梅村行男-日本航空业的安全经验

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航空

Ministry of Land, Infrastructure, Transport and Tourism
日本航空业的安全经验
2009. 5.152009. 5.15
北京
梅村行男
日本民用航空局 (JCAB)
飞行标准处副处长
中国民航发展论坛20092009
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报告摘要
1. 日本的交通流量和事故数量
2. 事故、严重事故征候以及日本民航局的应对行动
3. 日本民航局的积极举措
4. 调查问卷
May 15, 2009
Safety Experience JCAB
Ministry of Land, Infrastructure, Transport and Tourism
安全是最成功的成本控制
事故告诉我们如何避免事故
零事故是最佳方法日本民航局的反应和预防性举措
4约3.53.5小时21002100千米
11-1 中国大陆与日本间的交通流量11001100万人访问中国和日本As of 2008As 2008Safety Experience JCAB
May 15, 2009每周约800800个航班
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1-2 访日的外国旅客２月-41.3％１月-18.4％10T20092009年22月, 访日人数与上年相比下降了41%。
May 15, 2009Safety Experience JCAB
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截至20082008年：1亿6千万人次//年
11--3 日本各航空公司
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11--4 全世界的事故
From ”ICAO ICAO” Data
致命事故（定期航班）（）Rate /M Dep.Number
Safety Experience JCAB
May 15, 2009
8012345199019921994199619982000200220042006(Number)0246810(Rate)PilotMechanical TroublesTurbulenceOthersAccidents per One Million Departure(财年)
1-5 涉及日本航空公司的事故○每年有几宗事故涉及日本航空公司。○自1986年以来，日本航空公司没有发生过涉及旅客生命的致命事故。1994/6/18A320, 降落时尾部接触1996/05/15A300-600,降落时尾部接触1997/06/08MD-11, 自动驾驶断开后的震荡造成机上乘客受伤2000/02/16YS-11A, 滑出跑道2003/06/07B767, 突然停止造成乘务员受伤2003/10/22B747, 起飞时尾部接触2007/3/13DHC-8, 前起落架收起状态下着陆注: 自然死亡等未计入2002/06/26B767, 接地时脱离跑道2004/01/01DC-9, 着陆滑行时主起落架倒塌2008/3/11MD90, 鸟击造成机身损坏2007/11/3B767, 餐车碰撞造成乘客受伤From ””JTSBJTSB””Home pageHome page飞行员机务维修问题紊流其他事故百万架次率
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2. 在日本发生的事故和严重事故征候
• 案例1. . TCAS 告警
空中危险接近
• 案例2. . 机械故障
发动机起火
• 案例3. . 客舱安全
餐车滑出厨房
• 案例4. . 跑道侵入
未接到放行许可时起飞
May 15, 2009
Safety Experience JCAB
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案例1. 空中危险接近事故
• 2001. 1. 31
• TCAS 提示““爬升””，飞机，AA却遵照管制员指令下降。两名乘务员受重伤，8181名乘客和另外1010名乘务员受轻伤，飞机A 轻微损伤。
• 飞机B 遵照TCASTCAS提示““下降””, , 机上250250名乘客无人受伤，飞机没有任何损伤。
• 飞机A的机长迅速进行规避机动，避免了与飞机BB的相撞。
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
11高度差B2B1A2仰角水平距离斜距垂直距离A1--B1: 飞机B越过飞机A时两架飞机的相对位置A1A2--B2: 最接近时两架飞机的相对位置最小斜距:135m+/-30m垂直距离:130ft+/-70ftBased on
Based 案例 1. 空中危险接近””JTSBJTSB””reportreportMay 15, 2009Safety Experience JCAB
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案例1: 飞机A机长的视野About 17About 17ﾟ0.36 s5555～～6060ﾟ3838～～4040ﾟposition of the sun2～10 seconds before the Closest ApproachBased on Based ””JTSBJTSB””reportreportMay 15, 2009Safety Experience JCAB太阳位置最危险时刻前2-10秒大约17。
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案例 1:TCAS 天线和显示器顶部ATC天线底部定向天线顶部定向天线TCASTCAS
底部ATC天线12612610101010主飞行显示器(PFD)导航显示器(ND)10306355210其他活动爬升指令拉起指令临近活动RATA
Based on ”JTSB JTSB” report
May 15, 2009
Safety Experience JCAB
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案例1：事故因素
：主要因素
• 飞机A 遵守ATC 指令
• 飞机B 遵守TCAS 指令
次要因素
• 交通拥挤（面积狭窄, 高度限制）
• 航路监视雷达的预测功能
• TCAS 可靠性
给ICAOICAO的安全建议
修改空中航行程序，飞行员按照TCAS RA 指令执行。
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
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案例1: 日本民航局的应对举措
• 2001, 修改条例，使飞行员遵守TCAS RA 指令。
• 2003, 新导航系统
• 2005, 改进ATC 程序和ATCATC基础设施。
May 15, 2009
Safety Experience JCAB
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案例1: 空中交通流量安排增加和有效利用空域容量May 15, 2009Safety Experience JCAB
