Tillögur í öryggisátt Síða 8

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Að mati Samgöngustofu getur ítrasta krafa í þessu sambandi verið íþyngjani og erfitt fyrir leyfishafa að framkvæma, enda er t.d. ekki möguleiki að gera kröfu um að reglur um flug-, vakt- og hvíldartíma fyrir áhafnir gildi fyrir lækna og sjúkraflutningamenn.

Samgöngustofa hefur hins vegar ákveðið að gera kröfu til leyfishafa sem sinna sjúkraflugi með flugvélum að læknar og sjúkraflutningamenn verði skilgreindir sem "Medical Passenger / Flight Physician". Þessa skilgreiningu má nú þegar finna fyrir sjúrka- og björgunarflug með þyrlum. Leyfishafar munu þurfa að skilgreina viðkomandi í flugrekstrarhandbók, með hliðsjón af CAT.OP.MPA.155. Þá verði gerð krafa um að leyfishafar skilgreini í þjálfunarhandbók þjálfunarkröfur fyrir viðkomandi og hafi til hliðsjónar EU 965/2012 SPA.HEMS.100 GM1 SPA.HEMS.100(a) eins og á við í rekstri sjúkraflugs með flugvélum.

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Isavia ANS mun taka PIR skeytin fyrir á samráðsfundi með Veðurstofunni. Isavia ANS sendir eingöngu PIR skeyti þegar ástæða er til og það ætti ekki að sía þau frá þótt þau innihaldi ekki ákveðin orð. Isavia ANS mun einnig skoða hvort ástæða sé til að breyta ferlinu við PIR skeyti og nota ISDS til þess. Þetta atvik verður tekið fyrir á öllum kjarnafundum, svo starfsmenn viti að það þurfi að setja inn upplýsingar um hvers konar veðurfyrirbæri á við í skeytinu til að það síist ekki frá hjá Veðurstofunni. 

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Samgöngustofa hefur brugðist við tilmælunum á þann hátt að verkferill hefur verið útbúin og tryggir hann að ávallt verði haft samráð við rekstraraðila flugvalla og flugleiðsögu áður en heimild til flugvottanna og/eða flugprófanna er gefin út af Samgöngustofu.

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Isavia ANS mun útbúa gátlista fyrir vaktstjórnanda þar sem brugðist er við vegna lokunar flugbrautar á alþjóðaflugvelli á Íslandi, þar sem m.a. er aflað upplýsinga um stöðu annarra alþjóðaflugvalla, (mönnun, fjölda stæða og ástand flugbrauta o.s.frv) og upplýsingum komið á framfæri til flugumferðarstjóra í vinnustöðum í flugstjórnarmiðstöð.

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Óafgreitt af Samgöngustofu

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Not actioned by Tecnam.

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Since the time of the Accident the company taken a number of measures to analyse, identify risks and mitigate. Effort has been made to keep ICETRA and RNSA abreast of all findings and changes resulting thereof. A number of changes include reconsideration of CRM/Human Factors elements in traininig and the operation as a whole. Changes include, but are not limited to:

• Company’s Emergency Response plan has been revised and published.
• A new, yonger model aircraft was purchased, financed and registered. TF-MYA. A factor in the descision was the superior avionics package, including traffic advisory system and terrain awareness functions.
• The company discarted the practice of conducting every other recurrent training in actual aircraft and in stead opted to conduct all recurrent training in full flight simulators.
• Normal operating procedures where completely rewritten and operational philosophy redefined to include industry best practices. Outside consultation was sought and used in this process to ensure a broader perspective.
• Normal checklist system revised based on new operational philosophy and new checklists published.
• Stricter emphasis placed on procedural adherence and standardization in all training. This effort is ongoing.
• Effort launched to reiterate that individuality in procedural adherence is not acceptable by management. This effort is ongoing.
• Training has and will continue to include material aimed at enforcing the relationship between flight standardization, professionalism and safety.
• IFR/VFR policy has been rewritten and published to make clear under what conditions visual flying is allowed. New policy reviewed in training.

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Turkish Airlines has performed the following actions, as a result of both the recommendation as well as in light of the information received during the investigation:

CRM Training Revisions: Training materials or presentations used to cover the topic of threat and error management, specifically referencing the severe turbulence event, and attendance records or schedules indicating when the updated CRM training was delivered.

• Attendance record form of related crew for extra CRM course (after the incident).
• In 2024 Combined CRM course had case study about severe turbulence and case was examined in accordance with TEM perspective.
• The specific incident in question is now included in Turkish Airlines P3 (cruise relief co-pilot) and TEM E-learning recurrent training presentations and is being examined in accordance with TEM perspective.

Inclusion of PF/PM Roles: Copies of the updated CRM training modules or OM-D where the "Monitoring" and "PM INTERVENTION STRATEGY" sections are revised; Any internal memos or directives issued to reinforce these role definitions.

• Regarding to PM / PF roles, initial CRM course has already included dedicated sections on “Monitoring” and “PM INTERVENTION STATEGY” 
• A Co-pilot classified as Cruise Pilot - that is authorized to relieve a Commander/Captain above FL200. (In addition, while the definition of cruise relief pilot in EASA actually defines a special crew that only performs relief duties (does not land or take off, only allows the crew to rest during the cruise phase), Turkish Airlines practice is to relieve the captain pilot by giving her the authority to sit in the left seat above 20,000ft.)

Task Sharing Procedures: Documentation reflecting the updates under PART B.3.1.1, including references to sections 3.1.1.1 and 3.1.1.3. and flight crew bulletins or procedural manuals reflecting these changes.

• Under B777 PART B 3.1.1 “TASK SHARING” the following sections explicitly address these procedures:
  • 3.1.1.1 The Pilot Flying (PF) and The Pilot Monitoring (PM)
  • 3.1.1.3 Transfer of Duty, Flight Controls and/or Communication (Attachment-7)

Note: Since the standard procedures of Turkish Airlines to be applied in case of threats caused by adverse weather and/or in case of an expectation/information in this direction are available in the Turkish Airlines manuals.

This incident is used as a case study to improve and review Turkish Airlines UPRT (Upset Prevention and Recovery Training) ground and simulator content.

• For ground training, all Turkish Airlines aircraft types, the relevant event has been included in Turkish Airlinesr classroom training and recurrent training since August 2023.

• Directorate of Type Training, published CSIN #76; has been covered in instructors’ meetings for approximately two years.

Finally, for the aim of increased awareness of the cockpit crews against adverse weather-related threats, Turkish Airlines arrange/publish webinars, fleet magazines, announcements, CSIN, recurrent training, etc.

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Isavia ANS: Þetta verður tekið fyrir í síþjálfun veturinn 2020-2021.

Ábending frá Isavia ANS: flugumferðarstjórar áttu til að neita beiðni um RNAV þegar vélar voru að koma þétt inn og t.d. vél nr. 2 eða 6 var að biðja um annað en allar hinar.