2011 Evair Safety Bulletin 7

EVAIR Safety Bulletin
No 7
EUROCONTROL Voluntary ATM Incident Reporting
2008-2010
EUROCONTROL
© Skyguide
contents
EVAIR Function Manager’s Perspective 4
Introduction to EVAIR Statistical Data 7
Section 1 - Phases of Flights 7
Section 2- ATM events and support to European action plans 8
l Training – The solution for contributors to ATM occurrences 9

l Go-Around 9
l Runway Incursions 11
l Level Busts 12
Section 3 - EVAIR Support to Call Sign Similarity Implementation Project 13
l Call Sign Confusion Summer 2008-2010 Trend 15
Section 4 - Air – Ground Communication 16
Section 5 - Specific events Laser Treats widespread across Europe 18
Section 6 - ACAS Reporting 19
l Part one – Manual ACAS Reporting 19

RA Instructions 2008 – 2010 20
ACAS FL Distribution 21
l Part two – ACAS RAs collected automatically from mode-S radar station 22
Annexes 31
l Annex 1 - European Action Plans 33

l Annex 2 - Definitions & Acronyms (from Heidi and HERA Taxonomies) 34
l Annex 3 - Acronyms 37
l Annex 4 - IATA Explanations of categories 38
EVAIR SAFETY BULLETIN N°7 - 2008-2010 3 EUROCONTROL

EVAIR MANAGER’S
PERSPECTIVE
The EVAIR team is pleased to bring you EVAIR Safety Bulletin only aim of collecting, analysing and identifying areas of safety
No7. The issue covers the period 2008-2010. It is a great pleasure concerns is to improve flight safety. It is this and only this that
to state that ATM occurrence reporting (by airlines and ANSPs) drives the agreement and relationships that EVAIR has with the
and the number of reports received continues to rise. data providers.
Data collection Verification of the robustness and the quality of EVAIR data
The graph below shows this constant increase in reporting for As a part of the verification process of the robustness and quality
period 2008-2010. Indeed, in 2010 the increase versus 2009 was of EVAIR data, EVAIR established a process to make a cross-check
57% in relative figures. This follows a similar large increase of 73% with the best reporters among the airlines and the best feedback
we already had in 2009 against 2008. It is very encouraging to see providers amongst the ANSPs.
this rising trend and we hope it will continue in the future.
During 2010, EVAIR verified its trend data with several ANSPs
many of whom are responsible for areas of high traffic density.
7
6 Dialogue with key stakeholders indicates that within ATM there
5 are no major differences between EVAIR and ANSPs data relating
4 to identified ATM trends. Moreover, there is a very strong match
3 in the identified areas of concern and their trends in terms of the
2
type of the events, and their increase or decrease, and also in
1
terms of causal factors.
0
2008 2009 2010
Figure 1 – Incident data collection 2008-2010 In addition, EVAIR compares trends of some specific events (e.g.
Go-around, Runway incursion, ACAS RA, Level Bust and Callsign
For the period 2008-2010, more than 110 airlines provided their confusion) with IATA STEADES data. In these areas, there is also no
ATM incidents to EVAIR; of these around 80 are reporting regularly. marked difference between European and global trends, in terms
The reporting airlines fly across the whole of Europe and account of an increase or decrease in the number of incidents.
for 72% of the overall European air traffic.
Feedback – Support to quick fixes
The high increase in reporting is not related to the quality of the The feedback mechanism is the driving factor for the increased
performance of the ATC or airlines’. Instead there are a number reporting. Our data shows that during the period 2008-2010,
of reasons for the rise. One of the most important of these is the EVAIR addressed requests for feedback to more than 50 different
feedback mechanism, which within a short period provides a reply
3000 ANSPs and more than 40 different airlines within and outside
to the incident reporter. The short time frame and information
2500 Europe. Regarding the airlines, most requests for the feedback
about the problem which was behind the incident as well as any
2000 were related to Callsign similarity/confusion issues. EVAIR is the
actions taken, motivates reporters to report more since they see
1500 monitoring mechanism for the EUROCONTROL Callsign simi-
very quickly the result of their reporting. EVAIR is the facilitator
1000 larity project and through the feedback process the airlines
of500
the feedback mechanism. The second important reason for are taking the necessary steps to change conflicting callsigns
the 0high reporting increase is the trust that all players have in the within the same airline or sometimes to make the agreement
2006 2007 2008 2009 2010
reporting and feedback mechanism. Specifically, EVAIR takes great between two different airlines to change the callsign of one
care with the sensitive parts of the reports like the names of the of them. In all 88% of feedback requests are successful. The
reporters or airlines and ANSPs as well as locations of the incidents usual feedback response time varies from a few days to a few
so that they will not be disclosed in public and not abused. The weeks, but sometimes this stretches to several months. This
EUROCONTROL 4 EVAIR SAFETY BULLETIN N°7 - 2008-2010

