Lennuamet · 15. juuni 2017
Sisu (failidest)
Dear all,
I would just like to let you know that the 2017 edition of EASA Annual Safety Review was recently
published and it is available at the link below.
https://www.easa.europa.eu/document-library/general-publications/annual-safety-review-2017
Kind regards,
Ionuț FLORIAN
Safety Analysis Coordinator (SNE)
Safety Analysis and Performance Section
European Aviation Safety Agency
Tel.: +49 221 89990-2123
🏠 Konrad-Adenauer-Ufer 3,
D-50668, Cologne (more info)
An agency of the European Union
2017
Disclaimer
The occurrence data presented is strictly for information purposes only. It is obtained from Agency databases
comprised of data from ICAO, EASA Member States, Eurocontrol and the aviation industry. It reflects knowledge
that was current at the time that the report was generated. Whilst every care has been taken in preparing the
content of the report to avoid errors, the Agency makes no warranty as to the accuracy, completeness or curren-
cy of the content. The Agency shall not be liable for any kind of damages or other claims or demands incurred as
a result of incorrect, insufficient or invalid data, or arising out of or in connection with the use, copying or dis-
play of the content, to the extent permitted by European and national laws. The information contained in the
report should not be construed as legal advice.
Acknowledgements
The authors wish to acknowledge the contribution made by the Member States to thank them for their support
in the conduct of this work and in the preparation of this report.
Photocredits
istock, istock, istock, istock, istock, istock, istock, istock, istock, L. Muir, istock, istock, istock
© European Aviation Safety Agency, 2017
Reproduction is authorised provided the source is acknowledged.
PAGE 1
Foreword by the Executive Director
2016 has brought continued improvements in safety across almost every operational domain. It was the lowest
year in terms of fatalities in airline operations in aviation history. However, the fatal accident involving a cargo
flight in Sweden that took place in January highlighted the complex nature of aviation safety and the significance
of addressing human factor aspects in further reducing accidents. Additionally, the tragic accident involving an
EC225 helicopter in Norway in April 2016 shows the importance of joining forces and together maintaining safety
as an aviation community.
During the past year EASA has advanced and developed key strategic activities across a diverse range of new
and emerging issues. The Agency has recently published the notice of proposed amendment on the regulatory
framework for the operation of drones. With the emergence of new and more sophisticated cyber threats, EASA
has commenced the implementation of the European Centre for Cyber Security in Aviation. The Agency contin-
ues to work with partners in Europe and at a global level to monitor the threat of conflict zones and pro-vide
rapid advice to civil aviation.
Over the past year, the Agency has further refined the way in which it applies Safety Risk Management principles.
In particular, the collaborative analysis groups, which bring together expertise from authorities and industry
stakeholders have proved to be successful tools in further underpinning a data-driven approach to managing
safety, which is now also reflected in the latest edition of the European Plan for Aviation Safety (EPAS). These
various efforts will help to ensure our continued vigilance and help improve safety for today and into the future.
Patrick Ky
Executive Director
Annual Safety Review 2017 PAGE 2
Contents
Introduction 6
How is the safety review produced?........................................................................................................6
What is the European Plan for Aviation Safety and why do we need it?...............................................6
How the EPAS is developed through the European safety risk management process..........................7
Chapter Overview......................................................................................................................................9
Typical structure of each chapter............................................................................................................10
CHAPTER 1. Cross-Domain Safety Overview 11
Key Cross- Domain Statistical Overview.......................................................................................................12
CHAPTER 2. Commercial Air Transport 14
Chapter 2a Commercial Air Transport Aeroplanes – Airline and Other Operations......................... 15
Key Statistics..................................................................................................................................................15
Commercial Air Transport Aeroplane – Airlines..........................................................................................16
Phase of Flight...............................................................................................................................................18
Propulsion type.............................................................................................................................................19
Safety Risk Portfolio......................................................................................................................................19
Use of ERCS for risk comparison...................................................................................................................23
Priority Key Risk Areas..................................................................................................................................24
Top Safety Issues............................................................................................................................................25
Performed Safety Issue Assessments and identified actions......................................................................25
Main Action Areas in the EPAS.....................................................................................................................26
Commercial Air Transport Aeroplane – Other.............................................................................................26
Propulsion type.............................................................................................................................................28
Safety Risk Portfolio......................................................................................................................................29
Priority Key Risk Areas..................................................................................................................................32
Top Safety Issues and Associated Actions....................................................................................................33
Chapter 2b Part Special Operations (SPO) – Aerial Work - Aeroplanes............................................ 34
Key Statistics..................................................................................................................................................34
Phase of Flight...............................................................................................................................................35
Operation Type..............................................................................................................................................36
Safety Risk Portfolio......................................................................................................................................37
Priority Key Risk Areas..................................................................................................................................39
Top Safety Issues and Associated Actions................................................................................................... 40
CHAPTER 3. CAT HELICOPTER OPERATIONS 41
Chapter 3a Offshore Helicopter Operations....................................................................................... 42
Key Statistics..................................................................................................................................................42
Phase of Flight...............................................................................................................................................43
Safety Risk Portfolio......................................................................................................................................43
Priority Key Risk Areas..................................................................................................................................46
Top Safety Issues and Associated Actions....................................................................................................46
Chapter 3b Other Commercial Air Transport Helicopters.................................................................. 48
Key Statistics................................................................................................................................................. 48
Phase of flight................................................................................................................................................49
Safety Risk Portfolio......................................................................................................................................49
Priority Key Risk Areas..................................................................................................................................52
Top Safety Issues and Associated Actions....................................................................................................52
PAGE 3
Chapter 3c Part Special Operations (SPO) – Aerial Work - Helicopters............................................. 54
Key Statistics................................................................................................................................................. 54
Phase of Flight...............................................................................................................................................55
Operation Type..............................................................................................................................................56
Safety Risk Portfolio......................................................................................................................................57
Priority Key Risk Areas..................................................................................................................................59
Top Safety Issues and Associated Actions................................................................................................... 60
CHAPTER 4. Non-Commercial Operations 61
Chapter 4a Non-Commercial Operations – Aeroplanes..................................................................... 62
Key Statistics..................................................................................................................................................62
Phase of Flight...............................................................................................................................................63
Operation Type............................................................................................................................................. 64
Safety Risk Portfolio..................................................................................................................................... 64
Priority Key Risk Areas..................................................................................................................................67
Top Safety Issues and Associated Actions....................................................................................................67
Chapter 4b Non-Commercial Operations – Helicopters..................................................................... 69
Key Statistics..................................................................................................................................................69
Phase of Flight...............................................................................................................................................70
Safety Risk Portfolio......................................................................................................................................71
Priority Key Risk Areas..................................................................................................................................73
Top Safety Issues and Associated Actions....................................................................................................73
CHAPTER 5. Balloons 75
Key Statistics..................................................................................................................................................76
Phase of Flight...............................................................................................................................................77
Safety Risk Portfolio......................................................................................................................................78
Priority Key Risk Areas................................................................................................................................. 80
Top Safety issues and associated actions.................................................................................................... 80
CHAPTER 6. Gliders/Sailplanes 82
Key Statistics..................................................................................................................................................83
Phase of Flight.............................................................................................................................................. 84
Safety Risk Portfolio......................................................................................................................................85
Priority Key Risk Areas..................................................................................................................................87
Top Safety Issues and Associated Actions................................................................................................... 88
CHAPTER 7. RPAS/UAS/Drones 89
Key Statistics..................................................................................................................................................90
Safety Risk Portfolio......................................................................................................................................92
Priority Key Risk Areas..................................................................................................................................94
Top Safety Issues and Associated Actions....................................................................................................94
CHAPTER 8. Aerodrome and Ground Handling 95
Key Statistics..................................................................................................................................................96
Safety Risk Portfolio......................................................................................................................................97
Priority Key Risk Areas................................................................................................................................101
Top Safety Issues and Associated Actions..................................................................................................102
CHAPTER 9. ATM/ANS 103
Key Statistics............................................................................................................................................... 104
Phase of Flight............................................................................................................................................ 106
ATM/ANS Safety Risk Portfolio....................................................................................................................107
Priority Key Risk Areas................................................................................................................................111
Top Safety Issues and Associated Actions..................................................................................................112
Annual Safety Review 2017 PAGE 4
List of Tables
Table 1 Overview of fatal accidents and fatalities 2016 Vs 10-year average (2006-2015)�������������������������������������� 12
Table 2 Key statistics CAT Aeroplane������������������������������������������������������������������������������������������������������������������������� 15
Table 3 Key statistics CAT Aeroplane - Other������������������������������������������������������������������������������������������������������������ 16
Table 2 Key statistics Part Special Operations (SPO) Aerial Work Aeroplanes�������������������������������������������������������� 34
Table 3 P
art Special Operations (SPO) Aerial Work Aeroplanes accidents and serious incidents
per phase of flight 2006-2015 vs 2016���������������������������������������������������������������������������������������������������������� 36
Table 4 P
art Special Operations (SPO) Aerial Work Aeroplanes accidents and serious incidents by operation
2006-2015 vs 2016����������������������������������������������������������������������������������������������������������������������������������������� 36
Table 5 Key statistics offshore helicopters����������������������������������������������������������������������������������������������������������������� 42
Table 7 Key statistics Other Helicopter Commercial Operations����������������������������������������������������������������������������� 48
Table 8 Offshore accidents and serious incidents per phase of flight 2006-2015 vs 2016������������������������������������� 49
Table 9 Key statistics Part Special Operations (SPO) Aerial Work Helicopters�������������������������������������������������������� 54
Table 10 Part Special Operations (SPO) Aerial Work Helicopters accidents and serious incidents
per phase of flight 2006-2015 vs 2016�������������������������������������������������������������������������������������������������������� 55
Table 11 Part Special Operations (SPO) Aerial Work Helicopters accidents and serious incidents
by operation 2006-2015 vs 2016����������������������������������������������������������������������������������������������������������������� 56
Table 12 Key statistics Non‑commercial operations aeroplanes������������������������������������������������������������������������������ 62
Table 13 Non-commercial operations accidents and serious incidents per phase of flight 2006-2016���������������� 63
Table 14 Non-commercial operations accidents and serious incidents by operation 2006-2016������������������������� 64
Table 15 Key statistics Non-commercial operations helicopters������������������������������������������������������������������������������ 69
Table 16 n on-commercial operations helicopters accidents and serious incidents per phase
of flight 2006-2016��������������������������������������������������������������������������������������������������������������������������������������� 70
Table 17 Key statistics Balloons���������������������������������������������������������������������������������������������������������������������������������� 76
Table 18 Balloons accidents and serious incidents per phase of flight 2011-2016������������������������������������������������� 77
Table 19 Key statistics Glider/Sailplanes�������������������������������������������������������������������������������������������������������������������� 83
Table 20 Sailplane accidents and serious incidents per phase of flight 2006-2016������������������������������������������������ 84
Table 21 Key statistics UAS from ECR occurrence database������������������������������������������������������������������������������������� 90
Table 22 Key statistics Aerodromes and Ground Handling�������������������������������������������������������������������������������������� 96
Table 23 Key statistics in ATM/ANS��������������������������������������������������������������������������������������������������������������������������104
Table 24 ATM/ANS related accidents and serious incidnets by phase
of flight during 2006-2016 in EASA MS����������������������������������������������������������������������������������������������������� 106
Table 25 ATM/ANS related actions included in the EPAS���������������������������������������������������������������������������������������� 113
PAGE 5
List of Figures
Figure 1. The European Safety Risk Management Process����������������������������������������������������������������������������������������� 7
Figure 1 CAT Aeroplane Airlines, evolution of fatal and non-fatal accidents, period 2006-2016�������������������������� 16
Figure 2 CAT Aeroplane Airline fatal accident rate for EASA MS AOC and non-EASA Ms, period 2006-2016������ 17
Figure 3 C
AT Aeroplane Airline non-fatal accident rate for EASA MS AOC and non-EASA Ms,
period 2006-2016����������������������������������������������������������������������������������������������������������������������������������������� 17
Figure 4 CAT Aeroplane Airline, evolution of fatal and non-fatal accidents, period 2006-2016��������������������������� 18
Figure 5 CAT aeroplane accidents and serious incidents per phase of flight 2006-2016��������������������������������������� 18
Figure 6 CAT aeroplane accidents and serious incidents by propulsion����������������������������������������������������������������� 19
Figure 7 A
ggregated Risk Score for Accidents and Serious Incidents Involving EASA MS operators
2015-2016 by Key Risk Areas������������������������������������������������������������������������������������������������������������������������ 23
Figure 8 Other CAT Aeroplane, number of fatalities, 2006-2016����������������������������������������������������������������������������� 27
Figure 9 Other CAT Aeroplane, evolution of fatal and non-fatal accidents (2006-2016)��������������������������������������� 27
Figure 10 O ther CAT Aeroplane, comparison of accidents and serious incidents by flight
phase between the average of 2006-2015 and the figures in 2016�������������������������������������������������������� 28
Figure 11 Other CAT Aeroplane, split of accidents and serious incidents in 2016 by propulsion type����������������� 28
Figure 12 Part Special Operations (SPO) Aerial Work Aeroplanes fatal and non-fatal accidents 2007-2016������� 35
Figure 13 Part Special Operations (SPO) Aerial Work Aeroplanes fatalities and serious injuries 2007-2016������� 35
Figure 14 Offshore fatal and non-fatal accidents 2007-2016����������������������������������������������������������������������������������� 42
Figure 15 Offshore fatalities and serious injuries 2007-2016����������������������������������������������������������������������������������� 43
Figure 16 Other Helicopter Commercial Operations fatal and non-fatal accidents 2007-2016����������������������������� 48
Figure 17 Other Helicopter Commercial Operations fatalities and serious injuries 2007-2016����������������������������� 49
Figure 18 P art Special Operations (SPO) Aerial Work Helicopter accidents and serious incidents
by operation 2007-2016����������������������������������������������������������������������������������������������������������������������������� 54
Figure 19 Part Special Operations (SPO) Aerial Work Helicopter fatalities and serious injuries 2007-2016��������� 55
Figure 20 Fatal and Non-Fatal Accident Rates for NCO Aeroplanes 2014-2016������������������������������������������������������� 62
Figure 21 Non-commercial operations aeroplanes fatal and non-fatal accidents 2007-2016������������������������������� 63
Figure 22 Non-commercial operations fatalities and serious injuries 2007-2016�������������������������������������������������� 63
Figure 23 Non-commercial operations helicopters fatal and non-fatal accidents 2007-2016������������������������������� 69
Figure 24 non-commercial operations helicopters fatalities and serious injuries 2007-2016������������������������������� 70
Figure 25 Balloons fatal and non-fatal accidents 2012-2016����������������������������������������������������������������������������������� 76
Figure 26 Balloons fatalities and serious injuries 2012-2016����������������������������������������������������������������������������������� 77
Figure 27 Glider/Sailplane fatal and non-fatal accidents 2007-2016����������������������������������������������������������������������� 83
Figure 28 Glider/Sailplane fatalities and serious injuries 2007-2016����������������������������������������������������������������������� 84
Figure 29 UAS reported occurrences per year 2012-2016���������������������������������������������������������������������������������������� 90
Figure 30 UAS accidents and other occurrences - Source ECR 2012-2016��������������������������������������������������������������� 91
Figure 31 Aircraft altitude vs. distance from drone at the time of detection 2010-2016��������������������������������������� 91
Figure 32 Aerodromes & Ground Handling, fatal and non-fatal accidents 2007-2016������������������������������������������� 96
Figure 33 Aerodromes & Ground Handling, fatalities and serious injuries 2007-2016������������������������������������������ 97
Figure 34 ATM/ANS related fatal and non-fatal accidents and ATM/ANS contribution per year,
2006-2016, in EASA MS���������������������������������������������������������������������������������������������������������������������������� 105
Figure 35 ATM/ANS related serious incidents and ATM/ANS contribution per year, 2006-2016, in EASA MS���� 105
Figure 36 ATM/ANS-related accident fatalities and serious injuries per year 2006-2016 in EASA MS���������������� 106
Figure 37 ATM/ANS-related accident fatalities and serious injuries per year 2006-2016 in EASA MS���������������� 107
Figure 38 ATM/ANS-related accidents and serious incidents, and those with ATM/ANS
contribution during 2006-2016��������������������������������������������������������������������������������������������������������������� 112
Annual Safety Review 2017 PAGE 6
Introduction
EASA would like to welcome you to the 2017 version of the EASA Annual Safety Review. The review has been
published since 2005 and is now in its 12th year. The analysis presented in this review together with the domain-
specific safety risk portfolios provide the data-driven input that supports the decision-making in formulating the
European Plan for Aviation Safety (EPAS). The latest edition further extends the provision of safety risk portfoli-
os through the addition of aerodromes/ground handling and ATM/ANS portfolios, bringing the total number of
analysed aviation domains to 13. The development of the European Safety Risk Management (SRM) process, and
in particular the valuable input from the Network of Analysts (NoA) and Collaborative Analysis Groups (CAGs),
means that the analysis in this year’s review provides not just a statistical summary of aviation safety in the EASA
Member States (MS) but also identifies the most important safety challenges faced in European aviation today.
This analysis will drive the development of safety actions for the next version of the EPAS and harnesses the
experience of both the EASA Member States (EASA MS) and industry to connect the data with the current and
future priorities of the Agency.
How is the safety review produced?
The EASA Annual Safety Review is produced by the Safety Intelligence and Performance Department (SM1) of
EASA.
The analysis in the review comes from two specific data sources:
EASA’s Occurrence Database. The main source of data is the Agency’s own database, being accidents and seri-
ous incidents reported to the Agency by Safety Investigation Authorities (SIAs) world-wide, which is augmented
by other information collected by the Agency from other sources. For commercial air transport aeroplanes, the
basic categorisation of accidents and serious incidents has been agreed upon at a global level in February each
year at the ICAO Safety Indicator Study Group (SISG). In all domains, the data and its quality is also checked with
the EASA MS through the NoA. EASA is grateful for the support of the safety analysis teams in each EASA MS in
developing the Review.
European Central Repository. The European Central Repository (ECR) is the central database of all occurrences
reported to the competent authorities of the EASA MS, the reporting of which is governed by Reg. (EU) 376/2014
on the reporting, analysis and follow-up of occurrences in civil aviation. This is the primary source of informa-
tion that is used to cross-check the accidents and serious incidents in EASA’s own database.
In addition, the analysis and the safety risk portfolios are developed following discussion with both the NoA and
CAGs. This ensures that the Agency’s work is enhanced by the invaluable experience and intelligence that the
members of these collaborative groups bring to the SRM process.
What is the European Plan for Aviation Safety and why do we need it?
The EPAS seeks to continuously improve aviation safety throughout Europe. The Plan looks at aviation safety in
a systemic manner and is based on available evidence of causal factors to accidents and incidents. Moreover,
the Plan addresses emerging safety issues in order to ensure our high level of safety is maintained in the future.
The EPAS is a key component of our integrated Safety Management System (SMS) at the European level, and is
constantly being reviewed and improved. As an integral part of the EASA Work Programme, the Plan is devel-
oped by the Agency in consultation with the Member States and industry through the SRM process. The Member
States are committed to the implementation of the Plan through their State programmes and plans. The current
EPAS edition covers the 5-year period from 2017 to 2021.
PAGE 7
The 3 key-issue categories addressed in the EPAS are:
Systemic Issues: Such problems affect aviation as a whole and play a role in accidents and incidents. As they may
affect operational issues, improvements can have an implicit effect on operational causes. An example of a sys-
temic issue is the potential danger that can occur if tasks and responsibilities are not properly distributed among
operational staff.
