Day 2 of EASA Safety Conference: “Staying in Control – Loss of Control (LoC) – Prevention and Recovery”

October 5, 2011

EASA Conference Day 2

The European Aviation Safety Agency (EASA) today, October 5, opened the second day of their third aviation safety conference. The conference was  attended by 250 professionals from the aviation industry.

The theme for the two-day conference is “Loss of Control”. A topic well chosen because Loss of Control (LoC) accidents are considered a safety priority by many organisations.

The U.K. CAA for instance named LoC as one of the “Significant Seven” issues that affect airline safety. The CAA’s efforts with regards to LoC focus on training and assessment of pilot monitoring skills, use of aircraft automation and maintenance of manual flying skills.

These issues were also raised by several other speakers. Several industry-wide committees and working groups are working actively on all fronts – Prevention, Detection, and Recovery with regards to LoC.

One of those joint efforts was to make a generic procedure for pilots how to handle a stall at low altitude. Past training focused to prevent altitude loss, many times leading the pilot to add maximum thrust as the first step for recovery. The new focus however is on CRM, making it a team effort to recover from stall instead of a pilot flown maneuver. An industry-wide group completed a new and generic procedure that has been verified and validated by Airbus and Boeing.

The stall recovery template as presented by Boeing and Airbus

Simulator training

Also, there is a  need for changing flight simulator training in relation to key issues involved in LoC accidents. Simulators today are satisfactory for teaching upset prevention but can cover an estimated 1/3 of what they need for teaching upset recovery.

For instance, events caused by atmospheric disturbances and flight control issues can be replicated in simulators. Disorientation though is harder to replicate. And for icing and stalls simulators are not up to the full job. Yet, those two account for a large amount of Upset accidents; almost half of all accidents according to research.

Research is being done in the European SUPRA projects with enhancing motion cueing in existing flight simulators and a new advanced simulator at TNO labs which can simulate continuous g-loads and even inverted flight.

Something to which everyone agreed is that is no single solution to Loss of Control; only a multifaceted approach to Prevention, Detection, and Recovery will reduce LoC  accidents.

There is a vital role for instructors. Also general aviation instructors should use this guidance in their training for future airline pilots.

The conference presentations will be published on the EASA conference website.

Meanwhile, a video of Dr. Sunjoo Advani’s excellent presentation during a previous conference is available online:

Presentations held during Day 2 were:

Stall Recovery: New international Standard
Claude Lelaie, (Flight Test Pilot, Airbus retired) and Philip Adrian, 737 Chief Technical Pilot, Chief Pilot Regulatory Affairs, The Boeing Company

Upset Recovery Training
Philip Adrian, 737 Chief Technical Pilot, Chief Pilot Regulatory Affairs, The Boeing Company and Capt Marc Parisis, VP Training and Flight Operations Support, Airbus

FAA Stall and Upset Recovery Training Initiatives
Capt Robert Burke, Aviation Safety Inspector, Air Carrier Training Branch, FAA

Flight Simulator for Upset Recovery
Dr Jeffery Schroeder, Chief Scientist and Technical Advisor for Flight Simulation Systems, FAA

Loss of Control: Significant Threat – Significant Actions
Capt David McCorquodale, Head of Flight Crew Standards, UK CAA

The ICATEE Programme
Dr Sunjoo Advani, Royal Aeronautical Society / Chairman of the ICATEE

Supra Project
Dr Eric Groen, SUPRA Technical Coordinator, TNO and Lars Fucke, SUPRA Dissemination Lead, Boeing R&T Europe

NASA Research on LoC
Dr Christine Belcastro, Chief Scientist, NASA

Summary – Way Forward and Conclusion
John Vincent, Deputy Director for Strategic Safety & Head of Safety Analysis, EASA

Day 1 of EASA Safety Conference: “Staying in Control – Loss of Control (LoC) – Prevention and Recovery”

October 4, 2011

EASA's safety conference

The European Aviation Safety Agency (EASA) today, October 4, opened their third aviation safety conference. The conference is being attended by 250 professionals from the aviation industry.

The theme for the two-day conference is “Loss of Control”. A topic well chosen because Loss of Control (LoC) accidents are considered a safety priority by many organisations.

This was again confirmed by speakers today. EASA research of airliner accidents over the past decade showed that 25% of all fatal accidents are caused by Loss of Control. Additionaly, ICAO data supports the conclusion that LoC accident account for most fatalities. It is one of four safety priorities for ICAO.

And alarmingly, the LoC accident rate is not decreasing.