is not necessarily a bad signal and is often an indication that As in the previous EVAIR Safety Bulletins, in this one we present
more work is being done, or needs to be done, with the specific ACAS RAs provided manually through the airlines’ and ANSPs’
ANSPs and airlines to make safety improvements. The feedback SMSs and automatically collected directly from the Mode-S radars.
process itself is under constant scrutiny and the work includes Received ACAS RA reports are analysed by air traffic controllers,
organisation of meetings with the interested ANSPs and airlines, EUROCONTROL ACAS experts, and when necessary pilots too.
improvement of the process, and establishment of better trust Automatic monitoring data covering ACAS RA downlink messages
and guarantees between stakeholders to ensure that the data has been provided by one ANSP. In the last 12 months the same
will be used only for safety improvements and not for blaming ANSP has expanded ACAS RA downlinks data collection from 1 to
or suing each other. 12 radars.
Main trends: Laser Interference

Phases of flight – The EVAIR statistics for the periods 2008 – The previous EVAR Safety Bulletins have highlighted the growing
2010 show that the highest number of incidents (82%) occurred menace to aviation caused by the misuse of hand-held laser
within the En-route and Approach phases together. During the devices which are being used to ‘target’ aircraft and sometimes
same period, 57% of incidents occurred only within the Approach ATC facilities. The data show that there was a dramatic increase
phase, which indicates where to look to make major improve- in the number of reported laser interference events in the period
ments. There was an increase of 108% in the Approach phase 2008-2010. Indeed, in 2010 the increase was almost 8 times higher
reported incidents comparing 2010 against 2009. than in 2009. The most affected phase of flight by laser is ‘Approach’
with 92%. The number of Laser incidents in 2010 had a higher rate
Events – Among five different events monitored by EVAIR per 10,000 operations than Level Busts and Runway Incursions
(Go-around/Missed approach, Level Bust, Runway Incursion, combined. Fifty three airlines reported laser interferences and we
ACAS RAs and Call Sign similarity/confusion), Go-around shows recorded events in 100 different locations within 27 states. In one
an increase of almost 200% in 2010. The main ATM causals for laser interference event in August 2011 the pilot was seriously
Go-around were ‘Mistakes’, ‘Lack of traffic information’ and ‘other injured which is the first time that we have received a report with
parties’, which involves vehicles, people animals etc. an injury on board. The rapid growth in reported laser interference
events prompted the decision for EUROCONTROL to host a multi-
Main Contributors to incidents – For the period 2008-2010, disciplinary Laser Interference in Aviation Seminar (10-11 Oct 2011).
‘Mistakes’ and ‘Air-ground communication’, which encompasses The intent was to gather appropriate experts from different fields,
spoken and operational communication, account for 63% of the to begin the search for more wide-ranging and possibly collective
overall contributors to the five events mentioned above. However, answers and proposals to mitigate the situation and reduce the
the highest increase was ‘Traffic information’, which was four times problem at national and international level.
higher than in 2009 whilst ‘Traffic and airspace problems’, were
almost twice as high. EVAIR data therefore suggests that these Call Sign Confusion
areas are perhaps worthy of more attention. We would contend Previous EVAIR Safety Bulletins have featured the monitoring
that improvements in training could be a fruitful place to begin activity involving the EUROCONTROL Callsign Similarity (CSS)
looking for solutions to the listed problems. Project. This project aims to reduce the incidence of Callsign
Similarity/Confusion. One way to reduce the CSS/C is the establish-
ACAS RA data collection ment of a pan-European coordinated Callsign Similarity Service
EVAIR ACAS monitoring aims to support the safe operation of ACAS and tool provided by the Callsign Management Cell (CSMC),
by identifying and measuring issues associated with RAs and their which is a part of the EUROCONTROL’s Directorate Network
trends, and taking preventive measures where necessary. Management (formerly CFMU).

