2022 Safety Recommendations

General
SR Number: 2022-08
Date Issued: 09/06/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2022-08 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

- From the investigation it was identified failure of HCAA during audits to detect noncompliance with the approved Operator’s OMM procedures, in terms of the risk assessment and analysis accomplishment before the operation on a new route.

SAFETY RECOMMENDATION 2022-08: The HCAA to ensure adherence to its published auditing procedures.
Response

SR Number:

2022-08 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2022-07
Date Issued: 09/06/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2022-07 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

- From the review of the Captain’s Logbook during the investigation, it was identified that the Captain’s total Helicopter flight hours were performed in a Multi Crew Environment. In this context, the transition of the Captain to a single-Pilot flight environment, resulted in the increased workload, with a possible negative effect on the situational awareness and at the same time risk increasement.

SAFETY RECOMMENDATION 2022-07: It is recommended to the HCAA to reconsider training requirements for pilots coming from multi crew environment to single crew environment and vice versa.
Response

SR Number:

2022-07 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2022-06
Date Issued: 09/06/2022
Addressee: Part 145 Maintenance Organization of iFly operator (EL145.0083)
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Response received awaiting Assessment SR_Partially_accepted
Recommendation

SR Number:

2022-06 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: Part 145 Maintenance Organization of iFly operator (EL145.0083)
Status: OPEN - Response received awaiting Assessment
Recommendation: PREAMBLE:

- From the wreckage examination, failure was identified of Part 145 Maintenance Personnel to comply, in the context of scheduled Maintenance, with the Maintenance task card requirements regarding the identification of No. 1 Engine faulty parts (worn breather flexible tube and damaged starter-generator Cable).

SAFETY RECOMMENDATION 2022-06: It is recommended to the Maintenance Organization to make sure that all procedures included in the Maintenance Organization Exposition (MOE), are followed.
Response

SR Number:

2022-06 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: Part 145 Maintenance Organization of iFly operator (EL145.0083)
Status: OPEN - Response received awaiting Assessment
Response: Operator’s response to AAIASB SR 2022-06 was received by email on 08/9/2022.

[Operator’s response]:

“ a. Technical info notice (TIN) 09_2022 dated 23/6/2022 has been issued to inform all the technical staff of the Organization, regarding the findings recorded and where of the Maintenance Organization concern .

b. Internal document 22/056 dated 27/6/2022 has been issued to define additional procedures, supplemental to those already mentioned in the Maintenance Organization Manual (MOE) and should be followed from the technical staff.

c. At the same time, the TIN 2a_2021 version regarding the Alert Commercial Service Letter (ACSL) of Rolls-Royce, (Maintenance Warning/External Lines), dated 26/7/2021, is highlighted to inform all the organization technical staff. The said ACSL pointed out the need to faithfully apply the procedures mentioned in the technical manuals (Operation and Maintenance Manual).

d. In addition, the existence of two inspections/signatures for all the tasks performed by the maintenance organization (performed by / inspected by) is emphasized, before the release of the aircraft (CRS issuance). ”

[AAIASB changed status of SR 2022-06 to “Open- Response Received awaiting assessment” and will assess the Response within 60 days as per EU Reg. 996/2010.]
General
SR Number: 2022-05
Date Issued: 09/06/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Awaiting Response SR OPEN
Recommendation

SR Number:

2022-05 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Recommendation: PREAMBLE:

- From the Investigation and the relevant review of the Operation Manuals (Part A and Part D), it was identified that the approved procedures regarding the criteria for the assignment of Captain duties were different.

SAFETY RECOMMENDATION 2022-05: The HCAA to review and revise its internal procedures in order to eliminate any contradictions in the submitted Manuals for approval.
Response

SR Number:

2022-05 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: HELLENIC CIVIL AVIATION AUTHORITY (HCAA)
Status: OPEN - Awaiting Response
Response:
General
SR Number: 2022-04
Date Issued: 09/06/2022
Addressee: iFly airline
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Response received awaiting Assessment SR_Partially_accepted
Recommendation

SR Number:

2022-04 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: iFly airline
Status: OPEN - Response received awaiting Assessment
Recommendation: PREAMBLE:

- From the Investigation and the relevant review of the Operation Manuals (Part A and Part D), it was identified that the approved procedures regarding the criteria for the assignment of Captain duties were different.

