Annual Safety recommendations review 2022.
Date: 2022-09-23
Institutions: European Union Aviation Safety Agency
Subjects: activity report, air safety, air transport, aviation security, transport accident

2022 Annual Safety Recommendations Review

1

Annual Safety 

ANNUAL SAFETY 
RECOMMENDATIONS 
REVIEW

Strategy & Safety 
Management Directorate

Safety Intelligence & 
Performance Department

2022

2022 Annual Safety Recommendations Review

2

Catalogue number

Catalogue number
TO-AE-22-001-EN-N

ISBN
978-92-9210-280-7

ISSN
2599-7793

DOI
10.2822/199328

2022 Annual Safety Recommendations Review

3

Annual Safety 

ANNUAL SAFETY 
RECOMMENDATIONS 
REVIEW

Strategy & Safety Management Directorate
Safety Intelligence & Performance Department

2022

Contents

Disclaimer:

The Annual Safety Recommendations Review is produced by the European Union Aviation Safety Agency (EASA). 
This edition provides an overview of the safety recommendations that have been addressed to EASA in 2021.  
It also presents the replies produced during the year.

This annual review aims at providing feedback on the follow-up given to safety recommendations in the context 
of openness, transparency and accountability that characterises European Public Administration.

Apart from its safety-related informative character, this review is also expected to provide relevant information 
related to safety concerns raised, for both EASA and its stakeholders, including the European public.

Neither the European Union Aviation Safety Agency, nor any person acting on behalf of the European Union  
Aviation Safety Agency may be held responsible for the use that might be made of the information contained 
within.

Image credits

© iStock 

European Union Aviation Safety Agency, 2022. All rights reserved. Proprietary document.

Printed copies are not controlled. Confirm revision status through the EASA-Internet site: www.easa.europa.eu. 
2022 Annual Safety Recommendations Review

2022 Annual Safety Recommendations Review

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Contents

Contents

0  Abbreviation list ............................................................................................................ 8

1  Executive summary .......................................................................................................11

2 

Introduction ................................................................................................................. 13

3  Safety Recommendations received in 2021 ..................................................................16

3.1   Overview of Safety Recommendations received in 2021 ................................................................. 16

3.2   Origin of the Safety Recommendations received in 2021................................................................ 19

3.3 

Involvement in accident and serious incident investigations ......................................................... 21

4  Safety Recommendations replies in 2021 ................................................................... 24

4.1   Overview of Safety Recommendations replies in 2021.................................................................... 24

4.2   Status of Safety Recommendations replies issued in 2021 .............................................................. 25

5  Overview of key safety topics processed and actions carried out in 2021 ..................29

5.1   Crash resistant fuel systems .............................................................................................................. 30

5.2  Conflict zones ..................................................................................................................................... 32

5.3  Airborne collision risks - collision avoidance systems for aircraft below 5700 MTOW .................. 33

5.4  Reporting of runway surface condition ............................................................................................ 35

5.5  Accidents involving the Boeing 737-8(MAX) .................................................................................... 36

6  Conclusions ...................................................................................................................39

List of Figures

2022 Annual Safety Recommendations Review

List of Figures

6

List of Figures

Figure 1:  Safety Recommendations addressed to EASA per year .................................................................. 16

Figure 2:  Annual Safety Recommendations by occurrence class 2012-2021 ................................................. 17

Figure 3:  Safety Recommendations received in 2021 by Type of Operation and Aircraft Category ............ 18

Figure 4:  Origin of Safety Recommendations received by EASA ................................................................... 19

Figure 5:  States contribution to Safety Recommendations received in 2021 ................................................ 19

Figure 6:  EASA replies to safety recommendations in 2021, by year received.............................................. 24

Figure 7:  Safety Recommendation Replies sent in 2021 [status, total number]............................................ 25

Figure 8:  Reply assessment received from the originator on the EASA Replies since 2016  ........................ 26

Figure 9:  Assessment received by EASA on the Final Responses sent in 2021 .............................................. 27

Figure 10:  Safety Recommendations addressed to EASA per topic by EU SIAs ............................................... 29

Figure 11:  Safety Recommendations addressed to EASA per topic and area ................................................. 30

2022 Annual Safety Recommendations Review

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CHAPTER 0

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3 

CHAPTER 4

CHAPTER 5

CHAPTER 6

ABBREVIATION
LIST

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3 

CHAPTER 4

CHAPTER 5

CHAPTER 6

Abbreviation list

2022 Annual Safety Recommendations Review

Abbreviation list

8

Abbreviation list

AAIB

AB

AD

AFM

AH

AIA

ALS

AMC

BEA

CAG

CAT

CAW

CRM

CS

CVR

CRFS

CRSS

CZIB

DSB

EASA

EFB

ED

EDD

The United Kingdom Air Accidents Investigations Branch

Advisory Body

Airworthiness Directive

Aircraft Flight Manual

Airbus Helicopters

Aerospace Industries Association

Airworthiness Limitations Section

Acceptable Means of Compliance

Bureau d’Enquête et d’Analyse pour l’Aviation Civile (France)

Collaborative Analysis Group

Commercial Air Transport

Continuing Airworthiness

Crew Resource Management

Certification Specifications

Cockpit Voice Recorder

Crash Resistant Fuel System

Crash Resistant Seats and Structures

Conflict Zone Information Bulletin

Dutch Safety Board, The Netherlands

European Union Aviation Safety Agency

Electronic Flight Bag

Executive Director

Executive Director Decision

ENCASIA

European Network of Civil Aviation Safety Investigation Authorities

EPAS

EU

FAA

FCL

FDM

FDR

GA

GM

GRF

HEMS

HMU

European Plan for Aviation Safety

European Union

Federal Aviation Administration, USA

Flight Crew Licencing

Flight Data Monitoring

Flight Data Recorder

General Aviation

Guidance Material

Global Reporting Format

Helicopter Emergency Medical Services

Hydro Mechanical Unit

Abbreviation list

2022 Annual Safety Recommendations Review

9

Abbreviation list

ICA

ICAO

JRC

MCTOM

MOPSC

MSL

MS

MST

Instructions for Continued Airworthiness

International Civil Aviation Organization

Joint Research Centre

Maximum Certified Take-Off Mass

Maximum Operational Passenger Seating Configuration

Mean Sea Level

Member States

Member State Task

MTOW

Maximum Take-off Weight

NM

NPA

NTSB

QMS

Nautical Miles

Notice of Proposed Amendment 

National Transportation Safety Board, USA

Quality Management System

RCZ Network

Conflict Zones Network of Focal Points

RES

RMT

RTS

RWY

Research

Rulemaking Task

Return to Service

Runway

RWYCC

Runway Condition Code

SHK

SIA

SIB

SPT

SMS

SRGC

SRIS

SRM

SRUR

SSP

STC

TC

ToR

UAV

UTC

Statens haverikommission, Sweden

Safety Investigation Authority

Safety Information Bulletin

Safety promotion Task

Safety Management System

Safety Recommendation of Global Concern

Safety Recommendation Information System

Safety Risk Management

Safety Recommendation of Union-wide Relevance

State Safety Programme

Supplemental Type Certificate

Type Certificate

Terms of Reference

Unmanned Aerial Vehicle

Coordinated Universal Time

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

EXECUTIVE SUMMARY

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

Executive summary

2022 Annual Safety Recommendations Review

11

Executive summary

Executive summary

The Annual Safety Recommendations Review provides information on the activities carried out by the Agency 
in the field of accident and incident investigation and follow-up in 2021. In addition, the review highlights  
a range of safety issues and Agency safety improvement actions that will be of interest to the European aviation 
community and the wider public.

