2021 Safety Recommendations

General
SR Number: 2021-13
Date Issued: 26/07/2021
Addressee: EGNATIA AVIATION Training Organization
Why this Recommendation was Developed: link_64Synoptic Report E04/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-13 -- Date Issued: 26/07/2021
Why this Recommendation was Developed: link_64Synoptic Report E04/2021
Addressee: EGNATIA AVIATION Training Organization
Status: OPEN - Awaiting Response
Recommendation: Safety promotion and accident / incident prevention.
Un-stabilized approaches have been acknowledged as been the major cause of most incidents and accidents during approach and landing.

SAFETY RECOMMENDATION 2021-13: In the concept of safety promotion and accidents incidents prevention it is recommended that EGNATIA AVIATION Training Organization insert ground school hours of classroom regarding past incidents and accidents, during training flights, in order to raise situation awareness to the student pilots.
Response

SR Number:

2021-13 -- Date Issued: 26/07/2021
Why this Recommendation was Developed: link_64Synoptic Report E04/2021
Addressee: EGNATIA AVIATION Training Organization
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-12
Date Issued: 26/07/2021
Addressee: EGNATIA AVIATION Training Organization
Why this Recommendation was Developed: link_64Synoptic Report Ε04/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-12 -- Date Issued: 26/07/2021
Why this Recommendation was Developed: link_64Synoptic Report Ε04/2021
Addressee: EGNATIA AVIATION Training Organization
Status: OPEN - Awaiting Response
Recommendation: Safety promotion and accident / incident prevention.

SAFETY RECOMMENDATION 2021-12: In the concept of safety promotion and accidents incidents prevention it is recommended that EGNATIA AVIATION Training Organization insert ground school hours of classroom regarding past incidents and accidents, during training flights, in order to raise situation awareness to the student pilots.
Response

SR Number:

2021-12 -- Date Issued: 26/07/2021
Why this Recommendation was Developed: link_64Synoptic Report Ε04/2021
Addressee: EGNATIA AVIATION Training Organization
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-11
Date Issued: 01/07/2021
Addressee: Airline CONDOR FLUGDIENST GmbH
Why this Recommendation was Developed: link_64Synoptic Report E02/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-11 -- Date Issued: 01/07/2021
Why this Recommendation was Developed: link_64Synoptic Report E02/2021
Addressee: Airline CONDOR FLUGDIENST GmbH
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

- The investigation revealed that the Flight Crew of D-AICD should have acted according to the SOP at the initial TA ‘’TRAFIC-TRAFIC’’ and subsequent RA “MAITAIN V/S” proposed manoeuvre by TCAS and during the TCAS escalation that resulted in the DUAL SIDE STICK INPUT.

- With the selection of ROSE mode before take-off, the intruder would have been displayed on ND during initial climb before the right turn.

SAFETY RECOMMENDATION 2021-11:

a. CONDOR FLUGDIENST GmbH to consider improving the efficiency of the Flight Crew members when performing Simulator training TCAS manoeuvres and to emphasize the importance of the SOP regarding ‘Takeover of control’ process.

b. Consider, when in VFR departures and a turn of more than 700 after take off, PF and PM to select ROSE mode on the ND instead of ARC. As such, an early detection of other traffics will be achieved.
Response

SR Number:

2021-11 -- Date Issued: 01/07/2021
Why this Recommendation was Developed: link_64Synoptic Report E02/2021
Addressee: Airline CONDOR FLUGDIENST GmbH
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-10
Date Issued: 01/07/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Why this Recommendation was Developed: link_64Synoptic Report E02/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-10 -- Date Issued: 01/07/2021
Why this Recommendation was Developed: link_64Synoptic Report E02/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

Kavala ATC should have informed D-AICD about the presence, position course and altitude, of the Helicopter in the area of responsibility of Kavala Airport. Furthermore, no information of actual QNH was transmitted to the Helicopter. English Language must at always be used in order for all traffic, in the area, to have situation awareness.

