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EASA Annual Safety Review 2025
Reproduced for study. Always verify against the official GACAR at gaca.gov.sa.
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Safety Management, Sustainability &
Global Outreach Directorate
Safety Intelligence & Performance Department
Catalogue number
TO-01-25-000-EN-N
ISBN
978-92-9210-287-6
ISSN
DOI
10.2822/5406205
Disclaimer:
The Annual Safety Recommendations Review is published by the European Union Aviation Safety Agency
(EASA). This 18th edition provides an overview of the safety recommendations addressed to EASA in 2024, as
well as the replies that EASA issued in the same timeframe.
This annual review highlights the actions EASA has undertaken in response to safety recommendations and is
published in the context of the openness, transparency and accountability that characterises European Public
Administration.
In line with EASA’s commitment to upholding and enhancing aviation safety, this review provides relevant
information related to safety concerns identified, for the benefit of EASA’s 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
© European Union Aviation Safety Agency, 2025. All rights reserved. Proprietary document.
Printed copies are not controlled. Confirm revision status through the EASA-Internet site:
www.easa.europa.eu. 2025 Annual Safety Recommendations Review
Annual Safety Recommendations Review 2025
Contents3
Contents
Contents
List of Abbreviations ............................................................................................................... 5
Chapter 1 Executive summary ............................................................................................. 10
Chapter 2 Introduction ........................................................................................................ 13
Chapter 3 Safety Recommendations addressed to EASA in 2024 ....................................... 16
3.1 Overview of Safety Recommendations received in 2024 ......................................................... 17
3.2 Origin of Safety Recommendations received in 2024 .............................................................. 20
3.3 Involvement in accident and serious incident investigations in 2024 .................................... 21
Chapter 4 Safety Recommendation replies issued in 2024 ................................................. 22
4.1 Overview of Safety Recommendation replies issued in 2024 .................................................. 23
4.2 Assessment of Safety Recommendation replies in 2024 .......................................................... 24
Chapter 5 Key Safety Topics and Actions Undertaken in 2024 ........................................... 27
5.1 Regulatory Updates & Certification Enhancements ................................................................. 29
5.2 Operational Safety & Training Initiatives .................................................................................. 29
5.3 Maintenance & Continued Airworthiness ................................................................................ 29
5.4 Fire Safety & Risk Mitigation ...................................................................................................... 30
5.5 Ground Handling & Infrastructure Improvements ................................................................... 30
Chapter 6 Conclusions ......................................................................................................... 31
Annex A Safety Recommendations Received and Replies Sent in 2024 ........................... 33
Annex B Definitions ......................................................................................................... 111
Annex C Safety Recommendations classification ........................................................... 116
Annual Safety Recommendations Review 2025
List of Figures4
List of Figures
List of Figures
Figure 1: SRs addressed to EASA per year, by Civil / Military SIAs ....................................................................... 17
Figure 2: SRs addressed to EASA per year, by Occurrence Class ........................................................................... 18
Figure 3: SRs addressed to EASA in 2024 by Type of Operation and Aircraft Category ..................................... 19
Figure 4: Origin of SRs addressed to EASA in 2024, by SIA ................................................................................... 20
Figure 5: EASA replies issued in 2024, by year of receipt of SR ............................................................................ 23
Figure 6: SR replies issued in 2024, by EASA assessment ..................................................................................... 24
Figure 7: SIA assessments of all EASA replies since 2020 (both intermediate and final replies) ...................... 25
Figure 8: SIA assessments of Final Replies sent in 2024 (not intermediate replies) .......................................... 26
Figure 9: SRs addressed to EASA in 2024, by SR topic ........................................................................................... 28
Figure 10: SRs addressed to EASA in 2024, by SR topic in detail .......................................................................... 29
Annual Safety Recommendations Review 2025
List of Figures5
List of Abbreviations
Annual Safety Recommendations Review 2025
List of Abbreviations6
List of Abbreviations
AB Advisory Bodies
AC Advisory Circular
AD Airworthiness Directive
AFCS Automatic Flight Control System
AFM Aircraft Flight Manual
AH Airbus Helicopters
ALS Airworthiness Limitations Section
AMC Acceptable Means of Compliance
AMM Aircraft Maintenance Manual
AMP Aircraft Maintenance Programme
ANAC Agência Nacional de Aviação Civil
AOC Air Operator Certificate
ATC Air Traffic Control
ATPL Airline Transport Pilot Licence
BEA Bureau d’Enquêtes et d’ Analyses pour la sécurité de l’aviation civile
BFU Bundesstelle für Flugunfalluntersuchung
BIS Best Intervention Strategy
BPS Ballistic Parachute System
CAAC Civil Aviation Administration of China
CAG Collaborative Analysis Groups
CARI Continued Airworthiness Review Item
CAT Commercial Air Transport
CEN European Committee for Standardisation
CFD Computational Fluid Dynamics
CFRS Crash-Resistant Fuel System
CIVP Continued Integrity Verification Programme
CM Certification Memorandum
CMA Common Mode Analysis
CPL Commercial Pilot Licence
CPR Changed Product Rule
CRI Certification Review Item
CRM Crew Resource Management
CS Certification Specification
Annual Safety Recommendations Review 2025
List of Abbreviations7
CVR Cockpit Voice Recorder
DAH Design Approval Holder
EASA European Union Aviation Safety Agency
EC European Community
ECU Engine Control Unit
ED Executive Director
ELT Emergency Locator Transmitter
ENCASIA European Network of Civil Aviation Safety Investigation Authorities
EPAS European Plan for Aviation Safety
EU European Union
EUROCAE European Organisation for Civil Aviation Equipment
EWIS Electrical Wiring Interconnection System
FAA Federal Aviation Administration
FADEC Full Authority Digital Engine Control
FCMIR Flight Crew-Machine Interface Recordings
FDR Flight Data Recorder
FEM Flight Examiner Manual
FHA Functional Hazard Assessment
FMEA Failure Modes and Effects Analysis
FSTD Flight Simulation Training Devices
GA General Aviation
GH Ground Handling
GHSP Ground Handling Service Providers
GM Guidance Material
HPA High-Performance Aeroplanes
HTAWS Terrain Avoidance and Warning System
IAMFTF International Aircraft Materials Fire Test Forum
ICA Instructions for Continued Airworthiness
ICAO International Civil Aviation Organization
IDE Instruments, Data and Equipment
ILS Instrument Landing System
IM Interpretative Material
IR Instrument Rating
Annual Safety Recommendations Review 2025
List of Abbreviations8
JRC European Joint Research Center
LTE Loss of tail rotor effectiveness
MASPS Minimum Aviation System Performance Standard
MBSA Model-Based Safety Analysis
MCTOM Maximum Certificated Take-off Mass
MGB Main Gear Box
MOPS Minimum Operational Performance Specifications
MOPSC Maximum Operational Passenger Seating Configuration
MPO Multi-Pilot Operations
MRBR Maintenance Review Board Report
MS Member States
MTOM Maximum Take-off Mass
NAA National Aviation Authority
NCA National Competent Authorities
NCC Non-Commercial operations with Complex motor-powered aircraft
NCO Non-Commercial Operations
NDT Non-Destructive Test
NLR Nederlands Lucht- en Ruimtevaartcentrum
NMSB Non-Modification Service Bulletin
NPA Noticed of Proposed Amendment
NPRM Notice of Proposed Rulemaking
OBWBS On Board Weight and Balance Systems
OHA Oxygen Hazards Analysis
PDA Premature Descent Alerts
PMC Program Management Committee
PSE Principle Structure Elements
PT Power Turbines
QMS Quality Management System
RCF Rolling Contact Fatigue
RMT Rulemaking Task
SA Single Aisle
SAIB Special Airworthiness Information Bulletin
SAR Search And Rescue Centers
Annual Safety Recommendations Review 2025
List of Abbreviations9
SB Service Bulletin
SC Special Condition
SEI Sustained Engine Imbalance
SFCL Sailplane Flight Crew Licensing
SHE Safran Helicopter Engines
SIA Safety Investigation Authority
SIB Safety Information Bulletin
SMS Safety Management System
SNPRM Supplemental Notice of Proposed Rulemaking
SPHP Single-Engine Turboprop High Performance
SPL Sailplane Pilot Licence
SPN Safety Promotion Network
SPT Safety Promotion Task
SR Safety Recommendation
SRGC Safety Recommendation of Global Concern
SRM Safety Risk Management
SRM Single Resource Management
SRUR Safety Recommendation of Union-wide Relevance
SSA System Safety Analysis
SSP State Safety Programme
STC Supplemental Type Certificate
SUB Sicherheitsuntersuchungsstelle des Bundes
TAWS Terrain Avoidance and Warning System
TCCA Transport Canada Civil Aviation
TCH Type Certificate Holder
TEM Threat and Error Management
TIP Technical Implementation Procedures
TOPMS Take-Off Performance Monitoring System
UAS Unmanned Aircraft Systems
UAV Unmanned Aerial Vehicles
UPRT Upset Prevention and Recovery Training
VAST Vertical Aviation Safety Team
Annual Safety Recommendations Review 2025
Chapter 1 | Executive summary10
Chapter 1 | Executive summary
Chapter 1
Executive summary
Annual Safety Recommendations Review 2025
Chapter 1 | Executive summary11
Executive Summary
Welcome to the 2025 edition of the Annual Safety Recommendation Review. The analysis presented in this
review provides an overview of the activities carried out in 2024 by the European Union Aviation Safety Agency
(EASA) in response to safety recommendations, as well as a comparison with historical data. This review also
highlights a range of safety issues and safety improvement actions that will be of interest to the European
aviation community and the wider public.
EASA has a key role in addressing safety concerns which emerge during safety investigations, and the processing
of safety recommendations in a systematic manner constitutes one of its core responsibilities. This has been
reflected in the establishment of a proven process for managing the safety recom mendations received and
tracking them through to closure. Due to its central position in the European aviation safety system, EASA can
take actions with respect to systemic problems and risk management.
Overview of Safety Recommendations in 2024
A total of 40 safety recommendations were addressed to EASA during 2024, stemming from 26 separate
occurrences , including 18 accidents and 8 serious incidents . The majority of these originated from EU-based
SIAs, maintaining a consistent trend observed over recent years. Notably, no safety recommendations concerning
Unmanned Aerial Vehicles (UAVs) were received in 2024.
These recommendations predominantly focused on procedures and regulations (52.5%) , followed by those
related to aircraft, equipment, and facilities (32.5%) , and personnel-related issues (15%) . This distribution
highlights the continuing relevance of regulatory frameworks and operational practices as core areas for safety
improvement.
EASA’s Involvement in Investigations
Beyond its role as a recipient of safety recommendations, EASA also provided direct technical expertise in
support of several high-profile investigations worldwide, including major occurrences in Japan, Serbia, Brazil,
and Lithuania. EASA’s participation in these investigations—often through the on-site deployment of Technical
Advisors—demonstrates its active contribution to international aviation safety and its support for collaborative
investigation efforts within and beyond Europe.
Formal Replies and Continuous Engagement
In 2024, EASA issued 97 formal replies in response to 92 safety recommendations . Of these, 55 were final
replies , 80% of which resulted in the closure of the safety recommendation through either direct implementation
or alternative corrective actions. The remaining 42 replies were interim updates, providing transparency on
ongoing safety actions and progress.
Importantly, the alignment of EASA’s responses with SIAs’ expectations improved measurably compared to 2023.
SIAs assessed 25 of EASA’s final replies as “adequate” or “partially adequate,” with only 10 replies rated as
“not adequate.” EASA welcomed a significant increase in SIA assessments received, compared with previous
years, which it views as vital for reinforcing the feedback loop and enhancing safety dialogue. However, a large
proportion of replies (36%) were still pending assessment at the end of the year, reflecting the time required for
meaningful evaluation.
Annual Safety Recommendations Review 2025
Chapter 1 | Executive summary12
Key Areas of Safety Focus
EASA’s responses to safety recommendations in 2024 reflect a multi-faceted safety strategy aligned with the
European Plan for Aviation Safety (EPAS). Five key areas of focus emerged from its replies:
• Regulatory Updates & Certification Enhancements: EASA pursued updates to Certification
Specifications and Acceptable Means of Compliance, addressing issues such as rotorcraft component
fatigue and pressurised oxygen systems.
• Operational Safety & Training: EASA supported enhanced training requirements and safety
promotion initiatives, including targeted campaigns on topics like unanticipated yaw in rotorcraft and
rejected winch launches for glider pilots.
• Maintenance & Continued Airworthiness: In response to maintenance-related failures, EASA
issued safety information bulletins and proposed regulatory changes to better address component
degradation and critical maintenance tasks.
• Fire Safety & Risk Mitigation: Several actions were taken to review and revise cockpit fire response
procedures and address hazards linked to oxygen-fed fires, including regulatory review and Safety Risk
Management process proposals.
• Ground Handling & Infrastructure: EASA contributed to the development of formal de-icing
regulations under the wider framework of ground handling oversight, as outlined in Opinion 01/2024.
Commitment to Continuous Improvement
Throughout 2024, EASA demonstrated its unwavering commitment to aviation safety through responsive,
evidence-based action. It continued to refine its internal procedures, strengthened collaboration with SIAs,
and aligned its actions with European-wide safety risk management processes. The integration of safety
recommendations into its broader safety strategy ensures that each recommendation not only receives due
attention but contributes to meaningful safety outcomes.
The year’s efforts highlight EASA’s role as a proactive, transparent, and safety-focused authority, dedicated to
protecting the travelling public and supporting the ongoing evolution of Europe’s aviation safety landscape.
Annual Safety Recommendations Review 2025
Chapter 1 | Executive summary13
Chapter 2
Introduction
Annual Safety Recommendations Review 2025
Chapter 2| Introduction14
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 of 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 (hereinafter SIA), which shall investigate accidents and serious incidents 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, also known as 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”.
EASA assigns a high priority to the follow-up of safety recommendations and has established effective procedures
designed to ensure that:
• EASA provides a first reply to each safety recommendation within 90 calendar days;
• Subsequent replies are provided as necessary to update the SIA of progress;
• Safety recommendations are subject to a continuous internal monitoring process until all agreed
corrective actions are closed;
• EASA reviews SIA assessments of its replies.
These procedures support EASA in ensuring transparency with respect to its decisions and actions in line with its
mission to uphold and improve aviation safety. EASA also supports effective cooperation in safety investigation
by working with the European Network of Civil Aviation Safety Investigation Authorities (hereinafter ENCASIA),
particularly in Working Group 6 on Safety Recommendations.
EASA 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 work performed by EASA in
response to safety recommendations for which it is the addressee.
The first edition of this Review was issued in 2007. This 18th edition reviews the work undertaken in 2024 and
presents:
• General statistical data on the safety recommendations that SIAs addressed to EASA in 2024;
• Information on the replies EASA issued in 2024 in response to safety recommendations;
• The main safety issues that have been addressed through the actions taken.
1 As amended by Regulation (EU) No 376/2014 and Regulation (EU) 2018/1139Chapter 2| Introduction
Annual Safety Recommendations Review 2025
Chapter 2| Introduction15
A process designed to identify, assess and mitigate safety risks at a European level was established by EASA in
2016. The European Safety Risk Management process involves the data-driven identification of safety issues, risk
assessment and decision-making on the best course of action to mitigate these risks. To facilitate this process,
EASA, the Member States (MS) and industry work together in Collaborative Analysis Groups (CAG) and Advisory
Bodies (ABs).
A separate EASA publication, the Annual Safety Review, highlights the main and most visible elements of 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 EASA, 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
potential deficiencies in the aviation system and propose solutions to mitigate the associated safety risks.
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202416
Chapter 3 | Safety Recommendations addressed to EASA in 2024
Chapter 3
Safety
Recommendations
addressed to EASA
in 2024
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202417
Safety Recommendations addressed
to EASA in 2024
3.1 Overview of Safety Recommendations received in 2024
In 2024, a total of 40 safety recommendations were addressed to EASA.
Figure 1 shows the total number of safety recommendations addressed to EASA over the last decade, by
civil aviation SIAs and military aviation SIAs. The follow-up of safety recommendations and the role of EASA
is mandated by Regulation (EU) No 996/2010. The issuance of safety recommendations addressed to EASA
started to develop shortly before this regulation entered into force in 2010. Until 2016, the number of safety
recommendations addressed to EASA remained relatively high, in the order of 80 – 100 per year. 2017
proved to be a turning point, when the number fell by around half. In subsequent years, the number of safety
recommendations addressed to EASA has remained relatively stable, fluctuating in the range 30 – 60 per year.
´Figure 1: SRs addressed to EASA per year, by Civil / Military SIAs
Civil aviation SIAs/zero.LT/one.LT/zero.LT/two.LT/zero.LT/three.LT/zero.LT/four.LT/zero.LT/five.LT/zero.LT/six.LT/zero.LT/seven.LT/zero.LT/eight.LT/zero.LT/nine.LT/zero.LT/one.LT/zero.LT/zero.LT
/two.LT/zero.LT/two.LT/three.LT /two.LT/zero.LT/two.LT/four.LT /two.LT/zero.LT/two.LT/two.LT /two.LT/zero.LT/two.LT/one.LT /two.LT/zero.LT/two.LT/zero.LT /two.LT/zero.LT/one.LT/nine.LT /two.LT/zero.LT/one.LT/eight.LT /two.LT/zero.LT/one.LT/seven.LT /two.LT/zero.LT/one.LT/six.LT /two.LT/zero.LT/one.LT/five.LT/eight.lowTab/six.lowTab/eight.lowTab/eight.lowTab
/four.lowTab/two.lowTab/five.lowTab/four.lowTab /five.lowTab/four.lowTab
/three.lowTab/two.lowTab/three.lowTab/four.lowTab /three.lowTab/three.lowTab/five.lowTab/five.lowTab/zero.lowTab/zero.lowTab
/four.lowTab/one.lowTab /zero.lowTab
/zero.lowTab/eight.lowTab
/three.lowTab/one.lowTab
/four.lowTab/zero.lowTab/zero.lowTab
Military aviation SIAs
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202418
The overall reduction in the number of safety recommendations addressed to EASA over the last 15 years can be
attributed in part to the proactive identification and mitigation of safety concerns through safety actions at an
earlier stage, before it becomes necessary to raise them during an investigation, as well as EASA’s active support
of investigations during the report drafting phase, leading to draft safety recommendations being discussed in
advance and where possible rendered more effective.
In 2024, the safety recommendations addressed to EASA related to 26 occurrences, comprising 18 accidents
(giving rise to 30 safety recommendations) and 8 serious incidents (giving rise to 10 safety recommendations) .
No safety recommendations were issued as an outcome of a study; nor as a result of investigations into incidents.
Figure 2 shows the total number of safety recommendations addressed to EASA over the past decade, by
occurrence class.
´Figure 2: SRs addressed to EASA per year, by Occurrence Class
Accident Serious Incident Incident Study and Other /zero.lowTab/one.lowTab/zero.lowTab/two.lowTab/zero.lowTab/three.lowTab/zero.lowTab/four.lowTab/zero.lowTab/five.lowTab/zero.lowTab/six.lowTab/zero.lowTab/seven.lowTab/zero.lowTab/eight.lowTab/zero.lowTab/nine.lowTab/zero.lowTab/one.lowTab/zero.lowTab/zero.lowTab
2024 2023 2022 2021 2020 2019 2018 2017 2016 2015
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202419
The 40 safety recommendations addressed to EASA in 2024 stemmed from 26 occurrences involving the aircraft
categories and operation types detailed in the table below.
´Figure 3 : SRs addressed to EASA in 2024 by Type of Operation and Aircraft Category
Type of OperationAircraft Category
Fixed Wing Rotorcraft
Grand Total
Large
AeroplaneSmall
AeroplaneGliderSmall
Helicopter
Commercial Air Transport 9 0 0 0 9
Airline 9 9
Non-Commercial Operations 4 16 7 0 27
Business 1 1
Flight Training/Instructional 2 2
Pleasure 4 10 7 21
Test Flight 2 2
Relocation 1 1
Specialised Operations (Aerial Work) 0 1 0 3 4
Aerial survey 1 0 1
Construction sling/load 3 3
State Operations 0 0 0 0 0
Grand Total 13 17 7 3 40
In 2024, no safety recommendations pertaining to UAVs were addressed to EASA.
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202420
3.2 Origin of Safety Recommendations received in 2024
In 2024, as in previous years, a significant majority of safety recommendations addressed to EASA were issued
by EU-based SIAs. Specifically, 10 SIAs within the EU and 3 SIAs outside the EU addressed a total of 40 safety
recommendations to EASA. The total number of safety recommendations addressed to EASA is in line with the
trend seen in recent years.
Figure 4 shows which SIAs addressed safety recommendations to EASA in 2024.
´Figure 4: Origin of SRs addressed to EASA in 2024, by SIA
Non-EU EU/zero.lowTab/two.lowTab/four.lowTab/six.lowTab/eight.lowTab/one.lowTab/zero.lowTab/one.lowTab/two.lowTab
AAIU BelgiumAIB Hong KongCIAIAC SpainCAAC China
DSB Netherlands GPIAAF PortugalAAIU Ireland
AAIB United KingdomAIB DenmarkSUB AustriaBFU GermanyBEA France ANSV Italy
The details of these Safety Recommendations can be found in Appendix A.
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202421
3.3 Involvement in accident and serious incident investigations
in 2024
EASA provided technical expertise in support of a number of investigations into notable occurrences in 2024.
Selected occurrences are listed below:
Accident involving an Airbus A350, registration JA13XJ on 02/01/2024, in Japan
• An Airbus A350, collided with Japanese Coast Guard Dash 8-300, JA722A, resulting in five fatalities on
the Dash-8-300 and the destruction of both aircraft. EASA appointed a Technical Advisor to the BEA
Accredited Representative and travelled on site together with the EU Go-Team.
Accident involving an EMB-195, registration OY-GDC on 18/02/2024, in Serbia
• A scheduled flight with 106 pax on board (45 EU citizens) and 5 crew members. There were no injuries.
Runway overrun during take-off, ground ILS antenna collision. Several warnings were triggered in
the cockpit due to aircraft damage, including a fuel leak from the LH hand wing. The EASA Technical
Advisor attended the FDR/CVR read-out carried out in Paris (BEA).
Accident involving an ATR 72-500, registration PS-VPB on 09/08/2024, in Brazil
• Scheduled flight from Cascavel to Guarulhos with 58 pax and 4 crew. Loss of control before starting
descent; all on-board fatally injured. EASA Technical Advisor travelled to the accident site with the
French Go-Team (BEA and ATR).
Accident involving a Boeing B737 (freight flight), registration EC-MFE on 25/11/2024, in Lithuania
• Communication with ATC was routine until the final approach, when the crew failed to contact the
tower after handoff. The aircraft crashed 0.87 nautical miles from the runway at 05:28 local time. 1
fatality on board. EASA appointed a Technical Advisor to the Investigator-in-Charge and travelled to
the BFU for the FDR read out.
Accident involving an Airbus A220, registration HB-JCD, on 23/12/2024, in Austria
• An Airbus A220-300 suffered an engine failure and a smoke event during cruise flight. After an
emergency diversion to Graz Airport, Austria, two cabin crew members were rushed to the hospital;
one of them died on December 30. EASA appointed a Technical Advisor who was involved directly in
different examinations.
Accident involving a Boeing 737, registration HL-8088, on 29/12/2024, in South Korea
• Collision with the ILS localizer antenna array that was installed on a concrete platform during an
emergency landing after bird ingestion in both engines. Of the 181 occupants, two flight attendants
seated in the tail section survived the accident. EASA appointed a Technical Advisor and is involved in
the engine examination phase.
In addition, multiple investigations launched in previous years were still ongoing or completed in 2024 and were
actively supported by EASA either through the monitoring of progress and / or provision of technical expertise.
Safety actions that were taken during or immediately following an investigation do not appear in this publication
unless the SIA issued an associated, formal safety recommendation to EASA in 2024.
Annual Safety Recommendations Review 2025
Chapter 3 | Safety Recommendations addressed to EASA in 202422
Chapter 4
Safety Recommendation
replies issued in 2024
Annual Safety Recommendations Review 2025
Chapter 4 | Safety Recommendation replies issued in 202423
Chapter 4 | Safety Recommendation replies issued in 2024
Safety Recommendations replies
issued in 2024
4.1 Overview of Safety Recommendation replies issued in 2024
In 2024, EASA issued 97 formal replies to 92 safety recommendations. As updates are provided, multiple replies
may be issued for the same recommendation within a calendar year. Most of the replies issued in 2024 were
EASA’s responses to safety recommendations first received that year.
However, replies to recommendations from earlier years were also issued, as illustrated in figure 5 below, for
those cases where follow-up actions and conclusions were reached, or which required updates and/or closure of
the safety recommendation.
Of the 97 replies provided in 2024, 96 were in response to safety recommendations issued by civil aviation SIAs
and 1 was in response to a safety recommendation issued by a military aviation SIA.
´Figure 5: EASA replies issued in 2024, by year of receipt of SR
Year Safety Recommendation Received
Interim Replies Final Replies /zero.lowTab/five.lowTab/one.lowTab/zero.lowTab/one.lowTab/five.lowTab/two.lowTab/zero.lowTab/two.lowTab/five.lowTab/three.lowTab/zero.lowTab/three.lowTab/five.lowTab/four.lowTab/zero.lowTab
2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2009 2008
Annual Safety Recommendations Review 2025
Chapter 4 | Safety Recommendation replies issued in 202424
4.2 Assessment of Safety Recommendation replies in 2024
Each final reply EASA issues closing a safety recommendation, as well as each SIA assessment of an EASA reply,
is classified according to the categories2 set out in Annex C.
Of the 97 replies issued by EASA in 2024, 55 were final replies which closed safety recommendations. These
replies were classified as follows:
• EASA agreed to take corrective action in 80% of cases , either by directly applying the recommended
course of action as was the case for 26 safety recommendations or, in a further 18 cases, by partially
agreeing but undertaking corrective actions other than those recommended.
• The actions proposed by 9 safety recommendations ( 16%) were not agreed , and in these cases any
alternative actions were deemed either not viable or not to provide a net safety benefit.
• The actions proposed by 2 safety recommendations ( 4%) were found to be outside of EASA’s remit
of responsibility.
This demonstrates progress compared with 2023, a year in which the corresponding percentages stood at 68%
(EASA agreed to take corrective action), 27% (the actions proposed were not agreed) and 5% (outside EASA’s
remit) respectively.
This development indicates greater alignment between SIAs and EASA in terms of consensus on which actions are
most likely to result in a net safety benefit, and also suggests an improved understanding among SIAs of EASA’s
remit of responsibility, in part thanks to information-sharing forums such as EASA’s annual meeting with EU SIAs,
bilateral meetings between EASA and individual SIAs, and ENCASIA.
Figure 6 illustrates the above figures in more detail.
´Figure 6: SR replies issued in 2024, by EASA assessment
Closed
Agreement, /two.lowTab/six.lowTab
Open, /four.lowTab/two.lowTabPartial agreement, /one.lowTab/eight.lowTab
Disagreement, /nine.lowTab
Not responsible, /two.lowTab
2 These definitions of classification categories were developed in collaboration with ENCASIA and are part of a taxonomy aimed at
facilitating the management of safety recommendations.
Annual Safety Recommendations Review 2025
Chapter 4 | Safety Recommendation replies issued in 202425
EASA continuously monitors its progress towards closing safety recommendations, but only considers them
closed once all related actions have been undertaken and completed, and a final reply has been issued.
In addition to the 55 final replies (closing the related safety recommendations), 42 updating replies (termed
“intermediate”, or interim responses) were issued. These updating replies provided information on the progress
of the actions decided upon by EASA but for which the related activities had not yet been completed.
To monitor whether SIAs consider EASA’s replies to be Adequate, Partially Adequate or Not Adequate, EASA has
implemented procedures in line with Regulation (EU) No 996/2010.
Figure 7 depicts the assessments received each year on all EASA replies (both intermediate and final replies). This
shows a significant year-on-year increase in the number of SIA assessments received in 2024. EASA welcomes
this positive development which, if it continues in years to come, will strengthen an important feedback loop
between SIAs and one of the main recipients of their safety recommendations.
´Figure 7: SIA assessments of all EASA replies since 2020 (both intermediate and final replies)
Adequate Partially adequate Not adequate/zero.lowTab/one.lowTab/zero.lowTab/two.lowTab/zero.lowTab/three.lowTab/zero.lowTab/four.lowTab/zero.lowTab/five.lowTab/zero.lowTab/six.lowTab/zero.lowTab/seven.lowTab/zero.lowTab
/two.LT/zero.LT/two.LT/four.LT /two.LT/zero.LT/two.LT/three.LT /two.LT/zero.LT/two.LT/two.LT /two.LT/zero.LT/two.LT/one.LT /two.LT/zero.LT/two.LT/zero.LT/eight.lowTab/nine.lowTab/one.lowTab
/one.lowTab/six.lowTab/one.lowTab/three.lowTab/one.lowTab/three.lowTab
/one.lowTab/one.lowTab/eight.lowTab/nine.lowTab
/nine.lowTab/one.lowTab/one.lowTab/nine.lowTab
/two.lowTab/six.lowTab/two.lowTab/one.lowTab/one.lowTab/five.lowTabKey Safety Topics and Actions Undertaken in 2
Annual Safety Recommendations Review 2025
Chapter 4 | Safety Recommendation replies issued in 202426
Figure 8 depicts the total number of assessments that EASA received from SIAs of the 55 final replies (not interim
replies) issued in 2024. As assessed, 17 replies were assessed as Adequate (shown in light blue), 8 replies were
assessed as Partially Adequate (in yellow) and a further 10 replies were assessed as Not Adequate (in dark blue).