This 15th edition includes:

•  General statistical data on the safety recommendations addressed by Safety Investigation Authorities 

to the Agency in 2021;

• 

Information on the replies that the Agency has provided to safety recommendations in 2021;

•  The main safety issues that have been addressed and the actions taken.

The Agency has a key role in safety investigation follow-up in Europe. This has been reflected in the establishment 
of a precise process for managing the safety recom mendations received. Due to its central position in the aviation 
safety system, the Agency is able to take actions with respect to systemic problems and risk management. 

The implementation of safety recommendations serves to ensure lessons are learned and help prevent future 
occurrences.

During 2021, Safety Investigation Authorities from 18 different States addressed 34 safety recommendations 
to the Agency in the context of EASA’s remit, 20 originating from EASA Member States and 14 from non-EASA  
Member States. This volume is slightly higher than the number of safety recommendations received in 2020.

The vast majority, 70%, of the safety recommendations were related to procedures or regulations. 15% of the 
safety recommendations addressed aircraft, equipment or facilities, 12% were related to personnel and 3% to 
quality and safety management.

The handling of safety recommendations in a systematic manner constitutes one of EASA’s key responsibilities. 
In 2021, the Agency provided 90 replies to 86 safety recommendations:

•  57 of these were final replies (closing safety recommendations) with 26 of these replies assessed as 

`agreed’ by EASA, and 21 assessed as `partially agreed’;

•  The remaining 33 replies were updates providing information on the progress of the actions decided 

upon by the Agency and for which the relevant activities were not yet completed;

•  As assessed by the originator, 29 of the responses provided by the Agency were deemed to be  
‘adequate’  or  ‘partially  adequate’  (16  and  13  respectively),  and  13  responses  were  deemed  
‘not adequate’. With respect to the 48 remaining replies sent in 2021, The Agency awaits the SIAs’ 
assessments.

2022 Annual Safety Recommendations Review

12

CHAPTER 0

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

INTRODUCTION

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

2022 Annual Safety Recommendations Review

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Introduction

Introduction

Within the European Union (EU), the principles governing the investigation of accidents and serious incidents 
are defined in Regulation (EU) No 996/20101 of the European Parliament and of the Council of 20 October 2010 
on the investigation and prevention of accidents and incidents in civil aviation.

Regulation (EU) No 996/2010 transposes international standards and recommended practices as described in 
Annex 13 to the Chicago Convention on International Civil Aviation. It sets outs an obligation for each Member 
State of the European Union to establish an independent, permanent national civil aviation Safety Investigation 
Authority, which shall investigate accidents and serious incidents in order to improve aviation safety and 
prevent future occurrences without apportioning blame or liability. Investigation reports and the related safety 
recommendations are sent to the aviation authorities concerned for consideration and action as needed.

Regulation (EC) No 2018/1139, the EASA Basic Regulation, states that: “The Agency and the national competent 
authorities shall undertake the necessary and effective actions to increase and promote awareness of civil 
aviation safety and disseminate safety related information relevant for the prevention of accidents and incidents”.

The Agency assigns a high priority to the follow-up of safety recommendations and has established effective 
procedures to that effect:

•  The Agency delivers a first reply to a safety recommendation within 90 days;

•  Safety recommendations are subject to a continuous internal monitoring process until all agreed 

corrective actions are closed;

•  The Agency receives assessments of its responses from Safety Investigation Authorities (SIAs).

These procedures support the Agency in ensuring transparency with respect to its decisions and actions in line 
with its mission for safety. The Agency also supports effective cooperation in safety investigation by working 
with the European Network of Civil Aviation Safety Investigation Authorities (ENCASIA) in Working Group 6 on 
Safety Recommendations.

The Agency also monitors safety recommendations that are issued to other aviation and non-aviation addressees. 

The Annual Safety Recommendations Review provides an overview of the follow-up performed by the Agency in 
response to recommendations received. 

The first edition of this Review was issued in 2007. This 15th edition reviews the 2021 activity and presents:

•  General statistical data on the safety recommendations addressed by Safety Investigation Authorities 

to the Agency in 2021;

• 

Information on the replies that the Agency has provided to past safety recommendations in 2021;

•  The main safety issues that have been addressed through the actions taken.

1 

 As amended by Regulation (EU) No 376/2014 and Regulation (EU) 2018/1139

2022 Annual Safety Recommendations Review

14

Introduction

In order to align this document with the other publications produced by The Agency, the naming of the Annual 
Safety Recommendation Review has been changed. Previously the title year referred to the year under review, 
whereas from this edition onwards, it will reflect the year of publication.

A process to identify, assess and mitigate safety risks at the European level has been established by the Agency 
since 2016. The safety risk management process involves the identification of safety issues, risk assessment and 
decision-making on the best course of action to mitigate these risks. The Agency, the Member States (MS) and 
industry work together in this process through Collaborative Analysis Groups (CAG) and Advisory Bodies (ABs). 

The Annual Safety Review published by the Agency provides the main and most visible elements from the 
European safety risk management process, such as key statistics relating to accidents and serious incidents, as 
well as an analysis of the key risk areas and safety risk portfolios for each domain. This risk management process 
is coordinated by the Agency, and it supports the European Plan for Aviation Safety (EPAS).

Safety recommendations are a key input to the safety risk management process. They provide information on 
the possible deficiencies in the aviation system and propose solutions to mitigate the associated safety risks.

2022 Annual Safety Recommendations Review

15

CHAPTER 0

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

SAFETY 
RECOMMENDATIONS 
RECEIVED IN 2021

CHAPTER 0

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

Safety Recommendations received in 2021

2022 Annual Safety Recommendations Review

16

Safety Recommendations received in 2021

Safety Recommendations 
received in 2021

3.1   Overview of Safety Recommendations  

received in 2021

EASA is the most frequent single addressee of Safety Recommendations. However, most safety recommendations 
issued during 2021 were addressed to the National Civil Aviation Authorities of EASA Member States.  

