Amended proposal for a Directive of the European Parliament and of the Council on occurrence reporting in civil aviation (COM(2001) 532 final — 2000/0343(COD)) (Text with EEA relevance)
Date: 2001-11-27
Institutions: European Commission
Subjects: accident prevention, air safety, civil aviation, data collection, transport accident

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Amended proposal for a Directive of the European Parliament and of the Council on occurrence
reporting in civil aviation (1)

(2001/C 332 E/19)

(Text with EEA relevance)

COM(2001) 532 final (cid:151) 2000/0343(COD)

(Submitted by the Commission pursuant to Article 250(2) of the EC Treaty on 26 September 2001)

(1) OJ C 120 E, 24.4.2001, p. 148.

INITIAL PROPOSAL

AMENDED PROPOSAL

THE EUROPEAN PARLIAMENT AND THE COUNCIL OF THE
EUROPEAN UNION,

Unchanged

Having regard to the Treaty establishing the European
Community, and in particular Article 80(2) thereof,

Having regard to the proposal from the Commission,

Having regard to the opinion of
Committee,

the Economic and Social

Having regard to the opinion of the Committee of the Regions,

Acting in accordance with the procedure laid down in Article
251 of the Treaty,

Whereas:

(1) The rate of accidents in civil aviation has remained fairly
constant in the last decade, generating concern that the
forecasted traffic increase could lead to an unacceptable
increase in the number of accidents in the near future.

(2) Council Directive 94/56/EC of 21 November 1994 estab-
lishing the fundamental principles governing the investi-
gation of civil aviation accidents and incidents aims at
preventing future accidents by facilitating the expeditious
holding of investigations.

(3) Experience has shown that before an accident occurs, a
number of incidents and numerous other deficiencies have
shown the existence of safety hazards.

(4) The improvement of the safety of civil aviation requires a
better knowledge of these occurrences to facilitate analysis
and trend monitoring in order
to initiate corrective
actions.

(5) When these occurrences involve aircraft registered in a
Member State or operated by an undertaking established
in a Member State, this occurrence should be reported
even when it happened outside the territory of
the
Community

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INITIAL PROPOSAL

AMENDED PROPOSAL

(6) Each Member State should set up mandatory reporting

systems.

(7) Various categories of personnel working in civil aviation
for the prevention of

observe occurrences of
accidents and should therefore report them.

interest

(8) The efficiency of detection of potential hazard would be
information on

greatly enhanced by the exchange of
occurrences.

(9) A supporting software for the exchange of information

between different system is necessary.

(10) Safety information shall be available to entities entrusted
to regulate civil aviation safety or to investigate accidents
and incidents within the Community and, as appropriate,
to the people who may learn from it and take or initiate
the necessary action to improve safety.

(11) The sensitive nature of safety information is such that the
only way to ensure the gathering of such information is
by ensuring its confidentiality, the protection of its source
and the confidence of
the personnel working in civil
aviation;

(12) The public should be provided with general information

on the level of aviation safety.

(13) Mandatory reporting systems shall be supplemented by
confidential reporting schemes to collect mainly human
factor related incidents.

(14) Legal measures should be put

in place to enable the

setting up of confidential reporting schemes.

(15) The measures necessary for the implementation of this
Directive should be adopted in accordance with Council
Decision 1999/468/EC of 28 June 1999 laying down the
procedures
implementing powers
the exercise of
conferred on the Commission (1).

for

(16) Consistency

should be

ensured with the

technical
reporting requirements developped by national experts
in EUROCONTROL and the JAA, the list of reportable
these two
occurences takes into account
European organisations.

the work of

___________
(1) OJ L 184, 17.7.1999, p. 23.

(16) Consistency

should be

ensured with the

technical
reporting requirements developped by national experts
in EUROCONTROL and the JAA, the list of reportable
these two
occurences takes into account
European organisations. Developments in the framework
of ICAO should also be taken into account.

the work of

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INITIAL PROPOSAL

AMENDED PROPOSAL

Unchanged

the proposed action,

(17) In accordance with the principles of subsidiarity and
proportionality as set out in Article 5 of the Treaty, the
improvement of air
objective of
safety, cannot be sufficiently achieved by the Member
States, because reporting systems operated by Member
States in isolation are less efficient than a coordinated
network with exchange of
information enabling an
earlier identification of possible safety problems, and can
therefore be better achieved by the Community. This
Directive confines itself
to the minimum required in
order to achieve this objective and does not go beyond
what is necessary for that purpose.

