loss of both engines was due to fuel exhaustion. The aircraft’s fuel exhaustion resulted in the subsequent off airport landing. 4) Case number AIB-2016-0067 (23/02/2016): 4.1) Description: SriLankan Airlines 282 (ALK282) was an Airbus 330-200 (A332) that was departing King Abdul-Aziz International Airport (OEJN), Jeddah Kingdom of Saudi Arabia (KSA) on a regular scheduled passenger flight to Bandaranaike International Airport (VCBI), Colombo, Sri Lanka. N851AB was an Embraer 300 (E55P) Phenom 300 business jet that was departing OEJN on a repositioning flight to King Khalid International Airport (OERK), Riyadh KSA.

4.2) Conclusion: A Runway Incursion occurred when N851AB entered RWY 34L at a location not planned by the controller. A Loss of Separation existed when N851AB was issued a taxi clearance onto RWY 34L

prior to the departure of ALK282 and without determining the location of the aircraft. A loss of Separation existed when N851AB was issued a take-off clearance without the

requisite turbulence separation minima. A Hazardous Situation (Risk of Collision) existed when ALK282 commenced a take-off

roll behind N851AB occupying the same runway. A Hazardous Situation existed when the controller was unsure of the location of

N851AB (having already departed). 5) Case number AIB-2014-0173 (06/07/2014): 5.1) Description: On 06 July 2014, an Airbus A320-214, Registration HZ-AS41, operated by Saudi Arabian Airlines as Flight SVA 1655, was performing a scheduled domestic flight from King Khalid International Airport (OERK), Riyadh to Abha Regional Airport (OEAB). When landing in

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Abha, the aircraft experienced a severe hard landing resulting in a computed vertical acceleration of 4.09 gravitation force (g). The Pilot-in-Command requested the Air Traffic Control Tower controller to arrange for an ambulance to meet the aircraft upon parking. One cabin crew member was seriously injured with two passengers receiving minor injuries during the severe hard landing.

Hard Landing 5.2) Conclusion: On the final approach into OEAB, at 240 ft., HZ-AS41 encountered vertical wind gusts resulting in the Pilot Flying manipulating the sidestick control. The approach for landing in OEAB became unstable below 240 feet. The Pilot Flying did not initiate a “Go-Around” procedure when the approach was destabilized. The simultaneous variant sidestick inputs from the Captain and First Officer for 14 seconds during the flare phase of the flight were not adequate to reduce the aircraft’s vertical speed before landing. The aircraft initially touched down at 4.09g as noted as a severe hard landing. The thrust levers were not retarded during the initial touchdown. The energy of the initial severe hard landing associated with the full back sidestick input applied at touchdown and the inhibition of the ground spoilers’ extension led to a gain of lift resulting in a light bounce. A strong nose down input applied during the bounce, associated with ground spoilers extension resulted in a sharp drop of lift creating a hard landing of 2.56g. The flight crew recognized the unstable approach between 100 and 50 feet but continued with the landing as they believed it was too late for an alternate flight action.

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Introduction: In accordance with the AIB Regulations Chapter 8, paragraph 8.2, the AIB recommend corrective or remedial actions as a result of investigations or safety studies for the purpose of preventing further aviation occurrences. If during the course of an investigation any safety deficiency becomes known for which prompt preventative action is required, then it will be addressed through a Stand-Alone Recommendation (SAR) in accordance to AIB Regulation Chapter 6, paragraph 6.3. The recommendations are usually broad in application to allow the addressees of the recommendations to have some discretion in implementing specific remedial actions. Responding to Safety Recommendations: This annual report contains the safety recommendations issued in 2016 for the completed investigation during 2016, including recommendations status. The status of the Safety recommendations are categorized in to the following categories: 1) Issued: The recommendation has been issued and sent. 2) Implemented: The recommendation has been accepted and implemented. 3) Open: The recommendation still open and waiting for replay. 4) Over Due: The recommendation. 5) Rejected: The implementation proposal is not accepted. Issued Safety Recommendations: In 2016, 88 safety recommendations were issued. These recommendations are listed in the following table:


Rec. No. Recommendation Assigned to Status

AIB-2013-0003-SR-01

The operator, Saudi Arabian Airlines, should coordinates with the manufacturer of the type of aircraft to replace the existing pitot probe protection device with a protection device that is heat resistive and made of inflammable material to avoid burning the device whenever the pitot probe is inadvertently activated.

Saudi Arabian Airlines

Over Due

AIB-2013-0003-SR-02

The operator, Saudi Arabian Airlines, should revise maintenance work order to include a log book entry for covering the pitot probes whenever an aircraft is intended to be parked for more than 24 hours.


Over Due

AIB-2013-0003-SR-03

The operator, Saudi Arabian Airlines, should revise maintenance work order to include placing a decal on the Pitot Probe switch in the cockpit whenever a protective cover is placed on the probes.


Over Due

AIB-2013-0013-SR-01

GACA should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing and other factors. Details of actions to include Completion dates or planned and estimated completion dates. Should no action be planned, rationale to be provided.

GACA Open

AIB-2014-0043-SR-01 GACA-Air Navigation Service (ANS) should GACA- ANS Over Due 14-

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establish and confirm the effectiveness of a system to monitor and alert controllers of validity dates of license validation certifications (Medical and English Language Proficiency). This alerting would include notification to Supervisors and Managers to ensure that no controller is assigned an operational position without possessing the required validations.

Jun-2016

AIB- 2014-0043-SR-02

GACA-ANS should confirm that a process is in place to ensure required documentation is complete. This includes confirming the required certificates and that these are all accurate and signed.

GACA- ANS Over Due 14-

Jun-2016

AIB-2014-0043-SR-03

GACA- ANS and the Regulatory Branch must ensure that controllers are fully aware of their individual responsibilities as per ATSP-1, 203.3 203.3 A person shall not provide an air traffic control service unless he holds an ATC license issued or approved by GACA, with a valid rating, including any associated rating and/or unit license endorsement relating to the air traffic control service to be provided, a current Class 3 Medical assessment certificate and a valid English proficiency certificate.


Jun-2016

AIB- 2014-0043-SR-04

The General Authority of Civil Aviation, Safety, Security and Air Transport must provide the necessary regulatory oversight to ensure full compliance with licensing and certification requirements.