SAFETY RECOMMENDATION 2022-04: It is Recommended to the Operator to review and revise the described procedures in the Operation Manuals as well as the procedures followed for the establishment of the Operation Manuals.
Response

SR Number:

2022-04 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: iFly airline
Status: OPEN - Response received awaiting Assessment
Response: Operator’s response to AAIASB SR 2022-04 was received by email on 08/9/2022.

[Operator’s response]:

“ You are kindly requested to read the following:

As it is referred on OM-PART A, §5.2.2 :

«5.2.2 Qualification to act as Pilot-In-Command/Commander
(ORO.FC.105 & 205)

“I Fly” shall only designate a flight crew member to act as pilot-in-command/ commander when he/she has:
5. Completed the “I Fly” Conversion Course, through a subcontracted ATO;
6. Acquired adequate knowledge of the route or area to be flown and of the aerodromes, including alternate aerodromes, facilities and procedures to be used;
7. Completed a Line Training
8. Completed the “I Fly” command course if upgrading from co-pilot to pilot-in-command/commander. »

and on OM-PART D / Appendix R, §1.2 it is stated:

1.3 « Command Course (ORO.FC.205)
For helicopter operations, the command course shall include at least the following elements:
(7) training in an FSTD, which includes line oriented flight training (LOFT) and/or flight training;
(8) operator proficiency check, operating as commander;
(9) command responsibilities training;
(10) line training as commander under supervision, for a minimum of:
(iii) 20 flight hours including at least 20 sectors, in the case of less than 2000 flight hours experience; and
(iv) 10 flight hours, including at least 10 sectors, in the case of more than 2000 flight hours experience;
(11) completion of a line check as commander and demonstration of adequate knowledge of the route or area to be flown and of the aerodromes, including alternate aerodromes, facilities, heliports, landing sites and procedures to be used and
(12) crew resource management training. »

According to the above, the criteria for assigning the duties to the Pilot-in-Command (PIC) are only mentioned in the Operations Manual Part A, while in the Operations Manual Part D only the Command Course is described, the completion of which is one of the conditions for the designation as Pilot in Command.

Additionally,

The minimum flight experience of the PIC for the undertaking of commercial flights is stated identically in OM-PART A, §5.2.1.B.HELICOPTERS (5) and in OM-PART D/ Appendix R/§1.1.( c )(5) , as below:

«(5) When a flight crewmember is required to operate a helicopter, following completion of a Type Rating (by an ATO) or the conversion course and the associated line flying under supervision, is not to be designated to commence a revenue or hired flight before he achieves the requirements on flight hours on the type as is referred below according to the total helicopter PIC flight experience.

(i) has achieved 20 flight hours totally on the type within a period of 60 days and performed at least 20 sectors, only for Cdr with less than 2000 flight hours as PIC on helicopters.

(ii) has achieved 10 flight hours totally on the type within a period of 60 days and performed at least 10 sectors, only for Cdr with more than 2000 flight hours as PIC on helicopters.

(iii) has achieved 100 flight hours on the type and/or in the role (no time limit);»

The above is a statement of the flight hours that the PIC must have completed upon completion of Conversion training and on-line training before being assigned the duties of PIC for commercial flights, recording the Company's policy to the strictest of Legislation which requires a minimum of ten (10) hours including a minimum of ten (10) flight sectors in accordance with ORO.FC.205 Command course.

As a conclusion, we believe that there is not any conflict between the OM – PART A and the OM – PART D of the company regarding the criteria for the assignment of Captain duties, as it is stated on the Safety Recommendation 2022-04.”

[AAIASB changed status of SR 2022-04 to “Open- Response Received awaiting assessment” and will assess the Response within 60 days as per EU Reg. 996/2010.]
General
SR Number: 2022-03
Date Issued: 09/06/2022
Addressee: iFly arline
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Response received awaiting Assessment SR_Partially_accepted
Recommendation

SR Number:

2022-03 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: iFly arline
Status: OPEN - Response received awaiting Assessment
Recommendation: PREAMBLE:

- From the last Helicopter’s Technical Logbook review, there were recorded repeated cases of non-certification of the execution of: the first flight of the day, the pre flight inspection (PDI) but also the inspection after the last flight (PFI).

SAFETY RECOMMENDATION 2022-03: It is recommended to the Operator to review the training process of the involved personnel in the task accomplishment certification in the Technical Logbook.
Response

SR Number:

2022-03 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: iFly arline
Status: OPEN - Response received awaiting Assessment
Response: Operator’s response to AAIASB SR 2022-03 was received by email on 08/9/2022.