During 2021, EASA received a total of 34 safety recommendations. 

Figure 1 shows the total annual number of safety recommendations that the Agency has received over the past 
10 years. The follow-up of safety recommendations and the role of the Agency is mandated by Regulation (EU) No 
996/2010. The issuance of safety recommendations addressed to the Agency started to develop shortly before this 
regulation came into force in 2010. In the years from 2012 to 2016, the annual number of safety recommendations 
addressed  to  the  Agency  remained  almost  constant.  In  2017,  this  amount  fell  by  around  half.  Despite  
a marginal increase in 2018, the general downward trend continues and the number in 2021 is close to the  
2020 amount.

 ´  Figure 1: Safety Recommendations addressed to EASA per year

Total annual number of safety recommendations  

140 

120 

118

100 

80 

60 

40 

20 

0 

99

94

90

86

88

55

54

46

32

34

2011 

2012 

2013 

2014 

2015 

2016 

2017 

2018 

2019 

2020

2021

2022 Annual Safety Recommendations Review

17

Safety Recommendations received in 2021

In 2021, 20 safety recommendations came from EASA MS whereas the number in 2020 was 26.  The decrease is 
since the United Kingdom is no longer an EASA Member State. The numbers in general still seem to reflect the 
factors identified in recent years, namely proactively identifying safety concerns and addressing them before 
they would be raised during an investigation, as well as the Agency’s active involvement in investigations during 
the report-drafting phase, leading to draft safety recommendations being discussed in advance and in some 
cases either withdrawn, revised or re-addressed. 

In 2021, the safety recommendations received related to 22 occurrences, comprising 15 accidents and 6 serious 
incidents. One arose from a study.

Figure 2 shows the total number of safety recommendations received by occurrence class since 2012.

 ´ Figure 2: Annual Safety Recommendations by occurrence class 2012-2021

0 30 12 2012 25 4 2019 10 1 202114 2018 13 202022 5 2013 24 13 7 2014 21 12 1 2015 2 18 0 2016 1 14 2 2017 2 Accident Serious Incident Incident Study and Other 5047477169244025231910 20 30 40 50 60 70 80 2022 Annual Safety Recommendations Review

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Safety Recommendations received in 2021

The aircraft categories and operation types involved in the occurrences that resulted in safety recommendations 
issued in 2021 are listed in the table below.

 ´ Figure 3: Safety Recommendations received in 2021 by Type of Operation and Aircraft 

Category

Type of Operation

Fixed Wing

Aircraft Category

Large 
Aeroplane

Small 
Aeroplane

Ultralight/
Microlight

Sailplane

Rotorcraft

UAV

Grand 
Total

17

0

0

0

3

0

15*

2

0

0

9

6

3

0

1

1

0

2

1

1

0

1

2

1

1

0

1

1

0

Commercial  
Air Transport

Cargo

Airline

Passenger

Airline

HEMS

Other

Non-Commercial 
Operations

Flight Training

Pleasure

Other

Specialised Operations 
(Aerial Work)

Parachute drop

Calibration

Aerial photography

Firefighting

Towing

20

0

0

0

15

1

4

14

6

5

3

0

0

0

0

0

0

Grand Total

17

9

1

2

4

1

34

* Includes 1 SR arising from a study into safe flight routes and conflict zones

Compared to the previous year, the number of recommendations related to Commercial Air Transport and Non-
Commercial Operations has slightly grown. The recommendations received also include one recommendation 
related to an UAV-event and one issued as a result of a safety study. There were no recommendations issued 
relating to Specialised Operations.

2022 Annual Safety Recommendations Review

19

Safety Recommendations received in 2021

3.2   Origin of the Safety Recommendations  

received in 2021

In 2021, the Safety Investigation Authorities (SIAs) of 18 different States addressed 34 safety recommendations 
to the Agency. 

Figure 4 shows the percentage distribution of safety recommendations that were addressed to EASA in 2021 
between EASA Member States and non-EASA Member States. The chart shows that EASA Member States issued 
59% of the safety recommendations received by EASA in 2021.

 ´ Figure 4: Origin of Safety Recommendations received by EASA

59%

EASA Member States

Non-EASA Member States (inc. UK)

41%

Figure 5 shows the contribution of the different SIAs to the total number of safety recommendations addressed 
to the Agency in 2021, as well as the number of occurrences that contributed to these safety recommendations.

 ´ Figure 5: States contribution to Safety Recommendations received in 2021

6 

5 

4 

3 

2 

1 

0 

G
K
N
U

N
A
R

I

D
E
W

S

Z
T
W

S

T
S
N
U

M
N
E
D

N
A
R
F

G
L
E
B

T
R
O
P

N
M
O
R

L
I
R
S

L
N
I
F

T
S
U
A

F
R
E
G

H
T
E
N

D
L
R

I

L
A
T
I

EASA Member States

Non-EASA Member States

2022 Annual Safety Recommendations Review

20

Safety Recommendations received in 2021

About 40% of the safety recommendations were related to six investigations.

The United Kingdom Air Accidents Investigations Branch (AAIB) issued five safety recommendations that are 
related to two occurrences. Four of them result from a serious incident involving an Airbus A321 in February 
2020 in UK, in which both of the aircraft’s engines lost power after take-off. The crew was able to maintain a safe 
flightpath using a lower thrust that was nevertheless sufficient for a return to the airfield. The cause of the serious 
incident was due to contamination of the engine Hydro Mechanical Units (HMU), resulting from an incorrect 
biocide shock treatment of the aircraft’s fuel system that was performed with considerably higher amount of the 
treatment agent than normal. The recommendations propose amending Acceptable Means of Compliance (AMC) 
concerning the requirements for the treatment of aircraft fuel systems with biocide additives, conducting safety 
promotion on the classification of biocide treatment of aircraft fuel systems as a critical maintenance task and 
reviewing the issue during the standardisation activities carried out by The Agency.

One safety recommendation was issued as a result of an investigation into an event involving an Alauda 
Airspeeder Mk II, UAV in July 2019 in UK. The pilot lost control of the UAV and it entered into controlled 
airspace climbing up to 8000 feet. After the battery had depleted, it fell to the ground 700 meters outside of 
the designated operating area. There were no injuries. The safety recommendation proposes the adoption of 
appropriate design, production, maintenance, and reliability standards for all Unmanned Aircraft Systems with 
aircraft capable of imparting over 80 joules of energy.

The Aircraft Accident Investigation Board of the Islamic Republic of Iran Civil Aviation Organization issued five 
safety recommendations resulting from an investigation involving an ATR-72 aircraft in February 2018 in Iran, 
where the aircraft started descending and prepared for landing, then lost altitude and impacted with a mountain. 
The collision led to the complete destruction of aircraft. All 66 persons onboard were fatally injured. The causal 
factors identified relate mostly to omissions by the crew. The safety recommendations address various topics, 
such as international sanctions affecting air traffic, aircraft operation procedures, flight crew licensing, and the 
content of the aircraft’s manuals.