Jun-2016

AIB-2014-0173-SR-01

Saudi Arabian Airlines should evaluate its pilot flight training program to mitigate any associated risks encountered during operations at special airports (high elevation /mountainous area).


Over Due 01-Jan-2017

AIB-2014-0173-SR-02

Saudi Arabian Airlines should evaluate its Cabin Crew member Training syllabus for dealing with passengers not seated while maintaining principal safety position during critical phases of flight.



AIB-2014-0173-SR-03

Saudi Arabian Airlines should communicate with the manufacturer to incorporate the activation of FDC alert for hard landing reports (LOAD ).



AIB-2014-0173-SR-04

Saudi Arabian Airlines should highlight in its simulator training curriculum the adverse impact of dual side stick inputs scenario during critical phases of flight.



AIB-2014-0178-SR-01

The General Authority of Civil Aviation (GACA), Air Navigation Services should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing and other factors (CF1- CF 6 and OF1). Details of actions to include Completion dates or

GACA Over Due 14-

Jun-2016

31



planned and estimated completion dates.

AIB-2014-0181-SR-01

Saudi Arabian Airlines should review the air carrier’s current A-320 oven maintenance program and make adjustments to this program to preclude equipment failures related to corroded water fittings.


Implemented

AIB-2014-0181-SR-02

Saudi Arabian Airlines should issue an alert to its cabin crewmembers noting: A) Pre-departure checks include an inspection

of all ovens to ensure that no foreign objects or other flammable residues are in the ovens.

B) A special emphasis should be placed on SVA firefighting practices used for combating on board fires.


Implemented

AIB-2014-0182-SR-01

The General Authority of Civil Aviation should create an advisory committee to assist the Saudi Aviation Club to develop the infrastructure that would allow it to exercise adequate oversight of sports aviation activities.

GACA Over Due 11-

Aug-2016

AIB-2014-0182-SR-02

The Saudi Aviation Club should establish a “policy and procedures” manual that includes: a) Minimum qualifications, experience and

training requirements for Saudi Aviation Club member pilots;

b) Minimum qualifications and standards for Saudi Aviation Club flight instructors.

c) Standardized Saudi Aviation Club pilot training program curriculum for entry level pilots;

d) Procedures for a Saudi Aviation Club pilot record keeping system;

e) Qualifications for maintenance personnel maintaining Saudi Aviation Club aircraft;

f) Procedures to follow the manufacturer recommended maintenance program to ensure Saudi Aviation Club aircraft are airworthy and provide historical maintenance documentation to support the aircraft airworthiness status; and,

g) Safety reporting system.

Saudi Aviation Club

Over Due 11-Aug-2016

AIB-2014-0182-SR-03

All aviation schools certified by the Saudi Aviation Club shall monitor all sport aviation activities under their jurisdiction to ensure compliance with applicable pilot operating handbook, maintenance requirements and report non-compliance to the Saudi Aviation Club.

All aviation schools


AIB-2014-0182-SR-04

The Saudi Aviation Club should establish procedures to effectively administer violations and issue penalties to Saudi Aviation Club schools and members who do not comply with Saudi Aviation Club policies, procedures and applicable General Authority of Civil Aviation

Saudi Aviation Club


32



regulations.

AIB-2014-0182-SR-05

The Saudi Aviation Club should ensure SAC certified pilots understand the contents of the Auto-Gyro MTO-sport Pilot Operating Handbook.

Saudi Aviation Club


AIB-2014-0221-SR-01

GACA-ANS shall re-evaluate the procedures to ensure the transmission of flights on the radar screens of ATC sectors of the regional areas, including the proper definition of the sectors

GACA-ANS Over Due 05-

Oct-2016

AIB-2014-0221-SR-02

GACA-ANS shall re-examine the ACNE, both top and the lowest level commensurate with the nature and the air traffic flying sector, taking into account the active maneuver operations requirements


Oct-2016

AIB-2014-0221-SR-03

GACA-ANS shall rationing comfort effective mechanism commensurate with the nature of the work and take into account the natural needs of the observers, while ensuring the effectiveness of the delivery and receipt and oversee the dissemination and application times.


Oct-2016

AIB-2014-0221-SR-04 GACA-ANS shall disclose and manage risks in the sectors centers and air traffic management and to take appropriate corrective action.


Oct-2016

AIB-2014-0221-SR-05

GACA-ANS shall not to allow observers who do not have licenses and certificates of medical and linguistic valid work in air traffic management sites.


Oct-2016

AIB-2014-0304-SR-01

Saudi Arabian Airlines, Flight Operation Department should consider introducing an additional item in the "Engine Start Procedures" checklist in the FCOM to ensure that "Thrust Levers … Check at CLOSED position".

Saudi Arabian Airlines-FO


AIB-2014-0304-SR-02

Saudi Aerospace Engineering Industries (SAEI) should introduce additional item in the Technical Preflight Checklist to address the tidiness and cleanliness of aircraft cockpit and its instrument/control panels.

SAEI Over Due 04-

Aug-2016

AIB-2015-0026-SR-01

The General Authority of Civil Aviation should review the phraseology for imperative instructions to ensure that the desired actions are immediately understood by the flight crew for expeditious compliance

GACA Open

AIB-2015-0026-SR-02

The General Authority of Civil Aviation should incorporate this part of Human Factors in Refresher Training so that controllers may be better prepared for these reactions.

GACA Open

AIB-2015-0026-SR-03

As a component of the Unit Preliminary Investigation, occurrences involving Loss of Separation or other significant event should be reviewed by a Training Manager and/or Supervisor to ensure that there are no

GACA-ANS Open

33



knowledge or skills gaps. Should any be noted during this review then appropriate, non-punitive corrective action can be taken coincident with the ATCO’s return to duty.

AIB-2015-0026-SR-04

The General Authority of Civil Aviation should review the practice of “penalizing” ATCOs who have experienced an Operating Irregularity, such as the “Black Mark” on personal record with the aim to ensure and maintain a climate of open reporting.

GACA Open

AIB-2015-0072-SR-01

The General Authority of Civil Aviation, ANS, should develop and deliver an educational training module on “Human Factors in Emergencies” to the air traffic control staff. This training would better prepare the control staff on dealing with emergency or other stressful situations that they may encounter.

