CONTENTS

Reproduction or use of content & Disclaimer v

Foreword vii
Executive Summary ix

1. Safety Analysis and Indian State Safety Plan 1

1.1 Introduction 2
1.2 State Safety Plan and Acceptable Level of Safety 3
1.3 Performance of State Safety Plan 2015-2016 4
1.3.1 Airborne Conflict 4
1.3.2 Controlled Flight Into Terrain 6
1.3.3 Runway Excursions and Overrun 8
1.3.4 Wildlife and Bird Strikes 11
1.3.5 Loss of Control in Flight 13
1.3.6 Ground Collision and Ramp Safety 14
1.3.7 Deficient Maintenance 16

2. Global Safety Scenario 19

2.1 Introduction 20
2.2 Review of Fatal Accidents 2015 20
2.3 Worldwide Fatal Accidents - Commercial Air Transport 22
Above 5700kgs

3. Indian Safety Scenario 25

3.1 Introduction 26
3.2 Review of Accidents 2015 26
3.3 Indian Commercial Air Transport Accidents above 5700kgs 27
3.4 Classification of accidents as per ICAO taxonomy 29

i
CONTENTS

4. Helicopter Analysis 31
4.1 Introduction 32
4.2 Indian Helicopter Accidents 33
4.3 Analysis Based on type of Helicopter 33
4.4 Helicopter Accidents According to Type of Operations 34
4.5 Classification of Accidents as per ICAO Taxonomy 35
4.6 Worldwide Helicopter Accidents 36

5. Non Scheduled Operators And General Aviation 39

5.1 Introduction 40
5.2 Analysis of Accidents under NSOP 40
5.3 Classification of Accidents as per ICAO Taxonomy 40
(Non Power Plant)
5.4 General Aviation Accidents 41
5.5 Classification of Accidents as per ICAO Taxonomy (Power Plant) 43

6. Incidents Analysis 45
6.1 Introduction 46
6.2 Review and Analysis of Safety Database for the year 2015 46
6.2.1 Mandatory Incidents Reporting 46
6.3 Analysis of Incidents Pertaining to Scheduled Airlines 46
6.4 Analysis of Incidents Pertaining to Scheduled Airlines 47
6.5 Analysis of Operational incidents 47
6.6 Fleet wise Engineering incident Analysis 48
6.7 Incidents Classification as per CICTT values 49

ii
CONTENTS

7. Aerodromes 51
7.1 Introduction 52
7.2 Study on Wildlife Strike 52
7.3 Ground Incidents 53
7.4 Runway Incursions 54
7.5 Causative Factors of Runway Incursions 55

8. Air Traffic Management 57

8.1 Introduction 58
8.2 Year wise Graphical Presentation of AIRPROX on the basis of 58
above listed errors
8.3 Classification in Accordance with ECCAIRS Taxonomy 59

9. State Safety Oversight 61

9.1 Introduction 62
9.2 Areas of Safety Oversight 62
9.3 Directorates Participating in the Safety Oversight Program 62
9.4 Overview of Safety Oversight 63
9.5 Areas of Safety concern 63

10. State Safety Promotion 65

10.1 Collection of Safety Information 66
10.1.1 Mandatory Occurrence Reporting 66
10.1.2 Voluntary/confidential Reporting System 66
10.2 Internal Training, Communication and Dissemination of 66
Safety information
10.3 External Training, Communication and Dissemination of 67
Safety information
10.4 Areas of Concern 67
10.4.1 Unstabilised Approaches 67
10.4.2 Wildlife Hazard Management 68
10.4.3 Similar/confusing Call Signs 69

iii
CONTENTS

10.5 Way Forward 69

10.5.1 Appropriate State Safety Oversight 69
10.5.2 Review of State Safety Plan 70
10.5.3 Progressive Adoption of Safety Culture 70
10.5.4 Safety Management System Implementation 70
by Operators

Glossary 71
List of table 73
List of figures 74

iv
REPRODUCTION OR USE OF CONTENT

The Data covering the Indian environment in this report is obtained from
DGCA database and external references have been sourced from sources such
as ICAO iSTARS, etc. No portion of this report shall be reproduced, copied or
published in any form or manner except with the expressed permission of the
DGCA.

DISCLAIMER

The data presented in this report is strictly for the information purposes only.
While every care has been taken to prevent error in the content of the report,
DGCA shall not be liable for any kind of damages, or other claims or demands
as a result of incorrect, insufficient or invalid data, or arising out of or in
connection with the use, copying or display of content. The information
contained in this report should not be construed as legal advice.

v
Intentionally left blank

vi
FOREWORD

I take this opportunity to release the first edition of Annual Safety Review.
It contains analysis of safety data of the year 2015 and also highlights the
significant safety issues world over. Although, DGCA has been carrying
out the analysis of safety data, however, this is the first attempt to provide
the composite picture which will make India look at the potential risks in
future and effectivity of the existing measures for containing these risks.

I welcome the readers to provide suggestions/inputs for further

improvement in the contents for the subsequent editions.

I also congratulate the DGCA Safety team for putting together this work.

BS Bhullar
Director General, Civil Aviation

vii
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viii
EXECUTIVE SUMMARY

The Annual Safety Review presents statistics on Indian and worldwide aviation
safety. Data covering the Indian environment has been obtained from DGCA
Safety database and external sources such as ICAO iSTARS, stakeholders etc.
The safety review covers the period 2008-2015.

The report projects the performance of State Safety Plan for the year 2015 in
terms of the safety priorities and the matrix of their performance indicators. The
analysis indicate that unstabilized approaches which continued to land
constitutes a safety concern. Performance of other safety indicators is in line
with the desired objectives.

Analysis of Worldwide and Indian Aircraft Accidents data (scheduled

commercial transport and aircraft with all up weight more than 5700 kgs)

The report contains details of significant accidents which occurred worldwide

during the year 2015 and the analysis of the accident data with respect to growth
in passenger traffic. A comparison has also been made between Indian Accident
dataand worldwide Accident data. The comparison indicates that the fatality rate
in accidents in India is below the world rate. However, there is an increase in rate
of total accidents per million departures. This is a matter of concern. Further,
most of the accidents have resulted in Runway Excursion, which has been made
one of the State Safety Priority with an objective to reduce such occurrences.

Analysis of Helicopter Accident Data

The report includes data on significant world-wide helicopter accidents and

analysis of Indian helicopter accident data. The analysis indicate that most of the
helicopter accidents have occurred during commercial operations. In most of the
accidents the occurrence category is Loss of Control In-flight. This is cause of
concern and relevant performance indicator matrix for helicopter will be
included in the revised State Safety Plan.

Mandatory Incident Reporting System

DGCA- India is using ECCAIRS for capturing the incident data. The analysis
indicates that more number of incidents have occurred due to component system
failure. This has also been identified as State Safety Priority. To contain this trend
emphasis has been laid on other factors which are contributory such incidents.
The data is also being captured through surveillance, voluntary reporting
system. This has resulted in increase in the reported data.

ix
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x
Chapter 1

Safety Analysis and

Indian State Safety Plan

1
1.1 INTRODUCTION

Annex 19 and Doc 9859 places responsibility on state to have State Safety
programme in place at the state level and Safety management system
implemented at the service provider level. ICAO through its standard and
recommended practices as contained in DOC9859 and Annex 19 has adopted
the concept of Acceptable Level of Safety (ALoS) in aviation. This objective
approach for managing the safety recognizes the limitations of the prescriptive
approach and the fact that the absolute safety is generally an unachievable and
very expensive goal. This provides a structured and balanced approach for
managing the risks which are existing in a State/organisation.

The Acceptable Level of Safety expresses the safety goals of an oversight

authority, an operator, or a services provider. The concept of acceptable level of
safety is expressed by two specific metrics, namely safety performance targets
(SPT) and safety performance indicators(SPI).

India began the process of the establishing the State Safety Programme in the
year 2010, and published higher level document SSP-India. The SSP-India
provides a framework to meet the safety management provisions contained in
ICAO Annexes and to progressively improve safety performance across all
affected aviation service providers.To ensure the implementation of the State
Safety Programme, Phase wise Implementation Plan was made. Each phase
defined a set of activities required to be accomplished.

A series of activities are being undertaken for the implementation of SSP-India.

As an outcome of these activities India has defined its acceptable level of safety
and has identified seven State Safety Priorities along with associated
performance indicators, their objectives, targets and the safety action plan in
partnership with the stake holders.