The  Swedish  Accident  Investigation  Authority,  Statens  haverikommission  (SHK),  issued  four  safety 
recommendations resulting from three investigations:

•  An accident involving a Socata TB9, in which the aircraft crashed during a training flight with no 
fatalities. The two recommendations request more guidance to high-risk manoeuvres and safety 
promotion regarding the risks of a turn-back to the aerodrome after an engine failure.

•  An accident involving a Schempp-Hirth powered sailplane, where the aircraft deviated from the final 
approach path and hit the ground. The recommendation is for a daily inspection and inspection 
following a hard landing to ensure proper functioning of the rudder system.

•  A non-fatal accident involving a Cessna 172, in which the aircraft was unable to get airborne again 
after a touch-and-go exercise. The safety recommendation seeks a review of the exercises contained 
in the training programmes that may pose a safety risk and a decision on the best course of action to 
make the training organisations aware of these risks.

The safety recommendations issued by SIAs in 2021 address a wide scope of subjects under the Agency’s remit 
including aircraft certification, maintenance and equipment, design, production and manufacturing, aircraft 
operations, safety risk management, security and flight crew training and checking. 

2022 Annual Safety Recommendations Review

21

Safety Recommendations received in 2021

3.3 

Involvement in accident and serious  
incident investigations

Below are listed some of the Investigations to which the Agency contributed its support in 2021: 

•  A fatal accident involving a Boeing 737-500 in Indonesia in January in which the aircraft crashed after 
an uncommanded thrust reduction on the left engine which led into a steep bank and unrecoverable 
descent.

•  A non-fatal accident involving an Embraer EMB500 in France in February in which the aircraft impacted 

hard the runway during landing and caught fire.

•  A fatal accident involving a Pilatus PC12 in Italy in March in which the aircraft crashed during the initial 

climb.

•  A fatal accident involving an Aerospatiale AS350-B in France in March in which the helicopter crashed 

on take-off.

•  A non-fatal accident involving an Airbus A320 in Mexico in March in which the aircraft experienced  

a nose gear collapse on runway.

•  A fatal accident involving a Leonardo AW119 in Mexico in April in which the helicopter hit power lines.

•  A fatal accident involving a LET 410 in Democratic Republic of Congo in June in which the aircraft 

crashed on take-off.

•  A non-fatal accident involving a Boeing 737-200 in Honolulu in July in which the aircraft lost an engine 
after take-off and after experiencing problems with the remaining engine, it ditched into the sea.

•  A fatal accident involving a De Havilland Canada DHC-2 I Sweden in July in which the aircraft crashed 

during parachuting operations.

•  A fatal accident involving a Gulfstream IV in Dominican Republic in December in which the aircraft 

crashed after experiencing control problems.

•  A serious incident involving an Airbus A320 in the Russian Federation in December in which a fault in 

the aircraft’s flight computer caused control problems.

In addition, several investigations launched in previous years were still on-going or completed in 2021 with 
the Agency’s participation in a supportive capacity by monitoring progress and providing technical expertise. 
Significant events are listed below:

•  A serious incident involving an Airbus A220 in France in February in which the aircraft experienced an 
engine failure at cruise. The engine type involved had already similar failure events in previous year. 
There were no injuries.

•  A serious incident involving an Airbus A321 in the UK in February in which the aircraft experienced a 
double engine problem during the initial climb from London Gatwick due to biocide contamination 
caused during maintenance. The investigation was completed in 2021.  

2022 Annual Safety Recommendations Review

22

Safety Recommendations received in 2021

•  An accident involving an ATR42 in Canada in December 2017 in which the aircraft crashed after take-
off due to ice accumulation on the wings. Several occupants received either serious or minor injuries. 
The final report was issued in 2021.

•  An accident involving an AW169 helicopter in the UK in October 2018 in which the helicopter crashed 
shortly after take-off from a football arena. The five occupants onboard were fatally injured. The draft 
report was issued in 2021.

The safety actions that were taken during or immediately following an investigation do not appear in this 
publication unless the Safety Investigation Authority issued an associated, formal safety recommendation to 
EASA in 2021. 

CHAPTER 0 

CHAPTER 1 

CHAPTER 2 

CHAPTER 3

CHAPTER 4 

CHAPTER 5 

CHAPTER 6

SAFETY 
RECOMMENDATIONS 
REPLIES IN 2021

CHAPTER 0 

CHAPTER 1 

CHAPTER 2 

CHAPTER 3

CHAPTER 4 

CHAPTER 5 

CHAPTER 6

Safety Recommendations replies in 2021

2022 Annual Safety Recommendations Review

24

Safety Recommendations replies in 2021

Safety Recommendations 
replies in 2021

4.1   Overview of Safety Recommendations replies  

in 2021

In 2021, the Agency issued 90 replies to 86 safety recommendations. As updates are provided, several response 
letters can be issued for the same recommendation within a year. The vast majority of replies produced in 2021 
were Agency’s responses to safety recommendations first received in the years 2016 to 2021.

However, replies to recommendations from earlier years were also issued, as shown in the table below, for those 
cases where follow-up actions and conclusions were reached, or which required updates and/or closure of the 
safety recommendation.

 ´ Figure 6: EASA replies to safety recommendations in 2021, by year received

30

25

20

15

10 

5 

0 

2009

2010

2011

2013

2014

2015

2016

2017

2018

2019

2020

2021

Year Safety Recommendation Received 

Intermediate Replies 

Final Replies 

2022 Annual Safety Recommendations Review

25

Safety Recommendations replies in 2021

4.2   Status of Safety Recommendations replies  

issued in 2021

Each final response closing a safety recommendation and the response assessment by the originator is classified 
according to the categories2 given in Annex C.

Among the 90 replies that were sent by the Agency in 2021, summarised in figure 7, 57 were final replies that 
closed safety recommendations. These resulted in the following responses by the Agency:

•  The Agency agreed to take corrective action in 47 cases, either by directly applying the recommended 
actions as was the case for 26 of them or, for the remaining 21, by partially agreeing but taking 
corrective actions other than those recommended; 

• 

In a further 9 cases, the safety recommendations were evaluated and the safety benefit was not 
agreed. 

• 

In 1 case, the safety recommendation fell outside EASA’s mandate.

Figure 7 below shows this distribution:

 ´ Figure 7: Safety Recommendation Replies sent in 2021 [status, total number]

Open; 33

Closed - Agreement; 26

Closed - Not responsible; 1

Closed - Disagreement; 9

Closed-partial agreement; 21

2 

These  definitions  of  classification  categories  were  developed  in  collaboration  with  the  European  Network  of  Safety  Investigation 
Authorities and are part of a taxonomy aimed at facilitating the management of safety recommendations.

