CAA CAP 667-1997 Review of General Aviation Fatal Accident 1985-1994 Reprinted May 2002《1985-1994年通用航空器重大事故的回顾》.pdf

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1、Safety Regulation Group CAP 667 Review of General Aviation Fatal Accidents 19851994 www.caa.co.uk Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Safety Regulation Group CAP 667 Review of Gene

2、ral Aviation Fatal Accidents 19851994 Important Note The CAA has made many of the documents that it publishes available electronically (in addition to traditional printed format). The contents of this document are unchanged from the previously printed version. For consistency with other CAA document

3、s new cover pages have been added. Further information about these changes and the latest version of documents can be found at www.caa.co.uk. March 1997 Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from

4、 IHS-,-,-CAP 667 Review of General Aviation Fatal Accidents 1985-1 994 O Civil Aviation Authority 1997 ISBN O 86039 695 9 First published March 1997 Reprinted Novem ber 1997 Reprinted May 2002 (incorporating new house style cover) Enquiries regarding the content of this publication should be address

5、ed to: General Aviation Department, Safety Regulation Group, Civil Aviation Authority, Aviation House, Gatwick Airport South, West Sussex, RH6 OYR. The latest version of this document is available in electronic format at www.caa.co.uk, where you may also register for e-mail notification of amendment

6、s. Printed copies and amendment services are available from: Documedia Solutions Ltd., 37 Windsor Street, Cheltenham, Glos., GL52 2DG. Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Contents

7、Page 1 INTRODUCTION 1 2 TERMINOLOGY 3 SCOPE OF THE REPORT 4 WORKING METHOD 5 FATAL ACCIDENT RATE 1985 TO 1994 6 FINDINGS OF THE WORKING GROUP 6.1 Types of Accident 6.2 Controlled Flight into Terrain 6.3 Loss of Control in Visual Meteorological Conditions 6.4 Low Flying/Aerobatics 6.5 Loss of Control

8、 in Instrument Meteorological Conditions 6.6 Causal Factors 6.7 Other Causal Factors 7 CONCLUSIONS 8 MAIN RECOMMENDATIONS 9 SECONDARY RECOMMENDATIONS 9.1 General 9.2 Operations 9.3 Licence and Training 9.4 Aircraft Appendices: Statistical Summary Controlled Flight into Terrain Loss of Control in VMC

9、 (LOC VMC) Low Flying and Aerobatics (LOW/AERO) Loss of Control in IMC (LOC IMC) Other Types of Accident - Discussion Discussion of Related Background Information Summary of each accident 1 1 2 2 4 7 8 9 9 9 9 10 13 15 19 21 23 25 29 37 iii Copyright Civil Aviation Authority Provided by IHS under li

10、cense with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Abbreviations AAIB Air Accidents Investigation Branch AIC Aeronautical Information Circular ANO Air Navigation Order AOPA CAA Civil Aviation Authority CAP Civil Aviation Publication C ofA Certificate of

11、Airworthiness CFIT Controlled Flight into Terrain GA General Aviation GASIL IMC Instrument Meteorological Conditions IR Instrument Rating JAA Joint Aviation Authorities JAR FCL LOC IMC LOC VMC LOW/AERO Low Flying/Aerobatics NATMAC NOTAMs Notices to Airmen PPL Private Pilots Licence SRG Safety Regula

12、tion Group The Aircraft Owners and Pilots Association General Aviation Safety Information Leaflet Joint Aviation Requirements - Flight Crew Licensing Loss of Control in Instrument Meteorological Conditions Loss of Control in Visual Meteorological Conditions National Air Traffic Management Advisory C

13、ommittee iv Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-1 INTRODUCTION 1.1 During 1987 there was a marked increase in the number of fatal accidents involving General Aviation (GA) aeroplan

14、es when the rate rose to 3.7 per 100,000 flying hours compared with the average annual figure of 2.1 for the preceding five years. In response to public concern at the time, the then CAA Chairman established a Study Group to analyse the 1987 accidents and to determine whether there were: factors com

15、mon to a number of accidents which might have contributed to the causes. regulatory or other measures which, if taken by the CAA, could be expected to reduce the number of accidents occurring without unreasonable detriment to the future growth and wellbeing of general aviation. The review was publis