GACA Over Due 13-

Apr-2016

AIB-2015-0072-SR-02

The General Authority of Civil Aviation, ANS, should ensure the process of monitoring and alerting controllers, supervisors and Unit Management of validity dates of license validation certifications (License, Medical and English Language Proficiency). This alerting would include notification to ensure that no controller is permitted to assume an operational position without the required validations.

GACA Over Due 13-

Apr-2016

AIB-2015-0072-SR-03

The General Authority of Civil Aviation, ANS, should confirm that a process is in place to ensure and confirm that required documentation is complete, this would include all certificates and forms have required signatures.

GACA Over Due 13-

Apr-2016

AIB-2015-0100-SR-01

The General Authority of Civil Aviation, ANS, should develop and deliver an educational training module on “Aircraft Flight Performance” and Flight Deck Operation to understand how react to normal and abnormal flight situations flight crew.

GACA-ANS Open

AIB-2015-0100-SR-02

The General Authority of Civil Aviation, ANS, should ensure the process of monitoring and alerting controllers, supervisors and Unit management of validity dates of license validation certifications (License, Medical and English Language Proficiency). This alerting would include notification to ensure that no controller is permitted to assume an operational position without the required validations.

GACA-ANS Open

AIB-2015-0100-SR-03

The General Authority of Civil Aviation, ANS, should undertake a Hazard Identification and Risk Assessment of the use of Bi-Directional Airways.

GACA-ANS Open

34



AIB-2015-0100-SR-04

The General Authority of Civil Aviation, ANS, should undertake a program of Random Audio/Radar Playback Review no less than yearly to assess controller Skill, Adherence to Approved Phraseology, Use of Approved Procedures, and Operational Proficiency. This review would include (at minimum) a controller/assessor debrief as well as a corrective action plan for any noted deficiencies.

GACA-ANS Open

AIB-2015-0152-SR-01

GACA ANS to provide the AIB with corrective actions (Planned, Initiated or Completed) to address Other Factor (OF1: The Jeddah East Controller was occupying an operational position and providing Air Traffic Control Services with an expired License). Details of actions to include Completion dates or Planned/Estimated Completion dates.


Jun-2016

AIB-2015-0152-SR-02

Ethiopian Airlines to provide AIB with corrective actions (Planned, Initiated or Completed) to address Contributing Factor (CF1: The Flight Crew of ETH3403 “forgot” to adjust the altimeter to Standard Pressure). Details of actions to include Completion dates or Planned/Estimated Completion dates

Ethiopian Airlines

Over Due 13-Jun-2016

AIB-2015-0171-SR-01

GACA-ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing factors (CF1 to CF6) and other factors (OF1). Details of actions to include Completion dates or planned and estimated completion dates. Should no action be planned, rationale to be provided.

GACA ANS Over Due 14-

Jun-2016

AIB-2015-0202-SR-01

GACA ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified Contributing Factors (CF1, CF2, CF3) and Other Factors (OF1, OF2, OF3).


Jun-2016

AIB-2015-0258-SR-01

GACA-ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing factors (CF1-CF6) and other factors (OF1-OF4). Details of actions to include Completion dates or planned and estimated completion dates. Should no action be planned, rationale to be provided.


Jun-2016

AIB-2015-0297-SR-01

GACA-ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing factors (CF1, CF2 and CF3) and other factors (OF1, OF2 and OF3). Details of actions to include Completion dates or planned and estimated completion dates.


Jun-2016

35



AIB-2015-0304-SR-01

Saudi Arabian Airlines must emphasize on the “Stress Management” techniques for crewmembers trainings, publications and related events.


Open

AIB-2015-0304-SR-02

Saudi Arabian Airlines must ensure proper implementation of “Fatigue Risk Management” as applies to its mode of operations and the variations of crew assignments.


Open

AIB-2015-0304-SR-03

Saudi Arabian Airlines Crew Management and Corporate Safety need to promote the awareness on the “Change” and “Change Management” concepts, being an element of Safety Management System that needs to cascade down to line operations level.


Open

AIB-2015-0328-SR-01

GACA ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified Contributing Factors (CF1, CF2, CF3, CF4, CF5) and Other Factors (OF1, OF2).

GACA ANS Open

AIB-2016-0001-SR-01

RSAF should provide the AIB with corrective actions (planned, initiated or completed) to address contributing factors (CF 1) and Other Factors (OF 1). Details of actions to include completion dates or planned and estimated completion dates. Should no action be planned, rationale to be provided.

Saudi Ground Services

Over Due 01-Oct-2016

AIB-2016-0023-SR-01

Saudi Ground Services Company (SGS) shall ensure operational staff situational awareness and compliance with established equipment handling procedures in order to reduce the risk of such avoidable occurrence.

RSAF Over Due 06-

Jun-2016

AIB-2016-0036-SR-01 Military Control Agencies should establish connectivity ability (hotlines) with civilian ATC at the operational level.

Military Control

Agencies Implemented

AIB-2016-0036-SR-02

A Military/Civilian workshop should be conducted to formalize shared use airspace procedures including:

Co-ordination.

Separation.

Terminology.

Reduced Separation Criteria.

Civilian Response to Military activity.

Levels of activity (training, operational).

All Implemented

AIB-2016-0036-SR-03 RSAF to ensure understanding and compliance with aircrew and control agency personnel.

RSAF Implemented

AIB-2016-0057-SR-01

When practicable, Air Traffic Control should provide advisory of observed flight activity within the OERY control zone for arriving aircraft that are west of the final approach for runway 33 left/right at OERK.

ATC Over Due 23-

Jul-2016

AIB-2016-0067-SR-01 GACA-ANS should provide the AIB with corrective actions (Planned, initiated or completed) to address identified Contributing


Jun-2016

36



Factors (CF-1 to CF-5) and Other Factors (OF1 to OF4).

AIB-2016-0067-SR-02

The Ground Controller should, for aircraft that have been approved for any intersection departure, instruct the aircraft to contact the Local Controller and to advise its position when ready to depart.

Ground Controller


AIB-2016-0067-SR-03

All controllers should be given formal briefings on the use of the REST checklists.

Checklist should be placed in each operational position.

Compliance with ATSP-2, 1102.3 is to be ensured by supervisors and random checks to be completed by the ANS manager and GACA-ANS Safety Department.