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案例1:降低最小垂直间距（（RVSMRVSM））
2005, 降低最小垂直间距
From ”EASA EASA” Home page pageMay 15, 2009Safety Experience JCAB
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案例1:用户优选航路（（UPRUPR））
• (用户优选航路) 在进行中
• 降低燃油消耗
• 减少二氧化碳排放May 15, 2009Safety Experience JCAB
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案例1:RNP1:RNP-AR
(要求授权的所需导航性能项目) 在进行中。
• 提供““高级RNAVRNAV””
May 15, 2009
Safety Experience JCAB
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案例 1: 空中高速路(区域导航 ))••20112011财年之前完成区域导航航路••航路总长度减少到98%••每年节约燃油6300063000千升••每年减少二氧化碳155000155000吨••减少飞行员和管制员间的通话May 15, 2009
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案例2. 发动机起火(严重事故征候)
• 2005 2005. 12. . 1.
• 波音767767-300 , 从鹿儿岛机场起飞后出现震动。
• 3分钟后, 右发动机的火警被激活, 关闭发动机, 飞机返回鹿儿岛机场。
• 无人受伤。飞机有轻度损伤。
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
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案例2: 右发动机DAMAGED AREA
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
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案例2: 高压压气机叶片上的白色沉积物前缘转子旋转方向
From ””JTSBJTSB””Home pageHome page
May 15, 2009
Safety Experience JCAB
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案例2: 扫描电子显微镜
From ”JTSB JTSB” Home page 白色碎片显示含较高的硫(S), 钠(Na) 钾(K) 和氧(O)(O)
May 15, 2009Safety Experience JCAB
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案例2: 航空公司的应对措施
• 发动机清洗
清洗发动机是为了提高燃油效率，同时也有利于清除沉积物。
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
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案例3. 客舱安全
From ”JTSB JTSB” Home page
• 2007 2007. . 11. 3.
• 餐车从厨房滑出。
• 撞到两名乘客, 一名乘客受重伤。
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案例3. 事故原因
From ”JTSB JTSB” Home page 制动未启用，转向限制器未锁定。
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案例3. 横向发展
林格尔曼效应••如有更多的人参加拔河比赛，个人的贡献就会减小。••人数力量运用的程度••1 100%••2 93%••3 85%••8 49%From ””WIKIPEDIAWIKIPEDIA”” 日本民航局进行客舱安全检查
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案例4. 跑道侵入
• 2008 2008. . 2. 16
• 飞机B 着陆后停在跑道上。
• 空管员给出空管指令，包括““起飞””。
• 飞机A 没有收到起飞许可, 却开始起飞滑行。
• 因此, 空管员发出指令，制止飞机A继续滑行, 飞机AA随后终止了起飞滑行。
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
303,000mSpot141028:40 Instruction to line-up and wait1032:43 Started take-off runNNA10B10A2B21034:15 Aircraft-B taxied off the RWY01R01R01L01L1033:251033:251029:26 to 1029:41ControlTowerClosed area dueto snow removalTaxing routeof Aircraft-ANew ChitoseAirportWind 300deg/13kt(1031 RJCC)Wind RWY-BRWY-A (closed)Approx. 1,800mMin approach distanceMax speedpointTake-off runof Aircraft-ATaxing routeof Aircraft-BThe point of Ground Speed zero1009:49 Instruction for crossing 01L and holding short of RWY01RFrom From ””JTSBJTSB””Home pageHome page
案例4. 下雪能见度低A机滑行路线地面停止点两机最小间隔距离，约1800米1028:40 指令:排队等待1032:43 开始起飞滑跑1009:49 指令:穿越01L跑道，在01R跑道待命跑道-A（关闭）
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案例4. 日本民航局的应对举措
• 修改空中交通管制条例，除发布放行许可或取消起飞外，其他场合不使用““起飞””指令。
• 空中交通管制员提供机上飞机培训
• 加强飞行员与管制员相互理解
• 研究多时段系统等。
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案例4. 多时段系统
从3个或3个以上接收站接收来自飞机的无线电信号，并根据接收时间的差异测量飞机的位置。
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
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案例4. 跑道状态灯光系统
• 研究新技术, 如跑道状态灯光系统
以保证机组的情景意识.
