1、Safety Regulation Group CAP 594 Air Accidents Investigation Branch (AAIB) Recommendations: Progress Report 1991 CAA Responses to AAIB Recommendations received up to 31 May 1991, presented to the Secretary of State for Transport May I991 www.caa.co.uk Copyright Civil Aviation Authority Provided by IH
2、S under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Safety Regulation Group CAP 594 Air Accidents Investigation Branch (AAIB) Recommendations: Progress Report 1991 CAA Responses to AAIB Recommendations received up to 31 May 1991, presented to th
3、e Secretary of State for Transport May I991 Important Note The CAA has made many of the documents that it publishes available electronically (in addition to traditional printed format). The contents of this document are unchanged from the previously printed version. For consistency with other CAA do
4、cuments new cover pages have been added. Further information about these changes and the latest version of documents can be found at www.caa.co.uk. September 1991 Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without li
5、cense from IHS-,-,-CAP 594 Air Accidents Investigation Branch (AAIB) Recommendations: Progress Report 1991 O Civil Aviation Authority 1991 ISBN O 86039 487 5 ISSN 0964 - 61 59 First edition September 1991 Reprinted May 2002 (incorporating new house style cover) Enquiries regarding the content of thi
6、s publication should be addressed to: Safety Analysis Department, Safety Regulation Group, Civil Aviation Authority, Aviation House, Gatwick Airport South, West Sussex, RH6 OYR. The latest version of this document is available in electronic format at www.caa.co.uk, where you may also register for e-
7、mail notification of amendments. Printed copies and amendment services are available from: Documedia Solutions Ltd., 37 Windsor Street, Cheltenham, Glos., GL52 2DG. Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without
8、license from IHS-,-,-FOREWORD In the UK the Civil Aviation Authority (0 is responsible for civil air safety ie: the setting up and monitoring of standards, including the licensing of fiight crews, aircraft engineers, air traffic controllers and aerodromes and the certification of airlines and aircra
9、ft. The Air Accidents Investigation Branch (AKB), a branch of the Department of Transport, is responsible for the investigation of all civil aircraft accidents occurring in or over the UK The two functions, and associated responsibilities, of accident investigation and safety regulation are clearly
10、different and the two organisations are deliberately kept independent of each other. However, the evaluation of the findings of an accident investigation and the determination of the need for, and the initiation of, appropriate action to maintain and enhance safety is an important part of safety reg
11、ulation ie: the responsibility of the CAA Thus a good working relationship between the two organisations is essential, while in no way jeopardising the independence of the accident investigation. While day to day liaison is maintained between CAAand MB in the aftermath of any accident, the formal pr
12、ocedure by which MB identify and convey to the CAAmatters which they believe require Authority action, is by means of Safety Recommendations. Recommendations can be, and are, made at any stage as the AKB investigation progresses. CAA has in place formal procedures for the receipt and evaluation of s
13、uch Recommendations and initiation of necessary action. In its evaluation the Authority has to consider all the implications of the Recommendation and any action being proposed; it must also take into account the views of other Regulatory Authorities eg: the Authority responsible for the initial cer
14、tification of the Aircraft type. The Authority responds to the AKB as quickly as possible on all Recommendations as they arise; those of an urgent nature are acted upon immediately In the case of MB Investigations for which an Accident Investigation Report is published, all Recommendations made are
15、listed in the final report. In such cases the Authority publishes its response to all the Recommendations on the day the report is published. This is done by means of a FACTAX (Follow-up Action to Accident Reports). Responses to Recommendations arising from other AKB investigations have not previous
16、ly been published; but are now included in this Annual Report. Some Recommendations involve long term investigation or research; in order to determine appropriate action when this is so, the Authority response will indicate that the status of the Recommendation is “Open“ until all action by the Whas