2
1.2 STATE SAFETY PLAN AND ACCEPTABLE LEVEL OF SAFETY

DGCA- India has developed State Safety Plan 2015-2016. It is an outcome of

some of the activities described in the State Safety programme (SSP) and
implemented in accordance with the phase wise activities. It has been supported
by the work undertaken by stakeholders in the development and
implementation of their Safety Management System (SMS). It sets out the
States' safety priorities, objectives, safety performance indicators and
associated action plans with the sole aim of further improving safety across the
civil aviation industry.

OUR KEY SAFETY PRIORITIES

Taking in to consideration the global aviation safety plan, initiatives by other

states and our own experience, supported by data from the State Safety
Database, the DGCA has established seven State Safety Priorities. These are:

a) Airborne conflict
b) Controlled flight into terrain
c) Runway excursions and overruns
d) Wildlife and bird strikes
e) Loss of control in flight
f) Ground collisions and ramp safety
g) Deficient maintenance

These Safety Priorities provided focus for the DGCA and the Indian aviation
community during the years 2015 and 2016.

Each of these safety priorities is linked to the more detailed operational

measures called safety performance indicators for a drill-down capability to
provide the supporting details for effective monitoring.

3
1.3 PERFORMANCE OF STATE SAFETY PLAN 2015-2016

Based on the data collected, safety performance with respect to the SPI for the
year 2015 has been evaluated and presented in subsequent pages:

1.3.1 Airborne Conflict

Safety objective: To reduce the risk of airborne conflict occurring through

tracking and actively managing events that can lead to a collision

Performance achieved along-with targets set for the year 2015 is given below
in table 1.1

Table 1.1 Target Performance vs Achieved Performance

4
2.0 20.0
16.49
1.8
1.61
15.0
1.6 1.49 12.33
1.41 11.75

1.4
10.0
1.2

1.0 5.0
2013 2014 2015 2013 2014 2015
Risk bearing AIRPROX per 10,00,000 flights
TCAS/RA per 10,00,000 flights Target
Target

Fig 1.1(a) Fig 1.1(b)

9.7
10.0 10.0 8.9
8.
8.0 8.0
5.89
6.0 6.0

4.0 2.82 4.0

2.50

2.0 2.0

0.0 0.0
2013 2014 2015 2013 2014 2015
Not complying with ATC instructions per 10,00,000 ATC/ system failure per 10,00,000 flights
flights
Target
Target

Fig1.1(c) Fig 1.1(d)

The TCAS/RA in the controlled airspace are marginally on the higher side than
the target. However, the risk bearing Airprox are within the targeted limits.

5
1.3.2 Controlled Flight into Terrain

Safety objective: To further reduce the risk of CFIT events occurring through
tracking and actively managing events that can lead to a collision.

Performance achieved along-with targets set for the year 2015 is given below in
table 1.2

Table 1.2 Target Performance vs Achieved Performance

No. Performance Indicators Target Achieved

Performance

1 Number of GPWS/EGPWS warnings 0.072 2.58

(Scheduled airlines)per 10,000 departures
2 Number of helicopter VFR flights that make 0.92 0.225
emergency landing due to degraded visual
environment per 10,000 departures

Performance of CFIT
3
2.58

1.93
2 1.72
2013
0.97 2014
1
2015
0.225
0.076
0
Helicopter emergency landing due to bad GPWS/EGPWS warning per 10000 departures
weather

Fig 1.2

6
 5.0

4.0

3.0

2.0 1.93

1.0 0.97

0.225
0.0
2013 2014 2015
Helicopter Emergency Landing due to bad
weather per 10000 departures
Target

Fig 1.2(a)

5.0

4.0

3.0
2.58
2.0 1.72

1.0
0.076
0.0
2013 2014 2015
GPWS/EGPWS Warning per 10000 departures
Target

Fig 1.2(b)

Number of GPWS/EGPWS warnings have increased, many are due to equipment

issues, unstabilised approaches, issues specific to the system.

7
1.3.3 Runway Excursions and Overrun

Safety objective: To reduce number of runway excursions at all India airports

and at all times of the year.
Performance achieved along-with targets set for the year 2015 is given below in
table 1.3

Table 1.3 Target Performance vs Achieved Performance

No. Performance Indicators Target Achieved
Performance
1 Number of unstabilised approaches per 10,000 9.51 16.35
approaches
2 Number of unstabilised approaches that continue to 1.281 14.5
land per 10,000 approaches
3 Number of unstabilised approaches when 4.98 9.66
performing a precision approach per 10,000
approaches.
4 Number of unstabilised approaches when 1.558 3.18
performing a non-precision approach (no vertical
guidance) per 10,000 approaches.
5 Number of unstabilised approaches when 2.97 3.51
performing a visual approach per 10,000
approaches
6 Number of near runway excursions per 10,000 0.042 0.0
approaches
7 Number of runway excursions per 10,000 0.072 0.045
approaches

Performance of Runway Excursion and Overrun

25.0

20.0
16.4 2013
14.5 2014
15.0
10.0 2015
8.2 9.7
10.0 7.4
5.6
5.2
5.0 3.2 3.1 3.5
1.4 1.6 1.1 0.0
1.4 0.0
0.0 0.0 0.1 0.0
0.0
Unstabilised Unstabilised Unstabilised Unstabilised Unstabilised Near runway Runway excursion
approach approach approach when approach when approach when excursion
continued to land perfroming perfroming non- perfroming visual
precision precision approach
approach approach

Fig 1.3

8
20.0 20.0

16.35
15.0 15.0 14.5
10.01
10.0 10.0
8.16 7.43
5.0 5.0
1.35
0.0 0.0
2013 2014 2015 2013 2014 2015
Unstabilised Approaches that continued to
Unstabilised Approach per 10,000 approaches land per 10,000 approaches
Target Target

Fig 1.3 (a) Fig 1.3(b)

15.0 5.0

10.0 9.66 3.18

2.5
5.24
5.64 1.64
5.0
1.43

0.0 0.0
2013 2014 2015 2013 2014 2015

Unstabilised Approaches when performing a Unstabilised Approaches when performing a Non-

precision approach per 10,000 approaches precision approach per 10,000 approaches
Target Target

Fig 1.3 (c) Fig 1.3(d)

9
0.05
5.0
0.045
0.04
4.0
3.51
0.03 0.03 3.0 3.13

0.02 2.0

0.01 1.0 1.09

0.00 0 0.0
2013 2014 2015 2013 2014 2015

Near Runway Excursions per 10,000 Unstabilised Approaches when performing

approaches a Visual approach per 10,000 approaches
Target Target

Fig 1.3 (e) Fig 1.3(f)

0.08
0.076

0.06

0.045
0.04

0.02
0.014

0.00
2013 2014 2015
Runway Excursions per 10,000 approaches
Target

Fig 1.3 (g)

It can be seen from the above graphs that the trend for unstabilised
approaches is increasing. This is basically due to enhancement in the
reporting culture among the stakeholders. However, it continues to be a
concern for the State. Fig. 1.3 (c) shows increase in the unstabilised
approaches when performing a precision approach. After the analysis, one of
the most common factors is decelerated approaches.

10
1.3.4 Wildlife and Bird Strikes

Safety objective: To reduce the number of wildlife and bird strike events at
Indian airports.
Performance achieved along with targets set for the year 2015 is given below in
Table 1.4
Table 1.4 Target Performance vs Achieved Performance

No. Performance Indicators Target Achieved

Performance
1 Number of reported bird strikes at Indian airports 4.68 3.16
per 10,000 movements (movements only for 18
Major Airports in India)
2 Number of reported wildlife strikes at all Indian 1.99 2.1
airports per day.
3 Number of runway incursions by wildlife at all 0.075 0.041
Indian airports per day

Performance of Wildlife & Bird Strike

6.0
4.92
3.96
4.0
3.16
2013
2.01 1.97 2.1
2.0 2014
2015
0.079 0.11 0.041
0.0
Reported Bird Strike per 10000 Reported Wildlife Strike per Day Runway Incursion by Wildlife per
movement day

Fig 1.4

3.0 5.0 4.92

2.5
4.0 3.96
2.01 2.1
2.0
1.97 3.16
3.0

1.5

2.0
1.0 2013 2014 2015
2013 2014 2015
Reported bird strikes per 10,000 movements
Reported wildlife strikes per day Target Target

Fig. 1.4 (a) Fig. 1.4 (b)

11
 0.15

0.11
0.10
0.079

0.05
0.041

0.00
2013 2014 2015

Runway Incursions by wildlife per day

Target

Fig. 1.4 (c)

Fig 1.4 (b) shows decrease in the rate of reported bird strike for the year 2015
when compared to earlier years, even though the reporting of bird strike has
increased. Refer fig 1.4 (a).

12
1.3.5 Loss of Control in Flight

Safety objective: To reduce the number of loss of control pre-cursor events.