Operational Issues: These issues are closely related to events reported during operations and are brought to
light through data analysis. The operational issues are split into 2 parts, which form the basis of the safety risk
portfolios that are provided in this review:
• Key Risk Areas: The key risk areas are the accident outcomes that the EPAS seeks to stop from happening.
Examples of these are aircraft upset (loss of control), runway excursions or runway collisions.
• Safety Issues: These are the causal and contributory factors that lead to the key risk areas (accident out-
comes). Examples of safety issues are icing in flight, or pilot awareness and decision making.
• Emerging Issues: These are suspected problems that are to be expected or anticipated in the future. Ex-
amples of emerging issues include new cybersecurity threats or risks associated with flying over conflict
zones.
How the EPAS is developed through the European safety risk management process
The EPAS is developed through the European SRM process, which is defined in 5 clear and specific steps as de-
scribed below.
´´ Figure 1. The European Safety Risk Management Process
5. Safety
Performance 1. Identification
Measurement of Safety Issues
4. Implementation 2. Assessment of
and Follow-up Safety Issues
3. Definition and
Programming of
Safety Actions
Identification of Safety Issues: While the identification of safety issues is the first step in the SRM process, be-
cause it is a closed loop process the main input comes from the safety performance measurement step at the
end of the process. Candidate safety issues are taken from the results of EASA’s safety analysis activities as well
from the members of the collaborative groups (NoA and the CAGs). The members of these groups are encour-
aged to raise safety issues that are not currently captured in safety risk portfolios. These candidate safety issues
are formally captured by the Agency and are then subject to a preliminary safety assessment. This assessment
then informs the decision on whether a candidate safety issue should be included formally within the relevant
safety risk portfolio or be subject to other actions. Advice is taken from the NoA and CAGs. The output of this
Annual Safety Review 2017 PAGE 8
step in the process are the domain safety risk portfolios. Within the portfolios, both the key risk areas and safe-
ty issues are prioritised.
Assessment of Safety Issues: Once a safety issue is identified and captured within the safety risk portfolio, it is
subject to a formal safety assessment. These assessments are prioritised within the portfolio. The assessment
process is led by EASA and is supported by the NoA and CAGs. These collaborative groups are always involved in
the review of each assessment’s terms of reference and the results of the assessment. In addition, group mem-
bers are encouraged to participate in the assessment itself; this external support is vital to achieving the best
possible results. The result of the assessment is the production of scenario based bow tie models that help to
identify weak controls for which potential actions can be identified. Together this forms the Safety Issue Assess-
ment (SIA), which provides potential actions for the EPAS. This is followed by the Preliminary Impact Assessment
(PIA), which assesses the wider implications and benefits of the proposed actions and makes recommendations
on the actions to be implemented in the EPAS.
Definition and Programming of Safety Actions: Using the combined SIA/ PIA, formal EPAS actions proposals are
then made to the advisory bodies. Once discussed and agreed upon, the actions are then included in the next
version of the EPAS. Prior to publication, the EPAS is approved by the EASA Management Board.
Implementation and Follow Up: The next step in the process involves the implementation and follow-up of the
actions that have been included within the EPAS. There are a number of different types of action within the EPAS.
These include focussed oversight, research, rulemaking and safety promotion.
Safety Performance Measurement: The final stage in the process is then the measurement of safety perfor-
mance. This serves two purposes, firstly to monitor the changes that have resulted from the implementation of
safety actions. Secondly, it also serves to monitor the aviation system so that new safety issues can be identified.
To ensure that there is a systematic approach to the work in this step of the SRM process, a Safety Performance
Framework has been developed that identifies different tiers of Safety Performance Indicators (SPIs). Tier 1 trans-
versally monitors all the domains and the overview of the performance in each domain. Tier 2 then covers the
key risk areas at domain level, whilst Tier 2+ monitors the safety issues. This Annual Safety Review is the annual
review of the Safety Performance Framework. It identifies safety trends, highlights priority domains, key risk ar-
eas and safety issues. From this step the SRM process begins again.
PAGE 9
Chapter Overview
This document is split into a number of chapters, each of which covers the different operational domains in the
European Aviation System. The different domains in each chapter cover the areas for which a specific safety risk
portfolio has been developed. Except for the chapter on Commercial Air Transport – Aeroplanes, the scope of
each domain chapter (and corresponding safety risk portfolio) is limited to the EASA MS, either as state of oper-
ator or state of registry. For the Aerodrome and ATM chapters, this scope is limited to the EASA MS as state of
occurrence. The chapters of this review cover the following areas:
Chapter 1 – Cross-Domain Safety Overview: This provides an overview of the most important statistics across
all the different domains. It helps to identify which domains are likely to need the greatest focus in the EPAS.
Chapter 2 – Commercial Air Transport.
Chapter 2a – Commercial Air Transport – Aeroplanes: This covers all commercial air transport airline
(passenger and cargo operators) operations involving aeroplanes. Commercial Air Transport – Other
CAT Aeroplanes: This covers the remaining parts of commercial air transport - aeroplanes that does not
involve airline operators. This includes air taxi and other such operations.
Chapter 2b – Part Special Operations (SPO)/ Aerial Work – Aeroplanes: This covers all aerial work/
Part SPO operations involving aeroplanes and involves a wide range of different operational activities
including aerial advertising, aerial patrol, agricultural, air shows, parachuting and towing (with glider
operations).
Chapter 3 – Commercial Operations with Helicopters.
Chapter 3a - Offshore Helicopters: This covers operations in the offshore helicopter domain and includes
some initial input on offshore renewable operations in addition to the oil and gas industry.
Chapter 3b – Other CAT Helicopters: This covers all other commercial air transport operations involving
helicopters such as passenger flights, air taxi and HEMS.
Chapter 3c – Part Special Operations (SPO)/ Aerial Work – Helicopters: This covers all aerial work/ Part
SPO operations involving helicopters and includes an even wider range of different operational activities
than the equivalent aeroplanes chapter, adding Construction/ Sling Load operations and Logging to the
categories already mentioned.
Chapter 4 – Non-Commercial Operations.
Chapter 4a - Non-Commercial Operations – Aeroplanes: The chapter covers all non-commercial
operations involving aeroplanes and includes analysis of what would be understood within the tradi-
tional definition of general aviation. The chapter also includes flight training and other non-commercial
activities.
Chapter 4b - Non-Commercial Operations – Helicopter: Similarly, the next chapter covers all non-com-
mercial operations involving helicopters.
Chapter 5 - Balloons: This chapter covers all operations involving hot air balloons.
Chapter 6 – Gliders/ Sailplanes: This chapter covers all operations involving gliders and sailplanes.
Chapter 7 – RPAS/UAS/Drones: This chapter covers operations involving Remotely-Piloted Air Systems (RPAS)/
Unmanned Aircraft Systems (UAS)/ drones.
Chapter 8 – Aerodrome/ Ground Handling: As previously described above, this chapter covers aerodrome op-
erations that occur within the EASA MS. Therefore the scope for this chapter is EASA MS as state of occurrence.
For the first time a safety risk portfolio is provided for this domain.
Annual Safety Review 2017 PAGE 10
Chapter 9 – ATM/ANS: As previously described, the scope for this chapter is EASA MS as state of occurrence and
covers ATM/ANS operations. An initial safety risk portfolio has also been provided for this domain for the first
time.
Typical structure of each chapter
Each of the domain chapters in this Annual Safety Review contains specific information which is useful in under-
standing the analysis of that domain. Such information includes:
Key Statistics: Every chapter starts with a set of key statistics. This provides information on the Tier 1 SPIs for that
domain, which includes details of the number of fatal accidents, non-fatal accidents and serious incidents. It also
outlines the number of fatalities and serious injuries in the domain. In all cases, the figures for 2016 are provid-
ed followed by comparison with the annual averages over the past 10 years. This helps to provide a reference on
how this year’s performance relates to historical trends. This information is also provided in a graphical format.
Domain Specific Analysis: As every domain has different facets to it, a further analysis of useful domain specific
information is included. For example, within the areas of special operations it is useful to provide information on
the type of operation involved in safety events, while some chapters include an analysis of the type of propulsion.
Safety Risk Portfolio: The next part of the analysis, and the most important in each chapter, is the domain safe-
ty risk portfolio. The portfolio has 2 axes. Along the top, information is provided on the key risk areas, which are
the most frequent accident outcomes or potential accident outcomes in that domain. In the context of the safe-
ty performance framework, the key risk areas are the Tier 2 SPIs for the domain. The key risk areas are, in most
cases, ordered on the basis of their percentage involvement in fatal followed by non-fatal accidents. When view-
ing these percentages, it should be understood that because multiple categories can be applied to one accident
the percentages may not necessarily add up to 100%. On the left hand axis of the portfolio are the safety issues,
which relate to the causal and contributory factors to the key risk areas (accident outcomes). In terms of safety
performance, these are the Tier 2+ SPIs. These are prioritised on the basis of their involvement in fatal accidents,
then non-fatal accidents, serious incidents and incidents. The occurrences related to the individual safety issues
and are identified by mapping event types in the ECCAIRS taxonomy to each safety issue.
Priority Key Risk Areas: The next part of the analysis provides more detail on the priority key risk areas (accident
outcomes) in each operational domain. These are intended to help the reader to understand the main types of
accident that should be prevented in order to improve the level of safety in each domain.
Top Safety Issues and Associated Actions: Finally, the last part of each chapter list the top safety issues that give
rise to the accident outcomes. More information is provided about each safety issue along with details of EASA
risk assessment work that might have taken place for this area. There is also a short overview of any related safe-
ty actions in the EPAS that relate to each safety issue.
PAGE 11
Cross-Domain Safety
Overview
1
Annual Safety Review 2017 PAGE 12
Cross-Domain Safety Overview
This chapter provides a general overview of aviation safety in the EASA Member States (MS). It compares the
number of fatal accidents and fatalities in each operational domain for 2016 with the annual average for the past
10 years. For the purposes of this overview, Aerodromes/ Ground Handling and ATM/ANS are not included. With
reference to the Safety Risk Management (SRM) process, as outlined in the introduction, and the safety perfor-
mance framework, this overview serves as the Tier 1 Safety Performance Indicators (SPIs).
Key Cross- Domain Statistical Overview
The only domain with an increase in fatalities in 2016 was Offshore Helicopters, where there was one accident
with 13 fatalities. This is the first year that a fatal accident has been recorded in this domain since 2013. For the
other domains, there has been a reduction in both the number of fatal accidents and fatalities. Because of the
low number of fatal accidents in CAT Aeroplanes, the median average is introduced to highlight that while the
mean average number of fatalities is high, this is largely due to a small number of large accidents.
Table 1 Overview of fatal accidents and fatalities 2016 Vs 10-year average (2006-2015)
Fatal Accidents
Fatal Accidents Fatalities Fatalities Annual Fatalities Annual
Domain Annual 10 Year
2016 2016 10 Year Mean 10 Year Median
Mean
CAT Aeroplanes
Airline (Passenger/
1 0.8 2 66.0 5.0
Cargo
Other 0 1.4 0 6.4 2.0
SPO Aeroplanes 6 10.7 12 18.6 16.5
CAT Helicopters
Offshore 1 0.4 13 3.0 0.0
Other 2 0.9 8 2.8 3.5
SPO Helicopters 0 4.1 0 7.4 6.0
Non-Commercial and Other
NCO Aeroplanes 46 51.4 78 94.4 95.5
NCO Helicopters 9 10.0 11 17.5 17.0
Balloons* 1 2.2 1 4.0 3.0
Gliders 19 26.5 20 31.1 31.0
RPAS 0 0.0 0 0.0 0.0
*Balloon data compares 2016 with the average for the five year period 2011-2015.
The top 5 operational domains in terms of the annual average of the number of fatalities for the past 10 years
(2007-2016) number of fatalities are:
Non-Commercial Aeroplanes: In terms of the average number of fatalities over the past 10 years, this domain
has the highest with 173.5. In 2016, it was also the domain with the highest number of fatalities and fatal acci-
dents, being 113 fatalities and 77 fatal accidents. In both cases, the figures for 2016 are lower than the 10 year
average.
CAT Aeroplanes Airline (Passenger/Cargo): The second highest average number of fatalities over the past 10
years is in CAT Aeroplanes Airline (Passenger/ Cargo) with 66.0 per year. In 2016, there was one fatal accident,
which led to 2 fatalities. This accident involved West Air Sweden Flight 294, a cargo flight using a Bombardier
PAGE 13
CRJ200 that crashed in Sweden on 8 January 2016. The final report for this accident was published by the Swed-
ish Accident Investigation Board in December 2016 1.
Gliders/ Sailplanes: In terms of the average number of fatalities, the gliding/sailplanes domain has the 3rd high-
est total with 31.1. It was also the domain that had the 2nd highest number of both fatalities and fatal accidents
in 2016, with 20 fatalities and 19 fatal accidents. Again, in both cases this represents a reduction of the previous
year and is lower that than the 10 year average.
SPO Aeroplanes: In 2016, part-SPO aeroplane operations recorded 6 fatal accidents. These accidents led to a to-
tal of 11 fatalities. In both cases, this is lower than the 10 year average and is also lower than the previous year.
NCO Helicopters: Non-commercial helicopter operations had the 5th highest average number of fatalities over
the past 10 years. In 2016, there were a total of 11 fatalities, which came from 9 fatal accidents. Again in both
cases both are below the 10 year average.
1 http://www.havkom.se/en/investigations/civil-luftfart/olycka-i-lappland-med-flygplanet-se-dux-av-typen-canadair-crj-200?cookie=ok
Annual Safety Review 2017 PAGE 14
Commercial Air Transport
Commercial Air Transport
2
PAGE 15
Chapter 2a Commercial Air Transport
Aeroplanes – Airline and Other
Operations
This chapter covers Commercial Air Transport (CAT) aeroplane operations. Following the high level key statis-
tics, the chapter is divided in two main sections, the airline passenger/cargo with aeroplanes having a maximum
take-off weight above 5700 kg. This is followed by other CAT aeroplane operations, which includes all other
operation types under CAT (such as air ambulance, air taxi, etc.) and the airline passenger/cargo operations in-
cluding aeroplanes with a maximum take-off weight below 5700 kg. For each sub-domain, the key statistics and
an occurrence based safety risk portfolio are presented. Except for the worldwide overview, the scope of this is
EASA Member State (MS) operators.
Key Statistics
The key domain statistics are in the tables below and include the accidents and serious incidents involving EASA
MS CAT airline operators and other CAT operations. This split provides a better focus for the analysis and a fair-
er grouping for the assessment of actions.
The only fatal accident in CAT aeroplane airline operations in 2016 that involved an EASA MS operator was the
accident of a Bombardier CRJ-200 performing a cargo flight on 8 January 2016. From the analysis, it can be ob-
served that there was a lower number of non‑fatal accidents involving EASA MS operators in 2016 than the
10-year average, with 16 accidents compared to the average of 23.1 over the previous 10 years. At the same time,
there was a 36% increase in the number of serious incidents over the same period resulting in a total of 106 se-
rious incidents compared with the average of 78.2. In terms of fatalities, the single fatal accident resulted in 2
fatalities (the flight crew, the only occupants of the aeroplane), which is much lower than the 10 year average.
There was also a slight decrease in serious injuries with 9 serious injuries compared with 10 over the previous
10 years.
Table 2 Key statistics CAT Aeroplane
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 0.8 23.1 78.2
2016 1 16 106
% of change 25% ã -31% ä 35% ã
Fatalities Serious Injuries
2006-2015 average 66 10
2016 2 9
% of change -97% ä -10% ä
In the domain of other CAT aeroplane operations involving an EASA MS operator, there were 3 non-fatal acci-
dents and 5 serious incidents.
Annual Safety Review 2017 PAGE 16
Commercial Air Transport
Table 3 Key statistics CAT Aeroplane - Other
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 1.4 4.1 2.7
2016 0 3 5
% of change ä -27% ä 85% ã
Fatalities Serious Injuries
2006-2015 average 6.4 1.1
2016 0 0
Commercial Air Transport Aeroplane – Airlines
The analysis focuses on the CAT aeroplane airline operations, which encompasses passenger and cargo. This do-
main covers the bulk of the commercial air transport activity.
Figure 1 shows that in 2016 there was only one fatal accident resulting in 2 fatalities, who were both flight crew
members on-board a cargo flight.
´´ Figure 1 CAT Aeroplane Airlines, evolution of fatal and non-fatal accidents, period
2006-2016
250 1.5
1.5
200
by MS Operator (Billion passengers)
Number of Passengers Transported
1.4
150 1.4
Number of Fatalities
1.3
100 1.3
1.2
50
1.2
0 1.1
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of Fatalities Pax MS (billion pax)
As can be seen in Figure 2 EASA MS Aircraft Operators Certificate (AOC) holders were involved in a lower rate of
fatal accidents per ten million departures than the rest of the world. This rate has remained below 2 fatal acci-
dent per ten million departures since 2006.
PAGE 17
´´ Figure 2 CAT Aeroplane Airline fatal accident rate for EASA MS AOC and non-EASA Ms,
period 2006-2016
14
12
per 10 Million Movements
Number of fatal accidents
10
8
6
4
2
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Non-EASA MS - Fatal Accident Rate (per 10M departures - ICAO)
EASA MS - Fatal Accident Rate (per 10M departures - ICAO)
With respect to non-fatal accident rates, as can be seen in Figure 3, the rate for EASA MS AOC holders has de-
creased for the last two years, although it is above the rate for non-EASA AOC. This higher rate is likely to be due
to the better reporting channels and data capture from the EASA MS AOC holders rather than being a reflection
on the safety performance of both groups.
´´ Figure 3 CAT Aeroplane Airline non-fatal accident rate for EASA MS AOC and non-EASA
Ms, period 2006-2016
60
Number of non-fatal accidents
50
per 10 Million deapartures
40
30
20
10
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Non-EASA MS - Non-Fatal Accident Rate (per 10M departures - ICAO)
EASA MS - Non-Fatal Accident Rate (per 10M departures - ICAO)
Regarding EASA MS AOC holders, the 2016 recorded figure of 16 of non-fatal accidents is equal to the lowest
figure recorded during the last decade, which has not occurred since 2009. However, one fatal accident was re-
corded as a result of fatal injuries to the two flight crew on board.
Annual Safety Review 2017 PAGE 18
Commercial Air Transport
´´ Figure 4 CAT Aeroplane Airline, evolution of fatal and non-fatal accidents, period
2006-2016
35
30
25
20
15
10
5
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of Fatal Accidents Number of non-Fatal Accidents
Phase of Flight
The numbers for 2016 show an overall decrease of accidents in all flight phases when compared to the 10 year
average. In same period however, there was an increase in the number of serious incidents, especially those oc-
curring during en-route, approach and landing flight phases.
´´ Figure 5 CAT aeroplane accidents and serious incidents per phase of flight 2006-2016
Number of Accidents and SIs per flight phase average 2006-2015 vs 2016
50
45
40
35
30
25
20
15
10
5
0
Standing Taxi Take-off En route Approach Landing
Accidents AVG 2006-2015 Accidents 2016 Serious Incidents AVG 2006-2015 Serious incidents 2016
PAGE 19
Propulsion type
The split by propulsion type shows a decrease for 2016 in both turbofan and turboprop accidents in reference to
the 10 year average. This decrease is in line with the overall reduction of accidents. More accidents involve tur-
bofan powered aircraft than turboprop aircraft and this is in line with the split in the aircraft fleet sizes.
