Hong Kong Airworthiness

The Hong Kong University of Science and Technology

MSc – Aeronautical Engineering
AESF 5710

QUALITY ASSURANCE SYSTEM

Ir Jun C S AU

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Understand the QA System in Aviation Industry

Topic
• Quality Assurance System in Aircraft
Maintenance
• Quality Assurance System in Operator
• Mandatory and Incident Reporting
• Accident Investigation
• Safety Management System

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 Understand the QA System in Aviation Industry

In aviation industry, quality system is

mandatory as a requirement for
approvals granted by authority, and a
best practice to ensure work
standard within industry.

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 Understand the QA System in Aviation Industry

National Aviation Authority (NAA), such as

HKCAD, CAAC, FAA, EASA demands quality
system for compliance to requirements.

Company/Corporation have quality standard to

follow as best practice.

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 Understand the QA System in Aviation Industry

Aviation Industry must follow NAA published

requirements including quality system, such
as CAD360, HKAR-21, HKAR-145 etc in order
to operate.

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 Understand the QA System in Aviation Industry

Aviation Industry may choose to follow other

industry quality standard in order to excel or
on same level with other competitors.

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 Understand the QA System in Aviation Industry

Other standards such as,

ISO: International Organisation for Standardisation

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 Understand the QA System in Aviation Industry

IATA : International Air Transportation Association

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 Understand the QA System in Aviation Industry

Both ISO and IATA are not government

body and with no authority over any
airlines.

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 Understand the QA System in Aviation Industry

ISO is an independent organisation that

develop common standards for industry.

IATA is a trade club which most airlines

participate as members and follow the
standards set upon.

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 Understand the QA System in Aviation Industry

Within IATA standards, there are quality

requirements.

Some quality requirements are unique in

aviation, whilst some requirements are
general and may refer to ISO9000
Quality Management.
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 Understand the QA System in Aviation Industry

Many airlines follow IATA quality standards in

service delivery such as passenger, cargo
operations, ground handling, security,
contracting, commercial settling etc to ensure a
common standard is achieved.

This practice of IATA quality requirements is a best

practice in aviation industry.

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 Understand the QA System in Aviation Industry

An airline does not need to be IATA member to operate.

However if not being IATA member, may affect co-operation

with other airlines or organizations EG: Ground Handling
Agent, Catering Supplier, Fueling Company who follow
IATA standards.

EG: Most airlines will not join code sharing with non-IATA
member, or allow to join major alliances if not IATA
member.

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 Understand the QA System in Aviation Industry

IATA standards are not necessarily

recognized by government authorities
to meet requirements for granting or
continuous holding of approvals, such
as AOC or Maintenance Organisation
Approval.
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 Understand the QA System in Aviation Industry

What is Approval?

Certain aviation operations require NAA to grant approvals

in order to operate. This approval is over and above an
industrial & commercial business license.

Example: Airline, Flight Training, Maintenance,

Maintenance Training, Design & Modification, Parts
Production

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 Understand the QA System in Aviation Industry

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Understand the QA System in Aviation Industry

All these approvals require to have

quality system acceptable to the
requirements of the NAA before
granting or continuous holding of
such approvals.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QA System in
Aircraft Maintenance

• Maintenance on large transport aircraft

has to be conducted by organizations that
hold the appropriate Part 145 Approved
Maintenance Organization Approval issued
by Authority such as
HKCAD/CAAC/FAA/EASA.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QA System in
Aircraft Maintenance
• Some typical aircraft maintenance
organisations in HKG:

• 1. HAECO – biggest in HKG

• 2. CASL – main competitor
• 3. PAPAS – Line Maintenance Only
• 4. Metrojet – Business Aircraft maintenance
• 5. Heliservice – Helicopter maintenance
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 QA System in
Aircraft Maintenance
• The aircraft State of Registration will
determine the approval issuing authority to
be used
• Example:
– HKG registered aircraft should be maintained
by HKAR-145 AMO
– USA registered aircraft by FAA-145 AMO
– EU registered aircraft by EASA-145 AMO

