International Civil Aviation Organization

Organisation de laviation civile internationale

Organizacin de Aviacin Civil Internacional

Tel.: Ref.:

+1 514-954-8219 ext. 8160 SD 37/4-11/63 9 September 2011

Subject: Safety recommendations of global concern Action required: To send safety recommendations of global concern and associated responses to ICAO Sir/Madam, 1. I have the honour to refer to the Accident Investigation and Prevention (AIG) Divisional Meeting (2008), held in Montral from 13 to 18 October 2008, which recommended that the International Civil Aviation Organization (ICAO) establish a system to make accessible, to all aviation stakeholders and the public, safety recommendations of global concern (SRGC) issued by States, as well as the responses to the recommendations and that ICAO develop guidelines on what constitutes a SRGC. 2. I am pleased to inform you that the Secretariat, with the assistance of the Accident Investigation Methodology Study Group, has developed a definition for SRGC along with associated guidance material. You are kindly invited to refer to the relevant guidelines outlined in Attachment A and to inform ICAO of SRGC issued in 2008 and onwards, as well as the responses received to the recommendations. 3. To facilitate your submission, a form has been included in Attachment B which may be completed and returned as appropriate. In this regard, I kindly request that the forms be sent to the attention of the Accident Investigation Section of the Air Navigation Bureau of ICAO. Accept, Sir/Madam, the assurances of my highest consideration.

Raymond Benjamin Secretary General Enclosures: A Guidelines on safety recommendation B Form for SRGC

999 University Street Montral, Quebec Canada H3C 5H7

Tel.: +1 514-954-8219 Fax: +1 514-954-6077

E-mail: icaohq@icao.int www.icao.int

ATTACHMENT A to State letter SD 37/4-11/63

GUIDELINES ON SAFETY RECOMMENDATION

1.

SAFETY RECOMMENDATION

As per Annex 13 Aircraft Accident and Incident Investigation safety recommendation is a proposal of an accident investigation authority based on information derived from an investigation, made with the intention of preventing accidents or incidents and which in no case has the purpose of creating a presumption of blame or liability for an accident or incident. Safety recommendations may also result from diverse sources, including safety studies. The following Annex 13 provisions address the processing of safety recommendations: Action on safety recommendations 6.10 A State that receives safety recommendations shall inform the proposing State, within ninety days of the date of the transmittal correspondence, of the preventive action taken or under consideration, or the reasons why no action will be taken. 6.11 Recommendation. A State conducting the investigation or any other State issuing a safety recommendation should implement procedures to record the responses to the safety recommendation issued. 6.12 Recommendation. A State that receives a safety recommendation should implement procedures to monitor the progress of the action taken in response to that safety recommendation. The development of meaningful and effective safety recommendations must be based on validated factual information, sound analysis and logical conclusions. When timely and properly implemented, safety recommendations should prevent other accidents or incidents from similar causes/contributing factors, and/or reduce the consequences of such occurrences. In order to ensure that appropriate action is taken, each safety recommendation should include a specific addressee. This is usually the appropriate authority of the State which has responsibility for the matters with which the safety recommendation is concerned. It should be noted that Annex 13 also requires that at any stage of the investigation, the accident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that is considered necessary to be taken promptly to enhance aviation safety. A safety recommendation should focus on the problem rather than the solution. In general, a safety recommendation should identify what actions to take, but leave scope for the authorities responsible for the matters addressed to determine how to accomplish the objective of the recommendation. This is particularly important when the salient facts are not available and additional examination, research and testing may be necessary. Moreover, the accident investigation authority may lack the detailed information and experience required to evaluate the financial, operational and policy impacts on the addressee of the recommendation.

A-2 A good recommendation would be performance based. This approach will facilitate both the investigation authority and the addressee of the recommendation in evaluating whether and to what degree the action proposed would mitigate the deficiency upon which the recommendation was made. Some key ingredients to be considered for successful safety recommendations include: a) identification of the authority best able to take action to mitigate the deficiency upon which the recommendation is based; b) validated information and analysis concerning the immediate circumstances that led to the event and the adverse consequences; c) identification of safety deficiencies underlying the adverse consequences; d) information regarding the probability of recurrence and adverse consequences of a recurrence; e) information on the magnitude of the existing risk, including the inadequacies of existing defences; f) the extent to which people/equipment will continue to be exposed to the risk if no action is taken; and g) a clear proposal to the responsible authority as to what action is required. The ICAO Manual of Aircraft Accident and Incident Investigation, Part IV Reporting (Doc 9756), provides additional guidance for making safety recommendations. 2. SAFETY RECOMMENDATION OF GLOBAL CONCERN (SRGC)

A SRGC is defined as follows: A safety recommendation made to a State civil aviation authority, to a regional certification authority, or to ICAO regarding a systemic deficiency having a probability of recurrence with potential for significant consequences, and requiring timely action to improve safety. A SRGC would meet one or more of the following criteria: a) the deficiency underlying the recommendation is systemic and not solely a local issue; b) the probability of recurrence of the accident and the adverse consequences are high; c) the risk to persons, equipment and/or environment is high; d) the urgency for taking effective remedial safety action is high; e) there is a history of recurrence of the relevant deficiency; f) the deficiency underlying the recommendation constitutes a risk to the airworthiness, design, manufacture, maintenance, operation and/or regulation of the involved aircraft type;