Performance achieved along-with targets set for the year 2015 is given below in
table 1.5

Table 1.5 Target Performance vs Achieved Performance

No. Performance Indicators Target Achieved

Performance
1 Loss of control precursor events per 10000 2.58 1.043
departures:
? Actual stick-shake and alpha floor
? Low speed during approach events
? Low speed during cruise events
? Bank angle exceeding maximum permitted as
per AFM for aircraft type
? Wind shear below 500 feet
2 Proportion of aircraft operators that actively 100% 100%
monitor loss of control precursor measures (Only
Scheduled operators)
3 Number of operators that have implemented loss 100% 100%
of control training

3.0 2.71

2.0

1.0 1.043
0.43

0.0
2013 2014 2015

Loss of Control Events per 10000 departures Target

Fig 1.5

Fig. 1.5 Shows a Decreasing trend in the rate of loss of control events per
10000 departures after the year 2013. Although the rate has increased in year
2015 when compared with year 2014, but it continues to remain well below
the set target and under manageable limits.

13
1.3.6 Ground Collision and Ramp Safety

Safety objective: To reduce the number of ground collisions between

aircraft, ground collisions between vehicles and aircraft and the number of
fatalities and serious injuries occurring on the ramp.

Performance achieved along-with targets set for the year 2015 is given below in
table 1.6

Table 1.6 Target Performance vs Achieved Performance

No. Performance Indicators Target Achieved

Performance
1 Number of runway incursions (aircraft) (15) (10)
2 Number of runway incursions (vehicle) (1) (2)
3 Number of runway incursions (person) (4) (2)
4 Number of ramp incidents that result in (42) (43)
damage to aircraft, vehicles or loss of
life/serious injury to personnel

Performance of Ground Collision and Ramp Safety

50
44 43

38 35

2013
25
18 2014
15
2015
13 10
5
2 3 2 2 2
0
RI(Aircraft) RI(Vehicle) RI(Person) Ground Incident

Fig 1.6

14
 20.0 18 5.0

15 4.0
15.0
3
10 3.0
10.0 2 2
2.0

5.0
1.0

0.0 0.0
2013 2014 2015 2013 2014 2015

Number of Runway Incursions (Aircraft) Number of Runway Incursions (Vehicle)

Target Target

Fig 1.6(a) Fig 1.6(b)

5.0
50.0
44 43
4.0
40.0
35
3
3.0
30.0
2 2
2.0 20.0

1.0 10.0

0.0 0.0
2013 2014 2015 2013 2014 2015
Number of ramp incidents that result in damage to
Number of Runway Incursions (Person) aircraft, vehicles or loss of life/serious injury to
Target personnel
Target

Fig 1.6(c) Fig 1.6(d)

The major factors involved in the above incidents are as listed below:
Misunderstood Communication
Inadequate signage Markings or Lighting
Inadequate training
Inadequate risk assessment
Non Adherence to SOP

15
1.3.7 Deficient Maintenance

Safety objective: To improve the maintenance of Indian registered passenger

carrying aircraft, thereby reducing the number of incidents relating to
maintenance issues.

Performance achieved along-with targets set for the year 2015 is given below in
table 1.7

Table 1.7 Target Performance vs Achieved Performance

No. Performance Indicators Target Achieved

Performance
1 Incident involving component/system failures (398) (394)
2 Number of Maintenance errors (22) (54)

Performance of Deficient Maintenance

1000
809
800

600
2013
419 394
400 2014
2015
200
23 33 54
0
Component/ System Failure Maintenance Error

Fig 1.7

16
 1000

809
750

500 419 394

250

0
2013 2014 2015

Incident involving component/system failures

Target

Fig 1.7(a)

60
54

45

33
30
23

15

0
2013 2014 2015
Number of Maintenance errors Target

Fig 1.7(b)

From above it is seen that the unstabilised approaches which continue to land
together with ground collision and Ramp safety are issue of concern for India.
Reporting of the maintenance errors have increased and further rise is expected.

17
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18
Chapter 2

Global Safety
Scenario

19
2.1 INTRODUCTION

This chapter covers the accidents which took place elsewhere in the world
involving commercial transport aircraft with all up weight more than 5700 kgs.
In the year 2015, a total of 92 accidents have taken place among which, 06 were
fatal accidents resulting in 474 fatalities.

World accident with accident rate per million departures

(three year moving rate)
200 5.0
4.37 4.37 4.36
4.15
4.0
150 139 3.85
128 125 3.37
3.03 2.9
116
3.0
98
100 90 97 92
2.0

50
1.0

0 0.0
2008 2009 2010 2011 2012 2013 2014 2015

Number of Accident Rate per Million Departures

Fig2.1

2.2 REVIEW OF FATAL ACCIDENTS 2015

Table 2.1 WorldWide Fatal Accidents 2008-2015

Year Accident Fatal Accidents Fatalities

2015 92 6 474

2008 to 2014 Average 102 14 535

From the year 2008-2015, there has been a gradual decrease in the number
and rate of worldwide fatal accidents.

20
 World fatal accident with fatal accident rate per million
departures(three year moving rate)
35 1.0

30
0.8
25 0.70
0.66
0.6
20 0.57
8
10 4
15 0.42
9 0.4

10 2 0.30
0.24
15 2
14 2 0.2
12 1
5 9 9
7 6 5
0 0.0
2008 2009 2010 2011 2012 2013 2014 2015

Passenger Cargo Rate per million departures (Three year moving rate)

Fig2.2

The worldwide fatality in air accidents and passengers travelled in billion are shown in
the Figure 2.3. Year 2014 shows a sudden increase in the number of fatalities when
compared to the trend seen between year 2008 and 2015. This increase is due to three
fatal accidents in year 2014 counting each to over 100 fatalities. However, in the year
2015, there have been 06 catastrophic accidents resulting into 474 fatalities lesser than
the year 2014.

World Fatalities, Passengers Travelled (In Billion)

1,500 4.0
3.441
3.048 3.218
2.787 2.894
3.0
1,000 2.628
911
2.25
2.208
768
695 2.0
523
474
500 424 386
1.0
173

0 0.0
2008 2009 2010 2011 2012 2013 2014 2015

Number of World Fatalities Passenger travelled (in billion)

Fig2.3

21
2.3 WORLDWIDE FATAL ACCIDENTS - COMMERCIAL
AIR TRANSPORT ABOVE 5700KGS

Table 2.2 Worldwide Fatal Accidents - Commercial Air Transport Above 5700kgs
Date Aircraft Location Fatalities Description
Type
04.02.2015 ATR 72 China 43 An ATR-72-600 aircraft took off from Tai-
pei-Sung Shan Airports at 10:51 hours local
time and turned right, climbing to an altitude
of 1350 feet. At 10:52 the master warning
sounded in the cockpit associated with the
right engine (no. 2) flame out procedure mes-
sage. Some 26 seconds later the left hand (no.
1) power lever was retarded to flight idle.
After twenty seconds the left engine condi-
tion lever was set to the fuel shutoff position
resulting in left engine shutdown.Instead of
continuing the climbing right hand turn, the
airplane turned left and began losing altitude
and speed with several stall warnings sound-
ing in the cockpit. At 10:53, the flight contact -
ed the Sung Shan Tower controller declaring
a Mayday and reporting an engine flameout.
The airplane then turned to the right while the
crew attempted to restart the left hand engine.
This succeeded at 10:54:20 hours. Fourteen
seconds later the stall warning sounded in the
cockpit, the aircraft impacted a highway.
24.03.2015 A 320 France 150 An Airbus A320 was destroyed in an accident
in a mountainous area in southern France. All
144 passengers and six crew members were
killed. Flight departed Barcelona, Spain at
10:00 hours local time (09:00 UTC) on a reg-
ular passenger service to Dusseldorf, Germa-
ny. After reaching the cruising altitude of FL
380, the captain left the cockpit and handed
over radio communication to co-pilot. The se-
lected altitude on the FCU was changed from
3800 ft to 100 ft, auto-pilot was changed to
open descent mode and auto-thrust changed
to thrust idle mode. The airplane started to
descend at high rate of descend. A buzzer
sounded requesting access to the cockpit but
co-pilot did not react. ATC kept contacting
the flight without any response. The aircraft
impacted a sloping rocky ravine in mountain -
ous terrain at an elevation of 1550 meters.