May 15, 2009
Safety Experience JCAB
From ”FAA FAA” Home page
3. 日本民航局的积极预防措施
May 15, 2009
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Safety Experience JCAB
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3-1 安全管理体系SMSSMS策划实施检查处置Safety Experience JCAB
““安全信息””在质量管理PDCA(PlanPDCA(Plan-DoDo-
CheckCheck--Act)循环模式中的收集, 检查, 分析和应用
May 15, 2009
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3-2 2005 年涉及航空公司的事故命令航空承运人改善经营(2005, 3. 17)○流量阀故障导致客舱失压(5.8)○在没有固定好餐车的情况下降落在成田国际机场，(5.15)○按照错误的高度表读数飞行(1.5)○在东京国际机场降落时，前起落架脱落(6.15)○在新千岁机场违反ATC指令(1.22)○在仁川机场违反ATC指令(3. 11) ○乘务员忘记改变舱门模式(3. 16)○2005年发生了一系列的事故和麻烦。○此命令之后, 麻烦继续出现在其他航空承运人身上。
May 15, 2009
Safety Experience JCAB
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3-3 民用航空法的修订人为因素和机械故障导致问题频繁发生实施系统改革以保证高水平的航空运输安全【民用航空法的修订】(自2006. 10.1 起生效)1. 航空公司建立安全管理体系2. 报告和公布安全信息3. 加强对航空公司的安全监督○制定“安全管理手册”○对机务和运行部门的外包实行直接监督○引入故障报告系统○国土交通省发布年度民航安全报告○对违反“改善运营命令”的情况加大处罚力度○航空公司发布年度民航安全报告•安全的第一要务•增进管理层与员工间的交流•信息共享和风险管理的落实○发布修订安全管理手册和解雇安全经理的命令○任命“安全经理”May 15, 2009Safety Experience JCAB
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3-4 日本民航局的措施
• 2000, 开展机坪检查
• 2006, 修订安全条例
加强安全审计检查
启用新报告系统
(强制/自愿报告系统))
• 2008, 在航空公司强制执行安全数据分析(FOQA)(FOQA)
• 2009, 安全信息共享系统
May 15, 2009
Safety Experience JCAB
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3-5 机坪检查
日本政府按照国际民航公约和民用航空法对外籍飞机实行现场检查
May 15, 2009
Safety Experience JCAB
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3-6 安全审计检查
••国际民航组织97749774文件••由日本民航局和航空公司内部机构共同实行安全审计May 15, 2009Safety Experience JCAB制定审计预案实施审计需要整改措施吗？是否提交报告决定整改措施决定后续行动
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3-7 安全审计检查
2006. 10. 1, 日本政府加强了现场检查，通过掌握日本航空承运人的安全状况和未来风险对系统进行检查。
May 15, 2009
Safety Experience JCAB
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3-8 现场检查结果○现场检查的结果(2007财年・国内航空承运人*)安全管理22％运行35％维修43％机组29％乘务员18％运控15％运输38％维修控制27％机械/维护29％设备/零部件32％地面服务12％结果(总)结果(飞行)结果(维护)Total: about 5000100200300FY2006FY2007○现场检查数量(国内航空承运人*)218290(35次临时抽检)(66次临时抽检)293293FY2008FY2008
* 运营100座以上或最大起飞重量超50吨飞机的航空承运人.