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 QA System in
Aircraft Maintenance

• There are special arrangements that some

states/places would accept other authority
approvals
• Example: HKCAD would accept following
approvals,
– JMM with China CAAC, Macau CAA
– TA with Singapore CAAS
– TA with Canada TCCA
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 QA System in
Aircraft Maintenance
• The Maintenance Organizations so approved
under Part 145 must establish a QA System
acceptable to the Authority
– The QA System in maintenance organization
serves to ensure compliance to Authority & self-
imposed requirements
– The Authority requirements are stated in Part145
– The self-imposed requirements are stated in
Organization Exposition & Engineering Manual
which are subject to approval by Authority
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 QA System in
Aircraft Maintenance
• The QA Manager in MO must be
acceptable to the Authority
• Criteria for QA Manager acceptance:
– Experience in quality
– Experience in aircraft engineering
– Good knowledge of company procedures
– Trained in airworthiness
– Trained in quality audit
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 QA System
in Aircraft Maintenance
• What does QA System do in Maintenance Organization?
– Internal audits
– Receive and coordinate external audits (by customer airlines,
by authorities)
– Publish quality procedures & notices
– Safety management
– Manage MOR reporting
– Investigations to MOR & incidents
– Assessment board for qualifications
– Issuing maintenance authorisations and approvals
– Quality system training
– Issuing concessions for deviations from procedures
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 QA System in Operator
– Operator refers to Airline Operator
– There are 2 parts of requirements that
Operator must meet in order to be approved
by HKCAD to issue Air Operator Certificate
(AOC) to operate as an Airline
– AOC Part 1 is Operation of Aircraft
– AOC Part 2 is Maintenance Support
Arrangement

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 QA System in Operator
– AOC Part 1 Operation of Aircraft is procedures
to fly an aeroplane including ground and air
procedures

– AOC Part 2 Maintenance Support

Arrangement is to organize maintenance of
aircraft either by airline own-self or outsource
to third party maintenance organization
including line and base maintenance

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QA System in Operator
– AOC Part 1 Operation of Aircraft has its own
Quality System that monitors activities such
as flying, fueling, cargo loading, passenger
safety, security screening, catering, crew
accommodations etc

– AOC Part 2 Maintenance Support

Arrangement includes Quality System to
oversight maintenance organization either in-
sourced or out-sourced

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 QA System in Operator
– Some airlines may adopt one single QA
System to oversee both AOC Part 1 and Part
2 quality requirements. This may be under the
term Corporate Quality, such as Corporate
Safety & Quality Department.

– The Quality Manager for AOC has to be

acceptable to HKCAD

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 QA System in Operator
• The QA Manager in Airline responsible for
Maintenance Arrangement must be
acceptable to the Authority
• Criteria for Engineering QA Manager
acceptance:
– Experience in quality
– Experience in aircraft engineering
– Good knowledge of company procedures
– Trained in airworthiness
– Trained in quality audit
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 QA System in Operator
• For large airline, there are usually different
QA Managers responsible for Part 1 & Part
2 activities.
• The Part 1 QA activities are more
broadened for the general operation of
airline.
• The Part 2 QA activities are focused in
engineering related areas.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QA System in Operator
• What does QA System do in Airline?
– Internal audits
– To audit service providers – maintenance, fueling, airport,
caterer, training facilities, hotels, other airlines etc
– Receive & coordinate external audits (IOSA, Authority)
– Publish quality procedures & notices
– Safety management
– Manage MOR reporting
– Investigations to MOR & incidents
– Quality system training
– Issuing concessions for deviations from procedures
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 QA System in Aviation
• Each aviation organisation is required to
have a quality system
• Minimum requirements are stated by
authority such as HKCAD published
requirements for various approvals
• Organisation may opt to exceed the
authority requirements

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QA System in Aviation
• The authority, like HKCAD, always refers the
Quality Manager (QM) as the representative
of the authority.
• The QM is to ensure compliance and
maintain oversight on behalf of the authority.
• The QM is the usual point of contact with the
authority for the approved organisation.
• The QM must maintain a smooth and timely
communication with the authority.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QA System in Aviation
• The QM has a direct reporting line in
his/her own organisation to the
Accountable Manager /Chief Executive but
also answerable to the authority.