EVAIR monitoring and data collection has helped to refine some of to EVAIR by both airlines and the service provider involved in the
the applied rules. Comparison of the trends between IATA global incident is counted as one incident. STEADES, on the other hand,
and EVAIR European data for 2008-2010, show very similar move- due to its de-identification practices, does not count the number
ments in terms of the increase/decrease. of incidents, but rather counts the number of reports received. For
example a single ACAS event reported by two airlines is counted
Stakeholders’ Corner – IATA in STEADES as two reports. However, it should be noted that the
As in previous EVAIR Safety Bulletin, in this edition we are also instances of more than one report being submitted for a single
providing a comparison of the areas of concern and trends event in STEADES is considered to be low. In addition, EVAIR deals
between EVAIR data and IATA STEADES as a global data reposi- only with the ATM related incidents, while in the STEADES data-
tory. Both databases represent officially non-investigated and base there are incidents which are not only ATM related. This is
voluntarily provided incident reports; EVAIR covering ATM within especially noted in the area of Go-around for example. In spite
Europe and STEADES global air transport, including ATM. Both of differences, and deficiences, making cross-checks between
partners are aware of the advantages of doing this work together these two databases gives additional opportunities to identify
but also recognise the obstacles and deficiences arising from the trends. In that regard common safety concerns in the ATM arena.
differences of the programmes objectives, taxonomy and the level Furthermore, it gives a better data-driven approach on where to
of data analysis of these two activities. allocate efforts and resources to improve safety.
Throughout the report, relative figures and reporting rates are For this Safety Bulletin, IATA STEADES prepared global information
lower in the EVAIR data set than in STEADES. Whilst several reasons based on the ASRs submitted from over 130 participating airlines
for this may exist, it is noteworthy to mention two specifically. throughout the world. The analysis included research of ASRs for
the period January 2008 - December 2010, during which 189,684
Firstly, the impetus for reporting. Airlines that cooperate with reports were submitted.
EVAIR do not provide all reports, they provide mainly reports
for issues where they seek feedback from the specific ANSP and Security and Confidentiality
which is facilitated by EVAIR. Whereas the airlines participating In collecting and processing data, EVAIR follows strict security and
in IATA’s STEADES program provide all their air safety reports to confidentiality arrangements. Safety data provided are properly
STEADES as part of their agreement with STEADES. safeguarded and de-identified and the information is only used
for the promotion and enhancement of aviation safety.
Secondly, the higher reporting rates in STEADES may also be
attributable to the fact that STEADES coverage is global. This
means that regional differences and/or deficiencies in ATC perfor- EVAIR Suggestions/Improvements
mance, ATM/CNS infrastructure, applied standards, level of the EVAIR is constantly looking at ways to improve its services and
performance, etc, when compared with Europe, may result in products. Suggestions and proposals are more than welcome.
more incidents reported per number of flights. Please forward any thoughts, ideas and comments to:
Ms Dragica Stankovic
Regarding taxonomy and level of analysis, in EVAIR the ATM data EVAIR Function Manager
are analysed by ATM experts and coded following ICAO ADREP dragica.stankovic@eurocontrol.int
taxonomy. STEADES data on the other hand is comprised of pilot
reports [Air Safety Reports, (ASR)] collected and coded by the
airline as part of an airline’s Safety Management System. In EVAIR
multiple reports of the same event are correlated and counted
once as a single incident, for example a single ACAS event reported

INTRODUCTION TO STATISTICAL DATA
The statistics presented in EVAIR Safety Bulletins are based on inci- EVAIR Safety Bulletins are issued twice per year. One covers the
dents received from commercial aircraft operators and feedback whole year period such as this one, whilst the other only the
data provided on some of them by ANSPs. Incident reports are summer season (April - September). Data are provided by 108
very much based on the subjectivity of those who were involved airlines. When solicited, all ANSPs have provided feedback to
and in the first place the pilots who filed the report and described airline reports.
the occurrence. However, improved feedback processes through
which EVAIR is provided with a reply either by Air Navigation Notes:
Service Providers (ANSPs) or airlines - the two main stakeholders 1. In this EVAIR Safety Bulletin within the manual part of
participating in the incident - improves significantly the view and reporting, only relative figures are presented - i.e. the
the knowledge about the causals of the analysed events. EVAIR number of reported occurrences per 10,000 flights of
statistics do not contain severity analysis, since the analysed the airlines participating in the reporting. Within the
reports are not officially investigated or the official (airline/state) automated ACAS RA data collection sections, the data
investigation is still waiting to be closed. Nonetheless, the statis- comprises absolute values.
tics do provide a general view and show some main trends of the 2. The graphs which show the drill down through the data-
current operational safety acceptability. base identifying causal factors could count the same
incident more than once. The reason for that is that one
EVAIR activity covers the whole ECAC airspace as well as some of incident could be associated with more than one causal
the airspaces neighbouring the ECAC region like the Eastern part factor.
of the ICAO EUR region, Middle East, Africa etc. In the same way,
the airlines and ANSPs who participate in EVAIR come from across Definitions:
Europe and, indeed, some airlines based outside of Europe but Definitions for each element contained in the graphs can be found
who regularly fly through European airspace. in the Annex 2..
SECTION 1 - PHASES OF FLIGHTS
INCIDENTS PER PHASE OF FLIGHT: PERIOD 2008 - 2010
Figure 2: Incident distribution per phases of