A-3 g) the deficiency underlying the recommendation constitutes a risk to more than one aircraft type, to more than one operator, to more than one manufacturer and/or to more than one State; and h) the mitigation of the risks associated with the deficiency will require coordinated efforts of more than one entity of the air transport industry, such as civil aviation authority(ies), manufacturer(s) and operator(s). 3. PUBLICATION OF SRGC

The ICAO Flight Safety Information Exchange (FSIX) website (http://www.icao.int/fsix/sr.cfm) was developed to provide the aviation community and the public with access to safety-related information. This site contains, among others, information related to safety recommendations made to ICAO in accordance with paragraph 6.9 of Annex 13. To this end, the web page contains the following information: the issuing State, recommendation area, aircraft involved, accident description, accident synopsis, State recommendation, ICAO actions in response to the recommendation, and the relevant Final Report. The FSIX website will be expanded to include SRGC, as well as responses to those safety recommendations. In this regard, it is noted that only SRGC issued in 2008 and onwards should be sent to ICAO. Attachment B to this letter provides a sample form that may be used for submission of SRGC and the related responses. 4. EXAMPLES OF SRGC

Based on the aforementioned criteria, the following are examples of safety recommendations that could be classified as SRGC.

EXAMPLES OF SAFETY RECOMMENDATION OF GLOBAL CONCERN Australia ATSB Safety Recommendation B-747, water leak, Bangkok, 7 Jan 2008 Significant safety issue: The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft. The ATSB considers that the risk of ongoing or emerging design, operation and maintenance issues with the potential to result in liquid contamination of electrical system units in transport category aircraft could be significantly reduced over time by improved regulatory guidance and oversight. For example, existing designs and processes should be monitored for continuing effectiveness while consideration of alternative design principles may be applied to new aircraft designs. ATSB Recommendation issued to: US Federal Aviation Administration The Australian Transport Safety Bureau recommends that the US FAA take safety action to address this safety issue.

A-4 Brazil CENIPA Safety Recommendation B-737 / Embraer Legacy, mid-air collision, 29 Sep 2006 To the Civil Aviation regulatory agencies, it is recommended: [RSV (A) 206/A/08 CENIPA, on 28 / Nov / 2008] - To review their regulations concerning the manmachine interface in the aircraft flight control station and/or flight deck, in terms of the positioning of the instruments, warnings and alerts, so as to prevent that inadvertent interactions between the crewmembers and such devices affect the safety of the operation. These revisions must be in accordance with the development of the requisites in progress in the aeronautical community, among them the Draft Rule 25.1302 - Installed Systems and Equipment for Use by the Flight Crew, which includes aspects related to the interaction between the crewmembers and the positioning of the instruments, in order to prevent that eventual inadvertent actions affect the operation. Canada TSB Safety Recommendation A06-05 Airbus A310, loss of rudder in-flight, 06 Mar 2005 The separation of the rudder from Air Transat Flight 961 and the damage found during the postoccurrence fleet inspections suggest that the current inspection program for Airbus composite rudders may not be adequate to provide for the timely detection of defects. In addition, preliminary tests demonstrating that disbonds can grow due to altitude-related pressure differential suggest that increased attention is warranted to mitigate the risk of additional rudder structural failures. The consequences of a rudder separation include reduced directional control and possible separation of the vertical tail plane (VTP). Therefore, on 27 March 2006, the Board recommended that: The Department of Transport, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders. (A06-05, issued March 2006) France BEA Safety Recommendation Concord, Gonesse, France, in-flight fire, 25 July 2000 The investigation showed that a shock or a puncture could cause damage to a tank according to a process of transmission of energy from a projectile. Such indirect processes, though known about, are complex phenomena which had never been identified on civil aircraft. Equally, the ignition of the kerosene leak, the possible forward propagation of the flame, its retention and stabilisation occurred through complex phenomena, which are still not fully understood. Consequently, the BEA recommends: The DGAC, in liaison with the appropriate regulatory bodies, modify the regulatory certification requirements so as to take into account the risks of tank damage and the risk of ignition of fuel leaks.

A-5 UK AAIB Safety Recommendation 2009-029 B 777, engine rollback, London, Heathrow, 17 Jan 2008 It is recommended that the Federal Aviation Administration and the European Aviation Safety Agency consider mandating design changes that are introduced as a result of recommendation 2009028, developed to prevent ice from causing a restriction to the fuel flow at the fuel oil heat exchanger on Boeing 777 aircraft powered by RollsRoyce Trent 800 engines. U.S. NTSB Safety Recommendation A-10-10 DHC-8-400, loss of control, 12 Feb 2009 As a result of the investigation of this (Colgan Air) accident, the National Transportation Safety Board makes the following recommendation to the Federal Aviation Administration: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120-71A, Standard Operating Procedures for Flight Deck Crewmembers; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring. (A-10-10)

ATTACHMENT B to State letter SD 37/4-11/63 SAFETY RECOMMENDATION OF GLOBAL CONCERN (SRGC) SUBMISSION FORM Registration: Manufacturer: Model: Date/local time: Location: City/State: Country:

AIRCRAFT

Operator:

ACCIDENT INCIDENT
_______________
(if other, please specify)

Investigation Authority: Investigation #: Classification: SRGC issued at: Executive Summary

(day/month/year)

SRGC number:

(brief history of the occurrence or circumstances associated with the SRGC)

Deficiency related to the SRGC

Safety Recommendation of Global Concern (see Note below)

Note: Use additional sheets to submit the responses to the above SRGC. As per Annex 13, a State that receives safety recommendations shall inform the proposing State, within ninety days of the date of the transmittal correspondence, of the preventive action taken or under consideration, or the reasons why no action will be taken.

END