This administrative appeal is brought by the VICTIMS ASSOCIATION OF THE\r\nFLIGHT NUM001 against the inactivity and tacit refusal of the Ministry of Public Works and Transportation to deal adequately with the application of said Association for the disclosure of the totality of the file relating to\r\nthe Technical Report A- 032/2008, developed following the accident to the McDonell Douglas DC-9-82, MD-82 aircraft operated by Spanair at Madrid-Barajas airport. |https://www.skybrary.aero/bookshelf/books/5879.pdf Just Culture Manifesto |EUROCONTROL|Just Culture|2020-11-09|2020-10-27||This document is the glossy version of the Just Culture Manifesto.|https://www.skybrary.aero/bookshelf/books/5880.pdf European CCO / CDO Action Plan|EUROCONTROL|Enhancing Safety,Publications|2020-11-11|2020-11-06|2022-02-02|EUROCONTROL has worked with a large number of stakeholders, including airlines, airports and air navigation service providers, to produce the European continuous climb (CCO) / continuous descent (CDO) operations Action Plan. This includes practical advice on how to make CCO/CDO work, with examples of best practices and how constraints can be overcome, building on the extensive experience Europe already has on optimising the efficiency of vertical flight profiles. The principles of the Action Plan have already been utilised this summer by DFS, the German ATC provider and by Lufthansa in their development of the ‘Efficient Flight Profile Concept’, bringing tangible benefits for the airline and for the environment.|https://www.skybrary.aero/bookshelf/books/5881.pdf Critical Incident Stress Management (CISM) - Implementation Quick Guide|EUROCONTROL|Accidents and Incidents,Human Factors|2020-11-11|2020-08-30|2023-02-02|Critical Incident Stress Management (CISM) is a structured and well-established peer based programme to support people/colleagues after a critical incident to facilitate recovery and resilience.\r\nCISM is more than a single intervention method. It is a comprehensive programme with different intervention methods for individuals, small groups, large groups, organisations and families.\r\nThe outlined CISM programme is based on concepts and intervention methods developed and continuously evaluated by the International Critical Incident Stress Foundation (ICISF).\r\nBeing a validated CISM programme, it is recognized and applied by different organizations worldwide e.g. the United Nations, in Healthcare and in Aviation.\r\nMeanwhile a number of European ANSPs also have adopted this CISM programme with very satisfying results.\r\n|https://www.skybrary.aero/bookshelf/books/5882.pdf Joshua's Story|HPA|Just Culture|2020-11-18|2020-11-17||This presentation shows the story of a newborn's death as seen from the Just Culture perspective. |https://www.skybrary.aero/bookshelf/books/5892.pdf Just Culture in Healthcare|Prof. Suzette Woodward|Just Culture|2020-11-18|2020-11-17||This presentation is part of the fourth webinar from the Just Culture Conference 2020.|https://www.skybrary.aero/bookshelf/books/5893.pdf Final Report B788 (VH-VKJ) en route SW of Kansai Japan, 29 March 2019|JTSB (Japan)|Accidents and Incidents,Airworthiness,Human Factors,Loss of Control|2020-11-20|2020-06-25|2022-02-02|On 29 March 2019, both engines of a Boeing 787-8 on descent to Kansai malfunctioned in quick succession causing auto ignition to be triggered by sub-idle engine rpm but thereafter, sufficient thrust was available to safely complete the flight just under half an hour after the dual malfunction. The Investigation found that the cause of these malfunctions had been contamination of the fuel system with abnormally large concentrations of residue which could be reliably traced to a routinely applied biocide and which had solidified and intermittently impeded the transfer of fuel from the tanks to the engines.|https://www.skybrary.aero/bookshelf/books/5894.pdf Final Report B763 (N1217A), east southeast of Houston TX USA, 23 Feb 2019|NTSB (USA)|Accidents and Incidents,Human Factors,Loss of Control|2020-11-21|2020-08-04|2022-02-02|On 23 February 2019, a Boeing 767-300 transitioned suddenly from a normal descent towards Houston into a steep dive and high speed terrain impact followed. The Investigation found that after neither pilot had noticed the First Officer’s inadvertent selection of go around mode during automated flight, the First Officer had then very quickly responded with an increasingly severe manual pitch-down, possibly influenced by a somatogravic illusion. He was found to have had a series of short air carrier employments terminating after failure to complete training, had deliberately and repeatedly sought to conceal this history and lacked sufficient aptitude and competency.