Approach
flight - 2008 - 2010
The Approach phase in total has the highest
En-route
number of incidents through 2008 to 2010. The
highest increase was in 2010 with more than
Landing
3.5 reports per 10,000 flights. It means that with
this level of reporting, which still is not as high
Standing
2010
as it should be, during the summer period when 2009
across Europe there are more than 30, 000 flights 2008
Take-off
daily there could be at least 20 incidents within
the Approach phase and around 5 incidents
Taxiing
across en-route phase.
0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0
Incidents rate per 10.000 flights
Figure 2

SECTION 2 - ATM EVENTS AND SUPPORT TO EUROPEAN ACTION PLANS
In this chapter EVAIR presents some of the events which are already addressed in the European Action Plans or projects like Air-ground
communication, Level Bust, Runway Incursion, ACAS, and Callsign Similarity/Confusion. Analysis of EVAIR data helps to monitor the situa-
tion and draws attention to the negative trends which require corrective actions. It also assists in prioritising actions which could be taken
on a pan-European level. ‘Missed approach’/ ‘Go-around’ type events were included in this section for the first time in EVAIR Safety Bulletin
No 6. The reason for this inclusion is the high growth of the events reported to EVAIR during 2010, but also an increase at the global level
which is seen from the IATA STEADES information. The inclusion of this area in the statistics aims to raise awareness amongst the experts
who read EVAIR Safety Bulletins to continue the work in identifying the spectrum of contributory factors for this type of the event and find
the best solutions for their mitigation. We want to emphasise that we are fully aware that missed approach/Go-around is a part of the ap-
proach procedures and that if the approach is unstable, pilots are trained to assess and to make the decision either to continue or to make
a Go-around to avoid e.g a runway excursion. However as it was said, the increased number of Go-arounds indicates that more in-depth
analysis are needed to discover the reasons behind the events. EVAIR has started with this analysis and we hope that more information will
be available for EVAIR Safety Bulletin No 8.
Figure 3 and 3a: ATM Events 2008 - 2010

Level Bust Among five types of events, (Go-around/Missed
approach, Level Bust, Runway Incursion, ACAS
RAs and Call Sign similarity/confusion), Missed
Runway incursion
approach’/Go-around and ACAS RAs have the
highest level. There was a particularly marked
Missed approach/
Go-around increase of Missed Approach/‘Go-Around’, which
is the procedure followed when the approach was
ACAS RAs not possible to be continued. It is interesting that

2010 according to IATA STEADES, as a global reposi-
2009 tory, the view on the situation is similar to EVAIR’s
Call sign confusion 2008
regarding the increase trend of the Go-around
reports. Relative figures of Go-around as well as
0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6
other events in IATA STEADES (11.2) are higher
Incident Rate per 10.000 flights
Figure 3 - European ATM Events 2008-2010 then in EVAIR (1,4). The main reasons behind were
already explained in the EVAIR Manager’s perspec-
tive within the chapter ‘’Stakeholders’ corner –
Altitude deviation reports IATA’’.
STEADES
Runway incursion reports

© International Air Transport
Association (IATA). All rights
reserved. No part of this
Go-around reports graph may be reproduced,
recast, reformatted or trans-
mitted in any form by any
means, elctronic or mechan-
TCAS reports ical, including photocopying,
2010 recording or any informa-
tion storage and retrieval
2009 system, without written
Call sign confusion reports 2008 consent of IATA, Senior Vice
President, Safety, Operations
& Infrastructure.
0 2 4 6 8 10 12
Reports(IATA).
© International Air Transport Association per All
10.000 flights
rights reserved.
No part of this graph may be reproduced, recast, reformatted or transmitted in any form
Figure 3a - Topics of interest 2008-2010
by any means, elctronic or mechanical, including photocopying, recording or any information
storage and retrieval system, without writtent consent of IATA, Senior Vice President, Safety,
Operations & Infrastructure.

TRAINING - A MITIGATION FOR CONTRIBUTORS
The identified and presented contributors are spread across all phases of flights and linked with the five selected events mentioned
previously. The contributors have the highest levels within our data base. Traditionally, ‘Mistakes’ and ‘Air-ground communication’
(Operational and Spoken) are the most common contributors through 2008 – 2010. However, ‘Traffic’ and ‘Airspace problems’, which
encompass traffic load and traffic complexity, airspace design, pilot problems with the airspace familiarity and lack of traffic informa-
tion, showed a very high increase in 2010 versus 2009. For the majority of them especially for ‘Traffic information’, and ‘Air-Ground
communication’ – language issues - better training is one mitigation factor. However, for our next Bulletin, we will continue to monitor
the situation and try to identify all potential problems behind these contributing factors.
Comm. Operational & Spoken
Mistakes
Lapses
Traffic information
2010
Coordination issues 2009
ATC Clearance/Instructions 2008
Trafffic and Airspace problems
0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6

