SAFER Archive

Recommendation text

Improve the working processes to assess operational risks of newly declared EASA Part-SPO operators, and to verify continued compliance with the applicable requirements in accordance with EASA Air OPS ARO.GEN.300 Oversight (a)(2).

Recommendation response

The UK CAA accepts this recommendation. The UK CAA will carry out a full review of the SPO oversight process, procedures and policy and will carry out a review of SPO accountabilities (across multiple teams). The date set to accomplish both reviews is set for 31 December 2020. Following the outcome of the aforementioned reviews, the UK CAA will implement changes to; accountabilities, process, procedures and policy with the aim of Improving the working processes to assess operational risks of newly declared EASA PartSPO operators, and to verify continued compliance with the applicable requirements in accordance with EASA Air OPS ARO.GEN.300 Oversight (a)(2). The date set to implement the changes is set for 30 April 2021.

Response update: 24/06/21

The UK CAA carried out a full review of the SPO oversight process, procedures and policy and a review of SPO accountabilities (across multiple teams). The date set to accomplish both reviews was set for 31 December 2020. Following the outcome of the aforementioned reviews, the UK CAA will implement changes to; accountabilities, process, procedures and policy with the aim of improving the working processes to assess operational risks of newly declared EASA Part-SPO operators. The improvements to compliance with the applicable requirements will be embedded within the new processes ensuring a more risk-based approach to SPO and better clarity on continued oversight requirements.

The original date set to implement the changes was set for 30 April 2021, we are now sequencing this activity alongside overseeing industry restart as Covid-19 restrictions ease in the UK, so the changes will now be implemented by 31 July 2021.

Response update: 20/09/21

The improvements described in our previous update have now been developed and embedded within our processes and procedures, ensuring a timely assessment of newly declared Part-SPO operators and a documented approach to risk-based oversight.

Update due

None

CAA status

Closed

Recommendation text

Conduct a baseline assessment of the operational risks, and a thorough compliance and safety audit of FCSL's safety management system, flight operations, pilot training, weight and balance procedures, and documented procedures for calibration flights.

Recommendation response

The UK CAA accepts this recommendation. The scope of the next Part-SPO audit conducted by the UK CAA, which it is anticipated will be completed by the 30 September 2020, will focus on a baseline assessment and a thorough compliance and safety audit of FCSL's Safety Management System, flight operations, pilot training, weight and balance procedures, and documented procedures for calibration flights.

Response update: 28/10/20

The CAA completed an on-site audit at Shoreham Airport with Flight Calibration Services Limited on 8th August 2020, producing a baseline assessment of the operator. Conducting a compliance audit of the operator's SPO operations focusing on the Safety Management System, flight operations, pilot training, weight and balance procedures, and a review of the documented procedures for calibration flights.

A satisfactory review of previous inspection reports was also carried out, verifying evidence and supporting documentation of any remedial actions.

The CAA conducted a review in conjunction with the requirements set out in (EU)965/2012. Specifically, a review of the requirements for operational oversight as detailed in Part-ARO and those requirements set out in Part-ORO and Part-SPO.

As a result of the above audit activity the CAA is satisfied that the Safety Management System, Training, Operations and associated procedures meet the requirements of FSCL's operation. 

Response update: 24/06/21

The CAA completed an on-site audit at Shoreham Airport with Flight Calibration Services Limited on 8th August 2020, producing a baseline assessment of the operator. Conducting a compliance audit of the operator's SPO operations focusing on the Safety Management System, flight operations, pilot training, weight and balance procedures, and a review of the documented procedures for calibration flights.

A satisfactory review of previous inspection reports was also carried out, verifying evidence and supporting documentation of any remedial actions.

The CAA conducted a review in conjunction with the requirements set out in (EU)965/2012. Specifically, a review of the requirements for operational oversight as detailed in Part-ARO and those requirements set out in Part-ORO and Part-SPO.

As a result of the above audit activity the CAA is satisfied that the Safety Management System, Training, Operations and associated procedures meet the requirements of FSCL's operation.  

CAA status

Closed

Recommendation text

The CAA to consider mandating additional cockpit crew to enable enhanced lookout for single-pilot survey operations.

Recommendation response

Whilst the CAA recognises the desired safety outcome, there are significant barriers to the CAA accepting this in its current form. The recommendation does not recognise where the ownership for this hazard of SPO operations and associated lookout risks lie. We must be clear about the respective roles of regulator and the regulated entity.
It is the CAA's role to assure itself that risk is assessed, and the associated mitigating actions are robust. This assurance is conducted through an assessment of the operator's operations manual under which all flights should be conducted. ORO.GEN.110 sets out clearly the responsibilities of the Operator to ensure safe conduct of any flight and it is against this regulation that the test is applied.