´´ Figure 6 CAT aeroplane accidents and serious incidents by propulsion
20
18
16
14
Number of Fatalities
12
10
8
6
4
2
0
Turbofan Turboprop
Safety Risk Portfolio
The safety risk portfolio for the CAT aeroplane airline domain provides a summary of the past performance of
this part of the aviation system. With reference to the safety performance framework, it covers the Tier 2 (Key
Risk Areas) and Tier 2+ (Safety Issues). Within the portfolio, the top risk areas and priority safety issues are iden-
tified, interlinked and prioritised. The portfolio is used to prioritise the assessment of safety issues, to target
analysis activities over key risk areas and to establish the interdependencies of safety actions.
In the upper part of the safety risk portfolio, the total number of fatal and non-fatal accidents for the past 10
years has been spread across the different key risk areas shown in columns. A key risk area includes both the un
desired outcome (accident) and immediate precursors to those outcomes. In rows, the SRP shows the main safety
issues and its negative contribution to the safety performance of the system in the last 5 years (fatal accidents,
non-fatal accidents, serious incidents and incidents, displayed in columns before the risk areas). The dotted grid
establishes the relation between safety issues and key risk areas – it identifies which safety issues may lead to
which accident outcomes. Dots come from occurrence data and expert judgement.
The initial prioritisation is done by the contribution to fatal accidents, non-fatal accidents, serious incidents and
then incidents.
Annual Safety Review 2017 PAGE 20
Commercial Air Transport
COMMERCIAL AIR TRANSPORT - AEROPLANES, AIRLINES
Outcome
Percentage of
8 75% 13% 13% 0% 0% 0% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 226 19% 30% 0% 26% 2% 1% 1% 1% 0% 4%
Accidents
(2007-2016)
Total number of
occurrences in 2012-2016
per safety issue
Unsurvivable Aircraft
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Security/non-Safety
Runway Excursion
Airborne Collision
Safety Issues
Serious Incidents
Runway Collision
Ground Damage
Terrain Collision
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Non-Safety
Excursion
Flight
Operational
Handling of
Technical 288 14 5 2
Failures
Icing in Flight 277 6 0 1
Turbulence 2 936 5 20 0
Approach Path
2 658 13 5 0
Management
Flight Planning
3 687 11 5 0
and Preparation
Windshear 3 919 2 5 0
Crosswind 224 5 2 0
Hail 17 1 2 0
Icing on Ground 116 0 2 0
Airborne
2 667 42 0 0
Separation
False or
Disrupted ILS 314 8 0 0
Signal Capture
Handling and
Execution of 219 8 0 0
Go-Arounds
Deconfliction
with Aircraft
192 4 0 0
Not Using
Transponders
Entry of Aircraft
Performance 50 3 0 0
Data
Bird/ Wildlife
13 003 2 0 0
Strikes
PAGE 21
COMMERCIAL AIR TRANSPORT - AEROPLANES, AIRLINES
Outcome
Percentage of
8 75% 13% 13% 0% 0% 0% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 226 19% 30% 0% 26% 2% 1% 1% 1% 0% 4%
Accidents
(2007-2016)
Total number of
occurrences in 2012-2016
per safety issue
Unsurvivable Aircraft
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Security/non-Safety
Runway Excursion
Airborne Collision
Safety Issues
Serious Incidents
Runway Collision
Ground Damage
Terrain Collision
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Non-Safety
Excursion
Flight
Taxi Speed and
Directional 12 1 0 0
Control
Dangerous
Goods Handling
719 0 0 0
and Lithium
Batteries
Wake Vortex 1 092 0 0 0
Security
Laser
Illumination
35 1 0 0
Effects (Not all
Illuminations)
Disruptive
2 505 0 0 0
Passengers
Technical
Aircraft
1 866 9 5 0
Maintenance
UAS Strikes 0 0 0 0
Human
Perception
and Situational 1 393 27 12 2
Awareness
CRM and
Operational 4 822 26 8 1
Communication
Mental Health 0 0 0 1
Decision Making
450 10 4 0
and Planning
Annual Safety Review 2017 PAGE 22
Commercial Air Transport
COMMERCIAL AIR TRANSPORT - AEROPLANES, AIRLINES
Outcome
Percentage of
8 75% 13% 13% 0% 0% 0% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 226 19% 30% 0% 26% 2% 1% 1% 1% 0% 4%
Accidents
(2007-2016)
Total number of
occurrences in 2012-2016
per safety issue
Unsurvivable Aircraft
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Security/non-Safety
Runway Excursion
Airborne Collision
Safety Issues
Serious Incidents
Runway Collision
Ground Damage
Terrain Collision
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Non-Safety
Excursion
Flight
Experience,
Training and
246 10 3 0
Competence of
Individuals
Monitoring
of Flight
Parameters and 147 8 2 0
Automation
Modes
Fatigue 335 3 2 0
Personal
Pressure and 97 9 1 0
Alertness
Gastrointestinal
2 439 34 0 0
Illness
Knowledge of
Aircraft Systems 94 5 0 0
and Procedures
Fumes Effects 130 0 0 0
Organisational
Effectiveness
of Safety
Management
Development
and Application
21 0 0 0
of Regulations
and Procedures
PAGE 23
Use of ERCS for risk comparison
The European Risk Classification Scheme or ERCS is the methodology being developed by a group of experts
who have been nominated by the European Commission in order to meet the requirement of the Regulation
(EU) 376/2014 to risk score all occurrences. The obligation is on organisations and authorities, though, while or-
ganisations can decide on any methodology to risk score occurrences, the authorities shall use a common risk
classification at European level, that being ERCS.
The objective of ERCS is to facilitate the identification of high risk occurrences and the identification of areas of
concern in the aviation system. For this second purpose, one of the possible strategies is to aggregate the risk
score of the individual occurrences. The indicator obtained by this addition is not a risk estimation per se, but
a parameter that reflects how far those occurrences were from the worst possible outcome, thus allowing a com-
mon reference point for comparison.
The aggregation of individual ERCS risk scores helps to perform a comparison between key risk areas. The com-
parison is a relative indicator measuring the past performance of the system, showing the risk areas where
barriers were penetrated either more often and/or to a greater extent, therefore resulting in a higher aggregat-
ed risk score. However, this indicator cannot be translated in terms of risk (severity X probability).
Figure 7 shows the key risk areas plotted by the number of high risk occurrences (x-axis), the number of fatalities
(y-axis) and the aggregated risk score of the individual high risk occurrences (diameter of the bubble) associated
to each risk area. As can be seen, depending on the parameter used (fatalities, frequency of occurrence or ag-
gregated risk score) the prioritisation of Key Risk Areas may be significantly different.
´´ Figure 7 Aggregated Risk Score for Accidents and Serious Incidents Involving EASA MS
operators 2015-2016 by Key Risk Areas
180
160
140
120
100 ο Aggregated ERCS Risk Score
Number of Fatalities
80
60
40
20
0
-2 0 2 4 6 8 10 12 14 16 18
-20
-40
Number of High Risk Occurrences
Ruway excursion Non-Safety Airborne collision Unsurvivable aircraf t environment
Aircraf t upset Runway collision Ground damage
Annual Safety Review 2017 PAGE 24
Commercial Air Transport
Priority Key Risk Areas
Taking into consideration the last 10 years of fatal and non-fatal accidents, and the representation of the aggre-
gated ERCS score, the priority key risk areas are:
Aircraft upset or loss of control is the most common accident outcome
Number 2 ERCS Score for fatal accidents in CAT aeroplanes operations, accounting for 75%
of them. It includes uncontrolled collisions with terrain, but also
occurrences where the aircraft deviated from the intended flight path
or aircraft flight parameters, regardless of whether the flight crew
6 Fatal Accidents realised the deviation and whether it was possible to recover or not.
Aircraft Upset
Materialised runway excursions, both high and low speed and
Number 1 ERCS Score occurrences where the flight crew had difficulties maintaining the
directional control of the aircraft or of the braking action during
landing, where the landing occurred long, fast, off-centred or hard,
or where the aircraft had technical problems with the landing gear
1 Fatal Accident (not locked, not extended or collapsed) during landing. This accounts
Runway for 13% of the fatal accidents in CAT aeroplane operations involving
Excursion airline/cargo operations in the past decade.
Non-Safety accident outcomes includes intended actions. Included,
Number 3 ERCS Score is the intention to cause harm or damage, or to disrupt the normal
operation of the aircraft. It also includes all terrorist or conflict
related actions, as well as any other situation where there was a clear
intention to cause harm, damage or disruption to the flight, regardless
1 Fatal Accident of the motivation to do so. It includes cases of hijacking, bomb-threat,
Non-Safety shoot-downs, intended laser interference, disruptive passengers, etc.
Runway collisions have been the outcome in 1% of fatal accidents in
Number 4 ERCS Score the past decade. Despite the low percentage, the ERCS evaluation
demonstrates that the risk was very real.
3 Non-Fatal Accidents
Runway
Collision
Airborne collisions are collisions between aircraft where both (all)
Number 5 ERCS Score aircraft were airborne. Although this outcome has not occurred in
the past 10 years, the risk scoring of accident and serious incidents
highlights the continued risk of this type of accident.
3 Non-Fatal Accidents
Airborne
Collision
Ground collisions and ground damage occur on the ramp and this key
Number 6 ERCS Score risk area does not include collisions on the runway. While it was not
the accident outcome for any fatal accidents, the risk score warrants its
inclusion in the priority key risk areas list.
59 Non-Fatal Accidents
Ground
Damage
PAGE 25
Top Safety Issues
As for the key risk areas, it is possible to establish a ranking of safety issues based on the past performance of
the system by counting high risk occurrences, or the number of fatalities or through the aggregated risk score.
• Perception and situational awareness
• Icing in flight
• Handling of technical failures
• Turbulence
• Airborne conflict
• Flight planning
• Decision making and planning
• Experience, training and the competence of individuals
• Wind-shear
• Flight- path management
• Mental health
Performed Safety Issue Assessments
and identified actions
Continuing with the SRM, the Collaborative Analysis Group for CAT aeroplanes composed of the industry stake-
holders, Member States and the Agency is currently working on several safety assessments on identified safety
issues during 2016.
Crew Resource Management: The assessment concluded that the performed regulatory actions (revision of AMC
and GM on Crew Resource Management (CRM) training) was sufficient, but that there was a need to support its
implementation with additional safety promotion material so as to provide operators and training organisations
with the best practices available. In November 2016, the Agency organised a dedicated workshop on CRM where
different stakeholders presented their approach to CRM implementation. The Agency will collect and publish
a list of best practices for CRM implementation (SPT.079).
Entry of Erroneous Take-Off Parameters: The assessment of the safety issue and the later review of the data
obtained via a targeted survey showed that the issue was more common than initially estimated. Therefore,
the Agency, together with the main stakeholders, decided to publish a Safety Information Bulletin2 to raise the
awareness of the operators and flight crews and to encourage the monitoring of the issue through FDM pro-
grammes. The Agency will launch a second survey to gauge the efficiency of the actions launched and the need
of further initiatives.
Ice On-Ground and In-Flight: As part of the former safety issue on “flying in adverse weather conditions”, the
CAT Aeroplane CAG launched a detailed assessment of two icing-related scenarios, on-ground and in-flight.
The ice-on-ground assessment put forward a number of recommendations for safety actions ranging from the
2 https://ad.easa.europa.eu/ad/2016-02
Annual Safety Review 2017 PAGE 26
Commercial Air Transport
improvements to the regulatory framework for de-icing providers, research on the means to estimate precipi-
tation intensity, to the assessment of technical solutions that estimate the degradation of aircraft performance
during the take-off run. All the proposed safety actions are being assessed under the Preliminary Impact Assess-
ment (PIA) process so as to determine the most efficient actions be implemented. The assessment of in-flight
icing is in its final stage. In the same manner, the assessment will identify the areas of improvement and draft
possible safety actions, which will be fed into the PIA process.
Flight Crew Awareness: The assessment team reviewed recent accident investigations with a view to modelling
those situations where flight crew awareness was a factor. The assessment established two main scenarios: The
flight crew failed to properly react to an automation disconnection or un-commanded mode transition and to
properly manage the aircraft attitude, energy or flight path and; the flight crew being surprised by an event that
they normally should have anticipated as part of managing the flight or should have detected through active
monitoring. The assessment team is finalising the evaluation of both scenarios and their impact on the perfor-
mance of the flight crew. The assessment will offer conclusions addressing the need for further actions beyond
those ones already launched.
Inadequate Handling of Go-Around: The assessment team is finalising the analysis, which will be based on
a data review of accidents and serious incidents that were investigated over the past 10 years and involved an
inadequate handling of the go-around manoeuvre. Per the SRM process, safety actions proposed in the assess-
ment report will feed the PIA process.
Main Action Areas in the EPAS
There is a wide range of different EPAS actions that already cover many of the key risk areas that have been out-
lined in this chapter. Owing to the number of those actions, it is difficult to summarise them here. However, the
action areas at the operational level are split into the strategic key risk areas of aircraft upset and runway safe-
ty, covering excursions and collisions.
Aircraft Upset: The main EPAS actions include RMT.0397 on unintended or inappropriate rudder usage (rudder
reversals), RMT.0581 concerning loss of control - prevention and recovery training and RMT.0647 on loss of con-
trol or loss of flight path during go-around or climb. There are also a number of safety promotion tasks covering
this key risk area.
Runway Safety: For the key risk areas of runway collisions and runway excursions, EPAS actions include RMT.0296
on the review of aeroplane performance requirements for CAT operations, RMT.0369 concerning the prediction
of wind shear for aeroplane CAT operations (IRs), and RMT.0570 on the reduction of runway excursions.
Commercial Air Transport Aeroplane – Other
The analysis now shifts its focus to other commercial aeroplane operations that are within the analysis scope of
passenger/cargo. This sub-domain covers CAT aeroplane operations performed with aeroplanes with a MTOW
below 5700kg or of a very specific type (air ambulance, air taxi) not yet being considered as Specialised Opera-
tions (SPO).
As was the case in 2015, Figure 8 shows that in 2016 there were no fatalities. This consolidates the decreasing
trend of the last 10 years. There is no reliable traffic information that splits out the other CAT aeroplane opera-
tions so as to determine an accident rate.
PAGE 27
´´ Figure 8 Other CAT Aeroplane, number of fatalities, 2006-2016
20
18
16
14
Number of Fatalities
12
10
8
6
4
2
0
Turbofan Turboprop
Figure 9 shows the evolution of the fatal and non-fatal accidents in the period 2006-2016. While fatal accidents
show a decreasing trend recording no fatal accidents in the last 2 years, the number of non-fatal accidents re-
mains quite stable with between 3 and 6 events per year.
´´ Figure 9 Other CAT Aeroplane, evolution of fatal and non-fatal accidents (2006-2016)
9
8
7
6
5
4
3
2
1
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of Fatal Accidents Number of non-Fatal Accidents
Annual Safety Review 2017 PAGE 28
Commercial Air Transport
Flight Phases
The comparison of accidents and serious incidents by flight phase shows that almost all occurrences in 2016 hap-
pened during the landing flight phase, all those connected to the risk of runway excursion.
´´ Figure 10 Other CAT Aeroplane, comparison of accidents and serious incidents by flight
phase between the average of 2006-2015 and the figures in 2016
Number of Accidents and SIs per flight phase average 2006-2015 vs 2016
6
5
4
3
2
1
0
Standing Taxi Take-off En route Approach Landing
Accidents AVG 2006-2015 Accidents 2016 Serious Incidents AVG 2006-2015 Serious incidents 2016
Propulsion type
Overall, the highest number of occurrences (Both accidents and serious incidents combined) involved aircraft
with reciprocating engines. There were 3 serious incidents involving turbofan powered aircraft and one accident
and one serious incident involving turboprop aircraft. Due to the low figures, the comparison with the previous
10 years was omitted.
´´ Figure 11 Other CAT Aeroplane, split of accidents and serious incidents in 2016 by
propulsion type
4
3
2
1
0
Turbofan Reciprocating Turboprop
Accident Serious incident
PAGE 29
Safety Risk Portfolio
The safety risk portfolio for Other CAT Aeroplanes is provided below. At this stage the portfolio has been de-
veloped only with EASA’s own data. The initial prioritisation of key risk areas and safety issues are done by the
contribution to fatal accidents, non-fatal accidents for the former and then adds serious incidents and then in-
cidents for the safety issues.
COMMERCIAL AIR TRANSPORT - AEROPLANES - OTHER
Outcome
Percentage of
10 50% 20% 10% 10% 10% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 42 21% 10% 5% 2% 0% 50% 7%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Operational
Flight Planning
176 0 1 2
and Preparation
Icing in Flight 9 0 0 1
Handling of
Technical 9 2 1 0
Failures
Crosswind 6 2 1 0
Airborne
91 2 0 0
Separation
Wake Vortex 14 1 0 0
Bird/ Wildlife
169 0 0 0
Strikes
Turbulence 30 0 0 0
Approach Path
17 0 0 0
Management
Windshear 13 0 0 0
Deconfliction
with Aircraft
7 0 0 0
Not Using
Transponders
False or
Disrupted ILS 5 0 0 0
Signal Capture
Annual Safety Review 2017 PAGE 30
Commercial Air Transport
COMMERCIAL AIR TRANSPORT - AEROPLANES - OTHER
Outcome
Percentage of
10 50% 20% 10% 10% 10% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 42 21% 10% 5% 2% 0% 50% 7%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Handling and
Execution of 3 0 0 0
Go-Arounds
Hail 2 0 0 0
Icing on Ground 2 0 0 0
Dangerous
Goods Handling
1 0 0 0
and Lithium
Batteries
Entry of Aircraft
Performance 0 0 0 0
Data
Taxi Speed and
Directional 0 0 0 0
Control
Security
Disruptive
2 0 0 0
Passengers
Laser
Illumination
1 0 0 0
Effects (Not all
Illuminations)
Technical
Aircraft
36 1 1 0
Maintenance
UAS Strikes 0 0 0 0
Human
Perception
and Situational 27 2 0 3
Awareness
Decision Making
7 2 1 2
and Planning
PAGE 31
COMMERCIAL AIR TRANSPORT - AEROPLANES - OTHER
Outcome
Percentage of
10 50% 20% 10% 10% 10% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 42 21% 10% 5% 2% 0% 50% 7%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Experience,
Training and
10 0 0 2
Competence of
Individuals
Mental Health 0 0 0 2
CRM and
Operational 182 3 0 1
Communication
Monitoring
of Flight
Parameters and 4 0 0 1
Automation
Modes
Fatigue 1 0 0 1
Personal
Pressure and 0 1 0 0
Alertness
Gastrointestinal
90 0 0 0
Illness
Knowledge of
Aircraft Systems 0 0 0 0
and Procedures
Fumes Effects 0 0 0 0
Organisational
Development
and Application
1 0 0 0
of Regulations
and Procedures
Effectiveness
of Safety
Management
Annual Safety Review 2017 PAGE 32
Commercial Air Transport
Priority Key Risk Areas
Taking into consideration the last 10 years of fatal and non-fatal accidents, the main key risk areas are below. For
the remaining chapters of the annual safety review, these are shown in a prioritised order based on the percent-
age involved in fatal followed by non-fatal accidents.
Aircraft upset or loss of control is the most common accident
5 Fatal Accidents outcome for fatal accidents in CAT aeroplanes operations with 50%
incidence. Aircraft upset had the second highest ERCS risk score.