With respect to the remaining 20 replies EASA sent in 2024, SIA assessments were still pending at the end
of 2024 (shown in grey). Although this is a significant improvement over previous years, it still represents a
large proportion of replies (36%), reflecting the time required for meaningful evaluation. While Article 18 of
Regulation (EU) No 996/2010 calls for SIAs to assess EASA’s replies within 60 days of receipt, the fact that this
deadline is not consistently met may suggest that it is challenging to meaningfully assess the impact of EASA’s
actions on safety outcomes within this timeframe.
´Figure 8: SIA assessments of Final Replies sent in 2024 (not intermediate replies)
Adequate Partially adequate Not adequate No response yet0 5 10 15 20 25 30Closed-Not ResponsibleClosed - DisagreementClosed - Partial agreementClosed - Agreement12
Annual Safety Recommendations Review 2025
Chapter 5 | Key Safety Topics and Actions Undertaken in 202427
Chapter 5 | Key Safety Topics and Actions Undertaken in 2024
Chapter 5
Key Safety Topics
and Actions
Undertaken in 2024
Annual Safety Recommendations Review 2025
Chapter 5 | Key Safety Topics and Actions Undertaken in 202428
Key Safety Topics and Actions
Undertaken in 2024
In 2024, 10 SIAs within the EU and 3 SIAs outside the EU addressed a total of 40 safety recommendations to
EASA. These 40 safety recommendation were categorised as pertaining to safety recommendation topics, in line
with the standard ECCAIRS2 – SRIS2 taxonomy. The distribution across the various safety recommendation topics
was substantially similar to that seen in previous years, with a significant majority of safety recommendations
primarily relating to procedures and regulations, followed by aircraft / equipment / facilities and personnel, in
order of precedence.
Figures 9 provides an overview, and Figure 10 a more detailed breakdown, of the safety recommendation topics
to which the 40 safety recommendations received in 2024 were attributed.
´Figure 9: SRs addressed to EASA in 2024, by SR topic
/zero.lowTab/one.lowTab/zero.lowTab/two.lowTab/zero.lowTab/three.lowTab/zero.lowTab/four.lowTab/zero.lowTab/five.lowTab/zero.lowTab/six.lowTab/zero.lowTab
Personnel/one.LT/five.LT./zero.LT%/three.LT/two.LT./five.LT%/five.LT/two.LT./five.LT%
Aircraft / Equipment / Facilities Procedures or Regulations
Annual Safety Recommendations Review 2025
Chapter 5 | Key Safety Topics and Actions Undertaken in 202429
´Figure 10: SRs addressed to EASA in 2024, by SR topic in detail
Aircraft/
Equipment/
FacilitiesProcedures/
Regulations
PersonnelAircraft certi/f_icationAir Navigation Services (ANS)
Aircraft equipment
OtherAircraft maintenance/inspection
Aircraft operations
ATS / ATS equipment / facilities
Design/Production/Manufacturing
Medical / Human Factors
Training/pro/f_iciency/checkSurvivabilitySearch and rescue
0 5 10 15 20 25
Five selected areas where EASA is actively working to improve aviation safety, as set out in 2024 through its
replies to safety recommendations, are summarised below:
5.1 Regulatory Updates & Certification Enhancements
EASA has been actively revising certification standards and enhancing regulatory frameworks to address safety
concerns. Many responses in 2024 indicated a commitment to updating Certification Specifications (CS) and
refining Acceptable Means of Compliance (AMC). For example, in response to UNKG-2023-002, EASA recognised
the risk of premature rolling contact fatigue failure in rotorcraft bearings and proposed clarifying the scope of
AMC1 29.571 to ensure that all critical bearings are properly assessed. Similarly, FRAN-2023-024 counselled a
review of pressurised oxygen system risks, prompting EASA to undertake a design review of Airbus Single Aisle
aircraft oxygen systems to evaluate overpressure risks.
5.2 Operational Safety & Training Initiatives
EASA has placed significant emphasis on promoting safety awareness throughout the aviation community,
including where this pertains to pilot training as well as standardised operational procedures to mitigate human
error. In response to AUST-2024-001, EASA acknowledged the need for recurrent winch launch failure training
for glider pilots, and subsequently reviewed the existing regulatory framework, demonstrating how it ensures
that pilots maintain proficiency, while upholding adherence to high safety standards uniformly across all aircraft
categories and types. Additionally, SWED-2023-003, which focused on unanticipated yaw risks in rotorcraft,
led to the EASA Rotorcraft Committee launching a targeted safety awareness campaign, featuring educational
videos, workshops, and training materials to inform pilots and operators about the phenomenon.
5.3 Maintenance & Continued Airworthiness
Aviation safety relies on robust maintenance practices and ongoing airworthiness evaluations. EASA has taken
steps to enhance oversight of maintenance procedures and address risks associated with aging components. In
response to PORT-2023-001, which questioned the continued airworthiness of Aerazur AIR 12A towing hooks,
Annual Safety Recommendations Review 2025
Chapter 5 | Key Safety Topics and Actions Undertaken in 202430
EASA concurred with the investigator’s assessment that poor maintenance had contributed to component failure.
While no unsafe condition was formally identified, EASA issued Safety Information Bulletin (SIB) 2024-11 to warn
operators about risks associated with improper maintenance. Similarly, UNKG-2021-018 and UNKG-2021-019 led
to a proposal —to be implemented under rulemaking task RMT.0735 —to include in the list of data sources used
to identify critical maintenance tasks EASA Safety Information Bulletin (SIB) 2020-06, which deals with biocide
treatment of fuel systems.
5.4 Fire Safety & Risk Mitigation
Fire hazards, particularly those linked to pressurized oxygen systems, were a recurring safety concern in 2024.
EASA has undertaken several design and procedural reviews to enhance fire safety measures. In response to
FRAN-2023-025, EASA initiated an assessment of cockpit fire and smoke procedures, evaluating whether existing
procedures adequately prepare pilots to identify and respond to oxygen-fed fires. Additionally, FRAN-2023-026
prompted EASA to review the risk of cigarette ignition in cockpits, leading to a proposal for a new European
Safety Risk Management (SRM) process entry on "Oxygen-fed fires in flight decks", which could result in future
regulatory changes.
5.5 Ground Handling & Infrastructure Improvements
Although a smaller category, ground handling safety and infrastructure management received regulatory
attention in 2024. In response to GERF-2018-002, which called for greater regulatory control over aircraft de-icing
operations, EASA integrated de-icing procedures into a broader rulemaking effort to improve ground handling
safety (Opinion 01/2024). The new framework introduces formal requirements for de-icing service providers,
including training, safety management systems, and fluid quality control.
Viewed collectively, EASA’s replies to safety recommendations in 2024 reflect a multi-faceted approach to
upholding and improving aviation safety, combining initiatives such as regulatory updates, operational
enhancements, maintenance oversight, fire safety measures, and improved ground handling regulations. These
actions demonstrate a strong commitment to continuous safety improvement and proactive risk management.
Annual Safety Recommendations Review 2025
Chapter 6 | Conclusions31
Chapter 6 | Conclusions
Chapter 6
Conclusions
Annual Safety Recommendations Review 2025
Chapter 6 | Conclusions32
Conclusions
In 2024, EASA continued its mission to uphold and improve aviation safety across the European Union and
beyond, through the diligent monitoring and follow-up of safety recommendations issued by national and
international Safety Investigation Authorities (SIAs). These recommendations, arising from accident and incident
investigations, represent a critical feedback loop that informs regulatory decisions, operational procedures, and
long-term strategic planning. EASA’s role in this domain, as defined under Regulation (EU) No 2018/1139 and
Regulation (EU) No 996/2010, places it at the heart of Europe’s aviation safety architecture.
In 2024, 10 SIAs within the EU and 3 SIAs outside the EU addressed a total of 40 safety recommendations to EASA.
The total number of safety recommendations addressed to EASA is in line with the trend seen in recent years.
The majority, 52.5% of the safety recommendations were related to procedures or regulations. Recommendations
related to aircraft, equipment, or facilities constituted 32.5%. Recommendations related to personnel constituted
15%. There were no safety recommendations which primarily concerned QMS, SMS, and SSP topics.
The themes identified collectively highlight systemic challenges in aviation safety, ranging from certification gaps
and operational risks to maintenance vulnerabilities and fire hazards. The safety recommendations addressed to
EASA in 2024 provide valuable insights for improving regulatory frameworks, enhancing training programmes,
and ensuring that aviation safety continues to evolve in response to emerging risks.
In 2024, EASA provided 97 replies in response to 92 safety recommendations:
• 55 of these were final replies, 80% of which closed the related safety recommendations through
corrective actions either as recommended (in 26 cases) or by taking alternative measures other than
those recommended (in 18 cases).
• The remaining 42 replies were updates providing information on the progress of the actions decided
upon by EASA and for which the relevant activities were not yet completed.
• As assessed by SIAs, 25 of EASA’s final replies were deemed to be “adequate” or “partially adequate”
and 10 responses was deemed as “not adequate”. With respect to the remaining replies sent in 2024,
the SIA assessments remained pending at the end of 2024.
The number of replies to safety recommendations issued by EASA in 2024 exceeded that of previous years. The
actions taken by EASA 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 identified within the European
safety risk management process.
2024 witnessed a significant year-on-year increase in the number of assessments received. EASA welcomes
this positive development which, if it continues in years to come, will strengthen an important feedback loop
between SIAs and one of the main recipients of their safety recommendations.
There was also greater alignment between SIAs and EASA in 2024 in terms of which actions are most likely to
result in a net safety benefit, in part thanks to information-sharing forums such as EASA’s annual meeting with
EU SIAs, bilateral meetings between EASA and individual SIAs, and ENCASIA.
Viewed collectively, EASA’s replies to safety recommendations in 2024 reflect a multi-faceted approach to
upholding and improving aviation safety, combining initiatives such as regulatory updates, operational
enhancements, maintenance oversight, fire safety measures, and improved ground handling regulations. These
actions demonstrate a strong commitment to continuous safety improvement and proactive risk management.
Annual Safety Recommendations Review 2025
Annex A | Safety Recommendations Received and Replies Sent in 202433
Annex B | Definitions Annex A | Safety Recommendations Received and Replies Sent in 2024
Annex A
Safety
Recommendations
Received and Replies
Sent in 2024
Safety Recommendation s Received and Replies Sent
January – December 2024
AUST -2017 -001
Schweizer 269C, OE -XRL, 09/08/2014
Safety Recommendation received on 07/03/2017 :
EASA should require for helicopter pilots a flight simulation training including a sufficient and dedicated
training on “Loss of tail rotor effectiveness” (LTE) and recovery actions for all training, examination and
proficiency check flights (on appropriate and certified simulators).
Interim r eply sent on 28/11/202 4:
For the training, test and check flights of helicopter pilots, the European Union Aviation Safety Agency
(EASA) was asked to require that the practice of the occurrence and elimination of Loss of tail -rotor
effectiveness (LTE) should be performed on suitab le and certified simulators. The Certification
Specifications for Helicopter Flight Simulation Training Devices (CS -FSTD(H)) already address antitorque
device ineffectiveness in Helicopter Full Flight Simulators with subjective testing of the loss of anti -torque
effectiveness.
Nevertheless, EASA has reviewed the requirements for helicopter Flight Simulation Training Devices (FSTD)
within the context of rulemaking task RMT.0196 ‘Update of flight simulation training devices requirements’,
which was launched on 15 July 2016 with th e objective of enhancing LTE simulation aspects on Helicopter
Full Flight Simulators.
The RMT concluded in the publication of a Noticed of Proposed Amendment, (NPA) 2020 -15, available at
https://www.easa.europa.eu/en/document -library/notices -of-proposed -amendment/npa -2020 -15.
Following consultation on the NPA, EASA intends to publish an Opinion, which is currently expected in Q2
2025. Subsequently, a Decision is expected one year after publication of the Opinion, in Q2 2026. A further
reply will be provided by EASA once the ado ption process has run its course.
Status: Open
_______________________________________________________________________________________
AUST -2022 -004
MD900, OE -XWF, 01/08/2017
Safety Recommendation received on 11/08/2022 :
It was noted that Figure 2 -2 from the MD900 Flight Manual, Chapter 2 “Limitations”, was properly
approved by the civil aviation authorities, but some information may be misinterpreted. It is recommended
that the information in Figure 2 -2 should be reevaluated and, in cooperation with the FAA a nd the
manufacturer, that consideration be given to whether and how the relevant information in this chart can
be presented more clearly, taking into account the possibility of misinterpretations. This may include,
among other things, extending the text “T AKEOFF AND LANDING WAT LIMIT” to include the word “HIGE”,
introducing safety margins, especially around the operating limit of 12400 ft, clarifying that wind from the
front can also have a negative effect, or, if necessary, changing the title, as “[...] Fo r Crosswind Operations”
could give the wrong impression that the chart is only to be used in crosswinds conditions.
Safety Recommendation s Received and Replies Sent
January – December 2024
Final r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) has formally requested Technical Assistance from the
State of Design (Federal Aviation Administration of the United States of America, hereinafter the FAA) in
the domain of Continuing Airworthiness for Safet y Recommendation (SR) AUST -2022 -004 on 10th July
In accordance with the Technical Implementation Procedures (TIP) for Airworthiness and Environmental
Certification between the FAA of the United States of America and the EASA of the European Union,
Revision 7, Section VIII, para. 4.1.1 and 4.1.2, the FAA is responsible for resolving in -service safety issues
related to the design or product of MD900 helicopters.
Considering that this SR calls for an update of the Rotorcraft Fight Manual, EASA’s expectation is that the
FAA will share information on manual changes as per Section VIII, para. 4.3.5 of the TIP and proceed with
the necessary steps for obtaining EASA val idation.
On 15th July 2024 the FAA Aviation Safety Recommendation Branch acknowledged EASA’s request for
Technical Assistance.
On 29th October 2024, the FAA directly informed the Austrian Sicherheitsuntersuchungsstelle des Bundes
(SUB) that the FAA’s Aircraft Certification Service was currently reviewing the final investigation report in
order to determine an appropriate action pl an to address the safety recommendations.
On 30th October 2024 the SUB acknowledged the FAA feedback and assessed it to be adequate, waiting for
further response, declaring the SR 24.027 (SUB number SE/SUB/LF/8/2022) OPEN.
Based on the above, it can be concluded that the FAA in its role as State of Design is addressing the SR
initially submitted to EASA by the SUB.
EASA, in its role of validating authority, will process any further request to approve design changes through
the normal process under the TIP.
EASA considers that there is no more action on AUST -2022 -004 that is de -facto replaced by FAA 24.027.
Status: Closed – Not Responsible
_____________________________________________________________________ __________________
AUST -2022 -005
MD900, OE -XWF, 01/08/2017
Safety Recommendation received on 11/08/2022 :
OSD (Operational Suitability Data) for the MD900 helicopter are not available from the type certificate
holder at EASA, nor does a legal obligation exist for the MD900 type to require such. However, the
operating limit regarding the aerodynamic controllabi lity (flight manual Figure 2 -2) is a peculiarity of this
helicopter model and the NOTAR system, which is uncommon in this form compared to helicopter models
with conventional tail rotor according to FAR Part 27 or CS -27. It is recommended to examine option s, in
cooperation with FAA and the type certificate holder, to make pilots aware of the aerodynamic and
operational peculiarities of MD900 type helicopters.
Safety Recommendation s Received and Replies Sent
January – December 2024
Final r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) has formally requested Technical Assistance from the
State of Design (Federal Aviation Administration of the United States of America, hereinafter the FAA) in
the domain of Continuing Airworthiness for Safet y Recommendation (SR) AUST -2022 -005 on 10th July
In accordance with Technical Implementation Procedures (TIP) for Airworthiness and Environmental
Certification between the FAA of the United States of America and the EASA of the European Union,
Revision 7, Section VIII, para. 4.1.1 and 4.1.2, the FAA is r esponsible for resolving in -service safety issues
related to the design or product of MD900 helicopters.
On 15th July 2024 the FAA Aviation Safety Recommendation Branch acknowledged EASA’s request for
Technical Assistance.
On 29th October 2024, the FAA informed directly the Austrian Sicherheitsuntersuchungsstelle des Bundes
(SUB) that the FAA’s Aircraft Certification Service was currently reviewing the final investigation report in
order to determine an appropriate action pl an to address these safety recommendations.
On 30th October 2024 the SUB acknowledged the FAA feedback and assessed it to be adequate, waiting for
further response, declaring the SR 24.028 (SUB number SE/SUB/LF/9/2022) OPEN.
Based on the above it can be concluded that the FAA in its role as State of Design is addressing the SR
initially submitted to EASA by the SUB.
EASA, in its role of validating authority, will process any further request to approve design changes through
the normal process under the TIP.
EASA considers that there is no more action on AUST -2022 -005 that is de -facto replaced by FAA 24.028.
Status: Closed – Not Responsible
_____________________________________________________________________ __________________
AUST -2023 -001
Theo Schröder Fire Balloons G60/24, OE -RTS, 12/11/2022
Safety Recommendation received on 06/09/2023 :
Take appropriate measures to prevent the pilot from falling out of the basket during landing. It is
recommended to equip and retrofit all balloons with a restraint system, no matter in which function and
equipment the balloon is operated. Furthermore, it w ould be necessary to equip balloons used in a DTO for
training pilots with restraint systems for student pilots and flight instructors as well.
Interim reply sent on 22/03/202 4:
The balloon type involved in the subject occurrence has a separate compartment for the pilot and was
consequently equipped with a pilot restraint system in accordance with BOP.BAS.320 of Annex II (Part -BOP)
to Regulation (EU) 2018/395. However, the restrai nt system was not used during this occurrence (as is
mandated by BOP.BAS.175). Therefore, the European Union Aviation Safety Agency (EASA) concludes that
the current operational rules for balloons would have been effective in preventing the occurrence.
Safety Recommendation s Received and Replies Sent
January – December 2024
The current formulation of BOP.BAS.320, which extended the requirement for a pilot restraint system to
include balloons equipped with turning vents, resulted from a consultation with relevant subject matter
experts and stakeholders as a part of Rulemaking Task 0674. According to Article 4, paragraph 2, of
Regulation (EU) 2018/1139, the measures taken under this Regulation, which include the rules for balloon
operations, shall correspond and be proportionate to the nature and risk of each particular activity to
which they relate. Specifically, regulations shall also take into account the type, scale, and complexity of the
operation or activity, including, where relevant, the size and type of the traffic handled by the responsible
organisation or person. EASA highlights that the majority of commercial operations, which may constitute a
higher risk, are carried out with large baskets equipped with multiple compartments for which the use of a
pilot restraint system is mandated by the current rules.
Furthermore, EASA has reviewed the available safety data for balloon operations in the EU since the entry
into force of the current rules. The review highlighted a decreasing trend of accidents related to pilot
ejection during landing between 2018 and 2023 . Consequently, EASA could not identify a safety issue that
would justify the retrofitting of a pilot restraint system on all approved balloons. EASA concludes that the
current formulation of the balloon operational rules is adequate and proportionate.
Notwithstanding the above, EASA noted that in the majority of fatal accidents on record the pilot restraint
system was not worn even if its use was mandatory. Therefore, EASA intends to issue a Safety Information
Bulletin to raise awareness on the risks of a balloon pilot ejection during landing, with the recommendation
to use a pilot restraint system whenever one is installed. Additionally, EASA intends to enhance its safety
promotion activities to foster the engagement of the balloon community and highlig ht the benefits of
wearing a pilot restraint system during the critical flight phases.
Status: Open
_____________________________________________________________________ __________________
AUST -2023 -004
ROBIN DR400 , D-EWLA , 25/06/2023
Safety Recommendation received on 07/12/2023 :
During a glider tow flight, the cockpit canopy of the Schempp -Hirth Duo Discus glider opened after take -off
at low altitude. The glider on a 30 m tow rope climbed over the tow plane, lifted its tail and caused it to
crash. The aircraft manufacturer Schemp p-Hirth published the Technical Note No. 396 -6 dated
02.07.2004, LBA approved 15.07.2004, approved by EASA 27.07.2004 as a replacement for the issue dated
04.07.2001 concerning canopy locking. With regard to urgency, the aircraft manufacturer states
“Reco mmended until the next annual inspection”.
In the case of the aircraft in question, the implementation of Technical Note No. 396 -6 dated 02.07.2004
recommended by the aircraft manufacturer was not carried out. The Austrian Federal Safety Investigation
Authority recommends that EASA orders to chang e the implementation of Technical Note No. 396 -6 dated
02.07.2004 from "Recommended" to "Mandatory".
Interim reply sent on 06/02/202 4:
In accordance with regulatory framework established under Regulation (EU) 2018/1139, the European
Union Aviation Safety Agency (EASA) shall determine corrective actions in response to safety issues for
entities in respect of which it acts as the competent authority. In the domain of airworthiness, provided
that an unsafe condition is determined, EASA can only mandate corrective actions through an airworthiness
directive (AD), as outlined in point 21.A.3B of Annex I (Part -21) to Regulation EU) 748/2012, and not by
changing the implementation status of a technical document. EASA finds that the issue addressed by the
Safety Recommendation s Received and Replies Sent
January – December 2024
Technical Note No. 396 -6 does constitute an unsafe condition. Therefore, EASA intends to mandate its
implementation with an Airworthiness Directive.
Final r eply sent on 26/04/202 4:
In accordance with regulatory framework established under Regulation (EU) 2018/1139, the European
Union Aviation Safety Agency (EASA) shall determine corrective actions in response to safety issues for
entities in respect of which it acts as the competent authority. In the domain of airworthiness, provided
that an unsafe condition is determined, EASA can only mandate corrective actions through an airworthiness
directive (AD), as outlined in point 21.A.3B of Annex I (Part -21) to Regulation EU) 748/2012, and not by
changing the implementation status of a technical document.
EASA finds that the issue addressed by the Technical Note No. 396 -6 does constitute an unsafe condition.
EASA has therefore mandated its implementation with AD 2024 -0059 issued on 05/03/2024, and published
here: https://ad.easa.europa.eu/ad/2024 -0059 .
Status: Closed – Agreement
_____________________________________________________________________ __________________
AUST -2024 -001
Discus -2c, OE-5300 , 22/05/2023
Safety Recommendation received on 04/03/2024 :
In accordance with Implementing Regulation 2018/1976 Annex III (SFCL), glider pilots are not required to
perform launch method -depending continuous training for dangerous situations during launches, once they
have completed their initial training. Pilots m ust be continuously trained for rejected winch launches in
order to be able to take the correct action in dangerous situations. As this is generally known, several flying
clubs and airfield operators in Austria, including all flying clubs based at Innsbruc k Airport since the
accident in question, require pilots to practice rejected winch launches on a regular basis.
Furthermore, the launch method is not prescribed for the training flights required every 24 months in
accordance with SFCL.160 (a)(1)(ii). If a glider pilot has several launch type ratings (e.g. winch launch and
powered aircraft tow launch), it is possible under the current legal situation that the pilot will never
complete a training flight with the winch launch type.
The European Union Aviation Safety Agency (EASA) is therefore recommended, in addition to SFCL.155 (c)
and SFCL.160 (a), require recurrent and compulsory practical exercises of rejected winch launches to
maintain proficiency in dangerous situations after i nitial training. Furthermore, it should be ensured that
training flights in accordance with SFCL.160 (a) are completed at regular intervals in each approved launch
method.
Interim r eply sent on 31/05/202 4:
The European Union Aviation Safety Agency (EASA) is examining the existing body of regulatory provisions
and guidance material as they pertain to training and proficiency requirements of sailplane pilots and will
provide a detailed update in Q3 2024.
Final r eply sent on 19/07/202 4:
Point SFCL.130 of Annex III (Part -SFCL) to Commission Implementing Regulation (EU) 2018/1976 of 14
December 2018 lays down requirements for the initial training of sailplane pilots. The associated
Safety Recommendation s Received and Replies Sent
January – December 2024
Acceptable Means of Compliance (AMC) AMC2 SFCL.130 SPL – Training Course and Experience
Requirements outlines the details of the training syllabus, including exercises for rejected winch take -offs
(cf. Exercise 11A). Furthermore, the Practical Skill Test, detailed in AMC1 SFCL.145 SPL – Practical Skill Test,
point (d)(1), Section 2A, incorporates this exercise, underscoring its significance.
According to SFCL.115.SPL (c) and SFCL.155.SPL (c), it is the responsibility of the sailplane licence holder
(SPL) to exercise their privileges only if they comply with the applicable recency requirements.
If SPL holders do not comply with the recency requirement of SFCL.155(c) for a launching method, in order
to renew their privileges they shall perform the additional number of launches flying dual or solo under the
supervision of an instructor.
Further to this, to maintain currency of SPL privileges in accordance with SFCL.160 SPL – Recency
Requirements, the alternative to the conditions in SFCL.160(a)(1) is a proficiency check with a Flight
Examiner for Sailplanes FE(S) on a sailplane, excluding Touring Motor Glider (TMGs). This proficiency check
aligns with the skill test for Sailplane Pilot Licence (SPL), granting the examiner FE(S) a risk -based flexibility
to select exercises. The European Union Aviation Safety Agency (EASA) deems this method safer, allowing
the examiner to tailor assessments based on a thorough review of the pilot’s logbook, encompassing past
exercises and operational activities. Furthermore, embracing Threat and Error Management (TEM), the
examiner may use exercises for discu ssion and, if identified as high risk, incorporate them into the
proficiency check to ensure applicant proficiency levels are met.
In view of the above, EASA considers that the current regulatory framework, as outlined in Part – SFCL,
adequately addresses these training and proficiency requirements. The inclusion of the exercise in both
initial training, as specified in AMC2 SFCL.130 SPL – Training Course and Experience Requirements (Exercise
11A), and the Practical Skill Test, as detailed in AMC1 SFCL.145 SPL – Practical Skill Test, point (d)(1), Section
2A, underscores the regulatory emphasis on the importance of this manoeuvre.
The European Union Aviation Safety Agency (EASA) believes that this regulatory approach is the most
appropriate for the revalidation of licenses and the fulfillment of recency requirements. This approach is
consistently applied across all aircraft categori es and types, ensuring uniformity and adherence to high
safety standards.
Status: Closed – Partial Agreement
_______________________________________________________________________________________
AUST -2024 -002
Diamond DA 42M, OE -VPW, 06/06/2009
Safety Recommendation received on 22/04/2024 :
The training program for test pilots who are used in aircraft as part of flight test programs does not provide
for any testing of the personality structure of prospective test and test pilots. In view of the course of the
accident in question, it seems advisable to check the personal suitability of applicants with regard to non -
technical skills.
The Federal Safety Investigation Board recommends that the European Aviation Safety Authority (EASA)
examine the requirements for testing non -technical skills and the suitability of applicants for acceptance as
pilots in flight test programs and propose gu idelines and procedures for this purpose.
Safety Recommendation s Received and Replies Sent
January – December 2024
Final r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA) has examined the existing regulatory framework and in
particular the requirements pertaining to the proficiency of test pilots within flight test programmes. For
any amendments to the regulatory material, cl ear and substantial evidence must be provided to
demonstrate a necessity for change. As of now, EASA believes that the existing measures are adequate to
ensure the safety and proficiency of test pilots within flight test programmes.
In this regard, the provisions included in the Acceptable Means of Compliance to Regulation (EU) No
1178/2011 (Annex I – Part FCL) AMC1 FCL.820 are comprehensive, ensuring that Flight Test rating training
is competency -based. This includes a pre -assessment to evaluate the applicant's capability to successfully
complete the course. Additionally, any instances of misconduct are addressed within the cultural
framework of the Training Organization’s Safety Management System (SMS).
Therefore, EASA considers that the existing regulatory framework is sufficiently robust to ensure the
competence and suitability of test pilots and find no evident deficiencies in accordance with the content of
the safety recommendation.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
AUST -2024 -008
Cirrus SR20 G1, D -ESFB, 02/11/2023
Safety Recommendation received on 18/11/2024 :
The warning placards on aircraft prescribed by EASA are not sufficiently suitable for warning rescue services
from a safe distance of the presence of an installed ballistic parachute system (BPS) on an aircraft involved
in an accident.
It is suggested to EASA that all registered aircraft within the EASA member states fitted with ballistic
parachute system (BPS) be recorded in a central aircraft register and these data made available to the
national search and rescue centers (SAR) in the event of an accident. In the event of an aircraft accident,
this would enable the rescue services to carry out a query by telephone or online with the respective
national search and rescue center (SAR) and, if necessary, request experts for the de -activati on or removal
of ballistic rescue systems (BPS) at an early stage.
Status: Open
_____________________________________________________________________ __________________
AUST -2024 -009
Cirrus SR20 G1, D -ESFB, 02/11/2023
Safety Recommendation received on 18/11/2024 :
It is difficult for rescue services to locate ballistic parachute system (BPS) rocket motors at accident sites
because they are not colour coded. It is therefore proposed that BPS rocket motors be colour coded in the
same way as flight data recorders (FDR) , cockpit voice recorders (CVR) or emergency locator transmitters
(ELT).
Safety Recommendation s Received and Replies Sent
January – December 2024
Status: Open
_____________________________________________________________________ __________________
AUST -2024 -010
Cirrus SR20 G1, D -ESFB, 02/11/2023
Safety Recommendation received on 18/11/2024 :
The only way to deactivate the rocket motor of a ballistic parachute system (BPS) in an aircraft is by
installing a safety pin on the release handle, which is connected to the BPS - system via a Bowden cable.
Structural deformations, such as those that occur in aircraft ac cidents, could alter the Bowden cable and
lead to uncontrolled activation of the rocket motor.
It is suggested to introduce a mechanical deactivation option directly on the rocket motors of ballistic
parachute systems (BPS) in the course of certifications to ensure that the BPS - system can be deactivated
safely, quickly and without special tools.