Ground Controller


AIB-2016-0067-SR-04

GACA-ANS should ensure that supervisors are aware of their roles and responsibilities as it pertains to compliance with existing rules and regulations and over-all decorum within the workplace. GACA-ANS should adopt a method of randomly assessing supervisory effectiveness and address any found deficiency accordingly.


Jun-2016

AIB-2016-0067-SR-05

A method of enhancing controller situational awareness should be determined to highlight significant areas on the Electronic Flight data strip (improve visual clues).


Jun-2016

AIB-2016-0067-SR-06

GACA-ANS should provide training to all tower controllers to confirm their understanding of the application of turbulence separation and a countdown timer installed in the Local Position to ensure timing compliance.


Jun-2016

AIB-2016-0067-SR-07

GACA-ANS should immediately take action to address the external distractors. This includes (not limited to):

Dedicated, approved and secure parking for operational tower staff at Gate 10;

Improvements into the airside vehicle usage; and

Shift Scheduling to ensure appropriate resource overlap to address briefing requirements.


Jun-2016

AIB-2016-0079-SR-01

Saudi Arabian Airlines to review the SOP in General Operations Manual paragraph (8.34.1) and consider adjustments to this policy to permit the First Officer to taxi the aircraft when a situation necessitates.


Implemented

AIB-2016-0079-SR-02

Saudi Arabian Airlines to review the “Flight Crewmember Incapacitation” procedures in Cabin Crew Operations Manual and establish a clear procedure of evacuating an incapacitated crewmember from the flight deck on all types of aircraft.


Implemented

AIB-2016-0079-SR-03 Saudi Arabian Airlines to review the “First Aid” Saudi Arabian Implemented

37



procedures in Cabin Crew Operations Manual and include a precaution against metal conductivity when using the automated external defibrillator (AED) in locations of aircraft cabin where metal structures exist on the floor or at the wall dividers or galley. Such a precaution should also include instructions to utilize non-conductive materials to isolate the victim from those metals.

Airlines

AIB-2016-0079-SR-04

Saudi Arabian Airlines to emphasize the importance of “Wide Perspective” concept of managing cabin safety when handling one emergency situation and being vigilant to other safety hazards.


Implemented

AIB-2016-0079-SR-05

Saudi Arabian Airlines to assess the body of knowledge and competence of its Station Managers and ensure that a development program is in place for such competencies.


Over Due 18-Dec-2016

AIB-2016-0079-SR-06

GACA-SSAT to ensure that the material and duration of the ATC ab-initio course fulfill the requirement as set forth in ICAO Annex 1 — Personnel Licensing and the guidelines of ICAO Doc.9835 and ICAO circular 323.

GACA - SSAT Over Due 18-

Dec-2016

AIB-2016-0079-SR-07 GACA/ANS/S&Q to ensure the efficiency of the annual competency check program for Air Traffic Controllers.

GACA ANS S&Q


AIB-2016-0079-SR-08

Saudi Academy of Civil Aviation (SACA) to fulfill the requirement for the ATC abinitio Course as set forth in ICAO Annex 1 — Personnel Licensing and the guidelines of ICAO Doc.9835 and ICAO circular 323 in terms of material and duration.

SACA Over Due 18-

Dec-2016

AIB-2016-0079-SR-09

GACA / AIRPORTS to review its Training Policies and Programs for “Airfield Operations Centers” and establish a systemic training and competency levels for AOC officers.

GACA AIRPORTS


AIB-2016-0079-SR-10

GACA/AIRPORTS to review its policy regarding the “Airfield Operations Centers” and its Officers and emphasize the importance of keeping proper and valid logs of the AOC activities.

GACA AIRPORTS


AIB-2016-0184-SR-01

The Saudi Private Aviation (SPA) must emphasize compliance with special ramp handling requirement pertaining to apron/stand within its Ground Handling Agreement with contracted operators.

Saudi Private Aviation

Implemented

AIB-2016-0184-SR-02

The Saudi Private Aviation (SPA) must ensure aircraft operators' compliance to Ramp Handling requirement and report incompliances to the Authority.

Saudi Private Aviation


AIB-2016-0563-SR-01 KAIA to develop and implement a detailed Runway / Taxiway closure procedures and compliance checklist with proper approvals

KAIA Open

38



that is acceptable to GACA-SSAT.

AIB-2016-0563-SR-02

KAIA to review and enhance the current NOTAM request procedures to ensure that NOTAMs are properly reviewed and validated prior to issuance.

KAIA Open

AIB-2016-0563-SR-03 KAIA to ensure the currency of its NOTAM originators list.

KAIA Open

AIB-2016-0563-SR-04

KAIA to activate the function of the runway safety committee and utilize that expertise in hazard identification and risk assessment and safety assurance for the runway systems.

KAIA Open

AIB-2016-0563-SR-05 KAIA to submit its SMS Implementation Plan for GACA-SSAT review within 30 days.

KAIA Over Due 15-

Jan-2017

AIB-2016-0563-SR-06 KAIA management team to attend Safety Management System training, initial and refresher.

KAIA Open

AIB-2016-0563-SR-07

KAIA accountable executive to ensure that the designated SMS Manager exercises his role especially in facilitating hazard identification and safety risk analysis while monitoring the effectiveness of safety risk controls.

KAIA Open

AIB-2016-0058-SAR-01 NasJet should provide a set of approved food containers and foil wrap that is suitable for the type of ovens on-board of aircraft.

NasJet Response awaited

AIB-2016-0058-SAR-02 NasJet should advise Cabin Crew to only use the company's provided food containers and foil wrap in aircraft’s oven.


AIB-2016-0058-SAR-03

NasJet should introduce procedures for the use of food containers and foil wrap in the training syllabus for the cabin crew training. The procedures should be included in both, in-flight service training and flight safety training along with its annual recurrent training.


AIB-2016-0058-SAR-04 NasJet should include procedures for the use of food containers and foil wrap in its related operations manuals.


AIB-2016-0067-SAR-01

General Authority of Civil Aviation (GACA), Kingdom of Saudi Arabia, must immediately undertake action to provide (short term) authorization (documented and traceable) to all operational Air Traffic Controllers to operate in contravention to ATSP-1, Section 203.1, And GACA Regulations, Personnel Licensing, Chapter 2, Sections 2.1.1.1 , 2.1.2.1 , 2.1.3.2 , 2.1.4.1. (a, b, & j ) , 2.1.4.2.1 , and that GACA assumes the responsibility for this action.