9 Non-Fatal Accidents
Aircraft Upset
Terrain collision occurred in 20% of fatal accidents and is still
2 Fatal Accidents a common accident outcome for other CAT aeroplanes.
4 Non-Fatal Accidents
Terrain
Collision
Airborne collisions are those between aircraft where both (all) aircraft
1 Fatal Accident were airborne. This has occurred in 10% of fatal accidents in the past
10 years.
2 Non-Fatal Accidents
Airborne
Collision
Obstacle Collisions have featured in 10% of fatal accidents in the past
1 Fatal Accident 10 years. This key risk area involves collisions between aircraft and
obstacles during the approach and landing phase of flight.
1 Non-Fatal Accidents
Obstacle
Collision
Runway collisions featured in 10% of fatal accidents in the past
1 Fatal Accident decade.
0 Non-Fatal Accidents
Runway
Collision
Runway excursions, side excursions as well as overruns were the
0 Fatal Accidents outcome for 50% (21 total) of the non-fatal accidents in other CAT
aeroplane operations in the past decade.
21 Non-Fatal Accidents
Runway
Excursion
PAGE 33
Top Safety Issues and Associated Actions
In the same way as for the key risk areas, it is also possible to establish a ranking of safety issues based on the
past performance of the system. This time the safety issues are ordered by their involvement in fatal accidents,
accidents, serious incidents and incidents, in that order. The top safety issues are shown below and the actions
are the same as those outlined for CAT aeroplanes airline/ cargo previously.
• Perception and situational awareness.
• Flight planning and preparation.
• Decision making and planning.
• Experience, training and competence of individuals.
Annual Safety Review 2017 PAGE 34
Commercial Air Transport
Chapter 2b Part Special Operations (SPO) –
Aerial Work - Aeroplanes
This chapter covers aerial work and special operations (AW/SPO) involving aeroplanes of all mass groups with an
EASA MS State of Registry. Key statistics and a safety risk portfolio based on occurrence data are presented. The
portfolios will continue to be revised and updated using the knowledge and expertise of operators, manufactur-
ers and National Aviation Authorities (NAAs).
Key Statistics
The key domain statistics are in the tables below. The number of fatal accidents in 2016 was lower than the aver-
age of the preceding decade. In 2016, the number of non-fatal accidents was less than half of the average of the
preceding 10-year-period. The number of serious incidents in 2016 was in line with the average of 2006-2015.
The number of fatalities in 2016 was slightly lower whilst the number of serious injuries was in line with the av-
erage of the previous decade.
Table 2 Key statistics Part Special Operations (SPO) Aerial Work Aeroplanes
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 10.7 37.0 4.8
2016 6 17 5
% difference -44% ä -54% ä 4% ã
Fatalities Serious Injuries
2006-2015 average 18.6 7.9
2016 12 8
% difference -35% ä +1% ã
There was quite a considerable reduction in the number of accidents. In particular, the number of fatal accidents
reduced to 6, compared with the 10 year average of 9.3.
PAGE 35
´´ Figure 12 Part Special Operations (SPO) Aerial Work Aeroplanes fatal and non-fatal
accidents 2007-2016
70
60
50
40
Number
30
20
10
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Number of Non-Fatal Accidents
´´ Figure 13 Part Special Operations (SPO) Aerial Work Aeroplanes fatalities and serious
injuries 2007-2016
30
25
20
Number
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of Flight
With reference to of the phase of flight, the numbers for 2016 were lower across all flight phases in comparison
with the 2006-2015 average. Most accidents and serious incidents took place during the take-off phase of flight,
which is unusual. Historically, the landing and manoeuvring phases have resulted in more occurrences.
Annual Safety Review 2017 PAGE 36
Commercial Air Transport
Table 3 Part Special Operations (SPO) Aerial Work Aeroplanes accidents and serious incidents
per phase of flight 2006-2015 vs 2016
Accidents and Serious Incidents
Phase of Flight
2006-2015 average 2016
Standing 0,7 0
Taxi 2,4 1
Take-off 11,4 8
En route 11,4 6
Manoeuvring 12,3 5
Approach 5,7 3
Landing 13,4 6
Post-impact 0 0
Unknown 0,6 0
Operation Type
In some operation types, namely aerial advertising, aerial observation, aerial patrol, construction/sling load, log-
ging and other, there were no accidents or serious incidents in 2016. For aerial survey, there was one accident
and an accident in this domain only occurs on average once every five years. For photography, there was one
accident as well, which is just below the average. For the other operation types, the 2016 numbers were lower
than the preceding decade average. Both towing and parachute dropping each recorded 7 accidents and serious
incidents. For the parachute drop operations, EASA has recently completed an initial analysis that considers the
need for future EPAS actions. These actions will shortly be reviewed in a Preliminary Impact Assessment (PIA) for
inclusion in the next version of the EPAS.
Table 4 Part Special Operations (SPO) Aerial Work Aeroplanes accidents and serious incidents
by operation 2006-2015 vs 2016
Accidents and Serious Incidents
Operation Type
2006-2015 average 2016
Aerial Advertising 1,2 0
Aerial Observation 0,3 0
Aerial Patrol 0,2 0
Aerial Survey 0,2 1
Agricultural 4,7 3
Air-show/Race 24,2 8
Parachute drop 8,9 7
Photography 1,2 1
Towing 11,2 7
Construction/Sling load 0 0
Logging 0 0
Other 2,2 0
PAGE 37
Safety Risk Portfolio
The safety risk portfolio for Part SPO/aerial work with aeroplanes is shown below.
SPECIALISED OPERATIONS - AEROPLANES
Outcome
Percentage of
98 46% 23% 15% 5% 2% 2% 1%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 396 31% 8% 8% 16% 27% 1% 1%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Runway
Runway
Aircraft
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Operational
Airborne
44 3 9 9
Separation
Intentional Low
5 1 12 6
Flying
Handling of
Technical 9 2 8 1
Failures
Flight Planning
54 0 7 1
and Preparation
Control of
Manual Flight 2 0 2 1
Path
Crosswind 0 0 2 0
Icing in Flight 3 1 1 0
Approach Path
1 0 1 0
Management
Bird/ Wildlife
37 0 0 0
Strikes
Icing on Ground 0 0 0 0
Indadvertent
Parachute - - - -
Operation
Annual Safety Review 2017 PAGE 38
Commercial Air Transport
SPECIALISED OPERATIONS - AEROPLANES
Outcome
Percentage of
98 46% 23% 15% 5% 2% 2% 1%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 396 31% 8% 8% 16% 27% 1% 1%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Runway
Runway
Aircraft
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Technical
System
366 19 69 18
Reliability
Aircraft
20 2 3 1
Maintenance
UAS Strikes 0 0 0 0
Human
Decision Making
4 0 3 4
and Planning
Perception
and Situational 13 1 7 3
Awareness
Experience,
Training and
3 1 4 3
Competence of
Individuals
CRM and
Operational 69 0 0 1
Communication
Knowledge of
Aircraft Systems 1 0 1 0
and Procedures
Personal
Pressure and 1 0 0 0
Alertness
Organisational
Development
and Application
0 0 0 0
of Regulations
and Procedures
Effectiveness
of Safety - - - -
Management
PAGE 39
Priority Key Risk Areas
The safety risk portfolio enables the identification of the priority key risk areas for this domain. These are cur-
rently prioritised by considering the percentage involvement in the number of fatal and non-fatal accidents in
that order.
Aircraft upset or loss of control is the most common accident outcome
21 Fatal Accidents for fatal accidents in SPO Aeroplane operations. 46% of fatal accidents
in the 2007-2016 period can be attributed to aircraft upset.
123 Non-Fatal Accidents
Aircraft Upset
Airborne collisions are collisions between aircraft where both (all)
22 Fatal Accidents aircraft were airborne. In SPO Aeroplane operations, this accounts for
23% of the fatal accidents in the previous 10 years.
32 Non-Fatal Accidents
Airborne
Collision
Terrain collision includes collisions with trees, elevated terrain and
15 Fatal Accidents level terrain/water. 15% of fatal accidents in the past decade are
attributed to terrain collision.
32 Non-Fatal Accidents
Terrain
Collision
Obstacle collision in-flight poses a high risk of resulting in a serious
5 Fatal Accidents accident. Powerline strikes, and collisions with buildings and masts are
the most common accidents in this risk area. 5% of fatal SPO Aeroplane
accidents during the last 10 years were caused by obstacle collisions
during the flight.
63 Non-Fatal Accidents
Obstacle
Collision
Runway excursions, side excursions as well as overruns, account for 2%
2 Fatal Accidents of the fatal accidents in SPO Aeroplanes operations in the past decade.
107 Non-Fatal Accidents
Runway
Excursion
An unsurvivable aircraft environment occurs when in the case of
2 Fatal Accidents on-board fire or the rupture of a pressurised cabin causing rapid
decompression. 2% of the fatal accidents last 10 years can be
attributed to this key risk area.
4 Non-Fatal Accidents
Fire
Runway collisions encompass all collisions between aircraft and other
1 Fatal Accident aircraft, vehicles, persons or other objects whilst the aircraft is on the
runway. 1% of the fatal accidents in the past decade in SPO aeroplane
operations can be attributed to this key risk area.
4 Non-Fatal Accidents
Runway
Collision
Annual Safety Review 2017 PAGE 40
Commercial Air Transport
Top Safety Issues and Associated Actions
Currently, there is no Aerial Work/Specialised Operations Collaborative Analysis Group. Therefore, the list of safe-
ty issues identified in the safety risk portfolio has been established using EASA analysis.
The top safety issues in Part SPO/aerial work operations with aeroplanes are:
Technical Safety Issues:
System Reliability: This safety issue addresses the goal of continually improving system reliability. Key actions
here include RMT.0049 on specific risk and standardised criteria for conducting aeroplane-level safety assess-
ments of critical systems, RMT.0217 covering CAMOs’ and Part-145 organisations’ responsibilities and RMT.0521
aimed at improving the airworthiness review process.
Operational Safety Issues:
Airborne Separation: The safety issue on airborne separation covers the range of issues from airspace design,
flight planning, and in-flight situational awareness through to collision warning systems. There are EPAS actions
covering this area, which include RMT.0445 on the technical requirements and operating procedures for airspace
design, including flight procedure design, RMT.0593 on the technical requirements and operational procedures
for the provision of data for airspace users for the purpose of air navigation, and MST.024 on the loss of separa-
tion between civil and military aircraft.
Intentional Low Flying: There are operational situations where low flying is required and is performed within
the regulatory framework. However, the analysis has shown that further work is needed in this area. Actions in-
clude RMT.0371 on TAWS operations in IFR and VFR and TAWS for turbine-powered aeroplanes under 5 700 kg
MTOM able to carry six to nine passengers (regularly used in this domain), while RMT.0599 on evidence-based
training will also tackle this safety issue.
Handling of Technical Failures: Analysis in the portfolio has identified the safety issue related to the handling of
technical failures by flight crew. A key action that supports this area is RMT.0599 on evidence-based training that
will enable flight crew to be better prepared to deal with the most common technical failures.
Human Factors Safety Issues:
• Decision making and planning.
• Perception and situational awareness.
• Experience, training and competence of individuals.
As mentioned previously, EASA has also undertaken further analysis of parachuting operations that identified the
need for improved processes and procedures by operators as a key safety action. Following the analysis a PIA is
underway to assess the impact of proposed actions. This will be completed over the summer for inclusion in the
next version of the EPAS.
CAT HELICOPTER
OPERATIONS
3
Annual Safety Review 2017 PAGE 42
CAT HELICOPTER OPERATIONS
This chapter covers commercial air transport operations involving helicopters and it is split into three different
parts in this review. The first of these covers offshore helicopters, in which are provided key statistics, the safety
risk portfolio and the key strategic safety priorities at the European level that have been developed with the Off-
shore Helicopter CAG. The other part of the chapter covers all other CAT helicopter operations. In the next phase
of the analysis for the EPAS, a specific safety risk portfolio for helicopter emergency medical services (HEMS) op-
erations will be developed. In these two parts of the chapter the scope is helicopter operations by an EASA MS
AOC holder. The third part of the chapter covers part special operations (Part SPO)/aerial work operations involv-
ing helicopters of all mass groups with an EASA MS state of registry.
Chapter 3a Offshore Helicopter Operations
Key Statistics
In the offshore helicopter domain, there was one fatal accident, which involved the loss of an Airbus Helicopters
EC225 Super Puma in Norway on 29 April 2016. There were also 2 non-fatal accidents and no serious incidents
in 2016. Previous to 2016, there have been no fatal or non-fatal accidents since 2013. With this single accident,
the numbers of both fatal accidents and non-fatal accidents are higher for 2016 than the 10 year annual average.
Table 5 Key statistics offshore helicopters
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 0.4 0.9 1.4
2016 1 2 0
% difference 150% ã 120% ã ä
Fatalities Serious Injuries
2006-2015 average 3 0.6
2016 13 0
% difference +333% ã ä
´´ Figure 14 Offshore fatal and non-fatal accidents 2007-2016
4
3
Number
2
1
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Number of Non-Fatal Accidents
PAGE 43
´´ Figure 15 Offshore fatalities and serious injuries 2007-2016
18
16
14
12
10
Number
8
6
4
2
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
The number of fatalities were higher in 2016 due to the fatal accident in Norway.
Phase of Flight
With reference to the phase of flight, there are no major differences for 2016 compared with previous years. The
fatal accident in Norway occurred during the en-route flight phase, while one accident took place while taxiing.
Table 6 Offshore accidents and serious incidents per phase of flight 2006-2015 vs 2016
Accidents and Serious Incidents
Phase of Flight
2006-2015 average 2016
Standing 0.1 0
Taxi 0.2 1
Take-off 0.1 0
En route 1 1
Manoeuvring 0 0
Approach 0.3 0
Landing 0.4 0
Post-impact 0 0
Unknown 0.4 0
Safety Risk Portfolio
The safety risk portfolio for offshore helicopter is provided below. The SRP has been developed with the support
of the Offshore Helicopter CAG. This group takes its membership from the 3 main NAAs with offshore opera-
tions involved (Germany, Norway and the UK), manufacturers (Airbus Helicopters and Leonardo), operators (Heli
Offshore, Babcock Mission Critical Services, Bristow, CHC and NHV) and representatives from the oil and gas com-
panies. The offshore helicopter SRP has been used to align the strategic safety priorities of both Heli Offshore
and also the Oil and Gas Producers Association (IOGP). Furthermore, with an increase in offshore operations
Annual Safety Review 2017 PAGE 44
CAT HELICOPTER OPERATIONS
supporting the renewable energy industry and their operations to offshore windfarms, an additional activity has
begun within the CAG to enable the risks of this developing area be considered as early as possible.
OFFSHORE
Outcome Percentage
of Fatal Accidents 4 75% 25% 0% 0% 0%
(2007-2016)
Outcome Percentage
of Non-Fatal Accidents 8 63% 13% 13% 13% 0%
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Incidents (ECR
Aircraft Upset
Unsurvivable
Environment
Safety Issues
Collision in
Non-Fatal
Accidents
Accidents
Incidents
Obstacle
Collision
Damage
Ground
Aircraft
Serious
Terrain
Flight
data)
Fatal
Operational
Flight Planning and
72 0 0 1
Preparation
Control of the Helicopter
Flight Path and Use of 2 0 0 1
Automation
Handling of Technical
12 2 1 0
Failures
Airborne Separation 54 0 0 0
Bird/ Wildlife Strikes 44 0 0 0
Icing in Flight 7 0 0 0
Approach Path
5 0 0 0
Management
Helicopter Obstacle See
4 0 0 0
and Avoid
Degraded Visual
1 0 0 0
Environment
Icing on Ground 1 0 0 0
Intentional Low Flying 0 0 0 0
Management of the
Dynamic Landing 0 0 0 0
Environment
Management of
the Static Landing 0 0 0 0
Environment
Use of Operationally
Ready Safety Systems for 0 0 0 0
Helicopters
PAGE 45
OFFSHORE
Outcome Percentage
of Fatal Accidents 4 75% 25% 0% 0% 0%
(2007-2016)
Outcome Percentage
of Non-Fatal Accidents 8 63% 13% 13% 13% 0%
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Incidents (ECR
Aircraft Upset
Unsurvivable
Environment
Safety Issues
Collision in
Non-Fatal
Accidents
Accidents
Incidents
Obstacle
Collision
Damage
Ground
Aircraft
Serious
Terrain
Flight
data)
Fatal
Technical
Diagnosis and Tolerance
1 659 5 2 1
of System Failures
System Reliability 1 659 5 2 1
Aircraft Maintenance 34 0 0 0
Airworthiness
2 0 0 0
Management
UAS Strikes 0 0 0 0
Human
Perception and
25 1 0 1
Situational Awareness
Experience, Training
and Competence of 3 1 0 0
Individuals
CRM and Operational
59 0 0 0
Communication
Navigation and Airspace
27 0 0 0
Knowledge
Decision Making and
12 0 0 0
Planning
Personal Pressure and
1 0 0 0
Alertness
Knowledge of Aircraft
0 0 0 0
Systems and Procedures
Organisational
Effectiveness of Safety
0 0 0 0
Management
Development and
Application of
0 0 0 0
Regulations and
Procedures
Annual Safety Review 2017 PAGE 46
CAT HELICOPTER OPERATIONS
Priority Key Risk Areas
The safety risk portfolio enables the identification of the priority key risk areas for this domain. These are cur-
rently prioritised by considering the percentage involvement in the number of fatal and then non-fatal accidents.
The key risk area with the highest priority in offshore helicopter
3 Fatal Accidents operations is aircraft upset or loss of control. Loss of control for
offshore helicopters generally falls into two scenarios, technical
failure that renders the aircraft uncontrollable or human factors.
5 Non-Fatal Accidents
Helicopter
Upset
The other fatal accident involved the key risk area of terrain
1 Fatal Accident collision. This makes this the second priority key risk area, although
equipment is now fitted to helicopters in this domain that will
significantly mitigate the risk of this outcome.
1 Non-Fatal Accident
Terrain
Collision
The third priority key risk area is ground collisions and other ground
0 Fatal Accidents damage. Whilst, this was not the outcome in any fatal accidents,
other non-fatal accidents fall into this category and these accidents
are costly to operators, both financially and in terms of in-service
effects.
1 Non-Fatal Accident
Ground
Damage
Although there were no further key risk areas involved in offshore
0 Fatal Accidents helicopters accidents, the CAG agreed that the risk of obstacle
collision in and around helidecks meant that it should be placed in
the priority list. This also includes wrong deck landings.
1 Non-Fatal Accident
Obstacle
Collision
Top Safety Issues and Associated Actions
The offshore helicopter safety issues have been prioritised on the basis of their involvement in fatal accidents,
non-fatal accidents, serious incidents and incidents in that order. The top safety issues for this domain are:
Technical Safety Issues:
Diagnosis and Tolerance of System Failures/ System Reliability: Recent accidents have shown the need for
continued efforts related to improving system reliability for offshore helicopters. In addition, the goal is to
continually improve the ability to diagnose system failures early. A key action here is RMT.0608, which aims
to strengthen the existing CS-29 requirements pertaining to rotor drive system lubrication. Also relevant is
RMT.0711, which covers vibration health monitoring and SPT.080 on the implementation of HUMS best practice
through the work of Heli Offshore.
PAGE 47
Operational Safety Issues:
Flight Planning and Preparation: This safety issue was identified in the safety risk portfolio and there are ac-
tions in this regard related to work on evidence-based training to improve the preparation of flight crew for the
most relevant operational scenarios.