HAVE ADOPTED THIS DIRECTIVE:

Article 1

Objective

this directive

The purpose of
to the
improvement of air safety by ensuring that safety critical
stored, protected and
information is
disseminated in order to facilitate its effective analysis and
monitoring.

to contribute

collected,

reported,

is

The sole objective of occurrence reporting is the prevention of
future accidents and incidents and not to attribute blame or
liability.

Article 2

Scope

This directive shall apply to occurrences which have

1.
occurred in the territory of the Community.

2.
This directive shall also apply outside the territory of the
Community to occurrences involving aircraft registered in a
Member State or operated by an undertaking established in a
Member State.

Article 3

Definitions

For the purpose of this Directive:

(cid:145)Disidentification(cid:146) means removing from reports submitted all
personal details pertaining to the reporter and technical details,
which might
the reporter, or third
parties, being inferred from the information.

lead to the identity of

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INITIAL PROPOSAL

AMENDED PROPOSAL

(cid:145)Occurrence(cid:146) means accidents, incidents and serious incidents as
defined in Article 3, point (a), (j) and (k), of directive 94/56/EC
as well as other defects or malfunctioning of an aircraft, its
equipment, ground equipment and any element of
the Air
Navigation System which is used or intended to be used for
the purpose or in connection with the operation of an aircraft
or with the provision of an air traffic management service or
navigational aid to an aircraft;

(cid:145)Reportable occurrence(cid:146) means an occurrence, endangering or,
its
which if not corrected would endanger an aircraft,
occupants or any other person. A non-exhaustive list of
examples of reportable occurences can be found in Annex I
and II.

Article 4

Mandatory reporting

1. Member States shall require that reportable occurrences
are reported to the competent authority referred to in Article
5(1) by every person who:

(a) is the operator or commander of a turbine powered aircraft
or a public transport aircraft used or operated under the
control of its competent civil aviation authority;

(b) carries on the business of manufacturing or maintaining

such an aircraft, or any equipment or part thereof;

(c) signs a certificate of maintenance review, or of release to
service in respect of such an aircraft, part or equipment;

(d) performs a function for which he requires to be a qualified

air traffic controller;

(e) performs the function of manager of an aerodrome open to

public transport aircraft;

(f) performs a function connected with the installation, modi-
fication, maintenance, repair, overhaul, flight checking or
inspection of equipment on the ground which is used or
intended to be used for the purpose or in connection with
the provision of an air traffic control service or navigational
aid to an aircraft.

(g) performs a function connected with the handling of aircraft
on the ground, including fueling, servicing, loadsheet prep-
aration, loading, de-icing and towing,

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INITIAL PROPOSAL

AMENDED PROPOSAL

2. Member States shall encourage voluntary reporting by
every person who exercise in other civil aviation operations,
similar functions as those listed in paragraph 1.

3.
The Commission may, in accordance with the procedure
laid down in Article 10(2), decide on the addition to paragraph
1 of new categories of reporters and modify the Annexes in
order to expand upon, or change, the examples.

Article 5

Collection and storage of information

1. Member States shall designate a competent authority to
put in place a mechanism to collect, evaluate, process and store
occurrence reports.

The following authorities may be entrusted with that respon-
sibility:

(a) The national civil aviation provided that the independence
of the exercise of this function from any other duty of that
authority is duly assured.

(b) The investigating body or entity established under Article 6

of Directive 94/56/EC.

The reports collected under the provisions of Article 4

2.
shall be stored in a database.

relevant
3. Member
States
information deriving
confidential
reporting covered by Article 9 are also stored in that database.

that
analysis of

shall
from the

ensure

safety

Article 6

Exchange of information

1. Member States shall participate in a mutual exchange of
information by making all relevant safety related information
stored in the database mentionned in Article 5(2) available to
the competent authorities of the other Member States and the
Commission.

The database shall be compatible with the software described
in paragraph 2.

The database shall be compatible with the software described
in paragraph 3.

Upon receipt of a report, the competent authority of a
2.
Member State designated in accordance with Article 5(1) will
register it in its data base and will notify, as appropriate, the
competent authority of the Member State where the occurrence
took place, where the aircraft is registered, where the aircraft is
manufactured and/or where the operator is certificated.

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INITIAL PROPOSAL

AMENDED PROPOSAL

2.
The Commission shall develop a specific software for the
purpose of this directive. Member States may use this software
for running their own database.

3.
The Commission shall develop a specific software for the
purpose of this directive. Member States may use this software
for running their own database.