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3-9 新报告系统以前的报告系统(由机长报告)事故: 致命或重伤, 对机身的严重损坏等严重事故征候: 发生事故征候当时的情形极有可能直接导致事故发生新呈报系统(由航空公司报告)强制报告系统(事故，严重事故征候，及其他可能影响到航空器安全运营的问题*)国土交通省对呈报的安全信息进行分析并采取积极措施*应上报的不安全事件示例:飞机结构损坏, 对维护安全运营有重要作用的系统的功能失灵, 紧急设备的功能失灵，紧急设备的错误操作海因里希法则新加入—将被报高事故严重事故征候问题目前已报告May 15, 2009Safety Experience JCAB
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3-10 FOQA (飞行操作质量保证)
20082008,,9.1, 日本民航局要求航空承运人执行强制FOQA （飞行操作质量保证）分析，FOQA 提高了操作效率。严重程度高严重程度中等正常
May 15, 2009
Safety Experience JCAB
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3-11 安全信息共享系统国土交通省积极的预防性措施航空承运人基本信息○航空公司信息○飞机信息○机场信息等.问题信息○事故，严重事故征候○人为因素○机械故障等.预防性举措对不安全事件恰当的分析分析示例：①发动机运行时间vs不安全事件数②维修控制vs被取消航班数量③机型vs人为因素02468102000400060008000時間新規発動機中古発動機01234567機種A機種B機種C機種D00.050.10.150.2空港A空港B空港C空港D安全监察对航空承运人安全监督的反馈航空安全情報管理・提供システムの整備○运行/维修监察○对外国承运人的机坪检查○积极预防性举措监察信息提供信息，加强预防性举措※This system started in April, 2009.民航安全信息管理和共享系统民航安全信息管理和共享系统New EngineOld Engine(OperatingTime)AirportABCDType ABCD
46(事故与严重事故征候)
3-12 呈报的安全信息8789624949596162516467686055586963817963851037272012345Oct.Dec.Feb.Apr.Jun.Aug.Oct.Dec.Feb.Apr.Jun.Aug.020406080100120AccidentsSerious IncidentsTroublesFY2006FY2007FY2008(不安全事件次数)事故严重事故征候不安全事件
47异物检测43机械故障337避让操作235人为因素83撞击26其他6•TCAS 或GPWS操作•燃油泵故障•前起落架打开/关闭机械故障等•错误部件安装•不慎超出最大速度限制2007财年总计730•乘务员忘记改变舱门模式•超出最大货物载重etc.
3-13 不安全事件的分类
48由来自民航各领域，如飞行员，机械师，客舱乘务员，制造商和工会等的专家组成航空承运人报告的安全信息航空承运人报告的安全信息总量：（FY2007）: 740○事故: 5○严重事故征候: 5○不安全事件: 730安全预防性措施公布年度航空安全报告对不安全事件原因和背景作客观分析指导航空公司采取适当措施避免影响航空安全的人为因素和机械故障○民用航空法111-4（自2006. 10. 1 起生效）当影响飞机正常飞行的事件发生时，国内航空承运人或空中作业者必须向国土交通省就事件做简要报告，包括失效因素分析，采取的预防措施等。航空安全信息分析委员会
3-14 分析和应用年度航空安全报告内容01234Apr.Jun.Aug.Oct.Dec.Feb.0255075100AccidentsSerious IncidentsTroubles
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3-15 年度航空安全报告国土交通省一年两次发布年度航空安全报告，包括事故、严重事故征候和不安全事件的概要，预防性措施，现场检查数量等。报告见以下网址：URL: http://www.mlit.go.jp/koku/15_bf_000188.htmlURL: html
50謝謝!!Flight Standards DivisionFlight DivisionEngineering Department, Civil Aviation BureauEngineering Bureau航空局技術部運航課梅村行男May 15, 2009Safety Experience JCAB2424年来日本航空承运人未发生一起致命事故。
Ministry of Land, Infrastructure, Transport and Tourism
Safety Experiences of
Japanese Aviation Industry
May 15, 2009
Beijing
Yukio UMEMURA
Deputy Director of Flight Standards Division
Japan Civil Aviation Bureau (JCAB)
China Civil Aviation Development Forum 2009China 2009
2
Summary of this Presentation
1. Traffic Volumes, Accident numbers
in Japan
2. Accidents and Serious Incidents and
Reactive Actions by JCAB
3. Proactive Actions by JCAB
4. Questionnaires
May 15, 2009
Safety Experience JCAB
Ministry of Land, Infrastructure, Transport and Tourism
Safety is the Most Successful
Cost Control
Accidents Shows us How to Avoid Accident
No AccidentNo Accidentis the Best wayReactiveReactiveand and ProactiveProactiveActions by Actions JCABJCAB
4About 3.5hour About 2,100km2,100km
1-1 traffic between Chinese mai mainland an land and Japan.