Control of the Helicopter Flight Path and Use of Automation. Both accidents and serious incidents have result-
ed from this important safety issue that covers the control by the flight crew of the helicopter flight path and the
use of automation. This is partially covered in the longer term by RMT.0713 on the reduction in human-factors-
caused rotorcraft accidents that are attributed to the rotorcraft design. There is also work that extends RMT.0599
on evidence-based training to offshore helicopter operations, which will help address this safety issue.
Handling of Technical Failures. This important safety issue was also identified in the safety risk portfolio. The
handling of the most common technical failures will also be covered within RMT.0599 mentioned above.
Human Factors Safety Issues:
Perception and Situational Awareness: The most important human factors safety issue is related to perception
and situational awareness of flight crew. Actions related training (such as RMT.0599 on EBT) will have a posi-
tive effect on this safety issue but further assessment will be carried out within the HF CAG. In addition, the
introduction of the Flight Crew Operating Manual (FCOM) being implemented by the manufacturers as part of
a Heli Offshore initiative linked to EPAS action SPT.082 will further enable flight crew to improve their situation
awareness.
Annual Safety Review 2017 PAGE 48
CAT HELICOPTER OPERATIONS
Chapter 3b Other Commercial Air Transport
Helicopters
Key Statistics
The key domain statistics for operations involving other commercial air transport - helicopter with an EASA MS
AOC holder or an EASA MS State of Registry are in the tables below. This domain mainly covers business avia-
tion and helicopter emergency medical services (HEMS). There was an increase in fatal accidents in 2016 – 1 fatal
accident occurred in Slovakia, and 1 in Moldova, which involved an EU operator. Both accidents involved HEMS
flights and both had 4 fatalities each. There were also 3 non-fatal accidents, which is lower than the 10-year aver-
age. The number of serious incidents was similar to the 10-year average, while fatalities were significantly higher
due to the two fatal accidents.
Table 7 Key statistics Other Helicopter Commercial Operations
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 0.9 4.1 0.9
2016 2 3 1
% difference 222% ã -27% ä 11% ã
Fatalities Serious Injuries
2006-2015 average 2.8 2.3
2016 8 0
% difference 285% ã ä
´´ Figure 16 Other Helicopter Commercial Operations fatal and non-fatal accidents 2007-2016
9
8
7
6
Number
5
4
3
2
1
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Number of Non-Fatal Accidents
PAGE 49
´´ Figure 17 Other Helicopter Commercial Operations fatalities and serious injuries 2007-2016
9
8
7
6
Number
5
4
3
2
1
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of flight
En-route and approach were the flight phases with the most accidents and serious incidents in 2016. However,
the low numbers in all categories make it difficult to draw conclusions from this part of the data.
Table 8 Offshore accidents and serious incidents per phase of flight 2006-2015 vs 2016
Accidents and Serious Incidents
Phase of Flight
2006-2015 average 2016
Standing 0.2 0
Taxi 0.2 0
Take-off 0.4 0
En route 1.8 2
Manoeuvring 0.9 1
Approach 0.6 2
Landing 1.7 1
Post-impact 0 0
Unknown 0.2 0
Safety Risk Portfolio
The safety risk portfolio for other commercial operations with helicopters has been developed using EASA data
as no CAG has as yet been established for this domain. It is intended to establish a CAG focussed on HEMS op-
erations in the second half of 2017. This will enable the portfolio to be further improved based on operational
experience. With regards to the fatal accident percentages, it should be noted that the existence of accidents
still under investigation with unknown causes is the reason why the key risk area identified in the portfolio do
not appear to add up to 100%.
Annual Safety Review 2017 PAGE 50
CAT HELICOPTER OPERATIONS
OTHER COMMERCIAL HELICOPTERS
Outcome Percentage
of Fatal Accidents 10 40% 40% 0% 0% 0%
(2007-2016)
Outcome Percentage
of Non-Fatal 37 59% 11% 22% 11% 5%
Accidents (2007-2016)
Total number of occurrences in 2012-
2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Obstacle
Collision
Damage
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Operational Fatal
Helicopter Obstacle
6 1 4 3
See and Avoid
Intentional Low Flying 7 1 5 2
Bird/ Wildlife Strikes 98 - 1 -
Approach Path
- - 1 -
Management
Airborne Separation 25 1 - -
Flight Planning and
30 - - -
Preparation
Degraded Visual
5 - - -
Environment
Icing in Flight 4 - - -
Handling of Technical
2 - - -
Failures
Control of the
Helicopter Flight
- - - -
Path and Use of
Automation
Icing on Ground - - - -
Use of Operationally
Ready Safety Systems - - - -
for Helicopters
Management of the
Dynamic Landing - - - -
Environment
Management of
the Static Landing - - - -
Environment
PAGE 51
OTHER COMMERCIAL HELICOPTERS
Outcome Percentage
of Fatal Accidents 10 40% 40% 0% 0% 0%
(2007-2016)
Outcome Percentage
of Non-Fatal 37 59% 11% 22% 11% 5%
Accidents (2007-2016)
Total number of occurrences in 2012-
2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Obstacle
Collision
Damage
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Technical Fatal
Diagnosis and
Tolerance of System 546 2 5 -
Failures
System Reliability 546 2 5 -
Aircraft Maintenance 14 - - -
Airworthiness
2 - - -
Management
UAS Strikes - - - -
Human
Perception and
9 - 1 1
Situational Awareness
CRM and Operational
32 1 1 -
Communication
Experience, Training
and Competence of 2 1 1 -
Individuals
Knowledge of
Aircraft Systems and 1 - 1 -
Procedures
Navigation and
8 - - -
Airspace Knowledge
Decision Making and
3 - - -
Planning
Personal Pressure and
1 - - -
Alertness
Organisational
Development and
Application of
- - - -
Regulations and
Procedures
Effectiveness of Safety
- - - -
Management
Annual Safety Review 2017 PAGE 52
CAT HELICOPTER OPERATIONS
Priority Key Risk Areas
The safety risk portfolio enables the identification of the priority key risk areas for this domain. These risks are
currently prioritised by considering the percentage involvement in the number of fatal and then non-fatal acci-
dents in that order.
Aircraft upset is the top key risk area: 50% of fatal accidents resulted
4 Fatal Accidents in this accident outcome.
22 Non-Fatal Accidents
Helicopter
Upset
Obstacle collisions is the second most common accident outcome in
4 Fatal Accidents this domain accounting for 40% of the fatal accidents. This highlights
the challenges of HEMS operations and their limited selection and
planning for landing sites.
4 Non-Fatal Accidents
Obstacle
Collision
Helicopter landing area excursions was the outcome in 11% of non-
0 Fatal Accidents fatal accidents. No such occurrences involved fatalities.
8 Non-Fatal Accidents
Landing Area
Excursion
Terrain collision includes collisions with trees, elevated terrain and
1 Fatal Accident level terrain/water. A total of 10% of fatal accidents in the past decade
are attributed to this key risk area.
4 Non-Fatal Accidents
Terrain
Collision
Top Safety Issues and Associated Actions
For other CAT helicopters, the safety issues have been prioritised on the basis of their involvement in fatal acci-
dents, non-fatal accidents, serious incidents and incidents in that order. The top safety issues for this domain are:
Technical Safety Issues:
Diagnosis and Tolerance of System Failures/ System Reliability: Similar types of helicopter are used in offshore
and other CAT helicopters operations so it is no surprise that system failure is also an issue in this domain. The
goal is to both improve system reliability and provide support in the earliest possible diagnosis of a system fail-
ure. A key action here is RMT.0608, which aims to strengthen the existing CS-29 requirements pertaining to rotor
drive system lubrication. Also of relevance is RMT.0711, which covers vibration health monitoring.
PAGE 53
Operational Safety Issues:
Helicopter Obstacle See and Avoid: Obstacle collisions are the second most common accident outcome in this
domain, making obstacle see and avoid one of the key safety issues. This involves the provision of the best equip-
ment and strategies to help flight crew maintain safe clearance from obstacles during take-off and landing. There
are presently no specific actions in this area.
Intentional Low Flying: The safety issue of intentional low flying, is very closely related to the see and avoid
safety issue above. In the domain of other CAT helicopter operations, there is routinely a requirement to fly at
low altitude (within the regulatory framework) and the analysis identified that a disproportionately high num-
ber of occurrences take place in the activity. Further work will be carried out to investigate this in more detail.
Human Factors Safety Issues:
Perception and Situational Awareness: The most important human factors safety issue is related to perception
and situational awareness of flight crew. Actions related training will have a positive effect on this safety issue
but further assessment will be carried out within the HF CAG.
Annual Safety Review 2017 PAGE 54
CAT HELICOPTER OPERATIONS
Chapter 3c Part Special Operations (SPO) –
Aerial Work - Helicopters
This chapter covers aerial work and special operations (SPO) involving helicopters of all mass groups having an
EASA MS State of Registry. The key statistics and an occurrence data based safety risk portfolio are presented.
Key Statistics
The key domain statistics are in the tables below. There were no fatal accidents in this domain in 2016. The num-
ber of non-fatal accidents was lower in 2016 compared with the average of the previous decade. The number of
serious incidents in 2016 was slightly higher in 2016 compared with the 2006-2015 average. The number of se-
rious injuries was somewhat lower in 2016 vis-a-vis the average of the preceding 10-year period. When looking
at the trend over time in the first graph, it is pleasing to see that the lower numbers of accidents has been sus-
tained for 4 years in a row.
Table 9 Key statistics Part Special Operations (SPO) Aerial Work Helicopters
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 4.1 17.2 1.3
2016 0 13 2
% difference ä -24% ä 53% ã
Fatalities Serious Injuries
2006-2015 average 7.4 6.5
2016 0 5
% difference ä -23% ä
´´ Figure 18 Part Special Operations (SPO) Aerial Work Helicopter accidents and serious
incidents by operation 2007-2016
40
35
30
25
Number
20
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Number of Non-Fatal Accidents
PAGE 55
´´ Figure 19 Part Special Operations (SPO) Aerial Work Helicopter fatalities and serious
injuries 2007-2016
18
16
14
12
Number
10
8
6
4
2
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of Flight
In terms of flight phase, the numbers for 2016 were similar to those for the average of the previous decade. The
number of occurrences during take-off was slightly higher than the 10 year average, while for manoeuvring there
was a reduction.
Table 10 Part Special Operations (SPO) Aerial Work Helicopters accidents and serious
incidents per phase of flight 2006-2015 vs 2016
Accidents and Serious Incidents
Phase of Flight
2006-2015 average 2016
Standing 0,5 0
Taxi 0 0
Take-off 3,3 4
En route 3,6 2
Manoeuvring 10 6
Approach 1,2 0
Landing 3,3 3
Post-impact 0 0
Unknown 0,8 0
Annual Safety Review 2017 PAGE 56
CAT HELICOPTER OPERATIONS
Operation Type
In some operation types, namely aerial observation, aerial patrol, aerial survey and photography, there were no
accidents or serious incidents in 2016. In parachute drop and towing there were more accidents and serious in-
cidents in 2016 compared to the previous decade average. For the remaining operation types the numbers were
similar.
Table 11 Part Special Operations (SPO) Aerial Work Helicopters accidents and serious
incidents by operation 2006-2015 vs 2016
Accidents and Serious Incidents
Operation Type
2006-2015 average 2016
Aerial Advertising 0 0
Aerial Observation 1,2 0
Aerial Patrol 1 0
Aerial Survey 0,7 1
Agricultural 5 3
Airshow/Race 0,4 0
Parachute drop 0 0
Photography 1,7 0
Towing 0,1 0
Construction/Sling load 4,5 4
Logging 1,3 0
Other 3,1 3
PAGE 57
Safety Risk Portfolio
The domain safety risk portfolio for Part SPO/aerial work operations with helicopters is provided below.
SPECIALISED OPERATIONS ROTORCRAFT
Outcome
Percentage of
38 29% 24% 18% 5% 3% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage of Non-
161 25% 35% 7% 3% 12% 1%
Fatal Accidents
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Aircraft Upset
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Runway
Aircraft
Serious
Terrain
Flight
Fatal
Operational
Intentional Low
131 4 16 6
Flying
Helicopter Obstacle
30 4 11 4
See and Avoid
Flight Planning and
26 0 3 0
Preparation
Handling of
2 0 1 0
Technical Failures
Bird/ Wildlife
31 0 0 0
Strikes
Airborne Separation 27 0 0 0
Degraded Visual
2 0 0 0
Environment
Approach Path
1 0 0 0
Management
Control of the
Helicopter Flight
0 0 0 0
Path and Use of
Automation
Technical
System Reliability 377 1 19 2
Aircraft
36 0 0 0
Maintenance
UAS Strikes 0 0 0 0
Airworthiness
0 0 0 0
Management
Annual Safety Review 2017 PAGE 58
CAT HELICOPTER OPERATIONS
SPECIALISED OPERATIONS ROTORCRAFT
Outcome
Percentage of
38 29% 24% 18% 5% 3% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage of Non-
161 25% 35% 7% 3% 12% 1%
Fatal Accidents
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Aircraft Upset
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Runway
Aircraft
Serious
Terrain
Flight
Fatal
Human
Perception
and Situational 23 2 5 1
Awareness
CRM and
Operational 48 0 1 0
Communication
Decision Making
6 0 1 0
and Planning
Personal Pressure
3 0 1 0
and Alertness
Experience, Training
and Competence of 3 0 0 0
Individuals
Knowledge of
Aircraft Systems and 2 0 0 0
Procedures
Organisational
Development and
Application of
0 0 0 0
Regulations and
Procedures
Effectiveness of
- - - -
Safety Management
PAGE 59
Priority Key Risk Areas
The safety risk portfolio enables the identification of the priority key risk areas for this domain. These are cur-
rently prioritised by considering the percentage involvement in the number of fatal and non-fatal accidents in
that order.
Obstacle collisions is the most common accident outcome in this
11 Fatal Accidents domain with 40% of the fatal accidents. It highlights the challenges of
HEMS operations and their limited selection and planning for landing
sites.
40 Non-Fatal Accidents
Obstacle
Collision
Aircraft upset or loss of control is the second most common accident
9 Fatal Accidents outcome for fatal accidents in SPO Aeroplane operations. 46% of fatal
accidents in the 2007-2016 period can be attributed to aircraft upset.
56 Non-Fatal Accidents
Helicopter
Upset
Terrain collision includes collisions with trees, elevated terrain and
1 Fatal Accident level terrain/water. A total of 18% of fatal accidents in the past decade
have been attributed to this key risk area.
5 Non-Fatal Accidents
Terrain
Collision
Airborne collisions are collisions between aircraft where both (all)
2 Fatal Accidents aircraft were airborne. In Part SPO helicopter operations, this accounts
for 18% of the fatal accidents in the previous 10 years.
3 Non-Fatal Accidents
Airborne
Collision
Runway excursions, side excursions as well as overruns, account for 2%
2 Fatal Accidents of the fatal accidents in SPO Aeroplanes operations in the past decade.
5 Non-Fatal Accidents
Landing Area
Excursion
Annual Safety Review 2017 PAGE 60
CAT HELICOPTER OPERATIONS
Top Safety Issues and Associated Actions
Currently, there is no Aerial Work/Specialised Operations CAG. Therefore, the list of safety issues identified in the
safety risk portfolio has been established solely using EASA data.
Technical Safety Issues:
Diagnosis and Tolerance of System Failures/ System Reliability: There is continual work in the design, manufac-
turing and maintenance regulatory framework to improve system reliability and provide support in the earliest
possible diagnosis of a system failure. A key action here is RMT.0608, which aims to strengthen the existing CS-29
requirements pertaining to rotor drive system lubrication. Another related action specifically in the aerial work
operations is RMT.0709 related to the prevention of catastrophic accidents due rotorcraft hoists issues.
Operational Safety Issues:
Intentional Low Flying: There are many operational situations where low flying is required and is performed
within the regulatory framework. However, the analysis has shown that further work is needed in this area. For
helicopters, the nature of many aerial work activities make this very specific to each one and the various operat-
ing communities will be involved in further analysis and assessment work when it takes place.
Helicopter Obstacle See and Avoid: Obstacle collisions are the most common accident outcome in this domain,
making obstacle see and avoid one of the key safety issues. This is very closely link to the previous safety issue
on low flying. The work previously described about would likely involve the provision of the best equipment and
strategies to help flight crew maintain safe clearance from obstacles during take-off and landing.
Non-Commercial
Operations
4
Annual Safety Review 2017 PAGE 62
Non-Commercial Operations
Chapter 4a Non-Commercial
Operations – Aeroplanes
This chapter covers general aviation non-commercial operations (GA NCO) involving aeroplanes in mass groups
below 5700 kg and having an EASA MS State of Registry. Key statistics and an occurrence data driven safety risk
portfolio are presented. The safety risk portfolio is enhanced with expertise from operators, manufacturers, fly-
ing clubs/ associations and National Aviation Authorities (NAAs) that support the GA Sectorial Committee and
other related advisory bodies. A GA NCO Aeroplane Collaboration and Analysis Group (CAG) has been formally
established in May 2017.
Key Statistics
The key domain statistics are in the tables below. There were fewer fatal accidents in 2016 compared to the 10-
year average and there was also a significantly lower number of non-fatal accidents. The numbers of fatalities
and serious injuries in 2016 were significantly lower than the averages for the preceding decade. In GA NCO aer-
oplanes, there were 46 fatal accidents, which continues the downward trend from the previous year and is lower
than the 10-year average. The number of fatalities has also been significantly reduced (78) compared to the 10-
year average.
Table 12 Key statistics Non‑commercial operations aeroplanes
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 51.4 388.1 25.9
2016 46 265 36
% difference -10% ä -32% ä 39% ã
Fatalities Serious Injuries
2006-2015 average 94.4 50.8
2016 78 36
% difference -17% ä -29% ä
For the first time, the Agency has been able to collect sufficient GA exposure data to create initial accident rates
for this domain. The exposure data was collected via a survey of the EASA Member States (MS) and through
merging data that was kindly provided by GAMA. The fatal accident rate reduced between 2014 and 2015,
however, despite the lower number of accidents the rate increased in 2016. The rate of non-fatal accidents has
reduced by over 40% between 2014 and 2016.
´´ Figure 20 Fatal and Non-Fatal Accident Rates for NCO Aeroplanes 2014-2016
16
Accident rate per 100 000 flight hours
14
12
10
8
6
4
2
0
2014 2015 2016
Non-Fatal Accident rate Fatal Accident rate
PAGE 63
´´ Figure 21 Non-commercial operations aeroplanes fatal and non-fatal accidents 2007-2016
600
500
400
Number
300
200
100
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Non-Fatal Accidents
´´ Figure 22 Non-commercial operations fatalities and serious injuries 2007-2016
120
100
80
Number
60
40
20
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of Flight
In terms of flight phase, in GA NCO aeroplanes accidents most of the accidents occur during take‑off, approach
and landing. The largest number of accidents take place during landing, however there were fewer landing ac-
cidents in 2016 compared to the 10-year average.
Table 13 Non-commercial operations accidents and serious incidents per phase of flight 2006-2016
Accidents and SIs
Phase of Flight
2006-2015 average 2016
Standing 11.8 6
Taxi 27.2 20
Take-off 80.9 61
En route 74.7 55
Manoeuvring 16.1 14
Approach 43.8 27
Landing 206.2 144
Unknown 4.2 20
Annual Safety Review 2017 PAGE 64
Non-Commercial Operations
Operation Type
Most of the accidents in the GA NCO aeroplanes domain occurred during pleasure flights. The next most numer-
ous operation type involves flight training/instructional flights.