Managing an effective lookout in any aircraft is the responsibility of the pilot in command following guidance issued by the operators concerned and stipulated in the Operations Manual. The AMC of EASA part SPO states:
SOPs should be based on a systematic risk assessment to ensure that the risks associated with the task are acceptable. The risk assessment should describe the activity in detail, identify the relevant hazards, analyse the causes and consequences of accidental events and establish methods to treat the associated risk.

It is the operator's responsibility to conduct this assessment task and the risks presented may be different dependent on the nature of the operation and the geographical area.

We recognise the unique hazard of the operations in question and therefore, in response to the recommendation, confirm that the CAA Partially Accepts this recommendation and will conduct a review of the risk assessments of survey operators, to ensure they meet the requirements of AMC SPO.OP.230(b) and are robust in addressing this risk.

Response update: 19/01/2021

In conjunction with a Safety Recommendation from the Accident Report into G-MDME which was operated by a Part SPO organisation, the CAA has conducted a review of the implementation of Regulation (EU) 965/2012 Part Specialised Operations (SPO). The review also considered Aerial work through a Foreign Carrier Permit (FCP) against Article 252[1] of the Air Navigation Order and arrangements for Unmanned Air Systems (UAS) as detailed in CAP722A.

The CAA will now consider the findings and recommendations of the review to determine the preferred option and the work needed to be undertaken to put any changes into effect.

The CAA Flight Ops department conducted a review of operator's risk assessment with particular emphasis on MAC mitigations and single pilot operations through a Special Objective Check. 57 operators have declared that they conduct survey operations, and a review of their operational Safety Assessment and associated mitigations has started under the auspices of the CAA SPO working group. The Impact of the EU withdrawal and Covid alongside recovery activity means that it is likely the original planned completion for this work (end of March 2021) will be missed. We expect to be able to complete the activity by 30th June 2021, when we will be in a position to report on the adequacy of Survey Operators risk assessments.

Response update: 09/08/21

The CAA has considered the findings and recommendations of our review on the implementation of Retained UK Regulation (EU) 965/2012 Part Specialised Operations (SPO) and, through the SPO Governance Group, has conducted targeted Safety Case assessments of involved operators.

It has been agreed that the addition of cockpit crew may form part of an operator's mitigation to the risk of mid-air collision, where the operating environment is assessed as presenting this particular risk, however it would be inappropriate to mandate it for all single pilot operations. The risk is the Operator`s responsibility to manage, the management of these risks being overseen by the UK CAA through established processes. Where a risk is considered relevant it would require the appropriate level of mitigations to manage the risk to an acceptable level. The addition of a second cockpit crew into a single pilot operation could add additional risks which would also need mitigating. In addition, the qualification and responsibilities of the second crew would need defining in the risk assessment so as ensure that the overall risk was reduced in the new safety case.

Should an operator's risk management and safety case support the additional cockpit crew to mitigate the risk, we would support this.

Additional information:
Following analysis of operator feedback, it seems that although a number of organisations may offer survey work as part of their portfolio, not many undertake the activity. Part CAT operators have their safety cases reviewed as part of normal oversight activities (including evidence that it is being used and effective) and covered in PBO Internal Review Meeting (IRM) discussions. Evidence so far is that CAT operators are aware of the hazards and have put mitigations in place.

Part NCC organisations that perform such activity have had their oversight frequency and focus reviewed.

The processes for including survey operators' risk assessment for single pilot work is now embedded in Flight Operations oversight, adequately captured in SARG procedures therefore it is now considered as BAU.

CAA Status

Closed

Recommendation text

The CAA review current regulation concerning RLLCs.

Recommendation response

The CAA is still reviewing current RLLC regulations, particularly with reference to civilian pilot responsibility. The CAA have been engaged with the DfT, Royal Household and TQHF to provide improvement in this area since March this year. Due to several factors including BREXIT and additional requests from the Royal Household this has resulted in a lengthy process to ensure correct measures are taken moving forward. The CAA is committed to undertaking this review correctly and ensuring any future change, if agreed, is implemented appropriately and without any ambiguity.

Response update: 17/08/21

Further to the response on the 18 December 2019 the CAA have been conducting a review of the Royal Low-Level Corridor (RLLC) regulations. Over the last 10 months the CAA have been liaising with The Queen's Helicopter Flight (TQHF) and representatives of the Military Aviation Authority (MAA). This was aimed at understanding the specific requirement and consider these against the current regulations and the recommendations with in the Airprox Report 2018185.