11 million People visit China & Japan11 JapanAs of 2008As 2008Safety Experience JCAB
May 15, 2009Around 800 FlightsAround Flights／／weekweek
5
1-2 Visit Japan Foreigners
２月-41.3％１月-18.4％February 2009, the rate of visiting Japan peopleFebruary peopleis decreased 41% compared is with previous yearwith year10TMay 15, 2009Safety Experience JCAB
6
As of 2008 : 160millon passengers / year
11--3 Japanese Air Carriers3 Carriers
7
11--4 World Accident
From ”ICAO ICAO” Data
FATAL ACCIDENT (SCHEDULED TRANSPORT)
Rate /M Dep.Number
Safety Experience JCAB
May 15, 2009
8012345199019921994199619982000200220042006(Number)0246810(Rate)PilotMechanical TroublesTurbulenceOthersAccidents per One Million Departure
1-5 Accident Involving Japanese Air Carriers
(Fiscal Year)○A few accidents involving Japanese air carriers per year.○Japanese air carriers have had no fatal accidents involving passengers since 1986.1994/6/18A320, tail contact at landing1996/05/15A300-600, tail contact at landing1997/06/08MD-11, injury of person on board caused by oscillation at auto-pilot disengage2000/02/16YS-11A, overrun2003/06/07B767, injury of CA caused by sudden stop2003/10/22B747, tail contact at take off2007/3/13DHC-8, landing with nose landing gear retractedNote: Natural Deaths etc. are not included2002/06/26B767, off-runway while touch and go2004/01/01DC-9, main landing gear collapsed while landing roll2008/3/11MD90, fuselage damage by bird strike2007/11/3B767, injury of passengers caused by jumping galley-cart strikeFrom From ””JTSBJTSB””Home pageHome page
9
2. Accident and Serious Incident in Japan
• Case 1 1. TCAS Avoidance
. Near Mid Mid-air Collision
• Case 2 2. Mechanical Failure
. Engine Fire
• Case 3 3. Cabin Safety
. Meal Cart jumped out from Galley
• Case 4 4. Runway Incursion
. Takeoff Roll started without a clearance
May 15, 2009
Safety Experience JCAB
10
Case 1. Near Mid Mid-air Collision Accident
• January 31, 2001
• Aircraft A complied with ATC instruction “DESCEND DESCEND”
though TCAS RA “CLIMB CLIMB” and 2 CA were seriously
injured, and 81 PAX and 10 CA slightly injured,
Aircraft A had minor damage.
• Aircraft B complied with TCAS RA “DESCEND DESCEND”, a total
, of 250 persons were on board, no one was injured
and Aircraft B had no damage.
• Aircraft A A’s Captain made a quick avoidance
s maneuver and could avoid the collision with Aircraft B.
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
11高度差B2B1A2Elevation angleHorizontal distanceSlant rangeVertical distanceA1--B1: Relative positions of both aircraft when Aircraft B crossed ahead of Aircraft AA1A2--B2: Relative position of both aircraft at the closest approachMinimum Slant distance:135m+/-30mVertical distance:130ft+/-70ft
Case 1: Near Mid Mid-Air Collision Accident
Based on ””JTSBJTSB””reportreportMay 15, 2009Safety Experience JCAB
12
Case 1: View of the Aircraft A A’s Captain
s About 17About 17ﾟ0.36 s5555～～6060ﾟ3838～～4040ﾟposition of the sun2～10 seconds before the Closest ApproachBased on Based ””JTSBJTSB””reportreportMay 15, 2009Safety Experience JCAB
13
Case 1: TCAS Antenna and Display
TOP ATC ANTENNABOTTOM DIRECTIONAL ANTENNATOP DIRECTIONAL ANTENNATCASTCAS
BOTTOM ATC ANTENNA12612610101010PRIMARY FLIGHT DISPLAY (PFD)NAVIGATION DISPLAY (ND)10306355210OTHER TRAFFICCLIMB COMMANDPULL UP COMMAND PROXIMITYTRAFFICRATA
Based on ”JTSB JTSB” report
May 15, 2009
Safety Experience JCAB
14
Case 1: the Accident Factors
Main Factors
• Aircraft A complied with ATC instruction.
• Aircraft B complied with TCAS RA.
Sub Factors
• Traffic congestion (narrow area, altitude
restriction)
• ARSR Predictive function
• TCAS reliability
Safety Recommendation to ICAO
To revise the PANS OPS to Comply TCAS RA by
Pilots.