|https://www.skybrary.aero/bookshelf/books/5895.pdf Final Report E190 manoeuvring NE of Lisbon Portugal, 11 Nov 2018|GPIAAF (Portugal)|Accidents and Incidents,Airworthiness,Human Factors,Loss of Control|2020-11-22|2020-06-24|2022-02-02|On 11 November 2018, an Embraer 190-100LR just airborne on a post maintenance non revenue positioning flight became extremely difficult to control as it entered cloud despite the complete absence of any flight control warnings. After reversion to Direct Law, partial normal control was regained and, once visual, the flight was guided to an eventually successful landing. The Investigation found that the aircraft had been released from heavy maintenance with the aileron system incorrectly configured and attributed this primarily to the comprehensively dysfunctional working processes at the maintenance facility involved. Extensive airframe deformation meant the aircraft was a hull loss.|https://www.skybrary.aero/bookshelf/books/5896.pdf Final Report BE20 (C-FRMV) vicinity Gillam Canada, 24 April 2019|TSB (Canada)|Accidents and Incidents,Human Factors,Loss of Control|2020-11-23|2020-07-27|2022-02-02| On 24 April 2019, the engine of a Beech B200 en-route from Winnipeg to Churchill at FL 250 failed due to fuel exhaustion and the crew realised that they had forgotten to refuel before departure. An emergency was declared and a diversion to the nearest available airport was commenced but the right engine later failed for the same reason leaving them with no option but to land on a frozen lake surface. The Investigation concluded that confusion as to relative responsibility between the trainee Captain and the supervising pilot-in-command were central to the failure to refuel prior to departure as intended. |https://www.skybrary.aero/bookshelf/books/5897.pdf Final Report B773 (F-GSQL) Maurutius, 16 Sept 2018|BEA (France)|Accidents and Incidents,Human Factors|2020-11-23|2020-06-19|2022-02-02|On 16 September 2018, a Boeing 777-300 was beginning its takeoff from Mauritius when an inadvertently unsecured cabin service cart left its stowage in the forward galley area and travelled at increasing speed towards the rear of the cabin injuring several passengers before it stopped after meeting an empty seat towards the rear of the cabin. The Investigation noted that cabin crew late awareness of an abnormal aircraft configuration and its consequences had led to them generally prioritising service delivery over safety procedures prior to takeoff with this then leading to an overlooked safety task not being detected.|https://www.skybrary.aero/bookshelf/books/5898.pdf Final Report A319 (F-GRHT) vicinity Paris CDG France, 12 March 2014|BEA (France)|Accidents and Incidents,Airworthiness,Human Factors,Loss of Control|2020-11-23|2020-02-20|2022-02-02|On 12 March 2014, an Airbus A319 left engine stopped without any apparent cause on approach to Paris CDG. The crew then started the APU which also stopped. The Investigation found that the cause was engine and APU fuel starvation caused by non-identification of a recurring intermittent malfunction in the fuel quantity indicating system because of a combination of factors including crew failure to record fuel status in line with clear instructions and an inadequate maintenance troubleshooting manual. An inadequately-written abnormal crew drill and the crew’s inadequate fuel system knowledge then resulted in the fuel crossfeed valve not being opened. |https://www.skybrary.aero/bookshelf/books/5899.pdf HindSight magazine - Guidance for Authors|Dr Steven Shorrock|Publications|2020-11-25|2020-11-24|2020-11-25|Template and guidance notes for authors submitting articles to HindSight magazine.|https://www.skybrary.aero/bookshelf/books/5900.pdf Final Report A320 (OE-LOA) London Stansted, 1 March 2019|UK AAIB|Accidents and Incidents,Airworthiness,Human Factors|2020-11-25|2020-08-06|2022-02-02|On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.