But how to decrease the number of LoC accidents? ICAO suggests that it should be a global approach with harmonization of efforts. Meanwhile several organisations are involved in research in relation to (aspects of) LoC. Some speakers noted that the monitoring skills of the ‘pilot monitoring’, or ‘ pilot not flying’ should be strengthened. With enhanced monitoring skills a copilot could be even better prepared to anticipate and recognize signs that, for instance a stall is imminent.

But not it is not just monitoring skills.  A French study in 2008 reported that many copilots felt that they were not adequately prepared for surprising situations.

It should be considered to take these kind of situations into account during pilot training. Especially given the growing automation on today’s flight decks. It is getting harder to anticipate all different failure modes in these automated systems. More so since several systems like Electronic Flight Bags do not go through the same certification processes as aircraft systems.

However, a slight change in training would not be sufficient, according to Jean Pariès. He even suggested a paradigm shift for training as a whole to, “”recognize real world unpredictability.. and to maintain/develop resilience features”.


Several LoC accidents were mentioned by different speakers. These accidents were:

23 Aug 2000 – A320 at Bahrain: nose down input by the captain during a night time go around; crash into the sea.

22 Dec 1999 – B747F near London-Stansted: captain lost control when his ADI failed.

23 Sep 2007 – B737-300 near Bournemouth, UK. Unrecognized disengaing of autothrottle during final approach.

14 Sep 2008 – B737-500 near Perm, Russia:  loss of spatial orientation of the crew during night time approach, pilot not familiar with Western ADI’s.

25 Feb 2009 – B737-800 near Amsterdam-Schiphol Airport: Stall following undetected autothrottle thrust reduction during final approach.


Day 1 of the conference featured the following speakers:

Welcome Speech – Opening Remarks
John Vincent, Deputy Director for Strategic Safety & Head of Safety Analysis, EASA

Keynote Speech
Patrick Goudou, Executive Director, EASA

EASA Rulemaking Forewords
Jean-Marc Cluzeau, Head of Flight Standards Department, EASA

EASA Safety Review – Loss of control accidents in numbers
Ilias Maragakis, Safety Analyst Expert, EASA

Accidents in Commercial Aviation Transport: Review and lessons learned
Capt Bertrand de Courville, Air France Corporate Safety Manager, ECAST Co-chair

Loss of Control Examples
Margaret Dean and Andrew Blackie, Senior Inspectors of Air Accidents (Operations), AAIB UK

Crew Resource Management
Jean Pariès, President, Dédale SAS

Flight Path Management Systems: Policy, Training and Operational use
Dr Kathy Abbott, Chief Scientific and Technical Advisor, Flight Deck Human Factors, FAA

EASA Automation Policy
Dr Michel Masson, HF Expert / Safety Action Coordinator, EASA

ICAO Activities in relation to LoC
Henry Defalque, Technical Officer, Licensing and Operations, Flight Operations Section, ICAO

EASA proposes Airbus Flight Control Primary Computer software update in wake of AF447 accident

August 3, 2011

The European Aviation Safety Agency (EASA) is proposing an Airworthiness Directive for an Airbus A330/A340 Flight Control Primary Computer (FCPC) software update in the wake of the fatal accident involving Air France flight AF447.

EASA states that it has been determined that, when there are significant differences between all airspeed sources, the flight controls of an Airbus A330 or A340 aeroplane will revert to alternate law, the autopilot (AP) and the auto-thrust (A/THR) automatically disconnect, and the Flight Directors (FD) bars are automatically removed.
Further analyses have shown that, after such an event, if two airspeed sources become similar while still erroneous, the flight guidance computers will display the FD bars again, and enable the re-engagement of AP and A/THR. However, in some cases, the AP orders may be inappropriate, such as possible abrupt pitch command.
In order to prevent such events which may, under specific circumstances, constitute an unsafe condition, EASA issued AD 2010-0271 to require an amendment of the Flight Manual to ensure that flight crews apply the appropriate operational procedure.

Since that AD was issued, new FCPC software standards have been developed that will inhibit autopilot engagement under unreliable airspeed conditions. The proposed AD requires software standard up-grade of the three FCPCs by either modification or replacement. The Proposed AD will be open for consultation until 30 August 2011.

More info:

EASA issues emergency AD on life limits of A330 and A340 landing gear parts

June 30, 2011

The European Aviation Safety Authority (EASA) issued an emergency Airworthiness Directive (AD) effecting specific Airbus A330 and A340-200/-300 aeroplanes. EASA requires reduction of the existing main landing gear (MLG) bogie beam life limits and replacement of each MLG bogie beam that has already exceeded the new limit.