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
15
Case 1: Reactive Actions by JCAB
• 2001, Revised Regulation to Comply TCAS
RA by Pilots
• 2003, New Navigation System
• 2005, Promoting of ATC procedures and
ATC Facilities
May 15, 2009
Safety Experience JCAB
16
Case 1: Arrangement of Air Traffic FlowsArrangement FlowsIncrease and Effectively utilize the Capacity of Increase AirspaceAirspaceMay 15, 2009Safety Experience JCAB
17
Case 1: RVSMCase RVSM
2005, Reduced Vertical Separation Minimum
From ”EASA EASA” Home page pageMay 15, 2009Safety Experience JCAB
18
Case 1: UPR
••((User Preferred Route ) is on the way ••Reduce Fuel ConsumptionReduce Consumption••Reduce CO2 EmissionReduce EmissionMay 15, 2009Safety Experience JCAB
19
Case 1: RNP RNP-AR
(Required Navigation Performance –
Authorization Required) is on the way.
• Provide “High Grade RNAV RNAV”
May 15, 2009
Safety Experience JCAB
20
Case 1: SKY HIGHWAY (RNAV)
••Completion of RNAV Route until FY2011Completion FY2011••Total Length of Airway Reduced to 98%••Saved Fuel 63,000kl / yearSaved year••Reduced CO2 155,000tons / yearReduced year••Reduce Pilot/Controller CommunicationsReduce CommunicationsMay 15, 2009
21
Case 2. Engine Fire (Serious Incident )
• December 1, 2005.
• The Boeing 767 767-300 , Took off from
Kagoshima Airport. After Takeoff, vibration
started.
• After 3 minutes, Fire Warning on the Right
engine was activated, shut down the engine,
returned to Kagoshima Airport.
• No one was injured. The aircraft suffered
minor damage.
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
22
Case 2: Right Engine
DAMAGED AREA
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
23
Case 2: White Deposits on the HPC Blades
FWDRotor Rotation Direction
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
24
Case 2: Scanning Electron MicroscopeScanning Microscope
From ”JTSB JTSB” Home page pageWhite Debris Exhibited Elevated Sulfur (S), Sodium (Na) and White Potassium (K) along with Oxygen (O)Safety Experience JCAB
May 15, 2009
25
Case 2: Reactive Actions by Air Carriers
• Engine Washing
Engine Washing is for the purpose of improving
Fuel Efficiency, Washing is also expected to be
effective in removing Deposits
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
26
Case 3. Cabin Safety
From ”JTSB JTSB” Home page
• November 3, 2007
• Half Cart Jumped Out from a Galley
• Hit 2 Passengers, 1 Passenger was Seriously Injured
27
Case 3. Cause of the AccidentCase Accident
From ”JTSB JTSB” Home page pageBrake was not put on, Turn Retainers were not Brake Locked PositionLocked Position
28
Case 3. Horizontal Development
Ringelmann EffectRingelmann Effect••if more people jointed in a tugif tug--ofof--war, the contribution of an individual was decreased.••Number of persons Degree of ability usedability used••1 100%••2 93%••3 85%••8 49%From ””WIKIPEDIAWIKIPEDIA””JCAB makes Cabin Safety Inspection Inspection. .
29
Case 4. Runway Incursion
• February 16, 2008
• Aircraft B existed on the runway after landing.
• ATC controller provided ATC information included
the words “TAKE TAKE-OFF ”.
• Aircraft A not receiving the takeoff clearance, and
started its takeoff run.
• Therefore, ATC Controller issued an instruction to
stop Aircraft A, and Aircraft A aborted Takeoff run.
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
303,000mSpot141028:40 Instruction to line-up and wait1032:43 Started take-off runNNA10B10A2B21034:15 Aircraft-B taxied off the RWY01R01R01L01L1033:251033:251029:26 to 1029:41ControlTowerClosed area dueto snow removalTaxing routeof Aircraft-ANew ChitoseAirportWind 300deg/13kt(1031 RJCC)Wind RWY-BRWY-A (closed)Approx. 1,800mMin approach distanceMax speedpointTake-off runof Aircraft-ATaxing routeof Aircraft-BThe point of Ground Speed zero1009:49 Instruction for crossing 01L and holding short of RWY01RFrom From ””JTSBJTSB””Home pageHome page
Case 4. Snowing and Poor Visibility
31
Case 4. Reactions by JCAB
• Amended the ATC Regulation which is not
used the term of "TAKE TAKE-OFF" except for
issuing a Takeoff clearance and its
Cancellation
• On Board Airplane Training by ATC
controller
• MTG with Pilots and ATC controllers for
mutual understandings
• Research MULTI MULTI-LATERATION SYSTEM etc,.