GACA Over Due 15-

Jun-2016

AIB-2016-0067-SAR-02

GACA must immediately undertake a detailed review of all required certificates as held by Air Traffic Controllers. This includes (not limited to):

Airman’s Certificate issued for the authority to provide Air Traffic Control Services.

GACA Over Due 15-

Jun-2016

39



Medical Certificate

English Language Proficiency (ELP) This review will identify all deficiencies and provide direction, corrective actions and further actions to address all licensing issues and to ensure compliance with all applicable regulations.

AIB-2016-0079-SAR-01

GACA/ANS shall immediately take appropriate action to ensure that, when an emergency is declared by an aircraft, the Air Traffic Controller shall ascertain the type of emergency and the intentions of the flight crew by writing/taking notes of the emergency message and crew intentions, confirm it (read back), and then shall relay the message exactly as received.

GACA/ANS Implemented

AlB-2016-0079-SAR-02 GACA/ANS to include the contents of recommendation AIB-2016-0079-SAR-01 in its operating procedures and training manuals

GACA/ANS Implemented

41

Activities: 2016 was the first full year of operation of FRL at AIB facilities, this allowed investment of more time from assigned investigators to brush up skills and explore additional capability features with available hardware and software. On the investigation side: downloaded and analyzed data for twenty-two (22) recorders. The product of these analyzed factual data are plots, excel sheet text data tables, audible sessions conducted in CVR LAB; all populated in FRL reports and to be used in completing the relevant investigations.

Quarter KSA Registered

Aircraft

Foreign Registered

Aircraft

Occurrences in KSA

Occurrences Abroad

Recorders Downloaded and

Analysed

1st 0 2 2 0 4

2nd 3 1 4 0 8

3rd 2 1 1 2 2

4th 2 2 3 1 8

Date Occurrence Downloaded Recorder Flight Recorder

Laboratory (FRL) Report

FDR CVR

24/03/2016 Air Atlanta, TF-AMU, and Returned from flight to Jeddah due to Engine NO.2 Stall during climb mode.

Yes Yes FRL-2016-03-001

29/03/2016 Tunis Air TS-IFN, Returned from flight to Madinah due to Engine NO.1 Stall during climb mode.

Yes Yes FRL-2016-03-002

17/04/2016 Air Arabia, A6-AOJ, Flight diverted to Riyadh due to smoke detection warnings in the aft cargo bay activated.

Yes Yes FRL-2016-04-003

20/04/2016 FLYNAS, VP-CXJ, returned from flight to Jeddah due to engine cowls were fully opened during climb mode.

Yes Yes FRL-2016-04-004

29/05/2016 SAUDIA, HZ-ASV, Crew incapacitation, in Riyadh.

Yes Yes FRL-2016-05-005

13/06/2016 SAUDIA, HZ-AS34, Hard Landing in Jeddah

Yes Yes FRL-2016-06-01

19/07/2016 Private, HZ-N777AS, Wing tip touched the ground. In Le Bourget, Paris, France

Yes Yes NO Report

04/09/2016 Emirates, EK-521, Crashed while landing, in Dubai

Copy of data from UAE

authority, GCAA NO FRL-2016-09-01

18/09/2016 SAUDIA HZ-AS38, Hard Landing in Taif Copy of data

from Operator NO FRL-2016-09-02

11/10/2016 Egypt Air, SU-GBD, flight diverted to MED due to Hydraulic system overheated.


17/10/2016 Korean air, HL-8211, Returned flight to Riyadh due to engine NO. 1, Stall during climb mode.


42

Date Occurrence Downloaded Recorder Flight Recorder

Laboratory (FRL) Report FDR CVR

03/11/2016

SAUDIA HZ-ASJ, Takeoff aborted due to engine NO.1 Master warning both visual and audible activated. In Alexandria, Egypt.


07/11/2016 FLYNAS, VP-CXO, TCAS RA, in Jeddah Yes Yes NO Report

Flight Recorders Activities (2015 vs 2016)

Flight Recorder Laboratory (FRL) facilities’ work flow arrangements: The Flight Recorder Laboratory (FRL) facility arranged for the following stages: Stage One: Receiving. Stage Two: Level two and three data recovery. Stage Three: Data download. Stage Four: CVR listing and transcribing. Stage One: Receiving: The receiving stage is the introductory phase of the flight recorders in AIB premises. Flight Recorders will be inducted at this stage in the same status as received from the operator/site, i.e. damaged or undamaged, and comply with the following receiving inspection check list: A) Photographing the Flight Recorders as received status. B) Cleaning Flight Recorders as needed, if the Flight Recorders are damaged all necessary

tasks will be accomplished in this room i.e. crashed, or underwater recovery procedures. C) Repairing the Flight Recorders as required. D) Once the recorders handling cycle in all stages is completed, the recorders will be

returned back to receiving stage to preserve and prepare for shipping back to operator.

0

2

4

6

8

1010

0 0

6 4

8

2

8

2015 2016

43

The four stages of receiving inspection

Stage Two: Level two and three data recovery: The main function at this stage is to obtain data from damaged Flight Recorders by applying Memory Retrieval Processes; A) Level Two recoveries are equipped to serve Flight Recorders with minor damaged Crash

Survivable Memory unit outer case that cannot be used, therefore the capability is to remove the damaged memory module and fit it on a dummy Flight Recorder/Bench Unit, and then proceed with regular downloading process.

Level two recovery

B) Level three recoveries are equipped to serve Flight Recorders with major damage and

requires repairing to the Chassis of the recorder and/or downloading data directly from Printed Circuit Board.

44

Level three recovery

Stage Three: Data Download: The main function of the FRL is performed at this stage i.e. download of flight recorders via downloaders, and configure the retrieved data into readable files for INSIGHT / FAS system.

Data download

Stage Four: Cockpit Voice Recorder (CVR) Listening and transcribing: The analog mixer with digital control console provides clear CVR replay with filtration and channeling functions and visual plotting for traceability of channels; the listening can be done through headsets, or wall-mounted speakers.

45

CVR Listening and transcribing

Equipment Maintenance: Equipment Inventory: In 2016, completed a review for all preventive maintenance (PM) requirement for available equipment, and software update. Developed a database to alert for due PM / software update, and a log for PM performed and/or software update completion.