During ground load test cycles on an A340-600 aeroplane, the MLG bogie beam prematurely fractured.
The results of the investigation identified that this premature fracture was due to high tensile standing stress, resulting from dry fit axle assembly method.
Improvement has been introduced subsequently with a grease fit axle assembly method.
Analysis was performed on other bogie beam with dry fit axles. It has been determined that MLG bogie beams with specific part numbers  are more likely to suffer from standing stress generated by dry-fit axles because these bogie beams are stiffer between the axle sockets. These two part numbers are fitted on A330, A340-200 and -300 series aircraft.

Fracture of a MLG bogie beam under high speed could ultimately result in the aeroplane departing the runway, or in the bogie detaching from the aeroplane, or MLG collapse, which could cause structural damage to the aeroplane and injury to the occupants.

More information:

Study: Regulation of ground de-icing and anti-icing services in Europe

June 20, 2011

EASA has published its Final Report on the study carried out on the regulation of ground de-icing and anti-icing services in EASA member states.

Born out of a large number of events of stiff or frozen flight control systems during the winters of 2005 and 2006 and the subsequent Safety Recommendations made by the UK Air Accident Investigations Branch (AAIB) and the German Federal Bureau of Aircraft Accident Investigation (BFU), followed by the conclusions of a 2006 Industry-wide ERA/JAA Winter Operations Workshop which addressed the issues surrounding fluid residues and de-icing/anti-icing standards, an study commissioned by EASA was carried out.

The Study’s scope was to investigate and recommend the means by which Aviation Authorities manage matters with respect to the certification of service providers and the availability of de-icing/anti-icing fluids.  Its aim was to make recommendations for improvements of service provision and the availability of Type I fluids.

EASA considers that the Study has been successful overall with regard to practical recommendations to raise standards and improve safety, but it falls short of recommending provision of Type I fluid, claiming that further data collection is required due to some conflicting survey results.  However, service providers are encouraged to provide Type I and/or two-step procedures if demanded by operators.  Equally, direct regulation of service providers has been excluded at this stage but may be considered as a future option.

The report presents 26 Recommendations that have been assessed for their impacts concerning safety, economic, environmental, social and the regulatory framework.  If adopted, EASA states that the Recommendations would generate a beneficial reduction in the risks associated with de-icing/anti-icing and that the improvements to the regulations would have a positive effect on the safety of other ground handling activities.

The Study recommends that EASA develops a targeted work programme which, if undertaken, would see generally higher de-icing/anti-icing operational standards within two years, harmonized more broadly across Member States. The six areas recommended for actions are:

  • improving coordination between Industry and the Aviation Authorities;
  • collecting more safety data and analyzing the existing risks;
  • ensuring regulations and guidance for air operations are comprehensive, unambiguous and practical;
  • conducting oversight activities to ascertain whether regulations are being harmoniously and consistently applied across Europe;
  • consider alternative regulatory means to support operators to achieve acceptable service levels from their providers, and to facilitate aerodromes and service providers in ensuring this;
  • engaging with all stakeholders to ensure that more focused research is conducted, and data gathered, into fluid qualities and performance.
More information:

Dassault Falcon 7X flight suspension partly lifted

June 17, 2011

A Dassault-owned Falcon 7X arrives at Rotterdam Airport (EHRD) on the day following the lifting of the ban (Photo: Harro Ranter, 17 June 2011)

On May 26, 2011 all flights involving Dassault Falcon 7X jets were prohibited following the EASA’s  issuance of  emergency AD 2011-0102-E. This suspension is now lifted for certain aircraft as of June 16, 2011.

The suspension of flight operations was considered to be an interim measure pending the outcome of an investigation into a serious incident involving an uncontrolled pitch trim runaway during descent.

The initial results of the investigations are showing that there was a production defect in the Horizontal Stabilizer Electronic Control Unit (HSECU) which could have contributed to the cause of the event.  One specific HSECU is potentially affected by this production defect. Investigations are continuing to confirm this cause.

In the meantime, to allow re-starting flight operations and providing protection against further pitch trim runaway events, Dassault Aviation have developed two modifications which are implemented through accomplishment of Dassault Service Bulletin (SB) F7X-211. In addition, it has determined that the flight envelope must be restricted, compared to the original certified flight envelope.

For aeroplanes equipped with HSECU P/N 051244-02, this AD, which supersedes EASA AD 2011-0102-E, requires:

  1. accomplishment of two Dassault Aviation modifications,
  2. amending the AFM and installing a placard in the cockpit,
  3. amending the Minimum Equipment List (MEL), and
  4. implementing an operational test of the HSTA electric motors reversion relays.