Figure 4 - Contributors to ATM Incidents
all phases of flight 2008-2010
GO-AROUND
First-time statistics about Go-around were presented in EVAIR Safety Bulletin No 6. It was noted that the number of occurrences in com-
parison with the other events was much higher and that the trend was consistently upwards. The EVAIR database showed a 196% jump in
2010 against 2009 and this confirmed our suspicions that there was an inexorable rise in this type of events. Consequently, we decided
to verify our information with IATA STEADES global data and several ANSPs that have areas of high traffic density. The IATA STEADES data
shows a 78% increases in the rate of reported Go-arounds for the period 2008-2010; furthermore ANSPs who were contacted also show a
similar steady growth.
The increasing number of Missed approach/Go-around events indicates that further work is needed to identify the main contributory
factors and define remedial actions. In this regard EUROCONTROL together with a number of other stakeholders (ANSPs, airlines and their
associations, manufacturers etc) has initiated a study which aims to capture the issues and identify potential solutions to mitigate the
situation. EVAIR data will be used as one of the main sources of information. Furthermore, EVAIR will make additional analysis to support
this initiative.
Finally, by extrapolating EVAIR data, it suggests that, each day, there are at least 4 Go-around events due to various reasons. Considering
that in many states/ANSPs the reporting culture is still too low, the likelihood is that in reality this figure is much higher.

Tendency of Go-around per 10,000 operations
1,6
EUROCONTROL
Yearly development per 10,000 operations

1,4
1,2
1,0
0,8
0,6
0,4
0,2
0,0
2008 2009 2010
Figure 5 - Missed approach-Go-around 2008-2010
Go-around reports
Go-around reports per 10,000 flights
STEADES
12 Linear (Go-around rpts per 10,000 flights) 4500 © International Air Transport
4000 Association (IATA). All rights
Reports per 10.000 flights
10 reserved. No part of this

3500 graph may be reproduced,
Number of reports
recast, reformatted or trans-

8 3000
2500 means, elctronic or mechan-
6 ical, including photocopying,
2000 recording or any informa-
4 1500 tion storage and retrieval
system, without written
1000 consent of IATA, Senior Vice
2
500 President, Safety, Operations
& Infrastructure.
0 0
2008 2009 2010
Figure 5a - Go-around reports 2008-2010
In 2010, from the ATM point of view, the Oper. Comm. Issue
largest number of Go-Arounds occurred
Spoken comm.
due to Mistakes either on the ATM or pilot
Mistakes
side. Lack of, or late essential traffic infor-
Lapses
mation is the 2nd highest contributor with
a strong rise in 2010. Another contributor Traffic information
which saw growth is ‘Other parties’ which Coordinations Issuies 2010

involves vehicles, animals or persons on the 2009
Ground-ground communication
2008
ground or in the air that were the reason
Other parties
for a Go-around. The first impressions from
ATC clearance/instruction related item
the ATM point of view is that some of the
solutions are closely linked with improved 0,00 0,05 0,10 0,15 0,20 0,25 0,30 0,35
training; however, as was said earlier, more Incidents rate per 10.000 flights
in-depth analysis is being done as a support Figure 6 - Go-Around contributors 2008-2010
to the EUROCONTROL Go-around project.

RUNWAY INCURSIONS
The EVAIR database shows that runway incursions reported by pilots had the lowest rate among five major categories of events presented
in this Safety Bulletin. The IATA STEADES database shows a similar pattern (Figures 3 and 3a). For the period 2008-2010, both EVAIR and
IATA STEADES data repositories show an increase in the number of RWY incursions. Relative figures for Runway Incursion as well as for
other type of the events within the STEADES database are much higher than within EVAIR. The explanation for that has been given within
the chapter, ‘Stakeholders corner – IATA’.
0,07
0,060
0,06
0,05
0,04
0,039
0,03
0,033
0,02
Tendency of Runway incursions per 10,000 operations
0,01 Yearly development per 10,000 operations
0,00
2008 2009 2010
Figure 7 - RWY incursion 2008-2010
Runway incursion reports

Runway inc. reports per 10,000 flights
STEADES
© International Air Transport Linear (Runway inc. rpts per 10,000 flights) 250
Association (IATA). All rights
reserved. No part of this 0,6
graph may be reproduced, 200
Number of reports
recast, reformatted or trans- 0,5
0,4 150
means, elctronic or mechan-
ical, including photocopying,
recording or any informa- 0,3 100
tion storage and retrieval
system, without written 0,2
consent of IATA, Senior Vice 50
President, Safety, Operations 0,1
& Infrastructure.
0,0 0
2008 2009 2010
Figure 7a - Runway incursion Reports 2008-2010
Oper. Comm. Issue