2022 Annual Safety Recommendations Review

26

Safety Recommendations replies in 2021

In  monitoring  safety  recommendations,  their  status  remains  open  until  the  action  related  to  each 
recommendation is fully developed and completed.

In addition to the 56 final replies closing a safety recommendation, 33 updating replies (intermediate responses) 
were issued. These updating replies provided information on the progress of the actions decided upon by the 
Agency but for which the relevant activities had not yet been completed.

To monitor whether Safety Investigation Authorities (SIA) consider the Agency’s responses to be adequate, or if 
they disagree with the actions proposed, the Agency has implemented procedures in line with Regulation (EU) 
No 996/2010.

Figure 8 Shows the assessment received from the originator on the EASA Replies since 2016.

 ´ Figure 8: Reply assessment received from the originator on the EASA Replies since 2016 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

32

7
5

36

35

8

9

34

27

10

11

28

37

5
8

12

63

1
9

8

48

13

13

16

2016

2017

2018

2019

2020

2021

Adequate

Partially adequate

Not adequate

No response yet

2022 Annual Safety Recommendations Review

27

Safety Recommendations replies in 2021

Figure 9 shows the total number of response assessments that EASA received from the SIAs based on the  
90 replies sent in 2021. As assessed, 29 of the responses provided by the Agency were deemed to be ‘adequate’ 
or ‘partially adequate’ (16 and 13 respectively), and 13 response was deemed as ‘not adequate’. With respect to 
the 48 remaining replies sent in 2021, EASA awaits the SIAs’ assessment.

 ´ Figure 9: Assessment received by EASA on the Final Responses sent in 2021

Closed - Agreement 

Closed - Partial agreement 

Closed - Disagreement 

Closed - Not responsible

0 

5

10

15

20

25

30

Adequate 

Partially adequate 

Not adequate 

No response yet

2022 Annual Safety Recommendations Review

28

CHAPTER 0 CHAPTER 1 CHAPTER 2 CHAPTER 3

CHAPTER 0 

CHAPTER 1 

CHAPTER 2 

CHAPTER 3

CHAPTER 4 

CHAPTER 5 

CHAPTER 6

OVERVIEW OF KEY 
SAFETY TOPICS  
PROCESSED AND ACTIONS 
CARRIED OUT IN 2021

CHAPTER 0 

CHAPTER 1 

CHAPTER 2 

CHAPTER 3

CHAPTER 4 

CHAPTER 5 

CHAPTER 6

Overview of key safety topics processed and actions carried out in 2021

2022 Annual Safety Recommendations Review

29

Overview of key safety topics processed and actions carried out in 2021

Overview of key safety topics 
processed and actions carried 
out in 2021

In 2021, Safety Investigation Authorities from 18 different States issued 34 safety recommendations to EASA  
that addressed issues within EASA’s remit. Figure 10 provides a breakdown of the safety recommendation topics. 
The processing of safety recommendations in a systematic manner constitutes one of EASA’s key responsibilities.

 ´ Figure 10: Safety Recommendations addressed to EASA per topic by EU SIAs

Aircraft / Equipment / 
Facilities, 15%

QMS/SMS/SSP, 3%

Personnel, 12%

Procedures or Regulations, 70%

2022 Annual Safety Recommendations Review

30

Overview of key safety topics processed and actions carried out in 2021

When comparing this with the data that the European Network of Civil Aviation Authorities (ENCASIA) presented 
in its Annual Report, a slight difference can be seen. At a European level, recommendations related to personnel 
constitute the second largest category of recommendations. A further breakdown of the topics is also provided 
below in figure 11.

 ´ Figure 11: Safety Recommendations addressed to EASA per topic and area

Procedures/Regulations

Aircraft/Equipment/Facilities

Personnel

QMS/SMS/SSP

Aircraft certification

Aircraft equipment 

Aircraft  maintenance/inspection

Aircraft operations

Design/Production/Manufacturing

Other

Safety risk management

Security

Training/proficiency/check

0 

5 

10 

15

20 

25

30 

Among the actions taken in 2021, several key safety topics are outlined below with accompanying information 
on the action that the Agency has taken. The description highlights the safety issues that were underlined by the 
safety recommendations, together with the actions taken by the Agency in response. 

5.1   Crash resistant fuel systems

As a result of safety recommendations received in recent years, The Agency has carried out work aimed at 
improving helicopter safety and post-crash survivability by issuing a Supplemental Type Certificates (STC) to 
enable the installation of crash resistant fuel systems to existing helicopter fleets. In 2021, The Agency has 
provided replies addressing this safety issue concerning two major helicopter manufacturer’s fleets. The actions 
are summarised below:

The European Union Aviation Safety Agency (EASA) has cooperated with Airbus Helicopters (AH) and the 
Federal Aviation Administration (FAA) to improve post-crash fire protection in the in-service AS350/EC130 
helicopter fleet.

Within this framework, new Crash-Resistant Fuel System (CRFS) modifications have been recently developed 
by different applicants, approved by EASA and made available for new helicopter deliveries or, as a retrofit 
kit, for helicopters already in service as detailed below:

•  EASA Major Change 10072097 approved on 18/12/2019, developed by AH and applicable to all AS350 

B3 helicopter models without any limitation.

•  EASA Supplemental Type Certificate (STC) 10064703 dated 20/06/2018, developed by Standard Aero 
(previously known as Vector Aerospace Helicopter Service USA, Inc.) and applicable to AS350 D, AS350 
B, AS350 B1, AS350 B2, AS350 BA, AS350 B3 and EC130 B4 helicopter models without any limitation.  

2022 Annual Safety Recommendations Review

31

Overview of key safety topics processed and actions carried out in 2021

•  EASA STC 10061056 Rev. 01 dated 24/01/2020 (original issue of the Supplemental Type Certificate is 
dated 16/02/2017), developed by AH and applicable to AS350 B3, if equipped with Safran Helicopter 
Engines Arriel 2D engine, and EC130 B4 helicopter models without any limitation.

•  EASA STC 10060852 Rev. 01 dated 27/01/2020 (original issue of the Supplemental Type Certificate is 
dated 30/01/2017), developed by AH and applicable to AS350 B3, if equipped with Safran Helicopter 
Engines Arriel 2D engine, and EC130 B4 helicopter models with limitation forbidding underbelly 
installations.

EASA considers that the installation of any of the modifications listed above will reduce the risk of post-crash 
fires for the in-service AS350/EC130 helicopters fleet and contribute to increased occupant escape time after 
a survivable crash.

Consequently, their installation has been recommended by EASA via the release of EASA Safety Information 
Bulletin (SIB) ref. 2017-18R2 (‘Installation of Crash Resistant Fuel System’) dated 14/01/2021. This is strongly 
promoted by AH through retrofit campaign incentives for operators.