No Name of Equipment Manufacturer Part

Number Serial Number Location

1 AC Power Supply MAGNUS LF1-400 2212 Download room

2 DC Power Supply MAGNUS LDC-28 2118 Download room

3 Computer Workstation

(WS1) DELL XPS 730 2HC7LH1 Download room


(WS2) DELL XPS 730 5HC7LH1 Audio room


(WS3) DELL XPS 730 4HC7LH1 Download room

6 LAPTOP (L1) DELL M1730 A042-74F8 Download room

7 LAPTOP (L2) DELL M1730 9202-AC70 Audio room

8 Ture RMS DMM GREENLEE DM-820 083270436 Receiving room

9 Oscilloscope AGILENT DS05014A MY48260312 Equipment rack

10 Function Generator AGILENT 33220A MY44039201 Equipment rack

11 Electronic Caliper STARRETT 799A-

06/150 08/300121-1 Receiving room

12 Data Retrieval Unit UNIVERSAL CORP 1601-75 101 Download room

13 CVR/FDR Test Set UNIVERSAL AVIONICS 1623-01 228 Download room

14 Ruggedized Service

Unit (Rsuii) AVIONICA INC 650-0300 15481

Download room (Photo)

15 Recorders Portable

Ground Support Equipment (RPGSE)

HONEYWELL 952-0035-

002 RPGSE 1-

00399 Download room

(Photo)

46

Downloaders

Measuring Equipment Calibration Requirement: Defined calibration requirement and interval for available measuring testing equipment and precision measuring tools.

No Equipment

Nomenclature Part No Serial No Manufacturer (OEM) Location at FRL Lab

1 True RMS DMM DM-820 083270436 GREENLEE Receiving room

2 Oscilloscope DS05014A MY48260312 Agilent Technologies Tape rack- mount

3 Function Generator 33220A MY44039201 Agilent Technologies Tape rack- mount

4 Electronic Caliper 799A-6/150 08/300121-1 STARRETT Receiving room

Measuring equipment Capability Development: Frame Format Description Files (FFD): FFD is the data format used by INSIGHT application. Aircraft Parameter Database files; describes how to “Demultiplex” flight parameters from ARINC Frame Data and convert them into engineering units. The Capability since initial start in 2010 until 2015 was limited to 18 files in FFD file library, in 2016 the capability has expanded by 100% and increased the number in FFD file library to 36 files.

47

Frame Format Description Files

Layout File (LF): AIB acquired a new system (FAS) Flight Analysis System to analyze, plot, and animate Flight Recorders data. The new system requires files conversion from original format to Layout File (LF). The LF is a file format that integrates the downloaded data into the new sophisticated real time data which is used with FAS. AIB started configuring these data files for the new system in the last quarter of 2016, and successfully completed 3 files. In 2017, our target is to convert 12 FFD files to LF configuration.

Layout Files configured in 2016 for some aircraft

Aircraft Type Bits

A320 256

A320 1024

A330 256

Flight Analysis System (FAS): FAS is a new system acquired in 2016, developed by Canadian Plane Sciences Inc., and fitted in Data Download room, it is a new integrated technology for accidents / incidents analysis and simulation. FAS is the next generation accident investigation system, it is a new aircraft generic display optimized for analysis plus traditional cockpit replica displays.

0

5

10

15

20

25

30

35

40

2010 - 2015 2016

18

36

2010 - 2015

2016

48

Flight Analysis System (FAS)

FAS software has many features built in to allow investigators to interactively work with the source data downloaded. A special ‘investigation’ display has been developed to enable investigators to quickly look at flight data in a common way across many aircraft types. The software can also model replicas of the cockpit instrumentation when needed but the generic investigative display is rapidly gaining acceptance as a ‘first look’ to undertand what is happening and next steps.

FAS Software

Memory Access Retrieval system (M.A.R.S): Under contract from the AIB, Plane Sciences has completed the first prototype of MARS (Memory Access Retrieval System) which enables the AIB to connect the memory board from the accident recorder directly and read the memory chips one by one. MARS was designed with an extendable methodology to allow additional recorder types to be added with an appropriate adapter cable to connect to the one standard MARS connection point. Since data is critical to accident investigators every precaution must be taken to ensure he memory cannot be damaged. To that end, AIB first uses a specially built tester to test the MARS reader as well as use special procedures to test that there are no shorts in the connector cable.

49

Solid State Memory Board from a past AIB accident connected directly to MARS

MARS reader connected to MARS Tester which has built in precautions to minimize any risk

to the readout process. Characteristics of MARS: Eliminates need for inventory of “Golden Chassis” Bench Units. One integrated system handles ALL ARINC recorders types. Memory structure / format source documentation provided (for potential chip level

retrieval). Bit editing for recovering sync losses/missing data. Circumvents CVR erase logic. Improves playback probability without reliance on recorder OEM.

50

Current industry practice to handle crash-damaged recorders.

MARS is now ready as a product handling (2) out of (7) Honeywell solid state recorder types with plans to complete testing of all seven in the first half of 2017. Product development plans include all other types of recorders within the next 24 months. The product will read the memory board directly without the recorder OEM Bench Unit.

53

Safety Study: Ground Accidents or Incidents represent a significant concern for the Aviation industry. Statistics indicate that various countries of the world suffer exhaustion of their resources in Ground Accidents or Incidents. Data developed by the International Air Transport Association (IATA) and the Flight Safety Foundation (FSF) estimates that 27,000 ramp Accidents and Incidents occur worldwide every year (one per 1,000 departures), resulting in about 243,000 injuries (9 injuries per 1,000 departures). The annual cost to major airlines worldwide is estimated at least US$10 billion. Aviation Investigation Bureau (AIB) receives all notifications related to Aviation Occurrences (as defined in the ICAO Annex 13) in which Ground Accidents or Incidents is one of them.

