Progress Report 2008

Report Overview

It contains all the recommendations made by the AAIB in 2007 including the responses to those recommendations received up to and including 30 June 2008 and those recommendations categorised as open from previous years where significant additional information has been received.

The recommendations are grouped into eight sections:

Aeroplanes 5,700kg MTWA and above
Aeroplanes above 2,250kg and below 5,700kg MTWA
Aeroplanes 2,500kg MTWA and below
Microlights
Rotorcraft 5,700kg MTWA and above
Rotorcraft above 2,250kg and below 5,700kg MTWA
Rotorcraft 2,500kg MTWA and below
Others

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Official Documents

Progress Report 2008

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Progress Report 2008

Responses to Air Accidents Investigation Branch (AAIB) Safety Recommendations Responses recieved to AAIB recommendations made up to 31 December 2007, presented to the Secretary of State for Transport Progress Report 2008 Progress Report 2008 Progress Report 2008 Progress Report 2008 GLOSSARY OF ABBREVIATIONS © Crown Copyright 2008 All rights reserved. Copies of this publication may be reproduced for personal use, or for use within a company or organisation, but may not otherwise be reproduced for publication. Extracts can be published without specific permission providing that the source is duly acknowledged. Published December 2008 Progress Report 2008 Enquiries regarding the content of this publication should be addressed to: Air Accidents Investigation Branch Farnborough House Berkshire Copse Road Aldershot Hampshire GU11 2HH. This document is also available in electronic (pdf) format at www.aaib.gov.uk aal above airfield level ACAS Airborne Collision Avoidance System ACARS Automatic Communications And Reporting System ADF automatic direction finding equipment AFIS(O) Aerodrome Flight Information Service (Officer) AFRS Aerodrome Fire & Rescue Service agl above ground level AIC Aeronautical Information Circular amsl above mean sea level AOM aerodrome operating minima APU auxiliary power unit ASI airspeed indicator ATC(C)(O) Air Traffic Control (Centre)( Officer) ATIS Automatic Terminal Information System BMAA British Microlight Aircraft Association BGA British Gliding Association BBAC British Balloon and Airship Club BHPA British Hang Gliding & Paragliding Association CAA Civil Aviation Authority CAVOK Ceiling And Visibility OK (for VFR flight) CAS calibrated airspeed CG centre of gravity cm centimetres cc cubic centimetres °C,F,M,T Celsius, Fahrenheit, magnetic, true DGAC Direction Général à l’Aviation Civile DME distance measuring equipment EAS equivalent airspeed EASA European Aviation Safety Agency EGPWS Enhanced GPWS EGT exhaust gas temperature EPR Engine Pressure Ratio ETA estimated time of arrival ETD estimated time of departure FAA Federal Aviation Administration (USA) FIR flight information region FL flight level ft feet ft/min feet per minute g normal acceleration GPS Global Positioning System GPWS Ground Proximity Warning System hrs hours (clock time as in 12:00 hrs) HP high pressure hPa hectopascal (equivalent unit to mb) IAS indicated airspeed IFR Instrument Flight Rules ILS Instrument landing system IMC Instrument Meteorological Conditions in inch(es) IP intermediate pressure IR Instrument Rating ISA International Standard Atmosphere kg kilogram(s) KCAS knots calibrated airspeed KIAS knots indicated airspeed km kilometre(s) kt knot(s) KTAS knots true airspeed LAA Light Aircraft Association lb pound(s) LP low pressure LDA landing distance available LPC licence proficiency check ltr litre(s) m metres mb millibar(s) MDA Minimum Descent Altitude METAR a timed aerodrome meteorological report min(s) minutes mm millimetre(s) mph miles per hour MTWA maximum total weight authorised N Newtons N R Main rotor rotation speed (rotorcraft) N g Gas generator rotation speed (rotorcraft) N 1 engine fan or LP compressor speed NDB non-directional radio beacon nm nautical mile(s) NOTAM Notice to Airman OPC Operator proficiency check PAPI Precision Approach Path Indicator PF Pilot flying PIC pilot in command PNF Pilot not flying psi pounds per square inch QFE pressure setting to indicate height above aerodrome QNH pressure setting to indicate elevation above mean sea level RA Resolution