16、hed as CAP 542 - General Aviation Accident Review in October 1988 and contained 13 recommendations. Most have been actioned or are awaiting progress through development of the Joint Aviation Requirements. 1.2 The Authority considered that a further review of General Aviation accidents should take pl

17、ace. Accordingly, in January 1995, a new Working Group was established with terms of reference as follows: to undertake a review of serious and fatal GA incidents and accidents with a view to focusing on their causal factors to help reduce such events in the future. to produce a report and make reco

18、mmendations to Safety Regulation Group (SRG) management for appropriate consideration and action. 2 TERMINOLOGY 2.1 General Aviation For the purpose of this report a General Aviation aircraft was considered to be a UK registered aeroplane or helicopter with a maximum take-off mass of 5700kg or less.

19、 SCOPE OF THE REPORT 3.1 The Group decided that a review of all GA accidents (over 250 per year) and incidents was impracticable. There was a risk that some significant issues could be outweighed by relatively minor accidents such as landing gear collapses. It was agreed that the review would concen

20、trate on fatal accidents to UK registered aeroplanes and helicopters of 5700kg maximum take-off mass and below which occurred in the UK and abroad during the 10 year period 1 January 1985 to 31 December 1994. Microlights, gyroplanes and gliders were excluded as they have different airworthiness code

21、s and pilot licensing standards. This provided a manageable number of accidents (166) for analysis while it corresponded with the CAP 542 work (aeroplanes). 1 Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without licens

22、e from IHS-,-,-3.2 3.3 3.4 4 4.1 4.2 4.3 5 5.1 Fatal accidents where there was only third party involvement (e.g. people moving into rotating propellers or rotors) were included since these could have been affected by the operational environment. The CAAs Mandatory Occurrence Reporting Scheme record

23、s all significant hazardous or potentially hazardous occurrences as well as accidents. For the purposes of this review, the occurrence computer database did not contain sufficient background material on the fatal accidents so Air Accidents Investigation Branch (MB) Bulletins, occurrence files and li

24、censing records as well as other sources were used. A number of accidents, 20 (12%), involved UK registered aircraft flying outside the UK and, thus, were investigated by foreign authorities. Very few had produced adequate reports and in spite of enquiries via Air Accidents Investigation Branch, ver

25、y little has been forthcoming and, in most cases, it was not possible to allocate any causal factors. The 1987 accident review group also experienced this difficulty. WORKING METHOD The Group was aware that work of this sort was very subjective, so in order to maintain consistency the group independ

26、ently read the relevant information on each accident and then met to reach a consensus view on the one type of accident and as few or many factors as necessary were allocated, all with equal weight. These were divided into four main groups: pilot knowledge or skill; attitude, stretching the limits;

27、pilot physiology; external factors. The list of factors was extended as the task progressed. This method attempted to ensure a reasonable degree of consistency. A few of the types of accident also appeared as factors. Statistical tests were performed to determine whether certain differences between

28、groups were statistically significant. (The test selected was the Mann-Whitney U test for comparison of two independent samples .) FATAL ACCIDENT RATE 1985 TO 1994 (See Appendix 1) The 166 fatal accidents mentioned in para 3.1 above comprised 140 accidents involving aeroplanes and 26 involving helic

29、opters. A total of 234 persons were killed in the aeroplane accidents and 46 in the helicopter accidents. This compared with the 158 persons killed during the same period in large aeroplane and large helicopter accidents. The fatal accident rate is measured as an accident rate per 100,000 flight hou

30、rs. During the period of the report, the fatal accident rate for aeroplanes varied from a high of 3.7 in 1987 to a low of 1.0 in 1994. The corresponding figures for helicopters varied from a high of 3.6 in 1990 to a low of 2 Copyright Civil Aviation Authority Provided by IHS under license with CAANo

31、t for ResaleNo reproduction or networking permitted without license from IHS-,-,-3.5 3 2.5 2 1.5 I 0.5 OT zero in 1985 and 1988. The numbers of accidents for both categories of aircraft were combined in the following graph to show rates per 100,000 hours: the 3 year moving average shows a generally

32、favourable trend throughout the period under review. - - - - - - - Rate per 100,000 hours + a 1985 1986 1987 1988 1989 1990 1991 1992+ 1993+ 1994+ 1995+* + Estimated hours * Not included in any other part of report 0 Rate + 3 Year Moving Average 5.2 The gradual improvement in the three year moving a