22
13.04.2015 SA 226 Canada 2 The aircraft disappeared from radar only a lit -
tle more than 5min after departure from Van-
couver. As per, Canadas Transportation Safe-
ty Board radar showed a steep descent which
was consistent with uncontrolled flight.
16.08.2015 ATR 42 Indonesia 54 An ATR-42 aircraft was making an approach
for landing at Oksibil airport. The visibility
was good but there was cloudat 8,000ft.It was
the crews second trip to Oksibil that day, and
at their last radio exchange they reported de-
scending through 11,500ft. ATC instructed
the crew to report overhead the aerodrome,
which is standard procedure, followed by a
right hand circuit for runway 11, but the crew
replied they would go for a left base leg onto
final approach. There was no further contact
with the flight. The aircraft hit a ridge of Tan-
goo mountain at approx. 8300 ft AMSL and
about 17 kms from the airport.
31.10.2015 A 321 Egypt 224 An Airbus A 321 aircraft took off from Sharm
El Sheikh Airport at 0500 local time. The last
contact with the flight was at about 0613
hrs, while the aircraft was climbing through
30888 ft altitude with the auto-pilot engaged.
As per the investigators the aircraft broke up
in the air. The wreckage of the aircraft was
spread over the area of more than 13 kms in
length. Traces of explosives were found in the
wreckage of the plane. As per Russian Feder -
al Security Services the crash was caused by
terrorist attack.
16.12.2015 A 319 India 1 An Airbus-319 Aircraft was involved in an
accident during departure from Bay V28 at
around 2050 at Mumbai. After push back
both engines were started, parking brake was
set and tow bar was disconnected, Sr. Service
Engineer was on the head set. Before he
could come out and give hand signal, aircraft
moved forward. All the other ground person-
nel ran away and Sr. Service Engineer was
sucked into No. 2 engine resulting in fatal
accident.
03.11.2015 B 737 Pakistan Nil A Boeing 737-400 aircraft was involved in an
incident of runway excursion while landing
at Lahore Allama Iqbal International Airport,
Pakistan. At the time of accident the visibility
was about 1500 m.

23
26.11.2015 B 737 Mexico Nil A Boeing 737-322 aircraft was involved in an
accident while landing at Mexico city airport.
After landing, during roll-out left hand main
landing gear collapsed and separated.
13.09.2015 A 380 Dubai Nil An Airbus-380-800 aircraft while descend-
ing towards Dubai observed no weather re-
turns on their weather radar while descending
through scattered under cast cloud layer and
the crew observed a cloud formation directly
in line with the Aircraft track and requested
a deviation to avoid the cloud. After passing
the clouds the aircraft encountered up and
down drafts resulting in 10 cabin crew re-
ceiving serious injuries.
08.09.2015 B777 USA Nil A Boeing 777-236 aircraft during the take-off
run at McCarran Airport, Las Vegas suffered
a catastrophic, uncontained failure of the left
engine. This resulted in a fire between left en-
gine and the fuselage.

24
Chapter 3

Indian Safety Scenario

Scheduled Operations

25
3.1 INTRODUCTION

This chapter covers the accidents which took place in India involving scheduled
commercial transport aircraft with all up weight more than 5700 kgs. In the year
2015, a total of 4 accidents have taken place, among which, 01 was fatal
resulting in 01 fatality.

3.2 REVIEW OF ACCIDENTS 2015

Table 3.1

Year Accident Fatal Accidents Fatalities

2015 4 1 1

2008 to 2014 4* 1 158

* One includes accident to foreign aircraft in India

Year 2015- Classification based on Mode of propulsion

Accident involving Jet 2 1 1

Engines
Accident involving 2 0 0
Turboprop Engines

Out of the 04 accidents to Indian aircrafts, two accidents occurred due to the
component failure (landing gear collapsed) and one accident resulted due to
wildlife strike. The details of accidentsis given in table 3.2.

26
3.3 INDIAN COMMERCIAL AIR TRANSPORT ACCIDENTS ABOVE 5700KGS

Table 3.2
Date Aircraft Location Fatalities Description
Type
08.03.2015 Q400 India Nil After landing at Hubli, aircraft veered to-
wards the left side of the runway and in the
process over run the runway edge light fol-
lowed by LH gear collapsed. Thereafter the
aircraft exited the runway to its left side on
Kutcha and came to the final stop at around
52 m away from the runway centre line.
13.04.2015 B737 India Nil The LH landing gear collapsed during land-
ing roll. The crew carried out emergency
evacuation.
04.12.2015 Q400 India Nil After landing on RWY 06 at Jabalpur, during-
ground roll crew suddenly saw 10-11 Boars
on runway. One of the boar hit the left land-
ing gear, which collapsed and the aircraft
skidded and went off the runway to the left.
All passengers were evacuated and there was
no injury.
16.12.2015 A319 India 01 Aircraft was involved in an accident during
departure from Bay V28 at around 2050 at
Mumbai. After push back both engines were
started, parking brake was set and tow bar
was disconnected, Sr. Service Engineer was
on the head set. Before he could come out
and give hand signal, aircraft moved forward.
All the other ground personnel ran away and
Sr. Service Engineer was sucked into No. 2
engine resulting in fatal accident.

The figure 3.1 & 3.2 shows safety performance of Indian aviation is better than
the world aviation safety.

After the tragic accident in year 2010 which resulted in 158 fatalities, major efforts
have been deployed to keep the fatal accident rate to the minimum possible.Due to
these efforts, despite a drastic increase in the number of passengers travelling over
a period of 08 years i.e. from 2008 to 2015, the fatalities count is almost negligible
in the years subsequent to the year 2010.

27
 Comparison Between World Fatalities with Indian
Fatalities
1000
911

768
750 695

523
474
500 424
386

250 173
158

0 0 0 0 0 0 1
0
2008 2009 2010 2011 2012 2013 2014 2015

World Fatalities Indian Fatalities

Fig 3.1

Fig 3.2

28
 Comparison Between World Accidents per Million
Departures With Indian Accident per Million Departures
6

5.09
4.7
4.07 4.3
4 4.07

3.17 3.04
2.79
2.88
2 1.66 1.59
1.38

0 0 0 0
0
2008 2009 2010 2011 2012 2013 2014 2015

Rate of World Accidents per Million Departures

Rate of Indian Accidents per Million Departures

Fig 3.3

3.4. CLASSIFICATION OF ACCIDENTS AS PER ICAO TAXONOMY

As per the worldwide used ICAO taxonomy, classification of Indian aircraft accidents
from the year 2008 to 2015 (excluding the investigations which are not completed) are
shown in fig. 3.4. The classification of the accident as per the CICTT values is based
on the events, factors and cause of the accident.

The figure 3.4 shows that Runway Excursion (RE) is the most commonly applied
category, which is mainly due to the unstabilised approaches which continued to land
coupled with adverse weather conditions and runway conditions.

Accidents classification based on ICAO Taxonomy

5

3
3

2 2
2

1 1 1 1
1

0
RE RI-A LOC-G ARC AMAN FPOST OTHR

*OTHR includes Unstabilised Approaches during landing.

Fig 3.4

29
Intentionally left blank

30
Chapter 4

Helicopter Analysis

31
4.1 INTRODUCTION

This Chapter covers accidents to helicopters in India during the period 2008 to
2015 (Fig. 4.1). Details of few significant helicopter accidents occurring world
over are also covered in this chapter. In the year 2015, a total of 4 accidents have
taken place, of which 03 resulted in 12 fatalities.

For improving the safety in helicopter operations, DGCA has adopted a three
pronged strategy as given below:

1. Regulatory Intervention
2. Audits/Surveillances
3. Interaction with stakeholders and operating crew

Helicopter Accidents
6

5 5 5
5
4 4
4
3 3

3 2 2 2 2

1 1 1

0 0 0
0
2008 2009 2010 2011 2012 2013 2014 2015
Helicopter Accident Fatal Accident

Fig 4.1

32
4.2 INDIAN HELICOPTER ACCIDENTS

Date Aircraft Location
Type
04.08.2015 AS365 N3 India
04.11.2015 AS365 N3 India
23.11.2015 AS350B3 India
24.11.2015 SA365 N India
Table 4.1
Fatalities Description
03 The helicopter was scheduled to operate flight
Dibrugarh-Khonsa-Longding-hanglangDi-
brugarh. Subsequent after the take-off, he-li
copter informed ATC Dibrugarh ETA Khonsa
0447 UTC and changed over to Chabua ATC
at 0429 UTC. At 0508 UTC ATC Chabua
called up to VT-PHK but did not get any re-
ply. Subsequently search and rescue opera-
tions started. On 13.08.2015, the helicopter
was located and bodies were recovered from
the crash site
02 The helicopter took off from JUHU at 4:15
PM and landed at 5PM at WIS platform and
again took off from WIS at 7:15 PM for train -
ing purposes and crashed while attempting to
go around at platform RONTAP MEYER.
07 An AS350B3 helicopter VT-JKB made a
forced landing in an open ground near ra-il
way station at Katra (J&K) on 23.11.2015
around 01:15 PM. The helicopter caught fire.
All the seven occupants received fatal inju-
ries.
Nil Dauphin SA365N helicopter VT-ELJ while
operating flight from Dimapur (Nagaland) to
Meluri (Nagaland) was involved in an acc-i
dent during landing at Meluri helipad (Naga-
land) on 24.11.2015. There were 04 passen-
gers on board the helicopter. After landing
the helicopter caught fire and was destroyed.
Both the flight crew and 02 passengers suf-
fered minor injuries.