Status: Open
_____________________________________________________________________ __________________
BELG -2021 -003
CESSNA 172S, D -EPCE, 29/05/2019
Safety Recommendation received on 09/09/2021 :
It is recommended that EASA incorporates in the projected EASA FEM:
• a thorough description on which items to be included in the pre -flight briefing (such as the designation
of the PIC, handover of controls, the roles in the event of an actual emergency, method of simulated
emergencies..)
• the guidelines (that were part of the former JAA FEM) and a formalized prior risk assessment on
performing simulated emergency landings during PPL test and SEP check flights.
Final r eply sent on 09/09/202 4:
The European Union Aviation Safety Agency (EASA) has developed the Flight Examiner Manual (FEM) which
was published on the EASA website on 02 November 2021.
In October 2023 the existing Flight Examiner Manuals have been updated and the scope was extended to
cover Rotorcraft.
Having allowed the industry a period of review and feedback, EASA is satisfied that the changes are now
fully accepted by the training community. The manuals cover the broadest possible range of licenses and
ratings. The specific items covered in the Safet y Recommendation are included in Paragraph 6 of each
document, entitled “Skill Test Items”. This provides a checklist of all the items that should be included.
The FEM can be downloaded at:
https://www.easa.europa.eu/en/document -library/general -publications/flight -examiners -manual -fem
Status: Closed – Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
BELG -2024 -001
Alexander Schleicher ASK -13, D -0019, 17/05/2022
Safety Recommendation received on 31/10/2024 :
It is recommended that EASA introduces a design requirement for sailplanes in order to alleviate the risk of
unwanted opening of the canopy in flight.
Final r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) considers that the design of sailplanes canopy locking
systems must remain sufficiently simple to ensure compliance with the applicable certification
specifications in CS -22 (Certification Specifications for Sailplanes and Powered Sailplanes) in particular CS
22.777 (Cockpit controls) and CS 22.807 (Emergency exit).
CS 22.777(a) requires that each cockpit control must be located to provide convenient operation, and to
prevent confusion and inadvertent operation. CS 22.777(d) requires that controls must maintain any
desired position without requiring constant attention by the pilot(s), and must not tend to creep under
system loads or vibration.
CS 22.807(a) requires that the cockpit must be so designed that unimpeded and rapid escape in emergency
situations during flight and in any normal or crash attitude on the ground is possible with the occupant
wearing a parachute.
CS 22.807(c) requires that the opening system must be designed for simple and easy operation. It must
function rapidly and be designed so that it can be operated by each occupant strapped in his seat and also
from outside the cockpit.
Imposing additional design features to increase the robustness of the securing of the locking system in the
‘locked’ position could result in the failure of the canopy emergency opening (and jettisoning where
applicable) in some emergency situations where the pilots have very limited time to perform the opening
action(s).
Furthermore, the design of the system must also be simple enough such that a passenger is able to use it in
emergency situations. On this aspect, Annex II (Part SAO) to Commission Implementing Regulation (EU)
2018/1976 on rules for the operation of sailpla nes, point SAO.OP.110 requires a briefing of passengers on
emergency procedures, and the corresponding Acceptable Means of Compliance (AMC) AMC1 point
SAO.OP.110 specifies that this should include the ‘location and use of emergency canopy opening’.
EASA’s position is that the above -mentioned CS -22 provisions have resulted in adequate designs providing
an adequate level of safety when pilots follow applicable checklists and procedures to ensure adequate
closing and locking of the canopy before startin g the flight. Regarding the risk of inadvertent operation in
flight, CS 22.777(a) and (d) already contain corresponding specifications to ensure designs mitigate this risk.
Hence EASA concludes that there is no need to amend CS -22 on this topic.
Status: Closed – Disa greement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
CHIN -2024 -002
Airbus A330 -300, B-5958 , 27/08/2019
Safety Recommendation received on 21/10/2024 :
EASA, in coordination with other primary certification authorities, to do related research on control
measures and design standards considering the fire risk and the risk of the presence of grease, pollutants,
and other foreign substances in hidden areas.
Final r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) conducted a thorough review of the investigation
report, identifying three key aspects to address this safety recommendation:
A) Ignition of the fire: The Civil Aviation Administration of China (CAAC) report determined that the
probable cause of the incident was internal heating and high temperatures within the electrical terminal
block, exacerbated by a pre -existing defect and f actors like degraded fire resistance of electrical
components, grease, pollutants, and other foreign substances. This issue is closely related to the Electrical
Wiring Interconnection System (EWIS) installation and maintenance. Point CS 25.1713 of Certific ation
Specification for Large Aeroplanes (CS -25) addresses the fire protection aspects of EWIS, particularly the
requirement for self -extinguishing properties (as per Part I of Appendix F to CS -25). Continued
Airworthiness Maintenance Instructions, such as cleaning, are mandated by CS 25.1729 and CS 25 Appendix
H “Instructions for Continued Airworthiness.” The Federal Aviation Administration (FAA) Advisory Circular
(AC) 25 -27A also provides information to improve EWIS maintenance practices. EASA believes th at no
additional research is needed, as the current design standards are sufficient and appropriate.
B) Propagation of the fire: To reduce the likelihood of fire propagation due to degraded fire resistance
properties from grease, pollutants, and other foreign substances, a proper maintenance program is
essential. CS 25 Appendix H outlines the required mai ntenance instructions, including inspection and
cleaning of each part of the aircraft. The Enhanced Zonal Analysis for the A330 did identify the wiring and
the risk of accumulation of combustible materials in this zone and resulted in a corresponding clean ing task
and inspection of the wire routes in the Maintenance Review Board Report (MRBR). EASA believes that no
further research is necessary, as the existing design standards and analysis methods are sufficient and
appropriate.
C) Material qualification in hidden areas: Part I of CS 25 Appendix F applies to all materials installed in
compartments occupied by crew or passengers, as required by CS 25.853(a). Part I of Appendix F also
applies to certain materials/parts installed in hidden areas, e.g. electrical conduit and air ducting.
Furthermore, CS 25.856(a) requires that thermal/acoustic insulation material installed in the fuselage must
meet the flame propagation test requirements of Part VI of Appendix F to CS -25, In 2023 and 2 019, the FAA
published a Notice of Proposed Rulemaking (NPRM) and a Supplemental Notice of Proposed Rulemaking
(SNPRM) (ref. Docket No.: FAA –2019 –0491; Notice No.23 –12) proposing the introduction of a new and
more stringent test method, the Vertical Flame Propagation test, to evaluate the performance of materials
installed in inaccessible areas. The new test method has been developed by the FAA Tech Center in
cooperation with the International Aircraft Materials Fire Test Forum (IAMFTF). EASA has been signi ficantly
involved in the design of the new structure of the flammability requirements proposed by the NPRM and is
closely following the FAA's activities and actively participating in the International Aircraft Materials Fire
Test Forum (IAMFTF) meetings, a long with the CAAC. EASA intends to harmonise with the FAA’s new
regulation once finalised and believes that no additional research effort is needed for design standards of
materials in hidden areas.
Safety Recommendation s Received and Replies Sent
January – December 2024
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
CHNH -2024 -001
Airbus A350 -1041, B -LXI, 02/09/2024
Safety Recommendation received on 03/09/2024 :
It is recommended that the European Union Aviation Safety Agency (EASA) requires Rolls -Royce
Deutschland Ltd & Co KG to develop continuing airworthiness information, including but not limited to,
inspection requirements of the fuel secondary manifolds of A irbus A350 Aircraft Rolls -Royce Trent XWB
Engines to ensure their serviceability.
Final r eply sent on 30/10/202 4:
The European Union Aviation Safety Agency (EASA) and Rolls -Royce have developed and mandated
appropriate Continued Airworthiness actions to ensure the airworthiness and serviceability of the affected
fleet. Rolls -Royce has issued the Non -Modification Servi ce Bulletin (NMSB) Trent XWB 72 -AL165 to provide
inspection and corrective action instructions for certain Trent XWB engines, and on September 5, 2024,
EASA issued EASA Emergency Airworthiness Directive AD 2024 -0174 -E mandating the NMSB and requiring a
one-time visual and dimensional inspection of the fuel manifold main fuel hoses on Trent XWB -97 engines.
AD 2024 -0174 -E can be downloaded at https://ad.easa.europa.eu/ad/2024 -0174 -E.
Since EASA issued AD 2024 -0174 -E, in -service and in -shop inspections have identified that a specific
cleaning process available during engine refurbishment may lead to fuel manifold main fuel hose
degradation. Additionally, it was determined that Trent XWB -75, Trent XWB -79, Trent XWB -79B and Trent
XWB -84 engines were also the subject of the suspect cleaning process, and therefore are potentially
affected by the unsafe condition addressed by the AD.
Prompted by this development, the affected cleaning process was discontinued by maintenance
organisations as instructed by Rolls -Royce Maintenance Repair and Overhaul Quality Alert No. MRO 2024 -
21 issue 1. Additionally, Rolls -Royce issued the NMSB Trent XW B 72 -AL167, and EASA issued on September
19, 2024 the Airworthiness Directive (AD) 2024 -0182, which partially retained the requirements of AD
2024 -0174 -E, which was superseded, and requires repetitive inspections and corrective actions for affected
populat ions of engines. This AD also introduces restrictions for installation of the affected parts, engines
equipped with the affected parts, and requires reporting of inspection results. AD 2024 -0182 can be
downloaded at https://ad.easa.europa.eu/ad/2024 -0182 .
Status: Closed – Agreement
_____________________________________________________________________ __________________
DENM -2021 -001
DASSAULT - FALCON900EX , OE-IMI, 29/11/2021
Safety Recommendation received on 29/11/2021 :
In order to prevent landings with frozen brakes, the AIB recommends that EASA in cooperation with the
aircraft manufacturer modify in a more directive and explicit manner the AFM normal procedures
(including the use of the brake heating system) and that the aircraft manufacturer accordingly modifies the
CODDE 2.
Safety Recommendation s Received and Replies Sent
January – December 2024
Final r eply sent on 22/03/202 4:
The European Union Aviation Safety Agency (EASA) and the manufacturer reviewed the content of the
Aircraft Flight Manual (AFM) and concluded that the use of the Brake Anti -Ice System is already correctly
documented. In fact, the contexts in which the use o f the Brake Anti -Ice System is deemed “necessary” are
operational considerations and those are clarified in the dedicated operational documentation (CODDE 2).
Notwithstanding this, in cooperation with EASA, the manufacturer has modified the operational manual
(CODDE 2) to include more explicit and more direct instruction on the usage of the Brake Anti -Ice System.
The manual temporary revision was released on 7th July 2023 under Change Project publication #183 (CP -
PUB -0183), for integration in subsequent AFM issue 19.
Status: Closed – Agreement
_____________________________________________________________________ __________________
DENM -2024 -001
Airbus A320 -214, CS-TNV , 08/04/2022
Safety Recommendation received on 20/02/2024 :
To prevent engine thrust reverser(s) not stowing on an A320 family aircraft during an aborted landing after
ground contact, the AIB recommends EASA to ensure that the aircraft and engine manufacturer modifies
the CFM56 -5B ECU software, and that the software modification is mandated and embodied on the entire
CFM56 -5B fleet when ready for entry into service estimated in 2025.
Interim r eply sent on 26/04/202 4:
Airbus is expected to modify the CFM56 -5B Engine Control Unit (ECU) software standard by introducing an
enhancement of the thrust reverser stowing logic to be robust against similar incidents.
There are around 3700 aircraft from the A320 family (i.e. A318/A319/A320/A321) fitted with CFM56 -5B
engines in operation (in -service or stored), which can be equipped with two different ECU F1+ and F3
standards, equally distributed.
- For the F1+ standard, the design change supporting the ECU software update is planned to be
certified during 2027.
Note: Due to a specific design configuration (a few engines accommodate an ECU logic for which no
software standard upgrade is possible), 11 engines will remain non -retrofitted.
- For the F3 standard, the design change supporting the ECU software update is planned to be
certified by end 2025.
The Airbus Service Bulletins supporting those software updates will be mandated by European Union
Aviation Safety Agency (EASA) airworthiness directives.
Status: Open
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
DENM -2024 -002
Airbus A320 -214, CS-TNV , 08/04/2022
Safety Recommendation received on 20/02/2024 :
To prevent future aircraft designs from incorporating an engine thrust reverser design that will not stow
during an aborted landing, the AIB recommends EASA to revise the certification requirement (CS -25/AMC)
to include evaluation of the serious incident aborted landing after thrust reverser selection during a
bounced landing scenario (in its most aggravated form).
Interim r eply sent on 26/04/202 4:
The Certification Specifications for Large Aeroplanes (CS -25) specify in Subpart B – Controllability and
manoeuvrability – paragraph CS 25.143(a) that the aeroplane must be safely controllable and
manoeuvrable during take -off, approach and go -around, appro ach and landing.
In addition, according to CS 25.143(b) it must be possible to make a smooth transition from one flight
condition to any other flight condition without exceptional piloting skill, alertness, or strength under any
probable operating conditions. This includes configuration changes, including deployment or retraction of
deceleration devices, and go -around manoeuvres with all engines operating.
The European Union Aviation Safety Agency (EASA) understands these specifications as including go -around
following touch down and selection of reverse thrust. This operating condition is however not specifically
addressed in Subpart E Powerplant of CS -25, in particular CS 25.933 Reversing systems.
Taking into account the lessons learnt from this incident, EASA will emphasise the need for CS -25 applicants
to consider appropriate operating conditions and factors that can influence the correct functioning of
thrust reversers during go -around after an a borted landing, such as flight/ground and ground/flight
transitions, aeroplane rebounds, and thrust asymmetries.
EASA plans to issue a generic Certification Review Item (CRI) providing Interpretative Material (IM) and
Means of Compliance (MoC). It is expected that the IM and MoC will be used to show compliance with CS
25.143(a) and (b) (Controllability and manoeuvrab ility – General), CS 25.933 (Reversing systems), CS 25.901
(Powerplant installation), CS 25.1301 (Function and installation), and CS 25.1309 (Equipment systems and
installation).
CS-25 should be amended later on once the above IM/MoC CRI content becomes mature.
The response to this safety recommendation will be updated once progress is made with the above actions.
Status: Open
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
FRAN -2008 -328
Study on the Use of Erroneous Parameters at Takeoff, containing several
occurrences between 2004 and 2006
Safety Recommendation received on 01/09/2008 :
The DGAC shall in liaison with FAA and EASA improve the certification norms so that computers trigger
crew warnings or activate protection systems when inconsistent data are inputted, obviously erroneous or
far from usual values.
Interim r eply sent on 19/07/202 4:
On-board computer functions rejecting or alerting flight crew to erroneous take -off performance data input
already exist in some modern large aeroplanes, however they are not mandated by EU regulations.
On 30 August 2023, the European Union Aviation Safety Agency (EASA) published the Terms of Reference
(ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
The ToR refers to this safety recommendation.
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing means of informing or alerting the flight crew in a timely manner.
This should include errors in the input and selection of the take -off performance parameters in the
aeroplane systems, thereby addressing this safety recommendation.
A Notice of Proposed Amendment (NPA) is being drafted with publication for consultation currently
expected in Q4 2024.
Status: Open
_____________________________________________________________________ __________________
FRAN -2016 -002
Dassault Falcon 7X, HB -JFN, 24/05/2011
Safety Recommendation received on 15/02/2016 :
The BEA recommends that EASA, in coordination with FAA, SAE and EUROCAE, evaluate and propose
alternative or additional methods to the FMEA for electronic equipment and software.
Final r eply sent on 07/06/202 4:
The European Union Aviation Safety Agency (EASA) coordinated with the Federal Aviation Administration
(FAA), but also Transport Canada Civil Aviation (TCCA) and the Agência Nacional de Aviação Civil (ANAC),
and was involved with SAE International and the E uropean Organisation for Civil Aviation Equipment
Safety Recommendation s Received and Replies Sent
January – December 2024
(EUROCAE) as part of the SAE S -18 and EUROCAE WG -63 Working Groups for the improvement of the
industry standards SAE ARP4761 “Guidelines and Methods for Conducting the Safety Assessment Process
on Civil Airborne Systems and Equipment” and also SAE ARP 4754 A “Guidelines for Development of Civil
Aircraft and Systems”.
The activities of these Working Groups were broader in scope and ambition than focusing on evaluating
and amending the specific methods related to Failure Modes and Effects Analysis (FMEA).
Indeed, an effective safety assessment process is achieved through different specific assessments at aircraft
and systems level which have to be conducted by applying distinct types of safety analysis methods. The
various possible safety analysis methods t o be used complement one another, and their combination is
essential to assess aircraft and system architectures from different perspectives.
The FMEA is one of a set of safety analysis techniques that support a more comprehensive safety
assessment process, which also includes, among others, Fault Tree Analyses and Common Cause Analyses –
such as Common Mode Analyses (CMAs), Particular Risk Analyses, and Zonal Safety Analysis.
Concurrent updates of industry standards ARP 4754B (revised) and harmonised EUROCAE ED -79B (revised),
as well as SAE ARP4761A (revised) and harmonised EUROCAE ED -135 (new), have been published in
December 2023. These bring significant improvements, all aim ed at enhancing the safety assessment
process in a global manner and, as far as ARP4761A/ED -135 is concerned, several steps of progress and
clarification are introduced. Namely:
• emphasis of the integration of safety assessment processes with system development processes, so
that to ensure safety considerations are also addressed throughout the entire lifecycle of the
aircraft system,
• expanded guidance for addressing safety assessment in complex systems, including more detailed
methods for analysing system interactions and interdependencies,
• improvement of the CMA appendix M, and the role of this specific analysis in safety assessments at
each stage of the systems development process,
• also a greater emphasis on risk assessment and mitigation strategies, to provide more
comprehensive methods for identifying, analysing, and mitigating potential hazards and risks
associated with aircraft systems,
• introduction of a new Appendix N dedicated to Model -Based Safety Analysis (MBSA).
With the newly developed standards now applicable, aircraft system designers should better appreciate the
limitations inherent to the FMEA technique. Especially when used on complex system architectures with a
high degree of integrated aircraft level funct ions, where development errors that may trigger undesirable
or unintended system behaviours present a greater safety risk, which require therefore an in -depth
evaluation of the interdependency between systems and their channels - command and monitor - to
ensure redundancy and independence principles through conducting several combined analysis methods
(to include in particular CMAs as detailed in the enhanced Appendix M of ARP4761A/ED -135).
Overall, the recently released industry standards build upon the foundation laid by previous editions to
provide a more comprehensive and up -to-date guidance for ensuring the safety of civil aircraft systems.
The use of development assurance processes now described in ARP 4754B/ED -79B and its association with
the safety analysis methods in ARP4761A/ED -135 ensures that development errors are minimised, and
independence requirements are better evaluated to meet the safety objectives. The changes introduced
reflect advancements in technology, industry best practices, and regulatory requirements, enhancing the
effectiveness and reliability of safety assessment processes in the aerospace industry.
Safety Recommendation s Received and Replies Sent
January – December 2024
It is EASA’s opinion that the industry standards evolution results in adequately addressing the intent of the
safety recommendation.
Status: Closed – Agreement
_____________________________________________________________________ __________________
FRAN -2016 -004
Dassault Falcon 7X, HB -JFN, 24/05/2011
Safety Recommendation received on 15/02/2016 :
The BEA recommends that EASA, in coordination with FAA, SAE and EUROCAE, develop means or methods
that make it possible to consolidate, during safety analyses, checks on the independence of system control
and the monitoring of said system.
Final r eply sent on 07/06/202 4:
Since JAR 25 (Joint Airworthiness Requirements for Large Aeroplanes) change 16, JAR/CS 25.1309(b)(1)(ii)
requires explicitly that catastrophic failure conditions must not result from a single failure. Systems with an
architecture with independent control and monitoring is one of the available means to comply with this
requirement.
The current AMC (Acceptable Means of Compliance) 25.1309 (System design and analysis) clarifies that a
single failure also consists in any set of failures, which cannot be shown to be independent from each
other. The AMC therefore drives aircraft system de signers to perform their safety assessment process with
the aim of ensuring that adequate system redundancy or independence is maintained. This is achieved
through different types of Common Cause Analyses to be conducted in accordance with the industry
standard SAE ARP4761 “Guidelines and methods for conducting the safety assessment process on civil
airborne systems and equipment” (as referenced in the AMC 25.1309). Namely, Particular Risk Analysis,
Common Mode Analysis (CMA), and Zonal Safety Analysis.
Carrying out an effective CMA is considered genuine “means or methods” in support of the safety
assessment at an aircraft and systems level intended to identify a possible lack of redundancy or
independence between control and monitoring functions. Indeed, the CMA Appendix of the SAE ARP4761
standard is “based on analysing design and implementation for elements that may defeat the redundancy
or independence of functions within the design”. When required redundancy or independence is
compromised, a justifica tion for the acceptability or elimination of the compromise is necessary.
For this reason, the European Union Aviation Safety Agency (EASA) participated in the activities of the
European Organisation for Civil Aviation Equipment (EUROCAE) WG -63 and SAE S -18 Working Groups,
whose goal was to revise the SAE ARP4761 standard and particularly improve the CMA Appendix thereof.
In this framework, EASA coordinated with the Federal Aviation Administration (FAA), but also Transport
Canada Civil Aviation (TCCA) and the Agência Nacional de Aviação Civil (ANAC), and was involved with SAE
International and EUROCAE in the development of “means or methods” that make it possible to
consolidate, during safety analyses, checks on the independence between the control and monitoring of
safety -critical systems. Industry standards as SAE ARP4761A (revised) and harmonised EUROCAE ED -135
(new) have been published in December 2023. Both standards contain an enhanced CMA Appendix M
addressing the subject matter and intent of this safety recommendation, especially with respect to
common mode failures.
Safety Recommendation s Received and Replies Sent
January – December 2024
Finally, in its coordination effort with the FAA, EASA also advocated for the harmonisation of the “no -single
failure” criteria between the two regulators at the level of the currently misaligned FAR (Federal Aviation
Regulation) 25.1309 and CS (Certificat ion Specification) 25.1309 certification requirements.
The FAA has published, under Docket Number FAA -2022 -1544, a Notice of Proposed Rulemaking (NPRM)
on “System Safety Assessments” on December 8, 2022, in which amendments to certain airworthiness
requirements of FAR 25 are proposed. These include standardise d criteria for conducting system safety
assessments and in particular the introduction of a non -single failure criterion, in order to align with EASA
on the current CS 25.1309(b)(1)(ii), which, as previously stated above, explicitly requires that catastrop hic
failure conditions must not result from a single failure.
Status: Closed – Agreement
_____________________________________________________________________ __________________
FRAN -2016 -006
Piper Aircraft PA31T, OE -FKG, 28/10/2011
Safety Recommendation received on 05/04/2016 :
The BEA recommends that EASA evaluate the possibility of developing an alternative programme for
complex high performance single -pilot aeroplanes for which there is no adequate flight simulator, for
example by using a flight simulator from a similar aeropl ane.
Interim r eply sent on 28/11/202 4:
To evaluate the possibility of developing an alternative programme for complex high performance single -
pilot aeroplanes for which there is no adequate flight simulator, for example by using a flight simulator
from a similar aeroplane, the European Union Av iation Safety Agency (EASA) conducted Rulemaking Task
(RMT).0196 ‘Improve flight simulation training devices (FSTDs) fidelity’ to make the necessary changes to
the Certification Specification for Aeroplane Flight Simulation Training Devices (CS -FSTD(A)) as well as the
associated Acceptable Means of Compliance (AMC) / Guidance Material (GM).
The RMT concluded in the publication of a Notice of Proposed Amendment, (NPA) 2020 -15, available at
https://www.easa.europa.eu/en/document -library/notices -of-proposed -amendment/npa -2020 -15.
Following consultation on the NPA, EASA intends to publish an Opinion, which is currently expected in Q2
2025. Subsequently, a Decision is planned one year after publication of the Opinion, in Q2 2026. A further
reply will be provided by EASA once the adop tion process has run its course.
Status: Open
_____________________________________________________________________ __________________
FRAN -2018 -022
Boeing 777, F -GUOC, 22/05/2015
Safety Recommendation received on 21/12/2018 :
Safety Recommendation s Received and Replies Sent
January – December 2024
The BEA recommends that EASA, in the scope of an update of its impact assessment, assess the safety
benefit of TOPMS -type systems, taking into account, in particular, the existing systems (Airbus TOM).
Final r eply sent on 19/07/202 4:
In 2022, the European Union Aviation Safety Agency (EASA) decided to revisit the Best Intervention
Strategy (BIS) ‘Entry of aircraft performance data’ with a specific focus on recent and mature technological
developments and to reassess the added value of those available design solutions to address the safety
issue.
The developments under consideration included:
• On Board Weight and Balance Systems (OBWBS),
• Take -Off Performance Monitoring Systems (TOPMS) (for example the Airbus TOM function),
• Position Checking Systems.
The analysis of reported accidents and incidents (85 occurrences involving large aeroplanes operated in
commercial air transport) over a 15 years period concluded that:
• 80 out of the 85 events under study (94%) could have been prevented with the use of available
design mitigation solutions;
• Considering the relative effectiveness of a single design mitigation solution, the following values
have been obtained:
- TOPMS: 46%
- Position checking system (Airbus TOS2 or similar system): 43%
- OBWBS: 31%;
• The Position checking system tackles different types of errors than the TOPMS and the OBWBS.
Therefore, these systems can be combined to obtain a higher rate of effectiveness in terms of
preventing accidents and incidents:
- TOPMS + Position checking system (TOS2 or equivalent): 90%
- OBWBS + Position checking system (TOS2 or equivalent): 74%.
Based on this safety benefit and a high -level economic impact assessment, the BIS proposed a new action
“New design specifications for the installation on large aeroplanes of mitigation means to protect against
erroneous take -off performance parameters and position errors”.
After consultation of the BIS proposal with EASA’s Advisory Bodies in April 2023, the above proposed action
was agreed owing to the positive support received.
On 30 August 2023, EASA published the Terms of Reference (ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing a means of informing or alerti ng the flight crew in a timely manner.
This should include the monitoring of real -time aeroplane performance during the take -off roll (TOPMS
types of systems, for example addressed by the Airbus TOM function).
A Notice of Proposed Amendment (NPA) is being drafted with a publication for consultation currently
expected in Q4 2024.
Safety Recommendation s Received and Replies Sent
January – December 2024
Status: Closed – Agreement
_____________________________________________________________________ __________________
FRAN -2018 -023
Boeing 777, F -GUOC, 22/05/2015
Safety Recommendation received on 21/12/2018 :
The BEA recommends that EASA, in the scope of an update of its impact assessment, assess the safety
benefit of gross error detection/warning systems, taking into account, in particular, existing systems (Airbus
TOS, Boeing FMS/EFB messages and protections, Lufthansa Systems LINTOP, etc.).
Final r eply sent on 19/07/202 4:
In 2022, the European Union Aviation Safety Agency (EASA) decided to revisit the Best Intervention
Strategy (BIS) ‘Entry of aircraft performance data’ with a specific focus on recent and mature technological
developments and to reassess the added value of those available design solutions to address the safety
issue.
The developments under consideration included:
• On Board Weight and Balance Systems (OBWBS),
• Take -Off Performance Monitoring Systems (TOPMS),
• Position Checking Systems.
The analysis of reported accidents and incidents (85 occurrences involving large aeroplanes operated in
commercial air transport) over a 15 years period concluded that:
• 80 out of the 85 events under study (94%) could have been prevented with the use of available
design mitigation solutions;
• Considering the relative effectiveness of a single design mitigation solution, the following values
have been obtained:
- TOPMS: 46%
- Position checking system (Airbus TOS2 or similar system): 43%
- OBWBS: 31%;
• The Position checking system tackles different types of errors than the TOPMS and the OBWBS.
Therefore, these systems can be combined to obtain a higher rate of effectiveness in terms of
preventing accidents and incidents:
- TOPMS + Position checking system (TOS2 or equivalent): 90%
- OBWBS + Position checking system (TOS2 or equivalent): 74%.
Based on this safety benefit and a high -level economic impact assessment, the BIS proposed a new action
“New design specifications for the installation on large aeroplanes of mitigation means to protect against
erroneous take -off performance parameters and position errors”.
After consultation of the BIS proposal with EASA’s Advisory Bodies in April 2023, the above proposed action
was agreed owing to the positive support received.
On 30 August 2023, EASA published the Terms of Reference (ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
Safety Recommendation s Received and Replies Sent
January – December 2024
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing a means of informing or alerti ng the flight crew in a timely manner.
This should include errors in the input and selection of the take -off performance parameters in the
aeroplane systems (for example addressed by Airbus TOS1 and TOS2 functions).
A Notice of Proposed Amendment (NPA) is being drafted with a publication for consultation currently
expected in Q4 2024.
Status: Closed – Agreement
_____________________________________________________________________ __________________
FRAN -2018 -024
Boeing 777, F -GUOC, 22/05/2015
Safety Recommendation received on 21/12/2018 :
The BEA recommends that EASA, in coordination with the FAA, incite manufacturers to develop, for
commercial aeroplanes which are the most prevalent and the most exposed to this risk, systems adapted to
the characteristics of each aeroplane family, providin g increased protection against the use of erroneous
parameters at take -off.
Final r eply sent on 19/07/202 4:
On 30 August 2023, the European Union Aviation Safety Agency (EASA) published the Terms of Reference
(ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing a means of informing or alerti ng the flight crew in a timely manner.
Design requirements will be considered to address new large aeroplane designs. An analysis and impact
assessment will be conducted to assess the feasibility and the benefit of design requirements applicable to
existing (already type certificated) large aer oplane designs.
EASA held three workshops with stakeholders (industry and foreign partner authorities, which included the
participation of the Federal Aviation Administration (FAA)) between November 2023 and May 2024.
During these workshops, EASA presented proposed draft new certification specifications and discussed
with industry the option of retroactive design requirements.