17、 been completed. This is the second Annual Progress Report submitted to the Secretary of State for Transport. It contains details of all Recommendations received during 1990 and the action taken. It also contains details of current actions in respect of previous Recommendations which were listed as
18、“Open“ in the first Annual Progress Report. . lu Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo repro
19、duction or networking permitted without license from IHS-,-,-CONTENTS CAARESPOKEES TO MB RECOMMENDATIOKE 1 Introduction Page 1 1 2 Recommendations received 1 3 Summary of Acceptance and Closure 1 PART 1 - MB RECOMMENDATIOKE REMAINING OPEN FROM 1ST REPORT (1990) 3 PART 2 - MB RECOMMENDATIOKE RECEIVED
20、 DURING 1990 35 Index 79 V Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking
21、permitted without license from IHS-,-,-CAARECPONCES TO AAIB RECOMMENDATIONS 2ND REPORT (MAY 1991) 1 2 2.1 2.2 3 Introduction This is the second Report in response to the Secretary of State for Transports request to the Authority for Annual Reports on the status and progress on its responses to the R
22、ecommendations made to the Authority from the Air Accidents Investigation Branch. This Report covers all of those Recommendations which remained open from the first Report and these are dealt with in Part 1. All Recommendations received during 1990 are dealt with in Part 2. No differentiation has be
23、en made in this Report between those Recommendations made via a full Aircraft Accident Report and those made by letter. Please note that Serial 3B9 (in toto) and Serial 11B9 Rec 4.28 in Part 1 were omitted from the first Report due to an oversight. Recommendations Received Recommendations Outstandin
24、g from First Report Of the 44 Recommendations that remained open from the first Report, 18 have now been closed and 26 remain open requiring further Authority action. Where amendments have been made they are sidelined. Recommendations Received During 1990 A total of 87 Recommendations were received
25、during 1990, either by formal AAR or by letter. Of the 87 Recommendations 48 have been closed and 39 remain open. Summary of Acceptance and Closure To ta 1 Pre 1990 364 1990 87* *NE3: Two to be advised. Recomrnenda tions Accepted Pa rtia lly o Y Open Closed Not Accepted 274 90 26 338 72 13 39 48 1 C
26、opyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-2 Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license
27、from IHS-,-,-PART 1 - AAIB RECOMMENDATIONS REMAINING OPEN FROM 1ST REPORT (1990) 1B9 ACCIDENT 13Aug81 WESSEX BACTON 81,02509 References: AAR 4B3 dated 23Aug83 FKTAR F4B4 dated 160ct84 RECOMMENDATION 4 The BCARs relating to helicopter main rotor behaviour following total power loss should be reviewed
28、. The review should consider the latest data on pilot response times, the practicability of requiring all helicopters to be fitted with a rotor speed decay warning system, and means by which rotor decay rates might be reduced. CAA Response The requirements applicable at the time of the certification
29、 of the Wssex 60 relevant to rotor speed decay warning systems have been reviewed and revised to reflect the necessity for such a system. The subject of pilot reaction times and rotor speed decay characteristics is being reconsidered, but this will be a long-term item. Status - April 1991 - Closed A
30、s indicated in the initial Response, the relevant requirements applicable at the time of the initial certification of the Wssex 60 in 1964 were reviewed and, in the context of the primary objective of this Recommendation, had been amended in 1980 to require that the crew be provided with adequate wa
31、rning when rotor speed approaches an unacceptably low level. With regard to the underlying objective of this Recommendation, to reduce the criticality of rotor speed decay characteristics in airworthiness terms, this has to be a long-term action as it impacts on the fundamental design of an helicopt
32、er. The CAA has in hand two research programmes, one to investigate pilot reaction times and one to investigate the practicality of rotor speed decay warning systems. When these two programmes have been completed, the CMwill review the results and initiate any necessary regulatory action. I 2B9 ACCI
33、DENT 12Aug81 BELL212 DUNLINALPHA 81,02469 I References: AAR 10B2 dated 28Jan83 FKTAR F1 B7 dated 02Jan87 RECOMMENDATION 4.12 The adequacy of the 1.5mhec vertical rate of descent component, required by the BCARs covering the strength of the emergency flotation equipment be reviewed. 3 Copyright Civil