When considering the Airprox Report 2018185, alongside the recommendation for the CAA to review the RLLC regulations the report also highlighted 3 points which have been drawn out to help inform the review.

1. Differences between current regulations place military controllers  in a position of having to apply separation standards between military aircraft and the Royal Flight and not having to provide separation between civilian aircraft and the Royal Flight.
2. Regulations for Royal Flights were split across three documents, UK Aeronautical Information Publication (AIP), Aeronautical Information Circular (AIC)1 and MAA Regulatory Article (RA) 3237 causing complexity and confusion.
3. Existing Regulations where not SERA compliant 'Members agreed that, for RLLCs, the AIC and UK AIP both implied that the onus on not flying into proximity with a Royal Helicopter flight rested entirely on the other pilot, whereas, under SERA this was not the case where Exempting Royal Helicopter Flights from SERA requirements would not be appropriate'.

Noting points raised within the Airprox report, the review has determined there is an on-going demand to support TQHF operations. There is however an additional emergent requirement to provide greater protection for flights carrying Her Majesty, where these flights cannot be conducted in existing Controlled Airspace (CAS). Significant work has been undertaken to determine the appropriate airspace structure to support this requirement. Due to variable nature of the tasking combined with the lack of existing CAS or available air traffic provision, Restricted Airspace provides the only viable option to provide the level of protection required.  Owing to the nature of Restricted Airspace this will need to be notified via NOTAM in a timely fashion, where each routing will require consideration to ensure safety to airspace users.  Due to the pandemic and the associated reduction on Royal travel the exact process for this is still within a trial phase in order to establish the exact process for ensuring timely relevant notification of these Restrictions.

For all other Royal Flights, it would not be practicable or appropriate to establish Restricted Airspace. Given this constraint and due to wider considerations beyond airspace, TQHF would not want to notify these flights via NOTAM; instead wishing to provide advance notice to selected entities only, principally the military. This is a balanced determination taking into consideration the number, type, and locations of military activity. This utilise the issuing of a 'signal' addressed to predominantly military units only, where the signal is forwarded internally within those units to the relevant entities. The practice of using a NOTAM to notify RLLC was adopted in 2018 but ultimately withdrawn that year with the withdrawal of the AIC cited in the Airprox report, reverting to the signal process. Work is currently underway to support the further improvement of this signal process by providing an automated generation of a visual representation of the routing alongside the standard signal text. This upgrade is currently being trialed and subject to feedback is expected to be adopted later this year. 

When considering applicability of RLLC to civilians, it is not possible to apply separation criteria without the establishment of a notified 'structure', such as CAS/TMZ. It would therefore not be appropriate or possible to expect civilian operators to assume a greater level or responsibility toward ensuring collision avoidance. Civilian pilots and controllers should discharge their responsibilities in accordance with the airspace. Noting this point the civilian Aeronautical Information Publication (AIP) has been amended since the Airprox, removing the unintended implication, and re-enforcing the applicability of RLLC to the military only, placing no obligation on civilian controller or pilot. Ultimately TQHF operate in accordance with the background classification of airspace and are not exempted from SERA requirements.

The Military MAA Regulatory Article (RA) 3237, outlines the regulations relating to RLLC, this RA still however includes the reference to civilian aircraft. TQHF have requested the MAA review RA3237 where this review is expected to occur in the coming months.  Alongside the review the CAA will request the reference to the civilian aircraft is removed from the RA. On completion of the MAA review the civilian AIP entry will be amended to reference the RA3237 only, removing the split of information across documents. Therefore, addressing point 2 and 3 above where point 1 will be considered more widely within the upcoming MAA review.

More broadly the review has identified TQHF maintain the requirement for the RLLC where there is a further requirement for added protection when carrying Her Majesty.  We remain engaged with TQHF and the MAA were work is continuing to refine both the timely establishment of Restricted Airspace, the processes regarding the current 'notification' of RLLC and to contribute to the MAA review of RA3237.

CAA Status

Closed

Recommendation text

It is recommended that the Civil Aviation Authority communicate to the general aviation community the importance of increasing the visibility of ground equipment.

Recommendation response

The CAA accepts this Recommendation. The CAA is working with the General Aviation Safety Council (GASCo) to highlight the need for thorough pre-flight external checks and will include this as part of the GASCo Safety Campaign for 2020. The CAA will require GASCo to highlight this incident at their Winter 2020/2021 GA Safety Evenings and recommend that pilots/owners enhance the visibility of their tow bars.