Safety Recommendation s Received and Replies Sent
January – December 2024
It appears that some large aeroplane manufacturers have developed or are developing some or all of the
envisaged functions to be mandated by design requirements.
For those manufacturers which have not yet started a design function development phase, these
workshops served as a means of encouraging them to take action regarding their aeroplane designs, hence
meeting the intent of this safety recommendation. It shoul d be acknowledged that in the absence of a
regulatory mandate some manufacturers may decide not to develop new protection functions.
A Notice of Proposed Amendment (NPA) is being drafted with a publication for consultation currently
expected in Q4 2024.
Status: Closed – Agreement
_____________________________________________________________________ __________________
FRAN -2023 -024
BEA safety study on cockpit fires fed by pressurized oxygen
Safety Recommendation received on 29/12/2023 :
The BEA recommends that EASA, in collaboration with the manufacturers, carry out additional risk analyses
to take into account the hypothesis of an overpressure in the distribution system and its consequences in
terms of failure mechanisms. The results sho uld be analysed with regard to the potential factors explaining
the scenario of the accident that occurred in flight [the accident is de -identified due to the ongoing
investigation]. These analyses may require additional testing as part of a research progr am.
Interim reply sent on 18/03/202 4:
The European Union Aviation Safety Agency (EASA) considers that there is no need to conduct research to
characterise oxygen fire ignition mechanisms in presence of overpressure in the distribution system, as this
risk is well known and taken into account i n the current applicable Certification Specifications for Large
Aeroplanes CS -25 (see paragraph below).
1) Initial airworthiness
New oxygen system designs installed on large aeroplanes must comply with the corresponding certification
specifications provided in CS -25, in particular CS 25.1441 ‘Oxygen equipment and supply’.
Sub-paragraph (b) requires: ‘The oxygen system must be free from hazards in itself, in its method of
operation, and in its effect upon other components’.
A corresponding Acceptable Means of Compliance (AMC) 25.1441(b) ‘Risk assessment related to oxygen
fire hazards in gaseous oxygen systems’ exists since CS -25 Amdt 21 (Executive Director Decision
2018/005/R).
This AMC stipulates that the applicant should demonstrate that the oxygen systems and their components
are designed so that the occurrence of an uncontrolled oxygen fire at the aircraft level is extremely
improbable and does not result from a single failur e.
To assess the consequences of system/component failures, the applicant should conduct an oxygen hazards
analysis (OHA) in either a qualitative or a quantitative manner, and include the conclusions of the OHA in
the oxygen systems system safety analysis (SS A).
The applicant should provide an OHA with a detailed assessment of the potential ignition and combustion
mechanisms.
The AMC details in chapter 4 the items expected to be addressed by the OHA. The list includes the
assessment of the possible internal ignition mechanisms. As a minimum, the following mechanisms should
be assessed:
Safety Recommendation s Received and Replies Sent
January – December 2024
— adiabatic compression (pneumatic impact),
— frictional heating,
— mechanical impact
— particle impact
— fresh metal exposure
— static discharge
— electric arc
— chemical reaction
— resonance.
The applicant should evaluate each ignition mechanism under the worst -case operating conditions,
including equipment failures, to determine whether the ignition mechanism exists in the component and in
the system considered. This evaluation includes the as sessment of failure cases leading to ‘overpressure in
the distribution system’.
Therefore, EASA considers that CS -25 contains adequate provisions meeting the intent of this safety
recommendation for new oxygen system designs.
2) Continuing airworthiness
EASA will review the in -service experience related to oxygen system leakages on all Airbus Types and
perform a design review of the oxygen system of the Airbus Single Aisle Type (A318, 319, 320, 321).
The design review will be conducted taking into account the elements contained in AMC 25.1441(b)
(introduced at CS -25 Amdt 21). This will include checking the susceptibility of the system to overpressure.
EASA may extend the scope of these continuing airworthiness actions to other large aeroplane
manufacturers once the investigation report has been officially published.
Status: Open
_____________________________________________________________________ __________________
FRAN -2023 -025
BEA safety study on cockpit fires fed by pressurized oxygen
Safety Recommendation received on 29/12/2023 :
The BEA recommends that EASA assess the appropriateness of cockpit fire/smoke procedures incorporating
the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch)
and the need for the immediate cutting off o f the oxygen supply in this case, and if applicable, review the
requirements for installing and carrying protective equipment independent of the oxygen distribution
system.
Interim reply sent on 18/03/202 4:
1) Continuing airworthiness
The European Union Aviation Safety Agency (EASA) will review the in -service experience related to oxygen
system leakages on all Airbus Types and perform a design review of the oxygen system of the Airbus Single
Aisle (SA) Type (A318, 319, 320, 321).
The design review will include, but will not be limited to:
- The means of shutting off oxygen flow,
- Operational procedures associated with oxygen leakage, oxygen fire, including checking that fire -
fighting procedures do not direct aircrew to use a fire extinguisher in case of oxygen fire,
- The number and location of portable breathing equipment,
- The number and location of fire extinguishers that may be used to fight a cockpit fire after the
oxygen leakage has been stopped.
Safety Recommendation s Received and Replies Sent
January – December 2024
Depending on the outcome of this review, actions may be decided to develop missing procedures (e.g. to
help identify oxygen leakage or an oxygen fire, to shut off oxygen flow etc), modify existing procedures,
require modification of available protective eq uipment, as deemed necessary.
EASA may extend the scope of these continuing airworthiness actions to other large aeroplane
manufacturers once the investigation report has been officially published.
2) Initial airworthiness
The certification specifications for large aeroplanes (CS -25) do not require the presence of a means of
shutting off oxygen systems.
Taking into account the result of the continuing airworthiness review, EASA may envisage the following
actions:
- For new certification project applications, EASA may raise Special Conditions and Interpretative
Material,
- In parallel, the creation of a new safety issue ‘Oxygen fed fire in the flight deck’ to be identified in
the European Safety Risk Management (SRM) process. The assessment of the safety issue may lead
to newly -proposed risk mitigation actions that would go through an impact assessment before a
decision to add them to the European Plan for Aviation Safety (EPAS).
The above actions may include mandating a means of shutting off oxygen flow, methods for the
identification and management of oxygen leakage and oxygen fires, and / or protective and firefighting
equipment, as deemed appropriate.
Status: Open
_____________________________________________________________________ __________________
FRAN -2023 -026
BEA safety study on cockpit fires fed by pressurized oxygen
Safety Recommendation received on 29/12/2023 :
The BEA recommends that EASA ensure that:
• the danger represented by a glowing cigarette in the cockpit be taken into account and the
associated risks assessed;
• certification and operational regulations be amended where applicable.
Interim reply sent on 18/03/202 4:
1) Air Operations regulation
Regulation (EU) 965/2012 laying down technical requirements and administrative procedures related to air
operations, contains very restrictive rules concerning smoking on board applicable to commercial air
transport (CAT) (c.f. Annex IV (Part -CAT),, point CAT.OP.MPA.240), Non Commercial operations with
Complex motor -power aircraft (NCC) (c.f. Annex VI (Part -NCC),, point NCC.OP.175), and Non Commercial
operations with other -than complex motor -powered aircraft (NCO) (c.f. Annex VII (Part -NCO),, point
NCO.OP.1 55).
Point CAT.OP.MPA.240 reads:
‘The commander shall not allow smoking on board:
(a) whenever considered necessary in the interest of safety;
(b) during refuelling and defuelling of the aircraft;
Safety Recommendation s Received and Replies Sent
January – December 2024
(c) while the aircraft is on the surface unless the operator has determined procedures to mitigate the risks
during ground operations;
(d) outside designated smoking areas, in the aisle(s) and lavatory(ies);
(e) in cargo compartments and/or other areas where cargo is carried that is not stored in flame -resistant
containers or covered by flame -resistant canvas; and
(f) in those areas of the passenger compartment where oxygen is being supplied.’
Provisions in points NCC.OP.175 and NCO.OP.155 are similar to those in point CAT.OP.MPA.240.
Therefore, the European Union Aviation Safety Agency (EASA) considers that the current provisions
applicable to EU operators are already sufficiently restrictive to address the identified risk of smoking on
board.
Regarding third country operators operating in the EU, article 59 of Regulation (EU) 2018/1139 establishes
that they need to comply with the International Civil Aviation Organization (ICAO) standards, and to the
extent that such standards do not exist, the essential requirements for airworthiness, aircrew and air
operations established in Annexes II, IV and V to that Regulation.
ICAO standards do not prohibit smoking on board an aircraft, neither in the passenger cabin, nor in the
cockpit. Similarly, there are no provisions in Annex V to Regulation (EU) 2018/1139 concerning this specific
issue, although there is a provision granting the pilot -in-command the authority ‘to give all commands and
take any appropriate actions for the purpose of securing the operation and the safety of the aircraft and of
persons and/or property carried therein’. Under this legal framework, it is doubtful that requirements
regarding smoking on board the aircraft could be enforced on third country operators operating in the EU
unless ICAO adopts dedicated standards.
Notwithstanding the above, EASA may endeavour to raise awareness of the dangers of oxygen fire in the
cockpit through Safety Promotion activities.
2) Initial airworthiness
The certification specifications for large aeroplanes (CS -25) do not contain provisions addressing specifically
the risk represented by the presence of a cigarette in the cockpit. This is not taken into account in the
oxygen hazards analysis to be performe d according to Acceptable Means of Compliance (AMC) 25.1441(b)
‘Risk assessment related to oxygen fire hazards in gaseous oxygen systems’.
EASA intends to propose the creation of a new safety issue ‘Oxygen fed fire in the flight deck’ to be
identified in the European Safety Risk Management (SRM) process. The assessment of the safety issue may
lead to newly -proposed risk mitigation actions tha t would go through an impact assessment before a
decision to add them to the European Plan for Aviation Safety (EPAS). This may include a rulemaking action
to create new certification specifications and / or acceptable means of compliance on oxygen systems in
order to better consider the risk of fire triggered by a cigarette present in the cockpit.
3) Continuing airworthiness
EASA decided to review the in -service experience related to oxygen system leakages on all Airbus Types and
to perform a design review of the oxygen system of the Airbus Single Aisle (SA) Type (A318, 319, 320, 321).
For the purpose of mitigating the risk represented by a cigarette, the design review is intended to include
an analysis of the current options for the installation of ashtrays in the cockpit and their proximity to the
oxygen mask stowage box or other sourc e of oxygen leakage.
EASA may extend the scope of these continuing airworthiness actions to other large aeroplane
manufacturers once the investigation report has been officially published.
Safety Recommendation s Received and Replies Sent
January – December 2024
Status: Open
_____________________________________________________________________ __________________
FRAN -2024 -003
Beech 1900 -D, F-GLNH , 10/12/2021
Safety Recommendation received on 08/02/2024 :
The BEA recommends that:
• whereas the manufacturer's solution of greasing and replacing the elevator trim actuators,
imposed by mandatory Service Bulletin SB 27 -3032 appears to be a risk mitigation solution that has
reduced the frequency of these events without making them disappea r;
• whereas there have been new occurrences in connection with a fault on the elevator control
system on the Beech 1900, subsequent to the introduction of mandatory Service Bulletin SB 27 -
3032;
EASA ensure that the manufacturer and the FAA are well informed of the occurrences in Europe involving
European operators, including the occurrences identified in this report, that it is informed of the analysis
made of these occurrences, of the actions ta ken by the manufacturer and the FAA, and that it draw the
consequences in the event of no measures or insufficient measures being taken.
Interim r eply sent on 26/04/202 4:
The European Union Aviation Safety Agency (EASA) highlights that a Bilateral Agreement on aviation safety
between the European Community and the United States of America is in force, and is published here:
https://www.easa.europa.eu/en/document -library/bilateral -agreements/eu -usa
Subsection 3.3 of Annex I to the Bilateral Agreement regulates the continued airworthiness process. In
particular, point 3.3.1 establishes the commitment of the Technical Agents to "take action to address
unsafe conditions in products that they have certif icated". Point 3.3.2(a) further explains that the Federal
Aviation Administration (FAA) “shall carry out the continued airworthiness State of Design functions
applicable to the United States under Annex 8 of the Chicago Convention for aircraft".
In the case of the Textron BEECH -1900 -D, EASA has informed the Type Certificate Holder of the occurrences
mentioned in the safety investigation report via the FAA, as per paragraph 4.1.5 of the Technical
Implementation Procedures (TIP) applicable to the Bilateral Agreement. EASA will review the conclusions
drawn by the FAA.
Status: Open
_______________________________________________________________________________________
FRAN -2024 -004
ISSOIRE AVIATION APM30, F -HHOP, 02/08/2020
Safety Recommendation received on 29/04/2024 :
The BEA recommends that EASA ensure with Issoire Aviation that relevant examinations of the collected
screws are carried out, and that the results are analysed in order to determine whether or not the risk of
failure persists, and impose new preventive measures, including a review of the design of the link between
the flap arm and its control rod, should these prove necessary.
Safety Recommendation s Received and Replies Sent
January – December 2024
Interim r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA) has been monitoring the issue and coordinating actions
with the Type Certificate Holder (TCH) since the early phases after the accident. The TCH has already
implemented a scheme to collect the flap screws of the fleet in service in order to analyse them in a
laboratory. The action was mandated by Emergency Airworthiness Directive (AD) No. 2023 -0096 -E dated 09
May 2023. Since then, all flap lever screws collected by the TCH have been substituted with new ones. The
collected screws were subject to destructive testing. Some screws showed cracks of varying lengths and
depths. However, the preliminary analysis of the tests could not establish a link between the estimated
cumulated flight hours, flight cycles and th e extent of the observed damage. A design change is being
developed to minimise the consequences of an erroneous installation of the flap lever screws. EASA
highlights that the above -mentioned actions were undertaken as part of its regular continuing
airwo rthiness oversight process.
Status: Open
_____________________________________________________________________ __________________
FRAN -2024 -005
ISSOIRE AVIATION APM30, F -HHOP, 02/08/2020
Safety Recommendation received on 29/04/2024 :
The BEA recommends that EASA ensures that Issoire Aviation develops a robust solution for the installation
of a distress beacon and its accessories on board APM aircraft and that this solution is also implemented for
aircraft already in service.
Interim r eply sent on 19/07/202 4:
The Type Certificate Holder is developing a design change to prevent inadvertent damage to the Emergency
Locator Beacon (ELT) of the affected APM fleet.
Status: Open
_____________________________________________________________________ __________________
FRAN -2024 -008
Airbus A320, 9H -EMU, 23/05/2022
Safety Recommendation received on 11/07/2024 :
The BEA recommends that EASA require that air traffic control units can systematically detect an incorrect
altimeter setting, in particular in the towers and approach units and define the associated phraseology for
the air traffic controllers .
Interim r eply sent on 09/09/202 4:
The European Union Aviation Safety Agency (EASA) will consider the need for regulatory changes as a result
of this safety recommendation as part of the regular amendments of Regulation (EU) 2017/373 laying down
common requirements for providers of air traf fic management/air navigation services (conducted in
rulemaking task 0719) and Regulation (EU) No 923/2012 laying down the common rules of the air
(conducted in rulemaking task 0476).
Safety Recommendation s Received and Replies Sent
January – December 2024
As a result of the analysis, which will be based on the assessment made by EASA during the draft report
reply process, and of the applicable regulatory processes EASA may update the affected regulatory material
as and if required. Afterwards EASA will update the reply to this safety recommendation accordingly.
Status: Open
_____________________________________________________________________ __________________
FRAN -2024 -009
Airbus A320, 9H -EMU, 23/05/2022
Safety Recommendation received on 11/07/2024 :
The BEA recommends that EASA, in coordination with the FAA and RTCA, study the revision of the
Minimum Operational Performance Specifications (MOPS) applicable to TAWS for Premature Descent
Alerts (PDA), in order to take into account at least a standard 3° vertical profile offset by around 280 ft to
the published vertical profile, representing an error of 10 hPa on a barometric approach .
Interim r eply sent on 09/09/202 4:
At the request of the Federal Aviation Administration (FAA) and the European Union Aviation Safety Agency
(EASA), the RTCA Program Management Committee (PMC) has given Special Committee (SC) 231 a
mandate to study the feasibility of an update to the Terrain Avoidance and Warning System (TAWS)
Minimum Operational Performance Specifications (MOPS), including, amongst other changes, an update to
the Premature Descent Alert (PDA) envelope. The topic is on the agen da of the first plenary meeting of SC -
231 on 27 -29 August 2024. Both EASA and FAA will be represented in SC -231.When the SC -231 agrees to
propose a PDA envelope update and include it in the SC -231 Terms of Reference (ToR) (currently being
drafted), and the Programme Management Committee approves the ToR, the MOPS revision work will be
planned.
The response to this safety recommendation will be updated once new information is available.
Status: Open
_____________________________________________________________________ __________________
FRAN -2024 -013
Cessna 172 , F-OOOO , 18/02/202 2
Safety Recommendation received on 26/07/2024 :
The BEA recommends that EASA identify all aeroplane types operated by the Member States likely to be
equipped with flight control cable attach fittings made of AISI 303 Se stainless steel and, for those, impose
appropriate corrective actions, where appropriate in coordination wit h primary certification authorities.
Interim r eply sent on 16/10/202 4:
The European Union Aviation Safety Agency (EASA) has published, on its Safety Publication Tool, the Safety
Information Bulletin (SIB) 2019 -12 (available at https://ad.easa.europa.eu/ad/2019 -12) endorsing the
recommendations of the Federal Aviation Administration’s (FAA) specified in the Special Airworthiness
Information Bulletin (SAIB) CE -19-13.
Safety Recommendation s Received and Replies Sent
January – December 2024
Such mentioned recommendations alert owners, operators, maintenance technicians and inspectors of the
airworthiness concern. In the interests of safety, these actors are expected to regularly review safety
publications. Nonetheless, EASA is evaluating a re vision of the SIB to further increase its visibility by
including a list of aeroplanes that are known to have flight control cable fittings made of AISI 303 Se steel.
EASA is also carrying out a review of occurrences involving a rupture or corrosion of flight control cables of
small aeroplanes operated by organisations registered in an EU Member State or in another State
participating in the work of EASA in accordance w ith Article 129 of Regulation (EU) 2018/1139 (i.e. EASA
Member State). If the analysis reveals a systemic safety issue across different aeroplane types equipped
with cable fittings made of steel AISI 303 Se, or a recurring critical concern with its use in a particular
design, EASA will proceed in accordance with point 21.A.3B of Annex I (Part -21) to Regulation (EU)
748/2012. In its analysis, EASA will consider the guidance of paragraph 2.5 of GM1 to 21.A.3B(b).
Furthermore, in the context of the bilateral agreement on cooperation in the regulation of civil aviation
safety between the United States of America and the European Union, EASA will coordinate with the
Federal Aviation Administration (FAA) to establish if an unsafe condition related to the use of AISI 303 Se
steel exists on the Textron Cessna 172 type.
To the above extent, in coordination with the FAA, EASA is reviewing the Aircraft Maintenance Manual
(AMM) of the Textron Cessna 172 to verify if Instruction for Continuing Airworthiness (ICA)
recommendations contained in the FAA SAIB CE -19-13 were impleme nted.
An update to this interim reply can be expected in Q4 2024.
Status: Open
_______________________________________________________________________________________
FRAN -2024 -014
Piper PA46 350P (Malibu Mirage) , N9190X , 14/09/2022
Safety Recommendation received on 28/11/2024 :
The BEA recommends that EASA establish regulatory requirements in order to guarantee the safety of
passengers carried on -demand for remuneration outside commercial air transport operations (Part CAT of
European regulation AIR OPS).
Status: Open
_______________________________________________________________________________________
FRAN -2024 -017
Piper PA28RT , HB-PNP , 23/07/2020
Safety Recommendation received on 27/12/2024 :
The BEA recommends that EASA, in coordination with the FAA, ensure that the risk of fire following a short -
circuit at the diode device attaching points is controlled by aircraft manufacturers using a diode device
similar to that on HB -PNP.
Status: Open
_______________________________________________________________________________________
Safety Recommendation s Received and Replies Sent
January – December 2024
FRAN -2024 -018
Hirth Janus CM , F-CVAS , 25/08/2022
Safety Recommendation received on 27/12/2024 :
The BEA recommends that EASA, in coordination with the manufacturers, Schempp Hirth and Rotax,
clarifies the situation and status of aircraft and engines whose type certificates are still valid, but for which
spare parts are no longer available.
Status: Open
_______________________________________________________________________________________
GERF -2018 -002
FOKKER - F28, HB -JVE, 20/01/2015
Safety Recommendation received on 09/02/2018 :
The European Aviation Safety Agency (EASA) should continue and expand the current activities regarding
aircraft de -icing. In addition, due to the importance of aircraft de -icing for flight safety, EASA should
consider placing aircraft de -icing under regulatory authori ty similar to aircraft maintenance.
Interim reply sent on 22/03/202 4:
Following the publication of the Terms of Reference for Rulemaking Task RMT.0728 ‘Development for
requirements for groundhandling’ on 22 November 2019, the European Union Aviation Safety Agency
(EASA) initiated the development of the ground handling (GH) r equirements with the aim of setting up a
regulatory framework for ground handling service providers (GHSP) to increase the overall safety level of
the aviation system and reduce the damages to aircraft and vehicles recorded yearly.
The first draft proposed requirements for GH were developed between 2019 and 2022 by EASA with the
support of an expert group composed of members from all affected stakeholders, i.e., national competent
authorities, GHSP, aircraft operators and aerodrome o perators. The draft proposed requirements were
included in the ‘Working Paper on the draft EU Ground Handling Regulation’. The Working Paper and its
annexes were presented during an online public event organised by EASA on 30 June 2022 and open for
consult ation until 30 September 2022 (see https://www.easa.europa.eu/en/newsroom -and-
events/events/webinar -eu-ground -handling -regulation ).
Following several rounds of additional consultations in 2022 and 2023 with all the affected stakeholders,
EASA published Opinion 01/2024 “Ground handling requirements” on 16 Jan 2024 [see Opinion No
01/2024]. This Opinion contains the proposed draft regula tion for the GHSP, their oversight by Member
States’ competent authorities, and the interfaces with air operators and aerodromes where the services are
being provided.
The proposed regulation is expected to increase the level of safety in ground operations by enabling
effective communication and common interaction between GH and the other areas with which it interacts
as a perfect interface – air operations and aerodrome operations.
Regarding de -icing, the following requirements are included in this Opinion: The GH organisations shall be
responsible for the safe provision of GH services, including de -/anti -icing services. These organisations shall
ensure that:
Safety Recommendation s Received and Replies Sent
January – December 2024
- They develop and implement a management system, including the main components of a safety
management system;
- The relevant parts of their safety management system are compatible and complementary with
those of the aerodrome operator and aircraft operator;
- Their personnel are trained and competent to perform their tasks in a safe manner, including for
de-/anti -icing services;
- The de -icing/anti -icing services are performed in accordance with the operational procedures of
the aircraft operator or, when so agreed with the aircraft operator, in accordance with their own
operational procedures;
- They identify the interfaces with the other stakeholders involved in the same GH activities and
ensure mutual communication and sharing of safety relevant information, as relevant;
- The quality of the fluids used for de -/anti -icing complies with the fluid quality standards and that
periodic testing is performed;
- The equipment used for the de/anti -icing services is properly maintained in accordance with a
maintenance programme and is compliant with the relevant requirements on ground support
equipment;
- They comply with the applicable de -icing/anti -icing requirements of Regulation (EU) 965/2012 on
air operations;
- They appoint a de -icing coordinator and implement proper communication procedures for de -
/anti -icing at remote platforms and stands.
Opinion 01/2024 has been notified to the European Commission which will manage from this point
onwards the adoption process.
Furthermore, EASA has organised the ‘Winter Readiness Week’, an online public event between 09 -10
August 2023 in collaboration with aircraft operators, GHSP and aerodrome operators. The aim of the event
was to share information on some of the potential win ter challenges expected for 2023 and best practices.
In addition to winter readiness and aerodrome snow clearance, the event hosted a dedicated session on
aircraft de -icing (see https://www.youtube.com/watch?v=8Vlb1djACKI ).
Subject to the European Commission’s adoption of Opinion 01/2024, EASA intends to issue Acceptable
Means of Compliance (AMC) and Guidance Material (GM). A further reply will be provided once the
European Commission’s adoption process has run its course and, assuming the Opinion is adopted, the
corresponding AMC / GM have been issued.
Status: Open
_______________________________________________________________________________________
GERF -2020 -004
Diamond DA40, D -EESU, 02/03/2018
Safety Recommendation received on 28/12/2020 :
The European Aviation Safety Agency (EASA) should include Single Pilot Operation CRM and the concept of
Safety Gates within Safety Promotion for General Aviation.
Final r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency’s (EASA) Safety Promotion Plan for General Aviation (GA) has
identified the following Key Decision Points to focus on:
• Manage Your Flight – Prepare thoroughly and stay alert at all stages.
Safety Recommendation s Received and Replies Sent
January – December 2024
• Stay in Control – Practice your emergency reactions to maintain control even in stressful situations.
• Cope with Weather – Don’t take chances! Know how to handle tricky weather conditions.
• See and be Seen - Avoid mid -air collisions by keeping good awareness of where you are and where
other aircraft are.
The Key Decision Points for GA were covered in a series following the EASA Annual Safety Review published
on 31 October 2024 - https://www.easa.europa.eu/community/topics/annual -safety -review -2024 -ga-
elements
Status: Closed – Agreement
_____________________________________________________________________ __________________
GERF -2024 -001
Olympia Meise , D-1348 , 05/09/2022
Safety Recommendation received on 25/04/2024 :
The European Aviation Safety Agency (EASA) should, in the scope of the further development of the current
European Plan for Aviation Safety (EPAS), develop the point 3. 1. 2. 3 Address safety risks in GA in a
proportionate and effective manner within the f ramework of Volume I 3. Strategy to the effect that safety
campaigns are to be developed, implemented and, adapted to the development of accident occurrences,
continuously updated to counteract accidents as a result of unsafe acts and their (pre -) conditio ns in the
rigging and following check of gliders.
Interim r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA) has a specific Safety Promotion Task, SPT.0125, to
promote the most important safety issues in General Aviation. This is detailed on page 123 of Volume II of
the 2024 edition of the European Plan for Aviatio n Safety (published at
https://www.easa.europa.eu/en/document -library/general -publications/european -plan -aviation -safety -
epas -2024 ).
The topics that are then covered in the Safety Promotion Plan for General Aviation, which includes Gliders
and Balloons, are then decided upon based on the European Safety Risk Management process and then
further discussion at the EASA General Aviation Community/ Technical Advisory Body (TeB) meeting with
National Aviation Authorities and other stakeholders. Currently, within this plan is the topic of glider rigging
and filming o f a video and development of associated promotion will take place in August and September
2024. This will then be promoted over the winter and then form a major part of EASA “Ready for the
Season” Campaign for Gliders in 2025.
A further update will be provided once the planned safety promotion material has been published.
Status: Open
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
GERF -2024 -002
Olympia Meise , D-1348 , 05/09/2022
Safety Recommendation received on 25/04/2024 :
The European Aviation Safety Agency (EASA) should demand a check and its documentation after the
rigging of sailplanes.
Interim r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA) has a specific Safety Promotion Task, SPT.0125, to
promote the most important safety issues in General Aviation. This is detailed on page 123 of Volume II of
the 2024 edition of the European Plan for Aviatio n Safety (published at
https://www.easa.europa.eu/en/document -library/general -publications/european -plan -aviation -safety -
epas -2024 ).
The topics that are then covered in the Safety Promotion Plan for General Aviation, which includes Gliders
and Balloons, are then decided upon based on the European Safety Risk Management process and then
further discussion at the EASA General Aviation Com munity/ Technical Advisory Body (TeB) meeting with
National Aviation Authorities and other stakeholders. Currently, within this plan is the topic of glider rigging
and filming of a video and development of associated promotion will take place in August and September
2024. This will then be promoted over the winter and then form a major part of EASA “Ready for the
Season” Campaign for Gliders in 2025.
A further update will be provided once the planned safety promotion material has been published.
Status: Open
_____________________________________________________________________ __________________
GERF -2024 -003
Airbus A320 , D-AICP, 11/07/2021
Safety Recommendation received on 02/05/2024 :
The European Aviation Safety Agency (EASA) should prompt airline operators to ensure that pilots have
clear guidelines in their operations manual or any other documentation to help them report key issues to
maintenance personnel in case of a “High Load Eve nt” so that mechanics have sufficient information to
apply the appropriate AMM inspection. Furthermore, this should clarify to pilots the importance of their
report as the primary means detection “High Load Events”.
Interim r eply sent on 07/06/202 4:
The European Union Aviation Safety Agency (EASA) recognises the safety issue referred in the safety
recommendation (SR) and agrees in principle with the SR objectives. Therefore, EASA intends to perform an
assessment in line with its Strategic Risk Managem ent processes and keep the German Federal Bureau of
Aircraft Accident Investigation updated of its actions.
Status: Open
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
GERF -2024 -004
Discus 2cT , D-KABC , 19/09/ 2019
Safety Recommendation received on 01/08/2024 :
To prevent Loss of Control In-flight (LOC -I) sailplane accidents, the European Union Aviation Safety Agency
(EASA) should amend the Certification Specification for sailplanes and powered sailplanes (CS -22) to the
effect that, in addition to the existing requirements (CS 22.207), a s tall warning device becomes mandatory.
Interim r eply sent on 16/10/202 4:
The European Union Aviation Safety Agency (EASA) will analyse potential actions to reduce the risk of
sailplane and powered sailplane accidents triggered by Loss of Control In -flight (LOC -I) after a stall. This will
be done in the context of the Sailplanes portfolio (see the European Plan for Aviation Safety (EPAS) 2024,
Vol. III) which includes the Key Risk Area ‘Aircraft upset’. This is published here:
https://www.easa.europa.eu/en/document -library/general -publications/european -plan -aviation -safety -
epas -2024
The possibility to mandate in the Certification Specifications for Sailplanes and Powered Sailplanes (CS -22)
the installation of a stall warning device will be considered.