34、 Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-CAA Response The 1.5mbec vertical rate of descent criterion is intended to ensure sufficient strength to cater for controlled landing on water and is considere
35、d adequate for this purpose. It is not practicable to require greater strength for emergency flotation equipment until requirements concerning crashworthiness are further developed. Status - April 1991 - Closed As indicated in the initial Response, the relevant BCAR has been reviewed and the 1.5mbec
36、 vertical rate of descent component is considered adequate to cater for a controlled landing on water. Arising from the review, it has been recognised that it may be possible to enhance overall postcrash survivability as a long-term action. To this end an extensive review of helicopter crashworthine
37、ss is being carried out at an international level. The review has identified that improvements can be made in individual occupant protection, prevention of postcrash fire and vehicle structural integrity Regulatory change for the first two of these is in hand. The subject of vehicle integrity is a b
38、alance between the energy absorption capabilities of the structure and the human tolerance to high short-term accelerations. International research into this activity is in hand and in particular the CAA is initiating a programme to study the response of helicopter structures to water impact. The ou
39、tcome of all this research will be reviewed and regulatory action initiated where necessary I 3B9 ACCIDENT 08Apr86 Ac 355 SWALCLIFFE,OXON 86,00990 I References: AAR 7B7 dated 16Dec87 FKTAR F78 dated 29Feb88 RECOMMENDATION 4.1 A review be conducted into the ability of the AS 355 F1 engine installatio
40、n to continue to operate in conditions of high humidity and at temperature of 0C plus or minus 5C. The review should also consider a mandatory requirement to fit automatic re-ignition or continuous ignition modifications to Allison 250420 series engines which are fitted to the AS 355 F1. CAA Respons
41、e The AS 355, as a type, is not approved for fiight in icing conditions, however, as part of its IMC Certification, the engines and their intakes demonstrated compliance with appropriate requirements for flight in these conditions. Nevertheless, the Authority has already completed a review of the su
42、sceptibility of engine air intakes to rainklushbce ingestion for all helicopter types operated in the UK. This review re-affirmed that the engine and intake of the AS 355 meets the appropriate airworthiness requirements; however, the type of intake could be more susceptible to extreme conditions of
43、rainklushbce ingestion because of its unheated inlet arrangement. On the basis of this review the French Airworthiness Authorities, in conjunction with the CA$ decided that the installation of an automatic relight system on Allison 250420 engines fitted to AS 355 F1 helicopters was necessary to 4 Co
44、pyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-provide additional protection when flying in conditions conducive to rainklushhce ingestion. To this end the revised French Airworthiness Directiv
45、e 86-153-31(B) Revision 41 accepted in toto by the CAA- has been issued to require the installation of an automatic engine relight system in the AS 355. Status - April 1991 - Closed RECOMMENDATION 4.2 Investigations into the feasibility of incorporating automatic collective pitch reduction mechanism
46、s following partial or total power loss should be urgently pursued. CAA Response The Authority accepts the Recommendation and will, therefore, give increased priority within its current investigation to the possible need for an automatic collective pitch reduction mechanism to operate in the event o
47、f a power loss. Such a system would most likely be of a similar concept to the stick-pusher on a fixed wing aircraft and thus will need to be designed and constructed to at least the same level of system integrity, so as to preclude any possibility of inadvertent operation. This type of system will
48、not be simple to design and develop as assurance will be needed that its installation does not reduce the airworthiness standard from that which originally prevailed. Status - April 1991 - Closed The outcome of the ongoing research into rotor speed decay characteristics (see Serial 1/89) will enable
49、 a decision to be made as to the need for automatic collective pitch reduction following total or partial power loss. If such a system is found to be necessary the research programme will be expanded to investigate ways in which this can be achieved, following which any necessary regulatory changes will be initiated. RECOMMENDATION4.3 Areview of those BCARc which deal w