32
Case 4. MULTI MULTI-LATERATION SYSTEM
Receive radio signals sent from aircraft at 3 or more receiving
stations and measure the position of aircraft based on
difference in reception time
From ”JTSB JTSB” Home page
May 15, 2009
Safety Experience JCAB
33
Case 4. Runway Status Lights System
••Research for new technologies, such as Runway Status Light SystemRunway Systemto ensure Crew Situational Awareness.
to May 15, 2009
Safety Experience JCAB
From ”FAA FAA” Home page
3. Proactive Actions by JCAB
May 15, 2009
34
Safety Experience JCAB
35
3-1 Safety afety Management anagement System ystem
PLANPLANDODOCHECKCHECKACTIONACTIONSafety Experience JCAB
Collect Collection ion, , Check, Analy Analysis sis and
Utiliz Utilization of ation “Safety Information Information”
PDCA cycle
May 15, 2009
36
3-2 Troubles involving Air Carriers in 2005
The Order for Improvement of Business to an Air Carrier (Mar. 17, 2005)○Cabin decompression due to failure of out flow valve (May 8)○Landing at Narita Int’l Airport without storing meal cart (May 15)○Flight in accordance with wrong altimeter indication (Jun. 5)○Nose gear wheels detached at Landing at Tokyo Int’l Airport (Jun. 15)○Violation against ATC at New Chitose Airport (Jan. 22)○Violation against ATC at Incheon Airport (Mar. 11) ○Cabin attendant omitted to change door mode (Mar. 16)○A series of Accident and troubles have occurred in 2005○After the order, troubles continued to occur in other air carriersin 2005
May 15, 2009
Safety Experience JCAB
37
3-3 Amendment of the Civil Aeronautics Law
Frequent occurrence of troubles caused by Human Errors and Mechanical troublesReform of the system to assure high level of safety in air transportation【Amendment of the Civil Aeronautics Law】(effective since Oct. 1, 2006)1. Establishment of a Safety Management System in air carriers2. Report and publication of safety information3. Reinforcement of safety oversight of air carriers○Development of a “Safety Management Manual”○Direct oversight and supervision of maintenance and operation outsources○Introduction of trouble reporting system○Release of Annual Aviation Safety Report by MLIT○Enhancement of penalty for disobedience to “The Order for Improvement of Business”○Release of Annual Aviation Safety Report by Air Carriers•The first priority on safety•Improvement of Communication between management and staffs•Information sharing and implementation of riskmanagement ○The order for the revision of Safety Management Manual and dismissal of the Safety Manager○Appointment of a “Safety Manager”May 15, 2009Safety Experience JCAB
38
3-4 JCAB Carried out4 out
• 2000, Ramp Inspection started
• 2006, Amendment of Safety Regulation
Safety Audit Inspection strengthened
New Reporting System started
(Mandatory/Voluntary Reporting System)
• 2008, Mandatory Safety Data Analysis
(FOQA) by Air Carriers
• 2009, Safety Information Sharing system
May 15, 2009
Safety Experience JCAB
39
3-5 Ramp Inspection
Japanese Government is implementing OnOn--site InspectionsInspectionson Foreign Aircraft based on the on Convention on International Civil Aviation and the Civil Aeronautics Law.
May 15, 2009
Safety Experience JCAB
40
3-6 Safety Audit Inspection
••ICAO Doc 9774ICAO 9774••Safety Audit performed by JCAB and Internal Organization of Air Carriers.May 15, 2009Safety Experience JCAB
41
3-7 Safety Audit Inspection
October 1, 2006, Japanese Government strengthen OnOn--site Inspectionsite Inspection, checking the , system by grasping the status of safety and future risks of Japanese Air Carriers.
May 15, 2009
Safety Experience JCAB
42
3-8 Results of On On-site Inspection
○Findings in On-site Inspection (FY2007・the Domestic Air Carriers*)Safety Management22％Operation35％Maintenance43％Flight Crew29％Cabin Attendant18％Operation Control15％Transport38％Maintenance Control27％Mechanic / Maintenance29％Facility /Parts32％Ground Handling12％Findings (Total)Findings (Flight Operation)Findings (Maintenance)Total: about 5000100200300FY2006FY2007○The number of On-site Inspection (the Domestic Air Carriers*)218290(w/o notice35)(w/o notice66)293293FY2008FY2008
* Air carrier which operate an aircraft with more than 100 passenger seats or with maximum take-off weight more than 50,000 kg.