EASA also brought the topic and this safety recommendation to the attention of the OSTIV (International
Scientific and Technical Soaring Organisation) SDP (Sailplane Development Panel, on which more
information is available here: https://ostiv.org/sections/technical -section/sailplane -development -
panel.html ).
The SDP is one of three panels within OSTIV. The SDP members are representatives of sailplane
manufacturers and aviation authorities (including EASA) as well as experts and scientists from all over the
world. During a plenary meeting held on 17 -18 August 2 024, the SDP decided to create a sub -group that
will work on this topic and provide recommendations, which could be an input for further assessment of
actions in the EPAS, such as safety promotion and rulemaking. This activity should include a review and a n
evaluation of mature technical solutions available on the market.
The response to this safety recommendation will be updated when new information is available on the
above -mentioned actions.
Status: Open
_____________________________________________________________________ __________________
GERF -2024 -005
Discus 2cT , D-KABC , 19/09/ 2019
Safety Recommendation received on 01/08/2024 :
To prevent Loss of Control In -flight (LOC -I) sailplane accidents, the European Union Aviation Safety Agency
(EASA) should undertake corresponding research and evaluate whether a requirement of a stall warning
device as mandatory minimum equipment for certified sailplanes and powered sailplane s is justified. Based
on these results, EASA should decide whether to amend Regulation (EU) No 2018/1976 Part -SAO.
Safety Recommendation s Received and Replies Sent
January – December 2024
Interim r eply sent on 16/10/202 4:
The European Union Aviation Safety Agency (EASA) will analyse potential actions to reduce the risk of
sailplanes and powered sailplanes accidents triggered by Loss of Control In -flight (LOC -I) after a stall. This
will be done in the context of the Sailplan es portfolio (see the European Plan for Aviation Safety (EPAS)
2024, Vol. III) which includes the Key Risk Area ‘Aircraft upset’. This is published here:
https://www.easa.europa.eu/en/document -library/general -publications/european -plan -aviation -safety -
epas -2024
The possibility to mandate the installation of a stall warning device on already certified sailplanes/powered
sailplanes will be considered.
EASA also brought the topic and this safety recommendation to the attention of the OSTIV (International
Scientific and Technical Soaring Organisation) SDP (Sailplane Development Panel, on which more
information is available here: https://ostiv.org/sections/technical -section/sailplane -development -
panel.html ).
The SDP is one of three panels within OSTIV. The SDP members are representatives of sailplane
manufacturers and aviation authorities (including EASA) as well as experts and scientists from all over the
world. During a plenary meeting held on 17 -18 August 2 024, the SDP decided to create a sub -group that
will work on this topic and provide recommendations, which could be an input for further assessment of
actions in the EPAS, such as safety promotion and rulemaking. This activity should include a review and a n
evaluation of mature technical solutions available on the market.
The response to this safety recommendation will be updated when new information is available on the
above -mentioned actions.
Status: Open
_____________________________________________________________________ __________________
IRLD -2023 -001
Boeing 737 -800, EI-EMM , 11/12/2021
Safety Recommendation received on 18/08/2023 :
EASA undertakes a safety promotion campaign to highlight to passengers and crew, the behaviours which
will minimise their personal risk of falling whilst embarking or disembarking an aircraft.
Final r eply sent on 28/11/202 4:
The European Union Aviation Safety Agency (EASA) has now completed two promotion items to the
industry on this topic. The ability of EASA and other regulatory authorities to influence passengers is
minimal, therefore the best method of promotion is through the operators.
An initial promotion was done in the Learning from Occurrences part of the Conversation Aviation
Magazine 2 -2024, published at https://www.easa.europa.eu/community/topics/conversation -aviation -2-
2024 -summer -reflection (Page 35). More in -depth promotion has just been completed for the Winter 2024
Edition of Conversation Aviation Magazine. This includes a dedicated article in the magazine that is then
used by many operators to promote safety to their own staff.
The article will also be published on the Air Ops Community as a standalone article with additional
promotion to reinforce the message for operators to promote the topic to passengers and also to
encourage their cabin crew to intervene and support passenge rs when situations arise that might result in a
Safety Recommendation s Received and Replies Sent
January – December 2024
fall (such as passengers trying to carry too many things while supervising children or elderly family
members or during bad weather).
Status: Closed – Agreement
_____________________________________________________________________ __________________
IRLD -2024 -001
VULCANAIR P68 Observer 2 , EI-ODA , 18/03/2022
Safety Recommendation received on 19/03/2024 :
EASA should review its Supplemental Type Certificate approval process to ensure that firefighting capability
is considered whenever additional electrical equipment associated with a Supplemental Type Certificate is
installed.
Final r eply sent on 07/06/202 4:
The rules applicable for the classification and approval of Major Changes and Supplemental Type
Certificates (STC) are provided in Section A, Subparts D and E as applicable, of Annex I (Part -21) to
Regulation (EU) 748/2012. Regarding Major Changes, point 2 1.A.101 - also named ‘Changed Product Rule
(CPR)’ - of the Part -21 approval process, details how to determine the type certification basis applicable for
the design change and areas affected by the change(s).
The corresponding CPR process itself includes the identification of the areas of the product affected by the
change, the identification of new design features and associated hazards, the evaluation of the adequacy of
the applicable certification specificat ions to cover and mitigate those features and hazards, and potentially
the issuance of additional special conditions or amendment of special conditions if it is found that the
applicable certification specifications are not adequate (point 21.A.101(d)).
The European Union Aviation Safety Agency (EASA) considers that the above -mentioned change approval
rules of Part -21 are sufficiently robust for the purpose of identifying hazards and prescribing certification
mitigations for new risks resulting from the p roposed Major Change(s).
When properly designed, installed and operated, the addition of equipment to an aircraft electrical system
should not introduce a new hazard compared to the initial type certification hypotheses. However, the
design and installation of the payload equipmen t of the occurrence aircraft was not approved.
The current airworthiness certification specifications applicable to the occurrence aircraft type
(Certification Specifications for Normal -Category Aeroplanes (CS -23) Amendment 6) already contain
provisions for fire protection. In particular, CS 23.2325(a) (1) prescribes that "The aeroplane is designed to
minimise the risk of fire initiation due to anticipated heat or energy dissipation or system failures or
overheat that are expected to generate heat sufficient to ignite a fire;[…]". Additionally, CS 23.232 5(b)(1)
requires that “The aeroplane is designed to minimise the risk of fire propagation by providing adequate fire
or smoke awareness and extinguishing means when practical".
The lessons learnt from past accidents highlight that firefighting and fire resistance should only be
considered as a last line of defence, to mitigate the residual risk after fire prevention measures are applied.
It should also be noted that an excessive use of firefighting equipment in a small and confined space during
flight might even have a negative safety impact as a result of the emission of powders, liquids, foams
and/or gases. EASA believes that these consi derations are already adequately taken into account in the
currently applicable CS -23, which are also found consistent with the principles outlined in Article 4((2) of
Regulation (EU) 2018/1139 of the European Parliament and of the Council which require th at measures
Safety Recommendation s Received and Replies Sent
January – December 2024
taken by EASA under this Regulation must correspond and be proportionate to the nature and risk of each
particular activity to which they relate.
In view of the above considerations, EASA finds that for CS -23 aeroplanes with fewer than 6 passengers,
only one fire extinguisher, reachable by the minimum crew on board (the pilot), is considered sufficient and
proportionate.
In conclusion, EASA agrees that the STC approval process should consider firefighting capability as a
mitigating factor whenever new hazards are introduced. EASA considers that the current Part -21 approval
process, including the CPR, is adequate for this p urpose. Furthermore, EASA considers that to ensure an
adequate level of safety, the certification focus should be on means of fire prevention and fire retardation
before considering additional firefighting capabilities.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
ITAL -2016 -013
Airbus A320, G -EZTC, 12/08/2013
Safety Recommendation received on 06/12/2016 :
ANSV recommends EASA to highlight to civil aviation national authorities that when certifying the
maintenance organization it must be ascertained that the organization MOE procedures, safety policy and
safety standards adequately indicate and encompass req uirements and methods to use the applicable
technical documentation during maintenance activities.
Final r eply sent on 28/11/202 4:
The European Union Aviation Safety Agency (EASA) has now completed two pieces of promotion on this
topic as key aspects of preventing maintenance error and mitigating risks coming from this domain.
Firstly, an article was published in the Conversation Aviation Magazine 1 -2024, published at
https://www.easa.europa.eu/community/topics/conversation -aviation -1-2024 -dirty -dozen -edition (Page
23) on 29 February 2024.
The topic was also covering in a specific article 1 July 2024 with an article on Preventing Maintenance Error,
published at https://www.easa.europa.eu/community/topics/preventing -maintenance -error .
The topic has also been discussed in the Safety Promotion Network (SPN) that is the collaborative group
with EASA and the National Aviation Authorities (NAAs) that coordinates safety promotion across Europe.
This is to ensure that the NAAs are also aware o f the work carried out and promote it to both their own
staff and maintenance organisations in their jurisdiction.
Status: Closed – Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
ITAL -2016 -151
AGUSTA AW609, N609AG, 30/10/2015
Safety Recommendation received on 23/06/2016 :
The ANSV recommends, in the framework of the certification process, to verify that the aerodynamic
behaviour of the aircraft at high -speed conditions will be reviewed, if necessary, making use of wind
tunnels tests in addition to updated models and simulations that can be representative of the complex
flight conditions of this peculiar aircraft.
Interim r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA), in its capacity as validating authority, is finalising a
draft tiltrotor Special Condition (SC) for the AW609. This includes special detailed technical specifications
derived mainly from Certification Speci fications CS -25 (Large Aeroplane) and CS -29 (Large Rotorcraft).
These CSs are complemented by specific requirements for tiltrotor design. Among these requirements, the
draft tiltrotor SC TR.253, directly addresses high -speed characteristics. Additionally, the draft tiltrotor (TR)
SC includes evaluating extreme conditions outside the normal operational envelope. The EASA certification
basis for the AW609 specifically includes SC TR regulations SC TR.141, SC TR.143, SC TR.145, SC TR.147, SC
TR.171, SC TR.173, SC TR.175, SC TR.177, SC TR.181, and SC TR.191, among others, which directly address
items such as flight control input, flight mode transition, controllability and manoeuvrability, and stability.
Compliance with the requirements listed previously require s assessment of the control laws, and
unexpected and un -commanded coupling effects.
In addition, EASA intends to publish a dedicated Acceptable Means of Compliance (AMC) with SC TR.253
and with other SC TR requirements addressing flight stability demonstration which advise supporting the
flight test activity with dedicated analysis/method ology aimed at assessing the robustness of the stability
margins through:
• Verification of the aerodynamic model with wind tunnel data and available flight test data;
• Verification that the Automatic Flight Control System (AFCS) model accurately matches the one
installed in the aircraft;
• Analysis ensuring the full understanding and confidence in the aircraft response under crew inputs
or perturbations.
All the above regulatory material will be applicable to certification of tiltrotor products. Therefore, the
intent of the Safety Recommendation is fulfilled by ensuring that key aspects of the airworthiness of the
product are thoroughly addressed by the Ap plicant and verifiable by the Certification Authority.
Status: Open
_____________________________________________________________________ __________________
ITAL -2016 -152
AGUSTA AW609, N609AG, 30/10/2015
Safety Recommendation received on 23/06/2016 :
The ANSV recommends, in the framework of the certification process, to verify that the control laws of the
aircraft will be reviewed in the management of the extreme flight conditions in which the aircraft could
possibly fly. That verification should be ad dressed to ensure the effectiveness of the flight controls inputs
given by the pilot avoiding the possibility of unexpected and un -commanded coupling effects.
Safety Recommendation s Received and Replies Sent
January – December 2024
Interim r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA), in its capacity as validating authority, is finalising a
draft tiltrotor Special Condition (SC) for the AW609. This includes special detailed technical specifications
derived mainly from Certification Speci fication CS -25 (Large Aeroplane) and CS -29 (Large Rotorcraft). These
CSs are complemented by specific requirements for tiltrotor design. Among these requirements, the draft
tiltrotor SC TR.253, directly addresses high -speed characteristics. Additionally, t he draft tiltrotor (TR) SC
includes evaluating extreme conditions outside the normal operational envelope. The EASA certification
basis for the AW609 specifically includes SC TR regulations SC TR.141, SC TR.143, SC TR.145, SC TR.147, SC
TR.171, SC TR.173, SC TR.175, SC TR.177, SC TR.181, and SC TR.191, among others, which directly address
items such as flight control input, flight mode transition, controllability and manoeuvrability, and stability.
Compliance with the requirements listed previously requires assessment of the control laws, and
unexpected and un -commanded coupling effects.
In addition, EASA intends to publish a dedicated Acceptable Means of Compliance (AMC) with SC TR.253
and with other SC TR requirements addressing flight stability demonstration which advise supporting the
flight test activity with dedicated analysis/method ology aimed at assessing the robustness of the stability
margins through:
• Verification of the aerodynamic model with wind tunnel data and available flight test data;
• Verification that the Automatic Flight Control System (AFCS) model accurately matches the one
installed in the aircraft;
• Analysis ensuring the full understanding and confidence in the aircraft response under crew inputs
or perturbations .
All the above regulatory material will be applicable to certification of tiltrotor products. Therefore, the
intent of the Safety Recommendation is fulfilled by ensuring that key aspects of the airworthiness of the
product are thoroughly addressed by the Ap plicant and verifiable by the Certification Authority.
Status: Open
_____________________________________________________________________ __________________
ITAL -2022 -009
AS350 B3 , I-AMVV , 07/01/2020
Safety Recommendation received on 07/12/2022 :
ANSV recommends [EASA] to request the manufacturer DART Aerospace to evaluate the possibility of
modifying the closing mechanisms of its baskets, in order to remove protrusions potentially dangerous
during ground operations around helicopters equipped with such products.
Final r eply sent on 19/07/202 4:
As Transport Canada Civil Aviation (TCCA) is the Primary Certification Authority for DART Aerospace baskets
design, following this Safety Recommendation (SR), the European Union Aviation Safety Agency (EASA),
acting as Validating Authority, proactively initiated coordination in January 2023 with both TCCA and DART
Aerospace (i.e. the basket design holder) to evaluate the possibility of modifying the basket closing
mechanism, in order to protect the hook of the opening lever or remo ve protrusions that are potentially
dangerous during ground operations. In March 2023, TCCA confirmed to EASA that DART was ready to
modify the current design as a safety improvement to their product.
Following that, in August 2023, DART designed a lower profile basket handle to reduce the risk of snagging
(ref. DSI 9913) and issued DART Service Instruction (ref. SB23 -1) for embodiment of the modification for the
Safety Recommendation s Received and Replies Sent
January – December 2024
fleet in -service. DART has contacted all their known customers to raise awareness of this design
improvement. With this specific product release initiative, DART is highlighting the input received from
EASA, hence it is assumed that Operators would volunta rily apply the design improvement.
EASA considers that this design of the basket closing mechanism was not a key factor contributing to this
specific accident and, therefore, the safety concern highlighted in this SR is still not considered to be a
design deficiency that would warrant Airwo rthiness Directive (AD) action under point 21.A.3B of Annex I
(Part -21) to Regulation (EU) no. 748/2012.
EASA is also satisfied with the awareness campaign put in place by DART and therefore does not consider it
necessary to launch additional safety promotion initiatives (i.e. Safety Information Bulletin).
In conclusion, based on the above actions, EASA considers that all the necessary steps are now in place to
minimise risks during ground operations of helicopters equipped with DART utility baskets.
Status: Closed – Agreement
_____________________________________________________________________ __________________
ITAL -2024 -001
Pilatus PC12/47E, YR -PDV, 03/10/2021
Safety Recommendation received on 21/06/2024 :
The ANSV recommends introducing the requirement for non -professional pilots qualified for the SET class
and, in particular for the PC -12, recurrency training. This could preferably take place on the simulator,
emphasising the aspects defined by the OE -GM Fligh t Crew (in particular by the TASE area) as well as the
notions exposed as part of the HPA preparatory course. This training, of a recurring nature, should include a
review of the normal, abnormal and emergency procedures, a periodic review of the on -board systems, not
least the avionics system. This is to ensure constant updates on the contents of the OE -GM Flight crew. This
recurrent training could therefore culminate with the proficiency check.
Final r eply sent on 17/09/202 4:
The European Union Aviation Safety Agency (EASA) considers that the current system is robust enough for
the operations of Single -Engine Turboprop High Performance (SPHP) aircraft. This is because there is
already a renewal training system in place referenc ed in FCL.740 and FCL.710 to Regulation (EU) No
1178/2011 laying down technical requirements and administrative procedures related to civil aviation
aircrew, and there are proficiency checks outlined in Appendix 9, thereof.
Repeated differences training and proficiency checks as per points FCL.710 and FCL.740 can be considered
as an evaluation of the pilot to ensure that pilots maintain the skills and knowledge that are necessary to
safely operate the aircraft.
Therefore, EASA considers that the existing training and proficiency check system is sufficient to ensure the
safe operation of SPHP aircraft and does not find it necessary to amend the existing rules or create
additional requirements as recommended.
Status: Closed – Disagreement
_______________________________________________________________________________________
Safety Recommendation s Received and Replies Sent
January – December 2024
ITAL -2024 -002
Pilatus PC12/47E, YR -PDV, 03/10/2021
Safety Recommendation received on 21/06/2024 :
The ANSV recommends considering the development of single resource management (SRM) courses for
single pilot HPA pilots, making both initial and recurrent training compulsory, as a prerequisite for achieving
and maintaining the class rating SET PC -12 and similar HPA aircraft.
Interim r eply sent on 17/09/202 4:
The European Union Aviation Safety Agency (EASA) is open to considering the inclusion of additional Crew
Resource Management (CRM) for Single Pilot High Performance (SPHP) aircraft within the current
Acceptable Means of Compliance (AMC), contingent on appr oval following consultations with advisory
bodies.
A further update will be provided after consultation with the advisory bodies in 2025.
Status: Open
_____________________________________________________________________ __________________
ITAL -2024 -003
Pilatus PC12/47E, YR -PDV, 03/10/2021
Safety Recommendation received on 21/06/2024 :
The ANSV recommends considering the development of specific training for the recognition and recovery
from unusual positions (UPRT), making it compulsory, both initial and recurrent training, as a prerequisite
for achieving and maintaining the SET PC class rating -12 and similar HPA aircraft.
Final r eply sent on 17/09/202 4:
The European Union Aviation Safety Agency (EASA) acknowledges that the implementation of Upset
Prevention and Recovery Training (UPRT) for the High -Performance Aeroplanes (HPA) was not anticipated,
despite the discussions during Rulemaking Task (RMT) RMT.0 581 which led to Opinion 06/2017. It was
determined by the expert group that UPRT should be mandated solely for complex airplanes, multi -pilot
(MP) airplanes, and any airplane operated in Multi -Pilot Operations (MPO). Beyond this specification, EASA
believ es that the elements of general UPRT are already integrated into the EU regulatory framework as
follows:
• Commercial Pilot Licence (CPL) courses incorporate basic UPRT elements within the flight training
syllabus, as per the Acceptable Means of Compliance (AMC1 to Appendix 3, Section C to E).
• For the Airline Transport Pilot Licence (ATPL) integrated courses and the multi -pilot airplane
courses, an advanced UPRT course, described in point FCL.745.A of Annex I (Part -FCL) to
Commission Regulation (EU) No 1178/2011 of 3 November 2011 laying down te chnical
requirements and administrative procedures related to civil aviation aircrew, is included within
these training programmes. App. 3. Section A, point 4.(d) and AMC1 App. 3, Section A, point (d)(5).
• Instrument Rating Training (IR) courses also incorporate UPRT elements within Appendix 7, Section
2 (C) “Recovery unusual attitudes” to Commission Regulation (EU) No 1178/2011 of 3 November
2011 laying down technical requirements and administrative procedu res related to civil aviation
aircrew.
Safety Recommendation s Received and Replies Sent
January – December 2024
Considering the circumstances of the accident and the fact that the applicable regulation already
incorporates relevant UPRT provisions, EASA also maintains its position and does not intend to propose
further regulatory changes.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
ITAL -2024 -004
Pilatus PC12/47E, YR -PDV, 03/10/2021
Safety Recommendation received on 21/06/2024 :
The ANSV recommends making mandatory the recommendations in ICAO Annex 6 Part II, International
General Aviation in points 2.4.16.1.2.1 and 2.4.16.2.1 in terms of on -board recording devices.
Final r eply sent on 09/09/202 4:
The European Union Aviation Safety Agency (EASA) considers that the current EU Instruments, Data and
Equipment requirements (IDE) Non -Commercial Operations with Other -than Complex Motor Powered
Aircraft (NCO) operation are adequate.
The assessment on the need to fit aeroplanes involved in non -commercial operations with on -board
devices has been performed as part of Rulemaking Task RMT.0392 (Regular update of Regulation (EU)
965/2012) and making the recommendations in points 2.4.16.1.2 .1 and 2.4.16.2.1 of ICAO Annex 6 Part II
mandatory in the EU regulatory framework was not supported.
EASA would consider amending the current IDE requirements should the International Civil Aviation
Organisation (ICAO) mandate the fitting of on -board devices in Annex 6 Part II. EASA would further support
any regulatory change in the EU framework.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
ITAL -2024 -005
AS350B3e, I -LGLG, 30/12/202 0
Safety Recommendation received on 21/06/2024 :
It is recommended to provide for the introduction of specific mandatory training requirements also for
pilots who intend to operate NCO.HESLO.
Final r eply sent on 09/09/202 4:
The European Union Aviation Safety Agency (EASA) must facilitate that the EU regulatory framework for
civil aviation, including the requirements in Annex VII (Part -NCO) of Commission Regulation (EU) No
965/2012, is appropriate for the level of activity and risk to third parties involved.
EASA published guidance material (GM) to NCO.SPEC.HESLO.100 to Annex VII (Part -NCO) to Regulation (EU)
965/2012, namely GM1 NCO.SPEC.HESLO.100, which refers to guidance for initial pilot training contained in
Safety Recommendation s Received and Replies Sent
January – December 2024
GM1 SPO.SPEC.HESLO.100 associated to said point of Annex VIII (Part -SPO) of the same Regulation. EASA
considers this guidance as adequate considering the level of HESLO activities being conducted under Part -
NCO.
In view of the above, EASA considers that introducing specific mandatory training requirements for pilots
who intend to operate NCO.HESLO would not bring about additional safety benefits.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
ITAL -2024 -006
AS350B3e, I -LGLG, 30/12/202 0
Safety Recommendation received on 21/06/2024 :
It is recommended to provide for the introduction of limitations regarding the presence of passengers on
board for operations carried out with external loads.
Final r eply sent on 09/09/202 4:
Article 5(7) of Regulation (EU) No. 965/2012 laying down technical requirements and administrative
procedures related to air operations, stipulates that flights taking place immediately before, during or
immediately after specialised operations and directly connected to those operations shall be operated in
accordance with paragraphs 3, 4 and 6 of said Article, as applicable. Except for crew members, persons
other than those indispensable to the mission shall not be carried on board.
Article 5(7) of said Regulation does not differentiate between specialised operations conducted for
commercial or non -commercial purposes. As such this Article prohibits the carriage of persons other than
those indispensable to the mission. Therefore, the European Union Aviation Safety Agency (EASA) considers
that the intent of the Safety Recommendation (SR) is already addressed by the existing and applicable
Commission Regulation (EU) No 965/2012.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
ITAL -2024 -007
AS350B3e, I -LGLG, 30/12/202 0
Safety Recommendation received on 21/06/2024 :
It is recommended to provide for the introduction of requirements that make the use of CRFS systems
mandatory on newly produced helicopters operated in European member states.
Safety Recommendation s Received and Replies Sent
January – December 2024
Final r eply sent on 09/09/202 4:
In the context of rulemaking task RMT.0710, the European Union Aviation Safety Agency (EASA) published
Opinion No 05/2024 on 21 June 2024:
https://www.easa.europa.eu/en/document -library/opinions/opinion -no-052024
This Opinion proposes to amend Regulation (EU) 2015/640 (on additional airworthiness specifications for a
given type of operations) to mandate the installation of a crash -resistant fuel system (CRFS) on some
existing helicopter designs that are still in pr oduction and the retrofit of some in -service helicopters, as
follows:
• newly manufactured helicopters with a compliance date of 2 years after the entry into force of the
amending regulation;
• in-service helicopters with 6 or more occupants certified after 2 October 1994 with a compliance
date of 7 years after the entry into force of the amending regulation;
• in-service helicopters with 5 or less occupants certified after 2 October 1994 with a compliance
date of 15 years after the entry into force of the amending regulation; and
• helicopters imported from a non -EU Member State.
Status: Closed – Agreement
_____________________________________________________________________ __________________
ITAL -2024 -008
Pilatus PC -6 NG , I-HSKC , 14/05/2021
Safety Recommendation received on 30/10/2024 :
EASA is recommended, in light of the evidence that has emerged, to provide guidance to the manufacturer
Pilatus to evaluate the opportunity to introduce a life limit for the relays that make up the electric pitch
trim system of the PC -6T.
Interim r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) and the manufacturer Pilatus agree on the need to
introduce a lifetime limit for the relays part of the PC -6T's electric pitch trim system as a preventive
maintenance action. A scheduled relay replacement wi ll be introduced in the Airplane Maintenance Manual
(AMM) in Q1 2025.
Status: Open
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
ITAL -2024 -009
Pilatus PC -6 NG , I-HSKC , 14/05/2021
Safety Recommendation received on 30/10/2024 :
EASA is recommended to provide guidance to the manufacturer Pilatus to reconsider, in light of the
evidence that has emerged, the Aircraft Level Functional Hazard Assessment (FHA), with reference to the
Horizontal trimmable stabilizer adjustment system of the PC -6/B2 -H4, with particular attention to any risk
mitigation action s associated with the pitch trim runaway.
Interim r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) concurs with this safety recommendation. The
manufacturer Pilatus has reviewed the Functional Hazard Assessment (FHA) for Pitch Trim Runaway (ER -06-
000078) in light of the safety recommendation. The outcome of the review confirmed that the conclusion
of the FHA ER -06-000078 is still valid. However, Pilatus will revise the FHA to expand the rationale provided
in the Failure Condition “pitch trim runaway” following the review above.
Status: Open
_____________________________________________________________________ __________________
ITAL -2024 -010
Tecnam P2008 -JC, I-CNTA , 20/03/2022
Safety Recommendation received on 27/09/2024 :
The ANSV recommends that EASA, in coordination with the manufacturer Rotax, develop a protocol that
allows the acquisition of sufficient data containing at least:
• Aircraft model
• Aerodynamic and engine parameters
• Symptomatology
• Flight phase of the event (with trim, speed and altitude)
• Areological and meteorological conditions
• Fuel characteristics
• s/n of carburettors and ignition boxes
• outcomes of troubleshooting (e.g., presence of water in carburettors, gascolators, dirt).
It also recommends that suitable initiatives be taken, also through dedicated working groups, to address
the problem of Rotax 912 engine malfunctions through in -depth investigations aimed at identifying and
understanding their nature.
Final r eply sent on 28/11/202 4:
The European Union Aviation Safety Agency (EASA) is leading a working group, the “Rotax occurrence task
force”, including National Aviation Authority (NAA) representatives, which is analysing mitigation actions to
the common root cause problems with Rotax 912 engines power losses. The group is meeting quarterly to
ensure the latest findings and insights of investigations from concurrent engine and airframe Type
Certificate Holder (TCH) occurrence investigations are considered.
Safety Recommendation s Received and Replies Sent
January – December 2024
In addition, EASA is reviewing all of the power loss occurrences in EASA -Rotax -airframe TCH meetings,
starting with the most affected airframe TCHs (Tecnam, Aquila, BRM Aero). These in -depth analyses have
already identified the main contributing factors an d possible causes for the majority of the unexplainable
cases of engine power loss, engine vibrations and engine piston damage. Although the in -depth analyses
have found that the root cause is invariably a combination of many concurrent contributing factor s, a
common factor is the Rotax engine 912 itself.
As an output from this work, Rotax has taken the initiative to issue an engine Service Bulletin SB -912-079
dated 11 November 2024. The SB provides information on the background, including airframe installation
and operator, and specifies recommended maintenance requirements. Compliance will be monitored and
the task force and working group will continue to develop lessons -learned, extending to certification,
installation, operation, maintenance and governance and will continue to co -ordinate with all stakeh olders.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
MALI -2016 -012
McDonell Douglas DC -9-83 (MD -83), EC-LTV, 24/07/2014
Safety Recommendation received on 22/04/2016 :
The Commission d’Enquête sur les Accidents et Incidents d’Aviation Civile du Mali and the BEA recommend
that the FAA and EASA ensure that this modification is implemented by the operators concerned.
Final r eply sent on 09/09/202 4:
Point M.A.302 of Annex I (Part -M) to Regulation (EU) No 1321/2014, published on 17 December 2014 (after
the accident), already requires that the maintenance of each aircraft is organised in accordance with an
aircraft maintenance programme which is periodi cally reviewed taking into account new or modified
maintenance instructions issued by the type certificate and supplemental type certificate holders and any
other organisation that publishes such data in accordance with Annex I (Part -21) to Regulation (EU) No
748/2012. Furthermore, according to point 145.A.45 of Annex II (Part -145) to Regulation (EU) No
1321/2014, the maintenance organisation shall hold and use applicable current maintenance data in the
performance of maintenance and that the organisation s hall establish a procedure to ensure that
maintenance data it controls is kept up to date.
