Aviation Safety: Trending Non-Conformances and Incidents
In the aviation industry, SGS carries out in excess of 500 audits, reviews and inspections annually.
All findings emanating from these projects are tracked to enable identification of any emerging trends, so that we as a group can concentrate our efforts on areas of concern.
Some examples of areas previously identified have been:
- Lack of stabilized approach criteria, leading to incidents or accidents on landing or approach
- Inadvertent flight into Instrument Meteorological Conditions (IMC)
- Inappropriate fuelling procedures
- Non-activation of Emergency Locator Beacons
- Lack of appropriate training relating to the go-around procedure when a missed approach has to be carried out
In each case it has led us, as an aviation audit and advisory company, to target these areas more closely during our work, which has in turn led to safety improvements in the aviation sectors we have influence in.
The tracking methodology used is that every finding has a major heading attached as per the category table (extracted from the audit report template) below and when specific areas trend high we review the category further to ascertain any area(s) of concern. Once identified, the audit team ensure the target area is reviewed in depth during upcoming audits to assist in raising the standard industry wide.
For statistical analysis purposes, each Deficiency/Recommendation is categorized as one of the following types:
- Management and Organization
- Safety Management System
- Flight Operations Quality Assurance
- Flight Operations Management and Operations Manual
- Flight Crew Training
- Flight Evaluation
- Aircraft Documentation
- Engineering Quality Assurance
- Engineering Management, Procedures and Training
- Engineering Facilities and Equipment
- Aircraft Inspection and Equipment Fit
- Supply Logistics
- Fuel Storage & Supply Systems
Benefits gained are two-fold, in that the operator’s safety standards are improved and the risks to our clients are further mitigated. In many cases, the audit can lead to changes in training programs, standard operating procedures and a review of crew resource management.
The go-around procedure can be taken as an example of an audit target emanating from a review of accidents and also of procedures reviewed during the audit program. It was found that a number of operators did not practice the manoeuver or have it as an on going exercise in license renewal checks; yet this manoeuver resulted in a number of fatal accidents. Whilst most overshoots or go-around procedures were seen to be flown in a straight line (following the runway direction), many have a curve in the procedure to avoid terrain or restricted areas and if not practiced can be difficult to fly, especially in bad weather.
It was also discovered that during simulator training sessions many operators did practice the manoeuver, but it was commonly flown with one engine inoperative. Once again the additional power available, (in an all-engines-operating go-around procedure) was found to have led to control issues in a number of accidents. The audits undertaken following this analysis therefore concentrated on:
- Whether appropriate policy was detailed in the Standard Operating Procedures
- Whether the go-around procedure was accepted by company management as a required maneuver if the aircraft was not stable or in an appropriate position to land safely
- Ensuring the go-around procedures were practiced in training sessions on a yearly basis
- If carried out in a simulator an all-engines-operating go-around procedure is to be practiced at least once annually
- That the intended go-around procedure was briefed prior to every approach to land regardless of whether it was an instrument approach or not
As a result of the study undertaken and target areas implemented by SGS, we were able to further mitigate the risks associated with operations in bad weather environments for clients who utilize the services of operators we audit.
Hopefully the added focus on correct procedures practiced regularly will avoid accidents that we will never have to read about, such as the news excerpts following:
“The probable cause of this accident was the sudden change of weather condition and the flight crew's failure to properly execute the published instrument approach, including the published missed approach procedure, which resulted in the aircraft impacting the terrain.”
“According to the operators Flight Operations Manual, the captain should have called for a go-around well before this point in the approach instead of trying to salvage the landing. For example, the operators stabilized approach criteria require an immediate go-around if the airplane flaps are not in the final landing configuration by 1,000 feet above the ground. In this case, the flaps were not correctly set until the airplane was 500 feet above the ground. The continued landing resulted in the aircraft being damaged beyond repair”
It is a fact that aviation accidents continue to occur; our role at SGS is to ensure that our client’s exposure to these events is negated or limited as far as is reasonably possible. The trending of non-conformances is just one tool in our safety tool box.
For more information, please contact:
Global Head of Aviation
t: +61 3 9347 5444
SGS is the world’s leading inspection, verification, testing and certification company. SGS is recognized as the global benchmark for quality and integrity. With more than 85,000 employees, SGS operates a network of over 1,800 offices and laboratories around the world.