Interim Report - Introduction - EASA

INTERIM REPORT – OPTIONS FOR CHANGE – ATTACHMENT A
EASA.2009.OP.21
3.5 Flight Safety Foundation (FSF) Air Safety Network – Summary
of Accident Report 1980 – 2009
A search was made of this publicly available database for accidents connected with de-icing /
anti-icing of aircraft on the ground between 1980 and 2009.
It must be noted that during this time, although awareness of the dangers to flight with
contaminated aircraft surfaces had increased, the spread of accidents included in the results
was unchanged:
− 1980 – 89: 13 events
− 1990 – 99: 13 events
− 2000 – 09: 12 events
Also note that many of the accident aircraft were types not necessarily associated with
commercial air transport in Europe today; however, the results do show that if procedures
are inadequate, or not followed, and aircraft depart with contaminated surfaces, then the risk
of an accident is extremely high.
In the search of the FSF database, 38 accident reports were identified. Of these, the
probable cause quoted was the failure to de-ice in 28 cases (74%), although failure to de-ice
was evident in 36 cases (95%).
Contributing factors are quoted below:
− 10 (26%) failure to inspect, or inadequate inspection,
− 9 (24%) inappropriate procedures and/or supporting regulations,
− 9 (24%) lack of awareness by pilots, and
− 8 (21%) failure to de-ice (only contributing because other factors were involved such
as overweight take-off).
3.6 Confidential Human Factors Incident Reporting Programme
(UK)
A search of the CHIRP database was requested for de-icing / anti-icing related events.
10 reports were recovered, spanning January 2004 to October 2010.
Of these, 5 were reported by flight-crew and 5 by cabin-crew.
This is a surprisingly low number of reports, bearing in mind that CHIRP is a confidential
repository. One explanation for this might be that there is growing confidence in the
effectiveness of in-house company confidential reporting systems, which are very effective
and trusted these days, and therefore CHIRP is probably used less often. Nothing
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