Therefore, after Boeing updated the Aircraft Maintenance Manual (AMM) with respect to the maintenance
check procedure for Cockpit Voice Recorders on the MD -80, all EU Approved Maintenance Organisations
have to use this latest maintenance data.
Status: Closed – Agreement
_____________________________________________________________________ __________________
NETH -2020 -001
Boeing 777, VT -JEW, 21/04/2017
Safety Recommendation received on 15/10/2020 :
To European Union Aviation Safety Agency and the Federal Aviation Administration: To take the initiative in
the development of specifications and, subsequently, develop requirements for an independent onboard
Safety Recommendation s Received and Replies Sent
January – December 2024
system that detects gross input errors in the process of takeoff performance calculations and/or alerts the
flight crew during takeoff of abnormal low accelerations for the actual aeroplane configuration as well as
insufficient runway length available in c ase of intersection takeoffs. Take this initiative in close consult with
the aviation industry, including manufacturers of commercial jetliners amongst which in any case The
Boeing Company.
Interim r eply sent on 19/07/202 4:
On 30 August 2023, the European Union Aviation Safety Agency (EASA) published the Terms of Reference
(ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing a means of informing or alerti ng the flight crew.
Design requirements will be considered to address new large aeroplane designs. An analysis and impact
assessment will be conducted to assess the feasibility and the benefit of design requirements applicable to
existing (already type certificated) large aer oplane designs.
EASA held three workshops with stakeholders (including all major large aeroplane manufacturers (including
Boeing) and foreign partner authorities) between November 2023 and May 2024.
During these workshops, EASA presented proposed draft new certification specifications and discussed
with industry the option of retroactive design requirements.
It appears that some large aeroplane manufacturers have developed or are developing some or all of the
envisaged functions to be mandated by design requirements.
For those manufacturers which have not yet started a design function development phase, these
workshops served as a means of encouraging them to take action regarding their aeroplane designs.
In parallel, the European Organisation for Civil Aviation Equipment (EUROCAE) created Working Group WG -
129 ‘Take -off Performance Monitoring System Strategy’ that held a first meeting on 30 April 2024 with the
participation of EASA. The WG is tasked with de veloping a minimum operational performance standard
(MOPS) and/or a minimum aviation system performance standard (MASPS) in order to facilitate the
introduction of a take -off performance monitoring system (TOPMS). A close relationship with RTCA is also
ensured by EUROCAE in view of issuing a common standard. EASA will take into account the work done by
this WG and ultimately consider any issued standard that could support the compliance demonstration
with new EASA certification specifications.
A Notice of Proposed Amendment (NPA) is being drafted with a publication for consultation currently
expected in Q4 2024.
Status: Open
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
NETH -2024 -001
Cessna 172 , D-EBTO & N98825 , 15/06/2022
Safety Recommendation received on 20/11/2024 :
To the International Civil Aviation Organisation and to the European Union Aviation Safety Agency:
For the purpose of accident and incident investigation, amend the retention period of background
communication and aural environment recordings in air traffic services from 24 hours of operation to 30
days (ICAO annex 11, Commission Implementing Regulation (EU) 2020/469, ATS.OR.460).
Status: Open
_______________________________________________________________________________________
NORW -2018 -001
EUROCOPTER EC225 , LN-OJF, 29/04/2016
Safety Recommendation received on 05/07/2018 :
The Accident Investigation Board Norway recommends that the European Aviation Safety Agency (EASA)
commission research into crack development in high -loaded case -hardened bearings in aircraft
applications. An aim of the research should be the prediction of the reductio n in service life and fatigue
strength as a consequence of small surface damage such as micro -pits, wear marks, and roughness.
Final r eply sent on 09/09/202 4:
The European Union Aviation Safety Agency (EASA) has completed the research project into “Integrity
Improvement of Rotorcraft Main Gear Box (MGB) - Research into crack development in high -loaded case -
hardened bearings in aircraft applications”.
The outcome of the research project is published at https://www.easa.europa.eu/en/research -
projects/integrity -improvement -rotorcraft -main -gear -box-mgb .
In parallel, EASA issued Acceptable Means of Compliance (AMC) in AMC1 27.571 to CS -27 (Certification
Specifications for Small Rotorcraft) at Amdt. 10 and AMC1 29.571 to CS -29 (Certification Specifications for
Large Rotorcraft) at Amdt. 11. These AMCs address rolling contact fatigue taking into consid eration
information from the research as well as from initial and continued airworthiness discussions held with
rotorcraft Type Certificate Holders (TCHs).
Building on the conclusions of this research project, EASA plans to host a web conference to discuss the
AMC on rolling contact fatigue with key stakeholders, including National Civil Aviation Authorities and
rotorcraft TCHs. This initiative is part of an ongoing dialogue with the expert community. Any necessary
follow -up actions will be planned and implemented accordingly.
Status: Closed – Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
NORW -2018 -005
EUROCOPTER EC225 , LN-OJF, 29/04/2016
Safety Recommendation received on 05/07/2018 :
The Accident Investigation Board Norway recommends that the European Aviation Safety Agency (EASA)
develop MGB certification specifications for large rotorcraft to introduce a design requirement that no
failure of internal MGB components should lead to a catastrophic f ailure.
Final r eply sent on 09/09/202 4:
The European Union Aviation Safety Agency (EASA) has completed research to better understand the
significance and impacts of design choices that would support the objective of this safety recommendation,
i.e. that no failure of internal Main Gear Box (MGB) components should lead to a catastrophic failure. The
outcome of the research project, which is published at https://www.easa.europa.eu/en/research -
projects/integrity -improvement -rotorcraft -main -gear -box-mgb , led to the following conclusions:
• Design solutions exist to eliminate the possibility of catastrophic consequences resulting from the
failure of individual internal MGB components.
• However, these design solutions address specific failure causes, and MGB internal components may
be subject to failure from several causes. This would result in different design solutions having to
be implemented simultaneously on the same component, which may not be viable.
• Furthermore, it could not be confirmed that all failure causes that may lead to catastrophic
consequences can be designed out.
• In addition, all of these design solutions result in added weight and complexity of the MGB design,
which could have a detrimental impact on the reliability of the MGB with a significant economic
impact.
In summary, EASA considers it is neither feasible nor practical to ensure that no failure of internal MGB
components should lead to a catastrophic failure. Consequently, EASA does not concur with the need to
introduce certification specifications for this purpose.
Finally, the rotor drive system design assessment specified by CS 29.917 (Certification Specifications for
Large Rotorcraft) requires that adequate compensating provisions shall be in place for failures that may
preclude continued flight and landing. As per Federal Aviation Administration (FAA) Advisory Circular (AC)
29 29.917, used as acceptable means of compliance, these compensating provisions aim to mitigate the
severity of MGB failures or minimise their likelihood of occurrence. As part of this certifi cation exercise,
EASA makes sure applicants pursue the minimisation of the number of catastrophic failures in their MGB
designs wherever this is technically feasible and practical to implement. In addition, as specified in CS
29.601, the rotorcraft may hav e no design features or details that experience has shown to be hazardous or
unreliable. This is deemed to include experience from past accidents and, therefore, an applicant for any
new CS -29 rotorcraft Type Certificate (TC) would be required to adequatel y demonstrate that any failure
such as the one experienced by the subject aircraft is adequately addressed within the CS 29.917 design
assessment. Nevertheless, it is not considered appropriate to systematically require the mitigation by
design of this and any other failures that may result from internal MGB components which could lead to a
catastrophic failure. Thus, for certain failures, ensuring a safe design may have to rely on minimising the
likelihood of occurrence. This may be due to, for example, th e complexity of fail -safe design solutions,
multiple possible failure mechanisms requiring different mitigation solutions, etc.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
NORW -2018 -013
AEROSPATIALE AS350 B3 , LN-OSG , 30/04/2016
Safety Recommendation received on 13/11/2018 :
It is recommended that the European Union Aviation Safety Agency study the opportunity to mandate the
solutions developed by Airbus Helicopter in cooperation with Safran Helicopter Engines.
Final r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA) has been cooperating with Airbus Helicopters (AH) and
Safran Helicopter Engines (SHE) to study technical solutions aiming at reducing the risk of unwanted Power
Turbines (PT) blade shedding occurrences on rotorc raft equipped with ARRIEL 2 engines and, hence,
reducing the potential for post -impact fire.
The result of this effort has been the implementation of an electronic over -speed protection function that,
if still operational after the impact, is intended to limit occurrence of PT blade shedding by early detection
of an over -speed condition and subseq uent rapid fuel flow shut -off. This new function has been introduced
through a Full Authority Digital Engine Control (FADEC) software modification and a wiring modification at
helicopter level as detailed below:
- EASA Major Change Approval 10065664 (i.e. FADEC software DM 116271) developed by SHE,
applicable to AS350 B3 and EC130 T2 helicopter models equipped with ARRIEL 2D engines and
made available for new helicopter deliveries or, as a retrofit kit, for helicopt ers already in service
via the SHE SB ref. 292 -73-2210.
- EASA Major Change Approval 10066998 (i.e. wiring modification 074831) developed by AH,
applicable to AS350 B3 and EC130 T2 helicopter models equipped with ARRIEL 2D engines and
made available for new helicopter deliveries or, as a retrofit kit, for helicop ters already in service
via the AH Service Bulletins (SBs) ref. AS350 -76.00.23 and EC130 -76-006.
These modifications are already part of the baseline for AS 350 B3 and EC 130 T2 helicopters (the two
models still in production), hence are implemented on all newly -built helicopters since late 2019.
Based on the review of in -service experience and available occurrence data, EASA did not consider it
necessary to mandate the modifications above to the AS 350 B3 and EC 130 T2 helicopters already in
service.
However, in 2019, via the release of the EASA Safety Information Bulletin (SIB) ref. 2019 -10 (“Power
Turbine Over -Speed Protection on ARRIEL 2D Engines”) dated 22/08/2019, EASA has recommended that
operators implement a voluntary embodiment of the over -speed protection function, promoted by both
AH and SHE with a free of charge retrofit campaign.
Subsequently, at the beginning of 2022, EASA certified similar modifications to provide AS350 B3 and EC130
B4 helicopter models equipped with ARRIEL 2B1 engines with an equivalent over -speed protection
function. SHE and AH made these modifications availabl e as a retrofit kit for helicopters already in service
via the AH SBs. Details on EASA Major Change Approval numbers and applicable AH SBs, are provided in
EASA SIB 2019 -010R1, issued to expand the applicability and recommendations to all affected helicopt ers
and engines.
In addition to that, EASA and AH have put in place a yearly meeting to monitor implementation of these
modifications for the in -service helicopter fleet.
Safety Recommendation s Received and Replies Sent
January – December 2024
In conclusion, EASA considers that all the necessary actions are now in place to minimise re -occurrence of
this accident scenario.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
NORW -2022 -001
AS350 B3 , LN-OFU , 31/08/2019
Safety Recommendation received on 18/03/2022 :
The Norwegian Safety Investigation Authority recommends that EASA requires that all helicopters, new and
used, delivered or imported to Europe be equipped with crash resistant fuel systems in accordance with CS
27.952 or CS 29.952, regardless of their type certification date.
Final r eply sent on 09/09/202 4:
In the context of rulemaking task RMT.0710, the European Union Aviation Safety Agency (EASA) published
Opinion No 05/2024 on 21 June 2024:
https://www.easa.europa.eu/en/document -library/opinions/opinion -no-052024
This Opinion proposes to amend Regulation (EU) 2015/640 (on additional airworthiness specifications for a
given type of operations) to mandate the installation of a crash -resistant fuel system (CRFS) onto some
existing helicopter designs that are still in production and the retrofit of some in -service helicopters, as
follows:
• newly manufactured helicopters with a compliance date of 2 years after the entry into force of the
amending regulation;
• in-service helicopters with 6 or more occupants certified after 2 October 1994 with a compliance
date of 7 years after the entry into force of the amending regulation;
• in-service helicopters with 5 or less occupants certified after 2 October 1994 with a compliance
date of 15 years after the entry into force of the amending regulation; and
• helicopters imported from a non -EU Member State.
Status: Closed – Agreement
_____________________________________________________________________ __________________
NORW -2022 -002
AS350 B3 , LN-OFU , 31/08/2019
Safety Recommendation received on 18/03/2022 :
The Norwegian Safety Investigation Authority recommends EASA to not permit commercial passenger
flights with helicopters not equipped with crash resistant fuel systems in accordance with CS 27.952 or CS
29.952, regardless of their type certification date.
Final r eply sent on 09/09/202 4:
In the context of rulemaking task RMT.0710, the European Union Aviation Safety Agency (EASA) published
Opinion No 05/2024 on 21 June 2024:
https://www.easa.europa.eu/en/document -library/opinions/opinion -no-052024
Safety Recommendation s Received and Replies Sent
January – December 2024
This Opinion proposes to amend Regulation (EU) 2015/640 (on additional airworthiness specifications for a
given type of operations (Annex I – Part 26) to mandate the installation of a crash -resistant fuel system
(CRFS) onto some existing helicopter designs that are still in production and the retrofit of some in -service
helicopters, as follows:
• newly manufactured helicopters with a compliance date of 2 years after the entry into force of the
amending regulation;
• in-service helicopters with 6 or more occupants certified on or after 2 October 1994 with a
compliance date of 7 years after the entry into force of the amending regulation;
• in-service helicopters with 5 or less occupants certified on or after 2 October 1994 with a
compliance date of 15 years after the entry into force of the amending regulation; and
• helicopters imported from a non - EU Member State.
Before the compliance dates specified in the amendment of Part -26 proposed by Opinion No 05/2024 (new
point 26.440), helicopters not equipped with CRFS may continue commercial operations with passengers.
After the compliance dates specified in the amendment of Part -26 proposed by Opinion No 05/2024 (new
point 26.440), only a very limited sub -population of helicopters (i.e. type certified before 2 October 1994
and for which the Certificate of Airworthiness was issued by an EU Member State before the entry into
force of the Regulation amending Regulation (EU) 2015/640) will be authorised to continue commercial
operations with passengers although not equipped with a CRFS.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
PORT -2020 -001
Aerospatiale AS350 B2 , CS-HFT, 05/09/2019
Safety Recommendation received on 14/07/2020 :
It is recommended that EASA follow its Rotorcraft Safety Roadmap publication principles, producing
rulemaking documentation requiring retroactive application of the current improvements in fuel tank crash
resistance for rotorcraft certified before the new certification specification for type design entered into
force. Helicopters used for Commercial Operations shall be subject to this additional airworthiness
requirement for operations.
Final r eply sent on 09/09/202 4:
In the context of rulemaking task RMT.0710, the European Union Aviation Safety Agency (EASA) published
Opinion No 05/2024 on 21 June 2024:
https://www.easa.europa.eu/en/document -library/opinions/opinion -no-052024
This Opinion proposes to amend Regulation (EU) 2015/640 (on additional airworthiness specifications for a
given type of operations) to mandate the installation of a crash -resistant fuel system (CRFS) onto some
existing helicopter designs that are still in production and the retrofit of some in -service helicopters, as
follows:
• newly manufactured helicopters with a compliance date of 2 years after the entry into force of the
amending regulation;
• in-service helicopters with 6 or more occupants certified after 2 October 1994 with a compliance
date of 7 years after the entry into force of the amending regulation;
• in-service helicopters with 5 or less occupants certified after 2 October 1994 with a compliance
date of 15 years after the entry into force of the amending regulation; and
Safety Recommendation s Received and Replies Sent
January – December 2024
• helicopters imported from a non -EU Member State.
Before the compliance dates specified in the amendment of Part -26 proposed by Opinion No 05/2024 (new
point 26.440), helicopters not equipped with CRFS may continue commercial operations with passengers.
After the compliance dates specified in the amendment of Part -26 proposed by Opinion No 05/2024 (new
point 26.440), only a very limited sub -population of helicopters (i.e. type certified before 2 October 1994
and for which the Certificate of Airworthiness was issued by an EU Member State before the entry into
force of the Regulation amending Regulation (EU) 2015/640) will be authorised to continue commercial
operations with passengers although not equipped with a CRFS.
Status: Closed – Agreement
_____________________________________________________________________ __________________
PORT -2023 -001
PZL-Swidnik PW -6U, D -5159, 11/11/2022
Safety Recommendation received on 21/12/2023 :
It is recommended that EASA, within 24 months, take all necessary and applicable actions to ensure the
continuous airworthiness requirements established by EU Regulation No 1321/2014 on type certified
aircraft equipped with Aerazur AIR 12A towing hooks, un til they are withdrawn from service.
Final r eply sent on 18/03/202 4:
Many of the products, parts and appliances currently in service were designed and certified many decades
ago, in compliance with the airworthiness standards applicable at the time. The fact that these products,
parts and appliances, including their associa ted documentation, were not developed in compliance with the
latest standards (e.g. Certification Specifications) that are applicable today does not make them unsafe.
Under the principles of Articles 3 to 5 of Regulation (EU) No 748/2012 products, parts an d appliances
certificated by EU Member States before the applicability of the common EU airworthiness requirements,
namely 28 September 2003, deemed to have a certificate or approval issued in accordance with said
Regulation (so called “grandfathering”). C onsequently, unless an unsafe condition is identified (as per point
21.A.3B(b) of Annex I (Part -21) to Regulation (EU) 748/2012 and the related AMC1 21.A.3B(b)))) during the
in-service life of the product, part or appliance, the European Union Aviation Saf ety Agency (EASA) cannot
mandate a redesign or removal from service. Additionally, point 21.A.101 of Part 21 defines the applicable
type certification basis when a change to the formerly approved design is necessary.
The occurrence Aircraft Maintenance Manual (AMM) for the “glider -towing” optional installation requires a
functional check of the release control and catch, a periodic inspection of the condition and attachment
parts of the catch and control bellcrank, and periodic lubrification of the hinges. The occurrence part was
known by the aeroclub to be defective, as clearly stated in the report. Therefore, the non -correct operation
of the part cannot be considered as an ‘unnoticed’ or a ‘latent’ condition. Addition ally, the investigation
revealed the presence of significant amount of dirt on the occurrence part and did not find evidence that
the instructions of the maintenance manual, namely cleaning and lubrication, were performed recently
(see page 12 of the final report). Eventually, the occurrence part was enclosed in metal sheets held
together by staking, thus making it a sealed and non -dismountable component. The user manual of the part
also states that any damaged unit should be returned to the manufacturer fo r repair. However, the
occurrence part had a non -approved component (the spring) installed in an incorrect way, hence, the part
was opened and refurbished at some point in its life. The report did not present any evidence that this
maintenance action was u ndertaken in accordance with approved design data, hence the part was not
Safety Recommendation s Received and Replies Sent
January – December 2024
airworthy. EASA considers that the information available in the maintenance manual is sufficient for the
level of maintenance expected from an operator.
EASA finds no unsafe condition warranting an Airworthiness Directive (AD) in accordance with Part 21.
Finally, EASA acknowledges that AD 77.76(A), issued by the French Civil Aviation Authority in 1977, was not
applied to the occurrence part for unknown reasons. EASA has republished the AD on its Safety Publication
Tool to increase its visibility.
Final r eply sent on 16/10/202 4:
Many of the products, parts and appliances currently in service were designed and certified many decades
ago, in compliance with the airworthiness standards applicable at the time. The fact that these products,
parts and appliances, including their associa ted documentation, were not developed in compliance with the
latest standards (e.g. Certification Specifications) that are applicable today does not make them unsafe.
Under the principles of Articles 3 to 5 of Regulation (EU) No 748/2012 products, parts an d appliances
certificated by EU Member States before the applicability of the common EU airworthiness requirements,
namely 28 September 2003, deemed to have a certificate or approval issued in accordance with said
Regulation (so called “grandfathering”). C onsequently, unless an unsafe condition is identified (as per point
21.A.3B(b) of Annex I (Part -21) to Regulation (EU) 748/2012 and the related AMC1 21.A.3B(b)) during the
in-service life of the product, part or appliance, the European Union Aviation Safet y Agency (EASA) cannot
mandate a redesign or removal from service. Additionally, point 21.A.101 of Part 21 defines the applicable
type certification basis when a change to the formerly approved design is necessary.
The occurrence Aircraft Maintenance Manual (AMM) for the “glider -towing” optional installation requires a
functional check of the release control and catch, a periodic inspection of the condition and attachment
parts of the catch and control bellcrank, and periodic lubrification of the hinges. The occurrence part was
known by the aeroclub to be defective, as clearly stated in the report. Therefore, the non -correct operation
of the part cannot be considered as an ‘unnoticed’ or a ‘latent’ condition. Addition ally, the investigation
revealed the presence of significant amount of dirt on the occurrence part and did not find evidence that
the instructions of the maintenance manual, namely cleaning and lubrication, were performed recently.
Possibly, the occurrence part was enclosed in metal sheets held together by staking, thus making it a sealed
and non -dismountable component. The user manual of the part also states that any damaged unit should
be returned to the manufacturer for repair. However, the occurrence pa rt had a non -approved component
(the spring) installed in an incorrect way, hence, the part was opened and refurbished at some point in its
life. Consequently, the part was not airworthy. EASA considers that the information available in the
maintenance man ual is sufficient for the level of maintenance expected from an operator.
EASA finds no unsafe condition warranting an Airworthiness Directive (AD) in accordance with Part 21.
Nonetheless, EASA has issued Safety Information Bulletin (SIB) 2024 -11 to inform owners and operators of
aircraft equipped with the Aerazur AIR A2 towing hook about the risks associated with an improperly
working and/or improperly maintained part. The SIB is published here: https://ad.easa.europa.eu/ad/2024 -
Finally, EASA acknowledges that AD 77.76(A), issued by the French Civil Aviation Authority in 1977, was not
applied to the occurrence part for unknown reasons. EASA has republished the AD on its Safety Publication
Tool to increase its visibility .
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
PORT -2023 -002
PZL-Swidnik PW -6U, D -5159, 11/11/2022
Safety Recommendation received on 21/03/2023 :
It is recommended that EASA, within 24 months, gives emphasis and detail to flight controls handover
during the theoretical and flight instruction of SPL student pilots by amending the AMC & GM to Part -SFCL,
as applicable, and engaging in corresponding saf ety promotion activities.
Interim reply sent on 18/03/202 4:
The European Union Aviation Safety Agency (EASA) considers that the modification to the associated
Acceptable Means of Compliance and Guidance Material to Annex III (Part -SFCL) to Commission
Implementing Regulation (EU) 2018/1976 laying down detailed rules for the operation of sailplanes, may
not necessarily improve the procedure for handing over control during the theoretical and flight instruction
of sailplane student pilots and would therefore not have an additional safety benefit.
This being said, EASA takes note of the recommendation concerning Safety Promotion activities, and
intends to include the topic of flight control hand over in the Safety Promotion plan for 2024 to provide
clear, simple material that pilots, instructors and training organisations can use.
Status: Open
_____________________________________________________________________ __________________
PORT -2024 -001
Airbus A321 NE O, CS-TJL, 23/10/2023
Safety Recommendation received on 19/12/2024 :
GPIAAF recommends, in the framework of the certification process, EASA to specify under CS 25.1189 (f) or
other, the design specifications and reliability requirements for the fire switch assembly in order to ensure
that the retention system does not rely on the condition of a single pin/mechanism.
Status: Open
_____________________________________________________________________ __________________
SPAN -2024 -001
THRUSH S2R -T660 , ECMXL, 19/10/2022
Safety Recommendation received on 09/09/2024 :
It is recommended that EASA take measures to improve the design of the ELT system in terms of its
resistance to the consequences of the very events that warrant its installation and operation on board the
aircraft (crashworthiness) in the interest of ensur ing that the risk of it being rendered non -operational is
minimised as far as possible.
Final r eply sent on 28/11/202 4:
Industry consensus on the installation of Emergency Locator Transmitters (ELTs) and ELT antennas as
documented in Eurocae ED -62B is set in force by the European Union Aviation Safety Agency (EASA) in
Safety Recommendation s Received and Replies Sent
January – December 2024
ETSO -C126c since amendment 16 of Certification Specifications for European Technical Standard Orders
(CS-ETSO) became applicable in 2020.
The installation of ELT systems into Aeroplanes with a Maximum Take -off Mass (MTOM) below 2 730 kg,
rotorcraft that are not complex motor -powered aircraft, with a MTOM below 1 200 kg and with 4
occupants or fewer, and any ELA2 aircraft is possible by apply ing Standard Change CS -SC101c
INSTALLATION OF EMERGENCY LOCATOR TRANSMITTER (ELT) EQUIPMENT / SATELLITE PERSONAL
LOCATOR BEACON from 2020. This standard change contains the requirement “It must be ensured that the
equipment is installed in a way that, in c ase of a crash, it is unlikely that the antenna would be detached
from the transmitter.” This requirement is applicable since in first issue of Certification Specifications for
Standard Changes and Standard Repairs (CS -STAN) in 2015.
EASA Certification Memorandum Installation of ELTs EASA CM –AS-008 Issue 01 issued 12th of December
2016 contains similar but more prescriptive statements, as it asks for “The antenna should be mounted as
close to the respective ELT as practicable. Provision should be taken to protect coaxial cables from
disjunction or from being cut. Therefore, installation of the external antenna close to the ELT unit is
recommended. Coax ial cables connecting the antenna to the ELT Unit should not cross aircraft production
breaks.” and “When the coaxial cable is installed and the connectors mated, each end should have some
slack in the cable, and the cable should be secured to aircraft structures for support and protection.”
EASA considers the above as sufficient to design proper ELT installations. Note that the 2024 edition of the
European Plan for Aviation Safety (EPAS) volume III documents a safety issue related to ELT malfunctions
(SI-9010). This is published at: https://www.easa.europa.eu/en/document -library/general -
publications/european -plan -aviation -safety -epas -2024 . Additional actions may be derived in the future
from the EU safety risk management process.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
SWED -2017 -008
BAE AVRO 146RJ 100, SE -DSP, 29/09/2016
Safety Recommendation received on 11/09/2017 :
EASA is recommended to encourage that components that require specially approved maintenance
facilities are sealed to detect unauthorized manipulation .
Final r eply sent on 28/11/202 4:
The European Union Aviation Safety Agency (EASA) has produced promotional material on this topic in the
Learning from Occurrences part of the Conversation Aviation Magazine 2 -2024, published at
https://www.easa.europa.eu/community/topics/conversation -aviation -2-2024 -summer -reflection (Page
35) where it is specifically mentioned that “Some aircraft parts are sealed as units before being made
available for fitting to aircraft […].When receiving such parts, engineers should check for such anti -tamper
seals and make sure they are not damaged before the components are fitted to the aircraf t”.
Status: Closed – Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
SWED -2020 -001
Model GA8 -TC 320, SE -MES, 14/07/2019
Safety Recommendation received on 09/09/2020 :
EASA is recommended to consider introducing a formal training programme for pilots in parachute
operations.
Interim r eply sent on 19/12/202 4:
Following incidents related to parachuting operations, a comprehensive Safety Impact Assessment was
conducted. As a result, the Best Intervention Strategy (BIS) “Parachuting Operations” Team was
established. This team comprises representatives from compete nt authorities, a parachuting club, and the
European Union Aviation Safety Agency (EASA).
The team convened multiple meetings during 2023 and 2024 to collaboratively address safety concerns and
develop actionable solutions.
Next Steps:
• Finalisation of the proposed actions in January 2025.
• Subsequent consultation with the Advisory Bodies (AB).
• Finalisation of the BIS is targeted for Q2 2025.
These efforts aim to ensure a comprehensive and effective approach to improving safety within
parachuting operations.
Status: Open
_______________________________________________________________________________________
SWED -2023 -003
Bell 206B , SE-JER, 26/06/2022
Safety Recommendation received on 25/08/2023 :
The EASA is recommended to inform concerned parties about the risks of unanticipated yaw in an
appropriate way.
Final reply sent on 06/02/202 4:
The European Union Aviation Safety Agency (EASA) has now completed the safety promotion activity
intended to address this safety recommendation, although the published material will continue to be
promoted and publicised throughout January 2024.
The topic of Unintended Yaw was chosen as the Safety Topic of the Year by the EASA Rotorcraft Committee
and the work to inform the Rotorcraft community about the risks of unanticipated yaw (termed unintended
yaw for the purposes of the promotion campaign) was then developed by the European Safety Promotion
Network – Rotorcraft (ESPN -R) that is co -led by EASA, Airbus Helicopters and Nederlands Lucht - en
Ruimtevaartcentrum (NLR). The work included a dedicated Vertical Aviation Safety Team (VAST) / ESPN -R
Safe ty Workshop at European Rotors that took place on the afternoon of 29 November 2023.
Safety Recommendation s Received and Replies Sent
January – December 2024
The event materials can be found on the Event Webpage for the EASA Rotorcraft and VTOL Symposium and
associated events at European Rotors:
https://www.easa.europa.eu/en/newsroom -and-events/events/easa -rotorcraft -and-vtol-safety -
symposium -2023 .
The material developed was also used to make a safety promotion article that was published on the EASA
Rotorcraft Community site on 1 December 2023, which can be found here:
https://www.easa.europa.eu/community/topics/handling -unanticipated -yaw.
There was also a safety video made on Unintended Yaw that was launched at the Workshop at European
Rotors that is published on the EASA Together4Safety Youtube Channel here:
https://youtu.be/HjN8mm9wtqY?si=GUGwMs9bP0rBRHra .
The material has also been shared with all Rotorcraft manufacturers and with the global rotorcraft
community through the VAST - https://vast.aero/safety -library/ .
Status: Closed – Agreement
_____________________________________________________________________ __________________
SWTZ -2022 -584
DG-Flugzeugbau GmbH DG800, HB-2320, 28/05/2022
Safety Recommendation received on 19/08/2022 :
The European Union Aviation Safety Agency (EASA), in cooperation with the aircraft manufacturer DG -
Flugzeugbau GmbH, should take measures to ensure that gliders of the DG -800 B type are operated safely
with regard to the installation of the rod ends.