Safety Study Description Status

RAMP Ground Incidents Reporting On-Going

Scope of Work: Aviation Investigation Bureau (AIB) receives notifications of Aviation Occurrences (as defined in the ICAO Annex 13) in the Kingdom of Saudi Arabia or whenever a Saudi registered or operated aircraft is involved. Amongst these occurrences there are incidents that occur during ground handling of aircraft at KSA airports which will be referred to as RAMP incidents. Comparison between 2014 and 2015 showed a noticeable increase in the number of RAMP Incidents at KSA Airports. The increase in number is partly attributed to enhancement of reporting. The increasing rate of RAMP incidents required a special focus on the circumstances and factors that contributed to RAMP incidents and to take the necessary action towards prevention. This initiative endeavored to shed light on the impact of RAMP incidents to get the required attention from the involved parties so that proper mitigation and prevention measures are sought and pursued. The initiative involved and engaged all of the relevant parties in a working group. 1) Data Collection: The AIB in coordination with Air Operators, Saudia Ground Services (SGS) and GACA –SSAT collected RAMP incidents data for 2014 and 2015. The data was then crossed referenced with the available data in AIB and following is the result:

Year: 2014 2015

Number of Ground incidents: 24 56

2) Data Analysis: The AIB analyzed the RAMP incident data and identified the following contributing factors: a. Lack of supervision by the Ground Services provider during ground operations; b. Poor serviceability condition of Ground Support Equipment. c. Not adhering to Standard Operating Procedures (SOP). d. Labors Fatigue due to lengthy working hours, Unavailability of proper rest areas, multi

task assignments… etc.).

54

3) Team Formation: The AIB established the Terms of Reference (ToR) for the working group for this initiative (appendix 1) addressing the project objectives, scope of work, time line and deliverables. The working group consisted of members representing the following organizations: a. Safety Security and Air Transport (SSAT- GACA); b. Safety and Quality Division (Saudi Arabian Airlines); c. Safety Department (Flynas); d. Safety, Security and Quality (SGS ); and e. Aviation Investigation Bureau (AIB). 4) Result of Working Group: The working group held four meetings to discuss RAMP incidents and prevention measures (minutes of meetings are in appendix 2). As a result the working group agreed on the following: a. Saudia and Flynas to adopt Flight Safety Foundation (FSF) method for calculating direct

cost of Ground Handling (RAMP) incidents. The calculation method depends on obtaining the rate of Incidents and / or Personal injuries per 1000 flight departures; it also considers the total number of flights, number of RAMP incidents and types of Airplanes during a specific period.

b. Standardizing and improving RAMP incidents reporting and collection of detailed data. AIB developed a standardized reporting form.

c. Continue coordination, review reports and effectiveness of safety recommendations related to RAMP incidents amongst the stakeholders of the working group periodically.

d. Operators (Saudia and Flynas) to evaluate/monitor the ground handling activities around their Airplanes through assigned safety officer and immediately report any discrepancies or violations to SGS duty manager for necessary action.

e. SGS removed 200 defective baggage trolleys outside KAIA Airport that contributed to RAMP incidents.

5) Standards' Assessment: Stakeholders were requested to assess current standards and regulations and following is the result: a. No comments were received from Stakeholders with an exception of Saudia Ground

Services. b. SGS Ground Operation Manual (GOM) chapter 6.2 stipulates the c. Responsibility of the Ramp Supervisor to ensure safe, secure and on. d. Time flight turn around. This responsibility is not applied due to lack of qualified staff. 6) Recommendations: 6.1) Security and Air Transport (SSAT-GACA): a. SSAT to promote awareness of GACA Regulations 151 and 68 amongst KSA airport

operators and ground handling service providers. b. Boost the audit program on ground handling service providers to ensure implementation

of applicable regulations. c. SSAT to lead a quarterly meeting involving stakeholders of the working group and

including representation of Airport operators to discuss AIB RAMP incidents report and required prevention measures.

55

6.2) Saudia Ground Services (SGS): a. SGS to effectively carry out daily inspection for motorized and non- motorized Ground

Support Equipment (GSE). b. SGS to assure that GSE operators are properly trained and certified in accordance with

GOM. c. SGS to assure that GSE are safe, serviceable and properly utilized. d. SGS to establish a mechanism - acceptable to SSAT - to prevent GSE operators from

operating unserviceable and unsafe equipment. e. SGS to effectively implement the Ramp Supervisor (Turnaround Coordinator) function as

required by SGS GOM chapter 6. f. SGS to submit a phase out plan to SSAT for GSE that are not in compliance with GACA

Regulation 151.83 paragraph (e): “Unless authorized by the President in the certificate holder's operations specifications, ground support equipment must not be more than fifteen years old”

g. SGS to ensure GSE maintenance service provider comply with Service Level Agreement (SLA).

6.3) Aviation Investigation Bureau (AIB): a. AIB to create data platform for collecting and capturing related RAMP incidents. b. AIB to provide Stakeholders with RAMP Incidents analysis reports for discussions in the

quarterly working group meeting. The reports shall contain incidents categorized by Airports, contributing factors and assessment of safety recommendation effectiveness.

c. AIB to establish standard notification mechanism for the stakeholders to report RAMP incidents.

d. AIB to establish standard data collection mechanism for stakeholders to report RAMP incidents findings, contributing factors and preventive measures.

6.4) GACA Airports: a. To establish Standard Operating Procedures (SOP) for handling the certification of

Ground Support Equipment in accordance with GACA regulations. b. Introduce the concept of third party inspections at KSA airports to ensure continuous

operational safety of ground service equipment. 6.5) Operators (Saudia and Flynas): Operators to utilize the Flight Safety Foundation cost calculation method to produce quarterly RAMP incidents financial impact report to stakeholders.

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Safety Concern and Issues: The AIB will be monitoring certain occurrences categories which are mostly quantitative but more initiatives are planned to mitigate the current escalating trends. The three most notable areas of concern are shown below.

Top three categories of safety concern

During 2016, there was a noticeable increase in incidents involving ground handling services. This includes catering trucks, airplane tugs and baggage vehicles colliding with serviced aircraft. In some cases, it resulted in serious injuries and/or significant damage to aircraft.

Ramp occurrences in the four major airports in the Kingdom

0

10

20

30

40

50

60

70

BIRD

CABIN

RAMP

42

4

46

62

27

61

BIRD CABIN RAMP

2015 42 4 46

2016 62 27 61

0

5

10

15

20

25

KAIAKKIA

KFIAPMIA

21

16

6

0

25

20

10

1

KAIA KKIA KFIA PMIA

2015 21 16 6 0

2016 25 20 10 1

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The main causes were: 1. Equipment operators were not following proper operating procedures due to lack of

knowledge or cutting corners. 2. Equipment failure due to poor maintenance. 3. Lack of supervision Bird Strike:

During the year 2015 forty-two (42), and sixty-two (62) in 2016 occurrences in kingdom of bird strike to the aircrafts has been reported. The damage to the aircraft was reportedly minor and all the occurrences were consequently not serious in nature. Most bird strikes occurred during the months of September, October and November which coincides with the seasonal bird’s migration period.