SAFETY RECOMMENDATION 2021-10: HCAA to remind and assure that Kavala Air Traffic Controllers strictly follow Regulations, regarding Air Traffic Management, according to Local, ICAO and EASA regulations
Response

SR Number:

2021-10 -- Date Issued: 01/07/2021
Why this Recommendation was Developed: link_64Synoptic Report E02/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-09
Date Issued: 11/02/2021
Addressee: Airline Orange2Fly
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-09 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

The Airline (ORANGE2FLY) must review its training program regarding the following items:

SAFETY RECOMMENDATION 2021-09

The Flight Operations and Training Department to:

- Review and incorporate procedures and criteria for hand over control of the Aircraft at low altitude.
Response

SR Number:

2021-09 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-08
Date Issued: 11/02/2021
Addressee: Airline Orange2Fly
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-08 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

The Airline (ORANGE2FLY) must review its training program regarding the following items:

SAFETY RECOMMENDATION 2021-08

Simulator training to include the above items [Safety Recommendation 2021-06 & 2021-07] plus:

- Vectors for ILS approach, in VMC and IMC conditions, in Manual Approaches with Auto thrust disengaged.
- Emphasise on FMA callout according to SOP’s
- Go Around decision and actions according to SOP’s
Response

SR Number:

2021-08 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-07
Date Issued: 11/02/2021
Addressee: Airline Orange2Fly
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Status: OPEN - Awaiting Response
Recommendation

SR Number:

2021-07 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

The Airline (ORANGE2FLY) must review its training program regarding the following items:

SAFETY RECOMMENDATION 2021-07: SMS review
Response

SR Number:

2021-07 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-06
Date Issued: 11/02/2021
Addressee: Airline Orange2Fly
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-06 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

The Airline (ORANGE2FLY) must review its training program regarding the following items:

SAFETY RECOMMENDATION 2021-06

Emphasis, during initial, recurrent, ground school and flight training, on the following items before being released to responsible duties. There after close monitor through FDM program Flight and Simulator checks:

- CRM
- Human factors
- Crew communication according to SOP’s
- Crew Cooperation
- Leadership and Managerial skills
- The importance of FMA callouts according to SOP’s
- Contributing factors to the loss of Situation awareness
- Decision Making
- Case study on low level approach to stall
- Go Around decision and actions according to SOP’s
Response

SR Number:

2021-06 -- Date Issued: 11/02/2021
Why this Recommendation was Developed: link_64Synoptic Report E03/2021
Addressee: Airline Orange2Fly
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-05
Date Issued: 14/01/2021
Addressee: To GENEL HAVACILIK A. S.
Why this Recommendation was Developed: link_64Final Report 02/2021
Status: CLOSED - Adequate SR_CLOSED
Recommendation

SR Number:

2021-05 -- Date Issued: 14/01/2021
Why this Recommendation was Developed: link_64Final Report 02/2021
Addressee: To GENEL HAVACILIK A. S.
Status: CLOSED - Adequate
Recommendation: SAFETY RECOMMENDATION 2021-05: GENEL HAVACILIK A. S. must enhanced efficiency of CRM training program
Response

SR Number:

2021-05 -- Date Issued: 14/01/2021
Why this Recommendation was Developed: link_64Final Report 02/2021
Addressee: To GENEL HAVACILIK A. S.
Status: CLOSED - Adequate
Response: Operator’s response to AAIASB SR 2021-05 was received by email on 09/6/2021.

[Operator’s response]: “CRM training is being given in accordance with the procedure as stated in our approved Part-D Manual and our company is being inspected regularly by Turkish DGCA [Turkish Civil Aviation Authority] every year. You can find the related procedure of OM [ΟPERATIONS MANUAL] Part-D in the attachment of this e-mail.” [Attached manuals are not made publicly available by AAIASB]

[AAIASB assessed this response as “Adequate” on 17/6/2021 and changed the SR 2021-05 status to “Closed”]
General
SR Number: 2021-04
Date Issued: 14/01/2021
Addressee: To GENEL HAVACILIK A. S.
Why this Recommendation was Developed: link_64Final Report 02/2021
Status: CLOSED - Adequate SR_CLOSED
Recommendation

SR Number:

2021-04 -- Date Issued: 14/01/2021
Why this Recommendation was Developed: link_64Final Report 02/2021
Addressee: To GENEL HAVACILIK A. S.
Status: CLOSED - Adequate
Recommendation: SAFETY RECOMMENDATION 2021-04: GENEL HAVACILIK A. S., in order to continue operating commercial flights to Mykonos (LGMK), must consider according to ICAO categorization criteria that Airport, and ascertain that all Flight Crews operating at LGMK, undergo special training taking into account the peculiarities (Airport terrain environment and weather phenomena as stated in AIP-Greece).
Response

SR Number:

2021-04 -- Date Issued: 14/01/2021
Why this Recommendation was Developed: link_64Final Report 02/2021
Addressee: To GENEL HAVACILIK A. S.
Status: CLOSED - Adequate
Response: Operator’s response to AAIASB SR 2021-04 was received by email on 09/6/2021.
[Operator’s response]:

“To increase the awareness of our crew about airport terrain environment and weather phenomena as stated in AIP [Aeronautical Information Publication], a safety bulletin was published within the company for future possible flights to this airport. You can find the safety bulletin published with 2021-01 number in the attachment of this email. Besides this, LGMK airport is categorised as CAT B airport on our Aerodrome Categorisation List.

