• This SAFER webpage is where the progress on Safety Recommendations (SRs) assigned to the CAA by the Air Accidents Investigation Branch (AAIB), the UK Airprox Board (UKAB) and other State Accident Investigation Authorities can be found.  

    To continuously learn and improve, we have reviewed how we deal with all aspects of our Safety Recommendation Management. As well as responding to SRs and acting where appropriate, our responses are independently evaluated and the through life management of the activity is now recorded and reported on centrally, providing assurance that we deliver on our commitments. Taking this one step further, we will analyse our responses and actions using bowtie methodology, ensuring that safety interventions are reflected in the bowtie Controls and that the bowties remain current. 


  • Accident G-SPAO

    G-SPAO - EC135 T2+ (Glasgow)

    AAIB Report: Aircraft Accident Report AAR 3/2015 - G-SPAO, 29 November 2013

    CAA Status Closed

  • This update covers all three Recommendations 

    The AAIB Safety Recommendations 2015-032 and 033 recommended that the CAA require certain helicopters operating under a Police Air operator Certificate to be fitted with flight recorders including cockpit image recorders (airborne image recorder (AIR)).  Additionally, SR 2015-034 recommended that the CAA consider requiring State aircraft not already covered by SR 2015-032 and 033 to be fitted with flight recorders, including cockpit image recorders.  

    The CAA conducted a focused consultation in 2016 with Police and SAR operators considering the various options for all the SRs and determined the way forward cognisant also of the feedback from industry. In response to SR 2015-034 specifically, it was decided not to pursue changes to State aeroplane equipment requirements but that it would be appropriate to align the requirements and meet the safety intent of the SRs for all State helicopters. The State SAR helicopters under contract with the UK Maritime Coastguard Agency (MCA) were already required to be equipped with FDR/CVR and therefore the alignment was limited to the fitment of airborne image recorders.

    To implement the necessary requirements, the CAA issued Safety Directive 2016-006 detailing the type and level of equipment to be fitted to current and future helicopters operating as State aircraft.  CAA Specification 23 was also introduced to provide detailed information on the technical requirements for the equipment and fitting.  However, due to some difficulties experienced by the operators in procuring and fitting the equipment, the compliance dates had to be extended and SD 2018-002, now superseded by 2020-001, were issued.  The operators are now meeting the following equipment requirements mandated by the SD:

    1. Helicopters with an individual Certificate of Airworthiness first issued before 1 January 2019 shall from 1 August 2021. 

    (a) for those with a maximum take-off mass (MTOM) of more than 2,730 kg but not more than 3,175 kg, be fitted with a Class A airborne image recording system (AIRS) except those which have a Class C AIRS; or 

    (b) for those with a MTOM more than 3,175 kg, be fitted with a Class A airborne image recorder (AIR). 

    2. Helicopters with an individual Certificate of Airworthiness first issued on or after 1 January 2019 shall: 

    (a) for those with a MTOM of more than 2,730 kg but not more than 3,175 kg, be fitted with a Class A AIRS; or 

    (b) for those with a MTOM more than 3,175 kg, be fitted with a Class A AIR.

    The CAA will incorporate these requirements into amendment of the scales of equipment for such operations in the Air Navigation Order at the next suitable opportunity.  Once done, this will provide for the SD to be revoked. 

     

    Recommendation text

    It is recommended that the Civil Aviation Authority requires all helicopters operating under a Police Air Operators Certificate, and first issued with an individual Certificate of airworthiness before 1 January 2018, to be equipped with a recording capability that captures data, audio and images in crash-survivable memory. They should, as far as reasonably practicable, record at least the parameters specified in The Air Navigation Order, Schedule 4, Scale SS(1) or SS(3) as appropriate. They should be capable of recording at least the last two hours of (a) communications by the crew, including Police Observers carried in support of the helicopter's operation, and (b) images of the cockpit environment. The image recordings should have sufficient coverage, quality and frame rate characteristics to include actions by the crew, control selections and instrument displays that are not captured by the data recorder. The audio and image recorders should be capable of operating for at least 10 minutes after the loss of the normal electrical supply.