4.3 ANALYSIS BASED ON TYPE OF HELICOPTER

Fig. 4.2 shows classification of helicopter accidents based on the major

types of helicopter being flown in the country. Both single engine and
multi-engine helicopters cater to equal shares in accidents. This is in line
with the types of helicopters used when performing operations.

33
4.6 WORLD-WIDE HELICOPTER ACCIDENTS

Table 4.2
Date Aircraft Location Fatalities Description
Type
09.03.2015 AS350B3 Argentina 10 Two helicopters were involved in a mid-air
collision near Villa Castelli in Northwest
Argentina. The crash resulted in fatality to
all the ten people on-board the two helicop -
ters. The aircrafts involved were both Eu-
rocopter AS350B3 cureuils, with registra -
tion numbers LQ-CGK and LQ-FJQ. Each
helicopter was carrying four passengers
in addition to the pilot. Just seconds after
take-off, the two helicopters were involved
in a mid-air collision at a height of about
100 m above the ground
08.01.2015 EC 130 B4 Mexico 02 The private helicopter with registration
XA-SMG with five occupants crashed en-
route to Juarez, Mexico. The helicopter
crashed under unknown circumstances.
Two of the occupants received fatal injuries
and the other three were injured.
02.06.2015 AS350 B3+ Nepal 04 The helicopter with registration 9N-AJP
crashed in the Sindhupalchowk district of
Nepal. All four occupants received fat-al
ities and the helicopter was consumed by
post-crash fire.
29.05.2015 AS355 N Brazil 05 The helicopter with registration PR-ADA
crashed near Tabatinga, Brazil. The he-li
copter took off to perform a patient remov-
al flight to Tabatinga. At approximately 19
NM from Tabatinga, the aircraft collided
with treetops. All the five occupants re-
ceived fatalities.
04.04.2015 SA365N2 Malaysia 06 The helicopter with registration 9M-IGB
crashed in Semenyih, Kajang, Malaysia.
All the six occupants received fatalities.
31.03.2015 Bell 206L-4 Chile 04 The helicopter with registration CC-APP
crashed in the Andes Mountain near Llan-
ta, Chile. All the four occupants received
fatalities. The helicopter was flying in the
crash region with 3 engineers to analyze
extensive floods caused by heavy rains.

36
27.03.2015 AS350 B3 Mexico 04 The helicopter with registration XA-DSO
crashed in the San Martin de Torres, Oaxa-
ca, Mexico. All the four occupants received
fatalities. The helicopter was engaged in
transport in support of phone system main-
tenance. It crashed in adverse weather con-
ditions shortly after take-off. There was
post-crash fire
13.03.2015 AS365 N3 South 04 The helicopter with registration B511
Korea crashed off Sinan-gun. South Korea. All the
four occupants received fatalities. The he-
licopter was engaged in transporting a pa-
tient to an inland hospital and crashed into
the sea while trying to land near a seawall
on Gageodo Island
28.01.2015 Bell UH-1H Vietnam 04 The helicopter with registration 7912
crashed in Ho Chi Minh City in Vietnam.
All the four occupants received fatalities.
The helicopter crashed on a training flight
just a few minutes after take-off.

37
Intentionally left blank

38
Chapter 5

Non Scheduled Operators

and General Aviation

39
5.1 INTRODUCTION

This chapter covers the accidents which took place in India involving Non-
Scheduled Commercial Transport (NSOP) and General Aviation (GA)
aircrafts. In the year 2015, a total of 4 accidents have taken place in NSOP
category and 01 in General Aviation category.

5.2 NSOP ACCIDENTS ANALYSIS

Fig 5.1 shows accidents which occurred in the category of Non-Scheduled

Operators compared to the number of fatal accidents. The trend indicates the
slight increase in the number of accidents in the NSOP category, which remains
the area of focus for the year 2016.

Comparison of Number of Accidents

6
5 5 5
5
4 4
4
3 3

3 2 2 2 2

1 1
1
0 0 0
0
2008 2009 2010 2011 2012 2013 2014 2015
Number of Accidents - NSOP Number of Fatal Accidents

Fig 5.1

5.3 CLASSIFICATION OF ACCIDENTS AS PER ICAO TAXONOMY

Multiple Occurrence categories have been assigned to each of the NSOP accident
from the year 2008-2014 (excluding the investigations which are not completed), for
assisting in the identification of particular safety issues. This was done using the ICAO
CICTT occurrence categories.

40
Figure 5.2, shows the number of NSOP accidents as per ICAO defined Occurrence
Category. The most common risk areas for accidents were Loss of Control Inflight
(LOC-I) followed by Abrupt Maneuver, Controlled Flight into terrain and System/
component failure or malfunction (non-power plant).

Accidents classification Based on ICAO Taxonomy-Aircraft

Under NSOP
10

8
7

4
3 3 3
2 2 2
2
1 1 1 1 1 1

0
AMAN CFIT CTOL UIMC LOC-I SCF-NPSCF-PP USOS F-POST RE LOC-G FUEL OTHR

*OTHR includes cabin crew fall from helicopter during flight.

Fig 5.2

5.4 GENERAL AVIATION ACCIDENTS

General Aviation is small but forms an important part of the aviation community.

General Aviation in India is broadly classified into following 03 (three) categories:

a. State Governments
b. Flying Schools
c. Private

Fig 5.3 shows comparison of total accidents with fatal accidents in the General
Aviation category. The trend indicates the decrease in the number of accidents in the
General Aviation category which is certainly positive.

41
 General Aviation
6
5

4
4
3 3 3 3

2 2 2
2
1 1 1 1 1 1 1

0
2008 2009 2010 2011 2012 2013 2014 2015

Number of Accidents Fatal Accidents

Fig 5.3

Fig. 5.4 shows the accidents as per the category of the operator for the years
2008 to 2015. Accidents in the General aviation category also indicate a
deceasing trend. This is after a high of 5 accidents in the year 2012.

In the year 2014 the number of accidents engaged in the flying training
activities has maintained the trend from the previous years. However, the
analysis of accident data pertaining to flying training organisations from the
year 2009 to 2013, points towards following causative factors:

? Improper Handling of Controls

? Improper Landing Technique
? Low Flying
? Maintenance
? Weather

As the number of accidents in flying training operations continued the trend,

this was the area of focus for the year 2015. Due to ongoing efforts, the rate has
been brought down to zero in the year 2015

42
 General Aviation Accident-Operator Type
4

3
3

2 2 2 2 2 2

2
1 1 1 1 1

0 0 0 0 0
0
2008 2009 2010 2011 2012 2013 2014 2015
State Government Flying School Private

Fig 5.4

5.5 CLASSIFICATION OF ACCIDENTS AS PER ICAO TAXONOMY

Multiple Occurrence categories have been assigned to each of the General Aviation
accidents from the year 2008-2015 (excluding the investigations which are not
completed), for assisting in the identification of particular safety issues. This was done
using the ICAO CICTT occurrence categories.

Figure 5.5, shows the number of General Aviation accidents as per ICAO defined
Occurrence Category. The most common risk areas for accidents were Loss of Control
Inflight (LOCI), Low Altitude Flying followed by Controlled flight into terrain,
Abrupt Maneuver and System/component failure or malfunction (power plant).

General Aviation Accidents classification based on ICAO Taxonomy

10

8
8
7

4 4
4
3 3
2
2
1 1 1 1 1 1

0
ARC AMAN BIRD LALT LOC-I SCF-NP SCF-PP USOS CFIT WSTRW RE FPOST UIMC

Fig 5.5

43
Intentionally left blank

44
Chapter 6

Incidents Analysis

45
6.1 INTRODUCTION

This chapter covers the incidents/occurrences which took place to Indian

aircrafts. In the year 2015, a total of 2226 occurrences were reported to DGCA
India which is itself a significant number but still needs improvement.
Occurrences include all incidents, accidents and serious incidents.

6.2 REVIEW AND ANALYSIS OF SAFETY DATABASE FOR THE YEAR 2015

6.2.1 Mandatory Incidents Reporting

CAR Section 5 Series C Part I on Notification of Incidents and Investigations

thereof requires reporting of occurrences to DGCA/AAIB.

