Interim Report - Introduction - EASA

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INTERIM REPORT – OPTIONS FOR CHANGE – ATTACHMENT A EASA.2009.OP.21 3 Other data sources 3.1 ADREPS The Study Team acquired 1014 occurrence reports from the ICAO ADREP database. There has not been enough time to filter these (many will be associated with in-flight icing conditions), nor to summarise and classify them. No doubt there will be some interesting information contained within; however, it is the opinion of the Study Team that any analysis will only confirm the conclusions reached by the other summaries contained in this paper. This dataset can be forwarded to EASA for further examination if required. 3.2 ECCAIRS A search of ECCAIRS, made by EASA Safety Analysis Department, was requested for all de-icing / anti-icing related occurrences since 2000. There were 5 accidents recorded, and 3 occurrences of engine failure not resulting in an accident. The results comprise 27 occurrence reports, 8 of which are related to known occurrences of elevator movement restrictions due to either ice or frozen residues. 7 occurrences were caused by inadequate de-icing / anti-icing, and 4 due to a failure to de-ice. Due to the lack of detail provided in the report summaries, conclusions cannot be made as to the primary reasons why de-icing / anti-icing was inadequate, nor why pilots failed to request de-icing / anti-icing. 3.3 NASA Aviation Safety Reporting System (ASRS) – Summary of the Study 1968 – 1993 4 This study analysed 52 reports which were submitted to ASRS between January 1986 – January 1993. 81% involved air carrier jet aircraft and 19% involved air carrier turboprops. The main events reported were: − takeoff with contaminated wing/tail surfaces in 52% of reports, − engine damage and/or failure due to ice ingestion, − aircraft control difficulties, and − rejected takeoffs. 4 Report Summary published in NASA ASRS Direct Line – Issue No5, March 1993, written by Robert L. Sumwalt, and available from: http://asrs.arc.nasa.gov/publications/directline/dl5_ice.htm ; last accessed 21.10.2010. airsight GmbH - 4 -
INTERIM REPORT – OPTIONS FOR CHANGE – ATTACHMENT A EASA.2009.OP.21 The majority of the problems found in this study may be classified into three major categories: − Problems associated with detection of and inspection for ice during pre-flight inspections; − Problems with ice removal, or the confirmation of successful ice removal after de-icing; and − Difficulties in confirming that aircraft critical surfaces were free from frozen contamination before takeoff. The procedural problems observed in 25% of reports included: − failure of de-icing crews to follow prescribed procedures, − inadequately designed procedures for de-icing and/or post de-icing checks, − poor communication between de-icing crews and flight crews, − improperly prepared de-icing fluids, − lack of reliable equipment, and − inadequate staffing levels to conduct de-icing. Inspections: 25% of the problems noted were the result of difficulties in detecting ice on aircraft wings during pre-flight. Half of these cited the elevated height of wing and tail surfaces as a major factor in ice inspection/detection difficulties. 11% cited ice detection problems such as crews being unable to see ice due to poor lighting conditions, the transparent nature of clear ice, or ice that was otherwise hidden from view. Not being able to reach ice during a tactile wing inspection was also cited. Schedule (time) pressures were also reported as contributing to inadequate inspections. Ice Removal: 50% of reports mentioned problems with ice removal and/or verification of ice removal. 25% cited problems of ice remaining on aircraft critical surfaces after de-icing was completed. In 12 cases where de-icing was ineffective at removing all the contamination the flight crew relied on the de-icing crew's statement or hand signals that de-icing had been completed, and therefore, failed to verify ice removal for themselves. Before Takeoff: A quarter of the reports in this study referenced problems with the captain making the determination of a “clean wing”. In the absence of an external pre-take-off contamination check by ground crew, pilots found checking the wings from the cockpit and cabin impossible to accomplish, in many cases due to anti-icing fluid obscuring the view airsight GmbH - 5 -
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Interim Report - Introduction - EASA

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