The Commission may lay down appropriate measures to
3.
facilitate the exchange of information foreseen in paragraph 1
in accordance with the procedure set out in Article 10(2).

The Commission may lay down appropriate measures to
4.
facilitate the exchange of information foreseen in paragraph 1
in accordance with the procedure set out in Article 10(2).

Article 7

Unchanged

Dissemination of information

Any entity entrusted to regulate civil aviation safety or to
1.
investigate civil aviation accidents and incidents within the
Community shall have access to information on occurrences
collected and exchanged in accordance with articles 5 and 6 to
enable it to draw the safety lessons from the reported occur-
rences.

The Commission may, in accordance with the procedure
2.
laid down in Article 10(2), decide on the release of selected
information to the categories of reporters listed in Article 4(1)
and to other interested parties. Such decisions, which can be
generic or individual, shall be based on the need to:

(cid:151) provide persons and/or organisations with the information
they need to correct deficiencies in aviation safety and
improve aviation safety, or

(cid:151) allow the analysis of occurences by bodies specialised in

aviation safety or directly related matters.

The decision to disseminate information under this paragraph
may be limited to what is strictly required for the purpose of
its user, without prejudice to the provisions of Article 8.

The decision to disseminate information under this paragraph
shall be limited to what is strictly required for the purpose of
its user, without prejudice to the provisions of Article 8.

The recipient of information shall in turn commit itself not to
disseminate the information further.

3. Member States shall publish at least annually a safety
review containing information on the types of occurrences
collected by their national mandatory occurrence-reporting
scheme to inform the public of the safety level of information.
Member States may also publish disidentified reports.

3. Member States shall publish at least annually a safety
review containing information on the types of occurrences
collected by their national mandatory occurrence-reporting
scheme to inform the public of the level of safety in civil
aviation. Member States may also publish disidentified reports.

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INITIAL PROPOSAL

AMENDED PROPOSAL

Article 8

Unchanged

Protection of information

The information exchanged in accordance with Article 6
1.
and disseminated in accordance with Article 7(1) and 7(2) shall
be confidential and shall be used solely for the purpose covered
by the activities of participants and addressees.

The information exchanged in accordance with Article 6
1.
and disseminated in accordance with Article 7(1) and 7(2) shall
be confidential and shall be used solely for the purpose covered
by the activities refered to in Article 1.

2.
Regardless of type or classification of occurrence, names
or addresses of individual persons shall never be recorded on
the database mentionned in Article 5(2).

Unchanged

The competent authority shall not disclose the name of
3.
the person submitting a report or of a person to whom it
relates unless required to do so in the context of
judicial
inquiries or unless the persons concerned authorise disclosure.

Deleted

4. Member States shall refrain from instituting proceedings
in respect of unpremeditated or inadvertent breaches of the
law, which come to its attention only because they have
been reported under
the national mandatory occurrence-
reporting scheme.

3. Member States shall refrain from instituting proceedings
in respect of unpremeditated or inadvertent breaches of the
law, which come to its attention only because they have
been reported under
the national mandatory occurrence-
reporting scheme, except in case of gross negligence.

5. Member States shall adapt their laws, regulations and
administrative provisions so as to ensure that employees who
duly and accurately report incidents, of which they may have
subjected to any detriment by their
knowledge, are not
employer.

4. Member States shall adapt their laws, regulations and
administrative provisions so as to ensure that employees who
duly and accurately report incidents, of which they may have
subjected to any detriment by their
knowledge, are not
employer.

This Article applies without prejudice to national rules

6.
related to access to information by judicial authorities.

This Article applies without prejudice to national rules

5.
related to access to information by judicial authorities.

Article 9

Unchanged

Confidential reporting

Member States shall adapt their laws, regulations and adminis-
trative provisions to permit the disidentification of voluntary
reports of non reportable occurrences by bodies created to
collect, analyse and disseminate to parties able to use it for
improving aviation safety, information on observed deficiencies
in the aviation system perceived by the reporter as an actual or
potential hazard.

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INITIAL PROPOSAL

AMENDED PROPOSAL

Article 10

Committee

1.
The Commission shall be assisted by the committee
instituted by Article 12 of Council Regulation (EEC)
No 3922/91 of 16 December 1991 on the harmonisation of
technical requirements and administrative procedures in the
field of civil aviation (1).

2. Where reference is made to this paragraph, Article 5 and
7 of Decision 1999/468/EC shall apply, having regard to the
provisions of Article 8 thereof.