• The QM needs to act as an independent

role among business operation and
compliance requirements to prevent step
out of limits.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 QA System in Aviation
• The QM needs to exercise skill to ensure
safety at all time, and meet compliance
requirements without compromising
business operations.

• The QM needs to exercise firm stance for

meeting compliance but could be
innovative in seeking alternative means of
compliance and discuss with authority for
acceptance.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 QA System in Aviation
• There may be occasions for the QM to
request for operation stop if compliance
requirements cannot be met.

• The QM needs to furnish the risk and clear

reasoning to the company management in
legible and easily understand terms.

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 Mandatory and Incident Reporting

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting

Topic
– International requirements and Hong Kong
legislations on occurrence reporting
– Discussion on common cases of occurrence
– Mandatory Occurrence Reporting (MOR)
investigation and closure
– MOR process

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting
– ICAO Requirements:

– Annex 13 Chapter 4

– ICAO Document 9760 Volume II Chapter 8

and Appendix B

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 Mandatory and Incident Reporting
– The Hierarchy of Aviation Rules

– ICAO under United Nations makes

recommendations and guidelines

– National Authority (HKCAD, CAAC, EASA,FAA,

TC, CASA…etc) issues aviation regulations
applicable to aircraft registered in the States of
Authority

– Airlines follow Authority regulations

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 Mandatory and Incident Reporting
– Incident reporting is made MANDATORY by Law
of Hong Kong

– MANDATORY means offending law if not in

compliance

– Accountable Person is subject to fine or

imprisonment according to the law.

– Approval may be suspended

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 Mandatory and Incident Reporting
– Hong Kong Legislative requirements

AN(HK)O 1995

– Article 86 Mandatory Reporting

– Regulation 16 of Schedule 15 Mandatory

Reporting - Prescribed Reportable
Occurrences, Time and Manner of Reporting
and Information to be reported
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 Mandatory and Incident Reporting
– CAD Guidance Materials:

– CAD 382 – Mandatory Occurrence Reporting

Scheme Information Guidance

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 Mandatory and Incident Reporting
– AN(HK)O 1995 Article 86
– Applicability:
• Turbine-powered aircraft
• AOC-operated aircraft

– Does MOR scheme apply to private business

jet operators?
– Is the aircraft turbine powered?
– Is the aircraft operated under AOC?
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 Mandatory and Incident Reporting
– Some organisations even not required by law
to submit MOR, but would voluntary
participate to indicate robust reporting and
monitoring system

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 Mandatory and Incident Reporting
– AN(HK)O 1995 Article 86
– Who shall report: 4 Categories of People
– 1. Operator/commander
– 2a. Certifying person (“licensed engineer”)
– 2b. Maintenance Organization
– 3. Licensed ATC Officer
– 4. Manager of licensed aerodrome

– Can I make a report if not any of the above personnel?

– Yes, anyone can make a report, but it is not mandatory
for any other personnel to make MOR.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Mandatory and Incident Reporting
– AN(HK)O 1995 Article 86
– What is a Reportable Occurrence?
– any incident ..., being an incident, malfunctioning
or defect endangering, or which if not corrected
would endanger, the aircraft, its occupants, or any
other person; or
– any defect in or malfunctioning of any facility on
the ground used or intended to be used ... in
connection with the operation of such an aircraft,
being a defect or malfunctioning endangering, or
which if not corrected would endanger, such an
aircraft or its occupants.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Mandatory and Incident Reporting
– AN(HK)O 1995 Article 86
– What is a Reportable Occurrence?
– A report should also be submitted on any
occurrence which involves, for example, a
defective condition or unsatisfactory behavior
or procedure which did not immediately
endanger the aircraft, but which if allowed to
continue uncorrected or which, if repeated in
different, but likely circumstances, would
create a hazard.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting
– Don’t Abuse the System