DGCA has established ECCAIRS (European Coordination Centre for Accident

and Incident Reporting Systems) for the recording/reporting of occurrences.
The system has become effective from January 2015 onwards, and the database
format is compatible with the ICAO requirements. All the operators have been
encouraged to report the occurrences in the ECCAIRS format.

A total of 2226 occurrences were reported to DGCA.

10 were Classified as Accidents
5 were Classified as Serious Incidents
11 were classified as incidents and were investigated by DGCA
under Rule 13 (1) of Aircraft Rules 2012.
574 were classified as incidents and were investigated

6.3 ANALYSIS OF INCIDENTS PERTAINING TO SCHEDULED AIRLINES

For analysis, incidents are classified in following categories:
Engineering Incidents
Operational Incidents
Ground Incidents
Human Error Incidents
Miscellaneous Incidents

Note: Miscellaneous incidents includes FOD damage, weather related

incidents (i.e. windshear, lightning strike and turbulence), cabin safety related
incidents (passenger smoking in lavatory, injury while servicing etc).

46
Fig. 6.1 shows incidents to scheduled airlines classification on the basis of
their area of occurrence. The major share among incidents is of engineering
incidents followed by operational incidents

6.4 ANALYSIS OF INCIDENTS PERTAINING TO SCHEDULED AIRLINES

Total Incidents
6

5 5.2

2
0.9
1 0.8
0.3 0.1
0
Engineering Operational Ground Human Error Misc.

Rate of Incidents per 10,000 departures

Fig 6.1

6.5 ANALYSIS OF OPERATIONAL INCIDENTS

Operational incidents are analysed as per phase of flight

Take off
Landing
Approach
En route
Operational Incidents as per Phase of Flight
Climb
Taxi
Standing/Push back 4% 3%10% 19%
Landing
13% Take -Off
Approach
26% Enroute
Climb
25%
Taxi
Standing

Fig 6.2

47
6.6 FLEET WISE ENGINEERING INCIDENT ANALYSIS
Analysis of incidents as per type of Aircraft
A 320
B 737
B 777
B 787
ATR
Q400
B757
Other Aircraft types
(A330, B747, CRJ)

Fleet Wise Engineering Incident Analysis

3% 2%

7%
10% A 320
44%
4% B 737
2% B 777
B 787
ATR
Q 400
28%
B 757
Other Fleets

Fig 6.3

48
6.7 INCIDENT CLASSIFICATION AS PER CICTT VALUES

Multiple Occurrence categories have been assigned to each of the General Aviation
accident, for assisting in the identification of particular safety issues. This was done
using the ICAO CICTT occurrence categories, which are given in Glossary.

Figure 6.4, shows the number of incident as per ICAO defined Occurrence Category.
The most common risk areas are System/component failure or malfunction (non
power plant), System/component failure or malfunction (power plant) followed by
turbulence and aerodrome related. This can also be related to fig 6.1, as the majority of
incidents are in the area of engineering.

Incident Classification as per CICTT Values

ADRM
4%
ARC
10%
1% ATM/CNS
0%
4% CABIN

69% CFIT
F-NI
2% 4%
FUEL
1%
ICE
1%
LOC-I

3% OTH
1% RAMP
SCF-NP

Fig 6.4

49
Intentionally left blank

50
Chapter 7

Aerodromes

51
7.1 INTRODUCTION

This Chapter covers the aerodrome related occurrences which took place to
Indian aerodromes. Aerodrome related occurrences are broadly classified into
three categories:

1. Wildlife Strikes
2. Ground Incidents
3. Runway Incursion

7.2 STUDY ON WILDLIFE STRIKE

Animal Strike/Animal Straying in Operational Area

40
34

30
24

20 17
14 13

10
6
4
2 1 2
0
2011 2012 2013 2014 2015

Animal Stray Confirmed Strike

Fig 7.1

Wildlife Analysis

18%

No Damage
Damage

82%

Fig 7.2

52
 Wildlife Analysis (Phase - wise)

0%
5% 3%
6% Landing
36%
Take -Off
18% Taxi
Approach
Ground Check
Manoeuvring
30%
2% Enroute
Unknown

Fig 7.3

7.3 GROUND INCIDENTS

Ground Incident Data

40

31
29
30
25

20

10 8
3 4 3 4
2 1 1 2
0 0 0
0
Ground Collision Ramp Vehicle/equipment to Vehicle to person Vehicle to vehicle
parked aircraft

2013 2014 2015

Fig 7.4

53
 Ground Incidents per 10000 departures
1.00

0.80
0.67

0.60 0.55
0.48

0.40

0.20

0.00
2013 2014 2015

Fig. 7.5

7.4 RUNWAY INCURSIONS

30

25
25

20
20
16
15 14

10
10
7

5 4
2

0
2008 2009 2010 2011 2012 2013 2014 2015

Runway Incursion

Fig 7.6

54
7.5 CAUSATIVE FACTORS OF RUNWAY INCURSIONS

The major factors involved in runway incursions are as listed below:

Use of non-standard phraseology.
Incorrect read back of ATC instructions by the pilot or the vehicle driver.
Failure of the controller to ensure that the read back by the pilot or the
vehicle driver conforms with the clearance issued.
The pilot and/or vehicle driver misunderstanding the controller's
instructions.
The pilot and/or vehicle driver accepting a clearance intended for another
aircraft or vehicle.
Loss of situational awareness by pilots, non-familiarization with
aerodrome layout.
Inadequate signage and markings (particularly the inability to see the
runway-holding position lines) or multiple holding position.
A complicated airport design/ taxiway.
Failure to obtain clearance to enter the runway by vehicle driver.
Vehicle driver non familiar with aerodrome layout.

55
Intentionally left blank

56
Chapter 8

Air Traffic Management

57
8.1 INTRODUCTION

Airprox incidents are investigated by the board constituted for AIRPROX

Incident Investigation. Based on the investigation various causative factors are
ascertained. Fig. 8.1 shows a decreasing trend in the year 2015 when compared
to the earlier years.

20

16.49
15

12.33 11.75
10

0
2013 2014 2015

Number of AIRPROX per million flights over Indian Airspace

Fig 8.1

8.2 YEAR-WISE GRAPHICAL PRESENTATION OF AIRPROX ON

THE BASIS OF ABOVE LISTED ERRORS

Factor Causing Airprox- Yearwise

25

20
20 18
16
15
11 11
10

5 5
5 3 3
2 2
1 1
0 0
0
2013 2014 2015

Attributable to ATCO Attributable to Crew Attributable to System

Attributable to Organisation Attributable to other factors

*Others includes AIRPROX attributable to Air Force/ Adjacent States

Fig 8.2

58
8.3 CLASSIFICATION IN ACCORDANCE WITH ECCAIRS TAXONOMY

A total of 28 contributory factor have been identified in accordance with ICAO

ECCAIRS taxonomy during the analysis of the AIRPROX incidents.This
includes incident data for three years from 2013 to 2015.

AIRPROX incidents as per ECCAIRS Taxonomy

30 Clearance-wrong altitude
27
Conflict detection/ resolution

Clearance-not suitable for the aircraft

23 Deviation-assigned details

Deviation-climb/descent
18
Organisation factor

Read back & Hear back error

15
Coordination

10 Military intervention
9
Updation of data by ATC person
7
8
6 ATM/CNS Serviceability
5
4 4 4
3 3 3 3 Flight crew & ATM data

Similar call sign

0 Others
ECCAIRS Factors

*Others includes: Deviation-approach, Approach on wrong rwy, Handing over

procedure, Deviation-ATM regulations, Deviation- ATCclearance, System/crew
mismatch,, Aircraft component failure, Failure of ATM, Deviation- landing, ATM
procedure not defined, Non-use of aids, Skill/knowledge, Provision of ANS traffic
information, Deviation- flight level/altitude, Clearance- wrong heading.

Fig. 8.3

59
Intentionally left blank

60
Chapter 9

State Safety Oversight

61
9.1 INTRODUCTION

The DGCA has prepared an Annual Surveillance Programme (ASP) based on

experiences gained during 2009 to 2014 comprising of safety oversight plan of
all Directorates. The Annual Surveillance Programme (ASP) of 2015 was
operationalized for safety oversight activities of the operator from January 1,
2015. The respective directorate carried out the surveillance activities as per
plan and provided data to Hqrs regularly during the year.