The period provided for in Article 5(6) of Decision

3.
1999/468/EC shall be set at three months.

Article 11

Implementation

1. Member States shall bring into force the laws, regulations
and administrative provisions necessary to comply with this
forthwith inform the
Directive by at
Commission thereof.

the latest. They shall

1. Member States shall bring into force the laws, regulations
and administrative provisions necessary to comply with this
the latest.
Directive two years after its entry into force at
They shall forthwith inform the Commission thereof.

When Member States adopt those provisions, they shall contain
a reference to this Directive or be accompanied by such a
reference on the occasion of
their official publication.
Member States shall determine how such reference is to be
made.

Unchanged

The Member

2.
the
Commission the texts of the main provisions of national law
which they adopt in the field governed by this Directive.

communicate

States

shall

to

Article 12

Entry into force

This Directive shall enter into force on the twentieth day
following that of its publication in the Official Journal of the
European Communities.

Article 13

Adressees

This Directive is addressed to the Member States.

___________
(1) OJ L 373, 31.12.1991, p. 4.

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ANNEX I

LIST OF EXAMPLES OF REPORTABLE OCCURRENCES

Note: Although this Annex lists the majority of occurrences which should be reported it cannot be completely compre-
hensive and any other occurrences judged by those involved, to meet the criteria should be reported.

A. AIRCRAFT FLIGHT OPERATIONS

(i) Operation of the Aircraft

(a) An avoidance manoeuvre required to avoid a collision with an aircraft, terrain or other object or an

unsafe situation, or when avoidance action would have been appropriate

(b) Take-off or landing incidents,

including precautionary or forced landings.

shooting, overrunning or running off the side of runways. Take-offs, aborted take-offs,
attempted landings on a closed, occupied or incorrect runway.

Incidents such as under-
landings or

(c) Gross failures to achieve predicted performance during take-off or initial climb

(d) Critically low fuel quantity or inability to transfer fuel or use total quantity of usable fuel.

(e) Loss of control (including partial or temporary loss of control) from any cause

(f) Occurrences close to or above V1 resulting from or producing a hazardous or potentially hazardous

situation (e.g. rejected take-off, tail strike, engine power loss etc.).

(g) Go-around producing a hazardous or potentially hazardous situation

(h) Unintentional significant deviation from airspeed, intended track or altitude. (more than 300 ft in non

RVSM airspace) from any cause

(i) Descent below decision height/altitude or minimum descent height/altitude without the required visual

reference.

(j) Heavy landing (cid:151) a landing deemed to require a (cid:145)heavy landing check(cid:146).

(k) Exceedance of fuel imbalance limits

(l)

Incorrect setting of an SSR code or of an altimeter subscale resulting in, or could result in, a hazardous
situation.

(m)

Incorrect programming of, or erroneous entries into, equipment used for navigation or performance
calculations, or use of incorrect data, which resulted in, or could have resulted in, a hazardous situation

(n)

Incorrect receipt or interpretation of radiotelephony messages which resulted in, or could have resulted
in, a hazardous situation.

(o) Fuel system malfunctions or defects, which had a significant effect on fuel supply and/or distribution.

(p) Aircraft leaving a paved surface which results in, or could have resulted in, a hazard

(q)

Inadvertent incorrect operation of any controls which resulted in, or could have resulted in, a significant
hazard

(r)

Inability to achieve the intended aircraft configuration for any flight phase (e.g. landing gear and doors,
flaps, stabilisers, slats etc)

(s) A hazard or potential hazard which arises as a consequence of any deliberate simulation of failure

conditions for training, system checks or training purposes

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(t) Abnormal vibration felt by the crew

(u) abnormal ice accumulation leading to significant effects on performance or handling qualities

(v) Operation of any primary warning system associated with manoeuvring of the aircraft e.g. configuration

warning, stall warning (stick shake), over speed warning etc. unless:

(w)

the crew conclusively established that the indication was false. Provided that the false warning did not
result in difficulty or hazard arising from the crew response to the warning.

(x) Unless operated for training or test purposes

(y) GPWS (cid:145)warning(cid:146) when:

1. the aircraft comes into closer proximity to the ground than had been planned or anticipated; or

2. the warning is experienced in IMC or at night and is established as having been triggered by a high

rate of descent (Mode 1); or

3. the warning results from failure to select landing gear or land flap by the appropriate point on the

approach (Mode 4); or

4. any difficulty or hazard arises or might have arisen as a result of crew response to the (cid:145)warning(cid:146) e.g.
possible reduced separation from other traffic. This could include warning of any Mode or Type i.e.
genuine, nuisance or false.