    Recommendation response

    The CAA accepts this recommendation and, subject to an impact assessment and liaison with the police operators, will require all helicopters operating under a Police Air Operators Certificate with a maximum take-off mass (MTOM) of more than 2,730 kg and first issued with an individual Certificate of Airworthiness before 1 January 2018, to be equipped with a recording capability that captures data, audio and flight deck images in crash-survivable memory. In order to put any change into effect, the CAA will need to amend General Exemption E4111 for the fitment of recorders to helicopters with a MTOM between 2,730 and 3,175 kg and the requirements for police helicopters with a MTOM greater than 3,175 kg. The CAA will work with the affected operators to agree a means of compliance for individual types in line with ICAO standards and recommended practices and ensure that appropriate protection provisions are afforded for image recordings. The CAA will also review, and amend as necessary, associated CAPs and CAA Specifications, for flight recorders. Introduction of amended requirements is expected to be completed by 3rd Quarter 2016.

    Update due

    August 2021

    CAA status

    Open - Tracked Actions

    Recommendation text

    It is recommended that the Civil Aviation Authority requires all helicopters operating under a Police Air Operators Certificate, and first issued with an individual Certificate of Airworthiness on or after 1 January 2018, to be fitted with flight recorders that record data, audio and images in crash-survivable memory. These should record at least the parameters specified in The Air Navigation Order, Schedule 4, Scale SS(1) or SS(3), as appropriate. They should be capable of recording at least the last two hours of (a) communications by the crew, including Police Observers carried in support of the helicopter's operation, and (b) cockpit image recordings. The image recordings should have sufficient coverage, quality and frame rate characteristics to include control selections and instrument displays that are not captured by the other data recorders. The audio and image recorders should be capable of operating for at least 10 minutes after the loss of the normal electrical supply.

    Recommendation response

    The CAA accepts this recommendation and, subject to an impact assessment and liaison with the police operators, will require all helicopters operating under a Police Air Operators Certificate and first issued with an individual Certificate of Airworthiness on or after 1 January 2018, to be equipped with a recording capability that captures data, audio and images in crash-survivable memory. To achieve this in the suggested timescale, the CAA will consider making a Direction to that effect but will also, as part of a wider review of the Air Navigation Order (ANO), prepare amendments to the flight recorder requirements that align with ICAO standards and recommended practices and European standards including the appropriate protection provisions for image recordings. The CAA would anticipate this change being addressed within the planned 2016 ANO amendment cycle.

    Update due

    January 2021

    CAA status

    Open - Tracked Actions

    Recommendation text

    It is recommended that the Civil Aviation Authority considers applying the requirements of AAIB Safety Recommendation 2015‑032 and AAIB Safety Recommendation 2015-033 to State aircraft not already covered by these Safety Recommendations.

    Recommendation response

    The CAA accepts this recommendation and will consider whether the requirements of AAIB Safety Recommendation 2015-032 and AAIB Safety Recommendation 2015-033 should be applied to civil registered State aircraft not already covered by these Safety Recommendations and in particular the suitability of the introduction and/or retrofitting of image recorders. Due to their size, all current civil Search and Rescue helicopters are fitted with flight data recorders and cockpit voice recorders. The CAA anticipates determination of this issue by 3rd Quarter 2016.

    Update due

    August 2021

    CAA status

    Open - Tracked Actions


  • Accident N264DB

    N264DB - Piper PA-46-310P Malibu (nr Guernsey)

    AAIB Report: Piper PA-46-310P Malibu, N264DB, 21st January 2019

  • Recommendation text

    It is recommended that the Civil Aviation Authority ensure that the system in place to meet the requirements of EASA Part ARA.GEN.220 is effective in maintaining accurate and up-to-date records related to personnel licences, certificates and ratings.

    Recommendation response

    The Civil Aviation Authority accepts this Recommendation. A review of the current system is underway for ensuring licence records held by the Authority are updated following any changes related to personal licences, certificates and ratings to ensure the requirements of EASA Part ARA GEN.220 are met. We intend to complete this review by October 2020 with recommendations implemented by January 2021. Please note that this timeline may be affected by operational changes required as a result of COVID19 contingency plans.