Final reply sent on 06/02/202 4:
In cooperation with the European Union Aviation Safety Agency (EASA), the manufacturer DG -Flugzeugbau
GmbH has evaluated the failure scenario related to unsecured locknuts of the adjustable rod ends for all DG
and LS motorgliders. EASA agrees with the manu facturer that the scenario does not constitute an unsafe
condition. However, to prevent such events from occurring in the future the manufacturer issued Service
Info No. 110/23 which gives instructions to inspect the locknuts and apply securing paint. The instructions
are to be complied with by the following annual inspection at the latest.
Status: Closed – Agreement
_____________________________________________________________________ __________________
UNKG -2009 -080
Airbus A330 -243, G -OJMC, 28/10/2008
Safety Recommendation received on 17/11/2009 :
It is recommended that the European Aviation Safety Agency develop a specification for an aircraft takeoff
performance monitoring system which provides a timely alert to flight crews when achieved takeoff
performance is inadequate for given aircraft configurations and airfield conditions.
Safety Recommendation s Received and Replies Sent
January – December 2024
Interim r eply sent on 19/07/202 4:
On 30 August 2023, the European Union Aviation Safety Agency (EASA) published the Terms of Reference
(ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing a means of informing or alerti ng the flight crew in a timely manner.
Design requirements will be considered to address new large aeroplane designs. An analysis and impact
assessment will be conducted to assess the feasibility and the benefit of design requirements applicable to
existing (already type certificated) large aer oplane designs.
In parallel, the European Organisation for Civil Aviation Equipment (EUROCAE) created Working Group WG -
129 ‘Take -off Performance Monitoring System Strategy’ that held a first meeting on 30 April 2024 with the
participation of EASA. The WG is tasked with de veloping a minimum operational performance standard
(MOPS) and/or a minimum aviation system performance standard (MASPS) in order to facilitate the
introduction of a take -off performance monitoring system (TOPMS). A close relationship with RTCA is also
ensured by EUROCAE in view of issuing a common standard. EASA will take into account the work done by
this WG and ultimately consider any issued standard that could support the compliance demonstration
with new EASA certification specifications.
A Notice of Proposed Amendment (NPA) is being drafted with a publication for consultation currently
expected in Q4 2024.
Status: Open
_____________________________________________________________________ __________________
UNKG -2014 -019
Eurocopter EC225 LP Super Puma , G-REDW , 10/05/2012 and G-CHCN , 22/10/2012
Safety Recommendation received on 04/06/2014 :
It is recommended that the European Aviation Safety Agency commission research into the fatigue
performance of components manufactured from high strength low alloy steel. An aim of the research
should be the prediction of the reduction in service -life and fatigue strength as a consequence of small
defects such as scratches and corrosion pits.
Final r eply sent on 28/11/202 4:
In the context of rotorcraft design and certification activities, an evaluation by Type Certificate Holders and
the European Union Aviation Safety Agency (EASA) of the effect of corrosion on fatigue strength for high -
strength steels had been carried out. This had already resulted in changes to the means provided by
applican ts to show compliance with CS 29.571 fatigue tolerance requirements.
Safety Recommendation s Received and Replies Sent
January – December 2024
EASA has completed the research project into “Integrity Improvement of Rotorcraft Main Gear Box (MGB)”
(ref. European Plan for Aviation Safety RES.0008).
The outcome of the research project is published at https://www.easa.europa.eu/en/research -
projects/integrity -improvement -rotorcraft -main -gear -box-mgb .
Status: Closed – Agreement
_____________________________________________________________________ __________________
UNKG -2015 -001
AIRBUS A319 -131, G -EUOE, 24/05/2013
Safety Recommendation received on 14/07/2015 :
It is recommended that the European Aviation Safety Agency publishes amended Acceptable Means of
Compliance and Guidance Material in Part 145.A.47(b) of European Commission Regulation (EC) No
2042/2003, containing requirements for the implementation of an effective fatigue risk mana gement
system within approved maintenance organisations.
Final r eply sent on 16/10/202 4:
Regulation (EU) 2021/1963 of 8 November 2021 introduced amendments to Regulation (EU) No 1321/2014,
among others, requiring the establishment of a Safety Management System (SMS) in all maintenance
organisations approved in accordance with Annex II (Part -145) to Regulation (EU) No 1321/2014. The
amendment is applicable as of 2 December 2022, with some transition time until 2 December 2024.
On the 10 May 2022 the European Union Aviation Safety Agency (EASA) published Executive Director
Decision 2022/011/R (available at https://www.easa.europa.eu/en/document -library/agency -decisions/ed -
decision -2022011r ) that provides Acceptable Means of Compliance (AMC) and Guidance Material (GM) to
the amended Regulation (EU) No 1321/2014. In particular, AMC1 145.A.47(b) "Production planning"
includes a chapter titled "Consideration of Fatigue in the Planning of Mainte nance" to ensure that the SMS
adequately considers effective fatigue risk management.
As of 2 December 2024, all maintenance organisations approved in accordance with Part -145 must have
implemented an SMS, which is expected to include an effective fatigue management.
Additionally, EASA has taken several measures since the subject accident, e.g. publication of Safety
Information Bulletin (SIB) 2015 -15, which can be downloaded at https://ad.easa.europa.eu/ad/2015 -15, to
raise awareness about the risk of taking off with unlocked fan cowl doors.
Status: Closed – Agreement
_____________________________________________________________________ __________________
UNKG -2016 -013
AS332 L2 Super Puma , G-WNSB , 23/08/2013
Safety Recommendation received on 08/03/2016 :
It is recommended that the European Aviation Safety Agency requires the installation of Helicopter Terrain
Awareness Warning Systems to all helicopters, used in offshore Commercial Air Transport operations, with
Safety Recommendation s Received and Replies Sent
January – December 2024
a Maximum Certificated Take -off Mass (MCTOM) of more than 3,175 kg, or a Maximum Operational
Passenger Seating Configuration (MOPSC) of more than nine, manufactured before 31 December 2018.
Interim r eply sent on 28/11/202 4:
The consideration to extend the existing helicopter terrain avoidance warning systems (HTAWS)
requirements for offshore helicopter operations included in point SPA.HOFO.160(c) of Subpart K Helicopter
Offshore Operations of Annex V (Part -SPA) to Commission Regulation (EU) No 965/2012 to include those
helicopters first issued with an individual Certificate of Airworthiness (CofA) on or before 31 December
2018 is being undertaken in rulemaking task RMT.0708 ‘Controlled flight into terrain prevention with
HTAWS ’.
Following a prioritisation exercise, Rulemaking Task RMT.0708 Subtask 1a on Controlled Flight Into Terrain
prevention with (HTAWS) for offshore operations, for which a Notice of Proposed Amendment (NPA) was
planned in 2025, will be put on hold. This will be reflected in the 2025 edition of the European Plan for
Aviation Safety (EPAS).
The European Union Aviation Safety Agency (EASA) will keep the Air Accidents Investigation Branch
informed of further progress on this rulemaking task.
Status: Open
_____________________________________________________________________ __________________
UNKG -2016 -014
AS332 L2 Super Puma , G-WNSB, 23/08/2013
Safety Recommendation received on 08/03/2016 :
It is recommended that the European Union Aviation Safety Agency introduces a requirement for the
installation of cockpit image recorders, in aircraft required to be equipped with Flight Data and Cockpit
Voice Recorders, to capture flight crew actions with in the cockpit environment.
Final r eply sent on 07/06/202 4:
In 2018, the International Civil Aviation Organization (ICAO) adopted a new standard on ‘Flight crew -
machine interface recordings’ (FCMIR) in Annex 6 Part I (International Commercial Air Transport —
Aeroplanes) Chapter 6, section 6.3.4, and the corresponding Appendix 8) with an applicability to aeroplanes
of a maximum take -off mass of over 27 000 kg and for which the application for type certification was
submitted on or aft er 1st January 2023. No standard similar to this one has been introduced to helicopters
in Annex 6 Part III (International Operations — Helicopters).
This standard requires the aeroplane to be equipped with a crash -protected flight recorder which shall
record the information displayed to the flight crew from electronic displays, as well as the operation of
switches and selectors by the flight crew as de fined in Appendix 8.
Compliance with this standard may be achieved by means of an airborne image recorder, or by other
means capable of meeting the objective of the standard. The use of image recorders in the cockpit was not
required due to privacy concerns.
ICAO Doc 10101, published in 2021, provides guidance material for the implementation of appropriate
provisions for FCMIRs as required by Annex 6 Part I, Chapter 6, 6.3.4 and provides references to the
protective measures needed for these recordings.
Safety Recommendation s Received and Replies Sent
January – December 2024
The European Union Aviation Safety Agency (EASA) will continue to follow the developments in ICAO and
will assess the need for transposition of such standards into EU requirements via its rulemaking process.
EASA does not intend to propose a rule mandating a FCMIR for helicopters if no corresponding ICAO
standard exists, however an assessment of the introduction of these recorders on aeroplanes will be done
through Rule Making Task 0392, Subtask 2.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
UNKG -2016 -016
AS332 L2 Super Puma , G-WNSB , 23/08/2013
Safety Recommendation received on 08/03/2016 :
It is recommended that the European Aviation Safety Agency instigates a research programme to provide
realistic data to better support regulations relating to evacuation and survivability of occupants in
commercial helicopters operating offshore. This prog ramme should better quantify the characteristics of
helicopter underwater evacuation and include conditions representative of actual offshore operations and
passenger demographics.
Final r eply sent on 28/11/202 4:
An initial review into the nature of the research that could be envisaged to provide realistic data to better
support regulations relating to evacuation and survivability of occupants in helicopters operating offshore
was commissioned by the European Union Aviation Safety Agency (EASA) in 2020.
The results of this first Helicopter Underwater Escape research project provided a comprehensive review of
currently available information on underwater escape, identified shortfalls, and recommended further
work to rectify this lack of information.
The final report is published on the EASA website: https://www.easa.europa.eu/en/research -
projects/helicopter -underwater -evacuation .
Two of the highest -priority recommendations identified in the initial review were investigated in a
subsequent research project: evaluation of the forces required to jettison push -out underwater emergency
exits and underwater escape from a passenger cabin with a full complement of passengers.
The final report of this additional research is published on the EASA website:
https://www.easa.europa.eu/en/research -projects/helicopter -underwater -escape -2
The main objective of the second research project was to review the related rules, requirements,
Acceptable Means of Compliance (AMC) and guidance material and propose areas for future rulemaking.
The research activity concluded that the current Certificat ion Specifications and Regulations are adequate
and, however, provided recommendations for updates to AMC material.
As a result, EASA has decided to further review these recommendations, which will now be expedited by
re-opening rulemaking task RMT.0120 or, alternatively, as a complement to another ongoing helicopter
RMT.
Following the successful completion of two successive research programmes, EASA considers that these
activities adequately address the intent of the safety recommendation and the results obtained will now be
further followed up within EASA’s continuous rul emaking programme aimed at improving helicopter
certification standards.
Safety Recommendation s Received and Replies Sent
January – December 2024
Status: Closed – Agreement
_____________________________________________________________________ __________________
UNKG -2018 -014
Boeing 737 -800, C-FWGH , 21/07/2017
Safety Recommendation received on 14/11/2018 :
It is recommended that the European Aviation Safety Agency, in conjunction with the Federal Aviation
Administration, sponsor the development of technical specifications and, subsequently, develop
certification standards for a Takeoff Acceleration Monitorin g System which will alert the crew of an aircraft
to abnormally low acceleration during takeoff.
Interim r eply sent on 19/07/202 4:
On 30 August 2023, the European Union Aviation Safety Agency (EASA) published the Terms of Reference
(ToR) for Rulemaking Task RMT.0741:
https://www.easa.europa.eu/en/document -library/terms -of-reference -and-rulemaking -group -
compositions/tor -rmt0741
The objective of this RMT is to mitigate, using on -board design means of protection, the risk of large
aeroplane accidents or incidents caused by the use of erroneous take -off performance parameters, and by
erroneous take -off positions.
Taking into account design solutions that have been developed by industry to date, this objective should be
achieved through the introduction of design requirements aiming at detecting and preventing these errors
by providing a means of informing or alerti ng the flight crew in a timely manner. This should include the
monitoring of real -time aeroplane performance during the take -off roll.
Design requirements will be considered to address new large aeroplane designs. An analysis and impact
assessment will be conducted to assess the feasibility and the benefit of design requirements applicable to
existing (already type certificated) large aer oplane designs.
In parallel, the European Organisation for Civil Aviation Equipment (EUROCAE) created Working Group WG -
129 ‘Take -off Performance Monitoring System Strategy’ that held a first meeting on 30 April 2024 with the
participation of EASA. The WG is tasked with developing a minimum operational performance standard
(MOPS) and/or a minimum aviation s ystem performance standard (MASPS) in order to facilitate the
introduction of a take -off performance monitoring system (TOPMS). A close relationship with RTCA is also
ensured by EUROCAE in view of issuing a common standard. EASA will take into account the work done by
this WG and ultimately consider any issued standard that could support the compliance demonstration
with new EASA certification specifications.
A Notice of Proposed Amendment (NPA) is being drafted with a publication for consultation currently
expected in Q4 2024.
Status: Open
_______________________________________________________________________________________
Safety Recommendation s Received and Replies Sent
January – December 2024
UNKG -2021 -015
Alauda Airspeeder Mk II (UAS) , no registration , 04/07/2019
Safety Recommendation received on 11/02/2021 :
It is recommended that the European Union Aviation Safety Agency adopt appropriate design, production,
maintenance and reliability standards for all Unmanned Aircraft Systems with aircraft capable of imparting
over 80 joules of energy.
Final r eply sent on 16/10/202 4:
The European Union Aviation Safety Agency (EASA) assisted the European Commission and the European
Committee for Standardisation (CEN) in the development of a set of industry standards for the design,
production, maintenance and reliability of drones capab le of imparting over 80 Joule of energy. In
summary, the applicable standards are:
• ASD -STAN prEN 4709 -001 P1, published at https://stan -shop.org/en/catalog/item/75627?search=4709 -
• DIN EN 4709 -002:2024 -03, published at https://www.dinmedia.de/de/norm/din -en-4709 -002/373551874
• ASD -STAN prEN 4709 -003 P1 - Corrigendum 1, published at https://stan -shop.org/en/catalog/item/75419
• ASD -STAN prEN 4709 -004 P1, published at https://stan -shop.org/en/catalog/item/75302
Following the publication in July 2024 of the last of this set of industry standards, the actions of EASA
resulting from the safety recommendation may be considered closed.
The above standards are in the process of being adopted by the European Commission as harmonised EU
norms for the placing on the market of Unmanned Aircraft Systems (UAS) in the open category, according
to Regulation (EU) 2019/945.
Status: Closed – Agreement
_____________________________________________________________________ __________________
UNKG -2021 -018
Airbus A321, G -POWN, 26/02/2020
Safety Recommendation received on 04/05/2021 :
It is recommended that the European Union Aviation Safety Agency amend the Acceptable Means of
Compliance AMC2(a)(3) for regulation Part -145.A.48(b), Performance of Maintenance, to include the
treatment of aircraft fuel systems with biocide additives as an example task that is to be considered as a
critical maintenance task.
Interim reply sent on 22/03/202 4:
The European Union Aviation Safety Agency (EASA) assessed the contents of the referred Acceptable
Means of Compliance (AMC) and considers that the best approach would be to include in the list of data
sources used to identify critical maintenance tasks (see point (b) of AMC2 145.A.48(c)(2)) relevant authority
publications such as EA SA Safety Information Bulletin (SIB) 2020 -06, which deals with biocide treatment.
This regulatory amendment will be addressed under rulemaking task RMT.0735, which addresses
miscellaneous non -controversial topics and identified issues to ensure that Regula tion (EU) No 1321/2014,
Safety Recommendation s Received and Replies Sent
January – December 2024
its AMC, and Guidance Material (GM) remain fit for purpose. The Terms of Reference (ToR) for RMT.0735
were published in December 2023 and a Notice of Proposed Amendment (NPA) is planned for Q3 2024.
Status: Open
_____________________________________________________________________ __________________
UNKG -2021 -019
Airbus A321, G -POWN, 26/02/2020
Safety Recommendation received on 04/05/2021 :
It is recommended that the European Union Aviation Safety Agency amend the Acceptable Means of
Compliance AMC1(c) for regulation M.A.402(h), Performance of Maintenance, to include the treatment of
aircraft fuel systems with biocide additives as an example task that is to be considered as a critical
maintenance task.
Interim reply sent on 22/03/202 4:
The European Union Aviation Safety Agency (EASA) assessed the contents of the referred Acceptable
Means of Compliance (AMC) and considers that the best approach would be to include in the list of data
sources used to identify critical maintenance tasks (se e GM M.A.402(h)) relevant authority publications
such as the EASA Safety Information Bulletin (SIB). This regulatory amendment will be addressed under
rulemaking task RMT.0735, which addresses miscellaneous non -controversial topics and identified issues to
ensure that Regulation (EU) No 1321/2014, its AMC, and Guidance Material (GM) remain fit for purpose.
The Terms of Reference (ToR) for RMT.0735 were published in December 2023 and a Notice of Proposed
Amendment (NPA) is planned for Q3 2024.
Status: Open
_____________________________________________________________________ __________________
UNKG -2021 -020
Airbus A321 , G-POWN , 26/02/2020
Safety Recommendation received on 04/05/2021 :
It is recommended that the European Union Aviation Safety Agency (EASA) conduct safety promotion with
the National Aviation Authorities (NAAs) of EASA Member States to promote the classification of biocide
treatment of aircraft fuel systems as a critical m aintenance task.
Interim r eply sent on 19/12/202 4:
The European Union Aviation Safety Agency (EASA) has implemented two safety promotion actions on this
topic as key aspects of preventing maintenance error and mitigating risks coming from this domain.
Specifically:
• an article was published in the Conversation Aviation Magazine 1 -2024, published at:
https://www.easa.europa.eu/community/topics/conversation -aviation -1-2024 -dirty -dozen -edition
(Page 23) on 29 February 2024.
• the topic was also covered in a specific article 1 July 2024 with an article on Preventing
Maintenance Error, published at https://www.easa.europa.eu/community/topics/preventing -
maintenance -error.
Safety Recommendation s Received and Replies Sent
January – December 2024
The topic has also been discussed in the Safety Promotion Network that is the collaborative group with
EASA and the National Aviation Authorities (NAAs) that coordinates safety promotion across Europe. This is
to ensure that the NAAs are also aware of the work carried o ut and promote it to both their own staff and
maintenance organizations in their jurisdiction.
EASA plans to launch another safety promotion initiative specific to the biocide topic in Q1 2025.
Status: Open
_____________________________________________________________________ __________________
UNKG -2023 -001
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency amend Certification Specification
29.602 to require type design manufacturers to provide the results of all relevant system and flight testing
to any supplier who retains the sole expertise t o assess the performance and reliability of components
identified as critical parts within a specific system application, to verify that such components can safely
meet the in -service operational demands, prior to the certification of the overall system.
Final reply sent on 06/02/202 4:
Pursuant to point 21.A.20 of Annex I (Part 21) to Regulation (EU) No 748/2012, the applicant for aircraft
type certification is responsible for the demonstration of compliance with the type certification basis (that
includes certification specifications), and to record justifications of compl iance within the compliance
documents as referred to in the certification programme. This implies ensuring that parts and systems
reach minimum performance and reliability targets.
Therefore, the applicant is responsible for providing any information such as, but not limited to, test results
to its suppliers to ensure a final airworthy design.
This principle is not specific to certain products and should not be repeated in each Certification
Specification where a supplier could be affected.
The European Union Aviation Safety Agency (EASA) considers that the above -mentioned regulatory
framework, including Certification Specifications, is adequate and does not envisage creating new
prescriptive requirements.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
UNKG -2023 -002
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency introduce additional requirements to
Certification Specification 29 to specifically address premature rolling contact fatigue failure across the full
operating spectrum and service life of bearings used in safety critical applications.
Interim reply sent on 06/02/202 4:
Point CS 29.571 (Fatigue Tolerance Evaluation of Metallic Structure) paragraph (d) of Certification
Specification for Large Rotorcraft (CS -29) specifies the following with regard to Principle Structure Elements
(PSE):
“Each PSE must be identified. Structure to be considered must include the rotors, rotor drive systems
between the engines and rotor hubs, controls, fuselage, fixed and movable control surfaces, engine and
transmission mountings, landing gear, and their related primary attac hments.”
The European Union Aviation Safety Agency (EASA) considers that this includes critical components within
the rotor control mechanism, such as the tail rotor duplex bearing of the AW169.
Acceptable Means of Compliance AMC1 29.571 (introduced with Amendment 11 of CS -29) addresses
Rolling Contact Fatigue (RCF) which should be included, when applicable, in the fatigue tolerance
evaluation of Principle Structure Elements (PSE). This AMC descri bes possible steps to be taken to minimise
the risk of crack initiation due to RCF on PSEs (and in particular for integrated bearing races). A fail -safe
approach is recommended wherever possible, such that cracking of the affected structural element(s) is
detected prior to its residual strength capability falling below the required levels prescribed in CS 29.571(f).
In addition to following a fail -safe approach, inspection and retirement times may be needed in order to
ensure that the assumptions supporting the fail -safety and detection of failure remain valid throughout the
operational life of the component.
EASA is however reviewing the opportunity to clarify the scope of application of AMC1 29.571, and similarly
of AMC1 27.571, to ensure that critical bearings are always considered. A proposed amendment of CS -27
and CS -29 is planned to be included in the nex t Notice of Proposed Amendment under rulemaking task
RMT.0128 ‘Regular update of the Certification Specifications for Very Light Rotorcraft (CS -VLR), Small
Rotorcraft (CS -27), and Large Rotorcraft (CS -29)’.
Status: Open
_____________________________________________________________________ __________________
UNKG -2023 -003
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency amend Certification Specification
29.602 to define the airworthiness status of life limits on non -structural critical parts and how they should
be controlled in service.
Safety Recommendation s Received and Replies Sent
January – December 2024
Final reply sent on 06/02/202 4:
Inspections and/or retirement times are introduced in the Airworthiness Limitations Section (ALS) of the
Instructions for Continued Airworthiness (ICA) based on:
1. The fatigue and damage tolerance evaluations performed when showing compliance with points CS
29.571 (Fatigue Tolerance Evaluation of Metallic Structure) and CS 29.573 (Damage Tolerance and
Fatigue Evaluation of Composite Rotorcraft Structures) of Certific ation Specification for Large
Rotorcraft (CS -29). Note: the European Union Aviation Safety Agency (EASA) considers that tail
rotor bearings are part of the scope of CS 29.571/573; or
2. Certification Maintenance Requirements (CMRs) identified when showing compliance with points
CS 29.1309 [or equivalent assessments performed when showing compliance with other CS -29
paragraphs such as CS 29.547(b) (Main and tail rotor structure) or CS 29.9 17(b) (Rotor drive system
design)] to ensure that safety objectives are met when addressing significant latent failures (refer
to Federal Aviation Administration (FAA) Advisory Circular 29 -2C, paragraph 29.1309, which is
recognised as Acceptable Means of C ompliance (AMC) to CS -29; in addition, details on CMRs are
provided in CS -25, AMC 25 -19, the content of which is also applied by EASA to CS -29 certification
projects through a Means of Compliance Certification Review Item).
Thus, EASA considers that the ‘airworthiness status of life limits’ of critical parts is ensured by means of
demonstrating that the necessary limits are established, when required, in compliance with the
Certification Specifications mentioned in points 1 a nd 2 above.
Following the creation of AMC1 29.571 (addressing rolling contact fatigue) as part of Amendment 11 of CS -
29 (ED Decision 2023/001/R), EASA will ensure that bearings installed in rotorcraft certified by EASA comply
with CS 29.571 and feature adequate life limits in the ALS, when required.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
UNKG -2023 -004
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency define the airworthiness status of life
limits and how they should be controlled for existing non -structural critical parts approved to Certification
Specification 29.602 requirements, already in service.
Final reply sent on 22/03/202 4:
In accordance with point 21.A.7 of Annex I (Part 21) to Regulation (EU) No 748/2012, the Type Certificate
Holder (TCH) must provide Instructions for Continued Airworthiness (ICA) for critical parts, either structural
or non -structural, and, in case of large rotorcraft, the preparation of ICA must be performed in compliance
with the Certification Specification (CS) 29.1529.
The ICA applicable to critical parts may be included within the Airworthiness Limitation Section (ALS) of the
ICA and/or in other appropriate Sections.
Retirement Times or Operational Time Limits provided in the ICA are necessary for the safe operation of
the aircraft and they have to be implemented in the Aircraft Maintenance Programme (AMP) to obtain
Safety Recommendation s Received and Replies Sent
January – December 2024
approval by the Competent Authority [ref. point M.A.302(d)(2) of Annex I (Part M) to Regulation (EU) No
1321/2014]. This requirement is applicable to both ALS and other Sections of the ICA.
In addition, point 21.A.3A of Annex I (Part 21) to Regulation (EU) No 748/2012 contains the necessary
provisions for ensuring the collection, investigation and analysis of occurrence reports to identify the
necessary mitigations in terms of changes to the design and/or to the ICA to prevent or minimize the
possibility of such occurrences in the future, as necessary. This includes, as per point 21.A.3A(a)(1), the
identification of adverse trends or deficiencies that cause or might cause adverse effects on th e continuing
airworthiness of the product. The ‘analysis’ is not limited to those occurrences that require the involvement
of the European Union Aviation Safety Agency (EASA) under point 21.A.3A(e).
Taking into account the information above, the EASA considers that the necessary regulatory framework is
already in place and, therefore, EASA does not intend to re -define or re -evaluate the airworthiness status
of ICA for critical parts, either structural or non -structural, already in service.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
UNKG -2023 -005
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency amend Certification Specification
29.602 to require manufacturers to implement a comprehensive post removal from service assessment
programme for critical parts. The findings from this should be used to ensure that reliability and life
assumptions in the certification risk analysis for the critical part or the system in which it operates remain
valid.
Interim reply sent on 06/02/202 4:
The European Union Aviation Safety Agency (EASA) issued Certification Memorandum (CM) CM -S-007
dated 19 August 2015 on ‘Post Certification Actions to Verify the Continued Integrity of Rotorcraft Critical
Parts’. The purpose of this CM is to supplement the existing guidance for compliance with Certification
Specifications CS 27.602 and CS 29.602 (Critical Par ts), detailing the need for post certification actions to
verify the continued integrity of Critical Parts. These actions should ensure that critical parts are controlled
throughout their service life in order to maintain the critical characteristics on wh ich certification is based.
In addition, the effectiveness of any associated design, maintenance and monitoring provisions, which
either help to ensure the continued integrity or provide advance indication of impending failure of critical
parts, should be assessed.
EASA also addressed this topic under rulemaking task RMT.0128 ‘Regular update of CS -27&29’. Notice of
Proposed Amendment (NPA) 2022 -01 was published on 14 February 2022. Under item 6, this NPA
proposed to amend CS -27 and CS -29 (certification specifications and acceptable means of compliance for
small and large rotorcraft).
The NPA proposed to create CS 27.602(c)/29.602(c) and associated acceptable means of compliance AMC1
27.602/29.602 to require the development of a continued integrity verification programme (CIVP). The
Safety Recommendation s Received and Replies Sent
January – December 2024
content of the proposed amendments was based on CM -S-007, which is currently used during new Type
Certifications (TC) and major changes to existing TC.
The CIVP should ensure the continued validity of assumptions made during certification that could affect
the integrity of critical parts. This should include, but not be limited to, demonstration of the continuity of
the effectiveness of design, maintenance and monitoring provisions (e.g. health monitoring, usage
monitoring and safety devices).
However, several comments have been raised during the public consultation of NPA 2022 -01 and
highlighted a need to clarify the applicability, to promote the proportionality and to better refine the
concept of CIVP before its introduction in CS -27 and CS -29. A dedicated webinar was organised on 28
November 2022 to discuss those concerns with industry and National Competent Authorities (NCA). The
feedback received was quite positive even if it was clear that the concept needs to be studied further
before CIVP is introduced within CS -27 and CS -29.
In consequence, it has been decided that this topic will not be included in the CS -27 and CS -29
amendments resulting from NPA 2022 -01.
The CIVP concept is being reviewed by EASA, and a revision of CM -S-007 is being prepared. In this revision,
it is envisaged to clarify that, in case of any findings during the CIVP questioning the validity of the
certification assumptions, the applicant should perform a detailed evaluation of the potential impact on
flight safety and, when nece ssary, report to its competent authority for continued airworthiness (EASA and
national competent authority). The analysis of a finding in a CIVP could lead to change s to the future
certification approach for similar components and/or to continued airworthiness actions.
In parallel, EASA intends to create a new rulemaking task to prepare a new proposal for CS -27 and CS -29
amendment in consultation with the industry.
The response to this safety recommendation will be updated when progress is made with the above -
mentioned actions.
Status: Open
_____________________________________________________________________ __________________
UNKG -2023 -006
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency require manufacturers to
retrospectively implement a comprehensive post removal from service assessment programme for critical
parts, approved to Certification Specification 29.602 requiremen ts, already in service. The findings from this
should be used to ensure that the reliability and life assumptions in the certification risk analysis for the
critical part or the system in which it operates remain valid.
Final reply sent on 22/03/202 4:
Point 21.A.3A of Annex I (Part 21) to Regulation (EU) No 748/2012 defines the obligations applicable to the
Type Certificate Holders (TCHs) to establish and maintain a system for collecting, investigating and
Safety Recommendation s Received and Replies Sent
January – December 2024
analysing occurrence reports. This includes, as per point 21.A.3A(a)(1), identification of adverse trends or
deficiencies that might cause adverse effects on the continuing airworthiness of the product.