A drill down through the EVAIR Runway Incursions
data shows five various contributory factors through
Spoken comm. 2008-2010. Interestingly during 2010, only three of
2010 them, ‘Mistakes’, ‘Spoken Communication’ and ‘Traffic
Mistakes
2009 Information’ were identified. However, ‘Mistakes’ and
Lapses
2008
‘Traffic Information’ had increased in 2010 versus 2009,
Traffic information
which is a very similar pattern to that seen in the other
monitored events. Once again this points towards
0,000 0,005 0,010 0,015 0,020
training as one of the possible solutions for improving
Incidents rate per 10.000 flights the situation.
Figure 8 - Runway incursions main contributors 2008 – 2010

0,30 Tendency of Level Bust per 10,000 operations
LEVEL BUSTS Yearly development per 10,000 operations
0,25
According to EVAIR data, the Level Bust rate is lower than Go-Around
0,20 and ACAS RA but higher than Runway Incursions and Callsign
similarity, in terms of the number of incidents per 10,000 flights. It is interesting that the yearly trends during 2008-2010 in EVAIR
0,15
and IATA STEADES databases are very similar. 2008 had a higher level than 2009 and then in 2010 at the European and global level
0,10
the number of Level Busts increased. Thus the overall trend in both databases shows an increase for this three-year period. At the
European level, the EVAIR data for 2010, within manual reporting, 0,05
shows that there is almost one Level Bust daily during the summer
season. The largest number of Level Busts occurred within the En-route phase. However, data collected automatically from one service
0,00
provider, shows that the Level Bust situation is much more problematic in TMAs, especially in busy
2008 and complex areas.
2009 2010Therefore for
better understanding and potential prevention activities, the introduction of the automatic data collection mechanisms such as ASMT
is recommended, at least in areas of high traffic density.
Altitude deviation reports

Altitude dev. reports per 10,000 flights
Tendency of Level Bust per 10,000 operations STEADES
0,30 1,4 Linear (Alt. dev. rpts per 10,000 flights) 500
450
EUROCONTROL
0,25 1,2
400
Number of reports
0,20 1,0 350
0,8 300
0,15 250
0,6 200
0,10
0,4 150
0,05 100
0,2
50
0,00 0,0 0
2008 2009 2010 2008 2009 2010
Incidents rate per 10.000 flights © International Air Transport Association (IATA). All rights reserved. No part of this graph
may be reproduced, recast, reformatted or transmitted in any form by any means,
Figure 9 - Level Bust 2008-2010 elctronic or mechanical, including photocopying, recording or any information storage
and retrieval system, without written consent of IATA, Senior Vice President, Safety,
Altitude deviation reports Figure 9a - Altitude Deviation reports 2008-2010

Altitude dev. reports per 10,000 flights
STEADES
1,4 Linear (Alt. dev. rpts per 10,000 flights) 500
450
1,2
400
1,0 350
0,8 300 Oper. Comm. Issue
250
0,6 200
0,4 150 Spoken comm.
100
0,2
Almost all of the top five contributors showed an increase 50
Mistakes
0,0 in 2010 versus 2009 but they are still lower than in 0
2008 2009 2010
2008. Prime among them with an increase was ‘Spoken
2010
Lapses
Communication’; however, ‘Traffic Information’ which 2009
was late or not provided also rose significantly in 2010 2008
Traffic information
compared with 2009.
0,00 0,02 0,04 0,06 0,08 0,10

Figure 10 - Level Bust contributors 2008-2010

SECTION 3 - EVAIR SUPPORT TO CALL SIGN SIMILARITY IMPLEMENTATION PROJECT
Previous EVAIR Safety Bulletins have featured the monitoring activity involving the EUROCONTROL Callsign Similarity (CSS) Project. This
project aims to reduce the incidence of Callsign Similarity/Confusion by establishing pan-European CSS solutions centred on a coordi-
nated Callsign Similarity Service and Tool provided by the Callsign Management Cell (CSMC) established in EUROCONTROL’s Directorate
Network Management (formerly CFMU).
Call Sign Similarity Tool Development of the EUROCONTROL Callsign Similarity Tool (CSS Tool) is ongoing. At the time of writing, the
manual and semi-manual version is being tested by a number of aircraft operators. More AOs are encouraged to join the testing regime
and those that are interested should contact the CSMC at cfmu.csmc@eurocontrol.int for more details.
The aim is for the evaluation of the initial CSS Tool to be completed using the IATA Winter Season 2011/12 schedules. Currently, the test
version is only available to AOs via a CFMU NOP Portal Test Platform; the intention is that it should be available for all AOs on the full
CFMU NOP Portal in Spring 2012 when Service Level 1 operations will begin.
Note: CSS Service Level 1 is the detection and deconfliction of callsign similarities within a single aircraft operator’s schedule.
Thereafter, as shown in Fig 11, a second, fully-automatic version of the Tool is planned to be released for testing in September 2012.
Unfortunately this is a year later than originally planned but it remains a medium-term aim of the Project. In the interim, the manual
and semi-manual version of the Tool will still offer AOs a useful and credible means to deconflict their flight schedules.
CSS Tool WP1 CSS Tool WP1 CSS Tool WP2

