Tillögur í öryggisátt Síða 8

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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.

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Isavia hefur unnið úrbætur vegna úrbótatillögu 18-104F018 T01  “ Regularly review the FOD Program “ og gefið út uppfært skjal VR700 12 -2 Öryggisáætlun vegna FOD  sem tekur til uppfærslu og endurskoðunar . Skjalið var gefið út 26.4.2021.

Til þess að tryggja að öryggisáætlun um FOD sé sem viðtækust skal vera fjallað um FOD að lágmarki hér:

(I) Nýliðafræðslu Isavia (allir starfsmenn)

(II) Fræðsluefni um öryggisvitund (allir starfsmenn sem fá aðgangsheimild)

(III) Öryggisreglum Isavia fyrir Keflavíkurflugvöll

(IV) Öryggishandbókum flugafgreiðsluaðila

(V) VR flugvallarþjónustu

(VI) Öryggisviku/dögum Isavia

(VI) Í öðru útgefnu efni

Upplýsingar og tilkynningar um FOD eru skráðar í Opscom af Isavia. Fylgst er með tíðni, umfang og eðli FOD tilkynninga og gripið til aðgerða í samræmi við það. Fjallað er um FOD á samráðsfundum með flugrekendum og flugafgreiðsluaðilum, Hlaðöryggisfundum (Apron safety meetings).

Atriði í áætluninni er hluti af úttektarviðmiðum flugafgreiðsluaðila.

Öryggisáætlun um FOD er uppfærð með hliðsjón af ofangreindu.

Samhliða voru eftirfarandi atriði einnig uppfærð:

1. HB700 01 Öryggisreglur Keflavíkurflugvallar
2. Nýliðafræðsla
3. VR710 13 Eftirlit og mælingar á athafnasvæðum loftfara
4. 139/2014 um Areodrome safety programmes og committees

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The FAA has issued Safety Recommendation 15.116, gathering and reviewing compliance data, including hazard assessments, for each type of Title 14, Code of Federal Regulations (14 CFR) Part 25 airplane operating under part 121. The FAA will be addressing Safety Recommendation 15.116 for U.S.-manufactured aircraft.

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Í svari Isavia kemur fram að í flugmálahandbók í kafla AD 2.6.1 kemur þegar fram að flugvellirnir geti uppfyllt kröfur um CAT-7 með 30 mín fyrirvara á Akureyri og Egilsstöðum og 45 mín fyrirvara á Reykjavíkurflugvelli. Isavia hefur reglulega yfirfarið mönnunarmótdelið og vaktaskiptan og þetta eru kröfur sem flugvellrnir geta mætt og staðið við.

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