Table 14 Non-commercial operations accidents and serious incidents by operation 2006-2016
Accidents and Serious Incidents
Operation Type
2006-2015 average 2016
Demonstration 1.1 0
Relocation 4.5 2
Flight Training/Instructional 88.9 54
Pleasure 312.9 163
Test Flight 5.1 3
Other 5.1 3
Unknown 4.4 39
Safety Risk Portfolio
The GA NCO aeroplanes safety risk portfolio is provided below and identifies the key risk areas and safety is-
sues. This portfolio comprises safety issues that have been identified through analysing safety occurrence data.
The portfolio has initially been developed by the Agency and then adjusted following discussion at a GA Safe-
ty Workshop held in October 2016. This work was further developed in the Network of Analysts. A GA NCO CAG
will continue the work and meets for the first time in May 2017.
NON COMMERCIAL OPERATIONS - AEROPLANES
Outcome
Percentage of
496 47% 23% 9% 8% 3% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 4 425 24% 5% 7% 3% 47% 2% 4%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Damage
Runway
Ground
Aircraft
Aircraft
Serious
Terrain
Upset
Flight
Total
Fatal
Operational
Flight Planning
1 988 5 49 18
and Preparation
Intentional Low
13 1 12 18
Flying
PAGE 65
NON COMMERCIAL OPERATIONS - AEROPLANES
Outcome
Percentage of
496 47% 23% 9% 8% 3% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 4 425 24% 5% 7% 3% 47% 2% 4%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Damage
Runway
Ground
Aircraft
Aircraft
Serious
Terrain
Upset
Flight
Total
Fatal
Airborne
347 15 56 10
Separation
Handling of
33 4 13 8
Technical Failures
Icing in Flight 26 2 53 3
Bird/ Wildlife
275 2 18 3
Strikes
Approach Path
18 3 37 2
Management
Control of Manual
5 - 5 2
Flight Path
Deconfliction with
Aircraft Not Using 101 3 1 1
Transponders
Crosswind 23 2 64 -
Turbulence 25 - 14 -
Icing on Ground 6 - 2 -
Baggage and
1 - - -
Cargo Loading
Technical
System Reliability 3 497 79 770 58
Aircraft
84 7 10 2
Maintenance
UAS Strikes 1 2 - -
Human
Perception
and Situational 429 10 104 12
Awareness
Decision Making
47 3 54 9
and Planning
Annual Safety Review 2017 PAGE 66
Non-Commercial Operations
NON COMMERCIAL OPERATIONS - AEROPLANES
Outcome
Percentage of
496 47% 23% 9% 8% 3% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 4 425 24% 5% 7% 3% 47% 2% 4%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable
Environment
Safety Issues
Collision in
(ECR data)
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Damage
Runway
Ground
Aircraft
Aircraft
Serious
Terrain
Upset
Flight
Total
Fatal
Experience,
Training and
45 4 42 6
Competence of
Individuals
Navigation
and Airspace 1 078 8 1 2
Knowledge
Personal Pressure
14 3 12 1
and Alertness
CRM and
Operational 1 151 3 9 1
Communication
Knowledge of
Aircraft Systems 14 1 8 -
and Procedures
Organisational
Development and
Application of
5 - - -
Regulations and
Procedures
PAGE 67
Priority Key Risk Areas
At 47%, aircraft upset is the most common type of accident outcome
232 Fatal Accidents in the last 10 years during non‑commercial operations with
aeroplanes. Aircraft upset is the area of greatest focus for future work
in this domain.
1061 Non-Fatal Accidents
Aircraft Upset
Terrain Collision was the second most common accident outcome in
112 Fatal Accidents the last 10 years, accounting for 23% of accidents, and continues to
present a significant safety challenge.
202 Non-Fatal Accidents
Terrain
Collision
Obstacle collision in flight is the third most frequent type of accident
46 Fatal Accidents outcome. It accounts for 9% of all the fatal accidents over the last 10
years.
320 Non-Fatal Accidents
Obstacle
Collision
The fourth key risk area is airborne collision, which accounts for 8% of
42 Fatal Accidents all the fatal accident outcomes in the last 10 years.
115 Non-Fatal Accidents
Airborne
Collision
Runway excursion is the fifth most frequent type of fatal accident
13 Fatal Accidents outcome in the last 10 years, accounting for 3% of all fatal accidents
in this domain. This risk area is quite common but carries low number
of fatalities.
2060 Non-Fatal Accidents
Runway
Excursion
Top Safety Issues and Associated Actions
The top identified safety issues in the non-commercial operations aeroplanes domain are:
Operational Safety Issues:
Flight Planning and Preparation: This is a safety issue that frequently results in CFIT accidents, particularly when
worsening weather leads to the need for in‑flight re‑planning, which considerably tests a pilot’s ability to con
currently fly the aircraft. EPAS action SPT.044, a safety promotion task to improve GA safety in Europe through
risk awareness and safety promotion, will have a specific focus on risk awareness to enhance the planning and
preparation of the pilot.
Annual Safety Review 2017 PAGE 68
Non-Commercial Operations
Intentional Low Flying: This issue affects the pilot’s decision making process. When either through self-made
or external pressures, effects such as marginal weather then lead some pilots to try to reach the planned des-
tination instead of waiting for the current weather situation to improve. This safety issue is recurrent in loss of
control accidents where stall or spin occurs while flying in low altitudes or entering IMC weather.
Airborne Separation: This safety issue is the 3rd highest when it comes to fatalities over the last 5 years. Pre-
flight planning and knowledge of complex airspace structures are common factors related to this safety issue.
In addition, situational awareness and the ability for inexperienced pilots to communicate effectively with ATC
have also been identified as causal factors. The EPAS action, SPT.044 will also help to support this safety issue
through specific targeting of strategies to prevent mid-air collisions. This action has specifically been chosen as
the first collaborative task for the European Safety Promotion Network (SPN).
Handling of Technical Failures: After a technical failure during flight the pilot’s workload increases significant-
ly. There is evidence of accidents occurring due to the pilot being too focused on the problem rather than flying
the aircraft. This in turn creates situations where the accident outcome becomes significantly worse than it could
have been had the technical failure been handled appropriately. SPT.044 will provide the pilot with tools to as-
sess better the encountered risk.
Human Factor Safety Issues
Perception and Situational Awareness: This safety issue is linked to a number of different types of accidents,
especially a pilot’s awareness of the aircraft’s energy state that may lead to a loss of control and also awareness
of both the geographical position of the aircraft and its position in relation to other aircraft. Rulemaking task
RMT.0677 will enable pilots to have easier access to an IFR rating, which should significantly reduce the risk of
unintended flights into clouds and enable private pilots to fly more safely in critical weather. Follow up action
SPT.088 involves a safety promotion campaign that promotes instrument flying for GA pilots.
Decision Making and Planning: The decision making and planning process varies between persons. This pro-
cess feeds directly into the pilot’s actions, which then provides the basis for the end result. It is therefore very
important that the correct information is available to the pilot when decisions are made so as to facilitate the
best possible outcome of any encountered scenario. The safety promotion task SPT.012 promotes the new Eu-
ropean provisions on pilot training, while rulemaking task RMT.0581, related to a loss of control prevention and
recovery training, will further help the decision making of pilots.
Experience, Training and Competence of Individuals: The final HF priority area is related to the knowledge,
training and competency of individuals. Through the analysis of airborne conflict performed by the NoA, the
complexity of airspace structures was identified as one example where the complex nature of the aviation system
makes things challenging, especially for private pilots. The safety risk assessment in this area will specifically con-
sider ways to provide clear, simple information to help pilots have the right information so as to perform flights
as safely as possible. Rulemaking task RMT.0678 is designed to aid pilots in their theoretical aviation knowledge
and the previously mentioned task SPT.044 is also important in supporting work on this safety issue. The former
task also considers a modular LAPL(A)/(S) training and a review of the mountain rating.
PAGE 69
Chapter 4b Non-Commercial
Operations – Helicopters
This chapter covers non‑commercial operations involving both helicopter and gyrocopters with a maximum take-
off weight under 5700 kg where the state of registry was an EASA MS. Key statistics and an occurrence data
based safety risk portfolio (SRP) are presented.
Key Statistics
The key domain statistics are in the tables below. There was one less fatal accident in 2016 compared to the 10-
year average, but there was a significantly lower number of non-fatal accidents. The numbers of fatalities and
serious injuries in 2016 were close to the half of the average for the preceding decade.
Table 15 Key statistics Non-commercial operations helicopters
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 10 57.0 2.2
2016 9 33 3
% difference -10% ä -42% ä 36% ã
Fatalities Serious Injuries
2006-2015 average 17.5 9.8
2016 11 6
% difference -37% ä -33% ä
In non‑commercial helicopter operations, there were 9 fatal accidents, which is 10% less than the 10-year aver-
age. There was also a significant reduction in the number of non‑fatal accidents.
´´ Figure 23 Non-commercial operations helicopters fatal and non-fatal accidents 2007-2016
90
80
70
Number of Accidents
60
50
40
30
20
10
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Non-Fatal Accidents
There were 11 fatalities in non‑commercial helicopter operations, which was 1 more than in 2015 and is 35% less
than the 10-year average.
Annual Safety Review 2017 PAGE 70
Non-Commercial Operations
´´ Figure 24 non-commercial operations helicopters fatalities and serious injuries 2007-2016
30
25
20
Number
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of Flight
In terms of flight phase, the number of accidents in 2016 was a marginally lower than the 10-year average. It
can be seen that most critical phases of helicopter flights are during the take‑off, en-route and landing phases
of the flight.
Table 16 non-commercial operations helicopters accidents and serious incidents per phase of
flight 2006-2016
Accidents and Serious Incidents
Phase of Flight
Number of Accidents and SIs 2006-2015 2016
Standing 2.1 2
Taxi 4.6 2
Take-off 15 8
En route 14.6 11
Manoeuvring 7.9 7
Approach 6.1 3
Landing 17.2 10
Post-impact 0 0
Unknown 2.4 3
PAGE 71
Safety Risk Portfolio
The non‑commercial helicopters operations safety risk portfolio is provided on the page below, and provides the
key risk areas and safety issues. This portfolio has been developed by EASA using safety occurrence data cover-
ing accidents and serious incidents that has been reported to the Agency.
NON COMMERCIAL OPERATIONS - ROTORCRAFT
Outcome
Percentage of
102 48% 14% 8% 7% 1% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 543 38% 7% 8% 3% 1% 28% 2%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Incidents (ECR
Aircraft Upset
Unsurvivable
Environment
Safety Issues
Collision in
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Airborne
Obstacle
Collision
Collision
Damage
Runway
Ground
Aircraft
Serious
Terrain
Flight
data)
Fatal
Operational
Helicopter
Obstacle See and 7 1 28 10
Avoid
Intentional Low
13 - 14 8
Flying
Flight Planning
229 - 3 3
and Preparation
Handling of
10 1 18 2
Technical Failures
Control of the
Helicopter Flight
- - 8 2
Path and Use of
Automation
Approach Path
22 2 2 -
Management
Bird/ Wildlife
22 1 2 -
Strikes
Airborne
18 1 1 -
Separation
Technical
System Reliability 509 6 79 17
Aircraft
28 1 3 -
Maintenance
UAS Strikes - - - -
Airworthiness
- - - -
Management
Annual Safety Review 2017 PAGE 72
Non-Commercial Operations
NON COMMERCIAL OPERATIONS - ROTORCRAFT
Outcome
Percentage of
102 48% 14% 8% 7% 1% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 543 38% 7% 8% 3% 1% 28% 2%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Incidents (ECR
Aircraft Upset
Unsurvivable
Environment
Safety Issues
Collision in
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Airborne
Obstacle
Collision
Collision
Damage
Runway
Ground
Aircraft
Serious
Terrain
Flight
data)
Fatal
Human
Perception
and Situational 55 1 7 3
Awareness
Personal
Pressure and - - 1 3
Alertness
Experience,
Training and
8 - 8 2
Competence of
Individuals
Decision Making
17 - 5 1
and Planning
CRM and
Operational 115 - - 1
Communication
Knowledge of
Aircraft Systems 2 - 1 -
and Procedures
Navigation
and Airspace 112 - - -
Knowledge
Organisational
Development
and Application
1 - - -
of Regulations
and Procedures
PAGE 73
Priority Key Risk Areas
At 48%, aircraft upset is the most common type of accident outcome
49 Fatal Accidents for non‑commercial operations with helicopters.
204 Non-Fatal Accidents
Helicopter
Upset
Terrain Collision is the second most significant type of fatal accident
14 Fatal Accidents in the last 10 years and occurred in 14% of fatal accidents.
37 Non-Fatal Accidents
Terrain
Collision
The third key risk area addresses obstacle collisions during flight. 8%
8 Fatal Accidents of all fatal accidents last 10 years are attributed to obstacle collisions.
46 Non-Fatal Accidents
Obstacle
Collision
The fourth key risk area is airborne collision. Of all fatal accidents
7 Fatal Accidents over the last 10 years, 7% of them can be attributed to airborne
collision.
16 Non-Fatal Accidents
Airborne
Collision
Top Safety Issues and Associated Actions
Operational Safety Issues:
Helicopter Obstacle See and Avoid: This safety issue is the most common cause of helicopter accidents as it
touches on all of the four key risk areas mentioned above. EPAS action SPT.044, a safety promotion task to im-
prove GA safety in Europe, will focus on this and some of the other issues in work it covers on GA NCO helicopter
operations.
Intentional Low Flying: The nature of NCO helicopter operations includes quite a lot of low flying. This relates
to the safety issue above as well as the perception and situational awareness issue mentioned below. The risk
of low flying does not only contains the risk of collisions but also less response time in case of technical failures.
Handling of Technical Failures: This safety issue has to do with flying the aircraft in spite of technical failures.
During technical failures the pilot’s workload increases and it is therefore of paramount importance that the pi-
lot puts his focus on flying the aircraft first and then address the technical issues.
Annual Safety Review 2017 PAGE 74
Non-Commercial Operations
Control of the Helicopter Flight Path and Use of Automation: This safety issue addresses the pilot’s control of
the helicopter flight path. This infers planning issues as well as ability/inability of the pilot to properly control the
aircraft due to various reasons.
Human Factors Safety Issues:
Perception and Situational Awareness: This safety issue is a common cause of helicopter accidents and it com-
plements all of the operational safety issues mentioned above. As helicopters land in a tighter area than fixed
wing aircraft, the landing process requires even higher level of awareness than in conventional landing as the pi-
lot has to consider the area behind him and to both sides while performing his landing.
Personal Pressure and Alertness: Working under high pressure can result in missing important information re-
lated to the current situation. This safety issue also relates to the level of a pilot’s alertness at the time of the
occurrence.
Balloons
5
Annual Safety Review 2017 PAGE 76
Balloons
This chapter covers balloon operations where the state of registry was an EASA MS. For this chapter minimal in-
cident data is available from the European Central Repository (ECR) so this has not been included in the safety
risk portfolio. The Balloon Collaborative Analysis Group (BCAG) was one of the first CAGs to be established by the
Agency. The group has reviewed all the fatal accidents and sufficiently sampled the non‑fatal accidents data for
the last five years. The BCAG comprises members from industry, manufacturer and NAAs providing an excellent
source of expert knowledge. The identified safety issues in relation to the available data give a realistic picture
of safety within the hot air balloon operations. The future work of the CAG will be to risk assess the balloon ac-
cidents and further support the EASA’s SRM process.
Key Statistics
The key domain statistics are in the tables below. The balloon domain has a very small number of occurrences
and this affects statistical analysis. A typically used 10-year data range was not possible as reliable balloon ac-
cident data has only been available since 2011. A 5-year average is therefore used in this section. In 2016 there
was 1 fatal accident in balloon operations, leading to 1 fatality, both figures being lower than the 5-year aver-
age. There was an increase in the number of non‑fatal accidents compared to 2015 and the number of serious
injuries decreased significantly compared to the 5-year average.
Table 17 Key statistics Balloons
Fatal Accidents Non-Fatal Accidents Serious Incidents
2011-2015 average 2.2 20.2 2
2016 1 11 4
% difference -55% ä -45% ä 100% ã
Fatalities Serious Injuries
2011-2015 average 4 24
2016 1 9
% difference -75% ä -62% ä
There was 1 fatal balloon accident in 2016, compared with 2 in 2015 and 2014. The number of non‑fatal acci-
dents increased in 2016 compared with 2015 but there is a significant decrease in non-fatal accidents compared
with the 5 year average.
´´ Figure 25 Balloons fatal and non-fatal accidents 2012-2016
35
30
Number of Accidents
25
20
15
10
5
0
2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Non-Fatal Accidents
PAGE 77
´´ Figure 26 Balloons fatalities and serious injuries 2012-2016
40
35
30
25
Number
20
15
10
5
0
2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of Flight
In terms of flight phase, the numbers for 2016 were similar to those for the average of the previous 5 years.
Table 18 Balloons accidents and serious incidents per phase of flight 2011-2016
Accidents and SIs
Phase of Flight
2011-2015 average 2016
Standing 1 2
Taxi 0 0
Take-off 1.6 2
En route 2.2 1
Manoeuvring 0.4 0
Approach 2 2
Landing 17 8
Post-impact 0 0
Unknown 0 0
Annual Safety Review 2017 PAGE 78
Balloons
Safety Risk Portfolio
The balloon operations safety risk portfolio is provided on the next page, which gives the key risk areas and
safety issues. This portfolio has been developed using EASA data and enhanced as a result of work by the BCAG.
BALLOONS
Outcome
Percentage of
12 33% 25% 17% 8% 8% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 185 34% 22% 5% 7% 2% 3%
Accidents
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Safety Issues Collision in
and Upset
(ECR data)
Non-Fatal
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Landing
Balloon
Balloon
Serious
Control
Terrain
Flight
Hard
Fatal
Fire
Operational
Presence and Use
1 1 6 4
of Pilot Restraints
Control of Manual
6 - 8 3
Flight Path
Flight Planning
16 - 12 -
and Preparation
Airborne
10 1 1 -
Separation
Approach Path
- - - -
Management
Technical
Fuel Systems 2 1 - 1
Exterior Colour
Schemes and - - - -
Markings
PAGE 79
BALLOONS
Outcome
Percentage of
12 33% 25% 17% 8% 8% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 185 34% 22% 5% 7% 2% 3%
Accidents
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Collision in
Safety Issues
and Upset
(ECR data)
Non-Fatal
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Landing
Balloon
Balloon
Serious
Control
Terrain
Flight
Hard
Fatal
Fire
Human
Decision Making
2 - 4 3
and Planning
Perception
and Situational 9 1 5 1
Awareness
Experience,
Training and
- - 1 -
Competence of
Individuals
Knowledge of
Aircraft Systems - - 1 -
and Procedures
CRM and
Operational 17 - - -
Communication
Personal Pressure
- - - -
and Alertness
Organisational
Passenger Safety
- - 4 1
Briefing
Development and
Application of
- - - -
Regulations and
Procedures
Effectiveness
of Safety - - - -
Management
Annual Safety Review 2017 PAGE 80
Balloons
Priority Key Risk Areas
4 Fatal Accidents Abnormal landings or hard landings are the most common cause for
balloon accidents. It rare that the balloon gets damaged during these
landings but the hard landings have been causing injuries to persons
on board or they are ejected from the basket. Broken or fractured feet
62 Non-Fatal Accidents and hands are the most common injuries. 33% of the fatal accidents
Hard Landings for the last 10 years can be attributed to these hard landings
Obstacle collision in flight poses a high risk of a serious accident.