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Bird strike comparison (all)

Bird strike comparison (between major and other airports in the Kingdom)

The Bird Strike Safety Study will be ongoing utilizing research and outreach programs with airports having the greatest number of bird strikes as the AIB wishes to stay ahead of the issue.

0

2

4

6

8

10

12

14

16


2

0

3 4

1 2

0 1

16

7

5

1

1 3

9 10

7

4

2

5

10

6

4

1


2015 2 0 3 4 1 2 0 1 16 7 5 1

2016 1 3 9 10 7 4 2 5 10 6 4 1

0

10

20

30

KAIAKKIA

KFIAPMIA

OtherAirports

11 7

4 3

21 17

7 10

2

26

KAIA KKIA KFIA PMIA Other Airports

2015 11 7 4 3 21

2016 17 7 10 2 26

2015 2016

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Air Proximity:

The AIB had issued numerous safety recommendations on this subject matter. In addition, two days’ workshop was organized on 11th and 12th May 2015 involving all the relevant stakeholders, Air Traffic Control Units, aircraft operators, GACA-ANS and GACA-SSAT. The purpose of the workshop was to address and highlight the noticeable rise in the number of TCAS RA incidents in KSA airspace and to discuss and promote safety and efficiency enhancement to the current KSA airspace structure, participants were given opportunity to share and present their experiences, challenges or issues related to Saudi Airspace. The outcome of the workshop was a list of recommendations addressing organizational, procedural, technical and work environment issues, aiming to achieve the safety and efficiency enhancement in the KSA airspace.

TCAS RAs occurrences based on aviation sectors

0

2

4

6

8

10

12

14

16

North East NorthEast

West Central RUHCTA

JED CTA South SouthEast

6

1 2 2

0

15

12

5

0

3

1

6

1 1

12

1 2

1

2015

2016

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Introduction: Need some text here 1) Human Resources: 1.1) Recruitment: 6 candidates were hired 4 of which are of technical expertise, 1 in Administration, and 1 in operations. 1.2) Employee Retention: Employee retention is at 97%. 1.3) Saudization: Saudization is at 95% in the whole organization and 100% at all positions in the Organization Structure. 1.4) Policies and Procedures: Overall 75% of AIB Financial and Admin. Affairs policies and procedures has been completed as follows: HR and Administration Policies and Procedures has been completed. IT Policies and procedures has been completed. Remaining policies and procedures are under process. 1.5) Training and Development: 2 year plan has been established to train Admin staff to be able to support the technical teams. 1.6) Employee-Engagement Program: To encourage job rotations and diversity, most employee are carrying out multiple functions in Administration and operations that are related to incident/accident sites. 1.7) Leave Planning: A built structured plan for the whole year regarding all types of leave, in order to know the whereabouts and availability of staff in case of an incident or accident. 1.8) Employee Database: All relevant information regarding training, employee information, overtime balance are registered and saved in the AIB SharePoint. 1.9) Job Descriptions: 100% of all positions’ Job Descriptions has been completed. 1.10) Attendance: Daily attendance reports and quarterly statistical analysis for each employee has been established to measure availability. 1.11) Forms: Forms that accommodate AIB functions and needs has been completely established.

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3) Information Technology: 3.1) AIB Website: An agreement has been established with GACA IT to create and interactive modern website that suites the AIB’s functions and role in Aviation Investigation. it will allow occurrences reporting from anonymous individuals and known organization which will be via the website to the designated AIB officials. The launch will be 2nd quarter of 2017. 3.2 FTP (File Transference Protocol): An agreement has been established with GACA IT to create it in order to exchange large files such as videos, high resolution 3D photographs, and files. The launch will be 2nd quarter of 2017. 3.3) Twitter: AIB Twitter official account has been established to update current events and aviation related safety and investigation occurrences. 2000+ followers so far in less than a year. People in safety and investigation background are interacting with the account asking questions in the field. 3.4) SharePoint System: It was created for the following reasons: To have a Powerful, reliable server platform designed to perform a great of applications

and services while suffering minimal downtime. To have Powerful, fast search engine – search for docs and via metadata. To Facilitate Collaboration. Flexible web server – serves up documents for different types of end user devices Scalable infrastructure – build and add apps and services Improve Workflows.

3.5) AOMS (Aviation Occurrences Management System): Exclusive in-house system is being created with the assistance of GACA IT in order to document occurrences and be able to extract information based on specific criteria. All departments can use the system to get the required information such as dates, airline, people etc. 3.6) Network Wireless Access Point: An access point was created in all AIB facilitates in order for employees and visitors to utilize the web using laptops and mobile phones to efficiently finalize tasks and facilitate communications. 3.7) Data Tracking System (DTS): The system was created to document internal memos and all documents to create a referencing mechanism for all AIB Ducments. 4.0) Public and Government Relations: 4.1) Workshops, Conferences and Events: The AIB is extremely vigilant in regard to media and social events to spread awareness and increase the safety standards of aviation. Henceforth, workshops and conferences are routinely conducted by the AIB inviting various key individuals and instructors to spread

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awareness and to educate key figures in the aviation field. Key figures from all over the world from airlines, airport, and organizations are participating. The AIB vision has been successfully shared across the world. Some of the key workshops are as follows: National Aviation Accident Communication Strategy. Quality Integrated Management System Training. Family Assistant Plan. Investigation Management Course. Aviation Accident Report Writing. 4.2) International Collaboration: Collaborating with government officials in the aviation fields and assisting when required in regard to blackbox data, analysis, etc. 4.3) Global Ministerial Aviation Summit: AIB was one of the partners and participated in spreading awareness by having booth. 4.4) Employee Discount Program: A program has been created to ensure the well-being of employees; discounts are available in regard to car accessories, gym memberships, hotel reservations, restaurant, etc.

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Introduction: One of the AIBs objec

subject annual report... · 2020. 5. 12. · 4.1) description 25 4.2) conclusion 25 5) case number...

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