IRM-09 HKG Oct 26-27,2010 1

IATAIncident Review Meeting

IRM-09Hong Kong, 26-27 October 2010

IRM-09 HKG Oct 26-27,2010 2

STEADES Current StatusWorld’s largest ASR database>105,000 ASRs annually With 4.5M annual sectors ,STEADES represents 28% of world’s western built jet traffic

STEADES Participation110+ airlines

Any languageOver 600 incident categories

Traffic STEADES Sectors (’09) % of world

A320 Family 734,000 12%

A330 138,000 27%

A340 55,000 28%

A380 8,600 100%

B777 129,000 37%

B737 828,000 23%

B747 163,000 26%

IRM-09 HKG Oct 26-27,20103

STEADES Analysis

STEADES data is comprised of Air Safety Reports collected from over 110 participating airlines and submitted to IATA quarterly.

DISCLAIMER: The information contained in this publication is subject to constant review in the light of changing government requirements and regulations. No subscriber or other reader should act on the basis of any such information without referring to applicable laws and regulations and/or without taking appropriate professional advice. Although every effort has been made to ensure accuracy, the International Air Transport Association shall not be held responsible for any loss or damage caused by errors, omissions, misprints or misinterpretation of the contents hereof. Furthermore, the International Air Transport Association expressly disclaims any and all liability to any person or entity, whether a purchaser of this publication or not, in respect of anything done or omitted, and the consequences of anything done or omitted, by any such person or entity in reliance on the contents of this publication.

© International Air Transport Association. All Rights Reserved. No part of this publication may be reproduced, recast, reformatted or transmitted in any form by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without the prior written permission from: Senior Vice President, Safety, Operations & Infrastructure

IRM-09 HKG Oct 26-27,2010 Cargo Smoke/Fire Warning - Preliminary Results4

STEADES Analysis: Cargo Smoke/FireDatabase Query Criteria

Date Range: Q1 2003 to Q1 2010 inclusive; AND

Descriptors/Categories:“Smoke/Fumes – Hold”,“Fire False Warning – Hold”,“Fire Detection System – Hold“Fire/Sparks – Hold”“Fire Protection System – Hold”

IRM-09 HKG Oct 26-27,20105

STEADES Analysis: Cargo Smoke/FireResults

718 reports matching criteria (7 year timeframe)Approx. 0.039 per 1,000 sectors OR 1 event per 25,400 flights

Industry (estimate): nearly 4 events each day (3 Ground, 1 Airborne) or 1,390/year

3% (20 events) confirmed actual presence of smoke or fire. (5 events airborne)

Approx 0.0011 per 1,000 sectors or 1 event per 880,000 flightsIndustry (estimate): 1 event every 9 days 4% (31 events) involved “non-normal” deplaning of passengers

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,20106

Cargo Smoke/Fire Events - Trend

Last reported Cargo Smoke/Fire event where the presence of smoke/fire was confirmed occurred in Q3 2007.

Reported Cargo Smoke / Fire Events

0

20

40

60

80

100

120

140

160

180

200

2003 2004 2005 2006 2007 2008 2009

Num

ber o

f Rep

orte

d E

vent

s

0.000

0.010

0.020

0.030

0.040

0.050

0.060

0.070

Repo

rted

Eve

nts

per

1000

Flig

hts

Actual Presence of Smoke/Fire Reported Events Events per 1000 Flights Linear (Events per 1000 Flights)

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,2010 7

Cargo Smoke/Fire Events - Risk

76% (546 events) included risk information

High: 16 events Medium: 94 eventsLow: 436 events

Note: The risk code assigned to an event is done at the airline. IATA does not validate incoming reports for risk assignment.

High2% Medium

13%

Low61%

Insufficient Information

24%

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,20108

Cargo Smoke/Fire Events – Sampling of High Risk Events

Translated: “Very heavy rain at BKO. Decided to hold at GATAM to calculate landing distance for wet runway. While waiting, FWD CARGO SMOKE alarm and LAND ASAP. Emergency checklist performed and declared MAYDAY. Immediate ILS 06. Visual at about 500 ft AGL. As soon as we vacated the runway, the airport fire service performed a visual inspection, nothing to report. Passengers deplaned. Inspection by a mechanic who explained that this is recurring item on this aircraft due to sensitivity of the smoke detectors.”