(z) GPWS (cid:145)alert(cid:146) when: any difficulty or hazard arises or might have arisen as a result of crew response to the

(cid:145)alert(cid:146).

(aa) ACAS RAs

(bb) Jet or prop blast incidents resulting in significant damage or serious injury.

(ii) Emergencies

(a) Fire, explosion, smoke or toxic or noxious fumes, even though fires were extinguished.

(b) The use of any non-standard procedure by the flight or cabin crew to deal with an emergency

(c) Inadequacy of any procedures designed to be used in an emergency, including when being used for main-

tenance, training or test purposes.

(d) An emergency evacuation.

(e) Depressurisation

(f) The use in flight or on the ground of any emergency equipment or prescribed emergency procedures in order

to deal with a situation.

(g) The declaration of an emergency ((cid:145)Mayday(cid:146) or (cid:145)Pan(cid:146))

(h) Failure of any emergency system or equipment, including all exit doors and lighting, to perform satisfactorily,

including when being used for maintenance, training or test purposes.

(i) Events requiring the emergency use of oxygen by the flight crew

(iii) Crew Incapacitation

(a) Incapacitation of any member of the flight crew, including that which occurs prior to departure if it is

considered that it could have resulted in incapacitation after take-off.

(b) Incapacitation of any member of the cabin crew which renders them unable to perform essential emergency

duties.

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(iv) Injury

Occurrences, which have or could have led to significant injury to passengers or crew but which are not
considered reportable as an accident.

(v) Meteorology

(a) A lightning strike which resulted in significant damage to the aircraft or loss or malfunction of any essential

service.

(b) A hail strike which resulted in significant damage to the aircraft or loss or malfunction of any essential

service.

(c) Severe turbulence encounter (cid:151) an encounter resulting in injury to occupants or deemed to require a

(cid:145)turbulence check(cid:146) of the aircraft.

(d) Windshear encounter resulting in significant handling difficulties

(vi) Security

(a) Unlawful interference of the aircraft including a bomb threat or hijack.

(b) Difficulty in controlling intoxicated, violent or unruly passengers which resulted in a hazardous situation

(c) Discovery of a stowaway

(vii) Other Occurrences

(a) Repetitive instances of a specific type of occurrence which in isolation would not be considered (cid:145)reportable(cid:146)

but which due to the frequency at which they arise form a potential hazard.

(b) A bird strike which resulted in significant damage to the aircraft or loss or malfunction of any essential

service.

(c) Wake turbulence encounters resulting in significant handling difficulties

(d) Any other occurrence of any type considered to have endangered or which might have endangered the

aircraft or its occupants

B. AIRCRAFT TECHNICAL

(viii) Structural

Aircraft structural failures not classified as an accident.

Note: Not all structural failures need to be reported. Engineering judgement is required to decide whether a
failure is serious enough to be reported. The following examples can be taken into consideration:

1. Damage to a Principal Structural Element that has not been qualified as damage tolerant (life limited
element). Principal Structural Elements are those which contribute significantly to carrying flight,
ground, and pressurisation loads, and whose failure could result in a catastrophic failure of the aircraft

2. Typical examples of such elements are listed for large aeroplanes in AC/ACJ 25.571(a) (cid:145)damage tolerance

and fatigue evaluation of structure(cid:146), and in the equivalent ACJ material for rotorcraft

3. Defect or damage exceeding admissible damages to a Principal Structural Element that has been qualified as

damage tolerant, found during scheduled inspections.

4. Damage to or defect exceeding allowed tolerances of a structural element which failure could reduce the
structural stiffness to such an extent that the required flutter, divergence or control reversal margins are no
longer achieved.

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5. Damage to or defect of a structural element which could result in the liberation of items of mass that may

injure occupants of the aircraft.

6. Damage to or defect of a structural element, which could jeopardise proper operation of systems.

7. Loss of any part of the aircraft structure in flight

(ix) Systems

The following generic criteria applicable to all systems are proposed:

(a) Loss, significant malfunction or defect of any system, subsystem or set of equipment when standard-

operating procedures, drills etc. could not be satisfactorily accomplished.

(b)

Inability of the crew to control the system: e.g.

1. uncommented actions

2.

incorrect and or incomplete response, including limitation of movement or stiffness

3. Runaway

4. Mechanical disconnection or failure

(c)

Failure or malfunction of the exclusive(s) functions of the system.
functions)

(one system could integrate several

(d)

Interference within or between systems.