3 Fatal Accidents Powerline strikes, collisions with buildings and masts are the most
common accidents in this risk area. Powerline strikes can cause fire
and electrical shock to persons on board the balloon. 25% of fatal
balloon accidents for the last 10 years are caused by obstacle collision
40 Non-Fatal Accidents during the flight.
Obstacle
Collision
Terrain collision includes collisions with trees, elevated terrain and
2 Fatal Accidents level terrain/water. 17% of fatal balloon accidents are attributed to
terrain collision.
9 Non-Fatal Accidents
Terrain
Collision
Aircraft upset or loss of control is not very common in Ballooning but
1 Fatal Accident does happen. 8% of fatal accidents last 10 years can be attributed
to loss of control. This involves pilots being ejected from the basket
during the take-off or landing phases of flight.
13 Non-Fatal Accidents
Balloon Upset
An unsurvivable Aircraft Environment happens in case of on board fire
1 Fatal Accident or the rupture of the envelope. 8% of the fatal accidents last 10 years
can be attributed to this key risk area.
4 Non-Fatal Accidents
Fire
Top Safety issues and associated actions
Operational Safety Issues:
Presence and Use of Pilot Restraints: When looking at the accidents during the last 5 years it can be seen that
in 6 non-fatal balloon accidents and 4 fatal accidents the pilot had been ejected during either take-off or landing.
It has been proven to be beneficial to have a harness on board the balloon to protect the pilot from being eject-
ed during the balloon operation. While there are no specific EPAS actions with regards to the use of harnesses,
there has been coordinated work at national level through NAAs and balloon clubs.
Control of Manual Flight Path: The control of the manual flight path includes the pilot’s understanding of the
Balloon inertia and balloon physics. The inertia changes with balloon size and the pilot’s actions need to reflect
that to correctly control the flight path.
PAGE 81
Human Factor Safety Issues
Decision Making and Planning: The pilot’s decisions and planning are of paramount importance when it comes
to the safe operation of the balloon. This includes both the decision to take-off and also to land. In the last 5
years 3 fatal and 4 non-fatal accidents have been attributed to decision making and planning as one of the caus-
al factors.
Perception and Situational Awareness: This safety issue is very important when it comes to balloon flights. Of-
ten these flights are made just over the tree tops and the corn fields. If the sun is low it can be impossible to
see powerlines. As powerline strikes are the most common of the obstacle collision accidents the pilots should
engage the passengers to help him avoid such collisions and that way increase his perception and situational
awareness.
Passenger Safety Briefing: It has been identified that a good passenger briefing is essential to ensure a safe
flight. Such briefing helps passengers to stay within the safety lines and to engage in the flight in the safest way
possible.
Gliders/Sailplanes
6
PAGE 83
This chapter covers glider/sailplane operations where the state of registry is an EASA MS.
Key Statistics
The key domain statistics are in the tables below. For gliders, there was a reduction in the numbers of fatal ac
cidents and fatalities in 2016 with 19 fatal accidents and 20 fatalities. The number of non‑fatal accidents was
lower than the 10-year average with 168. There was a slight decrease in the number of serious injuries to 33.
Table 19 Key statistics Glider/Sailplanes
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 26.5 168 4.6
2016 19 148 6
% difference -28% ä -12% ä 30% ã
Fatalities Serious Injuries
2006-2015 average 31.1 35.0
2016 20 33
% difference -36% ä -6% ä
There were 20 fatalities in gliders/sailplanes operations in 2016. This the lowest result since the data collection
for these operations began. The graph shows a downward trend in number of fatalities from 2007 to 2016. How-
ever, the number of serious injuries is increasing.
´´ Figure 27 Glider/Sailplane fatal and non-fatal accidents 2007-2016
300
250
Number of Accidents
200
150
100
50
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Non-Fatal Accidents
Annual Safety Review 2017 PAGE 84
Gliders/Sailplanes
´´ Figure 28 Glider/Sailplane fatalities and serious injuries 2007-2016
50
45
40
35
30
Number
25
20
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Phase of Flight
In terms of flight phase, the majority of the glider/sailplane accidents occur during take‑off or landing. Accidents
during take‑off may be attributed to a wing touching ground during a winch launch and during landing it is
mostly attributed to situational perception resulting in hard landings and/or ground loops.
Table 20 Sailplane accidents and serious incidents per phase of flight 2006-2016
Accidents and SIs
Phase of Flight
2006-2015 average 2016
Standing 2.5 1
Taxi 3.9 3
Take-off 44.4 36
En route 33.3 28
Manoeuvring 15.8 10
Approach 30.1 14
Landing 96.9 96
Post-impact 0.2 0
Unknown 3 4
PAGE 85
Safety Risk Portfolio
The glider/sailplane operations safety risk portfolio provides the key risk areas and safety issues in this domain.
SAILPLANES/GLIDERS
Outcome
Percentage of
251 50% 12% 8% 4% 3% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 1 973 15% 14% 3% 42% 15% 2%
Accidents
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
in Flight
Runway
Ground
Aircraft
Serious
Terrain
Upset
Fatal
Operational
Intentional Low
2 1 11 6
Flying
Tow Rope
Disconnects and 5 - 22 5
Cable Failures
Airborne
17 2 14 4
Separation
Handling of Off-
Field/Forced - - 14 3
Landings
Handling of
3 2 11 3
Technical Failures
Control of Manual
- - 15 1
Flight Path
Approach Path
2 - 13 -
Management
Flight Planning
62 - 8 -
and Preparation
Bird/Wildlife
3 - 2 -
Strikes
Technical
Aircraft
3 1 3 -
Maintenance
Annual Safety Review 2017 PAGE 86
Gliders/Sailplanes
SAILPLANES/GLIDERS
Outcome
Percentage of
251 50% 12% 8% 4% 3% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 1 973 15% 14% 3% 42% 15% 2%
Accidents
(2007-2016)
Total number of occurrences in 2012-
Key Risk Areas (Outcomes and precursors)
2016 per safety issue
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
in Flight
Runway
Ground
Aircraft
Serious
Terrain
Upset
Fatal
Human
Perception
and Situational 40 1 27 4
Awareness
Decision Making
2 - 18 4
and Planning
Experience,
Training and
2 - 16 1
Competence of
Individuals
Organisational
Development and
Application of
2 - - -
Regulations and
Procedures
PAGE 87
Priority Key Risk Areas
Aircraft Upset is the top key risk area responsible for 50% of all fatal
125 Fatal Accidents accidents in the last 10 years. It addresses all of the operational and
human factor safety issues.
296 Non-Fatal Accidents
Aircraft Upset
The second key risk area of terrain collision accounts for 12% of fatal
30 Fatal Accidents accidents over the last 10 years. These accidents include safety issues
such as handling off-field landings, intentional low flying, control of
manual flight path as well as approach path management and flight
planning. Perception and decision making are the main human factor
276 Non-Fatal Accidents issues.
Terrain
Collision
The 3rd key risk area is Airborne Collision. The collision risk is
20 Fatal Accidents significantly higher in gliding as often there are many sailplanes
searching for lift in the same area – even climbing together under
the same cloud with very little space between them. There is also
significant risk where powered aircraft and gliders are in the same
59 Non-Fatal Accidents area and efforts to communicate the position has not been successful.
Airborne 8% of fatal accidents last 10 years are attributed to airborne collision.
Collision
In Sailplane operations an Off-field Landing is considered to be
10 Fatal Accidents a perfectly normal way to end a flight. It bares with it higher risk
which is for the most part accepted by the community. However, the
outliers are when a landing occurs after failed take-off, technical
failures or approach management and the aircraft needs to land in
829 Non-Fatal Accidents an area that is not suitable for sailplane landing causing damage or
Runway even injuries. 4% of fatal accidents last 10 years are attributed to such
Excursion failed landings.
The last mentioned key risk area is Obstacle Collision in Flight. 3%
8 Fatal Accidents of fatal accidents last 10 years have been attributed to this risk area.
The main issues have to do with the approach and landing phases
of the flight. What differentiates gliding from other types of flying is
that sailplanes do not have the same opportunity to avoid obstacles
on the ground as they do not have any powerplant to abort or to
303 Non-Fatal Accidents adjust the flight to the landing area. Many of the accidents have to do
Obstacle
Collision with collisions with trees, bushes, fences, tall vegetation during the
landing phase, causing substantial damage to the sailplane.
Annual Safety Review 2017 PAGE 88
Gliders/Sailplanes
Top Safety Issues and Associated Actions
Operational Safety Issues
Intentional Low Flying: This safety issue relates to 3 of the key risk areas; aircraft upset, terrain collision and ob-
stacle collision in flight. As with many of the safety issues SPT.044, a safety promotion task to improve GA safety
in Europe will be also relevant to this safety issue. In the gliding domain, there will be close collaboration be-
tween EASA, the European Gliding Union (EGU) and national associations.
Tow Rope Disconnects and Cable Failures: Various key risk areas are related to this safety issue including aircraft
upset, runway excursions and obstacle collision in flight.
Airborne Separation – In sailplane operations the separation between aircraft is not always easy to achieve. The
perception and situational awareness training is therefore important to mitigate occurrences involving this safe-
ty issue.
RPAS/UAS/Drones
7
Annual Safety Review 2017 PAGE 90
RPAS/UAS/Drones
This chapter covers Unmanned Aircraft Systems (UAS) Operations, otherwise known as Remotely Piloted Aviation
Systems (RPAS) and as drones, which occurred in EASA Member States. EASA continues to work in great depth
on various aspects of UAS operations. The number of drones within the EU has multiplied over the last 2 years.
EASA has already introduced a technical opinion to initiate the definition of the regulatory framework required
at EU level. Most of the occurrences in this UAS analysis were related to either airspace infringements that occa-
sionally lead to a near collision with an aircraft or issues with controlling the RPAS’s flight path.
Key Statistics
Analysis of UAS occurrences in the European Central Repository (ECR) alone identified 606 occurrences of all se-
verity levels for the last 5 years, of which 37 had been classified as accidents. None of the accidents involved
fatalities. The collection of data on UAS occurrences is still in its infancy and there is still a lot of work to be done
to ensure the correct application of taxonomy terminology related to UAS. The application of the definition of
accident in relation to UAS has improved since new definitions were provided in ICAO Annex 13. However the in-
crease in the number of non-fatal accidents and serious incidents demonstrates mainly the rapid development
of drone operations.
Table 21 Key statistics UAS from ECR occurrence database
Fatal Accidents Non-Fatal Accidents Serious Incidents
2011-2015 average 0 2.6 0.3
2016 0 15 7
% difference = 470% ã 2230% ã
Fatalities Serious Injuries
2011-2015 average 0 0
2016 0 0
Figure 29 below shows the development of reported UAS occurrences for the last 5 years. The dataset is com-
bined with the ECR and data reported to EASA from several European operators flying to and from the United
Kingdom. This figure therefore provides an indication of the situation. These occurrences, observations and
sightings come mostly from pilots flying commercial aircraft. So far it is rare to receive a report from UAS pilots
regarding occurrences they encounter.
´´ Figure 29 UAS reported occurrences per year 2012-2016
1600
1400
1200
1000
800
600
400
200
0
2012 2013 2014 2015 2016
PAGE 91
´´ Figure 30 UAS accidents and other occurrences - Source ECR 2012-2016
2500
2000
1500
1000
500
0
Accidents Other occurrences
Based on the available data containing altitude information (Figure 31) it can be seen that when the drones are
spotted the manned aircraft is most often in the area from 0-6000 feet above the ground and the distance from
the aircraft to the drone is from 0-1000 feet.
´´ Figure 31 Aircraft altitude vs. distance from drone at the time of detection 2010-2016
2500
2000
Distance from aircraft to drone in feet
1500
1000
500
0
0 2000 4000 6000 8000 10000
Aircraft altitude in feet
400ft
Incidents Serious incidents Accidents
Annual Safety Review 2017 PAGE 92
RPAS/UAS/Drones
Safety Risk Portfolio
This second version of the UAS Safety Risk Portfolio is shown below, which provides the full picture of the key
risk areas and safety issues. Further analysis is ongoing with the NoA and the CAT Aeroplanes CAG as part of an
EASA task force created to assess the risk of collision between drones and aircraft. The task force:
• Reviewed all relevant occurrences including the occurrences collected by the European Member States.
Analyse the existing studies on the subject of impact between drones and aircraft.
• Studied the vulnerabilities of aircraft (windshields, engines, and airframe) taking into account the differ-
ent categories of aircraft (large aeroplanes, general aviation, and helicopters) and their associated design
and operational requirements.
• Considered the possibility to do further research and perform actual tests (for example on windshields).
Such tests are currently ongoing.
The regulatory framework for the safe operations of drones in Europe currently being developed by EASA ad-
dresses the issue of collision between drones and aeroplanes. A combination of measures are envisaged such
as operation in visual line of sight, flight under 150 m height above ground, being equipped with identification
and geo‑limitation functions and drone registration. Any operation of drones close to aerodromes would require
a specific authorization from the national aviation authority based on a risk assessment.
RPAS/UAS
Outcome Percentage
of Fatal Accidents 0 0% 0% 0% 0%
(2012-2016)
Outcome Percentage
of Non-Fatal Accidents 32 50% 16% 13% 3%
(2012-2016)
Key Risk Areas (Outcomes and precursors)
Accidents
Incidents
Incidents
Safety Issues
Airborne
Obstacle
Collision
Collision
Collision
in Flight
Serioius
Aircraft
Terrain
Upset
Operational
Control of the UAS
Flight Path and Use of 3 1 5
Automation
Airspace Infringement 185 5 1
Bird/Wildlife Strikes 1 - 1
Flight Planning and
3 - -
Preparation
Landing Management 1 - -
Airborne Separation 42 - -
Technical
System Reliability 20 1 11
PAGE 93
RPAS/UAS
Outcome Percentage
of Fatal Accidents 0 0% 0% 0% 0%
(2012-2016)
Outcome Percentage
of Non-Fatal Accidents 32 50% 16% 13% 3%
(2012-2016)
Key Risk Areas (Outcomes and precursors)
Accidents
Incidents
Incidents
Safety Issues
Airborne
Obstacle
Collision
Collision
Collision
in Flight
Serioius
Aircraft
Terrain
Upset
Human
Navigation and Airspace
102 4 -
Knowledge
Knowledge of Aircraft
- - -
Systems and Procedures
Experience, Training
and Competence of - - -
Individuals
Organisational
Development and
Application of
- - -
Regulations and
Procedures
Management of Change
- - -
and New Situations
Annual Safety Review 2017 PAGE 94
RPAS/UAS/Drones
Priority Key Risk Areas
The first key risk area is the aircraft upset. Most of the accidents
0 Fatal Accidents are related to drone pilots losing control of the drone resulting in
a damage and most often a destruction of the aircraft. 50% of the
RPAS accidents are related to such incidents.
16 Non-Fatal Accidents
Airborne Collision is the 2nd key risk area. Even though there are
0 Fatal Accidents very few occurrences where actual collisions between a drone and
a manned aircraft the risk is considered to be substantial and with
a continuing exponential increase of unmanned aircraft in the air of
5 Non-Fatal Accidents all sizes and shape, it is considered vital to monitor this area closely
and to work on solutions that prevent actual collisions.
Obstacle Collision in Flight is the 3rd key risk area. Drones used in
0 Fatal Accidents aerial work operations and in space constrained areas are susceptible
to higher collision risk than manned aircraft.
4 Non-Fatal Accidents
Top Safety Issues and Associated Actions
In the UAS domain, there is a large strategic EPAS action that will cover all the various safety issues identified in
the safety risk portfolio. This is RMT.0230 which involves the development of implementing rules for UAS.
Operational Safety Issues:
Control of the UAS Flight Path and Use of Automation: This safety issue covers all control aspects of the drone,
including loss of link and automation measures for control. Drone development is ongoing and so is work on
rules and certification for the drone environment.
Airspace Infringement/ Airborne Separation: This safety issue addresses the potential risk of collision by drones
entering controlled airspace without permission. Today it is impossible to fully identify the extent of the problem,
especially due to the fact that smaller drones do not have transponders on board and sightings of birds and other
objects are sometimes raised as drones due to recent publicity of the issue. Countermeasures are being currently
discussed on how best to mitigate the risk and there is a great deal of work ongoing on the airspace structures
to enable safe drones operations in the long term.
Aerodrome and Ground
Handling
8
Annual Safety Review 2017 PAGE 96
Aerodrome and Ground Handling
This chapter covers aerodrome and ground handling operations, with the scope being the EASA Member States
as State of Occurrence. Data is fetched from the EASA database (accidents and serious incidents) as well as the
European Central Repository. It is worth noting that the accidents and serious incidents in this Chapter are those
related to aerodrome/ground handling operations in a general context, which means that the aerodrome itself
may or may not have had a contribution to the given occurrence, but it may have a role in preventing similar oc-
currences in the future.
A Safety Risk Portfolio for Aerodrome and Ground Handling operations is also provided. This has been devel-
oped with the support of the Aerodrome and Ground Handing Collaborative Analysis Group (CAG), launched in
March 2017.
Key Statistics
In Aerodrome and Ground Handling related activities there was one fatal accident in 2016 with one fatality, both
numbers significantly below the average of the preceding decade. There was 73 non-fatal accidents in 2016,
which is just over half of the average of the preceding decade.
Table 22 Key statistics Aerodromes and Ground Handling
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 6,5 138,9 12,7
2016 1 73 21
% difference -85% ä -47% ä 60% ã
Fatalities Serious Injuries
2006-2015 average 11 18,6
2016 1 14
% difference -91% ä -25% ä
´´ Figure 32 Aerodromes & Ground Handling, fatal and non-fatal accidents 2007-2016
180
160
140
120
Number
100
80
60
40
20
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatal Accidents Non-Fatal Accidents
PAGE 97
´´ Figure 33 Aerodromes & Ground Handling, fatalities and serious injuries 2007-2016
35
30
25
Number
20
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries
Safety Risk Portfolio
For the first time, the Agency is pleased to publish its first safety risk portfolio for aerodromes and ground
handling.