According to this procedure which is explained on OM [ΟPERATIONS MANUAL] Part-A 08.01.02.03.02.01 Operations to Airport Category B is as follows; “Prior to operating to a Category B airport, the commander should be briefed…(by the contracted dispatch company)”

You can find the related procedure of OM [ΟPERATIONS MANUAL] Part-A in the attachment of this e-mail.” .” [Attached manuals are not made publicly available by AAIASB]

[AAIASB assessed this response as “Adequate” on 17/6/2021 and changed the SR 2021-04 status to “Closed”]
General
SR Number: 2021-03
Date Issued: 26/11/2020
Addressee: Airworthiness Management Organization EL.MG.0037 & Maintenance Organization EL.145.0078
Why this Recommendation was Developed: link_64Final Report 01/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-03 -- Date Issued: 26/11/2020
Why this Recommendation was Developed: link_64Final Report 01/2021
Addressee: Airworthiness Management Organization EL.MG.0037 & Maintenance Organization EL.145.0078
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:
The investigation revealed that the Aircraft was maintained based on a maintenance program prepared by the organization EL.MG.0037, was approved by the CAA but was not based on the current revision of the Aircraft service manual at the time of its issuance and approval. Also, during inspection of the maintenance works of the Aircraft, it was found that:

1. Engine components were replaced in the Maintenance Organization EL.145.0078 by others with part number which were not specified in the manufacturer's IPC.
2. The calendar restriction for carrying out the inspection of the fuel filter was not observed.
3. There was a mandatory directive which was not assessed as to whether it was applicable.
4. The inspection of the battery and cables was not carried out within the stipulated calendar deadline.
5. In the list of the remaining hours for the inspections, it appeared that there were incorrect entries in the date of execution of works but also in the number of flight hours of the Aircraft in tasks performed during the last maintenance.

SAFETY RECOMMENDATION 2021-03: It is recommended that the Airworthiness Management Organization EL.MG.0037 and the Maintenance Organization EL.145.0078 to review and possibly revise their operating procedures of those Organizations.
Response

SR Number:

2021-03 -- Date Issued: 26/11/2020
Why this Recommendation was Developed: link_64Final Report 01/2021
Addressee: Airworthiness Management Organization EL.MG.0037 & Maintenance Organization EL.145.0078
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-02
Date Issued: 26/11/2020
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Why this Recommendation was Developed: link_64Final Report 01/2021
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2021-02 -- Date Issued: 26/11/2020
Why this Recommendation was Developed: link_64Final Report 01/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:
The investigation revealed that the Aircraft was maintained based on a maintenance program prepared by the organization EL.MG.0037, was approved by the CAA but was not based on the current revision of the Aircraft service manual at the time of its issuance and approval. Also, during inspection of the maintenance works of the Aircraft, it was found that:

1. Engine components were replaced in the Maintenance Organization EL.145.0078 by others with part number which were not specified in the manufacturer's IPC.
2. The calendar restriction for carrying out the inspection of the fuel filter was not observed.
3. There was a mandatory directive which was not assessed as to whether it was applicable.
4. The inspection of the battery and cables was not carried out within the stipulated calendar deadline.
5. In the list of the remaining hours for the inspections, it appeared that there were incorrect entries in the date of execution of works but also in the number of flight hours of the Aircraft in tasks performed during the last maintenance.

SAFETY RECOMMENDATION 2021-02: It is recommended that the CAA review and possibly revise the implementation of internal procedures for the control of:
- The Airworthiness Management Organization EL.MG.0037,
- The Maintenance Organization EL.145.0078 and
- The manuals to be approved.
Response

SR Number:

2021-02 -- Date Issued: 26/11/2020
Why this Recommendation was Developed: link_64Final Report 01/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2021-01
Date Issued: 26/11/2020
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Why this Recommendation was Developed: link_64Final Report 01/2021
Status: OPEN - Response received awaiting Assessment SR_Partially_accepted
Recommendation

SR Number:

2021-01 -- Date Issued: 26/11/2020
Why this Recommendation was Developed: link_64Final Report 01/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Response received awaiting Assessment
Recommendation: PREAMBLE:
In the No. D3/C/12041/2861 regulation of the CAA entitled “Regulation of Refueling Aircrafts at Airports”, article 19 describes, among others, the process of refueling and the possibility of supplying fuel for light and ultra-light Aircraft, while in effect is the from January 2003 decision of the CAA Director approving the use of fuel of specifications ASTM D4814 or EN 228.