(e)

Failure or malfunction of the protection device or emergency system associated with the system.

(f)

Loss of redundancy of the system outside the limits.

(g) Any occurrence resulting from unforeseen behaviour of a system.

(h) For aircraft types with single main systems, subsystems or sets of equipment

Loss, significant malfunction or defect in any main system, subsystem or set of equipment.

(i)

For aircraft types with multiple independent main systems, subsystems or sets of equipment

The loss, significant malfunction or defect of more than one main system, subsystem or set of equipment

(j) Operation of any primary warning system associated with aircraft systems or equipment unless the crew
conclusively established that the indication was false provided that the false warning did not result in
difficulty or hazard arising from the crew response to the warning.

(k) Leakage of hydraulic fluids, fuel, oil or other fluids which resulted in a fire hazard or possible hazardous

contamination of aircraft structure, systems or equipment, or risk to occupants

(l) Malfunction or defect of any indication system when this results in the possibility of misleading indications to

the crew.

(m) Any failure, malfunction or defect if it occurs at a critical phase of flight and relevant to the operation of that

system.

(n) Occurrences of significant shortfall of the actual performances compared to the approved performance which
resulted in a hazardous situation (taking into account the accuracy of the performance calculation method)
including braking action, fuel consumption etc.

(o) Asymmetry of flight controls; e.g. flaps, slats, spoilers etc.

Annex II gives a list of examples of reportable occurrences resulting from the application of these generic criteria
to specific systems

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(x) Propulsion and APU Systems (Including Engines, Propellers, Rotor Systems and APUs)

(a) Engines

A i r c r a f t

t y p e s w i t h o n e o r t w o e n g i n e s

(a)

flameout, shutdown or significant malfunction of any engine

A i r c r a f t

t y p e s w i t h t h r e e o r m o r e e n g i n e s

(b)

flameout, shutdown or significant malfunction of more than one engine

E n g i n e s : A l l a i r c r a f t

t y p e s :

(c) Flameout, shutdown or significant malfunction of any engine when: it occurs at a critical phase of flight
(e.g. V1, or during approach/landing) or exceptional circumstances exist or unforeseen consequences arise
(e.g. uncontained failure, fire, aircraft handling problems etc)

(d) Uncontained failure, significant overspeed or inability to control the speed of any high speed-rotating
component (for example: Auxiliary power unit, air starter, air cycle machine, air turbine motor, propeller
or rotor).

(e)

failure or malfunction of any part of an engine or powerplant resulting in any one or more of the
following:

1. non containment of high energy debris

2. sustained internal or external fire, or hot gas breakout

3. break up of the engine structure or mountings, or partial or complete loss of a major part of the

powerplant

4. engine defect causing visible fumes or any sort of invisible noxious or toxic fumes in the cabin

conditioning air

(f)

an uncommanded thrust/power loss, change or oscillation where:

1. this could affect more than one engine in a multi-engine aircraft, particularly in the case of a twin-

engined aircraft, or

2.

it is considered excessive for a single engine aircraft application, or

3.

it involves a multi-engine aircraft where the same, or similar, engine type is used in a single engine
aircraft application.

(g) any defect causing part retirement found in a life controlled part before completion of the full life of the

part

(h) defects of common origin which could cause an in flight shut down rate so high that there is the

possibility of more than one engine being shut down on the same flight

(i)

thrust in a different direction from that demanded by the pilot, or a thrust reversing system failing to
operate or operating inadvertently

(j)

significant lack of response to pilot’s throttle lever movement for a single engine application

(k) an engine limiter or control device failing to operate when required or operating inadvertently

(l)

significant exceedance of engine parameters

(m) inability, by use of normal procedures, to shutdown an engine or to control power, thrust or rpm

(n)

inability to restart a serviceable engine

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(b) Propellers and transmissions

1. damage or defect which could lead to complete or partial blade separation, and or significant vibrations

2. damage or defect of propeller gearbox/attachment which could lead to in flight separation of the propeller

assembly, and/or malfunctions of propeller control

3. untimely reverse thrust activation

4. untimely auto feather or pitch change

5. significant overspeed

6.

loss of ability to control the pitch

(c) APUs

1.

shut down when APU is used in accordance with the MEL

2.

inability to shut down the APU

3. significant overspeed

4.

inability to start the APU when needed for operational reasons

(xi) ETOPS

(a) Loss of one hydraulic system

(b) Loss of one bleed air system

(c) Any failure or malfunction that could affect the integrity of ETOPS operations.

