2022 Annual Safety Recommendations Review

Auslieferung an Kunden die Funktion des Gesamtsystems in voll konformer Installation über einen wesentlichen Zeitraum der angestrebten TBO ohne Antriebsausfall oder markantem mechanischen Defekt nachgewiesen wird. Reply No 1 sent on 13/10/2009: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. Reply No 2 sent on 05/12/2011: The Agency has initiated a rulemaking task RMT.0180 (former E.010) ‘Initial Maintenance Inspection’ to address this issue. The Agency will consider the Safety Recommendation as part of this rulemaking task. Reply No 3 sent on 28/04/2017: This Safety Recommendation will be considered within the framework of rulemaking task RMT.0180 ‘CS-E engine testing, 6 endurance/IMI/ETOPS’ which is included in the Agency’s rulemaking programme 2017- 2021 and planned to be launched in the first quarter of 2018 with the publication of its terms of reference. Reply No 4 sent on 31/07/2021: Paragraph (c)(5) of CS-E 25 ‘Instructions for Continued Airworthiness’ states: ‘Scheduling information for each part of the Engine that provides the recommended periods at which it should be cleaned, inspected, adjusted, tested and lubricated, and the degree of inspection, the applicable serviceability limits, and work recommended at these periods. Necessary cross references to the airworthiness limitations section must also be included. In addition, if appropriate, an inspection programme must be included that states the frequency of the inspections necessary to provide for the continued airworthiness of the Engine.’ However, paragraph (c)(5) of CS-E 25 and the related AMC do not provide any means to substantiate a time between overhaul (TBO). In practice, a project-specific certification review item (CRI) means of compliance (MoC) is agreed between EASA and applicants to define how a TBO may be substantiated. The substantiation is primarily based on the outcome of the 150-hour engine endurance test that is carried out in accordance with CS-E 440. EASA nevertheless accepts only a limited initial TBO based on this test (e.g. the credit that may be taken depends on whether the design of the engine is completely new or derives from an existing design). To substantiate TBO values higher than the commonly accepted initial TBO values, the CRI MoC may define additional means of substantiation that typically include an engine cyclic endurance test that is run on an engine representative of the type design, and using a cycle profile that is based on estimated aircraft flight profiles. Although the process above is conducted in a way to ensure a robust demonstration of the TBO and therefore complies with the intent of this safety recommendation, the absence of CS-E certification specifications (CSs) and acceptable means of compliance (AMC) for the substantiation of the TBO does not necessarily ensure a rigorous and harmonised demonstration by different applicants. Also, the above mentioned CRI process may be well known among established applicants, but potential new applicants may not be aware of EASA’s expectations. Recognising this situation and taking into account this safety recommendation, EASA decided to address this issue in the frame of EASA rulemaking task RMT.0180 for which the Terms of Reference Issue 1 were published on 7 May 2021 on the EASA Website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0180 A Notice of Proposed Amendment (NPA) will propose to amend CS-E to indicate how applicants should substantiate the TBO interval and the related maintenance programme. This proposal will be based on the established substantiation method used in the CRI process mentioned above. The publication of the NPA for public consultation is foreseen by 2022Q3 in the European Plan for Aviation Safety (EPAS) 2021-2025 (https://www.easa.europa.eu/document- library/general-publications/european-plan-aviation-safety-2021-2025). Status: Open 7 United States Registration Aircraft Type Location Date of event Event Type N106US AIRBUS A320 the Hudson River about 8,5 miles from La Guardia Airport, New York, USA 15/01/2009 Accident Synopsis of the event: On January 15, 2009, accident involving the ditching of US Airways flight 1549 on the Hudson River occurred about 8.5 miles from LaGuardia Airport, New York City, after an almost complete loss of thrust in both engines following an encounter with a flock of birds. The 150 passengers, including a lap-held child, and 5 crewmembers evacuated the airplane by the forward and overwing exits. One flight attendant and four passengers were seriously injured, and the airplane was substantially damaged. Safety Recommendation UNST-2010-091: The National Transportation Safety Board makes the following recommendations to the European Aviation Safety Agency: Require applicants for aircraft certification to demonstrate that their ditching parameters can be attained without engine power by pilots without the use of exceptional skill or strength. (A-10-091) Reply No 1 sent on 28/05/2010: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. Reply No 2 sent on 06/01/2012: Certification Specification (CS) 25.801 (c) requires that “The probable behaviour of the aeroplane in a water landing must be investigated by model tests or by comparison with aeroplanes of similar configuration for which the ditching characteristics are known”. The requirement does not specify whether this should be investigated in an engine power on or power off condition. EASA understands the “ditching parameters” are those parameters assumed at the point of impact for demonstration of compliance with CS 25.801 (c) (such as: descent rate, pitch attitude, forward velocity, etc.), and which are also used as inputs to define the ditching emergency procedure. EASA believes that the ditching parameters of in-service aircraft might be potentially difficult to attain in a power off condition, in addition such a demonstration was not required explicitly by the certification requirements nor routinely investigated by applicants. For new certification projects, EASA requires a demonstration that the ditching parameters can be attained by pilots without the use of exceptional skill, but not explicitly accounting for a power off condition. It is considered that the introduction of 8 the power off condition is a significant change in the means of compliance to the rule, with a potential impact on dimensioning load cases for the aircraft structure. However, it is recognised that the majority of actual ditching cases are power off events, therefore EASA accepts to review how this Safety Recommendation could be best addressed and the rulemaking task RMT.0453 'Ditching parameters without engine power' is added to the Rulemaking Programme inventory list. Reply No 3 sent on 15/03/2016: Certification Specification (CS) 25.801 (c) requires that “The probable behaviour of the aeroplane in a water landing must be investigated by model tests or by comparison with aeroplanes of similar configuration for which the ditching characteristics are known”. The requirement does not specify whether this should be investigated in an engine power on or power off condition. Therefore the Agency has planned rulemaking task RMT.0453 in the Rulemaking Programme 2016-2020 to investigate how this safety recommendation could be addressed in the CS-25 certification specifications. RMT.0453 will also consider the outcome from the ARAC Crashworthiness and Ditching Working Group which has been tasked to provide recommendations regarding the incorporation of airframe-level crashworthiness and ditching standards, which includes the topic subject to this safety recommendation (refer to FAA task notice in Federal Register / Vol. 80, No. 107 / Thursday, June 4, 2015). EASA is represented in this ARAC group, and the schedule of RMT.0453 will be adjusted taking into account the ARAC progress. Reply No 4 sent on 23/03/2021: Certification Specifications CS-25 amendment 24 was published on 13 January 2020 (Executive Director (ED) Decision 2020/001/R): https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020001r It introduces an amendment to CS 25.671 providing specifications applicable to large aeroplanes flight control systems. CS 25.671(d) requires the following: “The aeroplane must be designed so that, if all engines fail at any time of the flight: (…) (3) a flare to a landing, and a flare to a ditching can be achieved; (…) A new Acceptable Means of Compliance (AMC) 25.671 is also introduced that includes the following elements in Section 8. EVALUATION OF ALL-ENGINES-FAILED CONDITION — CS 25.671(d): “b. Procedures. (1) The aeroplane should be evaluated to determine that it is possible, without requiring exceptional piloting skill or strength, to maintain control following the failure of all engines and attain the parameters provided in the operational procedure of the aeroplane flight manual (AFM), taking into account the time necessary to activate any backup systems. The aeroplane should also remain controllable during restart of the most critical engine, whilst following the AFM recommended engine restart procedures. (…) (4) It should be possible to perform a flare to a safe landing and ditching attitude, in the most critical configuration, from a stabilised approach using the recommended approach speeds, pitch angles, and the appropriate AFM procedures, without requiring exceptional 9 piloting skills or strengths.” Status: Closed 10 United Kingdom Registration Aircraft Type Location Date of event Event Type 4X-BAU BOEING 757 London Gatwick Airport, United Kingdom 03/10/2000 Incident Synopsis of the event: After an uneventful flight from Ben Gurion Airport, Tel Aviv, the crew made an ILS approach to Runway 26 Left at London Gatwick Airport. The commander was 'pilot not flying' (PNF) in the right seat and another captain was the 'pilot flying' (PF) in the left seat. The landing was made with Flap 25 and Mode 2 autobrake selected in conditions of slight drizzle. The crew considered that a normal landing had been made, touching down at approximately 135 kt, just beyond the PAPIs and slightly left of the runway centre-line. Shortly after touchdown the commander stated that the autobrake had disconnected. The PF acknowledged and reselected Mode 2 on the autobrake. The PF had selected reverse thrust and both pilots considered that retardation was normal until 100 kt when some vibration was felt. Around this time an engineer working on an aircraft to the north of the runway heard what he described as two separate distinct "bangs", separated by some 5 to10 seconds. The PF continued to slow the aircraft and, on the instructions from ATC, cleared the runway at fast exit. On initial check-in with the ground controller, the PNF advised that they would be holding position as they suspected a "flat tyre". The crew had also noticed an indicated loss of some hydraulic fluid contents in both left and right systems. Safety Recommendation UNKG-2002-014: It is recommended that Airworthiness Authorities such as the JAA and FAA consider implementing the measures outlined in AAIB Safety Recommendations 99-11 and 99-12 concerning requirements for tyre pressure monitoring and warning systems. Reply No 1 sent on 13/09/2010: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. Reply No 2 sent on 18/12/2012: The Agency prepared a pre-Regulatory Impact Assessment (pre-RIA) proposing the creation of a rulemaking task that would require the installation of a tyre pressure monitoring system on large aeroplanes. The pre-RIA will be used to consult with our advisory bodies representing aviation authorities and industry. The Agency will make a decision to create a rulemaking task after this consultation. Reply No 3 sent on 07/07/2017: With the amendment 14 of CS-25 (effective on 20 December 2013, applicable to new certification projects of large aeroplanes), the Agency 11 introduced new certification specifications to upgrade the protection against the damaging effects of tyre and wheel failures. However, the Agency has initiated a new rulemaking task, RMT.0586, to propose a regulatory change to better ensure that the inflation pressures of tyres of large aeroplanes remain within the pressure specifications defined by the aeroplane manufacturer. The terms of reference and the rulemaking group composition were published on 30 May 2017 on the EASA Website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0586 Mandating the installation of a tyre pressure monitoring system is one of the elements to be considered among the objectives of RMT.0586. The next step of RMT.0586 is the publication of a Notice of Proposed Amendment (NPA) which is envisaged during 03Q2018. Reply No 4 sent on 22/06/2020: With amendment 14 of CS-25 (Certification specifications and acceptable means of compliance for large aeroplanes) (effective as of 20 December 2013, applicable to new certification projects of large aeroplanes), the European Union Aviation Safety Agency (EASA) introduced new certification specifications to upgrade protection against the damaging effects of tyre and wheel failures. After that, EASA initiated rulemaking task RMT.0586 to propose a regulatory change to better ensure that the inflation pressures of tyres of large aeroplanes remain within the pressure specifications defined by the aeroplane manufacturer. The terms of reference and the rulemaking group composition were published on 30 May 2017 on the EASA website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0586 This safety recommendation has been taken into account in this rulemaking task. Notice of Proposed Amendment (NPA) 2020-05 (‘Tyre pressure monitoring’) was published for consultation on 6 March 2020: https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2020-05 This NPA proposes to amend CS-25 to require applicants to provide a means to ensure that no tyre is below its minimum serviceable inflation pressure during operation. This can be achieved either by providing a task in the instructions for continued airworthiness (ICA) that requires operators to perform tyre pressure checks at a suitable time interval (i.e. daily or at another substantiated interval), or by installing a tyre pressure monitoring system that alerts the flight crew in the case of a tyre with an unsafe pressure. It also proposes to amend Annex I (Part-26) to Commission Regulation (EU) 2015/640) and CS-26 (Certification specifications and guidance material for additional airworthiness specifications for operations) to require the same objective to be implemented by operators of large aeroplanes, i.e. either by including in the aeroplane maintenance programme (AMP) tyre inflation pressure checks at a suitable time interval, or by installing a tyre pressure monitoring system. The related EASA Decision and Opinion are scheduled for Q1/2021. 12 Reply No 5 sent on 03/03/2021: With amendment 14 of the certification specification CS-25 (effective on 20 December 2013, applicable to new certification projects of large aeroplanes), the European Union Aviation Safety Agency (EASA) introduced new certification specifications to upgrade the protection against the damaging effects of tyre and wheel failures. After that, EASA initiated rulemaking task RMT.0586 to propose a regulatory change to better ensure that the inflation pressures of tyres of large aeroplanes remain within the pressure specifications defined by the aeroplane manufacturer. The terms of reference and the rulemaking group composition were published on 30 May 2017 on the EASA website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0586 This safety recommendation has been taken into account in this rulemaking task. Notice of Proposed Amendment (NPA) 2020-05 (‘Tyre pressure monitoring’) was published for consultation on 6 March 2020: https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2020-05 Executive Director (ED) Decision 2020/024/R on amendment 26 of CS-25 was published on 22 December 2020. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020024r This therefore applies to the certification of new large aeroplane designs. A new objective based certification specification CS 25.733(f) has been created to require that the applicant provides a means to minimise the risk that a tyre is below its minimum serviceable inflation pressure during operation. The corresponding new acceptable means of compliance AMC 25.733(f) indicates how the applicant can demonstrate compliance. These new provisions are not prescriptive and do not universally mandate the installation of a system indicating the tyre inflation pressures in the cockpit. The applicant should use one, or a combination, of the following means: (a) Provide a task in the Instructions for Continued Airworthiness (ICA) that requires tyres inflation pressure checks to be performed at a suitable time interval, (b) Install a system that monitors the tyres inflation pressures and: (1) provides an alert to the flight crew, in compliance with CS 25.1322, whenever a tyre inflation pressure is below the minimum serviceable inflation pressure, or (2) allows the tyres inflation pressures to be checked prior to the dispatch of the aeroplane, and a tyre inflation pressure check task is included in the Aeroplane Flight Manual (AFM) pre-flight procedures. Concerning already certified large aeroplanes, EASA plans to issue an Opinion to the European Commission that intends to propose an amendment to Part-26 (Annex I) to Commission Regulation (EU) 2015/640 to require operators of large aeroplanes to minimise the risk that a tyre is below its minimum serviceable inflation pressure during operation. Certification specifications to comply with this requirement is also planned to be adopted by EASA in an amendment to CS-to26. Flexibility would be provided to the operators who may choose to include a task in the aeroplane maintenance programme (AMP) to perform tyre inflation pressure checks at a suitable time interval, and/or install a system that monitors the tyres inflation pressures. The Opinion is scheduled for publication during Q3 2021. Status: Open 13 Denmark Registration Aircraft Type Location Date of event Event Type OY-KFF BOMBARDIER CL600 2B19 Copenhagen Airport, Kastrup (EKCH), Runway 04R 09/10/2009 Incident Synopsis of the event: Following initial take-off from Runway 04R, the pilots noticed a flock of birds in the beam of the aircraft's searchlights. Immediately thereafter, at an altitude of 256 ft, the aircraft was hit by birds, which resulted in powerful vibrations in the aircraft. The vibrations made it difficult for the pilots to read the engine instruments, but they were nevertheless able to read the level of vibrations in the right engine which were fluctuating around the maximum values. The pilots were not able to tell whether the left engine had been hit which is why, in the first instance, they were hesitant to stop the right engine. Since the vibrations in the right engine only partially ceased when the pilots pulled the throttle grip back, they decided to stop the engine. The left engine functioned normally throughout the flight. Safety Recommendation DENM-2010-003: It is recommended that the authorities evaluate possible technical solutions for the observation of and warning against migratory birds in darkness and in reduced visibility. This includes the option of installing and using radar equipment for this purpose. Reply No 1 sent on 13/09/2010: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. Reply No 2 sent on 22/03/2011: The Agency accepts that wildlife may be a risk to the safety of aircraft operation. The Agency will therefore evaluate the existing technical solutions for the observation of birds in darkness and in reduced visibility conditions, and will then consider the best course of action in the context of the Implementing Rules on aerodromes. Reply No 3 sent on 30/01/2012: The Notice of Proposed Amendment (NPA) 2011-20 (Authority, Organisation and Operations Requirements for Aerodromes) published on 13 December 2011 includes the operational requirements for wildlife management by the aerodrome operators (ADR-OPS.B.020, AMC—ADR-OPS.B.020, as well GM1—ADR- OPS.B.020 up to GM4—ADR-OPS.B.020). As far as the issue of technical equipment for wildlife monitoring in darkness and in reduced visibility is concerned, the Agency intends to address it through rulemaking task RMT.0161/0162 [requirements for systems, constituents and equipment used in air 14 traffic management (ATM)/air navigation services (ANS) and aerodromes (ADR)] of the Agency’s rulemaking programme 2012-2015. Reply No 4 sent on 20/06/2014: Commission Regulation (EU) No 139/2014 of February 2014 includes the operational requirements for wildlife hazard management by the aerodrome operators (ADR.OPS.B.020) and Annex to ED Decision 2014/012/R includes the necessary acceptable means of compliance (AMC) and guidance material (GM). As far as the issue of technical equipment for wildlife monitoring in darkness and in reduced visibility conditions, the Agency intends to address the issue through a dedicated rulemaking task. Reply No 5 sent on 16/01/2018: The Agency is considering this safety recommendation under RMT.0591 ‘Regular update of aerodrome rules‘, which is expected to be finalised by the end of 2019. In the meantime, EASA is planning to organise workshops related to wildlife strikes prevention, to raise awareness and address the issue. Reply No 6 sent on 10/06/2021: Commission Regulation (EU) No 139/2014 includes requirements on wildlife hazard management by aerodrome operators (ADR.OPS.B.020). The related Annex to Executive Director Decision (EDD) 2014/012/R provides the associated Acceptable Means of Compliance (AMC) and Guidance Material (GM). Effective implementation of these provisions should minimise the risk of collisions between wildlife and aircraft. The provisions focus on the establishment of means and procedures to limit the presence of wildlife at aerodromes and in their surroundings through a wildlife risk management process. This also includes monitoring the presence of wildlife but without specifying the use of certain equipment, thus providing flexibility for applying suitable technical solutions. The ‘avian’ radar and other technical solutions need to be evaluated on a case-by-case basis depending on the environmental conditions of the aerodrome, the local wildlife activity, and the type of operations at the aerodrome. According to ADR.AR.C.005, Competent Authorities are required to verify compliance by aerodrome operators with the applicable provisions on wildlife strike hazard reduction (ADR.OPS.B.020). When doing so, Competent Authorities must evaluate if appropriate means are provided by the aerodrome operator to ensure a robust wildlife