    In addition, the CAA has and continues to remind examiners of their responsibility to submit the required examination documentation to the Authority within 14 working days from the skill test, proficiency check or assessment of competence.

    Recommendation update: 12/07/2021

    The CAA has reviewed its processes for maintaining and updating records related to personnel licences, certificates and ratings. CAA are recruiting additional resources to maintain accurate and up to date individual records. The additional measure of assessing these documents will continue to ensure we always give the correct information. We believe this addresses the intent of the recommendation. 

    The “Aviation Licensing Discovery” activity will still be planned for a later date and should provide a more enhanced solution for personnel licensing. The CAA are currently focused on improving the quality of existing application forms by moving more forms from paper to online.

    Update due

    TBC

    CAA status

    Open - Awaiting Confirmation 

     

    Recommendation text

    It is recommended that the Civil Aviation Authority require piston engine aircraft which may have a risk of carbon monoxide poisoning to have a CO detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide.

    Recommendation response

    "The Civil Aviation Authority does not currently accept this Recommendation, however we will revisit this position at the conclusion of our operational trial of carbon monoxide detectors.

    We are considering what barriers in addition to good design and maintenance practice will be both effective in further minimising the likelihood of critical CO contamination in the UK GA fleet, whilst acknowledging that any such additional measures should be both practical and proportionate. 

    On 3 March 2020, we published a Safety Notice, CAA SN 2020/003, which highlights the potential benefits of carrying low cost available commercial/domestic active detectors, as well as conventionally installed, approved aviation units.  We will further advertise this Safety Notice through communication to all pilots when the current restrictions on recreational flying due to COVID-19 are lifted, to reduce the risk of this announcement being overlooked. Importantly, the Safety Notice includes reference to a CAA-sponsored carriage trial of low-cost, widely available units which we see as facilitating informed decisions in the future regarding recommending (or possibly mandating) specific categories of devices. This trial  will establish if there are any negative safety implications (such as loose article hazard or distraction) associated with the carriage of carbon monoxide detectors. However, given the implications of COVID-19 on the 2020 flying season and stakeholder events, the timing for this trial is currently under review.

    Recommendation update: 12/07/2021

    The CAA recognises the risk identified by the AAIB and is therefore conducting an operational trial of active CO detectors. The CAA will use the trial to assess the safety and practical implications of carrying active CO detectors onboard general aviation aircraft and expects to publish a report on the outcomes and findings of the trial in February 2022. The trial was originally scheduled to start in December 2020 but was delayed due to restrictions from COVID-19.

    In the meantime, the CAA is taking the following steps:  
    SN-2020/003 has been updated (published April 30th 2021) to reflect the latest status of the CO detector trial and to reference the specific CO concentration check included in the Minimum Inspection Programme of    UK Reg (EU) No 1321/2014 Annex Vb (Part-ML). 
    A Safety Sense Leaflet dedicated to carbon monoxide detection and prevention is being developed and will be published after the trial concludes to reflect the latest information and recommended practices. A further update will be provided when the trial report is published.

    Update due

    December 2021

    CAA status

    Open - Tracked Actions

  • Recommendation text

    Improve the working processes to assess operational risks of newly declared EASA Part-SPO operators, and to verify continued compliance with the applicable requirements in accordance with EASA Air OPS ARO.GEN.300 Oversight (a)(2).

    Recommendation response

    The UK CAA accepts this recommendation. The UK CAA will carry out a full review of the SPO oversight process, procedures and policy and will carry out a review of SPO accountabilities (across multiple teams). The date set to accomplish both reviews is set for 31 December 2020. Following the outcome of the aforementioned reviews, the UK CAA will implement changes to; accountabilities, process, procedures and policy with the aim of Improving the working processes to assess operational risks of newly declared EASA PartSPO operators, and to verify continued compliance with the applicable requirements in accordance with EASA Air OPS ARO.GEN.300 Oversight (a)(2). The date set to implement the changes is set for 30 April 2021.