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,20109

Cargo Smoke/Fire Events – Sampling of High Risk Events

B777 - “During cruise, the crew received a smoke warning indication for the bulk cargo hold. The fire extinguisher bottles were discharged and the fire indication went out, but returned after 5 minutes. The aircraft was diverted to an enroute airport where a safe overweight landing was performed. Inspection carried out found a smoking passenger bag.”

Cargo Smoke/Fire Warning - Preliminary Results

0.000

0.020

0.040

0.060

0.080

0.100

0.120

0.140

0.160

0.180

0.200

PUSH-BACK

TAXI-OUT

TAKE-OFF

INITIAL C

LIMB

CLIMB

CRUISEDESCENT

HOLDIN

GAPPROACH

LANDIN

G

TAXI-INPARKED

NONE

SEVERAL PHASES

Even

ts p

er 1

000

Flig

hts 2003 2004 2005 2006 2007 2008 2009

Cargo Smoke/Fire Events – Flight Phase

61% (437 events) occurred during Parked Phase7% (30 events) due to exhaust fumes from ground equipment vehicles66% (287 events) due to insecticide spray

Cargo Smoke/Fire

Drill-down on Actual Smoke/Fire Eventsversus Benign Events

IRM-09 HKG Oct 26-27,201012

Cargo Smoke/Fire Events –

Cargo Smoke/Fire Warning - Preliminary Results

All Events

Benign89%

Insufficient Information19%

Insecticide Spray50%

Hazard Report1%

Insufficient Information6%

Confirmed Smoke/Fire3%

Dangerous Goods1%

Humidity / Perishables7%

Ground Equipment Exhaust Fumes

4%Fire Detection System

Problem9%

IRM-09 HKG Oct 26-27,201013

Cargo Smoke/Fire Events – Actual Smoke/Fire Events

Actual Smoke/Fire Events: 20 eventsPower Drive Unit (PDU): 6 eventsPassenger Bag or Courier Material: 6 eventsWires: 2 events

Found wire bundle damagedFound wires cut and shorting-out, circuit breaker tripped

Failed electronic system: 1 eventEntertainment System: 1 eventLeaking Heat Exchanger: 1 eventLeaking oil pipe: 1 eventInsufficient Information: 2 events

Last Actual Smoke/Fire Event reported in Q3 2007

Cargo Smoke/Fire Warning - Preliminary Results

Cargo Smoke/Fire

Drill-down on Airborne Events

IRM-09 HKG Oct 26-27,201015

Cargo Smoke/Fire Events – Airborne

166 events during airborne phasesApprox. 0.0089 per 1,000 sectors OR 1 event per 112,000 flightsIndustry (estimate):

Roughly 1 event per day somewhere in the world

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,2010 16

Airborne Events

Benign84%

Hazard Report1%

Dangerous Goods2%

Confirmed Smoke/Fire

3%

Insufficient Information

10%

Cargo Smoke/Fire Events – Airborne

Confirmed Cargo Smoke / Fire events:

3% (5 events) involved confirmed smoke or fire during airborne phases

166 benign events mainly false warnings, problems with Smoke/Fire detection equipment, or humidity / perishables

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,201017

Cargo Smoke/Fire Events – Airborne

Sample narrative

B777- “On arrival and during unloading of the bulk cargo bay, a courier bag was found to have suffered heat damage. The outer cover was melted through and the cardboard box contents showed signs of scorching. Ground staff stated that the bag was located above the marked limit and was found in contact with the hold ceiling, covering a hold lighting unit. Engineering have completed installation of modification kits to adapt the hold lighting to a lower wattage system…”

Cargo Smoke/Fire Warning - Preliminary Results

IRM-09 HKG Oct 26-27,2010 Published October 201018

STEADES Analysis for IRMGoal: introduce each section (accident category) at IRM with high level analysis of accident category precursors found in STEADES.

