Learning is a key part of safety. It is vital for every organisation to have the right mindset to continuous improvement. It takes a lot of commitment to want to know what is happening in your operations - where the gap exists between what you imagine and the day-to-day reality. Then when things go wrong, encourage conversations about that, do effective investigations and continually change how you operate to apply what you have learned. Finally, its vital to have a Just Culture to help create the trust your staff needed to feed your organisation's learning.
More about learning with Nuno Aghdassi from the Portuguese Accident Investigation Board
EASA's John Franklin recently talked to Nuno Aghdassi from the Portuguese AIB about the importance of learning in safety. Watch below, or the Together4Safety Youtube Channel or subscribe to the Conversation Aviation Podcast on Spotify.
EASA's Annual Safety Review - Learning in action
Updated - 30 July 2020: EASA has published the 2020 (14th) Edition of the Annual Safety Review. The Air Ops part of the review summarizes aviation safety both worldwide and in the EASA Member States. It uses data from EASA’s Occurrence Database and the European Central Repository that pools reports from across the EASA Member States. Its scope covers both Regulation (EU) 996/2010 on accident and serious incident investigation and Regulation (EU) 376/2014 on occurrence reporting, follow-up and analysis.
The purpose of the ASR
The main function of the ASR is to support strategic decision making on the strategic mitigations in the European Plan for Aviation Safety (EPAS). In these challenging times of COVID-19, EASA has worked with our collaborative partners to identify safety issues related to the pandemic that you can find more information about on this site. The task teams are now developing mitigations that we will also have on this website as the work develops.
Global fatal accidents and fatalities
In large aeroplane passenger and cargo operations worldwide you can see the general reduction over the past years in the two graphs below of fatal accidents and fatalities.
The number of fatalities has also slightly decreased over this time. Although, naturally the numbers vary due to the type and size of the aircraft involved.
In 2019 there were 268 fatalities worldwide, while as in European numbers for EASA Commercial Air Transport – Airlines and Air Taxi – Large Aeroplanes there were no fatal accidents. The graph below shows the trend in the number of fatalities worldwide since 1970, which highlights the since safety improvements that have been achieved over the long term.
Accidents and Serious Incidents for EASA MS Operators
In terms of the situation in Europe, the EASA MS the graphics below show the number of accidents and serious incidents as well as the fatalities and injuries. For this analysis a comparison is made between 2019 and the previous 10 years - 2009 to 2018. In 2019 the majority of the 8 serious injuries came from turbulence encounters in-flight.
Safety Risks for Large Aeroplanes
The accidents and serious incidents are classified in terms of the actual or potential accident outcome. Effectively this is the type of accident that took place or could have happened if the incident has escalated into an accident. Every occurrence is assigned a risk score using the European Risk Classification Scheme (ERCS) which considers how close the occurrence was to a fatal outcome. The ERCS score for each accident outcome or "Key Risk Area" as they are called is then grouped to help identify where our safety efforts at European Level should be focused for the greatest effect.
From the graphic below you can see that the main key risk areas involving commercial air transport were: Airborne Collision, Runway Excursion and Aircraft Upset.
Top Safety Issues
Within the ASR we then identify the most important safety issues, which is then shown in the data portfolio on Page 54 of the Safety Review. We don't show all the safety issues here but the most important are identified through a risk management process according to the number of occurrences and the ERCS risk score.
For 2019 the most important were: State of wellbeing and fitness for duties, Handling of technical failures, Crew resource management, Monitoring of flight parameters and automation modes, Flight planning and preparation and Braking and steering.
How do these safety issues match up to your own organisation?
Human Factors Analysis
For the first time, the ASR specifically highlights the Human Factors (HF) aspects from the analysis of accidents and the coding of occurrence reports. By considering these human and organisational aspects of past accidents and incidents we can feed this into the risk assessment process to help identify the appropriate mitigating actions. This work on HF is a key part of our safety efforts.