Evaluation
AO Familiarisation Operational Release* Release*
and Evaluation*
Service Level 1 start
CSS Tool Initial CSS Tool WP1 Continued

Development Refinement
Contract CSS Tool WP1 CSS Tool WP2
Development CSS Tool WP1 Initial Development
Release on OPT*
Rules Start of CSS Tool WP2
April April 2010 - March 2010 - Summer Spring Summer September

March 2010 February Spring 2011 2011 2012 2012 2012
2010 2011
CSS Tool Development Work Packages: WP1 (Manual and Semi-Manual Deconfliction)
WP2 (Automatic Deconfliction)
Work Package Release Date
2009 CSMC Service Level 0 (including ex DSNA task) until Spring 2013
* AO Involvement
Figure 11 - CSS Service Level/Tool - Timeline

Call Sign Similarity Rules A key element in reducing the number of callsign similarities is having an understanding of what actually consti-
tutes a ‘similarity’. The Callsign Similarity User Group (CSS UG) formulated some general rules for detection of similarities and these were
published in April 2010. The rules also included some basic principles that describe the acceptable formats for the creation or correction
of ATC callsigns. The General Callsign Similarity Rules can be found at: http://www.cfmu.eurocontrol.int/cfmu/public/standard_page/cfmu_
programmes_css.html
These rules were also used as the baseline set to be configured in the initial version of the CSS Tool. However, it soon became apparent
that when applied to aircraft operators’ schedules (in particular the larger ones) certain rules were too broad in nature and resulted in the
detection of too many similarity conflicts.
Thanks to data collected by EVAIR, the application of some rules has now been refined. By analysing actual callsign similarities and
confusions occurrences reported to EVAIR, it was possible to identify the most common patterns/ combinations of numbers and letters
used in the callsign suffixes that occurred in real-life operations. Consequently, a number of rules were changed and many of the more
obscure similarity conflicts are no longer detected. This has significantly improved the overall performance of the CSS Tool and increased
its credibility amongst the testing AOs.
Callsign Similarity Monitoring As the CSS Project progresses, it will be necessary to monitor the effectiveness of the CSS Tool by those
aircraft operators using it in ‘live’ operations. It is hoped that a number of the AOs engaged in the testing will come forward and volunteer
to use the output from their work detecting and deconflicting their IATA winter season 2011/12 schedules for this purpose.
The CSS UG has agreed that the existing EVAIR communications channels should be used for the transmission of Callsign Similarity/Confusion
reports to EUROCONTROL. Namely, as with other air safety reports, these can be sent to mailbox, Dragica.stankovic@eurocontrol.int.
Pleasingly, some EVAIR members are playing an active role in the CSS UG. Furthermore, many EVAIR colleagues are already contributing
CSS reports to EVAIR. In particular, a growing number of ANSPs that are monitoring callsign similarities in their areas of operation are
providing callsign similarity data to EVAIR. This is excellent news and will become even more important in the future when the ANSPs’
monitoring role really kicks-in as more and more AOs start to use the Tool.
As an example, the Czech ANS provider has recently forwarded a significant amount of CSS data gathered from recorded radar and FPS
data to capture the number of conflicts when two aircraft with similar callsigns (according to the rules) crossed through their airspace in
the same sector and on the same frequency. This data reinforces information received from other ANSPs and also confirms previous asser-
tions that detecting and deconflicting callsign similarities between aircraft from different airlines should be a long-term goal of the CSS
Project. Similar contribution come regularly to EVAIR from ENAV, the Italian ANSP, as well as from France’s DSNA and Aena, Spain’s ANSP.
As described previously, the data already supplied by ANSPs has played a very useful role in determining a more representative and refined
application of the similarity rules inside the Tool. Moreover, the growth in reporting has led to increased contact with aircraft operators
who have been asked to conduct ad-hoc deconfliction on reported similarity events. This contact has also provided a useful recruitment
opportunity and a number of new airlines have joined the CSS UG/Project. More importantly though, the changes the AOs subsequently
make to their callsign schedules based on this feedback are reducing the potential for the same similarities to occur again. This
should reduce the risk and have a positive impact on operational flight safety which is the ultimate aim of the CSS Project.
For those AOs and ANSPs who are already submitting CSS data to EVAIR, we thank you. For those of you who are not, there is an open
invitation to begin sending us such data now.
Important Reporting Note: It is requested that reports sent to EVAIR use the ATC Call Sign or operational Flight Identification rather
than the Commercial Flight Number (CFN) (unless they are the same) as this helps the EVAIR staff process the data more easily and efficiently.