– Over-enthusiastic reporting of such items

which fall below this criteria will involve
unnecessary duplication and work to both the
reporters and the CAD and will also tend, by
sheer volume of data generated, to obscure
the more significant safety items.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting
– Don’t Abuse the System

– Over reporting would lost focus on important

indicators
– May take away the alertness of people and
organisation due to the massive volume of
reports
– Reporting culture should be encouraged with
different categories of reports for different
level of response
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 Mandatory and Incident Reporting
– If your QA or Safety Department could not
determine for sure, it is safe to report as
MOR, or discuss with your CAD officer

– It is possible to withdraw report of incident as

MOR with the agreement of CAD

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 Mandatory and Incident Reporting

– When reports should be made ?

Within 96 hours
from discovery

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 Mandatory and Incident Reporting
Guidance provided in CAD 382 document
3 objectives
 1.To ensure that the Director-General is advised of
hazardous or potentially hazardous incidents and
defects;
 2. To enable knowledge of these occurrences to be
disseminated so that other persons or organizations
can learn from them; and
 3. To enable an assessment to be made by those
concerned of the safety implications of each
occurrence, both itself and in relation to previous
similar occurrences, so that necessary actions may be
initiate
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Mandatory and Incident Reporting
Guidance provided in CAD 382 document
 Submission of report – DCA201 or CAD approved
format
 Submission through company reporting system
or Individual submission
 Confidential Report permitted

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting
Roles of CAD - Report categorization
Reportable
Eg: flight operations, aircraft technical,
ground services equipment or facilities,
others
Non-reportable – don’t meet MOR criteria
Closed on receipt – meet MOR criteria but
no immediate follow up require eg bird-
strike, lightening strike
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 Mandatory and Incident Reporting
Common Case Discussions

Engine in-flight shut-down

- One-engine aircraft - MOR
- Two-engine aircraft - MOR
- Three or More-engine aircraft
- MOR if more than 1 engine shutdown
- MOR if severe damage

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 Mandatory and Incident Reporting
Common Case Discussions

– Heavy landing
• Crew report in technical log
• QAR data finding

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 Mandatory and Incident Reporting
Common Case Discussions

 Airworthiness Directive compliance

- Miss compliance
- First Finding
 Missing aircraft structural parts
- Always MOR
- Other parts missing from aircraft?
 Fire and false fire warning during flight
- Always MOR
 Smoke / Fumes / Smell
- Use of emergency equipment or procedures
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Mandatory and Incident Reporting
Common Case Discussions
* Primary warning
- Not MOR if it can be confirmed as false either at
the time of occurrence, or immediately after
landing

* Un-commanded aircraft attitude change

- Always MOR
* Repetitive occurrences
- Occurrence may not be MOR on its own but can
become MOR after several repeated occurrences
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 MOR investigation and closure

Conducted by CAD and/or the Operator

Completed in agreed timescales
Recommendation for closure from the
Operator
CAD may accept closure or request for further
investigation
Possible re-opening of investigation, upon
receipt of new or updated information
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 MOR and Incident Reporting
Process
-Incident Capturing
-Assessment
-Reporting
-Investigation
-MOR Meeting
-Recommend Closure
-Trend analysis

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 MOR and Incident Reporting
Process
-Incident Capturing
-Assessment
-Reporting
-Investigation
-MOR Meeting
-Recommend Closure
-Trend analysis

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 MOR and Incident Reporting

• -MOR Meeting
− Chair by senior manager, usually chief of quality or
safety, committee members: other senior department
or section heads who can commit resources to final fix
− Other stake holders: CAD, FOP, CSD, OEM, Training
School
− Review the submissions made by the responsible
sections
− Agree on the mitigation plan
− Agree on the final fix
− Agree to close report internally
− Report to CAD for recommended closure
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 Mandatory and Incident Reporting

• Trend Analysis

– Highlight areas for attention

– Feedback to responsible parties & OEMs

– Look for improvements : human factor,

management system, technical reliability etc…

– Prevent re-occurrence
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 >80%
accidents
are caused
% by the
100 human and Human Causes
90 rising