    Response update: 24/06/21

    The UK CAA carried out a full review of the SPO oversight process, procedures and policy and a review of SPO accountabilities (across multiple teams). The date set to accomplish both reviews was set for 31 December 2020. Following the outcome of the aforementioned reviews, the UK CAA will implement changes to; accountabilities, process, procedures and policy with the aim of improving the working processes to assess operational risks of newly declared EASA Part-SPO operators. The improvements to compliance with the applicable requirements will be embedded within the new processes ensuring a more risk-based approach to SPO and better clarity on continued oversight requirements.  

    The original date set to implement the changes was set for 30 April 2021, we are now sequencing this activity alongside overseeing industry restart as Covid-19 restrictions ease in the UK, so the changes will now be implemented by 31 July 2021.

    Update due

    August 2021

    CAA status

    Open - Tracked Actions

    Recommendation text

    Conduct a baseline assessment of the operational risks, and a thorough compliance and safety audit of FCSL's safety management system, flight operations, pilot training, weight and balance procedures, and documented procedures for calibration flights.

    Recommendation response

    The UK CAA accepts this recommendation. The scope of the next Part-SPO audit conducted by the UK CAA, which it is anticipated will be completed by the 30 September 2020, will focus on a baseline assessment and a thorough compliance and safety audit of FCSL's Safety Management System, flight operations, pilot training, weight and balance procedures, and documented procedures for calibration flights.

    Response update: 28/10/20

    The CAA completed an on-site audit at Shoreham Airport with Flight Calibration Services Limited on 8th August 2020, producing a baseline assessment of the operator. Conducting a compliance audit of the operator's SPO operations focusing on the Safety Management System, flight operations, pilot training, weight and balance procedures, and a review of the documented procedures for calibration flights.

    A satisfactory review of previous inspection reports was also carried out, verifying evidence and supporting documentation of any remedial actions.

    The CAA conducted a review in conjunction with the requirements set out in (EU)965/2012. Specifically, a review of the requirements for operational oversight as detailed in Part-ARO and those requirements set out in Part-ORO and Part-SPO.

    As a result of the above audit activity the CAA is satisfied that the Safety Management System, Training, Operations and associated procedures meet the requirements of FSCL's operation. 

    Response update: 24/06/21

    The CAA completed an on-site audit at Shoreham Airport with Flight Calibration Services Limited on 8th August 2020, producing a baseline assessment of the operator. Conducting a compliance audit of the operator's SPO operations focusing on the Safety Management System, flight operations, pilot training, weight and balance procedures, and a review of the documented procedures for calibration flights.

    A satisfactory review of previous inspection reports was also carried out, verifying evidence and supporting documentation of any remedial actions.

    The CAA conducted a review in conjunction with the requirements set out in (EU)965/2012. Specifically, a review of the requirements for operational oversight as detailed in Part-ARO and those requirements set out in Part-ORO and Part-SPO.

    As a result of the above audit activity the CAA is satisfied that the Safety Management System, Training, Operations and associated procedures meet the requirements of FSCL's operation.  

    CAA status

    Closed


  • Serious Incident G-SAJK/G-CDMH

    EMB-145EP - G-SAJK and Cessna P120N - G-CDMH 02-20 (London Southend)

    AAIB investigation to EMB-145EP, G-SAJK and Cessna P210N, G-CDMH 

    CAA Status Closed

  • The General Aviation Unit within the CAA have created a communications campaign on the risk and mitigation actions surrounding the Southend serious incident and made a clear call to action to pilots to consider painting their tow bars in bright colours.

    Firstly, the AAIB report was highlighted to the community via Skywise with a request for pilots to consider painting their tow bars in bright colours. This was followed by a call on social media for pilots to show and tell the CAA what colour they had painted their own tow bars and to encourage those that haven't, to follow suit. An article was written about the Southend incident and shared via Skywise, highlighting the factors that led to the event; lack of visibility of the tow bar and inadequate checks due to distraction. Again, a call to action was made to pilots to paint their tow bars in highly visible colours and for them to consider if they are fit to fly. On behalf of the CAA, GASCo have also contributed to the campaign with a slide on external checks as part of covering the incident within their March and April 2021 safety webinars. Once these presentations have commenced the CAA hope to have further reduced the risk of this incident re-occurring and will have fulfilled the above recommendation. 