hazard reduction. The installation of an ‘avian’ radar is one of the available means that may be considered by the aerodrome operator to support their risk management processes. Moreover, the bird strike safety issue is identified by the European Union Aviation Safety Agency (EASA) in the applicable safety risk portfolios. This is a systematic approach which is embedded in EASA’s safety risk management process. Through this process, EASA monitors, with input from stakeholders through the established collaborative analysis groups, the safety performance of all aviation domains and takes appropriate action where an additional need is identified. EASA has published Safety Information Bulletin (SIB) No 2020-07R1 on 17 July 2020 and revised SIB No 2020-07R2 on 27 January 2021 on ‘Progressive Restart of Aerodrome Operations after Complete or Partial Closure’. The SIB provides detailed guidelines for Competent Authorities and aerodrome operators on how to ensure the safety of operations at the aerodromes, also concerning wildlife hazard management, under the changing circumstances related to the COVID-19 pandemic. Detailed guidance is available under point 7 of the SIB, including a recommendation on an increase in the frequency of inspections for wildlife presence. The SIB can be accessed at: https://ad.easa.europa.eu/blob/EASA_SIB_2020_07_R2.pdf/SIB_2020-07R2_1 15 EASA has also shared information from aviation stakeholders on wildlife hazard management in the context of the COVID-19 pandemic (on 26 August 2020 and updated on 14 April 2021). This collaborative document produced under EASA’s ‘Together4Safety’ initiative includes guidance on wildlife detection and can be accessed at: https://www.easa.europa.eu/community/topics/wildlife-hazard-management Finally, it should also be considered that currently Annex 14, Volume I of the International Civil Aviation Organisation (ICAO) does not include a Standard or Recommended Practise (SARP) on technical solutions (including radar equipment) for the observation of and warning against migratory birds in darkness and in reduced visibility. In conclusion, EASA considers that the existing provisions under Commission Regulation (EU) No 139/2014 together with the above-mentioned actions taken by EASA to support the industry in the implementation of wildlife risk management processes should minimise the risk of collisions between wildlife and aircraft. It should be noted that the current regulatory framework does not preclude use of technical solutions for the observation of and warning against migratory birds in darkness and in reduced visibility if deemed appropriate. Status: Closed 16 United Kingdom Registration Aircraft Type Location Date of event Event Type G-CJCC CESSNA 680 London Luton Airport 30/09/2010 Serious incident Synopsis of the event: The crew experienced an uncommanded transfer of fuel from the right to the left fuel tank after following the checklist procedures for a left main electrical bus fault indication. The aircraft subsequently became left wing heavy and exceeded the lateral imbalance limits. It returned to Luton Airport where a flapless landing was completed without further incident. As a result of this incident, Special Bulletin S1/2010 was published on 8 October 2010, containing two Safety Recommendations. The investigation established that the isolation of the left main bus had caused a false fuel cross-feed command which resulted in the uncommanded fuel transfer. The aircraft manufacturer has published a temporary flight crew procedure to mitigate the effects of a recurrence and has also issued a service bulletin to incorporate a design solution. Safety Recommendation UNKG-2011-027: It is recommended that the European Aviation Safety Agency review their certification requirements, guidance and procedures to ensure that controlled documentation, sufficient to satisfy operator flight data recorder documentation requirements, are explicitly part of the type certification and supplemental type certification processes where flight data recorder installations are involved. Reply No 1 sent on 16/09/2011: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. Reply No 2 sent on 05/12/2011: Part 21 (Annex to Commission Regulation (EC) 1702/2003) and CS-25 (Certification Specifications for Large Aeroplanes) require the type certificate (TC) [or supplemental type certificate (STC)] holder to provide instructions for continued airworthiness and this is considered applicable to flight data recorders (FDR). Nevertheless the Agency accepts to review ways of improvement of the certification specifications to better indicate that the TC (or STC) holder has to provide the adequate documentation to the operator or owner of the aircraft, which should include: ?the necessary information to convert FDR raw data into engineering units, and ?FDR maintenance requirements. This subject will be treated as part of rulemaking task RMT.0268 (former MDM.068) dealing with revision of FDR and cockpit voice recorder (CVR) certification specifications. This task is currently part of the Agency's Rulemaking Programme inventory. 17 Reply No 3 sent on 06/02/2015: As a temporary measure, the Agency updated Safety Information Bulletin (SIB) 2009-28, Flight Data Recorder and Cockpit Voice Recorder Systems Serviceability (Revision 1, published on 08 January 2015). SIB 2009- 28 Revision 1 recommends that ‘the TC or STC Holder should provide the necessary information to convert FDR raw data into flight parameters expressed in engineering units.’ In addition, SIB 2009-28 Revision 1 recommends that National Aviation Authorities transmit to the Agency reports from aircraft operators of cases where a TC or STC holder fails to provide the information needed by an aircraft operator to comply with Commission Regulation (EU) No 965/2012. Annex IV to this Regulation requires in paragraph CAT.GEN.MPA.195 that the aircraft operator ‘keeps and maintains up-to-date documentation that presents the necessary information to convert FDR raw data into parameters expressed in engineering units.’ Furthermore, this safety recommendation is considered within the framework of EASA rulemaking task RMT.0249 entitled “Recorders installation and maintenance thereof - certification aspects”, whose Terms of Reference were published on 18 September 2014 on the EASA website. The general objective of this rulemaking task is to improve the availability and quality of data recorded by flight recorders in order to better support safety investigation authorities in the investigation of accidents and incidents. One of the specific objectives is “optimise data recovery and analysis process by adding provisions to clearly establish the (Supplemental) Type Certificate applicant’s obligation to provide the necessary information to convert FDR raw data into engineering units, as well as maintenance procedures”. Reply No 4 sent on 09/05/2018: This safety recommendation has been taken into account within the framework of EASA rulemaking task RMT.0249 entitled “Recorders installation and maintenance thereof - certification aspects”. The general objective of this rulemaking task is to improve the availability and quality of data recorded by flight recorders in order to better support safety investigation authorities in the investigation of accidents and incidents. One of the specific objectives is to optimise the data recovery and analysis process by adding provisions to clearly establish the (Supplemental) Type Certificate applicant’s obligation to provide the necessary information to convert Flight Data Recorder (FDR) raw data into engineering units as well as maintenance procedures. This topic is identified in the Terms of Reference Issue 2 of RMT.0249, under item 1.5 ‘Provisions for ensuring serviceability of flight recorders’: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0249-mdm051 It will be addressed in the second Notice of Proposed Amendments (NPA) of RMT.0249, currently planned to be published in Q2/2019. Reply No 5 sent on 18/12/2019: This safety recommendation has been taken into account within the framework of EASA rulemaking task RMT.0249. 18 The second Notice of Proposed Amendment (NPA) of this rulemaking task (NPA 2019-12) entitled ‘Installation and maintenance of recorders – certification aspects’ has been published for consultation on 13.11.2019. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2019-12 This NPA proposes to amend AMC 25.1459 (for large aeroplanes) and AMC 29.1459 (for large rotorcraft) to include FDR decoding documentation in the list of items to be included in the FDR Instructions for Continued Airworthiness. The objective is for FDR decoding documentation to be prepared for every new FDR system installation and updated for every change to an FDR system installation, and that this documentation should be made available to aircraft operators so that they can fulfil their responsibilities with regard to FDR decoding documentation and FDR serviceability. Guidance should also be provided on the content and format of the FDR decoding documentation. Reply No 6 sent on 03/03/2021: This safety recommendation has been taken into account within the framework of European Union Aviation Safety Agency (EASA) rulemaking task RMT.0249. The second Notice of Proposed Amendment (NPA) of this rulemaking task (NPA 2019-12) entitled ‘Installation and maintenance of recorders – certification aspects’ was published for consultation on 13 November 2019. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2019-12 This NPA proposed to amend the Acceptable Means of Compliance (AMC) 25.1459 (for large aeroplanes) and AMC 29.1459 (for large rotorcraft) to include Flight Data Recorder (FDR) decoding documentation in the list of items to be included in the FDR Instructions for Continued Airworthiness. The objective is for FDR decoding documentation to be prepared for every new FDR system installation and updated for every change to an FDR system installation, and that this documentation should be made available to aircraft operators so that they can fulfil their responsibilities with regard to FDR decoding documentation and FDR serviceability. Executive Director (ED) Decision 2020/024/R on amendment 26 of certification specification CS-25 was published on 22 December 2020. This amendment contains these new provisions in a new section 7 of AMC 25.1459 dedicated to FDR instructions for continued airworthiness. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020024r An equivalent ED Decision is planned to be issued in 2021 to amend CS-29 in a similar way. Reply No 7 sent on 19/08/2021: This safety recommendation has been taken into account within the framework of European Union Aviation Safety Agency (EASA) rulemaking task RMT.0249. 19 The second Notice of Proposed Amendment (NPA) of this rulemaking task (NPA 2019-12) entitled ‘Installation and maintenance of recorders – certification aspects’ was published for consultation on 13 November 2019. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2019-12 This NPA proposed to amend the Acceptable Means of Compliance (AMC) 25.1459 (for large aeroplanes) and AMC 29.1459 (for large rotorcraft) to include Flight Data Recorder (FDR) decoding documentation in the list of items to be included in the FDR Instructions for Continued Airworthiness. The objective is for FDR decoding documentation (document that presents the information necessary to retrieve the raw binary data of an FDR data file and convert it into engineering units and textual interpretations) to be prepared for every new FDR system installation and updated for every change to an FDR system installation, and that this documentation is made available to aircraft operators so that they can fulfil their responsibilities with regard to FDR decoding documentation and FDR serviceability. Executive Director (ED) Decision 2020/024/R on amendment 26 of Certification Specifications and Acceptable Means of Compliance for Large Aeroplanes (CS-25) was published on 22 December 2020. This amendment contains these new provisions in a new section 7 of AMC 25.1459 dedicated to FDR instructions for continued airworthiness. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020024r Executive Director (ED) Decision 2021/010/R on amendment 9 of Certification Specifications, Acceptable Means of Compliance and Guidance Material for Large Rotorcraft (CS-29) was published on 16 June 2021. This amendment contains these new provisions in a new section 4 of AMC 29.1459 dedicated to FDR instructions for continued airworthiness. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2021010r Status: Closed 20 United Kingdom Registration Aircraft Type Location Date of event Event Type G-CJCC CESSNA 680 London Luton Airport 30/09/2010 Serious incident Synopsis of the event: The crew experienced an uncommanded transfer of fuel from the right to the left fuel tank after following the checklist procedures for a left main electrical bus fault indication. The aircraft subsequently became left wing heavy and exceeded the lateral imbalance limits. It returned to Luton Airport where a flapless landing was completed without further incident. Safety Recommendation UNKG-2011-029: It is recommended that the European Aviation Safety Agency provides guidance detailing the standards for the flight data recorder documentation required for the certification of systems or system changes associated with flight data recorders. Reply No 1 sent on 16/09/2011: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. Reply No 2 sent on 05/12/2011: In response to Safety Recommendation UNKG- 2011-027 the Agency accepts to review ways of improvement of the certification specifications to better indicate that the type certificate (TC) [supplemental type certificate (STC)] holder has to provide the adequate flight data recorder (FDR) documentation to the operator or owner of the aircraft. This subject will be treated as part of rulemaking task RMT.0268 (former MDM.068) dealing with revision of FDR and cockpit voice recorder (CVR) certification specifications. In this framework, the Agency will also review the existing FDR documentation standards and will provide guidance in the certification specifications. Reply No 3 sent on 06/02/2015: The Agency accepted to improve the certification specifications to better indicate that the TC (or STC) holder has to provide adequate FDR documentation to the operator or owner of the aircraft. This subject is part of rulemaking task RMT.0249 entitled “Recorders installation and maintenance thereof - certification aspects”, whose Terms of Reference were published on 18 September 2014 on the EASA Website. In this framework, the Agency will also review the existing FDR documentation standards and will provide guidance in the Certification Specifications. A reference to this safety recommendation has been included in the Terms of Reference of RMT.0249. 21 Reply No 4 sent on 09/05/2018: This safety recommendation has been taken into account within the framework of EASA rulemaking task RMT.0249 entitled “Recorders installation and maintenance thereof - certification aspects”. The general objective of this rulemaking task is to improve the availability and quality of data recorded by flight recorders in order to better support safety investigation authorities in the investigation of accidents and incidents. One of the specific objectives is to optimise the data recovery and analysis process by adding provisions to clearly establish the (Supplemental) Type Certificate applicant’s obligation to provide the necessary information to convert Flight Data Recorder (FDR) raw data into engineering units as well as maintenance procedures. This topic is identified in the Terms of Reference Issue 2 of RMT.0249, under item 1.5 ‘Provisions for ensuring serviceability of flight recorders’: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0249-mdm051 It will be addressed in the second Notice of Proposed Amendment (NPA) of RMT.0249, currently planned to be published Q2/2019. In this frame, the Agency will also review the existing FDR documentation standards and will provide guidance in the certification specifications. Reply No 5 sent on 18/12/2019: This safety recommendation has been taken into account within the framework of EASA rulemaking task RMT.0249. The second Notice of Proposed Amendment (NPA) of this rulemaking task (NPA 2019-12) entitled ‘Installation and maintenance of recorders – certification aspects’ has been published for consultation on 13.11.2019. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2019-12 This NPA proposes to amend AMC 25.1459 (for large aeroplanes) and AMC 29.1459 (for large rotorcraft) to include FDR decoding documentation in the list of items to be included in the FDR Instructions for Continued Airworthiness. The objective is for FDR decoding documentation to be prepared for every new FDR system installation and updated for every change to an FDR system installation, and that this documentation should be made available to aircraft operators so that they can fulfil their responsibilities with regard to FDR decoding documentation and FDR serviceability. Guidance should also be provided on the content and format of the FDR decoding documentation. Reply No 6 sent on 03/03/2021: This safety recommendation has been taken into account within the framework of European Union Aviation Safety Agency (EASA) rulemaking task RMT.0249. The second Notice of Proposed Amendment (NPA) of this rulemaking task (NPA 2019-12) entitled ‘Installation and maintenance of recorders – certification aspects’ was published for consultation on 13. November 2019. 22 https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2019-12 This NPA proposed to amend Acceptable Means of Compliance (AMC) 25.1459 (for large aeroplanes) and AMC 29.1459 (for large rotorcraft) to include Flight Data Recorder (FDR) decoding documentation in the list of items to be included in the FDR Instructions for Continued Airworthiness. The objective is for FDR decoding documentation to be prepared for every new FDR system installation and updated for every change to an FDR system installation, and that this documentation should be made available to aircraft operators so that they can fulfil their responsibilities with regard to FDR decoding documentation and FDR serviceability. The proposal also included guidance regarding the content and the format of the FDR decoding documentation. Executive Director (ED) Decision 2020/024/R on amendment 26 of CS-25 was published on 22 December 2020. This amendment contains these new provisions in a new section 7 of AMC 25.1459 dedicated to FDR instructions for continued airworthiness. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020024r An equivalent ED Decision is planned to be issued in 2021 to amend CS-29 in a similar way. Reply No 7 sent on 19/08/2021: This safety recommendation has been taken into account within the framework of European Union Aviation Safety Agency (EASA) rulemaking task RMT.0249. The second Notice of Proposed Amendment (NPA) of this rulemaking task (NPA 2019-12) entitled ‘Installation and maintenance of recorders – certification aspects’ was published for consultation on 13. November 2019. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2019-12 This NPA proposed to amend Acceptable Means of Compliance (AMC) 25.1459 (for large aeroplanes) and AMC 29.1459 (for large rotorcraft) to include Flight Data Recorder (FDR) decoding documentation in the list of items to be included in the FDR Instructions for Continued Airworthiness. The objective is for FDR decoding documentation (document that presents the information necessary to retrieve the raw binary data of an FDR data file and convert it into engineering units and textual interpretations) to be prepared for every new FDR system installation and updated for every change to an FDR system installation. The proposal also included guidance regarding the content and the format of the FDR decoding documentation. Executive Director (ED) Decision 2020/024/R on amendment 26 of Certification Specifications and Acceptable Means of Compliance for Large Aeroplanes (CS-25) was published on 22 December 2020. This amendment contains these new provisions in a new section 7 of AMC 25.1459 dedicated to FDR instructions for continued airworthiness. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020024r Executive Director (ED) Decision 2021/010/R on amendment 9 of Certification Specifications, Acceptable Means of Compliance and Guidance Material for Large 23 Rotorcraft (CS-29) was published on 16 June 2021. This amendment contains these new provisions in a new section 4 of AMC 29.1459 dedicated to FDR instructions for continued airworthiness. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2021010r Status: Closed 24 Iceland Registration Aircraft Type Location Date of event Event Type TF-FIJ BOEING 757 SSE London Gatwick Airport 04/06/2009 Serious incident Synopsis of the event: Icelandair B757-200, TF-FIJ, departed Paris Charles de Gaulle airport (LFPG) France at 11:39 UTC (13:39 local time) on June 4th 2009 for its flight to Keflavik airport (BIKF) Iceland. Seventeen minutes into the flight the flight crew noticed white smoke entering the flight deck. The smoke intensified rapidly to such an extent that the flight crew could barely see their instruments. Shortly after, smoke also entered the whole cabin section and intensified rapidly. The commander noticed engine #1 surging and shut it down. Shortly thereafter the smoke started to decrease. The airplane diverted and made an emergency landing at London Gatwick airport (EGKK) United Kingdom. Safety Recommendation ICLD-2013-001: EASA and ICAO: Set guiding rule for airframe and engine manufacturers such that Maintenance Planning Document (MPD) and Engine Maintenance Manual (EMM) clearly include recommended maintenance information from subcomponent Component Maintenance Manuals (CMM). Reply No 1 sent on 10/07/2013: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. This reply gives the status within the 90 days period in compliance with Article 18 of Regulation (EU) No 996/2010. Reply No 2 sent on 13/08/2013: This safety recommendation will be submitted to the working group of EASA rulemaking task MDM.056 (RMT.0252) “Instructions for continued airworthiness”. This reply will be amended once the outcome of the working group discussion is available. Reply No 3 sent on 08/09/2016: This safety recommendation has been evaluated by the sub-group 1 of EASA rulemaking task RMT.0252 (MDM.056) ‘Instructions for Continued Airworthiness’. The current position of this sub-group is summarised below. 