IRM-09 HKG Oct 26-27,2010 19

Events with potential for or resulting in a

Mid-air Collision

IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 20

Mid-Air Collision Extract from Safety Report 2009:

None in Safety Report 2009

IRM-09 HKG Oct 26-27,2010 Published October 201021

Mid-Air Collision Precursors from STEADES:

UAS: TCASAltitude DeviationLateral Deviation

Errors:Flight Crew Manual HandlingFlight Crew Auto HandlingFlight Crew Mis-selectionChecklist / SOP useInsufficient crew rest

Threats: Auto Flight (defects / failures with autopilot, uncommanded pitch/roll, roll/pitch exceedence…)Instrument failuresLoss of CommsPressurization failures / problemsNavigation System failuresMeteorological (fog…)

Drill down

Drill down

Drill down

IRM-09 HKG Oct 26-27,2010 Published October 201022

Mid-Air Collision Precursors from STEADES:Mid-Air Collision Precursors

0

0.2

0.4

0.6

0.8

1

1.2

2003 2004 2005 2006 2007 2008 2009

Rat

e (E

vent

s pe

r 10

00 fl

ts)

TCAS Altitude Deviations Loss of Comms Index Linear (Index)

IRM-09 HKG Oct 26-27,2010 23

Events with potential for or resulting in a

Loss of Control

IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 24

Loss of Control In-flight Extract from Safety Report 2009:

IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 25

Loss of Control In-flight Precursors from STEADES:

UAS: Aircraft Limit ExceedenceUnstable ApproachTemporary Loss of ControlAvoidance ManoeuvreStall Warning/Alpha protection Fuel imbalanceAircraft out of trim

Errors:Flight Crew Manual HandlingFlight Crew Auto HandlingConfiguration warnings (Flaps)

Threats: Flight Controls (defects with Trim, Flaps, Rudder…)Auto Flight (defects / failures with autopilot, uncommanded pitch/roll, roll/pitch exceedence…)BidstrikeEnvironmental (volcanic ash, animal strike…) Meteorological (turbulence, windshear, crosswind…)Fuel (failure of crossfeeds, booster pumps, contamination…)Ice / Rain Protection (failure of anti/de icing)Instrument failuresDamage to structures (wings, fuselage, fin…)Documentation (error with fuel plan)

Drill down

Drill down

Drill down

IRM-09 HKG Oct 26-27,2010 Published October 201026

Loss of Control Precursors from STEADES:Loss of Control Precursors

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

2003 2004 2005 2006 2007 2008 2009

Rat

e (E

vent

s pe

r 100

0 flt

s)

Aircraft Limit Exceedence Stall Warning / Alpha Protection Configuration Warnings (all)Index Linear (Index)

IRM-09 HKG Oct 26-27,2010 27

Events with potential for or resulting in aCFIT

IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 28

CFIT Extract from Safety Report 2009:

IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 29

CFIT Precursors from STEADES:

UAS: Unstable ApproachAircraft out of trimEGPWS warnings

Errors:Flight Crew Manual HandlingFlight Crew Auto HandlingFlight Crew Mis-selectionChecklist / SOP useInsufficient crew rest

Threats: Auto Flight (defects / failures with autopilot, uncommanded pitch/roll, roll/pitch exceedence…)Instrument failuresPressurization failures / problemsNavigation System failuresMeteorological (fog…)Windshear

Drill down

Drill down

Drill down

Drill down

IRM-09 HKG Oct 26-27,2010 Published October 2010STEADES Analysis - IRM 30

CFIT Precursors from STEADES:

CFIT Precursors

0

0.2

0.4

0.6

0.8

1

1.2

2003 2004 2005 2006 2007 2008 2009

Rate

(Eve

nts

per 1

000

flts)

Ustable Approach EGPWS Warnings Flight Crew Mis-SelectionsWindshear Warning Index Linear (Index)

IRM-09 HKG Oct 26-27,2010 31

5 CFIT Accidents classified by ACTF (193 fatalities) in 2010

Aviastar-TU (0) Mar 22Pamir Airways (38) May 17Aero Service (Congo Brazzaville) (9) June 19Air Blue (146) July 28National Air Cargo (0) Oct 12