80
70
60 <20%
50 accidents
are caused
40 by the
30 Machine
machine,
20 weather etc Causes
and
10 dropping

1903 Today
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Mandatory and Incident Reporting

Typical Example of Trend Analysis Highlight

-Major areas of MOR Increase :
Airbus A330 Fleet
Maintenance Error – procedures not followed
Hydraulic Loss
Boeing B777 Fleet
Maintenance Error - procedures not followed
Maintenance Error – maintenance overdue

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Mandatory and Incident Reporting
Trend Analysis

 The aircraft and their engines are technically more

reliable
 Automation, redundancy etc. reduced burden on
flight crew
 But there are 3 to 4 million removable parts on the
typical large transport aircraft
 Aircraft are getting more complex both in hardware
and software
 Maintenance/Human Errors are dominating in
incidents/accidents. Do pay attention in HF effect.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 MOR Summary
Keypoints

– Remember the mandatory nature of

reportable events – legally liable
– 96 hours to report
– Over-reporting could mask off the focuses
– Investigate into root causes and learn from
MORs
– Study MOR trend
– Take actions to prevent re-occurrence
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Accident Investigation

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation

– Topic
– International requirements and Hong Kong
legislations on accident reporting
– Accident reporting and lessons learnt from
previous accidents

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation

Requirements:

• Annex 13 – Aircraft accident and

incident investigation

• CAP 448B – Hong Kong Civil Aviation

(Investigation of Accidents) Regulations

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 ICAO Annex 13

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation
Definition – Accident / Incident
Objective of investigation
Notification to Chief Inspector of
Accidents
Company procedures
Preservation of evidence

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation
In accordance to ICAO Annex 13
An accident is defined as:
An occurrence associated with the operation of an aircraft which takes place
between the time any person boards the aircraft with the intention of flight until
such time as all such persons have disembarked, in which:

a) a person is fatally or seriously injured as a result of:

being in the aircraft, or
direct contact with any part of the aircraft, including parts which have become
detached from the aircraft, or
direct exposure to jet blast,
except when the injuries are from natural causes, self-inflicted or inflicted by
other persons, or when the injuries are to stowaways hiding outside the areas
normally available to the passengers and crew;
*An injury resulting in death within 30 days of the date of the accident is
classified as a fatal injury by ICAO.
*Serious injury requires hospitalization for more than 48 hours
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Accident Investigation
An accident is defined as:
b) the aircraft sustains damage or
structural failure which:
adversely affects the structural strength,
performance or flight characteristics of
the aircraft, and
would normally require major repair or
replacement of the affected component,

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation

• An accident is defined as:

• c) the aircraft is missing or is completely inaccessible.

• Missing – when official search is terminated

• MH370 KUL-BJS 8March2014

Note 2.— An aircraft is considered to be missing when the official

search has been terminated and the wreckage has not been
located.