25 The determination of applicable instructions for continued airworthiness (ICA) and maintenance instructions of a product, especially those to be performed on the aircraft, is under the responsibility of the Design Approval Holder (DAH) of this product. This includes appliances which are part of the certified product. For that purpose, the DAH may consider maintenance instructions provided by suppliers if considered applicable and effective. Those maintenance instructions may be then incorporated either by reference or may be copied (with or without changes) directly into the ICA and maintenance instructions of the DAH. On the other hand this also means that the DAH may decide not to endorse maintenance instructions provided by suppliers if considered either not applicable or not effective. Therefore, it is not appropriate to enforce on airframe and engine manufacturers that “Maintenance Planning Document (MPD) and Engine Maintenance Manual (EMM) clearly include recommended maintenance information from subcomponent Component Maintenance Manuals (CMM).” At this stage, the sub-group 1 intends to propose in guidance material, that DAH should systematically review initial maintenance recommendations provided by suppliers and to consider them if applicable and effective. This review included European Technical Standard Order (ETSO) articles where certain maintenance instructions may be even required to be picked up by the DAH to ensure that the ETSO article continues to satisfy the terms of its ETSO authorization after installation. Further information will be provided in the Notices of Proposed Amendment (NPA) dealing with this topic (publication currently planned 01Q2017). Reply No 4 sent on 22/03/2018: This safety recommendation has been evaluated by the sub-group 1 of EASA rulemaking task MDM.056 (RMT.0252) ‘Instructions for Continued Airworthiness’. The current position of this sub-group is summarised below. The determination of applicable instructions for continued airworthiness (ICA) and maintenance instructions of a product, especially those to be performed on the aircraft, is under the responsibility of the Design Approval Holder (DAH) of this product. This includes appliances which are part of the certified product. For that purpose, the DAH may consider maintenance instructions provided by suppliers if considered applicable and effective. Those maintenance instructions may be then incorporated either by reference or may be copied (with or without changes) directly into the ICA and maintenance instructions of the DAH. On the other hand this also means that the DAH may decide not to endorse maintenance instructions provided by suppliers if considered either not applicable or not effective. Therefore it is not appropriate to enforce on airframe and engine manufacturers that “Maintenance Planning Document (MPD) and Engine Maintenance Manual (EMM) clearly include recommended maintenance information from subcomponent Component Maintenance Manuals (CMM).” 26 The sub-group 1 proposed guidance material stating that DAH should systematically review initial maintenance recommendations provided by suppliers and consider them if applicable and effective. This review should include ETSO articles where certain maintenance instructions may be even required to be picked up by the DAH to ensure that the ETSO article continues to satisfy the terms of its ETSO authorisation after installation. This position is reflected in the proposal of NPA 2018-01 ‘Instructions for continued airworthiness’ which has been published on 29 January 2018 on the EASA Website: https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2018-01 It includes a proposal for guidance material as indicated above (refer to page 14, GM N°2 to 21.A.7(a) ‘Determination of which supplier’s data are part of ICA’). The next step of this rulemaking task will be an Opinion to the European Commission (EC) by end of 2018, proposing an amendment of Part-21 (Annex I to Commission Regulation (EU) No 748/2012). The EASA ED Decision amending the corresponding AMC/GM to Part-21 will be issued once the associated amending regulation to Part-21 is published. Reply No 5 sent on 31/07/2021: This safety recommendation has been taken into account by the European Union Aviation Safety Agency (EASA) in the frame of rulemaking task MDM.056 (RMT.0252) ‘Instructions for Continued Airworthiness’, and in particular within its Subtask 1 ‘Definition and identification of ICA, Completeness of ICA and Certification of ICA by the competent authority’. The Terms of Reference of this RMT are available under: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-mdm056-rmt0252 EASA then published notice of proposed amendment (NPA) 2018-01 ‘Instructions for continued airworthiness’ on 29 January 2018 on the EASA website: https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2018-01 The NPA proposed to amend Annex I (Part-21) to Commission Regulation (EU) No 748/2012 as well as the corresponding Acceptable Means of Compliance (AMC) and Guidance Material (GM). After reviewing the comments received, EASA published Opinion 07/2019 in December 2019 proposing an amendment of Part 21 to the European Commission: https://www.easa.europa.eu/document-library/opinions/opinion-072019 On 28 April 2021, Commission Delegated Regulation (EU) 2021/699 of 21 December 2020 was published, thereby amending Regulation (EU) No 748/2012. This amendment provides in point 21.A.7 a definition of ‘instructions for continued airworthiness’ (ICA) and establishes ICA as part of the type certificate (point 21.A.41) in order to strengthen their control by the design approval holder (DAH), including the amendments to the ICA (ref. point 21.A.7 – in particular subparagraph (d) related to changes to ICA) that will enter into force on18/05/2022. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32021R0699&from=EN On 28 May 2021, EASA published Executive Director Decision 2021/007/R amending the AMC and GM to Part 21 (Issue 2, Amendment 12). The amendment provides guidance 27 and acceptable means of compliance explaining how DAH should develop and identify ICA, as well as what kinds of publication format may be used. https://www.easa.europa.eu/sites/default/files/dfu/amc_gm_to_part_21_- _issue_2_amendment_12.pdf The determination of applicable ICA and maintenance instructions of a product, especially those to be performed on the aircraft, is under the responsibility of the DAH of this product. This includes appliances which are part of the certified product. For that purpose, the DAH may consider maintenance instructions provided by suppliers if considered applicable and effective. Those maintenance instructions may then be incorporated either by reference or may be copied (with or without changes) directly into the ICA and maintenance instructions of the DAH. On the other hand, the DAH may decide not to endorse maintenance instructions provided by suppliers if they are considered either not applicable or not effective. The new GM2 21.A.7(a) (‘Determination of which supplier data is part of the ICA’) explicitly states that scheduled maintenance on components should be endorsed by the DAH before becoming part of the aircraft ICA, to define and confirm that the supplier data is applicable and effective. It is not deemed appropriate to universally enforce on aircraft and engine manufacturers that “Maintenance Planning Document (MPD) and Engine Maintenance Manual (EMM) clearly include recommended maintenance information from subcomponent Component Maintenance Manuals (CMM).” Status: Closed 28 United Kingdom Registration Aircraft Type Location Date of event Event Type G-EENN SCHEMPP HIRTH NIMBUS3 Portmoak Airfield, Scotlandwell, Kinross 04/09/2012 Accident Synopsis of the event: The glider was being winch launched from a grass airfield. At an early stage of the launch the right wing tip contacted the ground, the left wing lifted and the glider cartwheeled to the right before coming to rest, inverted. The pilot was fatally injured. Safety Recommendation UNKG-2013-008: It is recommended that the European Aviation Safety Agency amend the certification standard for Sailplanes and Powered Sailplanes (CS 22) to include the requirement that the cable release mechanisms can be operated at any stage of the launch without restricting the range of movement of any flying control. Reply No 1 sent on 13/08/2013: EASA support the proposal to make a change to Certification Specifications (CS) 22 that introduces a specification for the cable release mechanism in line with the safety recommendation. The plan is to develop this change in cooperation with the Organisation Scientifique et Technique du Vol à Voile (OSTIV) Sailplane Development Panel (SDP). Because this existing forum has support and involvement of a high number of stakeholders, EASA intends to introduce the necessary change to CS-22 through rulemaking task RMT.0037 (22.010) 'Regular update of CS-22' that is already in the current EASA rulemaking programme. Reply No 2 sent on 28/04/2017: EASA supports the proposal to make a change to Certification Specifications (CS) CS-22 that introduces a specification for the cable release mechanism for sailplanes and powered sailplanes in line with the safety recommendation. The plan is to develop this change in cooperation with the Organisation Scientifique et Technique du Vol à Voile (OSTIV) Sailplane Development Panel (SDP). Because this existing forum has the support and involvement of a high number of stakeholders, EASA intends to introduce the necessary change to CS-22 through rulemaking task RMT.0037 (22.010) 'Regular update of CS-22' that is already in the current EASA rulemaking programme 2017-2021. A Notices of Proposed Amendment (NPA) is planned to be published in 2nd quarter 2018. Reply No 3 sent on 03/03/2021: In accordance with certification specification CS 22.777(b) ‘The controls must be located and arranged so that the pilot, when strapped in the seat, has full and unrestricted movement of each control without interference from either clothing (including winter clothing) or from the cockpit structure. The pilot must 29 be able to operate all the controls necessary for the safe operation of the aeroplane from the seat designated to be used for solo flying’. This certification specification is generic and it does not specifically mention that it should be possible to operate the cable release mechanisms at any stage of the launch without being restricted by the range of movement of any flight controls. However, in the frame of rulemaking task RMT.0037 (22.010) "Regular update of CS-22" the European Union Aviation Safety Agency (EASA) published notice of proposed amendment (NPA) 2020-013 on 14 December 2020 that, under item 2, takes into account this safety recommendation. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2020-13. In particular, the NPA proposes a new acceptable means of compliance (AMC) to 22.777(b) to address this feature. The proposal reads as follows: “Special consideration should be given to ensuring that cable release mechanisms can be operated at any stage of the launch without restricting the range of movement of any flying control, including when the pilot has the hand on the release during the launch.” Reply No 4 sent on 02/12/2021: CS-22 (Certification Specifications for Sailplanes and Powered Sailplanes) states at CS 22.777(b) the following: ‘The controls must be located and arranged so that the pilot, when strapped in the seat, has full and unrestricted movement of each control without interference from either clothing (including winter clothing) or from the cockpit structure. The pilot must be able to operate all the controls necessary for the safe operation of the aeroplane from the seat designated to be used for solo flying’. This certification specification is generic and it does not specifically mention that it should be possible to operate the cable release mechanisms at any stage of the launch without being restricted by the range of movement of any flight controls. In the frame of the European Union Aviation Safety Agency (EASA) rulemaking task RMT.0037 (Regular update of CS-22), EASA published Notice of Proposed Amendment (NPA) 2020-013 on 14 December 2020. https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2020-13 This NPA made reference to this safety recommendation under item 2 and proposed a new AMC (Acceptable Means of Compliance) 22.777(b) to address the identified safety issue. Following the NPA public consultation, EASA published on 17 September 2021 Executive Director Decision 2021/013/R amending CS-22 (CS-22 Amendment 3). A new AMC 22.777(b) has been created that reads: “Special consideration should be given to ensuring that cable release mechanisms can be operated at any stage of the launch without restricting the range of movement of any flying control, including when the pilot has the hand on the release during the launch.” Status: Closed 30 United Kingdom Registration Aircraft Type Location Date of event Event Type G-EENN SCHEMPP HIRTH NIMBUS3 Portmoak Airfield, Scotlandwell, Kinross 04/09/2012 Accident Synopsis of the event: The glider was being winch launched from a grass airfield. At an early stage of the launch the right wing tip contacted the ground, the left wing lifted and the glider cartwheeled to the right before coming to rest, inverted. The pilot was fatally injured. Safety Recommendation UNKG-2013-009: It is recommended that the European Aviation Safety Agency require that Type Certificate holders of EASA Type Certificated gliders ensure, where practicable, that the cable release control can be operated at any stage of the launch without restricting the range of movement of any flying control. Reply No 1 sent on 13/08/2013: EASA is investigating the issue in cooperation with sailplane Type Certificate Holders in order to identify affected sailplanes and possible retrofit. A rulemaking activity is planed [reference rulemaking task RMT.0037 (22.010) ‘Regular update of CS-22’]. Practical solutions and the way to implement them will be decided also taking into account the certification basis for these aircrafts at the time of certification. Reply No 2 sent on 07/07/2017: The Agency assessed the issue and had identified the sailplane Types that are potentially affected, with the support of the Type Certificate Holders (TCH). Following this investigation, the following actions will be pursued: •EASA will issue within 2017 a Safety Information Bulletin (SIB) to make owners and pilots aware of the possible interference between the flight and the cable release controls. Owners/Pilots who identify their sailplane (specific serial number) being affected will be requested to get in contact with the respective TCH. •A clearer and more specific wording of the Acceptable Means of Compliance ( AMC ) to Certification Specifications (CS ) 22.777 ‘Cockpit Controls’ has been developed and agreed by the external advisory body the International Scientific and Technical Soaring Organisation (OSTIV) and will be included by the next revision of CS-22. Reply No 3 sent on 02/12/2021: Certification Specifications for Sailplanes and Powered Sailplanes (CS-22) amendment 3 was issued by the European Union Aviation Safety Agency (EASA) on 15 September 2021 by Executive Director Decision 2021/013/R and includes a new Acceptable Means of Compliance AMC 22.777 (b) foreseeing that special consideration should be given to ensuring that the cable release mechanisms can be operated at any stage of the launch without restricting the range of movement of any flying control. 31 For the current fleet, EASA has not received further occurrence reports of similar events and will take safety action in accordance with its continuing airworthiness procedures in case other occurrences are reported. Status: Closed 32 United Arab Emirates Registration Aircraft Type Location Date of event Event Type N571UP BOEING 747 Dubai Airport UAE 03/09/2010 Accident Synopsis of the event: A Boeing 747‐44AF departed Dubai International Airport (DXB) on a scheduled cargo flight to Cologne, Germany. Twenty two minutes into the flight, at approximately 32,000 feet, the flight crew advised Bahrain Air Traffic Control (BAH‐C) that there was an indication of an onboard fire. The crew declared an emergency and requested a return to Dubai International Airport. The crew further advised ATC that the cockpit was ‘full of smoke’ and that they ‘could not see the radios’. The Cockpit Voice Recorder (CVR) detailed a pitch control problem discussed by the crew in the first five minutes of the emergency. After the airplane turned back toward DXB, on the descent one of the crew experienced an emergency oxygen problem, leading to the probable incapacitation of the crew member. As the airplane approached DXB the crew were advised that they were ‘too high and too fast’ as they approached the airport and that a ‘360° turn was required’. The crew responded ‘Negative, negative, negative’ to the 360° turn request. The airplane overflew the airport. Following the airport over flight a relay aircraft advised the flight crew that an alternate airport , Sharjah International Airport (SHJ), was available to the airplane’s left at approximately 10 nm. Following confirmation of the heading change by the crew, the airplane reduced speed, entered into a descending right turn south of Dubai International Airport before radar contact was lost. Safety Recommendation UNAR-2013-050: The NTSB, FAA and/or EASA fire test divisions to perform a test on lithium batteries to determine the ignition properties for lithium type batteries when subjected to external sources of mechanical energy, including acoustic energy in flight range modes, acoustic harmonic modes and a separate test to determine the susceptibility of lithium batteries to vibration from a mechanical source. The purpose of this testing is to determine the safe limits for the air carriage of lithium type batteries in dynamic aeroelastic, vibrating structures where the battery electrolyte composed of an organic solvent (and dissolved lithium salt) could become unstable when exposed to these forms of mechanical energy. Reply No 1 sent on 13/08/2013: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. This reply gives the status within the 90 days period in compliance with Article 18 of Regulation (EU) No 996/2010. 33 Reply No 2 sent on 17/11/2017: The Agency and the European Commission are involved in a research project: “Safe transport of lithium batteries by Aircraft”. One of the firsts steps of this project is to identify the hazards that may be encountered during the air transport of lithium batteries (e.g. battery chemistry, design, size) to further identify mitigating measures that can be used to enhance safety when transporting lithium metal and lithium ion batteries on board an aircraft. The risks and measures will be fed to a risk assessment method to enable operators to establish and evaluate safe conditions for transport. Reply No 3 sent on 26/04/2021: The European Union Aviation Safety Agency (EASA) and the European Commission have been involved in a research project: “Safe transport of lithium batteries by Aircraft" (Sabatair). The main objective of the Sabatair project was to propose and evaluate the existing and novel potential mitigating measures to enhance the safe transportation of both lithium- metal and lithium-ion cells and batteries as cargo on passenger and cargo aeroplanes. The testing activities conducted provided relevant information to generate representative thermal models enabling the simulation of thermal runaway propagation inside lithium cell packages. A cell thermal model was built to: (i) simulate the thermal runaway initiation mechanism and the associated heat propagation inside the cell; (ii) model the propagation of a thermal runaway inside a package filled with Liion cells, and (iii) predict the performance of a given packaging scenario. Mitigating measures have been proposed and full-scale fire tests were conducted to assess the effectiveness of certain mitigation measures identified, in particular, the use of a Fire Containment Cover, to prevent the involvement of lithium cells or batteries in a fire event initiated externally to the lithium battery packaging. The tests were performed in a test chamber designed to evaluate the performance of the extinguishing agents used for fire suppression in Class C cargo compartments of large aeroplanes. Guidance to assist operators in the creation of their own safety risk assessments for the transport of lithium batteries when carried as cargo have been proposed. EASA believes that the extent of testing suggested by this safety recommendation would not be practical (Lithium type batteries in dynamic aeroelastic, vibrating structures where the battery electrolyte composed of an organic solvent could become unstable) and that the thermal models validated by tests enable the simulation of thermal runaway propagation inside lithium cell packages similar to that of the accident batteries In line with the above, EASA considers that it has effectively addressed the intent of this safety recommendation and considers the action complete. Status: Closed 34 Austria Registration Aircraft Type Location Date of event Event Type EC-FPD MCDONNELL DOUGLAS MD88 Vienna Schwechat Airport (LOWW) 31/07/2008 Serious incident Synopsis of the event: The MD 88 aircraft took off from the Vienna Schwechat airport for Madrid on 31.07.2008 at 17:34 UTC. During the take-off run immediately before becoming airborne, the left engine experienced loss of power and vibration, as well as a smell of burning, upon which the pilots shut the engine off. The pilots returned to the airport and landed at 18:50. The aircraft was able to leave the runway under its own power. The incident did not cause any personal injury, but the aircraft was seriously damaged. Safety Recommendation AUST-2013-008: EASA, FAA: SE/SUB/ZLF/8/2013: Supplement to Certification Specifications 25 (CS-25), pressure displays of landing gear tyres: Insufficient pressure in landing gear tyres can, as happened in this serious incident, cause massive damage to the aircraft and result in flight situations with increased risk. On this topic also see, for example, the accident report issued by the US National Transportation Safety Board (NTSB): Runway Overrun During Rejected Takeoff, Global Exec Aviation, Bombardier Learjet 60, N999LJ, Columbia, South Carolina, September 19, 2008, http://www.ntsb.gov/doclib/reports/2010/aar1002.pdf. CS-25 should be revised to specify installation of pressure indicators for all landing gear tyres in the cockpit of commercial aircraft. [[%_A133%]] - EASA, FAA: SE/SUB/ZLF/8/2013: Ergänzung der Certification Specifications 25 (CS-25), Druckanzeigen der Fahrwerksreifen: Unzureichender Reifendruck in Fahrwerksreifen kann, wie bei gegenständlicher schwerer Störung aufgetreten, zu massiven Schäden am Luftfahrzeug und Flugsituationen mit erhöhtem Risiko führen. Siehe zu diesem Thema auch z. B. den Unfallbericht des US National Transportation Safety Board (NTSB): Runway Overrun During Rejected Takeoff, Global Exec Aviation, Bombardier Learjet 60, N999LJ, Columbia, South Carolina, September 19, 2008, http://www.ntsb.gov/doclib/reports/2010/aar1002.pdf. Die CS-25 sollten dahingehend ergänzt werden, dass im Cockpit von Verkehrsflugzeugen Druckanzeigen aller Fahrwerksreifen vorgeschrieben werden. Reply No 1 sent on 19/02/2014: EASA acknowledges receipt of this Safety Recommendation. Please be advised that it is under consideration and that the outcome will be communicated to you in due course. This reply gives the status within the 90 days period in compliance with Article 18 of Regulation (EU) No 996/2010. Reply No 2 sent on 05/06/2014: The Agency recognizes the importance of ensuring that tyres remain correctly inflated within the pressure specifications defined by the aircraft manufacturer. 