9.2 AREAS OF SAFETY OVERSIGHT

The DGCA Safety Oversight Programme had been divided into 8 areas:

1. Surveillance Activities (Planned Inspection)

2. Regulatory Audit (Planned Audit)
3. SOFA
4. Spot Checks (Unplanned Checks)
5. Night Surveillance
6. Ramp Checks
7. Surveillance of Foreign MRO
8. Inspections carried out under the directions of the DG.

Followings additional programme were introduced in the 2015 ASP:

1. The Ramp inspections program for schedule operators

2. Surveillance of Foreign MROs to comply with the requirements

9.3 DIRECTORATES PARTICIPATING IN THE SAFETY

OVERSIGHT PROGRAM
1. Directorate of Airworthiness
2. Directorate of Air Safety
3. Flight Standards Directorate
4. Directorate of Aerodrome
5. Air Space & ANS Directorate
6. Directorate of Flying, Grant & Training
7. Ramp/SAFA Inspection
8. Cabin Safety Division
9. Dangerous Goods Division
10. Directorate of Aircraft Engineering

62
9.4 OVERVIEW OF SAFETY OVERSIGHT

328

2091

12

5521

Total no. of surveillance conducted Total deficiency detected level I

Total deficiency detected level II Enforcement

Fig 9.1

A total of 2091 surveillances were carried out in the year 2015 on the
stakeholders in India. Deficiencies observed during the surveillance are
classified as level I and level II findings.

Level I findings correspond to a significant non-compliance with the applicable

requirement which lowers the safety standard and seriously hazards flight
safety. In the year 2015, 12 level I findings were observed.

Level II findings correspond to any non-compliance with the applicable

requirement which could lower the safety standard and possibly hazard
flight safety. In the year 2015, 5521 level II findings were observed.

Based on the discrepancies observed while carrying out oversight of the various
stakeholders in DGCA, a total of 328 enforcement actions were taken which
consisted of warnings, suspensions, corrective actions, show cause notices,
withdrawals, de-rostering, non-renewal of CPL, cancellations etc.

9.5 AREAS OF SAFETY CONCERN

Analysis of the discrepancies observed during the oversight indicates non-
compliances against major eight parameters. The eight weak areas for most of
the operators are as enumerated.

63
 1. Facility Staffing and Training
2. Personnel Proficiency
3. System of Disseminating Information
4. Currency and Adequacy of manuals
5. Facility Organization and Effectiveness
6. Mass and Balance.
7. Emergency response plan
8. Recurrent flying training

The areas of concern observed from the Surveillance Inspections of aerodromes

carried out in the year 2015 are as mentioned below:

1. Runway surface condition

Rubber deposit on Runway

Depressions / cracks on Runway

2. Runway / Taxiway strip maintenance

Undulated strip
Vegetation growth

3. RESA (Runway End Safety Area) maintenance- Vegetation growth

4. Fire station

Maintenance of vehicles
Maintenance of training records of fire personnel
Refresher training for fire personnel

5. Calibration of Navigational Aids (VOR / ILS / PAPI)

6. Manpower shortage in departments such as Fire, ATC, CNS etc.

64
Chapter 10

State Safety Promotion

65
10.1 COLLECTION OF SAFETY INFORMATION

10.1.1 Mandatory Occurrence Reporting

CAR Section 5 Series C Part I on Notification of Incidents and Investigations

thereof requires reporting of occurrences to DGCA/AAIB.

DGCA has established ECCAIRS (European Coordination Centre for Accident

and Incident Reporting Systems) for the recording/reporting of occurrences.
The system has become effective from January 2015 onwards, and the database
format is compatible with the ICAO requirements. All the operators have been
encouraged to report the occurrences in the ECCAIRS format.

10.1.2 Voluntary/confidential Reporting System

Aeronautical Information Circular 03/2015 on Voluntary Reporting

System has been issued.
Air Safety Circular 02 of 2015 on Voluntary Reporting System has
been issued which enhances aviation safety through the collection of
reports on actual or potential safety deficiencies that would otherwise
not be reported through other channel.

10.2 INTERNAL TRAINING, COMMUNICATION AN

DISSEMINATION OF SAFETY INFORMATION
The DGCA has established appropriate Training Programme for its
officers. Each individual's development and training needs including
SSP/SMS is being assessed upon induction at DGCA by Training
Directorate. Both initial and recurrent training is provided to
officials/inspectors. The trainings are being conducted at regular
intervals as per the annual training programme developed by the
Training Directorate in consultation with the concerned directorates.

DGCA communicates and disseminates safety-relevant information

within the DGCA through circulars, emails, DGCA website, DGCA
intranet, Safety alerts, workshops etc.

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10.3 EXTERNAL TRAINING, COMMUNICATION AND
DISSEMINATION OF SAFETY INFORMATION

DGCA communicates with Stakeholders in many different ways. At a

high level, safety is addressed in the MOCA's Annual Report. DGCA has
developed a State Safety Plan which describes in more detail the high-
level safety objectives and outline the DGCA's programme of work to
achieve continuous safety improvement and is published on DGCA
website.

DGCA also provides/publishes guidance to support regulatory action in

the form of case studies, circulars, public notices, seminars, meetings,
etc.

10.4 AREAS OF CONCERN

10.4.1 Unstabilised Approaches

The trend for unstabilised approaches is increasing. This is primarily due

to enhancement in the reporting culture among the stakeholders.
However, it continues to be a concern for the State. Fig. 1.4 (c) shows
increase in the unstabilised approaches when performing a precision
approach. The analysis has indicated one of the most common factors as
decelerated approaches.
To address this area of concern, a study on unstabilized approaches was
undertaken by DGCA. To emphasize this issue and develop action plan
for reducing unstabilised approach which continue to land, data for the
past few years was analysed and shared with the stakeholders. The study
also points out to the fact that majority of unstabilised approaches have
continued in to landing, which mirrors the word wide trend.
The aim is to encourage pilots to go around when approach becomes
unstabilised and also to reduce the number of unstabilised approaches by
policy intervention and participation by all the stake holders and fine
tuning of training of the pilots.
In this direction, DGCA has issued instructions in form of two circulars
as a safety measure i.e

Air Safety Circular prescribing speed control during approach

(below FL100 and below 3000 feet and within 20 nm)

Operation circular emphasizing on non-punitive policy towards

Go Around

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10.4.2 Wildlife Hazard Management

As part of the State Safety Programme, one of the most important State
Safety Priority and another area of concern was identified as Wildlife
(Bird/Animal) Strike to the aircraft. Analysis of data has revealed that 18
Airports are critical with respect to Wildlife Strikes.
DGCA has carried out the aerodrome inspection for these identified 18
airports and all the findings have been addressed by the aerodrome
operators.
A high power National Bird Control Committee has been set up by
Government of India.
DGCA has also conducted several seminars to educate the stakeholders
on the management of wildlife hazards.
The following measures are being adopted by the wildlife control
Management units at various airports in India to achieve the targets,
which are as follows:

Identification & mapping of attractant & habitat locations.

Implement an effective structured and systematic process of
mapping, monitoring, and identifying bird movements on the
critical locations on airside on daily basis.
Data base management systematic process in monitoring and
mapping the movement pattern.
Deploy manpower and equipment based on the previous week
bird movement analyzed data.
Deploying additional equipment and devices for monitoring wild
life activity and replacing devices due wear and tear for
increasing efficiency in control management.
Grass cutting in Basic strip, Taxiway shoulders, Taxiway strips,
ILS areas, and RESA for maintaining height of grass upto 15 cm.
Effective disposal of organic material (plant material) outside the
airside areas to avoid insect attraction.

Due to the above efforts, Indian Airports have been able to control
wildlife hazard.

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10.4.3 Similar/Confusing Call Signs

The use of similar/confusing call signs by aircraft operating in the same

area, at the same time, and on same frequency often give rise to potential
and actual confusion leading to misunderstanding between pilots of
different aircraft/pilots and controllers. As a result, one aircraft may act
on the clearance meant for another aircraft. This hazard is usually
referred to as Call Sign confusion.
The potential safety consequences of an aircraft taking and acting on a
clearance intended for another can cause serious incident. This could
result in loss of communication, level burst, loss of separation, airprox
or a mid-air collision.
To review the current practices in India regarding assigning of call
signs and harmonizing them with the international best practices,
DGCA, India constituted a committee while recognizing the hazards
of similar call signs.
Based on the study and analysis, the committee gave the following
recommendations:

Necessary regulations containing call sign similarity rules, and

general practices may be issued for compliance by the airlines
and the airport operators.
Mechanism for continuous monitoring and dispute resolution
should be established which should also include notification of
call sign confusion to the flight operation department of the
concerned airlines/ANS provider.
All the airline operators may be directed to amend the confusing
call signs on urgent basis.