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 Accident Investigation
– Accident official investigation is always
conducted by government authority, not by
airline
– The state where accident taken place is the
primary state to conduct accident investigation.
Investigation will be subject to local law of
accident site
– If accident happens in open sea/territory, the
aircraft State of Registration will be the primary
state of investigation, such as MH37.
– to be missing when the official search has been
terminated and the wreckage has not been
located.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Accident Investigation
– The primary state of investigation may invite
other state authorities to assist investigation
such as UK AAIB, US NTSB
– The aircraft State of Registration is the
primary state to support investigation by the
State Authority
– The aircraft depart and planned arrival states
will also participate
– is considered to be missing when the official
search has been terminated and the
wreckage has not been located.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Accident Investigation
– The official report will be published by the
primary State of investigation
– The report will usually be agreed by all
participating states and airline before
published.
– However it is possible that airline and/or
state authority do not agree with the official
report.
aircraft is considered to be missing when
the official search has been terminated and the
wreckage has not been located.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Accident Investigation
– 31Oct2000 Taiwan
– Singapore Airlines SQ006 B747-400 hit mobile crane during
takeoff from Taipei Taoyuan Airport. Aircraft crashed onto airport
area after lifted off. 83 people died.
– It was typhoon day, with heavy rain, poor visibility. One runway
05R was closed under maintenance. Crew should be using runway
05L but took off from the closed runway and hit construction
equipment
– Official report published by Taiwan Air Safety Council states pilot
error using wrong runway
– Singapore authority and airline rejected the report, quoting
inappropriate ATC instructions, insufficient ground barriers to
prevent aircraft turned into the closed runway.
– Dispute unresolved. But both SQ and Taoyuan Airport took up
report recommendations to correct/improve shortfalls.
– aircraft is considered Hong
Copyright©2020 Henry Leung
to be missing when the official search has
Kong Airworthiness AESF 5710
been terminated and the wreckage has not been locate
 Accident Investigation
– Airline may conduct their own internal
investigation
– Airline investigation report will not be official but
may be accepted as evidence or reference for the
official report
– The Airline has obligation to assist Authority in
investigation by providing all data necessary
– All Airline data related to the accident aircraft and
flight are officially impounded by registration state
authority subject to investigation
Note 2.— An aircraft is considered to be missing when
the official search has been terminated and the
wreckage
Copyright©2020 has not been
Henry Leung located.
Hong Kong Airworthiness AESF 5710
 Accident Investigation
– Hong Kong Air Accident Investigation Authority, HKAAIA
– Set up in 2018
– The Air Accident Investigation Authority (AAIA) is an
independent investigation authority formed under
Transport & Logistics Bureau, responsible for the
investigation of civil aircraft accidents and serious
incidents in Hong Kong in accordance with the
principles of ICAO Annex 13 and Hong Kong Civil
Aviation (Investigation of Accidents) Regulations
(Chapter 448B):
– The purpose of aviation safety investigations is to
improve safety for the travelling public and prevent the
reoccurrence of accidents and incidents.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation
Latest HK Accident Report Published
– Fixed Wing Aircraft
– 21 May 2016 Cessna 152
– Owner/Operator: Hong Kong Aviation Club Limited
– Aircraft Type: Cessna 152
– Nationality / Registration: B-HPA
– Place of Accident: Shek Kong Airfield, Yuen Long
– Hard landing with nose wheel touched
– down first then veered to the right and
– stopped at the runway in a nose down
– position.
– The solo pilot climbed out uninjured.
– The propeller, nose landing gear and various parts of the aircraft
were substantially damaged. There was no fuel leakage or fire.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation
Latest HK Accident Report Published
– 21 May 2016 Cessna 152
– The following cause was identified:
– After a bounced landing, the balked landing procedures, where
go-around should be executed, were not performed. Upon its
second touch-down, the aircraft had a hard nose landing, which
resulted in the stoppage of the rotation of propeller after the
blades contacting the ground (i.e. propeller strike), the collapse
of the nose landing gear and the subsequent damage to the
aircraft.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation
Latest HK Accident Report Published

– Contributing Factor
– Given the pilot’s limited flying experience,
the startle factor when encountering an
actual balked landing situation could
possibly contribute to any delay, deviation
or lapse from the required go-around
procedures.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation
Latest HK Accident Report Published
– 3 Safety Recommendations:
1. HKAC to specify detailed training requirements on balked
landing procedures

2. HKAC to review guidelines or checklists to standardize criteria

when conducting pre-solo flight assessments

3. HKAC to review its training record system, to include:

- A grading system for assessment of student pilots’ performance
during the training lesson
- Training reports to log instructors’ feedbacks and necessary
follow-up for improvement.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Latest Large Aeroplane Accident in HKG
Report published Feb2013

– 13 April 2010
– Airbus A330, B-HLL
– Cathay Pacific Airways Limited (CPA)
– A total of 57 passengers and six
cabin crew were injured during
evacuation.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Latest Large Aeroplane Accident in HKG
Report published Feb2013
– Flight CPA780 declared “MAYDAY” when approaching
Hong Kong International Airport (VHHH) with control
problem on both engines. The aircraft landed at a
groundspeed of 231 knots, with No. 1 engine stuck at
above idle(70 % N1) and No. 2 stuck at sub-idle (17 %
N1).
– Five main tyres were deflated after the aircraft came to
a complete stop on Runway 07L.
– After being advised by the rescue leader that there was
fire and smoke on the wheels, the Commander initiated
an emergency evacuation of passengers.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Latest Large Aeroplane Accident in HKG
Report published Feb2013
– The accident aircraft had uplifted
24,400 kg of fuel at Juanda
International Airport, Surabaya,
Indonesia (WARR).