(xii) Other Occurrences

(a) An occurrence not normally considered as reportable (for example, furnishing and cabin equipment, water
systems, items included in the Minimum Equipment List), where the circumstances resulted in endangering of
the aircraft or its occupants.

(b) A fire, explosion, smoke or toxic or noxious fumes

(c) Any other event which could hazard the aircraft, or affect the safety of the occupants of the aircraft, or people

or property in the vicinity of the aircraft or on the ground

(d) Failure or defect of passenger address system resulting in loss or inaudible passenger address system

(e) Loss of pilot’s seat control during flight

C. AIRCRAFT MAINTENANCE AND REPAIR

(xiii) Incorrect assembly of parts or components of the aircraft found at the opportunity of an inspection or test

procedure not intended for that specific purpose

(xiv) Hot bleed air leak resulting in structural damage

(xv) Any defect causing part retirement found in a life controlled part before completion of the full life of the part

(xvi) Any damage or deterioration (i.e. fractures, cracks, corrosion, delamination, disbonding etc) resulting from any

cause (such as flutter, loss of stiffness or structural failure) to:

(a) primary structure or a principle structural element (as defined in the manufacturers’ Repair Manual) where
such damage or deterioration exceeds allowable limits specified in the Repair Manual and requires a repair
or complete or partial replacement of the element;

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(b) secondary structure which consequently has or may have endangered the aircraft.

(c) the engine, propeller or helicopter rotor system

(xvii) Any failure, malfunction or defect of any system or equipment, or damage or deterioration found as a result of
compliance with an Airworthiness Directive or other mandatory instruction issued by a Regulatory Authority,
when:

(a)

it is detected for the first time by each operator or organisation implementing compliance;

(b) on any subsequent compliance where it exceeds the permissible limits quoted in the instruction and/or
the
to the Design Authority or Regulatory Authority for an

published repair/rectification procedures are not available. For example, a report
condition found necessitates a request
extension of limits and/or special repair/rectification schemes or procedures;

is required if

(xviii) Failures or defects to any part subject to a finite life or any rotorcraft (cid:145)critical parts(cid:146) (as defined in Manu-

facturers Manuals).

(xix) Failure of any emergency system or equipment, including all exit doors and lighting, to perform satisfactorily,

including when being used for maintenance or test purposes.

(xx) Non compliance or significant errors in compliance with required maintenance procedures.

D. AIR TRAFFIC SERVICES, FACILITIES AND GROUND SERVICES

(xxi) Air Traffic Services

(a) Provision of significantly incorrect, inadequate or misleading information from any ground sources, e.g.

ATC, ATIS, Meteorological Services, navigation databases, maps, charts, manuals, etc.

(b) Provision of less than prescribed terrain clearance.

(c) Provision of incorrect altimeter setting.

(d) Incorrect transmission, receipt or interpretation of significant messages when this results in a hazardous

situation.

(e) Separation between aircraft less than that prescribed for the situation.

(f) Unauthorised infringement of any form of regulated airspace.

(g) Unauthorised or illegal RTF transmissions.

(h) Failure of ATS ground or satellite facilities

(i) Major failure or significant deterioration of aerodrome movement area surfaces.

(j) Aerodrome movement areas obstructed by aircraft, vehicles, animals or foreign objects, resulting in a

hazardous or potentially hazardous situation

(k) Errors or inadequacies in marking of obstructions or hazards on aerodrome movement areas resulting in a

hazardous situation.

(xxii) Aerodrome and Aerodrome Facilities

(a) Failure, significant malfunction or unavailability of airfield lighting.

(b) Significant contamination of aircraft structure, or systems and equipment arising from the carriage of

baggage or cargo.

(c) Incorrect loading of passengers, baggage or cargo, likely to have a significant effect on aircraft mass and/or

balance.

(d) Incorrect stowage of baggage or cargo (including hand baggage) likely in any way to hazard the aircraft, its

equipment or occupants or to impede emergency evacuation

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(e) Inadequate stowage of cargo containers or other substantial items of cargo.

(f) Carriage or proposed carriage of dangerous goods in contravention of applicable regulations including

incorrect labelling and packaging of dangerous goods

(xxiii) Passenger Handling, Baggage and Cargo

(a) Collision between a moving aircraft during flight and any other aircraft, vehicle or other ground object

(b) Significant spillage during fuelling operations.