|https://www.skybrary.aero/bookshelf/books/5901.pdf Final Report A320 (EC-KLT) vicinity Birmingham UK, 26 Aug 2019|UK AAIB|Accidents and Incidents,Air Ground Communication,Human Factors,Loss of Control|2020-11-25|2020-08-20|2022-02-02|On 26 August 2019, an Airbus A320 attempted two autopilot-engaged non-precision approaches at Birmingham in good weather before a third one was successful. Both were commenced late and continued when unstable prior to eventual go-arounds, for one of which the aircraft was mis-configured causing an ‘Alpha Floor’ protection activation. A third non-precision approach was then completed without further event. The Investigation noted an almost identical event involving the same operator four months later, observing that all three discontinued approaches appeared to have originated in confusion arising from a slight difference between the procedures between the aircraft operator’s and AIP plates’.|https://www.skybrary.aero/bookshelf/books/5902.pdf Final Report A320 (G-EUYB) vicinity London Heathrow UK, 23 Sep 2019|UK AAIB|Accidents and Incidents,Fire Smoke and Fumes|2020-11-25|2020-07-30|2020-02-02|On 23 September 2019, the flight crew of an Airbus A320 on approach to London Heathrow detected strong acrid fumes on the flight deck and after donning oxygen masks completed the approach and landing, exited the runway and shut down on a taxiway. After removing their masks, one pilot became incapacitated and the other unwell and both were taken to hospital. The other occupants, all unaffected, were disembarked to buses. The very comprehensive investigation was unable to establish the origin of the fumes but did identify a number of circumstantial factors which corresponded to those identified in previous similar events.|https://www.skybrary.aero/bookshelf/books/5903.pdf Final Report E190 B738 Amsterdam Netherlands, 27 July 2018|DSB (Netherlands)|Accidents and Incidents,Human Factors,Runway Incursion|2020-11-25|2020-06-15|2022-02-02|On 27 July 2018, Amsterdam ATC cleared a Boeing 737-800 to line up for departure from an intermediate taxiway but the 737 crew then heard the controller issue a takeoff clearance to an Embraer ERJ190 from the full length of the same runway. Having stopped past the holding point but clear of the actual runway and reported on the runway, they were then given a takeoff clearance, too, but held position. The 190 crew heard the 737 takeoff clearance and rejected their own takeoff, passing clear of the 737 at high speed. The Investigation suggested a review of intersection takeoffs. |https://www.skybrary.aero/bookshelf/books/5904.pdf Final Report B738 (CN-RGJ) London Gatwick UK, 28 Feb 2020|UK AAIB|Accidents and Incidents,Controlled Flight Into Terrain,Human Factors,Runway Excursion|2020-11-25|2020-09-10|2022-02-02|On 28 February 2020, a Boeing 737-800 taking off from the full length of the London Gatwick main runway, which is in excess of 3000 metres long, was observed to get airborne only 120 metres before the end of the paved surface. The Investigation found that the crew response when the automatic V1 and VR calls did not occur was unduly delayed with rotation only occurring at a much higher than normal speed. No system fault was subsequently found and it was concluded that the crew had most likely omitted to input these speeds to the FMC after calculation.|https://www.skybrary.aero/bookshelf/books/5905.pdf Final Report B789 (ET-AUP), Oslo Norway, 18 Dec 2018|AIBN (Norway)|Accidents and Incidents,Ground Operations,Human Factors|2020-11-26|2020-06-29|2022-02-02|On 18 December 2018, a Boeing 787-9 was instructed to taxi to a specified remote de-icing platform for de-icing prior to takeoff from Oslo but on entering the assigned area, was in collision with a lighting mast causing significant damage to both aircraft and mast. The Investigation found that in the absence of any published information about restricted aircraft use of particular de-icing platforms and any markings, lights, signage or other technical barriers to indicate to the crew that they had been assigned an incorrect platform, they had visually assessed the clearance as adequate. Relevant Safety Recommendations were made.