[Operator’s response]:

“ a. The company with Crew Notice No 01/2019, drew the attention of all the involved parties to correctly and thoroughly fill in and sign all the fields of the technical logbook of the aircraft, which apply to each flight.

b. The company revised the Continuing Airworthiness Management Exposition (CAME) manual Issue 2 in CAME Issue, giving more detailed instructions regarding the obligation to correctly complete and supervise the execution of the tasks in the technical log of the aircrafts.

c. In addition, the company proceeded in the investment regarding the procurement and training of all the involved personnel in a dedicated software program, the application of which prevents any error in the process of certifying the execution of the tasks in the technical log of the air operator.”

[AAIASB changed status of SR 2022-03 to “Open- Response Received awaiting assessment” and will assess the Response within 60 days as per EU Reg. 996/2010.]
General
SR Number: 2022-02
Date Issued: 09/06/2022
Addressee: iFly airline
Why this Recommendation was Developed: link_64Final Report 04/2022
Status: OPEN - Response received awaiting Assessment SR_Partially_accepted
Recommendation

SR Number:

2022-02 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: iFly airline
Status: OPEN - Response received awaiting Assessment
Recommendation: PREAMBLE:

- The investigation process revealed that the Operator, in the context of Safety Management System, focused on the flight activity reactive approach but did not follow the flight activity proactive approach through the timely hazard identification and risk assessment process.

SAFETY RECOMMENDATION 2022-02: It is recommended to the Operator, to re-evaluate the Safety Management System implementation process in order to timely identify the hazards arising from its activity that potentially can cause accidents or serious incidents.
Response

SR Number:

2022-02 -- Date Issued: 09/06/2022
Why this Recommendation was Developed: link_64Final Report 04/2022
Addressee: iFly airline
Status: OPEN - Response received awaiting Assessment
Response: Operator’s response to AAIASB SR 2022-02 was received by email on 08/9/2022.

[Operator’s response]:

“ a. The Flight Operations Department of the company has recognized the potential general hazards that helicopters face during their flight activities. The hazards are categorised in three (3) categories (Human Factors - work / mission environment - Aerial Missions), defenses (mitigation measures) have been taken and a risk assessment was performed.

The Safety Department of the company maintains an electronic Database with potential hazards with all the as above mentioned data, which it is revalidated every year.

b. In addition, the company has established a Pre-Flight Risk Management Check List procedure, according to which the Pilot-in-Command (PIC), before undertaking a flight task each day, completes a Check List and sends it to the company's Flight Operations Department for evaluation.”

[AAIASB changed status of SR 2022-02 to “Open- Response Received awaiting assessment” and will assess the Response within 60 days as per EU Reg. 996/2010.]
General
SR Number: 2022-01
Date Issued: 17/02/2022
Addressee: SKYSERV S.A.
Why this Recommendation was Developed: link_64Final Report 01/2022
 
Status: CLOSED - Adequate SR_CLOSED
Recommendation

SR Number:

2022-01 -- Date Issued: 17/02/2022
Why this Recommendation was Developed: link_64Final Report 01/2022
 
Addressee: SKYSERV S.A.
Status: CLOSED - Adequate
Recommendation: In order to raise Situation Awareness, it is recommended that SKYSERV S. A., refer and analyse during Initial and Recurrent Training of its Employees, the Cases of Accidents and Incidents that had happened during aircraft Ground Services and training should focus on the exclusion areas around the aircraft, whether there is use of HOTEL MODE or not.
Response

SR Number:

2022-01 -- Date Issued: 17/02/2022
Why this Recommendation was Developed: link_64Final Report 01/2022
 
Addressee: SKYSERV S.A.
Status: CLOSED - Adequate
Response: The addressee’s response to AAIASB Safety Recommendation (SR) 2022-01 was received by email on 14/6/2022.

[Addressee response to AAIASB SR 2022-01]:

“Further to your relevant e-mail [AAIASB SR Transmittal letter], we inform you that our company, within the framework of the applied safety management system, has already installed and implemented a system of integrating safety information into its relevant training modules, as applicable. Incidents, occurrences, serious incidents, accidents and general safety issues, before and after the investigation, are evaluated to be included in the staff information system, to increase the level of awareness and avoiding repetition.

In any case, thank you both for your cooperation and for sharing the information.”

[AAIASB assessed this response as “Adequate” on 08/8/2022 and changed the SR 2022-01 status to “Closed”]
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