For aeroplanes equipped with HSECU P/N 051244-04, the prohibition of flights is maintained.

View this document on Scribd

Download PDF: EASA EAD 2011-0114-E

EASA grounds all Dassault Falcon 7X aircraft pending incident investigation

May 26, 2011

A Falcon 7X jet (photo: Jerome K. /CC: by-nc-nd)

The European Aviation Safety Agency (EASA) issued an Emergency Airworthiness Directive (AD), prohibiting flight operations of Dassault Falcon 7X jets.

The AD is considered to be an interim measure pending the outcome of an investigation into a serious incident currently carried out by the manufacturer. Further AD action is expected to follow when additional information is available.

The incident involved a Falcon 7X which experienced an uncontrolled pitch trim runaway during descent. The crew succeeded in recovering a stable situation and performed an uneventful landing. Analysis of the Digital Flight Data Recorder (DFDR) and Fault History Database (FHDB) confirmed the event, but did not allow explaining the origin of the pitch trim runaway.

This condition, if occurring again, could lead to loss of control of the aeroplane. To address this potential unsafe condition, Dassault Aviation has proposed to EASA to prohibit, from the effective date of this AD, any flight operations of Falcon 7X aeroplanes, to which EASA agreed by issuing this AD.

View this document on Scribd

EASA proposes new certification rules for large aeroplanes and turbine engines flying in icing conditions

March 24, 2011

The European Aviation Safety Agency (EASA) published a proposal to update the Certification Specifications for large aeroplanes and turbine engines for flights in icing conditions.

The proposed Certification Specifications update aim at better protecting large aeroplanes and turbine engines when flying in atmospheric icing conditions.  Icing environments such as freezing rain and freezing drizzle (Supercooled Large Drops), ice crystals and mixed phases, only partly covered in the existing Certification Specifications, will be taken into account in the updated proposal. EASA also proposes a revision of the requirements for engine air intake de-icing and anti-icing systems with an update of the freezing fog conditions and the introduction of falling and blowing snow conditions.

This new proposal includes EASA’s analysis of the recommendations made in 2009 by the Ice Protection Harmonization Working Group and the service experience gathered from large aeroplanes and turbine engines operations over the past 15 years. In particular, the group has outlined an evolution over the years of atmospheric conditions at flying altitude and the need to take into account these new weather environments.

The amendment of the certifications specifications for large aeroplanes (CS-25) and for turbine engines (CS-E) is expected to enter into force during the second quarter of 2012, after a period of public consultation and comments. Manufacturers of large aeroplanes and turbine engines will then have to comply with these updated rules.

The Ice Protection Harmonization Working Group is an international group that was tasked by the FAA Aviation Rulemaking Advisory Committee (ARAC) in 1997 to prepare recommendations for regulation change on the topic of flight in icing conditions. The proposed Certification Specifications update is fully harmonized with those of the FAA adopted in 2009.

More information:


Emergency AD: Falcon 50 fire extinguishing system inspection

February 21, 2011

The European Aviation Safety Agency (EASA) issued an emergency airworthiness directive, requiring inspection of the fire extinguishing system of Dassault Falcon 50 and Falcon 50EX aircraft.

On two occurrences on Falcon 50 aeroplanes in service, it was detected that two pipes had been swapped in maintenance at the frame 42 firewall. The swapped lines are the extinguishing system line to engine # 2,and engine # 2 Low Pressure (LP) bleed line.

If the swapping of these two lines is not detected and corrected, in case of engine # 2 fire, the fire extinguishing capability would not be operational.

For this reason, the AD requires an inspection of the connection of the two lines (extinguishing and LP bleed lines) at frame 42 in the rear compartment and, in case of findings, proper re-installation of the lines. This AD requires as well reporting to Dassault Aviation. This AD is considered to be an interim measure and, depending on the inspection results provided by operators, further AD action may follow.


EASA amends emergency AD on Trent engines

November 22, 2010

The European Aviation Safety Agency (EASA) issued a new  emergency airworthiness directive (2010-0242-E) for Rolls Royce RB211 Trent 900 series engines following a recent incident involving  such an engine on a Qantas A380.  This AD supersedes a previous emergency AD ( 2010-0236-E) that was issued on Novemer 10, 2010.

Since issuance of AD 2010-0236-E, the incident investigation has progressed and inspection data from in-service engines has been gathered and analysed.
The results of this analysis show the need to amend the inspection procedure, retaining the inspection of the air buffer cavity and focusing on the oil servicetubes within the HP/IP structure.

This AD partially retains the requirements of AD 2010-0236-E, which is superseded, and requires implementation of the amended procedure and accomplishment of the associated inspections.


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