43
3-9 New Reporting System
The reporting system before (by Captain)Accident: Fatal or serious injury, Serious damage to airframe, etc.Serious Incident: An incident involving circumstances indicatingthat an accident nearly occurredThe new reporting system (by Air Carrier)Compulsory reporting system(accidents, serious incidents, and other troubles which may affect safety operation of aircraft*)Analysis of the reported safety information and proactive actionby MLIT*Examples of troubles which should be reportedamage to aircraft structure, Loss of function of systems important to maintain safe operation, Loss of function of emergency equipment, Incorrect operation of emergency equipmentHeinrich’s LawNewly added to be reportedAccidentsSerious IncidentsTroublesHave been reported so farMay 15, 2009Safety Experience JCAB
44
3-10 FOQA (Flight Operational Quality Assurance )
September 1, 2008, JCAB made FOQA Analysis mandatory for Air Carriers to carry out, FOQA increase Operational Efficiency.High SeverityMedium SeverityMedium SeverityNormal
May 15, 2009
Safety Experience JCAB
45
3-11 Safety Information Sharing System
Proactive Actions by MLITAir CarriersBasic Information○Airline info.○Aircraft info.○Airport info. etc.Trouble Information○Accidents, Serious Incidents○Human Errors○Mechanical Troublesetc.Proactive measuresAppropriate analysis to the troublesAnalysis example：①Engine operating time vs. Troubles②Maintenance Control vs. the number of cancels③Aircraft type vs. Human Error02468102000400060008000時間新規発動機中古発動機01234567機種A機種B機種C機種D00.050.10.150.2空港A空港B空港C空港DSafety OversightFeed back to Air Carrier Safety Oversight航空安全情報管理・提供システムの整備○Oversight to Operation /Maintenance○Ramp Inspection to Foreign Air Carriers○Preventive actionsetc.Oversight InformationSupply information, and promote proactive actions※This system started in April, 2009.Aviation Safety Information Management and Sharing SystemAviation Safety InformationManagement and Sharing SystemNew EngineOld Engine(OperatingTime)AirportABCDType ABCD
46
3-12 Safety Information Reported
(Accidents and Serious Incidents)8789624949596162516467686055586963817963851037272012345Oct.Dec.Feb.Apr.Jun.Aug.Oct.Dec.Feb.Apr.Jun.Aug.020406080100120AccidentsSerious IncidentsTroublesFY2006FY2007FY2008(Troubles)
47Foreign Objects Detects43MechanicalTroubles337AvoidanceOperations235Human Errors83Strike Hits26Others6•Operation of TCAS or GPWS•Fuel pomp failure•Nose Landing GearOpen/Close mechanismfailureetc.•Wrong parts installation•Excess of max speed by carelessFY2007Total 730•Cabin attendant omitted to change door-mode•Excess of max cargo loadetc.
3-13 Classification of Troubles
48Organized by literates and specialists from each field such as pilot, mechanic, cabin attendant, manufacturer and unionSafety Informationreported by Air CarriersTotal number of Safety Information by Air carriers（FY2007）: 740○Accidents: 5○Serious Incidents: 5○Troubles: 730Proactive Actions for SafetyRelease of Annual Aviation Safety ReportObjective analysis for cause of troubles and its backgroundsDirection to take appropriate measure against human errors and mechanical troubles which may affect safety○Civil Aeronautics Law 111-4（effective since Oct. 1, 2006）When an event which affects normal flight operations of any aircraft occurs, any domestic air carrierand any aerial work operatorshall report the summary, failure factor analysis, preventive actions etc. tothe Minister of Land,Infrastructure, Transport and Tourism.Aviation Safety Information Analysis Committee
3-14 Analysis and Utilization
Contents of Annual Aviation Safety Report01234Apr.Jun.Aug.Oct.Dec.Feb.0255075100AccidentsSerious IncidentsTroubles
49
3-15 Annual Aviation Safety Report
MLIT issues the Annual Aviation Safety Report, including the summary of Accidents, Serious
Incidents and Other Troubles, the preventive
actions, the number of on on-site inspection, and so
on, Twice per year on following website.
URL: http://www.mlit.go.jp/koku/15_bf_000188.html
50謝謝!!Flight Standards DivisionFlight DivisionEngineering Department, Civil Aviation BureauEngineering Bureau航空局技術部運航課梅村行男May 15, 2009Safety Experience JCABNo fatal accident by Japanese Air No Carriers for 24 years.