APPENDIX D Data Requirements
The type of data collected by a safety management process should be tailored to the requirements of the risk analysis and risk management functions so enough of the right kind of data is collected but the database management system is not overwhelmed by unnecessary data. The information presented in this appendix describes a sample set of aircraft safety data. This information is not intended to limit the user's approach, which may be altered to meet individual requirements.
Data is collected from aircraft accident or incident reports, service difficulty reports, and other reports of deficiencies in the users' sphere of interest. Relevant information includes data identifiers, descriptors, symptoms, events, causes, consequences, injury/death factors, miscellaneous data, and corrective action.
Identifiers should include an identification number, time of occurrence, classification, location, aircraft, mission type, operator, meteorological conditions, and phase of operation.
The identification number could be a nine-digit number denoting the date of the accident or incident, followed by the level of damage, and a sequence number indicating the number of reported accidents and incidents on that day. For example, the number could be formatted as YYMMDDLSQ:
YY = the year, MM = the month, DD = the day
L = the level of damage, with 1 = destroyed/fatal, 2 = destroyed/nonfatal, 3 = substantial/fatal, 4 = substantial/nonfatal, 5 = incident, 6 = service difficulty, and 7 = other
SQ = the two-digit number of the occurrences on that date
The time should be recorded in universal time and local time (24-hour clock) along with ambient lighting conditions: dawn, daylight, dusk, or night.
Classification options would be accident, incident, or service difficulty.
The location of the aircraft at the time of the problem should be recorded using the four-digit codes for the departure and arrival airports as designated in the Official Airline Guide. The latitude and longitude or the distance and direction to or from the nearest city should also be recorded.
The aircraft type, model, registration number, fuselage number, fuselage serial number, engine make and model, engine serial numbers, and flight number should be recorded.
Possible mission types include scheduled passenger flight, nonscheduled passenger flight, cargo flight, ferry flight, training flight, in-flight refueling, and flight test.
The aircraft owner, operator, lessor, airline name, and nation of registry should be recorded.
The meteorological conditions should be recorded, indicating whether visual or instrument meteorological conditions (VMC or IMC) were present.
The phase of operation should be described using the following choices: boarding, cargo loading, engine start, taxi, takeoff (including roll, rotation, initial climb), climb to cruise, cruise, in-flight refueling (including precontact, contact, and disconnect), descent, approach, landing (including flare and touch-down, roll, and touch-and-go), go-around, and deplaning. For ground operations, the phase could be parked, refueling, inspection, or towing. If the problem was related to maintenance, the phase could be overhaul, servicing, routine, or inspection.
In addition to identifiers, the following list of descriptors could be used to categorize similar accidents, incidents, and service difficulties in more detail for subsequent sorting:
pre-takeoff or post-landing
smoke, fire, and/or fumes
landing and taxi
landing gear and/or brakes
flight control problems
other aircraft factors
other personnel factors
As many subcategories as necessary should be used to describe accurately each accident, incident, or service difficulty.
Pre-takeoff and post-landing problems can involve the ground crew, passengers, collisions with vehicles, emergency evacuations, returns to the gate, rejected takeoffs and other takeoff problems, tires, engines, bird strikes, running off the end or side of the runway, weather, darkness, using the wrong runway, overrotation and/or tail strike, under-rotation, slat disagreement warnings, wet runways, loss of directional control, premature retractions of the landing gear, and spoiler position warnings.
Collisions may involve other aircraft on the ground or in flight; terrain; water; objects on the ground or water; foreign objects or domestic objects on the ground or in flight; birds impacting engines, windscreens, or structure; airport vehicles or ground equipment; and formation flying or refueling operations. For the purposes of safety management and accident prevention, near misses would be treated the same way as collisions.
Lift problems may be caused by the loss of one or more lifting surfaces; contaminated lifting surfaces; improper configurations; or asymmetric, partial, or erroneous deployment of slats, flaps, or spoilers.
Accidents, incidents, and service difficulties involving smoke, fire, and/or fumes should be classified by the source of the problem (electrical systems, flammable fluids, cargo, auxiliary power unit, or other system) and the location of the problem within the aircraft (cockpit, cabin, galley, lavatory, cargo compartment).