In addition, EASA, in cooperation with the Robinson Helicopter Company (RHC) and the FAA took additional 
actions to improve post-crash fire protection for the RHC in-service helicopters fleet. This activity led to the 
development of modifications approved by EASA and made available for new helicopter deliveries or, as a 
retrofit kit, for helicopters already in service as detailed below:

•  EASA Major Change 10028494 approved on 18/01/2010 (‘Installation of bladder fuel tanks’), applicable 
to R44 and R44 II helicopter models and mandated via the EASA AD 2014-0070 dated 19/03/2014.

•  EASA Major Change 10046416 approved on 18/09/2013 (‘Installation of bladder fuel tanks’), applicable 

to R22, R22 Alpha, R22 Beta and R22 Mariner helicopter models.

Rulemaking action has also been initiated on this subject.

On  16  December  2021,  EASA  published  the  Terms  of  Reference  (ToR)  for  rulemaking  task  RMT.0710 
‘Improvement in the survivability of rotorcraft occupants in the event of an otherwise survivable crash’:

https://www.easa.europa.eu/document-library/terms-of-reference-and-group-compositions/tor-rmt0710

The overall objective of this RMT is to improve rotorcraft occupant protection in the event of a survivable 
crash scenario and enhance safety by increasing the number of rotorcraft that are fitted with crash-resistant 
fuel systems (CRFS) and crash-resistant seats and structures (CRSS). 

Compliance with the CRFS and CRSS requirements is expected to provide this protection to rotorcraft 
occupants, and will contribute to safety improvements.

To ensure an efficient process, the RMT.0710-related activities will be performed in two phases, under two 
different subtasks.

Subtask 1 will assess the proportionate retroactive application of the certification specifications for CRFSs to 
existing rotorcraft fleets and/or to the future production of already type-certified rotorcraft. If supported by 
the outcome of that assessment, a proportionate retroactive requirement will be proposed.

The publication of the corresponding Notice of Proposed Amendment (NPA) for public consultation is 
expected by the end of 2022.

2022 Annual Safety Recommendations Review

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Overview of key safety topics processed and actions carried out in 2021

5.2   Conflict zones

As a consequence of the downing of Malaysian Airlines flight MH17, there is general consensus that States should 
improve the sharing of information on possible risks in conflict zones. Passengers world-wide are experiencing 
higher levels of uncertainty with respect to security issues, especially for journeys over conflict zones. The threat 
of terrorism to civil aviation is likely to remain high in the foreseeable future. High aviation safety and security 
standards and real-time information are therefore imperative for the functioning and competitiveness of the air 
transport system.

In  the  current  climate  of  political  unrest  in  many  parts  of  the  world,  airlines  have  expressed  a  need  for 
a consolidated picture of the safety/security situation. The safety of passengers, and aircraft crews, can be 
effectively improved if timely and accurate information is made available to all stakeholders.

EASA acts as coordinating entity for activities not directly under Member State or European Commission 
responsibility and initiates the drafting, consultation and publication of Conflict Zone Information Bulletins or 
EASA Information Notes both in cases of availability and unavailability of a common EU risk assessment.

EASA acts also as the Administrator of the European Information Sharing and Cooperation Platform on Conflict 
Zones.

In case of availability of a common EU risk assessment when a “high” risk level has been concluded, EASA will 
initiate the drafting of a Publication of Conflict Zone Information Bulletin (CZIB) which, in some cases, may 
contain an operational recommendation. Such recommendations are non-mandatory and do not constitute flight 
prohibitions.

In case of availability of a common EU risk assessment when a risk level lower than high has been concluded, 
the drafting of a CZIB highlighting the availability of national publications, when there are some, could be 
considered.

For circumstances that may require a rapid reaction, available information will only be shared on the ‘Need-to-
know’ principle within the RCZ Network, and in coordination with the European Commission.

As a result of a safety recommendation requesting the Agency to further develop the European Information 
Sharing and Cooperation Platform on Conflict Zones by expanding the available information without losing 
rapidity, including analysis and recommendations to member states, airlines and other stakeholders, the Agency 
issued the following reply:

The European Union Aviation Safety Agency (EASA) further developed the European Information Sharing and 
Cooperation Platform on Conflict Zones, in particular:

•  On 25 February 2021 the Agency launched a trial version of the European Information Sharing 
and Cooperation Platform on Conflict Zones (the Platform). The trial version of the Platform was 
implemented in order to fine tune its scope and to design the required IT functionalities in partnership 
with the Members of the Platform. The overall purpose of the Platform was to support the existing EU 
Conflict Zone Alerting System and particularly the ‘Integrated EU Aviation Security Risk Assessment 
Group’. 

•  The Platform provides access to relevant, credible and accurate information for aviation operators and 
states to complement their own risk assessments and is a means of exchanging timely information and 
alerts between EU Institutions, EASA Member States and air carriers. 

2022 Annual Safety Recommendations Review

33

Overview of key safety topics processed and actions carried out in 2021

•  Between 10 and 21 May 2021, the Agency conducted an assessment of the Platform through a survey 
addressed to the Members of the Platform (EU air carriers, EASA Member States and EU institutions). 
The outcome confirmed the usefulness of the mechanism to improve the risk assessments conducted 
by States and operators (over 96% of respondents indicated that they were either satisfied or extremely 
satisfied with the Platform). Furthermore, the members requested that EASA ensure the continuity of 
the Platform given its relevance for information sharing and risk assessments.

•  A virtual Conflict Zone Platform Evaluation workshop was held on 17 June 2021 to give the members 
an additional opportunity to express their expectations and to discuss possible ways forward regarding 
the future of the Platform, taking into consideration the operational interests of the various aviation 
stakeholders. 

•  Considering the positive feedback and the interest of the European aviation community in the services 
provided by the Platform, the Agency launched a procurement procedure aimed at implementing the 
European Information Sharing and Cooperation Platform on Conflict Zones as a long-term solution, 
following completion of the trial period. The contract for the Conflict Zones Platform has since been 
awarded for a period of four years, and is expected to commence in February 2022, paving the way 
for the implementation of a long-term solution. In the meantime, the trial version of the Platform will 
continue to operate.

•  The Agency is committed to ensuring a smooth transition between the trial phase and the long-term 
solution, as well as to further streamlining information sharing and cooperation, so that the relevant 
information on conflict zone developments potentially affecting the safety of flights can be shared 
without delay among the Platform members.