|https://www.skybrary.aero/bookshelf/books/5906.pdf Final Report E195 (G-FBEJ) Exeter UK, 28 Feb 2019|UK AAIB|Accidents and Incidents,Airworthiness,Fire Smoke and Fumes,Human Factors|2020-11-26|2020-09-17|2022-02-02|On 28 February 2019, an Airbus A320 abandoned takeoff from Exeter when fight deck fumes/smoke accompanied thrust applied against the brakes. When informed of similar conditions in the cabin, the Captain ordered an emergency evacuation. Some passengers using the overwing exits re-entered the cabin after becoming confused as to how to leave the wing. The Investigation attributed the fumes to an incorrectly-performed engine compressor wash arising in a context of poorly-managed maintenance and concluded that guidance on overwing exit use had been inadequate and that the 1.8 metre certification height limit for exits without evacuation slides should be reduced.|https://www.skybrary.aero/bookshelf/books/5907.pdf Final Report A343 (F-GLZO) Bogota Colombia, 19 Aug 2017|BEA (France)|Accidents and Incidents,Loss of Control,Weather|2020-11-27|2019-12-16|2022-02-02|On 19 August 2017, an Airbus A340-300 encountered significant unforecast windshear on rotation for a maximum weight rated-thrust night takeoff from Bogotá and was unable to begin its climb for a further 800 metres during which angle of attack flight envelope protection was briefly activated. The Investigation noted the absence of a windshear detection system and any data on the prevalence of windshear at the airport as well as the failure of ATC to relay in English reports of conditions from departing aircraft received in Spanish. The aircraft operator subsequently elected to restrict maximum permitted takeoff weights from the airport.|https://www.skybrary.aero/bookshelf/books/5908.pdf Final Report B738 (F-GZHM) en route west of Bar Montenegro, 13 Feb 2019|BEA (France)|Accidents and Incidents,Human Factors,Weather|2020-11-27|2020-02-21|2022-02-02|On 13 February 2019, a Boeing 737-800 en-route over the southern Adriatic Sea unexpectedly encountered severe clear air turbulence and two unsecured cabin crew and some unsecured passengers were thrown against the cabin structure and sustained minor injuries. The Investigation found that the Captain had conducted the crew pre-flight briefing prior to issue of the significant weather chart applicable to their flight by which time severe turbulence due to mountain waves at right angles to an established jetstream not shown on the earlier chart used for the briefing was expected at a particular point on their route.|https://www.skybrary.aero/bookshelf/books/5909.pdf Final Report CRJ7 & A319, Lyon Saint-Exupery France, 17 March 2017|BEA (France)|Accidents and Incidents,Human Factors,Runway Incursion|2020-11-27|2020-04-23|2022-02-02|On 17 March 2017, a Bombardier CRJ 700 which had just landed on runway 35R at Lyon Saint-Exupéry was about to cross runway 35L as cleared when its crew saw the departing Airbus A319 on runway 35L accelerating towards their intended crossing position and braked to a stop before entering the runway. The Investigation found that both aircraft had complied with all instructions issued by the TWR controller and concluded that safety management processes at the airport were not commensurate with the incursion risk involved and had been unchanged since an almost identical incident a year previously.|https://www.skybrary.aero/bookshelf/books/5910.pdf Final Report E550 (RA-02788) Paris Le Bourget France, 27 Nov 2017|BEA (France)|Accidents and Incidents,Human Factors,Loss of Control|2020-11-27|2020-08-05|2022-02-02|On 27 November 2017, an Embraer EMB 550 crew ignored a pre-takeoff indication of an inoperative airframe ice protection system despite taxiing out and taking off in icing conditions. The flight proceeded normally until approach to Paris Le Bourget when the Captain was unable to flare for touchdown at the normal speed and a 4g runway impact which caused a main gear leg to pierce the wing followed. The Investigation found that the crew had failed to follow relevant normal and abnormal operating procedures and did not understand how flight envelope protection worked or why it had activated on approach.