Advisory rpm revolutions per minute RTF radiotelephony RVR runway visual range SAR Search and rescue SSR secondary surveillance radar TA Traffic Alert TAF Terminal Aerodrome Forecast TAS true airspeed TAWS Terrain Awareness and Warning System TCAS Traffic Collision Avoidance System TGT turbine gas temperature TODA takeoff distance available UHF ultra high frequency USG US gallons UTC Co-ordinated Universal Time (GMT) V 1 Takeoff decision speed V 2 Takeoff safety speed V R Rotation speed V REF Reference airspeed (approach) V NE never exceed airspeed VASI Visual Approach Slope Indicator VFR Visual Flight Rules VHF very high frequency VMC Visual Meteorological Conditions VOR VHF omni-range Progress Report 2008 CONTENTS Page No Foreword i The Report 1 Statistics 1 Section 1 Aeroplanes 5,700kg MTWA and above 3 Section 2 Aeroplanes above 2,250kg and below 5,700kg MTWA 39 Section 3 Aeroplanes 2,500kg MTWA and below 44 Section 4 Microlights 64 Section 5 Rotorcraft above 2,250kg and below 5,700kg MTWA 66 Section 6 Rotorcraft 2,500kg MTWA and below 69 Section 7 Others 73 Index by Section 78 Index by Safety Recommendation Number 81 Progress Report 2008 Progress Report 2008 i www.aaib.gov.uk Foreword The Air Accidents Investigation Branch (AAIB) is the part of the Department for Transport responsible for the investigation of all civil aircraft accidents and serious incidents (collectively referred to as 'accidents' in this document) occurring in or over the United Kingdom. Its authority is enshrined in the Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996 and its purpose is 'to improve aviation safety by determining the causes of air accidents and serious incidents and making safety recommendations intended to prevent recurrence'. The AAIB reports directly to the Secretary of State for Transport on safety matters. The Civil Aviation Authority (CAA) Safety Regulation Group's (SRG) role is to ensure that UK civil aviation standards are set and achieved in a co-operative and cost effective manner. Until recently the SRG had to satisfy itself that aircraft were properly designed, manufactured, operated and maintained; that airlines were competent; that flight crews, air traffic controllers and aircraft maintenance engineers were fit and competent; that licensed aerodromes were safe to use and that air traffic services and general aviation activities met required safety standards. They continue to fulfil most of these functions but, in September 2003, the responsibility for certification and continued airworthiness of aircraft was transferred to the European Aviation Safety Agency (EASA). Therefore AAIB recommendations relating to airworthiness are now directed to the EASA. Accident investigation and safety regulation are clearly different and the two functions are deliberately kept independent from each other. However, the evaluation of the findings of an accident investigation and the determination of the need for, and the initiation of, appropriate action to maintain and enhance safety is an important part of safety regulation. Thus a good working relationship between the AAIB, the CAA and the EASA is essential, while in no way jeopardising the independence of the accident investigation. Effective liaison has been maintained between the AAIB, the CAA and the EASA, which has been particularly useful in the immediate aftermath of any accident. However, the formal procedure by which the AAIB identifies and conveys to the CAA, the EASA or other bodies, matters which it believes require action, is by means of Safety Recommendations. Safety Recommendations can be made at any stage as the AAIB investigation progresses. Both the CAA and the EASA have formal procedures for the receipt and evaluation of such recommendations and initiation of necessary action. The CAA is informed of all AAIB Safety Recommendations and has, until now, responded to the AAIB, in the form of a Follow-up Action on Occurrence Report (FACTOR), on all Safety Recommendations, regardless of whether they were the action addressee. In future, however, the CAA will only formally respond to the AAIB with a FACTOR if a Safety Recommendation is specifically addressed to them. They have assured the AAIB, however, that they will continue to react appropriately to a

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