35 The Agency acknowledges that rulemaking to review and improve, as far as possible, current regulations enforcing tyre inflation requirements could contribute to mitigating the identified risk. The installation of tyre pressure monitoring systems can mitigate the cases escaping current safety barriers (e.g. air leakage in the tyre/wheel assembly, maintenance error or negligence, failure/inaccuracy of the inflation equipment, operator not correctly performing the regular checks, etc.). The Agency considers implementing a new task in the rulemaking programme, and an updated response will be provided when the decision has been taken. Please note that CS-25 was also recently amended to upgrade large aeroplane certification standards for protection against the effects of tyre and wheel failures (which includes the threat from under-inflated tyres). Reply No 3 sent on 07/07/2017: With the amendment 14 of CS-25 (effective on 20 December 2013, applicable to new certification projects of large aeroplanes), the Agency introduced new certification specifications to upgrade the protection against the damaging effects of tyre and wheel failures. However, the Agency has initiated a new rulemaking task, RMT.0586, to propose a regulatory change to better ensure that the inflation pressures of tyres of large aeroplanes remain within the pressure specifications defined by the aeroplane manufacturer. The terms of reference and the rulemaking group composition were published on 30 May 2017 on the EASA Website: https://www.easa.europa.eu/document-library/terms-of- reference-and-group-compositions/tor-rmt0586 Mandating the installation of a tyre pressure monitoring system is one of the elements to be considered among the objectives of RMT.0586. The next step of RMT.0586 is the publication of a Notice of Proposed Amendment (NPA) which is envisaged during 03Q2018. Reply No 4 sent on 22/06/2020: With amendment 14 of CS-25 (Certification specifications and acceptable means of compliance for large aeroplanes) (effective as of 20 December 2013, applicable to new certification projects of large aeroplanes), EASA introduced new certification specifications to upgrade protection against the damaging effects of tyre and wheel failures. After that, EASA initiated rulemaking task RMT.0586 to propose a regulatory change to better ensure that the inflation pressures of tyres of large aeroplanes remain within the pressure specifications defined by the aeroplane manufacturer. The terms of reference and the rulemaking group composition were published on 30 May 2017 on the EASA website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0586 This safety recommendation has been taken into account in this rulemaking task. Notice of Proposed Amendment (NPA) 2020-05 (‘Tyre pressure monitoring’) was published for consultation on 6 March 2020: https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2020-05 36 This NPA includes a proposal to amend CS-25 to require applicants to provide a means to ensure that no tyre is below its minimum serviceable inflation pressure during operation. This can be achieved either by providing a task in the instructions for continued airworthiness (ICA) that requires operators to perform tyre pressure checks at a suitable time interval (i.e. daily or at another substantiated interval), or by installing a tyre pressure monitoring system that alerts the flight crew in the case of a tyre with an unsafe pressure. The related EASA Decision is scheduled for Q1/2021. Reply No 5 sent on 03/03/2021: With amendment 14 of certification specification CS-25 (effective on 20 December 2013, applicable to new certification projects of large aeroplanes), EASA introduced new certification specifications to upgrade the protection against the damaging effects of tyre and wheel failures. After that, the European Union Aviation Safety Agency (EASA) initiated rulemaking task RMT.0586 to propose a regulatory change to better ensure that the inflation pressures of tyres of large aeroplanes remain within the pressure specifications defined by the aeroplane manufacturer. The terms of reference and the rulemaking group composition were published on 30 May 2017 on the EASA website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0586 This safety recommendation has been taken into account in this rulemaking task. Notice of Proposed Amendment (NPA) 2020-05 (‘Tyre pressure monitoring’) was published for consultation on 6 March 2020: https://www.easa.europa.eu/document-library/notices-of-proposed-amendment/npa- 2020-05 Executive Director (ED) Decision 2020/024/R on amendment 26 of CS-25 was published on 22 December 2020. https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2020024r A new objective based certification specification CS 25.733(f) has been created to require that the applicant provides a means to minimise the risk that a tyre is below its minimum serviceable inflation pressure during operation. The corresponding new AMC 25.733(f) indicates how the applicant can demonstrate compliance. These new provisions are not prescriptive and do not universally mandate the installation of a system indicating the tyre inflation pressures in the cockpit. The applicant should use one, or a combination, of the following means: (a) Provide a task in the Instructions for Continued Airworthiness (ICA) that requires tyres inflation pressure checks to be performed at a suitable time interval, (b) Install a system that monitors the tyres inflation pressures and: (1) provides an alert to the flight crew, in compliance with CS 25.1322, whenever a tyre inflation pressure is below the minimum serviceable inflation pressure, or (2) allows the tyres inflation pressures to be checked prior to the dispatch of the aeroplane, and a tyre inflation pressure check task is included in the Aeroplane Flight Manual (AFM) pre-flight procedures. Status: Closed 37 Ireland Registration Aircraft Type Location Date of event Event Type G-COBS G-FCSL DIAMOND DA42PIPER PA31 5 NM east of Ireland West Airport (EIKN), Knock, Co. Mayo 22/04/2013 Serious incident Synopsis of the event: While in the process of conducting separate flights for the calibration of navigation aids at EIKN, the lateral separation between two calibrating aircraft reduced to 0.42 nautical miles (NM) with no vertical separation. One aircraft initiated avoiding action following a Traffic Advisory System (TAS) warning and subsequently declared an AIRPROX. Both aircraft landed without further incident. There were no injuries. Safety Recommendation IRLD-2014-017: The European Aviation Safety Agency (EASA) should consider a requirement for calibration aircraft operating in Europe to be fitted with TCAS. Reply No 1 sent on 01/08/2014: EASA current 2014-2017 rulemaking programme includes rulemaking task RMT.0376 'Carriage of ACAS II equipment on aircraft other than aeroplanes in excess of 5700kg or 19 Pax'. This task envisages amendments to regulation 1332/2011 and regulation 965/2012 as last amended, in particular Part-NCC (non-commercial operations with complex motor-powered aircraft), Part-NCO (non- commercial operations with other-than complex motor-powered aircraft) and Part-SPO (specialised operations). The intent of this safety recommendation will be considered within the framework of the above rulemaking task. Reply No 2 sent on 31/08/2017: EASA Rulemaking Task RMT.0376 'Carriage of ACAS II equipment on aircraft other than aeroplanes in excess of 5700 kg or 19 Pax' is included in the Rulemaking programme 2017-2021 to ensure alignment with other on- going developments within the Agency, namely the efforts to find a solution for cost- effective collision avoidance equipment for General Aviation aircraft. This task will also include a thorough impact assessment aimed at evaluating the cost- benefit of ACAS II equipment anti-collision systems carriage. The publication of the associated terms of reference (ToR) for the rulemaking task RMT.0376, is planned to be published in the second quarter of 2018. Reply No 3 sent on 02/12/2021: Based on the outcome of the Best Information Strategy (BIS) report on Airborne Collision, the European Plan for Aviation Safety (EPAS) 2021-2025 deleted rulemaking task (RMT) RMT.0376 on anti-collision and traffic awareness systems for aircraft with a maximum take-off mass less than 5700 kg or carrying less than 19 passengers. The BIS considers a different approach instead, through which the European Union Aviation Safety Agency (EASA) intends to undertake 38 a set of actions that are deemed to be more effective in reducing the risk of airborne collisions. The BIS concluded that a broader use of iConspicuity solutions and improvement of their interoperability together with a better airspace utilisation and design, while ensuring compatibility with the U-space regulatory framework established under Implementing Regulation (EU) 2021/664, should be at the heart of the future actions. iConspicuity (or in-flight electronic conspicuity plus) means in-flight capability to transmit position of aircraft and/or to receive, process and display positions of other aircraft in a real time with the objective to enhance pilots’ situational awareness about surrounding traffic. It is an umbrella term for a range of technologies and solutions, regardless whether airborne or on the ground, which can help airspace users and other affected stakeholders to be more aware of other aircraft in their vicinity or in a given airspace. Additional justifications of the new approach are provided in the BIS report, which describes a detailed review and assessment of the airborne collision risk, and whose outcome was validated through a survey and a stakeholders’ consultation. The new approach results in a strategy composed of a set of EPAS tasks compounded of existing rulemaking tasks which will be implemented together with new safety promotion (SPT), research (RES) and member state tasks (MST). The best safety benefits are expected to be achieved through synergies of all actions, while utilising the U-space regulatory framework as a catalyst for safety improvements. The following bullet points summarize the collective actions which are planned to be implemented for anti-collision and traffic awareness systems