The investigation had identified that

contaminated fuel uplifted at
Surabaya had caused both engines
loss of thrust control during approach
to HKG.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Latest Large Aeroplane Accident in HKG
Report published Feb2013
– SAFETY RECOMMENDATIONS
* Surabaya Airport should conduct an extensive review of the re-
commissioning procedures of hydrant refuel system in accordance with
the best practice in aviation fuel industry.
* Surabaya Airport should ensure the re-commissioning procedures are
completed before resuming the hydrant refueling operation for Stands
No. 1 to 10
* ICAO to establish requirements for oversight and quality control on
aviation fuel supply at airports. Such requirements should also cover the
refuel operational procedures and associated training for relevant
personnel.
* ICAO to specify the requirements of installing a device in equipment
used in refuelling civil aircraft. This device should be able to automatically
alert the equipment operator and stop the refuelling process when the
differential pressure across the equipment filtration system is outside the
equipment designed value or range.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Accident Investigation Summary
Keypoints

– Remember the mandatory nature of

reportable events – legally liable
– Accident reporting and cooperation in
investigation by law
– Airline to work with authority and provide all
necessary data
– Airline to take up relevant safety
recommendations to prevent re-occurrence

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
 Definition
 A safety management system (SMS) is a systematic approach to
managing safety, including the necessary organisational structures,
accountabilities, policies and procedures. (ICAO)

 Safety Management System (SMS) - A systematic and explicit

approach defining the activities by which safety management is
undertaken by an organisation in order to achieve acceptable or
tolerable safety. (ESARR-Eurocontrol
Safety Regulation Requirements).

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System

 Definition
 HK CAD712 1.2
 A systematic approach to managing safety, including the
necessary organisational structures, accountabilities, policies
and procedures.
 SAME AS ICAO

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
– Safety management requires planning,
organising, communicating and providing
direction.

– The SMS development begins with setting the

organisational safety policy. The policy
outlines the strategy for achieving acceptable
levels of safety within the organisation.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
 Effective safety management systems use risk and
quality management methods to achieve their safety
goals.

 In addition, SMS also provides the organisational

framework to establish and foster the development
of a positive corporate safety culture.

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 Safety Management System
 The ICAO Standards and Recommended Practices (SARPS)
 require the implementation of a safety management system by
the following 4 aviation service provider organisations:

 aircraft operators;
 aircraft maintenance organisations;
 air navigation services providers;
 airport operators.

 Later from 2010, 2013 includes additional 2 organisations

 training organisations, and
 aircraft manufacturers.
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Safety Management System
- Organisations other than the 6 categories may
participate into SMS.
- It is getting common that many organisations would
have some forms of SMS integrated into business
operation.
- This is to boost corporate image and indicates a
responsible organisation.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
 Under the ICAO recommendations, the service provider must implement an
SMS accepted by their State that, as a minimum,
 - Identifies safety hazards

 - Ensures that remedial action necessary to maintain an acceptable

level of safety is implemented

 - Provides for continuous monitoring and regular assessment of the

safety level achieved

 - Aims to make continuous improvement to the overall level of safety

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
• An aviation SMS program is a set of processes and tools to
manage aviation safety. These processes are organized into
four components:

• Safety Policy;
• Safety Risk Management;
• Safety Assurance; and
• Safety Promotion.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Policy

• Management commitment & responsibility

• Safety Accountabilities
• Appointment of key safety personnel
• Coordination of emergency response planning
• SMS documentation

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Policy
The safety and quality policy should as a minimum include a
statement committing the organisation to:
 Recognise safety as a prime consideration at all times
 Apply Human Factors principle
 Encourage personnel to report maintenance related
errors/incidents
 Recognise that compliance with procedures, quality standards
safety standards and regulations is the duty of all staff

This should be part of the Organisation Exposition and signed by

the Accountable Manager

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management

• Hazard identification
• Risk assessment
• Risk mitigation

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management

• Hazard identification
– Know the hazards
– Know the risks
– Who are responsible to identify the hazards
and determine risks?