AERODROMES
Outcome
Percentage of
68 32% 19% 16% 4% 1% 1% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 1 361 14% 38% 13% 7% 23% 1% 1% 1%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable Aircraft
Ground Damage and
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Runway Excursion
Serious Incidents
Runway Collision
Terrain Collision
Safety Issues
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Excursion
Injuries
Flight
Operational
Baggage and
7 775 3 2 2
Cargo Loading
Aerodrome
Design and 1 857 4 9 1
Layout
Coodination
and Control of 1 204 2 5 1
Turnrounds
Ground
Operations in
155 1 5 1
Adverse Weather
Conditions
Annual Safety Review 2017 PAGE 98
Aerodrome and Ground Handling
AERODROMES
Outcome
Percentage of
68 32% 19% 16% 4% 1% 1% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 1 361 14% 38% 13% 7% 23% 1% 1% 1%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable Aircraft
Ground Damage and
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Runway Excursion
Serious Incidents
Runway Collision
Terrain Collision
Safety Issues
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Excursion
Injuries
Flight
Fuelling
1 583 1 4 1
Operations
Positioning
and Securing
412 17 253 0
of Ground
Equipment
Condition and
Serviceability of
14 880 15 39 0
Airport Operating
Environment
Operation
of Ground
19 2 26 0
Equipment
(Non-Motorised)
Operation of
Vehicles (and
959 1 11 0
Other Motorised
GSE)
Bird/ Wildlife
5 007 0 8 0
Strikes
Wildlife Strikes
and Wildlife 4 736 0 8 0
Control
Jet Blast 79 1 6 0
Pushback
399 1 2 0
Operations
Design and
Serviceability
187 1 2 0
of Vehicles
(Motorised GSE)
Control of
Passengers on 742 0 1 0
the Apron
PAGE 99
AERODROMES
Outcome
Percentage of
68 32% 19% 16% 4% 1% 1% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 1 361 14% 38% 13% 7% 23% 1% 1% 1%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable Aircraft
Ground Damage and
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Runway Excursion
Serious Incidents
Runway Collision
Terrain Collision
Safety Issues
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Excursion
Injuries
Flight
Baggage and
609 0 1 0
Cargo Securing
Operation of Jet
79 0 1 0
Bridges
Parking and
Positioning of 275 2 0 0
Aircraft
Dangerous Goods
Handling and 1 328 0 0 0
Lithium Batteries
Load Sheets
and Other
313 0 0 0
Documentation/
Systems
Design and
Serviceability
of Ground 71 0 0 0
Equipment
(Non-Motorised)
Ground Staff
Movement 14 0 0 0
Around Aircraft
Handling of
Passengers with 0 0 0 0
Reduced Mobility
Unreported
Damage to
0 0 0 0
Composite
Structure
Annual Safety Review 2017 PAGE 100
Aerodrome and Ground Handling
AERODROMES
Outcome
Percentage of
68 32% 19% 16% 4% 1% 1% 1% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 1 361 14% 38% 13% 7% 23% 1% 1% 1%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Unsurvivable Aircraft
Ground Damage and
Obstacle Collision in
Non-Fatal Accidents
Incidents (ECR data)
Runway Excursion
Serious Incidents
Runway Collision
Terrain Collision
Safety Issues
Taxiway/ Apron
Fatal Accidents
Aircraft Upset
Environment
Excursion
Injuries
Flight
Human
Decision Making
36 2 17 2
and Planning
Perception
and Situational 1 161 13 45 1
Awareness
Experience,
Training and
76 2 17 1
Competence of
Individuals
CRM and
Operational 613 2 10 1
Communication
Personal Pressure
29 3 7 0
and Alertness
Fatigue 7 1 2 0
Weather Effects 0 0 0 0
Organisational
Commercial
28 1 4 0
Pressures
Effectiveness
of Safety 0 0 0 0
Management
PAGE 101
Priority Key Risk Areas
Aircraft upset or loss of control is the most common accident
22 Fatal Accidents outcome for fatal accidents where there was a relation to aerodromes
and ground handling operations. 32% of fatal accidents in the 2007-
2016 period can be attributed to aircraft upset.
190 Non-Fatal Accidents
Runway excursions, side excursions as well as overruns, account for
13 Fatal Accidents 19% of the fatal accidents where there was a relation to aerodromes
and ground handling operations in the past decade.
517 Non-Fatal Accidents
Obstacle collision in flight poses a high risk of a serious accident.
11 Fatal Accidents Powerline strikes, collisions with buildings and masts are the most
common accidents in this risk area. In 16% of fatal accidents during
the last 10 years where there was a relation to aerodrome and ground
177 Non-Fatal Accidents handling operations this key risk area was identified.
Terrain collision includes collisions with trees, elevated terrain and
3 Fatal Accidents level terrain/water. In 4% of fatal accidents in the past decade where
there was a relation to aerodromes and ground handling operations
terrain collisions were identified as a key risk area.
95 Non-Fatal Accidents
The key risk area ground damage and injuries comprise damage to
1 Fatal Accident aircraft sustained whilst on the ground, and injuries sustained to
persons when the aircraft is on the ground. In 1% of fatal accidents in
the 2007-2016 period where there was a relation to aerodrome and
313 Non-Fatal Accidents ground handling this key risk area was identified.
Runway collisions encompasses all collisions between aircraft and
1 Fatal Accident other aircraft, vehicles, persons or other objects whilst the aircraft
is on the runway. In 1% of fatal accidents in the past decade where
there was a relation to aerodrome and ground handling operations
14 Non-Fatal Accidents runway collisions were identified as a key risk area.
An unsurvivable aircraft environment happens in case of on board fire
1 Fatal Accident or the rupture of a pressurised cabin causing rapid decompression. In
1% of fatal accidents in the past decade where there was a relation to
aerodrome and ground handling operations one of the identified key
14 Non-Fatal Accidents risk areas was unsurvivable aircraft environment.
Annual Safety Review 2017 PAGE 102
Aerodrome and Ground Handling
Top Safety Issues and Associated Actions
The list of safety issues have been developed during the first meeting of the Aerodromes and Ground Handling
CAG, which met in the first quarter of 2017. These has since be matched with data and a check was made to en-
sure that there were no safety issues missing from the data. The top safety issues in addition to the general safety
issue on human performance, identified from the data are:
• Decision making and planning.
• Baggage and cargo loading.
• Perception and situational awareness.
• Experience, training and competence of individuals.
• CRM and operational communication.
• Aerodrome design and layout.
• Control and coordination of turnarounds.
PAGE 103
ATM/ANS
9
Annual Safety Review 2017 PAGE 104
ATM/ANS
This chapter covers accidents and serious incidents related to the provision of ATM/ANS services in the EASA
Member States. The analysis includes accidents and serious incidents extracted from EASA’s occurrence data-
base that occurred within an EASA MS as State of Occurrence, involving at least one CAT, fixed-wing aircraft with
MTOM of 2250 kg or above.
It is worth noting that the accidents and serious incidents mentioned in this chapter are those related to the pro-
vision of ATM/ANS services, which means that the ATM system may or may not have had a contribution to the
given occurrence, but it may play a role in preventing or decreasing the severity of similar occurrences in the fu-
ture. These are named as “ATM/ANS related”. Among them, there are occurrences where the ATM/ANS provision
of services was a factor contributing to the occurrence, or at least one ATM/ANS factor potentially increased the
level of risk, or it played a role in the occurrence encountered by the aircraft. These events are usually known as
events with “ATM/ANS contribution”. In the chapter, these two types of events are distinguished when necessary.
Currently, an ATM/ANS safety risk portfolio is being developed so as to identify key risk areas and main Safety
Issues in relation to the ATM/ANS provision of services. To accomplish this task, an ATM/ANS Collaborative Anal-
ysis Group (CAG) has been launched in 2017 to engage related stakeholders (i.e., ANSPs, national supervisory
authorities, air traffic controller associations, airports and airline operators). The chapter introduces the initial
draft portfolio, which is under construction and foreseen to be consolidated during 2017, to provide a first hint
on the major candidate safety issues. In addition, the safety issues will also serve to prioritise actions included
in the European Plan for Aviation Safety (EPAS).
Key Statistics
There were no fatal accidents related to ATM/ANS services provided in an EASA MS in 2016, which continues the
trend since 2012. The total number of non-fatal accidents and the number of serious incidents in 2016 remains in
line with the average of the preceding ten-year period. Although there were no fatalities associated to ATM/ANS
related accidents, the number of serious injuries was significantly higher than the average of the ten-year period.
Table 23 Key statistics in ATM/ANS
Fatal Accidents Non-Fatal Accidents Serious Incidents
2006-2015 average 0.5 5.7 35.5
2016 0 6 33
% difference -100% ä 5% ã -7% ä
Fatalities Serious Injuries
2006-2015 average 1.8 3.7
2016 0 8
% difference -100% ä +116% ã
Figure 34 shows the total CAT (fixed-wing aircraft > 2,250kg) accidents ATM/ANS related between 2006 and 2016
(light blue bars) including those accidents with ATM/ANS contribution for the EASA MS.
The decreasing trend in the number of ATM/ANS related accidents observed since 2014 continued in 2016,
despite the increase in traffic. In addition, the number of accidents with ATM/ANS contribution has remained rel-
atively constant and low during the last decade with none observed in 2016. It is worth noting that no ATM/ANS
related fatal accident has been recorded since 2012, and that no fatal accident with ATM/ANS contribution was
registered in the last decade, thus making them rare.
PAGE 105
´´ Figure 34 ATM/ANS related fatal and non-fatal accidents and ATM/ANS contribution per
year, 2006-2016, in EASA MS
12 7
10
6.5
Millions of movements
Number of Accidents
8
(departures)
6 6
4
5.5
2
0 5
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Accidents (ATM/ANS related) Number of Accidents (ATM/ANS contribution)
Number of Fatal Accidents (ATM/ANS related) Number of Fatal Accidents (ATM/ANS contribution)
Departures (ICAO source)
Figure 35 shows ATM/ANS-related serious incidents and serious incidents with ATM/ANS contribution in CAT
(fixed-wing aircraft > 2250kg) in EASA MS area between 2006 and 2016. Following the decreasing trend from
2010, it seems that 2016 shows a change in the trend line with an increasing number of ATM/ANS-related seri-
ous incidents being recorded. However, the number of those with ATM/ANS contribution has remained relatively
stable for the last six years.
´´ Figure 35 ATM/ANS related serious incidents and ATM/ANS contribution per year, 2006-
2016, in EASA MS
60 7
55 6.8
50
Millions of movements (departures)
6.6
Number of Serious Incidents
45
6.4
40
35 6.2
30 6
25 5.8
20
5.6
15
5.4
10
5 5.2
0 5
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Serious Incidents (ATM/ANS related) Departures (ICAO source)
Number of Serious Incidents (ATM/ANS contribution)
Annual Safety Review 2017 PAGE 106
ATM/ANS
Figure 36 shows the ATM/ANS-related accident fatalities and serious injuries in CAT (fixed-wing aircraft > 2,250kg)
in EASA MS area between 2006 and 2016. While the number of serious injuries has increased in 2016, no fatali-
ties have been associated with ATM/ANS related accidents since 2012, thus maintaining this trend in 2016.
´´ Figure 36 ATM/ANS-related accident fatalities and serious injuries per year 2006-2016 in
EASA MS
12 0.8
Number of Passenger Transported by MS
10 0.8
(1 Billion pax departures)
Number of Fatalities
8 0.7
6 0.7
4 0.6
2 0.6
0 0.5
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Number of Fatalities Number of Serious Injuries Pax departures (Eurostat)
Phase of Flight
In terms of flight phase, the majority of accidents and serious incidents in ATM/ANS-related accidents took place
during the en-route and approach phases, followed by take-off, taxi and landing phases. In comparing the 2016
data with the 2006-2015 average, differences can be seen in almost all phases. While accidents and serious inci-
dents during taxi were reduced by one-third compared to the preceding ten-year period, en route and take-off
were also reduced, but those during the landing phase were almost doubled. The approach phase remains rel-
atively constant.
Table 24 ATM/ANS related accidents and serious incidnets by phase of flight during 2006-
2016 in EASA MS
Accidents and SIs
Phase of Flight
2006-2015 average 2016
Standing 0.6 0
Taxi 6.4 2
Take-off 9 7
En route 14.8 10
Manoeuvring 0.3 0
Approach 13.4 14
Landing 4.1 8
Unknown 1.7 4
The distribution of ATM/ANS –related accidents and serious incidents are shown below, separately, by phase of
flight. The data show that accidents happened only in three phases, namely landing, approach and en-route, and
the serious incidents are unevenly distributed among the phases.
PAGE 107
´´ Figure 37 ATM/ANS-related accident fatalities and serious injuries per year 2006-2016 in
EASA MS
14
12
Number of Occurrences
10
8
6
4
2
0
Standing Taxi Take-off En route Manoeuvring Approach Landing Unknown
Phase of Flight
Accidents 2016 Serious Inccidents 2016 2006-2015 Average Acc 2006-2015 Average SIs
ATM/ANS Safety Risk Portfolio
The initial safety risk portfolio for this domain has been prepared by the Agency using EASA’s occurrence data-
base. This portfolio will be further developed by the ATM CAG during the second half of 2017.
ATM/ANS
Outcome
Percentage of
2 100% 50% 50% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 59 3% 5% 0% 46% 29% 15% 5%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Operational
Deconfliction
between IFR/
VRF traffic
with one or
more traffic
uncontrolled
ACAS RA not
followed
Annual Safety Review 2017 PAGE 108
ATM/ANS
ATM/ANS
Outcome
Percentage of
2 100% 50% 50% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 59 3% 5% 0% 46% 29% 15% 5%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Deconfliction
of aircraft
operating
without
transponder or
dysfunctional
one
Conflict
detection with
closest aircraft
(blind spot)
Level Bust
Airspace
infringement
High energy
runway conflict
Undetected
occupied
runway
Landing without
clearance
Procedure
design and
obstacle
publication
Provision
of weather
information
(turbulance/
windshear/
convective
weather)
Provision
of weather
information
(wind at low
heigh
PAGE 109
ATM/ANS
Outcome
Percentage of
2 100% 50% 50% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 59 3% 5% 0% 46% 29% 15% 5%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
ATM influence
on the non-
stabilised
apporaches
Coordination/
handling of
pushback
Ground
Operations
in Adverse
Weather
Conditions
Technical
Failure of
Navigation
service
Failure of
Surveillance
service
Failure of
Air/Ground
communications
Ab-normal
operating
conditions/
Degraded
modes
Human
Compliance with
ATM procedures
(e.g. clearances)
New
technologies
and automation
(e.g. rTWR,
SWIM)
Annual Safety Review 2017 PAGE 110
ATM/ANS
ATM/ANS
Outcome
Percentage of
2 100% 50% 50% 0% 0% 0% 0%
Fatal Accidents
(2007-2016)
Outcome
Percentage
of Non-Fatal 59 3% 5% 0% 46% 29% 15% 5%
Accidents
(2007-2016)
Total number of occurrences in
Key Risk Areas (Outcomes and precursors)
2012-2016 per safety issue
Collision in
Safety Issues
(ECR data)
Non-Fatal
Excursion
Accidents
Accidents
Incidents
Incidents
Airborne
Obstacle
Collision
Collision
Collision
Damage
Runway
Runway
Ground
Aircraft
Serious
Terrain
Upset
Flight
Fatal
Experience,
Training and
Competence of
Individuals
Personal
Pressure and
Arousal
Fatigue
Perception
and Situational
Awareness
Decision Making
and Planning
Operational
Communication
Organisational
Effectiveness
of Safety
Management
Understanding/
monitoring sys-
tem performance
interdependen-
cies
Other
Cybersecurity
Integration of
RPAS/Drones
PAGE 111
Priority Key Risk Areas
Following the first meeting of the ATM CAG in May 2017, the key risk areas derived as a result of EASA analysis
were revised. The two major key risk areas for the ATM/ANS domain are airborne collision and runway collision.
From an ATM perspective, airborne collision is the first safety priority.
1 Fatal Accident Analysis of MAC/airprox occurrences with the EASA MS in the NoA
identified a number of specific HF related safety issues that will be
subject to individual safety risk assessment with the different ATM
3 Non-Fatal Accidents safety partners.
The next safety priority for ATM is the prevention of runway
0 Fatal Accidents incursions and ultimately collisions on the runway.
3 Non-Fatal Accidents
Annual Safety Review 2017 PAGE 112
ATM/ANS
´´ Figure 38 ATM/ANS-related accidents and serious incidents, and those with ATM/ANS
contribution during 2006-2016
UIMC: Unintended flight in IMC
EVAC: Evacuation
CABIN: Cabin safety events
F-POST: Fire/smoke (post-impact)
LOC-G: Loss of control - ground
F-NI: Fire/smoke (non-impact)
AMAN: Abrupt maneuvre
)SCF-PP: powerplant failure or malfunction
RAMP: Ground Handling
UNK: Unknown or undetermined
FUEL: Fuel related
NAV: Navigation error
!LOC-I: Loss of control - inflight
RE: Runway excursion
ADRM: Aerodrome
ARC: Abnormal runway contact
@SCF-NP: System/component failure
or malfunction [non-powerplant]
.CFIT: Controlled flight into or toward terrain
!WSTRW: Windshear or thunderstorm.
GCOL: Ground Collision
TURB: Turbulence encounter
2RI: Runway incursion - vehicle,
aircraft or person
FMAC: Airprox/ ACAS alert/
loss of separation/ (near) midair collisions
0 50 100 150 200 250
Number of accidents and serious incidents
ATM/ANS Related ATM/ANS Contribution
Top Safety Issues and Associated Actions
The elaboration of safety issues is under development and it is premature to present the top safety issues in this
domain until the analysis has been completed and a consolidated version of the ATM Safety Risk Portfolio is is-
sued later in 2017 based on the work of the ATM CAG.
PAGE 113
The table below lists all actions that address the service providers of ATM/ANS services or the Member States
with an impact on these service providers that are included in the EPAS 2017-20213.
Table 25 ATM/ANS related actions included in the EPAS
RMT.0148 Rulemaking Requirements on air navigation service provision
RMT.0157 Rulemaking Requirements on competent authorities in ATM/ANS
Assessment of changes to functional systems by service providers in ATM/
RMT.0469 Rulemaking
ANS and the oversight of these changes by competent authorities
Technical requirements and operational procedures for the provision of
RMT.0473 Rulemaking
meteorological services
Alignment of implementing rules & AMC/GM with Regulation (EU) No
RMT.0681 Rulemaking
376/2014
RMT.0706 Rulemaking Update of authority requirements
MST.001 Action on Member States Member States to give priority to the work on SSPs
MST.002 Action on Member States Promotion of SMS
SPT.057 Safety Promotion SMS international cooperation
SPT.059 Safety Promotion SMS implementation support in ATM
SPT.062 Safety Promotion Comparable risk classification of events across the industry
SPT.063 Safety Promotion Continuous monitoring of ATM safety performance
RMT.0486 Rulemaking Alignment with ICAO on ATCO fatigue management provisions
FOT.003 Focused Oversight Unavailability of adequate personnel in competent authorities
FOT.004 Focused Oversight Unavailability of adequate personnel in competent authorities
RMT.0703 Rulemaking Runway safety
MST.007 Action on Member States Include runway excursions in national SSPs
MST.011 Action on Member States Runway safety teams
MST.014 Action on Member States Include runway incursions in national SSPs
Technical requirements and operating procedures for airspace design,
RMT.0445 Rulemaking
including flight procedure design
RMT.0464 Rulemaking Requirements for air traffic services
Technical requirements and operational procedures for aeronautical
RMT.0477 Rulemaking
information services and aeronautical information management
Technical requirements and operational procedures for the provision of
RMT.0593 Rulemaking
data for airspace users for the purpose of air navigation
MST.010 Action on Member States Include MACs in national SSPs
MST.024 Action on Member States Loss of separation between civil and military aircraft
SPT.087 Safety Promotion Weather awareness for pilots
MST.016 Action on Member States Airspace infringement risk in General Aviation
European Safety Promotion on Mid-air collisions and airspace
SPT.089 Safety Promotion
infringement
FOT.010 Focused Oversight Service provision to GA flights
RMT.0230 Rulemaking Introduction of a regulatory framework for the operation of drones
SPT.091 Safety Promotion European Safety Promotion on civil drones
SPT.071 Safety Promotion Cybersecurity road map
MST.020 Action on Member States Loss of radar detection
3 https://www.easa.europa.eu/system/files/dfu/EPAS_2017-2021.pdf
TO-AA-17-001-EN-N
ISBN 978-92-9210-207-4 ISSN 2314-9272 doi: 10.2822/26228
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