for aircraft with maximum take-off mass less than 5700 kg or carrying less than 19 passengers: • EASA, with support of technical partners, to demonstrate and validate feasibility of achieving interoperability of different iConspicuity devices/systems through network of stations while respecting data privacy requirements. • EASA to analyse ‘Net Safety Benefit’ and ‘Operational Safety Assessment’ concepts for the use of iConspicuity devices/systems in Flight Information Services. • EASA to facilitate installation of iConspicuity devices in all EASA certified aircraft types and promote their use by airspace users at user affordable cost. • EASA to actively support initiatives enhancing interoperability of iConspicuity devices/systems. • EASA to promote good practices in airspace design that reduce ‘airspace complexity’ and ‘traffic congestion’ with the aim to reduce the risk of collisions involving uncontrolled traffic. • Member States to consider ‘airspace complexity’ and ‘traffic congestion' as safety relevant factors in airspace changes affecting uncontrolled traffic, including the changes along international borders. • EASA to ensure technical and operational compatibility of U-space and iConspicuity solutions. • EASA to conduct a Safety Issue Assessment (SIA) of airspace infringements. • EASA to explore the use of iConspicuity data for enhanced safety monitoring of Airborne Collision Risk. Collectively, the aforementioned EASA actions serve as a multi-pronged final strategy in response to airborne collision risks. This strategy will be reviewed at regular intervals. Status: Closed 39 United Kingdom Registration Aircraft Type Location Date of event Event Type G-REDW EUROCOPTER EC225 20 NM east of Aberdeen 10/05/2012 Accident Registration Aircraft Type Location Date of event Event Type G-CHCN EUROCOPTER EC225 North Sea, 32nm southwest of Sumburgh 22/10/2012 Accident Synopsis of the event: While operating over the North Sea, in daylight, the crews of bot helicopters experienced a loss of main rotor gearbox oil pressure, which required them to activate the emergency lubrication system. Both helicopters should have been able to fly to the nearest airport; however shortly after the system had activated, a warning illuminated indicating that the system had failed. This required the crews to ditch their helicopters immediately in the North Sea. Both ditchings were successful and the crew and the passengers evacuated into the helicopter’s life rafts. There were no injuries. Safety Recommendation UNKG-2014-013: It is recommended that the European Aviation Safety Agency provide Acceptable Means of Compliance (AMC) material for Certification Specification (CS) 29.1585, in relation to Rotorcraft Flight Manuals, similar to that provided for Aeroplane Flight Manuals in the AMC for CS 25.1585 to include cockpit checklists and systems descriptions and associated procedures. Reply No 1 sent on 01/08/2014: An amendment of the Acceptable Means of Compliance where EASA would take into account the specificity of helicopter type and intended operations is under consideration. An update will be provided as soon as any progress is available. Reply No 2 sent on 04/02/2019: This safety recommendation will be taken into account in the frame of rulemaking task RMT.0724 entitled ‘Rotorcraft flight crew operating manuals (FCOMs)’. This RMT is included in the EASA European Plan for Aviation Safety (EPAS) 2019-2023 published on 15th January 2019, with Terms of Reference planned to be issued in 2019Q3. The objective of this RMT is to improve the operational information provided to rotorcraft flight crew in the aircrew manuals. This could be achieved by standardising the structure and approach used to present operational information in rotorcraft manuals, thereby improving the clarity of this information. 40 Reply No 3 sent on 10/06/2021: This safety recommendation will be taken into account in the frame of rulemaking task RMT.0724 for which the Terms of Reference (ToR) (entitled ‘Improvement of operating information provided to rotorcraft flight crew’) and the Rulemaking Group Composition have been published on 12 March 2021 on the European Union Aviation Safety Agency (EASA) website: https://www.easa.europa.eu/document-library/terms-of-reference-and-group- compositions/tor-rmt0724 The objective is to improve the operational information provided to the rotorcraft flight crew. The ToR envisages to reach this objective as follows: — A gap analysis will be conducted to identify the elements to be improved in the existing acceptable means of compliance (AMC) for the preparation of Rotorcraft Flight Manuals (RFM); — The results of the gap analysis will be used to identify the points to be addressed by new AMCs, elements that could be relevant for flight crew operating manuals (FCOMs), and elements that cannot be addressed by this rulemaking task; — A new AMC will be drafted in order to develop guidance for a more comprehensive RFM, with the objective of filling the gaps in the current material; — This new AMC should ensure that rotorcraft manufacturers will provide more details regarding the procedures to be followed for rotorcraft operations, both for normal and emergency procedures, which take into account the number of crew members, the configuration and the operational environment. As a result, these additional details should help to clarify which elements belong to the airworthiness domain and which elements are related to the operational domain; — The overall structure and the minimum contents of an FCOM will be defined, allowing type certificate holders (TCHs) to introduce it on a voluntary basis if they decide to publish part of the operational information in this manual; — The applicability of the proposed material will be assessed, and simplified if necessary, to ensure a proportionate approach; — An impact assessment will be prepared on the basis of the initial assessment already performed by EASA. A Notice of Proposed Amendment (NPA) will be prepared and published for public consultation. The NPA will propose amendments of CS-29, CS-27 and, if considered necessary, CS-VLR. The publication is foreseen for Q1 of 2023 according to the European Plan for Aviation Safety (EPAS) 2021-2025. Status: Open 41 Australia Registration Aircraft Type Location Date of event Event Type VH-HWQ ROBINSON R44 Bulli Tops, New South Wales 21/03/2013 Accident Synopsis of the event: A Robinson Helicopter Company R44 helicopter (R44), registered VH-HWQ, landed at a grassed area adjacent to a function centre at Bulli Tops, New South Wales. Shortly after landing, the helicopter was observed to simultaneously lift off, yaw right through 180° and drift towards nearby trees. The helicopter struck branches of the trees before descending, impacting the ground nose low and rolling onto its right side. A short time after coming to rest a fire started and engulfed the helicopter. The pilot and three passengers were fatally injured. Safety Recommendation ASTL-2015-029: The ATSB recommends that the European Aviation Safety Agency take action to increase the number of existing helicopters that are fitted with a crash-resistant fuel system or have an equivalent level of safety in respect of post-impact fire. Reply No 1 sent on 18/08/2015: The Agency is supporting certification or validation of retrofit kits with improved crashworthiness characteristics for the designs identified as most critical (e.g. on the Robinson R22 or AS350/EC130). The EC130T2 is already certified and delivered with a crash-resistant fuel system (CRFS) and the Agency is in contact with Airbus Helicopter in order to evaluate different options applicable to the AS350 fleet. Reply No 2 sent on 26/04/2021: The European Union Aviation Safety Agency (EASA) has cooperated with Airbus Helicopters (AH) and the Federal Aviation Administration (FAA) to improve post-crash fire protection in the in-service AS350/EC130 helicopter fleet. Within this framework, new Crash-Resistant Fuel System (CRFS) modifications have been recently developed by different applicants, approved by EASA and made available for new helicopter deliveries or, as a retrofit kit, for helicopters already in service as detailed below: -EASA Major Change 10072097 approved on 18/12/2019, developed by AH and applicable to all AS350 B3 helicopter models without any limitation. -EASA Supplemental Type Certificate (STC) 10064703 dated 20/06/2018, developed by Standard Aero (previously known as Vector Aerospace Helicopter Service USA, Inc.) and applicable to AS350 D, AS350 B, AS350 B1, AS350 B2, AS350 BA, AS350 B3 and EC130 B4 helicopter models without any limitation. -EASA STC 10061056 Rev. 01 dated 24/01/2020 (original issue of the Supplemental Type Certificate is dated 16/02/2017), developed by AH and applicable to AS350 B3, if equipped with Safran Helicopter Engines Arriel 2D engine, and EC130 B4 helicopter models without any limitation. 42 -EASA STC 10060852 Rev. 01 dated 27/01/2020 (original issue of the Supplemental Type Certificate is dated 30/01/2017), developed by AH and applicable to AS350 B3, if equipped with Safran Helicopter Engines Arriel 2D engine, and EC130 B4 helicopter models with limitation forbidding underbelly installations. EASA considers that the installation of any of the modifications listed above will reduce the risk of post-crash fires for the in-service AS350/EC130 helicopters fleet and contribute to increase occupant escape time after a survivable crash. Consequently, their installation has been recommended by EASA via the release of EASA Safety Information Bulletin (SIB) ref. 2017-18R2 (“Installation of Crash Resistant Fuel System”) dated 14/01/2021. This is strongly promoted by AH through retrofit campaign incentives for operators. In addition, EASA, in cooperation with the Robinson Helicopter Company (RHC) and the FAA took additional actions to improve post-crash fire protection for the RHC in-service helicopters fleet. This activity led to the development of modifications approved by EASA and made available for new helicopter deliveries or, as a retrofit kit, for helicopters already in service as detailed below: -EASA Major Change 10028494 approved on 18/01/2010 (“Installation of bladder fuel tanks”), applicable to R44 and R44 II helicopter models and mandated via the EASA AD 2014-0070 dated 19/03/2014. -EASA Major Change 10046416 approved on 18/09/2013 (“Installation of bladder fuel tanks”), applicable to R22, R22 Alpha, R22 Beta and R22 Mariner helicopter models. EASA considers that these actions have increased the number of existing helicopters fitted with a crash-resistant fuel system or having an equivalent level of safety in respect of post-impact fire and, therefore, the intent of this Safety Recommendation has been properly met. Status: Closed 43 United Kingdom Registration Aircraft Type Location Date of event Event Type G-WNSB AEROSPATIALE AS332 on approach to Sumburgh Airport in the Shetland Islands 23/08/2013 Accident Synopsis of the event: Super Puma helicopter with sixteen passengers and two crew on board crashed in the sea during the approach to land at Sumburgh Airport. Four of the passengers did not survive. The approach was flown with the autopilot in 3-axes mode, which required the commander to manually operate the collective pitch control. The co-pilot was responsible for monitoring the helicopter’s vertic