Landing and taxi accidents may be classified as unscheduled landings, gear-up landings, excursions off the end or side of the runway, brake malfunctions or difficulties, goarounds, short landings, long landings, overweight landings, hard landings, problems from contaminated runways, using the wrong runway, ditching, loss of directional control, or runway contact by nacelle, wing, tail, or fuselage.
Landing gear and brake problems include collapse of the landing gear, tire failure, wheel failure, brake failure, asymmetric braking, main landing gear up or unlocked, nose landing gear up or unlocked, false gear indication, antiskid system failure, steering failure, strut failure, emergency extension (gear free-fall), asymmetric gear extension, and tire damage by foreign objects.
Thrust problems include in-flight engine shutdowns, failure or asymmetric deployment of thrust reversers, inadvertent thrust reverser deployment in flight or on the ground, engine flameout, engine failure that is not contained by the engine case and/or the nacelle, engine fire warning, engine separation, high exhaust gas temperature, engine stab or surge, engine power loss, multiple engine failure, foreign object damage to engine, engine overspeed, and abnormalities involving the oil system, throttles, gear box, or fuel.
Flight control problems include gross weight and center-of-gravity problems, jammed or locked controls, aircraft stall, instrument error or false indications, wake turbulence, buffet, or vibrations caused by structural failures, improper actions by the pilot or autopilot, uncommanded actuation of control surfaces, adverse weather, or other system cause.
Weather-induced problems include ice formation, ice shedding, turbulence, lightning strike and/or static discharge, clouds, winds (tailwinds, headwinds, and crosswinds), thunderstorms, wind shear, microbursts, fog, haze, and all forms of precipitation: rain, heavy rain, freezing rain, snow, slush, hail, etc.
Other aircraft factors include depressurization, emergency descent, fuselage shell opening, warning indications, uncommanded actuation of aircraft systems or controls, oxygen system problems, hazardous cargo, rotating machinery failure, multiple failures, air conditioning and pressurization problems, pneumatic system malfunctions, hydraulic system malfunctions, electrical system malfunctions, fuel system problems, exceeding ''g'' limits, separation of parts in flight, fluid seepage and spills, blue ice, jettisoning of fuel, leakage of fluids from cargo, loose cargo, improper activation of fire extinguishers, malfunctions of items on the minimum equipment list.
Other personnel factors include problems caused by the flight crew, cabin crew, passengers, ground crew, air traffic controllers, maintenance crews, and others because of confusion, fatigue, inadequate coordination, poor communications, terrorist acts, etc.
Facility problems include airfield obstacles, inadequate braking because of runway contamination or other reasons, poor lighting, inadequate signage, problems with landing or navigational aids, malfunctions of air traffic control equipment, inadequate emergency crash/fire/rescue equipment, etc.
At some point, almost all accidents, incidents, and service difficulties generate symptoms that indicate something has gone wrong.
Visual symptoms include instrument indications, warning or advisory lights, and observations of smoke, fire, or other abnormal conditions.
Aural symptoms include horns, bells, and verbal warnings generated by the central aural warning system; warnings and alarms generated by other systems, such as the
ground proximity warning system or fire and smoke alarms; and abnormal sounds generated by malfunctioning equipment.
Tactile symptoms include aircraft "g" loading, stick shaker, control forces, heat, cold, pressure change, electrical shock, and vibration.
Olfactory symptoms include smoke or fumes from electrical systems, oil, kerosene, food, rubber, or other materials.
LINKS IN THE CHAIN OF EVENTS
Accidents and, to a lesser extent, incidents and service difficulties typically involve a chain of events. Each event or link in the chain should be categorized and described.
Personnel errors should be recorded by identifying the individuals involved (captain, first officer, second officer, cabin crew, ground crew, maintenance crew, passenger, other flight crew, etc.), describing the errors, such as failure of the flight crew to properly secure passengers, take immediate action, follow air traffic control instructions, use checklists, compensate for wind, maintain direction control, go around, monitor weather, monitor instruments, recover from unusual attitude, inform cabin crew or other flight crew, see and avoid other aircraft, accurately estimate altitude, interpret instrument readings, or maneuver the aircraft in accordance with approved procedures. Personnel errors include voluntary acts that are poorly performed or failures to act when action is appropriate.
