Interim Report - Introduction - EASA

INTERIM REPORT – OPTIONS FOR CHANGE – ATTACHMENT A
EASA.2009.OP.21
4 Conclusions
Most of the accidents and serious incidents summarised above are what may be termed the
“top of the triangle”. Referring to the Heinrich Triangle (see Options for Change) we can ask
ourselves – what about the 600 low-level events for every accident? We just do not know
what the situation is concerning these regular slips, errors, oversights, problems, hazards etc
that must be visible to the de-icing / anti-icing operatives.
With the advent of ICAO SMS SARPs there can be no denying the facts that are available. It
is now the responsibility of everyone involved, through SMS regulations, best-practice safety
management, and within a positive safety culture, to collect this data, analyse it and share
the results.
This short Summary and Analysis of available safety data provides some guidance as to
where effort and safety resources should be directed. Notably, this includes improvements
to:
− communication,
− coordination,
− inspections/checks
− procedures,
− adherence to procedures,
− knowledge, and
− training.
These issues may be addressed via:
− the creation of new direct and indirect regulations,
− the provision of clear concise and unique regulatory interpretive and guidance
material, or
− an Industry-wide awareness programme and associated voluntary accreditation
scheme for operations and training.
The available options are discussed and presented in full detail in Options for Change.
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