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management

• Hazard identification
– Identify potential scenario that may develop into
damages to business operation. Those related to
safety would be under SMS.
– Safety: pax/crew/staff injuries, loss of aeroplane
– Finance: debt/equity,
– Commercial: cash flow, sales, fuel price
– Operations: loss of approval, delays
* Other risks are managed under separate Risk
Management
Copyright©2020 Henry Leung Systems
Hong Kong Airworthiness AESF 5710
 Safety Management System
Safety Risk Management

• Risk assessment
– The accountable persons or senior
management would assess the risk level by
determining the severity and frequency that
hazard may occur.
– The product of severity and frequency
determines the risk level.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management
Hazard Severity
Verbal Numeric Description

Catastrophic 5 Likely to result in death

Critical 4 Potential for severe

injury

Moderate 3 Potential for moderate

injury

Minor 2 Potential for minor

injury

Negligible 1 No significant risk if

injury

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management
Hazard Frequency
Verbal Numeric Description

Frequent 5 Hazard likely to occur

Probable 4 Hazard will be

experienced
Occasional 3 Some manifestations of
the hazard are likely to
occur
Remote 2 Manifestations of the
hazard are possible but
unlikely
Improbable 1 Manifestations of the
hazard are very unlikely

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management
Risk Matrix

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management
Risk Matrix

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management
Risk Mitigation

– Now that the risks are known, what are the

actions require to make the risks go away, or
if/when happened, the response to address
the risk.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Risk Management
Risk Mitigation
– The Company needs to determine what courses of actions for
different levels of risk
– Example:
• Level >12
– Must have preventive measures;
– Develop Crisis Manual with recovery procedures
– Manage by Department Head
• Level 6 – 12
– Isolate and rectify within 10 days
– Manage by General Manager or above
• Level <6
– No immediate action require
– Data capture for analysis to prevent frequency increase
Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710
 Safety Management System
Safety Assurance

• Safety performance monitoring &

measurement
• Management of change
• Continuous improvement of the SMS

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Assurance
• Safety performance monitoring &
measurement
– Utilize tangible measurements to determine
effectiveness of SMS
– Number of staff/pax injuries
– Number of staff days off due to injuries
– Number of safety incidents
– Number of safety findings by audit

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Safety Promotion

• Training & education

• Safety communication

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
allows operators to integrate their diverse
safety activities into a coherent system

• Examples of safety activities that might be integrated into an

operator’s SMS include:

• a) Hazard and incident reporting;

• b) Flight Data Analysis (FDA);
• c) Line Operations Safety Audit (LOSA); and
• d) Safety Reviews

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Summary
The 6 aviation services that must
implement SMS

 1. aircraft operators;
 2. aircraft maintenance organisations;
 3. air navigation services providers;
 4. airport operators;
 5. training organisations, and
 6. aircraft manufacturers.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 Safety Management System
Summary
The 4 main components of SMS

• Safety Policy;
• Safety Risk Management;
• Safety Assurance; and
• Safety Promotion.

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QUALITY ASSURANCE SYSTEM
SUMMARY
• You’ve learnt QA in maintenance & airline
environment
• Incident Reporting & MOR
• Accident Reporting
• Safety Management System
• These make up quality system of airworthiness,
and along with other elements contribute to
meet airworthiness requirements

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710

 QUALITY ASSURANCE SYSTEM
of Airworthiness

QUESTIONS

Copyright©2020 Henry Leung Hong Kong Airworthiness AESF 5710