The investigation revealed that in the Hellenic Territory the unleaded automotive gasoline that is available, has quality characteristics as they are mentioned in the Government Gazette 293/12.02.2016 and in the standard EN 228: 2014. Among other characteristics, the vapor pressure and the possible legal percentage of ethanol and methanol, the maximum value of which is mentioned in the above Government Gazette and in the standard EN:228, can have a direct effect on the operation of the Aircraft engines and are a latent cause of accident. For this reason it is necessary to check if the fuel meets the characteristics mentioned in the above texts and especially if it complies with the limit of zero alcohol.

Also, in the two fuel tanks the existence of a quantity of foreign bodies was observed, whose presence is not compatible with an Aircraft fuel tank. Since the fuel tanks were found closed and intact after the crash of the Aircraft, it appears that there was probably a refueling with fuel that had not previously been filtered.

SAFETY RECOMMENDATION 2021-01: It is recommended that the Civil Aviation Authority review and possibly revise the implementation of the applied procedure so that the supply and transportation of unleaded gasoline and the refueling of Aircrafts with unleaded gasoline is in accordance with applicable regulations.
Response

SR Number:

2021-01 -- Date Issued: 26/11/2020
Why this Recommendation was Developed: link_64Final Report 01/2021
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Response received awaiting Assessment
Response: Hellenic Civil Aviation Authority (HCAA) response to AAIASB Safety Recommendation (SR) 2021-01 was received by email on 29/7/2021.

[HCAA response to AAIASB SR 2021-01]:

"Our Directorate [HCAA Airports Directorate - Department of Airports Fire Safety and Equipment] has issued the Regulation on the aircraft refuelling at airports (Government Gazette, Series B, No 1109/2011), which, in Chapter 19, refers to the refuelling of light and ultra-light aircraft at airports, where aeroclubs, air schools, etc. operate and the necessary type of fuel is not available by the airport fuel companies for this type of aircraft, for their self-handling only. This chapter regulates fuel handling (19.2), storage (19.3), measures to protect fuel storage areas (19.4), and the process of aircraft refuelling (19.5).

Item 19.5, which regulates the refuelling of these aircraft, includes details on the person who will refuel, as well as its training (19.5.1), the use of suitable anti-explosive pumps and special filters to ensure the quality of the transferred fuel, such as filters for water retention and microparticles, which may be contained in the transfused fuel (19.5.2 & 19.5.3). It is also envisaged that these aircraft will be refuelled with specially certified fuel tanks (19.5.3).

Regarding the type of fuel required for the aircraft engine(s) and the quantity required to perform the flight, the pilot or owner of the aircraft shall be solely responsible (19.5.5). As regards the quality of the fuel, if supplied by the pilot or the owner of the aircraft, he is responsible (19.6.3). Otherwise, it is the refueller who is responsible (19.6.1 & 19.6.2).

In Chapter 19, reference is also made to the use of MOGAS fuel specifications ASTM D 4814/EN 228, where in addition to the above, those referred in Decision No Δ2/Ν8337/2475/9-3-2005 of the Governor of HCAA apply. At this point, it should be clarified that, in practice, MOGAS has been identified with unleaded car petrol, which is sold by petrol stations [outside of airports] and is used by all light and ultra-light aircraft permitted by their engines, and its use has been consolidated in many aircraft and helicopters operating in LGMG airport [main general aviation airport near Athens]. It should be noted that the provisions of Chapter 19 allow refuelling of petrol from a fuel service station [outside of airports] only for ultra-light aircraft (19.10.1), which can be checked at airports, unlike in landing fields, where there is no control at all, i.e. not only on the type of fuel but also on its transport (e.g. type of container) and the refuelling process.

It must therefore be concluded that the current regulatory framework, at least regarding refuelling at airports, is capable, if accurately applied, of ensuring the quality of the transferred fuel on the aircraft in question. At the same time, there should be clarification in relation to MOGAS in order to address the practical problems arising from the use of unleaded petrol.

In view of the above and in the context of the safety recommendation 2021-01, the Directorate [HCAA Airports Directorate - Department of Airports Fire Safety and Equipment] will intensify the inspections to ensure that the provisions of the Regulation on the refuelling of aircraft (Government Gazette, Series B, No 1109/2011) are strictly complied with at airports and landing areas”

[AAIASB changed the status of SR 2021-01 to “Open- Response Received awaiting assessment” and will assess the Response within 60 days as per EU Reg. 996/2010.]
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