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Follow-up Action on Occurrence Report
ACCIDENT TO BOEING B757-200, TF-ARE, AT MANCHESTER AIRPORT ON 11 JUNE 2005
(CABIN CREW MEMBER INJURED WHILST CLOSING AIRCRAFT DOOR)
CAA FACTOR NUMBER : F19/2006
FACTOR PUBLICATION DATE : 10 May 2006
OPERATOR : Excel Airways
CAA OCCURRENCE NUMBER : 2005/04509
AAIB REPORT : Bulletin 4/2006
SYNOPSIS
(From AAIB Report)
Whilst closing the R4 door prior to departure, a cabin crew member trapped her left forearm between the door
assist handle and aircraft bulkhead, causing her wrist to fracture in three places.
Last updated: 10 May 2006
lessons
Safety II
Proactive Lessons
Behaviours, cultures or
activities that, if left
unchecked, could result in a
safety incident or accident
CAA
• MORs - may or may not be
analysed and addressed
• Voluntary reporting
• Whistleblowing
CHIRP
AAIB
• Specific investigations
Normal Operations
(Errors, omissions, unsafe acts)
Reportable Incidents
Serious
Accidents/Incidents
Fatal
Accidents
1
10
30
600
CHIRP’s Mandate & Role
Overview
56
• History
• Commenced 1982, in current charitable form since 1996
• Founding member International Confidential Aviation Safety Systems (ICASS) group in 1990
• Focus
• Human Factors and confidential reporting
• Non-punitive, non-judgemental, Just Culture
• Funding
• By CAA but fully autonomous charitable trust independent & external to regulator
• No statutory authority
• Voluntary reporting
• Regulator / industry conscience
• Panels of peers (Advisory Boards) with rigour & credibility as experts in own right
• Flight/Cabin
Last updated: 13 March 2023
B - - (M) (O) One required cabin attendant seat may be
inoperative provided:
(a) The inoperative seat is not occupied,
(b) The cabin crew member displaced by the
inoperative seat occupies the passenger
aisle seat nearest to the inoperative crew
seat,
(c) Alternate procedures are established and
approved for the displaced cabin crew
member,
(d) Folding type seat is stowed or secured in
the retracted position,
(cont..)
Last updated: 23 July 2004
It may be found in the future that
EASA has a different interpretation and so the CAA’s position may
change following discussion and agreement with the Agency and the
other National Aviation Authorities.
3
• Background for the Management of Fatigue risk
• Requirements under ORO.FTL.110
• Demonstrable Actions to meet Requirements
ORO.FTL.110
Operator Responsibilities
4
ICAO Regulations
Flight Time, Flight Duty Time and
Rest Periods
NOW
Fatigue Management
5
Safety Management System
• Fatigue is a hazard
• EASA has stated “Safety Management Systems (SMS)
should manage all risks, including the risk of Flight and
Cabin Crew being fatigued.”
6
Background for the Management of
Fatigue Risk
The Responsibility for Management of Fatigue Risk
Regulations place responsibilities for avoidance of fatigue on
both operators and crew members.
Last updated: 29 October 2021
• Crew Behaviour: consisting of the number and role of cabin crew, level of assertiveness
displayed by the crew at exits and the exit ready times
Last updated: 15 April 2005
Having liaised with the cabin crew, and made an announcement to reassure the
passengers, the commander taxied the aircraft slowly back on to the stand whence it had just departed.
Last updated: 12 February 2004
(f) If the aircraft is subject to direct view
requirements, direct view of the passenger
cabin by the cabin crew must not be impaired.
Last updated: 12 March 2004
ORO.AOC.120(a): Provision of initial
cabin crew training courses.
Last updated: 23 February 2022
Duty extensions due to in-flight rest
a) Consistent in-flight relief planning
b) Augmented flight/cabin crew when applicable
(to be defined)
c) Minimum rest period onboard requirement
d) Extension of FDP dependent on type of onboard rest,
facilities and number of additional crew carried
e) Use of depart window to optimise crew alertness
during critical phases of flight
f) Requirement of prior notification of crew position for
optimal rest planning (operating or relief crew)
g) Limit the number of sectors
h) Augmented Cabin Crew
i) Minimum rest at destination
6.1
All relevant
operations
Flight sectors beyond
maximum FDP
j) Minimum rest at home base following extended FDP
7.
Last updated: 08 November 2021
Follow-up Action on Occurrence Report
ACCIDENT TO BAE 146-200, G-JEAX, NEAR BIRMINGHAM AIRPORT ON 12 DECEMBER 2002
(RAPID PITCH UP IN CLIMB INJURED TWO CABIN CREW MEMBERS)
CAA FACTOR NUMBER : F11/2004
FACTOR PUBLICATION DATE : 16 March 2004
OPERATOR : flybe
CAA OCCURRENCE NUMBER : 2002/08911
AAIB REPORT : Bulletin 2/2004
SYNOPSIS
(From AAIB Report)
The aircraft was carrying out a scheduled passenger flight from Birmingham to Belfast City.
Last updated: 16 March 2004
