Leita
Re-evaluation of CRM training
Tillaga í öryggisátt
It is recommended to the operator to re-evaluate its CRM training.
Afgreiðsla
Since the time of the Accident the company taken a number of measures to analyse, identify risks and mitigate. Effort has been made to keep ICETRA and RNSA abreast of all findings and changes resulting thereof. A number of changes include reconsideration of CRM/Human Factors elements in traininig and the operation as a whole. Changes include, but are not limited to:
- Company’s Emergency Response plan has been revised and published.
- A new, yonger model aircraft was purchased, financed and registered. TF-MYA. A factor in the descision was the superior avionics package, including traffic advisory system and terrain awareness functions.
- The company discarted the practice of conducting every other recurrent training in actual aircraft and in stead opted to conduct all recurrent training in full flight simulators.
- Normal operating procedures where completely rewritten and operational philosophy redefined to include industry best practices. Outside consultation was sought and used in this process to ensure a broader perspective.
- Normal checklist system revised based on new operational philosophy and new checklists published.
- Stricter emphasis placed on procedural adherence and standardization in all training. This effort is ongoing.
- Effort launched to reiterate that individuality in procedural adherence is not acceptable by management. This effort is ongoing.
- Training has and will continue to include material aimed at enforcing the relationship between flight standardization, professionalism and safety.
- IFR/VFR policy has been rewritten and published to make clear under what conditions visual flying is allowed. New policy reviewed in training.
Paramedic as a crew member
Tillaga í öryggisátt
It is recommended to the Icelandic transport authority (ICETRA) to consider that a paramedic in an ambulance flight should be defined as a crew member.
Afgreiðsla
Að mati Samgöngustofu getur ítrasta krafa í þessu sambandi verið íþyngjani og erfitt fyrir leyfishafa að framkvæma, enda er t.d. ekki möguleiki að gera kröfu um að reglur um flug-, vakt- og hvíldartíma fyrir áhafnir gildi fyrir lækna og sjúkraflutningamenn.
Samgöngustofa hefur hins vegar ákveðið að gera kröfu til leyfishafa sem sinna sjúkraflugi með flugvélum að læknar og sjúkraflutningamenn verði skilgreindir sem "Medical Passenger / Flight Physician". Þessa skilgreiningu má nú þegar finna fyrir sjúrka- og björgunarflug með þyrlum. Leyfishafar munu þurfa að skilgreina viðkomandi í flugrekstrarhandbók, með hliðsjón af CAT.OP.MPA.155. Þá verði gerð krafa um að leyfishafar skilgreini í þjálfunarhandbók þjálfunarkröfur fyrir viðkomandi og hafi til hliðsjónar EU 965/2012 SPA.HEMS.100 GM1 SPA.HEMS.100(a) eins og á við í rekstri sjúkraflugs með flugvélum.
Auknar kröfur við samsetningu og viðhaldi fisa
Tillaga í öryggisátt
RNSA ítrekar fyrri tillögu sína frá 17. september 2014 til Samgöngustofu úr skýrslu vegna flugslyss á fisi TF-303, er varð þann 20. október 2012, um að „auknar kröfur verði gerðar um þekkingu og vinnubrögð þeirra sem vinna að samsetningu sem og viðhaldi fisa.“
Afgreiðsla
Samgöngustofu hefur í samvinnu við Fisfélag Reykjavíkur hafið vinnu við endurskoðun á samþykktum handbókum fyrir fisfélögin auk þess sem ferli Samgöngustofu við samþykktir á handbókum er til endurskoðunar.
Verklag við lendingar á jöklum og í snjó
Tillaga í öryggisátt
RNSA beinir því til Norðurflugs að setja í handbækur sínar verklagsreglur varðandi lendingar á jöklum og á snjó, þegar hætta er á að flugmenn geti misst viðmið á jörðu.
Afgreiðsla
Norðurflug hefur innleitt tillöguna á eftirfarandi hátt:
- Hluti í handbók 8.1.2.2
- Hluti af OPC formi
- Hluti af þjálfun fyrir þyrlu skíðun þar sem einkum reynir á þetta og í kennsluefni er ítarlega farið yfir „whiteout“
- Hluti af áhættumati sem gert er vegna nýrrar reglugerðar Ferðamálastofu
Tvíþátta mæling eldsneytis við fyrirflugsskoðun
Tillaga í öryggisátt
RNSA beinir því til flugskólans Keilis að hann endurskoði handbók flugnema í þeim tilgangi að tryggja tvíþátta mælingu og samanburð á eldsneyti við fyrirflugsskoðun.
Afgreiðsla
Flugakademía Íslands hefur samið nýja eldsneytishandbók og hafa tveir starfsmenn verið þjálfaðir af Olíudreyfingu í meðhöndlun eldsneytissins og aðstoðuðu þeir okkur líka við skrif á handbókinni.
Að auki hefur flugvélahandbók (OM) hefur verið endurskoðuð:
Aircraft type specific,
information and data for fuel consumption;
detailed instruction on how to use the provided data;
unit of fuel measurement;
are to be found in the manual provided by the manufacturer. Refer to the List of aircraft used for training.
For the applicable fuel calculation form, refer appropriate form in Flight Logger
Both, the instructor/examiner and the student/applicant are familiar with the fuel calculation and the actual fuel data of the aircraft used.
As part of the pre-flight planning, the pilot in command/student shall make a careful calculation of the amount of fuel required specific to the intended flight session. In addition, the following shall be taken into consideration:
the correct and consistent application of the fuel consumption data including associated unit of measurement as applicable for the concerned aircraft;
the actual and forecast meteorological conditions;
the planning of an alternative course of action to provide for the eventuality that the flight cannot be completed as planned;
possible traffic delays for the anticipated ATC routings and aerodromes;
any other condition that may delay (e.g. temporary operating restriction or closing of runway / and/or aerodrome, required re-routing) the landing of the aircraft;
procedures specific to the type of aircraft, such as failure of one engine while en-route, loss of pressurisation etc. or any other condition that may increase the fuel and oil consumption.
As part of the briefing, the instructor shall evaluate the student’s fuel calculation prior to commencing the flight.
Updating of operator's manual
Tillaga í öryggisátt
The ITSB recommends that Göbler Hirthmotoren KG updates its Operator‘s Manual for Hirth engine 3503 with the correct spark plug information in Table 4.1 of Chapter 6. Specifications – 3503 engine.
Afgreiðsla
Not actioned by Göbler Hirthmotoren KG / Hirth Engines GmbH.