|https://www.skybrary.aero/bookshelf/books/5911.pdf Final Report E190 (CS-TPV) Nice France, 6 Nov 2017|BEA (France)|Accidents and Incidents,Air Ground Communication,Human Factors|2020-11-28|2020-04-02|2022-02-02|On 6 November 2017, an Embraer E190 cleared for a normal visibility night takeoff at Nice began it on a parallel taxiway without ATC awareness until it had exceeded 80 knots when ATC noticed and a rejected takeoff was instructed and accomplished without any consequences. The Investigation found that although both pilots were familiar with Nice, their position monitoring relative to taxi clearance was inadequate and both had demonstrated a crucial lack of awareness of the colour difference between taxiway and runway lighting. Use of non-standard communications phraseology by both controllers and flight crew was also found to be contributory.|https://www.skybrary.aero/bookshelf/books/5912.pdf Final Report B735 (LY-KLJ) vicinity Madrid Barajas Spain, 5 April 2019|CIAIAC (Spain)|Accidents and Incidents,Airworthiness,Human Factors,Loss of Control|2020-11-28|2020-07-02|2022-02-02|On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.|https://www.skybrary.aero/bookshelf/books/5913.pdf Final Report A320 (a6-EIT) Calicut India, 20 June 2019|GCAA (UAE)|Accidents and Incidents,Human Factors,Runway Excursion,Weather|2020-11-28|2020-08-04|2022-02-02|On 20 June 2019, an Airbus A320 about to touchdown at night at Calicut drifted to the right once over the runway when the rain intensity suddenly increased and briefly left the runway before regaining it and completing the landing and taxi in. Runway edge lighting and the two main gear tyres were damaged. The Investigation attributed the excursion to loss of enough visual reference to maintain the centreline until touchdown followed by late recognition of the deviation and delayed response to it. The visibility reduction was considered to have created circumstances in which a go-around would have been advisable. |https://www.skybrary.aero/bookshelf/books/5914.pdf Final Report D8C (C-FJXZ) Toronto Canada, 10 May 2019|TSB (Canada)|Accidents and Incidents,Ground Operations,Human Factors|2020-11-29|2020-09-05|2022-02-02|On 10 May 2019, a Bombardier DHC8-300 taxiing in at Toronto at night was hit by a fuel tanker travelling at “approximately 25 mph” which failed to give way where a designated roadway crossed a taxiway causing direct crew and indirect passenger injuries and substantial damage. The Investigation attributed the collision to the vehicle driver’s limited field of vision in the direction of the aircraft coming and lack of action to compensate for this, noting the need for more effective driver vigilance with respect to aircraft right of way rules when crossing taxiways. The aircraft was declared beyond economic repair.|https://www.skybrary.aero/bookshelf/books/5915.pdf Final Report AT76 (OY-JZC) en route near Forde Airport Norway 14 Nov 2016|NSIA (Norway)|Accidents and Incidents,Human Factors,Loss of Control,Weather|2020-11-29|2020-09-09|2022-02-02|On 14 November 2016, an ATR72-600 crew lost control at FL150 in severe icing conditions. Uncontrolled rolls and a 1,500 feet height loss followed during an apparent stall. After recovery, the Captain announced to the alarmed passengers that he had regained control and the flight was completed without further event. The Investigation found that the crew had been aware that they had encountered severe icing rather than the forecast moderate icing but had attempted to continue to climb which took the aircraft outside its performance limitations. The recovery from the stall was non-optimal and two key memory actions were overlooked.|https://www.skybrary.aero/bookshelf/books/5916.pdf Final Report B737 & B738 vicinity Amsterdam Netherlands, 29 March 2018|DSB (Netherlands)|Accidents and Incidents,Air Ground Communication,Loss of Separation|2020-11-29|2020-09-24|2022-02-02|On 29 March 2018, a Boeing 737-700 commenced a late go-around from landing at Amsterdam on a runway with an extended centreline which passed over another runway from which a Boeing 737-800 had already been cleared for takeoff. An attempt by the controller responsible for both aircraft to stop the departing aircraft failed because the wrong callsign was used, so low level divergent turns were given to both aircraft and 0.5nm lateral and 300 feet vertical separation was achieved. The Investigation concluded that the ATC procedure involved was potentially hazardous and made a safety recommendation that it should be withdrawn.|https://www.skybrary.aero/bookshelf/books/5917.pdf