    Recommendation text

    It is recommended that the Civil Aviation Authority communicate to the general aviation community the importance of increasing the visibility of ground equipment.

    Recommendation response

    The CAA accepts this Recommendation. The CAA is working with the General Aviation Safety Council (GASCo) to highlight the need for thorough pre-flight external checks and will include this as part of the GASCo Safety Campaign for 2020. The CAA will require GASCo to highlight this incident at their Winter 2020/2021 GA Safety Evenings and recommend that pilots/owners enhance the visibility of their tow bars.

    Update due

    May 2021

    CAA status

    Open - Tracked Actions


  • Airprox C152/AA5

    Cessna 152 & Grumman AA5 (nr Tatenhill)

    AIRPROX REPORT No 2019071

    CAA Status – Closed

  • In accordance with our initial response dated 02 Mar 2020 the following changes to chapter 4 of the Manual of Radiotelephony (CAP 413), have now been actioned and are contained within Edition 23 AL1 (Published 26 November 2020) of the manual:

    • Page 1 subtitle 'Aerodrome Control Service Phraseology' to move to page 5.
    • Paras 4.6/4.7 to be moved to Chap 4 Introduction.
    • Designated Positions in the Traffic Circuit and Standard Overhead Join Procedure content to follow the Introduction and be applicable to ATC, AFIS and AGCS alike.  New header to indicate applicability.
    • The requirement in both cases for aircraft to report base leg is to be enhanced to read 'if required by ATS provider or aerodrome operator'.  It may not be universally applicable; the decision can be made at local level to satisfy local requirements.

    In addition, we have reviewed the Skyway Code pages relevant to circuit radio procedures and they appear correct, but we are making some minor changes such that the relevant diagram in the code more closely aligns with the diagram at 4.4 in CAP413. With the update planned to be released in the first quarter of 2021. 

    Recommendation text

    The CAA review R/T Procedures at non-ATS aerodromes.

    Recommendation response

    We note that radiotelephony procedures at the subject aerodrome did not in themselves appear to have been a contributory factor to the occurrence, and we are unaware of other instances of aircraft operating at AGCS aerodromes experiencing losses of situational awareness as a result of incomplete or inaccurate circuit position or standard overhead join reporting calls by other pilots.

    Response update: 26/11/20 

    In accordance with our initial response dated 02 Mar 2020 the following changes to chapter 4 of the Manual of Radiotelephony (CAP 413), have now been actioned and are contained within Edition 23 AL1 (Published 26 November 2020) of the manual:

    • Page 1 subtitle 'Aerodrome Control Service Phraseology' to move to page 5.
    • Paras 4.6/4.7 to be moved to Chap 4 Introduction.
    • Designated Positions in the Traffic Circuit and Standard Overhead Join Procedure content to follow the Introduction and be applicable to ATC, AFIS and AGCS alike.  New header to indicate applicability.
    • The requirement in both cases for aircraft to report base leg is to be enhanced to read 'if required by ATS provider or aerodrome operator'. It may not be universally applicable, the decision can be made at local level to satisfy local requirements.

    We have reviewed CAP 413 (Radiotelephony Manual) Chapter 4 Aerodrome Phraseology but do not believe there is a case for introducing a requirement for pilots to report at all designated positions in the aerodrome traffic circuit. However, the review has highlighted the need for some structural changes to Chapter 4, and the following will be considered:

    • Page 1 subtitle 'Aerodrome Control Service Phraseology' to move to page 5.
    • Paras 4.6 and 4.7 to be moved to Chapter 4 Introduction.
    • 'Designated Positions in the Traffic Circuit' and 'Standard Overhead Join Procedure' content to follow the Introduction and be applicable to ATC, AFIS and AGCS alike.  
    • New header to indicate applicability.
    • Requirement in both cases for aircraft to report base leg to be enhanced to read 'if required by ATS provider or aerodrome operator'.  It may not be universally applicable - the decision can be made at local level to satisfy local requirements.