5.3   Airborne collision risks - collision avoidance 
systems for aircraft below 5700 MTOW

The Agency has received a number of safety recommendations aimed at offering a solution to equip aircraft 
with less than 5700 kg MTOW with collision avoidance systems. This category of aircraft is not currently required 
to carry such equipment and the safety benefits of doing so have been studied extensively. A wide range of 
operations are performed with this category of aircraft such as aerial work, air taxi operations and recreational 
aviation and the impact of mandating such equipment across the whole category has been seen challenging, 
also by the users of the aircraft. The evolution of unmanned aviation and the increased number of operations in 
this category has created additional challenges for airspace management, for which novel solutions have been 
studied and started to develop. The Agency had previously committed to including the topic in its rulemaking 
programme but after an evaluation of the whole spectrum of airspace users, the strategy was changed.  
The Agency’s reply to the safety recommendations on this issue was the following:

The European Plan for Aviation Safety (EPAS) 2020-2024 foresees the rulemaking task (RMT) RMT.0376 Anti-
collision and traffic awareness systems for aircraft with maximum take-off mass less than 5700 kg or less than  
19 passengers, through which the European Union Aviation Safety Agency (EASA) intended to set-up a framework 
for reducing the risk of airborne collisions. 

Before initiating RMT.0376, EASA undertook a detailed review and assessment of the airborne collision risk.  
The outcome of the assessment was summarised in a Best Intervention Strategy (BIS) that has been validated 
through a survey and a stakeholders’ consultation.

2022 Annual Safety Recommendations Review

34

Overview of key safety topics processed and actions carried out in 2021

The BIS concluded that a broader use of iConspicuity solutions and improvement of their interoperability 
together with a better airspace utilisation and design, while ensuring compatibility with the U-space regulatory 
framework established under Implementing Regulation (EU) 2021/664, should be at the heart of the future 
actions.

iConspicuity (or in-flight electronic conspicuity plus) means in-flight capability to transmit position of aircraft and/
or to receive, process and display positions of other aircraft in a real time with the objective to enhance pilots’ 
situational awareness about surrounding traffic. It is an umbrella term for a range of technologies and solutions, 
regardless whether airborne or on the ground, that can help airspace users and other affected stakeholders to 
be more aware of other aircraft in their vicinity or in a given airspace.

Therefore EASA decided that RMT.0376 will be removed from the EPAS and replaced by a strategy composed of 
a set of EPAS tasks compounded of existing rulemaking tasks which will be implemented through new safety 
promotion (SPT), research (RES) and member state tasks (MST).  The best safety benefits are expected to be 
achieved through synergies of all proposed actions, while utilising the U-space regulatory framework as a 
catalyst for safety improvements.

The following bullet points summarize the collective actions which are planned to be implemented for Anti-
collision and traffic awareness systems for aircraft with maximum take-off mass less than 5700 kg or less than 
19 passengers:

•  EASA,  with  support  of  technical  partners,  to  demonstrate  and  validate  feasibility  of  achieving 
interoperability of different iConspicuity devices/systems through network of stations while respecting 
data privacy requirements.

•  EASA to analyse ‘Net Safety Benefit’ and ‘Operational Safety Assessment’ concepts for the use of 

iConspicuity devices/systems in Flight Information Services.

•  EASA to facilitate installation of iConspicuity devices in all EASA certified aircraft types and promote 

their use by airspace users at user affordable cost.

•  EASA to actively support initiatives enhancing interoperability of iConspicuity devices/systems.

•  EASA to promote good practices in airspace design that reduce ‘airspace complexity’ and ‘traffic 

congestion’ with the aim to reduce the risk of collisions involving uncontrolled traffic.

•  Member States to consider ‘airspace complexity’ and ‘traffic congestion' as safety relevant factors in 
airspace changes affecting uncontrolled traffic, including the changes along international borders.

•  EASA to ensure technical and operational compatibility of U-space and iConspicuity solutions.

•  EASA to conduct a Safety Issue Assessment (SIA) of airspace infringements.

•  EASA to explore the use of iConspicuity data for enhanced safety monitoring of Airborne Collision Risk.

Collectively, the aforementioned EASA actions serve as a multi-pronged final response which address the safety 
concern for mitigating airborne collision risks.

2022 Annual Safety Recommendations Review

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Overview of key safety topics processed and actions carried out in 2021

5.4   Reporting of runway surface condition

Runway  surface  conditions  affect  the  aircraft’s  take-off  and  landing  performance.  Contamination  on  the 
runway, such as water, snow, ice, or slush would need to be considered by the flight crew when determining 
the required take-off and landing distance since the contamination may decrease the aircraft’s acceleration on 
the runway or decrease its stopping capability. The Agency transposed between 2019 and 2021 the standards 
and recommended practises developed by ICAO to European regulatory framework for aerodromes and aircraft 
operations and provided the following reply to two safety recommendations addressing the topic.

Aerodromes:

Commission Regulation (EU) No 139/2014 requires the aerodrome operator to provide data, relevant to the 
aerodrome and available services, to the users and the relevant air traffic services and aeronautical information 
services [ADR.OPS.A.005 (b)].

The International Civil Aviation Organization (ICAO), through Amendment 13 to Annex 14 ‘Aerodromes’, Volume 
I ‘Aerodrome Design and Operations’ and Amendment 1 to ICAO Doc 9981 ‘PANS-Aerodromes’, has introduced 
a global reporting format (GRF) for assessing and reporting runway surface conditions, with the objective of 
ensuring a link between the reporting and aircraft performance as published by the aircraft manufacturers.

The above-mentioned ICAO amendments have been transposed into the European regulatory framework 
through  Commission  Delegated  Regulation  (EU)  2020/2148  (amending  Commission  Regulation  (EU)  
No 139/2014), published on 18 December 2020, and the European Union Aviation Safety Agency (EASA) Executive 
Director Decision 2021/003/R was published on 04 March 2021, following EASA’s rulemaking task RMT.0703 
‘Runway safety’.

The newly introduced GRF aims to ensure the reporting of runway surface conditions in a standardised manner 
so that flight crews can accurately determine take-off and landing performance for the prevailing runway surface 
conditions. Reporting of friction coefficients is no longer applicable. 

To raise awareness and support the deployment of the GRF in the Member States, EASA organised workshops 
on 17 March 2021 with the National Aviation Authorities and on 10 March 2021 with Industry (Aerodrome 
Operators, Air Operators, Aeroplane Manufacturers, Air Traffic Services Providers and Aeronautical Information 
Service Providers).

Aircraft operations:

The  International  Civil  Aviation  Organisation  (ICAO),  through  amendments  to  applicable  Standards  and 
Recommended Practices (SARPs) and ICAO Documents, has introduced a global reporting format (GRF) for 
assessing and reporting runway surface conditions, with the objective of ensuring a link between the reporting 
and aircraft performance as published by the aircraft manufacturers.