10.5 WAY FORWARD

10.5.1 Appropriate State Safety Oversight

Indian aviation is in a state of continuous change. The aviation sector is one of

the fastest growing in the world and service providers are experiencing a
number of operational, technical and financial challenges all of which can have
an effect on safety. A key focus for the DGCA during the period of this Safety
Plan will be on ensuring that it remains fit-for-purpose and continues to provide
an appropriate and effective level of regulatory and safety oversight that
balances needs of the industry, travelling public and the international
community.

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10.5.2 Review of State Safety Plan

The safety analysis has brought out areas of concern. The state safety plan and
safety action plan will be reviewed to address the concern and achieve
acceptable level of safety.

10.5.3 Progressive Adoption of Safety Culture

Adoption of an appropriate safety culture, which encourages reporting and

helps to reduce risk across the aviation sector, is a challenge. Whilst the DGCA
and many service providers (through their SMS) have initiated their own
activities to develop a safety culture, it is likely to take a number of years before
tangible benefits are realised. Therefore, DGCA aims at progressing the
development of a safety culture amongst all service providers' staff, initially
evidenced by increased reporting and a willingness to share more safety related
information, and to develop a means of measuring the safety culture of an
organisation.

10.5.4 Safety Management System Implementation by Operators

Safety Action Plan to achieve the targets has been established in

consultation with stakeholders. Detailed targets and safety action plan
issued in the form of Handbook State Safety Plan (2015-2016) has been
published. Based on the DGCA India State Safety Plan, operators have
developed their own action plans to cater the risks evolving in the
aviation sector.

The focus will also be on other applicable service providers that have
completed the implementation of their SMS viz. NSOPs, MROs,
Aircraft design & production Organizations, and Flying training
organizations.

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 GLOSSARY
Acronym Definition
ADRM Aerodrome
AIRPROX Air Proximity incident
AMAN Abrupt Maneuver
ARC Abnormal Runway Contact
ATC Air Traffic Control
ATM ATM/CNS
CAR Civil Aviation Requirement
CFIT Controlled Flight Into Terrain
CTOL Collision With Obstacle(s) During Takeoff and Landing
DGCA Directorate General of Civil Aviation
EGPWS Enhanced Ground Proximity Warning System
FL Flight Level
F-NI Fire/Smoke (non-impact)
F-POST Fire/Smoke (Post- Impact)
FUEL Fuel Related
GCOL Ground Collision
GPWS Ground Proximity Warning System
ICAO International Civil Aviation Organization
ICE Icing
LALT Low Altitude Operations
LOC-1 Loss of Control-Inflight
LOC-G Loss of Control-Ground
LVP Low Visibility Procedure
MoCA Ministry of Civil Aviation
MRO Maintenance Repair and Overhaul
NSOPs Non Scheduled Operator Permit
OTHR Other
RA Resolution Advisory
RAMP Ground Handling
RE Runway Excursion

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RI-A Runway Incursion- Animal
RI-VAP Runway Incursion-Vehicle, Aircraft or Person
SCF-NP System/Component Failure or Malfunction (Non-Power
Plant)
SCF-PP System/Component Failure or Malfunction (Power Plant)
SMS Safety Management System
SOPs Standard Operating Procedures
SPI Safety Performance Indicator
SSP State Safety Programme
TCAS Traffic Collision Avoidance System
TURB Turbulence Encounter
UIMC Unintended flight in IMC
USOS Undershoot/overshoot
VFR Visual Flight Rules
WSTRW Windshear or Thunderstorm

72
 LIST OF TABLES

Chapter 1

Table 1.1 Target Performance vs Achieved Performance - Airborne Conflict

Table 1.2 Target Performance vs Achieved Performance - CFIT

Table 1.3 Target Performance vs Achieved Performance -

Runway excursions and overrun

Table 1.4 Target Performance vs Achieved Performance -

Wildlife and Bird strikes

Table 1.5 Target Performance vs Achieved Performance -

Loss of Control in Flight

Table 1.6 Target Performance vs Achieved Performance -

Ground collision and Ramp Safety

Table 1.7 Target Performance vs Achieved Performance -

Deficient Maintenance

Chapter 2

Table 2.1 WorldWide Fatal Accidents 2008-2015

Table 2.2 Worldwide Fatal Accidents - Commercial Air Transport Above

5700kgs

Chapter 3

Table 3.1 Indian Accidents 2008-2015

Table 3.2 Indian Commercial Air Transport Accidents above 5700kgs

Chapter 4

Table 4.1 Indian Helicopter Accidents

Table 4.2 Worldwide Helicopter Accidents

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 LIST OF FIGURES

Chapter 1

Fig 1.1 Performance of Airborne Conflict, KPI - 1

Fig 1.1(a) Risk bearing AIRPROX per 10,00,000 flights

Fig 1.1(b) TCAS/RA per 10,00,000 flights

Fig 1.1(c) Non compliance with ATC instructions per 10,00,000 flights

Fig 1.1(d) ATC/System failure per 10,00,000 flights

Fig 1.2 Performance of CFIT

Fig 1.2(a) Helicopter emergency landing due to bad weather per 10,000
departures

Fig 1.2(b) GPWS/EGPWS Warning per 10,000 flights

Fig.1.3 Performance of Runway Excursion and Overrun

Fig 1.3(a) Unstabilised approach per 10,000 approaches

Fig 1.3(b) Unstsbilised approaches that continued to land per 10,000

approaches

Fig 1.3(c) Unstabilised approaches when performing a precision

approach per 10,000 approaches

Fig 1.3(d) Unstabilised approaches when performing a non precision

approach per 10,000 approaches

Fig 1.3(e) 'Near' Runway excursions per 10,000 approaches

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Fig 1.3(f) Unstabilised approaches when performing a visual approach
per 10,000 flights

Fig 1.3(g) Runway excursions per 10,000 approaches

Fig 1.4 Performance of wildlife & Birds Strike

Fig 1.4(a) Reported wildlife strikes per day

Fig 1.4(b) Reported bird strikes per 10,000 movements

Fig 1.4(c) Runway incursions by wildlife per day

Fig 1.5 Loss of control events per 10,000 departures

Fig 1.6 Performance of Ground Collision and Ramp Safety

Fig 1.6(a) Number of runway incursions (aircraft)

Fig 1.6(b) Number of runway incursions (vehicle)

Fig 1.6(c) Number of runway incursions (person)

Fig 1.6(d) Number of ramp incidents that result in damage to aircraft,

vehicles, or loss of life/serious injury to personnel

Fig 1.7 Performance of Deficient Maintenance

Fig 1.7(a) Incidents involving component/system failures

Fig 1.7(b) Number of maintenance errors

Chapter 2

Fig 2.1 World accidents with accidents rate per million departures
(three year moving rate)

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Fig 2.2 World fatal accident with fatal accidents rate per million
departures (three year moving rate)
Fig 2.3 World fatalities, passengers traveled (in billion)

Chapter 3
Fig 3.1 Comparison Between World Fatalities with Indian Fatalities
Fig 3.2 Fatalities per Million Passenger Traveled
Fig 3.3 Comparison Between World Accidents per Million Departures
with Indian Accident per Million Departures
Fig 3.4 Accidents classification based on ICAO Taxonomy

Chapter 4
Fig 4.1 Helicopter accidents
Fig 4.2 Helicopter accident based on helicopter type from year 2008 to
2015
Fig 4.3 Helicopter Accidents according to type of operations
Fig 4.4 Helicopter Accidents Classification Based on ICAO Taxonomy

Chapter 5
Fig 5.1 Comparison of number of accidents
Fig 5.2 Accidents classification Based on ICAO Taxonomy-Aircraft
Under NSOP
Fig 5.3 General aviation
Fig 5.4 General aviation accidents operator type
Fig 5.5 General aviation Accidents classification based on ICAO
Taxonomy

Chapter 6
Fig 6.1 Total Incidents
Fig 6.2 Operational Incidents as per Phase of Flight

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Fig 6.3 Fleet Wise Engineering Incident Analysis
Fig 6.4 Incident Classification as per CICTT Values

Chapter 7
Fig 7.1 Animal strike/ Animal straying in operational area
Fig 7.2 Wildlife analysis
Fig 7.3 Wildlife analysis (phase wise)
Fig 7.4 Ground Incidents Data
Fig 7.5 Ground incidents per 10,000 departures
Fig 7.6 Runway Incursion

Chapter 8

Fig 8.1 Number of AIRPROX per million flights over Indian airspace

Fig 8.2 Factors causing AIRPROX - Year wise

Fig 8.3 AIRPROX incidents as per ECCAIRS Taxonomy

Chapter 9

Fig 9.1 Overview of safety oversight

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 End
of
Report

78