Issued: 09-JAN-2019 | To: PIA | AP-BHO(1) |
AAIB advised PIA to implement SB-21878 (incorporated as a revision in EMM Chapter 5 about six months prior to crash) for replacement of PT-1 blades on entire ATR fleet held at PIA according to the prescribed schedule / criteria. AAIB also advised CAA Pakistan (Airworthiness Directorate) to improve oversight function / mechanism accordingly. |
Issued: 20-AUG-2019 | To: PIA | AP-BHO(2) |
AAIB advised PIA to initiate recycling / inspection (in a phased manner) at an OEM facility (Collins USA), of all (Qty 48) OSGs, either installed on ATR aircraft in operation or held in inventory with PIA. |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(10) |
CAA Pakistan (Directorate of Airworthiness, State Safety Programme Management and / or any other relevant departments), must identify relevant performance indicators and establish a mechanism of monitoring of such indicators (in light of purposes and objectives of relevant ICAO publications and applicable SARPs). P&WC data about comparison of reliability of PIA ATR fleet, and details of IFSD cases of ATR (as per records held with PIA / CAA), can be considered as a reference. The established mechanism must also include relevant management tools to identify trends and recognize weak areas, and execute proactive intervention(s), proportionate with the nature and extent of identified concerns. |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(11) |
CAA Pakistan (Directorate of Airworthiness), must undertake necessary improvements (in light of purposes and objectives of relevant ICAO publications and applicable SARPs) to ensure that appropriate management tools are evolved / adopted, and effective procedures are established to identify weak areas, related to the compliance with the OEM specified requirements / procedures etc. P&WC shop visit of PIA MRO for the maintenance of PW127 series Engines can be considered as a reference. |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(12) |
Keeping in view the actions by the cockpit crew regarding Energy State Management, Automation Management, Crew Resource Management (CRM) failure aspects, CAA Pakistan (Directorate of Flight Standards) is to consider following measures: - |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(13) |
Revamp the CRM training system (in light of purposes and objectives of relevant ICAO publications and applicable SARPs) and institute and implement regular / periodic CRM facilitator"s interactive training workshops for emphasizing upon the objectives of CRM, sharing of experiences and knowledge from accident / incident investigations of aviation industry, and evaluating the positive outcomes of CRM. |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(14) |
Evolve a purposeful internal assessment mechanism (for the operators), to increase the effectiveness of CRM training by identifying tangible performance indicators, and may consider to develop a software module to accumulate database of CRM observations for analysis. |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(15) |
Institute and implement feedback and analysis tools for use by the operators along with necessary training / guidelines. It may include use of existing systems of FDM analysis, hazard reporting system, voluntary reporting of events, and self-assessment by the cockpit crew etc. |
Issued: 16-NOV-2020 | To: CAA Pakistan | AP-BHO(16) |
Institute and implement an elaborate mechanism for the operators, of separately recording the weak areas identified during CAA Flight Inspector"s supervised flights / simulator tests, and continuous monitoring during regular training sessions, and FDM analysis. Ensure effective utilization by establishing detailed records of operational trends and utilize same to feed the airline SOP and training program etc. |
Issued: 16-NOV-2020 | To: ATR | AP-BHO(17) |
ATR: ATR is to consider inclusion, as part of the training philosophy, of a procedure in the relevant aircraft publications to handle the aircraft in case of severe structural damage (to correlate an aerodynamic degradation similar to the event), to enable the cockpit crew to respond to such situations in a more appropriate manner. |
Issued: 16-NOV-2020 | To: FAA | AP-BHO(18) |
FAA: Woodward has completed review and update to OSG CMM. Maintenance group review report225 by NTSB summarizes the completion of this activity. FAA may re-evaluate that the revised CMM encompasses all conditions to rule out possibility of incorrect assembly of the lower body of the OSG and consequent damage to the pin. |
Issued: 16-NOV-2020 | To: FAA | AP-BHO(19) |
FAA / Collins Aerospace: Collins Aerospace has issued a service information letter (SIL-568F-796) to remind operators to maintain proper cleanliness and FOD prevention during engine and propeller storage and maintenance. FAA and Collins Aerospace are to consider a system review and possible improvements to the oil system filtration inside the propeller control system to enhance existing protections against debris entering the PVM OSG line (including feather solenoid and SLPS solenoid) that could affect safety functions. |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(3) |
PIA is to ensure replacement of PT-1 blades as per schedule given in EMM Chapter 5 in letter and spirit on the entire fleet of ATR aircrafts (in light of First Immediate Safety Recommendation)221. |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(4) |
PIA is to ensure recycling of all the Qty-48 OSGs (currently held with PIA) from an OEM"s certified MRO facility to verify and confirm that no other OSG is having any internal pre-existing anomaly (in light of Second Immediate Safety Recommendation)222. |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(5) |
PIA is to ensure strict compliance of service information letter (SIL-568F-796)223 issued by Collins Aerospace to maintain proper cleanliness and FOD prevention during engine and propeller storage and maintenance. |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(6) |
PIA is to undertake improvements (and ensure continued compliance) in all the areas identified in P&WC site survey report of the MRO facility established for the maintenance of PW127 series engines22 |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(7) |
PIA Safety Management must identify critical performance indicators both in the domains of airworthiness as well as flight operations. The data is to be utilized for establishing trends and weak areas, further leading towards proactive corrective measures and corresponding improvements in SOPs / training programme. |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(8) |
PIA is to ensure effective utilization of FDM system, observations noted during the simulator check flights and training sessions to identify and maintain records of operational trends. This mechanism may also include continuous monitoring and must enable requisite / proportionate improvements in relevant SOPs and training program. |
Issued: 16-NOV-2020 | To: PIA | AP-BHO(9) |
PIA is to revamp its CRM training system (in light of purposes and objectives of relevant ICAO publications and applicable SARPs) and evolve a purposeful internal assessment mechanism to gauge the effectiveness of CRM training. |