33、verage may be due to a number of factors including: improvements in instructional standards and syllabus content. an improved safety culture in general over the last 10 years as demonstrated by the now common use of household smoke alarms, cyclists crash helmets, motorists airbags etc. the long-term

34、 effect of initiatives to promote safety within the general aviation community via the General Aviation Safety Information Leaflet (GASIL) , Safety Evenings, Safety Sense Leaflets etc. Nevertheless, because of a high incidence of pilot error and poor decision making/judgement it was clear that most

35、of the recent fatal accidents could still be classified as avoidable. It could not be argued, therefore, that the accident rate was close to an irreducible minimum. 5.3 Most members of the group felt strongly that general aviation in the context of this report should not be regarded as purely recrea

36、tional and that every effort should be made to help pilots of all levels to become more proficient. The public has come to expect regular reductions in road fatalities brought about by a combination of education backed up by legislation and enforcement together with improved crashworthiness/occupant

37、 protection. This resulted in an approximate 5% per annum reduction in the fatal accident rate. Some of those measures may not be appropriate in the general aviation world. Nevertheless, as a target, a 5% per annum improvement in the aircraft accident rate was believed to be a realistic objective. T

38、his has almost been achieved in the UK, in terms of the 3 year moving average, over the last 10 years (1.8 per 100,000 hours down to 1.2). 3 Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-5.4

39、 Attempts were made to compare the UK situation with that in other countries. Unfortunately, it was not possible to make direct comparisons because of differing definitions of general aviation separation of helicopters, terrain, weather, licence requirements etc. In general terms the accident causes

40、 were very similar to the UK with loss of control, continued flight into adverse weather and controlled flight into terrain as major factors. 6 FINDINGS OF THE WORKING GROUP 6.1 Types of Accident The pie-chart below shows the types of accident which occurred most often. Four of the major types - con

41、trolled flight into terrain (CFIT), loss of control in VMC (LOC VMC), low flying/aerobatics (LOW/AERO), and loss of control in IMC (LOC IMC) - are discussed in detail in Appendices 2 to 5. IAkF2a :% Clearly the greatest benefits result from addressing the four major accident types since 67.5% of acc

42、idents were in these areas. Nevertheless the less frequent types must not be ignored. Discussion of the less frequent accidents is at Appendix 6. A summary of detail on all 166 accidents reviewed is at Appendix 8. 6.2 Controlled Flight into Terrain (CFIT) (See Appendix 2) A CFIT accident was defined

43、 as an event where an aircraft strikes the ground during powered, controlled flight. The review has shown that in 20.5% of fatal accidents CFIT was a feature leading to 61 fatalities. Typically, the CFIT accident involved the more mature and experienced pilot who, despite his experience, seemed to b

44、e oblivious to the dangers of continuing the flight into deteriorating weather conditions. Eighty-two percent of pilots in CFIT accidents continued into bad or worsening weather or showed a lack of appreciation of the weather situation. In 74% of CFIT accidents, the safety altitude was apparently no

45、t observed by the pilots concerned or was not correctly calculated. In many cases, a descent was initiated to achieve visual conditions below cloud, with disastrous consequences. Usually, training for the Private Pilots Licence (PPL) takes place in good weather and with the advent of more candidates

46、 training for the PPL overseas, this trend is likely to 4 Copyright Civil Aviation Authority Provided by IHS under license with CAANot for ResaleNo reproduction or networking permitted without license from IHS-,-,-increase. The average PPL student has little if any exposure to adverse weather during

47、 training and, on obtaining his licence, is unlikely to understand how to assess weather conditions or be able to relate his own skills to a deteriorating weather situation. It was considered that PPL training should be subjected to a greater level of CAA oversight to ensure that the best informatio

48、n is made available to candidates particularly in the areas of weather appreciation, calculation of safety altitude, flight planning and diversion techniques. 6.3 Loss of Control in Visual Meteorological Conditions (LOC VMC) (See Appendix 3) 6.3.1 This type of accident was defined as one where the p

49、ilot lost control of the aircraft while operating in accordance with normal aviation procedure, under the Visual Flight Rules, and not engaging in low level aerobatics. LOC VMC is associated more with inexperienced pilots and accounted for 20% of the accidents and 61 fatalities; two thirds of those involved in these accidents had less than 500 flying hours. This type of accident is the result of a la