Problems with aircraft, engines, and aircraft systems should be identified using the standard Air Transport Association chapter number. If possible, the make, model, name, and serial number should be recorded, along with failure mode, total service time, and total time since overhaul, as appropriate.
Events related to the air traffic management system include air traffic control functions, such as clearance delivery, ground control guidance, tower operations, approach and departure control, guidance from air route traffic control centers; air traffic control directives, facilities, navigation aids; and weather reporting.
Environmental conditions of interest include poor visibility because of darkness, the position of the sun, or whiteout; clear-air turbulence; birds; volcanic ash; dust; and weather.
Each link in the chain of events has one or more cause factors that describe the underlying reasons, problems, deficiencies, or acts that caused the event.
Personnel errors and human factors problems may be caused by inadequate preparation or supervision, poor judgment, poor execution, inadequate crew rest, carelessness, improper use of equipment, alcohol or other drags, exceeding aircraft operating limitations, improper maintenance, improper aircraft modifications, failure to use proper safety precautions, slow response when immediate action is needed, inadequate procedures, and failure to execute proper procedures.
Cause factors associated with aircraft, engines, and systems include abnormalities in the design, manufacture, maintenance, operation, or operating environment of the aircraft or its systems, including inadequate overhaul or inspection, foreign object damage, or the effects of failures of other aircraft systems.
Cause factors associated with air traffic management include deficient regulations, directives, or procedures; problems with air traffic control and runway facilities, such as navigational aids, communications systems, crash/fire/rescue equipment, runways, runway lighting, and taxiways; and personnel errors associated with the above.
Environmental cause factors include inaccurate forecasts of hazardous environmental conditions, failures to report hazardous conditions, or inappropriate responses to actual or forecast hazardous conditions.
Maintenance-related cause factors include improperly performed maintenance and inadequate maintenance procedures and plans.
Combinations of factors and cascading cause-and-effect sequences are also important and should be carefully examined and recorded.
Accidents, incidents, and service difficulties can lead to abnormal actions by the air crew, aircraft damage, and personnel injuries.
Actions by the flight crew include air turn back, rejected takeoff, return to gate, emergency descent, unscheduled landing, dumping fuel, in-flight shutdown of one or more engines, delayed departure, emergency evacuation, and evasive action.
Levels of aircraft damage include destroyed, substantial, minor, none, engine only, or property.
Personnel losses should be described in terms of the numbers of passengers, cabin crew, flight crew, ground crew, and other personnel injured and the extent of injuries: fatal, serious, minor, or none.
If the aircraft impacts ground or water, it should be noted whether the aircraft was under control at the time of impact.
For accidents, the official determination of whether it was survivable or nonsurvivable should be entered.
Additional information should be recorded about factors associated with personnel injuries in case additional remedial action is needed.
Crash and non-crash-related injury factors should be recorded separately. Non-crash-related injuries may be caused
by falls, crushing, sharp edges, dropped objects, turbulence, electric shocks, electric burns, open flames, toxic smoke or fumes, hot surface or liquids, radiation, or toxic chemicals. Crash-related injuries may be caused by impact forces, inadequate seat or occupant restraints, fires, crushing, unrestrained objects, post-crash fires, toxic gases, drowning after ditching, or lack of post-crash egress because of physical blockages, smoke, flame, or inoperative emergency exits.
Crash and non-crash-related death factors should be recorded and categorized in the same manner as the injury factors.
Other crash factors that should be recorded include the passenger load factor in percent, the passenger distribution in the cabin, and impact "g" force.
The aircraft history should be recorded in terms of the number of flight hours and landings, along with a record of the flight crew's experience and demographics. A narrative of the accident, incident, or service difficulty with analyst's comments should also be included.
When available and as appropriate, the corrective action should be recorded. Options include airworthiness directives, alert service bulletins, service bulletins, "all operator" letters, operational occurrence reports, and/or official recommendations.