IRM-09 HKG Oct 26-27,2010 32

Events with potential for or resulting in a

Runway Excursion

IRM-09 HKG Oct 26-27,201033

05

101520253035

2004 2005 2006 2007 2008 2009

Runway Excursions 2004 - 2009

Excu

rsio

ns a

s ra

tio to

# o

f ac

cide

nts

The % is relative to the total number of accidents during that year

33%24%

27% 24%27%

Actual R

unway

Excursions

32%

29 2924212734

IRM-09 HKG Oct 26-27,201034

34

Runway Excursions (Rates) 2004-2009 per Million Sectors

NAM0.33

LATAM1.33

EUR0.41

CIS0.71

MENA3.39

AFI3.76 ASPAC

1.30

NASIA0.16

Based on region of operator

IRM-09 HKG Oct 26-27,201035

Runway Excursions - Regional Occurrences 2004-2009 accident count

2

43

23 2320

4

2623

05

101520253035404550

NASIA ASPAC AFI MENA EUR CIS NAM LATAM

IRM-09 HKG Oct 26-27,201036

Runway Excursions - Regional Occurrences Region of Operator Vs. Occurrence

1%

26%

14% 14%12%

2%

16%14%

1%4%

18%

12%12%13%13%

27%

0%

5%

10%

15%

20%

25%

30%

NASIA ASPAC AFI MENA EUR CIS NAM LATAM

Region of Operator Region of Occurrence

IRM-09 HKG Oct 26-27,201037

Take off vs. Landing

Overrun vs. Veer off

75

89

65

70

75

80

85

90

95

Overrun Veer off

Excursion Take of f17%

Excursion Landing83%

IRM-09 HKG Oct 26-27,201038

Turboprops vs. Jets Substantial Damage and Hull Loss

Substantial Damage

52%

Hull Loss48%

Turboprops

Hull Loss55%

Substant ial Damage45%

Jets

IRM-09 HKG Oct 26-27,201039

2010 Runway Excursion Accidents (Till Sep 2010) accident data

Year to September, there have been 77 events

26 Accidents200 fatalities

51 other Runway Excursion Incidents (known)Ratio is 26/77 (34 %)

22

11

14

9

16

1314

0

5

10

15

20

25

2004 2005 2006 2007 2008 2009 2010

IRM-09 HKG Oct 26-27,201040

EMAS Arrests vs. Overrun Accidents (2004-2010) accident data

1613

11 1214

9

11

1

10

02468

1012141618

2004 2005 2006 2007 2008 2009 2010

Overrun accidents EMAS Saves

To date, there have been five incidents where the technology has worked successfully to arrest aircraft which overrun the runway and in several cases has prevented injury to passengers and damage to the aircraft

From 2004- Sep 2010, a total of 3 accidents were arrested by EMAS

IRM-09 HKG Oct 26-27,2010© International Air Transport Association 2011. All

Rights Reserved. Extract from the Runway Excursion Risk Reduction (RERR) Toolkit Second Edition 2011

and subject to the disclaimer contained therein. 41

Incidents

Accidents

2010 Runway Excursion (thru Sept 2010)

IRM-09 HKG Oct 26-27,201042

2010 STEADES Analysis publishedTopic Origin of Request Type Timeline Status

1. Airport Markings Deficiencies IRM/SG 2009 Mini May 2010 Published

2. South Atlantic ATM Events Airline requests Mini May 2010 Published

3. ATM Events at Toronto Airline requests Mini July 2010 Published

4. ATM Events in Philippines Airline requests Mini Sept 2010 Published

5. Anti/De Icing Events Airline requests Mini Oct 2010 Published

IRM-09 HKG Oct 26-27,201043

2010 Analysis scheduledTopic Origin of Request Type Timeline Status

6. Turbulence Injuries Cabin Safety TF Mini Oct 2010 In progress

7. Medical Diversions Cabin Safety TF Mini Oct 2010 In progress

8. Cargo Door Indications Airline requests Mini Nov 2010 In progress

9. Airport Markings/construction IRM/SG 2010 In-depth Nov 2010 In progress

10. Cargo Smoke/Fire Warnings Airline Requests In-depth Oct 2010 In progress

11. Foreign Object Damage Airline Request In-depth Oct 2010 In progress

12. NOTAM Issues IRM/SG 2010 In-depth Nov 2010 In progress

13. Unstable approach Customer survey In-depth Dec 2010 In progress

IRM-09 HKG Oct 26-27,2010 44

© International Air Transport Association 2011. All Rights Reserved. Extract from

the Runway Excursion Risk Reduction (RERR) Toolkit Second Edition 2011 and

subject to the disclaimer contained therein.