The above-mentioned ICAO amendments have been transposed into the European regulatory framework 
through  Commission  Implementing  Regulation  (EU)  2019/1387  (amending  Commission  Regulation  (EU)  
No 965/2012 on air operations), published on 01 August 2019, and the European Union Aviation Safety Agency’s 
(EASA) Executive Director Decision EDD 2021/005/R, published on 23 April 2021, following EASA’s rulemaking 
task RMT.0296 ‘Review of the aeroplane performance requirements for air operations’.

2022 Annual Safety Recommendations Review

36

Overview of key safety topics processed and actions carried out in 2021

The newly introduced GRF aims to ensure the reporting of runway surface conditions (which may include 
contamination with slush or water) in a standardised manner so that flight crews can accurately determine take-
off and landing performance for the prevailing runway surface conditions.

According to Commission Implementing Regulation (EU) 2019/1387 and the associated EDD, determination 
of take-off performance for wet and contaminated runways should be based on the reported runway surface 
condition in terms of contaminant and depth. Determination of landing performance should be based on 
information provided in the operations manual on the reported runway condition code (RWYCC). The RWYCC is 
determined by the aerodrome operator using the runway condition assessment matrix (RCAM) and associated 
procedures defined in ICAO Doc 9981 — ‘PANS Aerodromes’.

To raise awareness and support the deployment of the GRF in the Member States, EASA organised workshops on 
10 March 2021 with Industry (Aerodrome Operators, Air Operators, Aeroplane Manufacturers, Air Traffic Services 
Providers and Aeronautical Information Service Providers) and on 17 March 2021 with the National Aviation 
Authorities of the EASA Member States.

Large aeroplane certification:

On 6 December 2021, EASA issued ED Decision 2021/015/R amending CS-25 (Amdt 27) (certification specifications 
and acceptable means of compliance for large aeroplanes).

https://www.easa.europa.eu/document-library/agency-decisions/ed-decision-2021015r

This amendment ensures that certification standards for the computation of take-off and landing performance, 
including at the time of arrival, are harmonised with the above-mentioned ICAO SARPs.

5.5  Accidents involving the Boeing 737-8(MAX)

The accidents involving the Boeing 737-8(MAX) caused a worldwide grounding of the fleet after safety concerns 
over the controllability of the aircraft in certain conditions. The aviation authorities globally launched an 
evaluation of the conditions allowing the aircraft’s return to service. The Agency carried out an extensive effort 
involving several experts from various domains and also collaborated with the FAA and provided the following 
reply in 2021 to the Ethiopian authority, in response to its safety recommendation ‘to verify that the review of the 
aircraft flight control system related to flight controllability has been adequately addressed by the manufacturer 
before the release of the aircraft to operations’:

The European Union Aviation Safety Agency (EASA) has performed an extended design review of the Boeing 737 
MAX aircraft, as well as the conditions under which the Boeing 737 MAX may return to service in the European 
Union.

EASA has defined a Return to Service (RTS) strategy based on the following two aspects:

(i)   a fully independent review of all certification activities associated with the design changes required 

to address the direct causes of the accidents;

(ii)  an  extended  independent  design  review  of  the  737  MAX  flight  control  system  and  associated 

functions.

2022 Annual Safety Recommendations Review

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Overview of key safety topics processed and actions carried out in 2021

EASA has additionally defined and agreed a set of post-RTS actions that Boeing has to complete for certain 
technical issues not representing an unsafe condition (i.e. not impacting the immediate safety of passengers).

The operation of the 737 MAX is indeed already considered safe with the approved changes and actions 
mandated in the EASA Airworthiness Directive 2021-0039 (and Safety Directive 2021-01).

The Agency published a closing report to explain its approach and the reasoning for its decisions. The report is 
available at the following link:

https://www.easa.europa.eu/sites/default/files/dfu/B737_Max_Return_to_Service_Report.pdf

2022 Annual Safety Recommendations Review

38

CHAPTER 0 CHAPTER 1 CHAPTER 2 CHAPTER 3

CHAPTER 0 

CHAPTER 1 

CHAPTER 2 

CHAPTER 3

CHAPTER 4 

CHAPTER 5 

CHAPTER 6

CHAPTER 0 

CHAPTER 1 

CHAPTER 2 

CHAPTER 3

CHAPTER 4 

CHAPTER 5 

CHAPTER 6

CONCLUSIONS

Conclusions

2022 Annual Safety Recommendations Review

39

Conclusions

Conclusions

In 2021, the Agency received a total of 34 safety recommendations that originated from 22 occurrences  
(15 accidents, 6 serious incidents and 1 safety study). These were sent by the Safety Investigation Authorities of 
18 different States.

•  20 safety recommendations originated from EASA Member States and 14 from non-EASA Member 

States; 

•  70% were related to procedures or regulations, while 15% were related to aircraft or aviation-related 

equipment/facilities. 

The number of safety recommendations that the Agency received in 2021 is slightly higher than the previous 
year. The number of safety recommendations addressed to EASA peaked between 2012 and 2016. 

In 2021 the Agency provided 90 replies in response to 86 safety recommendations:

•  57 of these were final replies (closing safety recommendations) with 26 of these replies assessed as 

‘agreed’ by EASA, and 21 assessed as ‘partially agreed’;

•  The remaining 33 replies were updates providing information on the progress of the actions decided 

upon by the Agency and for which the relevant activities were not yet completed;

•  As  assessed  by  the  originator,  29  of  the  responses  provided  by  the  Agency  were  deemed  to 
be ‘adequate’ or ‘partially adequate’ (16 and 13 respectively), and 13 response was deemed as  
‘not  adequate’.  With  respect  to  the  48  remaining  replies  sent  in  2021,  The  Agency  awaits  the  
SIAs’ assessment.

The number of replies provided in 2021 is higher than the number of replies provided in 2020. The 57 closing 
replies sent in 2021 translates into a modest reduction in the number of safety recommendations currently 
open for the Agency. Furthermore, the actions taken by the Agency in response to the safety recommendations 
encompassed several key safety topics that are currently part of the European Plan for Aviation Safety (EPAS) and 
which are included in the European safety risk management process.

2022 Annual Safety Recommendations Review

40

Conclusions

2022 Annual Safety Recommendations Review

41

Conclusions

2022 Annual Safety Recommendations Review

42

EUROPEAN UNION AVIATION SAFETY AGENCY

EUROPEAN UNION AVIATION SAFETY AGENCY
SAFETY INTELLIGENCE
DEPARTMENT

Catalogue number
TO-AE-22-001-EN-N

ISBN
978-92-9210-280-7

ISSN
2599-7793

DOI
10.2822/199328

Postal address  
Postfach 10 12 53 
50452 Cologne 
Germany

Visiting address 
European Union Aviation Safety Agency 
Konrad-Adenauer-Ufer 3, D-50668  
Köln, Germany

Tel.   +49 221 89990 - 000  
Mail   safetypromotion@easa.europa.eu
Web   www.easa.europa.eu