(c) Loading of incorrect fuel quantities likely to have a significant effect on aircraft endurance, performance,

balance or structural strength

(d) Loading of contaminated or incorrect type of fuel or other essential fluids (including oxygen and potable

water).

(xxiv) Aircraft Ground Handling and Servicing

(a) Failure, malfunction or defect of ground equipment used for test or checking of aircraft systems and
equipment when the required routine inspection and test procedures did not clearly identify the problem
when this results in a hazardous situation

(b) Non compliance or significant errors in compliance with required servicing procedures.

ANNEX II

The following subparagraphs give examples of reportable occurrences resulting from the application of the generic
criteria to specific systems listed in Annex I, point B), ix).

1. Air conditioning/ventilation

(a) complete loss of avionics cooling

(b) depressurisation

2. Autoflight system

(a) failure of the autoflight system to achieve the intended operation while engaged

(b) significant reported crew difficulty to control the aircraft linked to autoflight system functioning

(c) failure of any autoflight system disconnect device

(d) unexpected autoflight mode change

3. Communications

(a) failure or defect of passenger address system resulting in loss or inaudible passenger address

(b) total loss of communication in flight

4. Electrical system

(a) loss of one electrical system distribution system (AC or DC)

(b) total loss or loss or more than one electrical generation system

(c) failure of the back up (emergency) electrical generating system

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5. Cockpit/Cabin/Cargo

(a) pilot seat control loss during flight

(b) failure of any emergency system or equipment, including emergency evacuation signalling system, all exit doors,

emergency lighting, etc

(c) loss of retention capability of the cargo loading system

6. Fire protection system

(a) fire warnings, except those immediately confirmed as false

(b) undetected failure or defect of fire/smoke detection/protection system, which could lead to loss or reduced fire

detection/protection

(c) absence of warning in case of actual fire

7. Flight controls

(a) Asymmetry of flaps, slats, spoilers etc.

(b) limitation of movement, stiffness or poor or delayed response in the operation of primary flight control systems

or their associated tab and lock systems

(c) flight control surface run away

(d) flight control surface vibration felt by the crew

(e) mechanical flight control disconnection or failure

(f) significant interference with normal control of the aircraft or degradation of flying qualities

8. Fuel system

(a) fuel quantity indicating system malfunction resulting in total loss or erroneous indicated fuel quantity on board

(b) leakage of fuel which resulted in major loss, fire hazard, significant contamination

(c) malfunction or defects of the fuel jettisoning system which resulted in inadvertent loss of significant quantity,

fire hazard, hazardous contamination of aircraft equipment or inability to jettison fuel

(d) fuel system malfunctions or defects which had a significant effect on fuel supply and/or distribution

(e) inability to transfer or use total quantity of usable fuel

9. Hydraulics

(a) loss of one hydraulic system (ETOPS only)

(b) failure of the isolation system to operate

(c) loss of more than one hydraulic circuits

(d) failure of the back up hydraulic system

(e) inadvertent Ram Air Turbine extension

10. Ice detection/protection system

(a) undetected loss or reduced performance of the anti-ice/de-ice system

(b) loss of more than one of the probe heating systems

(c) inability to obtain symmetrical wing de icing

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(d) abnormal ice accumulation leading to significant effects on performance or handling qualities

(e) crew vision significantly affected

11. Indicating/warning/recording systems

(a) malfunction or defect of any indicating system when the possibility of significant misleading indications to the

crew could result in an inappropriate crew action on an essential system

(b) loss of a red warning function on a system

(c) failure or malfunction of recording systems (FDR, CVR)

(d) for glass cockpits: loss or malfunction of more than one display unit or computer involved in the display/

warning function

12. Landing gear system/brakes/tyres

(a) brake fire

(b) significant loss of braking action

(c) unsymmetrical braking leading to significant path deviation

(d) failure of the L/G free fall extension system (including during scheduled tests)

(e) unwanted gear or gear doors extension/retraction

(f) multiple tyres burst

13. Navigation systems (including precision approaches system) and air data systems

(a) loss or multiple navigation equipment failures

(b) total failure or multiple air data system equipment failures

(c) significant misleading indication

14. Oxygen

(a) for pressurised aircraft: loss of oxygen supply in the cockpit

(b) loss of oxygen supply to a significant number of passengers (more than 10 %), including when found during

maintenance or training or test purposes

15. Bleed air system

(a) hot bleed air leak resulting in fire warning or structural damage

(b) loss of all bleed air systems

(c) failure of bleed air leak detection system