Final Recommendation response

The General Aviation Unit within the CAA have created a communications campaign on the risk and mitigation actions surrounding the Southend serious incident and made a clear call to action to pilots to consider painting their tow bars in bright colours.

Firstly, the AAIB report was highlighted to the community via Skywise with a request for pilots to consider painting their tow bars in bright colours. This was followed by a call on social media for pilots to show and tell the CAA what colour they had painted their own tow bars and to encourage those that haven't, to follow suit. An article was written about the Southend incident and shared via Skywise, highlighting the factors that led to the event; lack of visibility of the tow bar and inadequate checks due to distraction. Again, a call to action was made to pilots to paint their tow bars in highly visible colours and for them to consider if they are fit to fly. On behalf of the CAA, GASCo have also contributed to the campaign with a slide on external checks as part of covering the incident within their March and April 2021 safety webinars. Once these presentations have commenced the CAA hope to have further reduced the risk of this incident re-occurring and will have fulfilled the above recommendation.  

CAA status

Closed

Recommendation text

The CAA review R/T Procedures at non-ATS aerodromes.

Recommendation response

We note that radiotelephony procedures at the subject aerodrome did not in themselves appear to have been a contributory factor to the occurrence, and we are unaware of other instances of aircraft operating at AGCS aerodromes experiencing losses of situational awareness as a result of incomplete or inaccurate circuit position or standard overhead join reporting calls by other pilots.

Response update: 26/11/20 

In accordance with our initial response dated 02 Mar 2020 the following changes to chapter 4 of the Manual of Radiotelephony (CAP 413), have now been actioned and are contained within Edition 23 AL1 (Published 26 November 2020) of the manual:

• Page 1 subtitle 'Aerodrome Control Service Phraseology' to move to page 5.
• Paras 4.6/4.7 to be moved to Chap 4 Introduction.
• Designated Positions in the Traffic Circuit and Standard Overhead Join Procedure content to follow the Introduction and be applicable to ATC, AFIS and AGCS alike.  New header to indicate applicability.
• The requirement in both cases for aircraft to report base leg is to be enhanced to read 'if required by ATS provider or aerodrome operator'. It may not be universally applicable, the decision can be made at local level to satisfy local requirements.

We have reviewed CAP 413 (Radiotelephony Manual) Chapter 4 Aerodrome Phraseology but do not believe there is a case for introducing a requirement for pilots to report at all designated positions in the aerodrome traffic circuit. However, the review has highlighted the need for some structural changes to Chapter 4, and the following will be considered:

• Page 1 subtitle 'Aerodrome Control Service Phraseology' to move to page 5.
• Paras 4.6 and 4.7 to be moved to Chapter 4 Introduction.
• 'Designated Positions in the Traffic Circuit' and 'Standard Overhead Join Procedure' content to follow the Introduction and be applicable to ATC, AFIS and AGCS alike.  
• New header to indicate applicability.
• Requirement in both cases for aircraft to report base leg to be enhanced to read 'if required by ATS provider or aerodrome operator'.  It may not be universally applicable - the decision can be made at local level to satisfy local requirements.

The changes would be undertaken as part of a routine amendment on a date yet to be determined.

Final recommendation response

In accordance with our initial response dated 02 Mar 2020 the following changes to chapter 4 of the Manual of Radiotelephony (CAP 413), have now been actioned and are contained within Edition 23 AL1 (Published 26 November 2020) of the manual:

• Page 1 subtitle 'Aerodrome Control Service Phraseology' to move to page 5.
• Paras 4.6/4.7 to be moved to Chap 4 Introduction.
• Designated Positions in the Traffic Circuit and Standard Overhead Join Procedure content to follow the Introduction and be applicable to ATC, AFIS and AGCS alike.  New header to indicate applicability.
• The requirement in both cases for aircraft to report base leg is to be enhanced to read 'if required by ATS provider or aerodrome operator'.  It may not be universally applicable; the decision can be made at local level to satisfy local requirements.

In addition, we have reviewed the Skyway Code pages relevant to circuit radio procedures and they appear correct, but we are making some minor changes such that the relevant diagram in the code more closely aligns with the diagram at 4.4 in CAP413. With the update planned to be released in the first quarter of 2021. 

CAA status

Closed

FOLLOW-UP ACTION ON OCCURRENCE REPORT - FACTORS
CAA Responses to AAIB Safety Recommendations