In addition, acceptable means of compliance AMC1 21.A.3A(a) clarifies that, for parts whose failure could
lead to an unsafe condition (and critical parts are candidates as they could have catastrophic effect upon
the rotorcraft), the ‘analysis’ function of the system should ensure that reports and information sent, or
available, to the Design Approval Holder (DAH) are fully investigated so that the exact nature of any event
and its effect on continuing airworthiness is understood. This may then result in ch anges to the design
and/or to the Instructions for Continued Airworthiness (ICA), and/or in establishing a mitigation plan to
prevent or minimize the possibility of such occurrences in the future, as necessary. The ‘analysis’ is not
limited to those occurr ences that require the involvement of the European Union Aviation Safety Agency
(EASA) under point 21.A.3A(e).
EASA considers that obligations outlined in 21.A.3A already indicate that the TCH shall collect, investigate
and analyse reports and information [including the early rejection of parts from service as mentioned in
guidance material GM1 21.A.3A(a) and 21.A. 3A(b) Reporting system] that might question the certification
assumptions for critical parts and when necessary, define design changes and implement mitigation plans.
Therefore, EASA considers that the necessary regulatory framework is already in place to address the intent
of this Safety Recommendation (SR) and, therefore, there is no need to retrospectively implement a
comprehensive post removal from service assessmen t programme for critical parts already in service.
Status: Closed – Disagreement
_____________________________________________________________________ __________________
UNKG -2023 -007
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency amend Certification Specification
29.602 to provide guidance and set minimum standards for the calculation of design load spectrums for
non-structural critical parts. They must encompass, with an a ppropriate and defined safety margin, the
highest individual operating load and combination of dynamic operating loads, and the longest duration of
exposure to such loads that can be experienced in operation.
Interim reply sent on 06/02/202 4:
The accident investigation report mentions a non -conservative load calculation at the time of certification
as a potential root cause of the bearing failure.
The European Union Aviation Safety Agency (EASA) does not share this single factor conclusion, considering
that other possible detrimental factors might also have contributed to the bearing failure, as already
explained in comments appended to the final in vestigation report as Appendix K, published here: AAR_1 -
2023_G -VSKP_Final_Vol_2.pdf (publishing.service.gov.uk)
The methodology for load calculation as used by Leonardo is not novel or unusual and does not require
complete reconsideration by new prescriptive certification specifications.
However, as lessons learnt from this accident, EASA considers that future approvals of hybrid bearing with
ceramic balls will deserve more attention as regards to the failure mechanics and the sensitivity of the
Safety Recommendation s Received and Replies Sent
January – December 2024
bearing to its working conditions (including abnormal conditions created by e.g. manufacturing defects,
degraded lubrication, improper maintenance, etc.,) in order to better cope with a wider range of scenarios.
EASA plans to issue a Certification Memorandum (CM) to provide specific guidance related to the
demonstration of compliance with applicable CS -27 and CS -29 certification specifications for hybrid
bearings (combination of steel races with ceramic ball beari ngs).
The response to this safety recommendation will be updated when the CM is issued.
Status: Open
_____________________________________________________________________ __________________
UNKG -2023 -008
Leonardo AW169 , G-VSKP , 27/10/2018
Safety Recommendation received on 25/08/2023 :
It is recommended that the European Union Aviation Safety Agency amend the relevant requirements of
Certification Specification 29 and their Acceptable Means of Compliance to emphasise that where
potentially catastrophic failure modes are identified, rathe r than rely solely on statistical analysis to address
the risk, the wider system should also be reviewed for practical mitigation options, such as early warning
systems and failure tolerant design, in order to mitigate the severity of the outcome as well a s the
likelihood of occurrence.
Final reply sent on 06/02/202 4:
The European Union Aviation Safety Agency (EASA) considers that some steps have already been taken to
ensure a more comprehensive evaluation of critical bearings installed in the rotor and rotor drive systems.
For instance, Certification Specification CS 29.571 (Fatigue tolerance evaluation of metallic structure) and
Acceptable Means of Compliance AMC1 29.571 (dealing with rolling contact fatigue (RCF)) address the
need to take into account the impact of RCF and minimise the risk of crack initiation resulting from RCF on
Principal Structural Elements (PSEs). In addition, AMC1 29.571 states that ‘as it is difficult to totally
preclude cracking initiated by RCF, a fail -safe approach is recommended wherever possible , such that
cracking of the affected structural element(s) is detected prior to its residual strength capability falling
below the required levels prescribed in CS 29.571(f)’.
No further change to CS -29 is planned on this topic.
Final r eply sent on 19/07/202 4:
The European Union Aviation Safety Agency (EASA) considers that practical mitigation options such as early
warning systems and failure tolerant designs are relevant means to achieve adequate safety levels in
rotorcraft designs.
According to CS -29 Amdt 11 (Certification Specifications, Acceptable Means of Compliance (AMC) and
Guidance Material for Large Rotorcraft), CS 29.571 (Fatigue tolerance evaluation of metallic structure) and
AMC1 29.571 (dealing with rolling contact fatigue (RCF)) address the need to take into account the impact
of RCF and minimise the risk of crack initiation resulting from RCF on Principal Structural Elements (PSEs). In
addition, AMC1 29.571 states that ‘as it is difficult to totally preclude cracking init iated by RCF, a fail -safe
approach is recommended wherever possible, such that cracking of the affected structural element(s) is
detected prior to its residual strength capability falling below the required levels prescribed in CS 29.571(f)’.
Hence AMC1 29 .571 clearly introduces the notion of fail -safe designs and of means of detection to fulfil the
Safety Recommendation s Received and Replies Sent
January – December 2024
objective of preventing failure as a result of RCF. This regulatory material was relatively new at the date of
publication of the accident investigation report and it appeared, in EASA’s view, not to have been
considered.
Nevertheless, additional CS -29 provisions help to meet the intent of this safety recommendation:
(1) The design assessments specified by CS 29.547(b) (Strength requirements - Main and tail rotor
structure) and CS 29.917(b) (Powerplant – Rotor Drive System - Design) require the identification of
all failures in rotors and rotor drive systems that will prev ent continued safe flight or safe landing,
as well as the means to minimise the likelihood of their occurrence. As per Federal Aviation
Administration (FAA) Advisory Circular (AC) 29 -2C Change 7 (recognised as AMC to CS -29) sections
29.547 and 29.917, ‘a d esign assessment […] should be carried out in order to substantiate that the
system is of a safe design and that compensating provisions are made available to prevent failures
classified as hazardous and catastrophic[…]’. The listed compensating provisions include design
features (such as redundancies and safety factors) and the use of safety devices or vibration health
monitoring systems, which cover the means proposed by the AAIB in this safety recommendation.
Other compensating provisions such as inspect ions or checks, as well as preventive maintenance
are also listed.
(2) Since some years EASA has recognised the need to clearly identify those continuing airworthiness
tasks which are listed as compensating provisions in the aforementioned design assessments and
are also considered key to ensuring that the hazardous and catas trophic failures of the design are
either adequately mitigated or their probability of occurrence has been adequately minimised.
EASA considers that these continuing airworthiness tasks should be:
i. considered as candidates for Certification Maintenance Requirements (CMRs) in
accordance with AMC 25 -19 of CS -25 (Certification Specifications and Acceptable Means of
Compliance for Large Aeroplanes). EASA currently addresses the application of the CS -25
CMR concept to support the demonstration of compliance with large rotorcraft
certification specifications requiring safety assessment and design assessment, including CS
29.547(b) and CS 29.917(b), through a Means of Compliance Certification Review Item.
Therein applicants are requested to detail the criteria and methods to demonstrate the
adequacy of these CMRs.
ii. evaluated for the need of dedicated certification testing to demonstrate adequate
performance and suitable intervals. EASA is currently considering the possibility of
introducing new AMC to CS 29.927(a) (Additional tests) to address this aspect. This would
clarify the need to support inspection intervals and retirement times with appropriate
directly applicable data.
In conclusion, while the relevance of a full assessment of the design and a detailed evaluation of the failure
scenarios is agreed and already present in CS -29, EASA considers that mandating design measures to
systematically mitigate the outcome of catastr ophic failures could be counterproductive. This could lead to
impractical and overly complex solutions, that negatively impact the reliability of rotors and rotor drive
systems.
Based on the above, EASA considers that the necessary elements are in place to ensure that hazardous and
catastrophic failures are adequately addressed during certification, by adequately mitigating such failures
and/or minimising their probability of occu rrence, thus, ensuring adequate safety levels.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
Safety Recommendation s Received and Replies Sent
January – December 2024
UNKG -2024 -004
Extra NG , G-MIIL , 02/04/2022
Safety Recommendation received on 16/02/2024 :
It is recommended that the European Union Aviation Safety Agency (EASA) ensure the canopies fitted to all
Extra NG aircraft are manufactured to meet the required certification standards and can withstand
expected aerodynamic and flight loads.
Interim reply sent on 26/04/202 4:
The European Union Aviation Safety Agency (EASA), together with the aircraft manufacturer, has reviewed
the design data of the EXTRA NG canopy. The manufacturing process, used to bond the inner and outer
canopy frames with each other, and the canopy glass with the previously bonded canopy frame, is
unchanged compared to the earlier Type Design EA 300 for which no similar in -service occurrence was
recorded. Additionally, the Type Certificate Holder (TCH) has conducted a computational fluid dynamics
(CFD) ana lysis under conservative assumptions which has shown that the canopy assembly meets the
required certification standards.
Nevertheless, EASA is evaluating, with the aircraft manufacturer, the need to perform on a voluntary basis,
a one -time Non Destructive Test (NDT) to verify the correct bonding of the in service canopy frames as
precautionary measure.
EASA is also considering the scenario presented by Bundesstelle für Flugunfalluntersuchung (BFU) on the
role that the change in the locking mechanism of the canopy of the Extra NG compared to the previous
models might have had in the accident.
Status: Open
_____________________________________________________________________ __________________
UNKG -2024 -005
Extra NG , G-MIIL , 02/04/2022
Safety Recommendation received on 16/02/2024 :
It is recommended that the European Union Aviation Safety Agency (EASA) assess the effectiveness of SB -
NG-2-22 in rectifying inadequate bonding.
Final r eply sent on 26/04/202 4:
The European Union Aviation Safety Agency (EASA) highlights that Service Bulletin (SB) SB -NG-2-22 was
issued as a precautionary measure following the subject accident. The intent of the SB was not to rectify an
assumed inadequate bonding. EASA finds that t he actions prescribed in the SB would be effective in
improving the bonding by fitting the canopy glass more homogeneously to the canopy frame.
Final r eply sent on 28/11/202 4:
The European Union Aviation Safety Agency (EASA) considers the conclusion received on 28/06/2024
(AAIB -28120) concerning the scope of the SB -NG-2-22 is correct. Notwithstanding the above, EASA’s view is
that Extra NG aircraft canopies comply with the appli cable certification requirements even without the
incorporation of the aforementioned SB. As precautionary measure, the manufacturer is willing to
recommend a one -off inspection of canopy frames as per Aircraft Maintenance Manual 20 -10-06 on
Safety Recommendation s Received and Replies Sent
January – December 2024
aeroplanes in service. Furthermore, not overlooking the possibility that the canopy was not correctly
latched, the manufacturer is offering an improvement on the latching system together with a proactive
replacement of the outer canopy frame, or even repla cing with a new canopy as an alternative. Together,
EASA finds that these improvements fully satisfy the intent of this safety recommendation.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
UNST -2019 -007
Boeing 737 -7H4, N772SW, 17/04/2018
Safety Recommendation received on 12/12/2019 :
Expand your certification requirements for transport -category airplanes and aircraft engines to mandate
that airplane and engine manufacturers work collaboratively to
(1) analyze all critical fan blade impact locations for all engine operating conditions, the resulting fan blade
fragmentation, and the effects of the fan -blade -out-generated loads on the nacelle structure and
(2) develop a method to ensure that the analysis findings are fully accounted for in the design of the nacelle
structure and its components.
Final r eply sent on 22/03/202 4:
The European Union Aviation Safety Agency (EASA) analysed the lessons learnt from the subject accident
and this safety recommendation and took several actions to improve the certification of turbine engines
and large aeroplanes.
I. Certification of turbine engines
The review of the existing certification specifications (CS) and acceptable means of compliance (AMC)
applicable to turbine engines in CS -E identified the following issues:
(a) The potential release of uncontained debris in the engine forward and rearward directions is not
sufficiently addressed. It is limited to a provision in AMC E 810 (‘Compressor and Turbine Blade Failure’)
related to the blade containment test, expecting to report the estimated size, weight, trajectory, and
velocity of any debris ejected from the intake or exhaust during the test.
(b) CS -E 520(c)(2) requires that validated data (from analysis or test or both) be established and provided to
enable the aircraft manufacturer to ascertain the forces that could be imposed on the aircraft structure and
systems as a consequence of the out -of-balance running and during any continued rotation with rotor
unbalance after shutdown of the Engine following the occurrence of blade failure as demonstrated in
compliance with CS -E 810 (‘Compressor and Turbine Blade Failure’). AMC E 520(c)(2) provides acceptable
means of compliance regarding the Engine model validation. However, it appears that the displacements
and loads transmitted to the engine nacelle structure (certified at aircraft level) have not been sufficiently
addressed during the certificati on of some engines and aircraft.
In order to address the above analysis’ findings, in the frame of rulemaking task RMT.0184 (‘Regular update
of CS -E’) EASA published on 22 November 2021 Notice of Proposed Amendment (NPA) 2021 -13
(https://www.easa.europa.eu/document -library/notices -of-proposed -amendment/npa -2021 -13),
proposing to amend CS -E.
Based on this NPA and on the comments received during the public consultation, EASA issued Executive
Director Decision 2023/020/R amending CS -E (‘CS -E Amendment 7’):
https://www.easa.europa.eu/en/document -library/certification -specifications/cs -e-amendment -7
Safety Recommendation s Received and Replies Sent
January – December 2024
This amendment includes the following changes:
(a) CS -E 520 (‘Strength’), paragraph (c)(1) is amended to require that compressor and turbine blades are
‘radially’ contained after their failure, instead of the current requirement to demonstrate no Hazardous
Engine effect. This better reflects the actual design and certification practices regarding engine casing
strength. The secondary effects associated with the blade failure are addressed by CS -E 810.
(b) AMC E 520(c)(2) (‘Engine model validation’) is amended to:
(1) add provisions clarifying that the engine model validated data (to be provided to the aircraft
manufacturer) includes the dynamic displacement of nacelle attachment features;
(2) clarify, regarding engines designed for the failure of the rotor support structure following a blade
failure, that engine manufacturers should also evaluate the effect of the most severe blade failure which
would not cause the failure of the rotor stru ctural support, and that the effect on the engine and on the
loads transmitted to the aircraft should be included in this evaluation; and
(3) specify that the engine model validation should consider any differences between the test configuration
and the aircraft installation.
(c) AMC E 510 (‘Safety analysis’), paragraph (3)(d)(iii) on ‘Hazardous Engine Effects - Non -containment of
high -energy debris’ is amended to specify:
(1) when debris, released after a failure, should be considered as uncontained high -energy debris causing a
hazardous engine effect, i.e. when this can cause an unsafe condition;
(2) how applicants should address the threat posed by major rotating parts (which are not required to be
contained);
(3) how applicants should address the threat posed by blade failure debris. A link is made with CS -E
520(c)(1) regarding the requirement for debris radial containment. In addition, the case where blade failure
debris is released forward, rearward or otherwise outside the engine containment structure is addressed.
The need to assess the hazard at the aircraft level is included and this assessment should be performed as
far as possible in coord ination with the aircraft manufacturer;
(4) how applicants should address other sources of uncontained high -energy debris, such as high -pressure
casing failures.
(d) CS -E 810 (‘Compressor and Turbine Blade Failure’) is amended to align with CS -E 520(c)(1) regarding the
‘radial’ containment requirement and clarify that Hazardous Engine Effects that may be triggered by the
blade failure must not occur at a rate great er than that defined as Extremely Remote. The previous wording
requiring to demonstrate that no Hazardous Engine Effect can happen was not considered as adequate, as
some debris may be released outside the radial containment area and this must be addressed and
mitigated.
(e) AMC E 810 (‘Compressor and Turbine Blade Failure’), paragraph (2)(c), related to the conditions
after the containment test, is amended to:
(1) reflect the amendments made to CS -E 810 and AMC E 510;
(2) specify that applicants should assess the threats represented by blade failure conditions other than the
test conditions;
(3) specify that the assessment of potential hazardous engine effect resulting from other damage before
engine shutdown should consider the long -term effects (e.g. unbalance loads) of blade failures which would
not be detected by the declared instrumentati on;
(4) specify that the assessment of potential hazardous engine effect resulting from the blade failure should
consider debris being released from the engine, forward, rearward or otherwise outside the containment
structure, thereby also referring to AMC E 5 10;
(5) remind the applicability of other CS -E specifications according to which some failures that could be
triggered after a blade failure are not acceptable.
Safety Recommendation s Received and Replies Sent
January – December 2024
II. Certification of large aeroplanes
The review of certification specifications and acceptable means of compliance for large aeroplanes (CS -25)
showed that the structural integrity of secondary structure elements (including engine nacelle elements) is
not explicitly addressed within the speci fications related to the protection of the aeroplane against the FBO
event and the related Sustained Engine Imbalance (SEI). Although aeroplane manufacturers generally take
into account these loads for the design of their nacelle components, EASA prepared a Special Condition (SC)
to supplement the CS -25 provisions. This SC would be provided in case of new application for certification
of a new aeroplane. It would require the following:
(a) Supplement CS 25.901(c) (on powerplant installation) to specify that the damaging effects from the SEI
are excepted from compliance with CS 25.1309.
(b) Supplement CS 25.1103(b), CS 25.1123, CS 25.1193(a), CS 25.1191(b) to specify that these structural
elements must resist the FBO event and the related SEI conditions and remain attached to the aeroplane.
This SC is complemented by Interpretative Material that supplement the following AMC material:
(1) AMC 25.362 (‘Engine Failure Loads’) and AMC 25 -24 (‘Sustained Engine Imbalance’) to address the
methods used to develop aeroplane design loads based on the FBO data provided by the engine
manufacturer,
(2) AMC 20 -128A (‘Design Considerations for Minimizing Hazards Caused by Uncontained Turbine Engine
and Auxiliary Power Unit Rotor Failure’) to address the consolidation of data provided by the engine
manufacturer for debris release that are not addressed by the existing rotor failure model of the AMC.
III. On -going certification projects
EASA cooperated with engine and aeroplane manufacturers to ensure that the above -mentioned topics are
addressed as far as possible in the frame of already on -going certification projects.
Status: Closed – Partial Agreement
_____________________________________________________________________ __________________
UNST -2021 -052
Saab 2000 , N686PA, 17/10/2019
Safety Recommendation received on 18/11/2021 :
Identify all currently certificated transport -category airplanes for which system safety assessments for
landing gear systems did not consider human error that could lead to cross -wiring of antiskid brake system
components, including the wheel speed transd ucers, and require manufacturers of transport -category
airplanes without such assessments to perform the assessments and then implement mitigations to
prevent cross -wiring of antiskid brake system components.
Interim r eply sent on 22/03/202 4:
Since the issuance of the Continued Airworthiness Review Item (CARI) 25 -10 (March 2022), inquiring if their
landing gear systems / architecture is robust to potential cross -wiring of antiskid brake system components,
and how their system safety assessments considered those failure condition(s), and the potential need for
mitigation, the European Union Aviation Safety Agency (EASA) received feedback from the Large Aeroplane
EU Type Certificate holders. Among those manufacturers’ outcomes, most of the product designs have
been confirmed as mitigating adequately the threat identified, whether per hardware and/or procedural
Safety Recommendation s Received and Replies Sent
January – December 2024
solutions. However, some manufacturers have initiated maintenance data (AMM, …) updates, which are
monitored by EASA.
The particular case of the SAAB 2000 architecture has been reassessed and enhanced by the mandate of
design change (through EASA Airworthiness Directive 2023 -0135, effective Date: 24 July 2023) to avoid the
mis-connection of the anti -skid harnesses.
Following the completion of the few remaining actions (maintenance data update, remaining feedback to
be analysed, …), a final reply to this recommendation will be issued to confirm that the products in the
scope of the CARI 25 -10, and for which EASA is th e Primary Certification Authority, have been evaluated
and confirmed as satisfactorily protected against the issue of the mis -connection of the anti -skid harnesses.
Status: Open
_____________________________________________________________________ __________________
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Annex B| Definitions
Annex B
Definitions
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Definitions
Accident: occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes
place between the time any person boards the aircraft with the intention of flight until such time as all such
persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is
ready to move with the purpose of flight until such time it comes to rest at the end of the flight and the primary
propulsion system is shut down, 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; or
(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, except for engine failure or damage, when the damage is limited
to a single engine, (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes,
tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small
dents or puncture holes) or minor damages to main rotor blades, tail rotor blades, landing gear, and those
resulting from hail or bird strike, (including holes in the radome); or
(c) the aircraft is missing or is completely inaccessible.
Incident: an occurrence, other than an accident, associated with the operation of an aircraft which affects or
would affect the safety of operation.
Serious incident: an incident involving circumstances indicating that there was a high probability of an accident
and is associated with the operation of an aircraft, which in the case of a manned aircraft, takes place between
the time any person boards the aircraft with the intention of flight until such time as all such persons have
disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move
with the purpose of flight until such time it comes to rest at the end of the flight and the primary propulsion
system is shut down.
A list of examples of serious incidents is given below. The list is not exhaustive and only serves as guidance with
respect to the definition of ‘serious incident’:
• a near collision requiring an avoidance manoeuvre to avoid a collision or an unsafe situation or when
an avoidance action would have been appropriate,
• controlled flight into terrain only marginally avoided,
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• aborted take-offs on a closed or engaged runway, on a taxiway, excluding authorised operations by
helicopters, or from an unassigned runway,
• take-offs from a closed or engaged runway, from a taxiway, excluding authorised operations by
helicopters, or from an unassigned runway,
• landings or attempted landings on a closed or engaged runway, on a taxiway, excluding authorised
operations by helicopters, or from an unassigned runway,
• gross failures to achieve predicted performance during take-off or initial climb,
• fires and smoke in the passenger compartment, in cargo compartments or engine fires, even though
such fires were extinguished by the use of extinguishing agents,
• events requiring the emergency use of oxygen by the flight crew,
• aircraft structural failure or engine disintegration, including uncontained turbine engine failures, not
classified as an accident,
• multiple malfunctions of one or more aircraft systems seriously affecting the operation of the aircraft,
• flight crew incapacitation in flight,
• fuel quantity requiring the declaration of an emergency by the pilot,
• runway incursions classified with severity A according to the Manual on the Prevention of Runway
Incursions (ICAO Doc 9870) which contains information on the severity classifications,
• take-off or landing incidents. Incidents such as undershooting, overrunning or running off the side of
runways,
• system failures, weather phenomena, operation outside the approved flight envelope or other
occurrences which could have caused difficulties controlling the aircraft,
• failure of more than one system in a redundancy system mandatory for flight guidance and navigation.
Safety investigation: process conducted by a safety investigation authority for the purpose of accident and
incident prevention which includes the gathering and analysis of information, the drawing of conclusions,
including the determination of cause(s) and/or contributing factors and, when appropriate, the making of safety
recommendations.
Safety recommendation: proposal of a safety investigation authority, based on information derived from a
safety investigation or other sources such as safety studies, made with the intention of preventing accidents and
incidents.
Safety Recommendation of Global Concern (SRGC)3: is defined as a safety recommendation made to a State
civil aviation authority, to a regional certification authority, or to ICAO regarding a systemic deficiency having
a probability of recurrence with potential for significant consequences and requiring timely action to improve
safety.
3 Source: ICAO Manual of Aircraft Accident and Incident Investigation (Doc 9756 -2014), Part IV Reporting, Chapter 1.6 RELEASE AND
DISTRIBUTION OF SAFETY RECOMMENDATIONS.
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An SRGC would meet one or more of the following criteria:
a. the deficiency underlying the recommendation is systemic and not solely a local issue;
b. the probability of recurrence of the accident and the adverse consequences are high;
c. the risk to persons, equipment and/or environment is high;
d. the urgency for taking effective remedial safety action is high;
e. there is a history of recurrence of the relevant deficiency;
f. the deficiency underlying the recommendation constitutes a risk to the airworthiness, design,
manufacture, maintenance, operation and/or regulation of the involved aircraft type;
g. the deficiency underlying the recommendation constitutes a risk to more than one aircraft type, to
more than one operator, to more than one manufacturer and/or to more than one State; and
h. the mitigation of the risks associated with the deficiency will require coordinated efforts of more than
one entity of the air transport industry, such as civil aviation authorities, manufacturers and operators.
Safety Recommendation of Union-wide Relevance (SRUR): a safety recommendation identified by the European
Network of Civil Aviation Safety Investigation Authorities according to Article 7 (g) of Regulation (EU) No
996/2010.
A safety recommendation of Union-wide Relevance (SRUR) would meet one or more of the following criteria:
• The deficiency underlying the safety recommendation is systemic, not related to a specific aircraft
type, operator, manufacturer component, maintenance organization, air navigation service and/or
approved training organisation, and not solely a national issue, or;
• There is a history of recurrence across Europe of the relevant deficiency.
Technical Adviser (Article 8 of REGULATION (EU) No 996/2010)
1. Safety investigation authorities shall, provided that the requirement of no conflict of interest is satisfied,
invite EASA and national civil aviation authorities of the Member States concerned, within the scope of
their respective competence, to appoint a representative to participate:
(a) as an adviser to the investigator-in-charge in any safety investigation under Article 5(1) and (2),
conducted in the territory of a Member State or in the location referred to in Article 5(2) under the control
and at the discretion of the investigator-in-charge;
(b) as an adviser appointed under this Regulation to assist accredited representative(s) of the Member
States in any safety investigation conducted in a third country to which a safety investigation authority
is invited to designate an accredited representative in accordance with international standards and
recommended practices for aircraft accident and incident investigation, under the supervision of the
accredited representative.
2. The participants referred to in paragraph 1 shall be entitled, in particular to:
a. (a) visit the scene of the accident and examine the wreckage;
b. (b) suggest areas of questioning and obtain witness information;
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c. (c) receive copies of all pertinent documents and obtain relevant factual information;
d. (d) participate in the read-outs of recorded media, except cockpit voice or image recorders;
e. (e) participate in off-scene investigative activities such as component examinations, tests and
simulations, technical briefings and investigation progress meetings, except when related to the
determination of the causes or the formulation of safety recommendations.
3. EASA and the national civil aviation authorities shall support the investigation in which they participate
by supplying the requested information, advisers and equipment to the safety investigation authority in
charge.
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Annex C | Safety Recommendations classification
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Recommendations
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Safety Recommendation
classification
This classification has been established in the scope of the safety recommendations taxonomy working group
in cooperation with representatives from European Safety Investigation Bodies, Eurocontrol, the European Joint
Research Center (JRC) and EASA. The aim of this group was to initiate a taxonomy dedicated to recommendations.
This activity took place in 2007 and is being used to implement a safety recommendation database developed
by the JRC.
In addition to common definitions, the taxonomy also defines a unique pre-defined format for referencing safety
recommendations. This format is composed by 4 digits originating state name followed by the year it was issued
and then a three digits number (ex: UNKG-2007-001 for recommendation #1 issued by United Kingdom in 2007).
Consequently, all references comply with this taxonomy foreseeing that existing safety recommendations will be
imported in a central database and shared with a community of users.
Recommendation assessment: assessment given to a safety recommendation by the addressee as defined
below:
• Agreement: safety recommendation for which the safety concern is agreed by the addressee and
subsequent action is planned or implemented.
• Partial agreement: safety recommendation considered relevant by the addressee but not applicable
and for which a safety issue has been recognised and a new orientation has been given to the
recommended action.
• Disagreement: safety recommendation considered not relevant or not applicable by the addressee.
• No longer applicable: safety recommendation has been superseded or has become no longer
applicable.
• Not Responsible: safety recommendation wrongly allocated or not in the scope of responsibility of
the addressee.
• More information required: safety recommendation for which more information is required by the
addressee before any action initiated. Additional information should be sent by the originator.
• Unknown: safety recommendation which was issued before any tracking implementation status and
for which insufficient information to assign any other status has been received.
Response assessment: The classification of the response as determined by the originator (when a response is
received):
• Adequate: safety recommendation for which appropriate action is planned or implemented or
sufficient evidence of completed action satisfying the objective has been received by the originator.
• Partially adequate: safety recommendation for which the planned action or the action taken will
reduce but not substantially reduce or eliminate the deficiency or for which a safety issue has been
recognised and a new orientation has been given to the recommended action.
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• Not adequate: safety recommendation for which no action has been taken or proposed that will
reduce or eliminate the deficiency, or for which the proposed action is considered not applicable/
unacceptable.
• Response is awaited: safety recommendation for which no response has been received.
• Response received awaiting assessment: response to the safety recommendation has been received
by the originator and is awaiting assessment.
• Superseded: if the recommendation has been superseded by another recommendation.
• Unknown: the safety recommendation is one which was issued before any tracking implementation
status and for which insufficient information to assign any other status has been received.
Status of a safety recommendation: progress of the implementation of the response to a recommendation as
defined below:
• Open safety recommendation : safety recommendation for which the reply has not yet been defined
or the appropriate action addressing the safety concern is still in progress.
• Closed safety recommendation: safety recommendation for which appropriate action has been taken
and completed addressing the safety issue.
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Catalogue number
TO-01-25-000-EN-N
ISBN
978-92-9210-287-6
ISSN
DOI
10.2822/5406205
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 info@easa.europa.eu
Web www.easa.europa.euEuropean Union Aviation Safety Agency
Safety Intelligence & Performance Department
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