    The changes would be undertaken as part of a routine amendment on a date yet to be determined.

    Update due

    April 2021

    CAA status

    Open - Tracked Actions


  • Airprox RV12/P68

    Vans RV12 & Partenavia P68 B (nr Chatteris)

    AIRPROX REPORT No 2019201

  • Recommendation text

    The CAA to consider mandating additional cockpit crew to enable enhanced lookout for single-pilot survey operations.

    Recommendation response

    Whilst the CAA recognises the desired safety outcome, there are significant barriers to the CAA accepting this in its current form. The recommendation does not recognise where the ownership for this hazard of SPO operations and associated lookout risks lie. We must be clear about the respective roles of regulator and the regulated entity.
    It is the CAA's role to assure itself that risk is assessed, and the associated mitigating actions are robust. This assurance is conducted through an assessment of the operator's operations manual under which all flights should be conducted. ORO.GEN.110 sets out clearly the responsibilities of the Operator to ensure safe conduct of any flight and it is against this regulation that the test is applied.

    Managing an effective lookout in any aircraft is the responsibility of the pilot in command following guidance issued by the operators concerned and stipulated in the Operations Manual. The AMC of EASA part SPO states:
    SOPs should be based on a systematic risk assessment to ensure that the risks associated with the task are acceptable. The risk assessment should describe the activity in detail, identify the relevant hazards, analyse the causes and consequences of accidental events and establish methods to treat the associated risk.

    It is the operator's responsibility to conduct this assessment task and the risks presented may be different dependent on the nature of the operation and the geographical area.

    We recognise the unique hazard of the operations in question and therefore, in response to the recommendation, confirm that the CAA Partially Accepts this recommendation and will conduct a review of the risk assessments of survey operators, to ensure they meet the requirements of AMC SPO.OP.230(b) and are robust in addressing this risk.

    Response update: 19/01/2021

    In conjunction with a Safety Recommendation from the Accident Report into G-MDME which was operated by a Part SPO organisation, the CAA has conducted a review of the implementation of Regulation (EU) 965/2012 Part Specialised Operations (SPO).  The review also considered Aerial work through a Foreign Carrier Permit (FCP) against Article 252[1] of the Air Navigation Order and arrangements for Unmanned Air Systems (UAS) as detailed in CAP722A.

    The CAA will now consider the findings and recommendations of the review to determine the preferred option and the work needed to be undertaken to put any changes into effect.

    The CAA Flight Ops department conducted a review of operator's risk assessment with particular emphasis on MAC mitigations and single pilot operations through a Special Objective Check. 57 operators have declared that they conduct survey operations, and a review of their operational Safety Assessment and associated mitigations has started under the auspices of the CAA SPO working group. The Impact of the EU withdrawal and Covid alongside recovery activity means that it is likely the original planned completion for this work (end of March 2021) will be missed. We expect to be able to complete the activity by 30th June 2021, when we will be in a position to report on the adequacy of Survey Operators risk assessments. 

    Update due

    July 2021

    CAA status

    Open - Tracked Actions

     


  • Airprox S76/DCH6

    Sikorsky S76 & De Havilland DCH6 100 (nr Wisbech)

    AIRPROX REPORT No 2018185  

  • Recommendation text

    The CAA review current regulation concerning RLLCs.

    Recommendation response

    The CAA is still reviewing current RLLC regulations, particularly with reference to civilian pilot responsibility. The CAA have been engaged with the DfT, Royal Household and TQHF to provide improvement in this area since March this year. Due to several factors including BREXIT and additional requests from the Royal Household this has resulted in a lengthy process to ensure correct measures are taken moving forward. The CAA is committed to undertaking this review correctly and ensuring any future change, if agreed, is implemented appropriately and without any ambiguity.

    Update due

    October 2021

    CAA status

    Open - Tracked Actions




  • FOLLOW-UP ACTION ON OCCURRENCE REPORT - FACTORS
    CAA Responses to AAIB Safety Recommendations 

     

     FACTORS 2020
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