Tendency of Callsign confusion per 10,000 operations
0,12
0,098
0,10
0,085
Learn More About Callsign Similarity 0,08
0,06
If you are interested in learning more about the CSS Project then please contact the CSS Project Manager and co-chair of the CSS User
Group, Mr Richard Lawrence, at: richard.lawrence@eurocontrol.int or0,04
via callsign.similarity@eurocontrol.int
0,026
0,02
The latest data reported to EVAIR is shown below.
0,00
2008 2009 2010
CALL SIGN CONFUSION 2008 – 2010 TREND
Callsign confusion reports

Tendency of Callsign confusion per 10,000 operations
Callsign conf. reports per 10,000 flights
Yearly development per 10,000 operations STEADES
0,12 0,6 Linear (Callsign conf. rpts per 10,000 flights) 200
0,098 EUROCONTROL
180
0,10 0,5
160
0,085
Number of reports
0,08 0,4 140
120
0,06 0,3 100
80
0,04 0,2 60
0,026 40
0,02 0,1
20
0,00 0,0 0
2008 2009 2010 2008 2009 2010
Incidents rate per 10.000 operations © International Air Transport Association (IATA). All rights reserved. No part of this graph
may be reproduced, recast, reformatted or transmitted in any form by any means,
Figure 12 -call sign confusion 2008-2010 elctronic or mechanical, including photocopying, recording or any information storage
and retrieval system, without written consent of IATA, Senior Vice President, Safety,
Callsign confusion reports Figure 12a -Call Sign Confusion 2001-2010
STEADES
0,6 Linear (Callsign conf. rpts per 10,000 flights) 200
180
0,5 It is very interesting to see that European and global Callsign similarity trends through 2008-2010 are very similar. In both areas, European
160
and global, 2009 had a higher number of occurrences than140 in 2008 and 2010. As already explained, in general the global STEADES rate is
0,4
much higher than EVAIR. 120
0,3 100
80
0,2 60
0,1 40
20 Mistakes
0,0 Spoken Communication through the monitored period 0
2008 2009 2010
had the highest rate. After an increase in 2009 it went
Spoken comm.
slightly down in 2010. As said above, the reason could be
the influence of the European Callsign similarity project. 2010
2009
Oper. Comm. Issue 2008
0,00 0,02 0,04 0,06 0,08 0,10

Figure 13 - Call Sign Confusion ATM Contributors
2008 – 2010

SECTION 4 - Air-Ground Communication
In-depth analysis of the operational Use of the English Language in ATM around Europe
Aviation represents a domain which arguably more than any other, requires world-wide standardised and harmonised regulations and
practices. As in other activities, common language and communication facilities represent the main means for exercising a job. But it
seems that in no other industry is the use of language and communications more critical, and where misunderstandings in pilot-air traffic
controller communication is so potentially disastrous, than in air traffic control.
The reason to dedicate attention to the language issues in this issue of EVAIR is that in our database the language (operational and spoken)
is the most frequent incident contributor to different type of events. This is also EVAIR’s contribution to the ongoing language discussions
across Europe and a trial to make the best use of the collected data.
Most EVAIR incidents come from pilots through their airlines’ SMSs. Flying across the world every day, pilots have a clear perspective of the
knowledge of the English language in air traffic control (ATC). The Air Traffic Controllers (ATCOs), on the other hand, have a direct line to the
different airlines and their pilots’ knowledge of the English language. EVAIR reports show that language problems are pan-European issues.
The graph below which represents the cumulative figures of the main incident contributors for the period 2008-2010, shows that
Air-Ground communication (Operational and Spoken) make 32% of the main contributors.
ATC clearance/
Traffic & instruction related item
airspace problems 2%
15%
Oper. & spoken comm.
Coordinations 31%
Issues
6%
Figure 14 – Contributors to ATM Incidents

cumulative figures 2008-2010
Traffic
information
11%
Lapses Mistakes
6% 29%
The most frequent Air-ground communication problems are shown in the graphs below (Figures 15 and 16)
Transfert of Call sign confusion

Situation not 11%
communications Handling of radio comm. conveyed by pilots
10% failure/unsusual situations High R/T workload
32%
25% 6%
R/T monitoring
sector
6%
Language/accent
Poor/no coordination 7%
16%
Misunderstanding/
Pilot breach of R/T interpretation
Phraseology 7%
30% 1%
Hearback ommited
29% Other pilot problems Noise interference
5% 2%
Figure 15– Drill down through Figure 16– Drill down through
Operational communication 2006-2010 Spoken communication 2006-2010
The most frequent events that have language as one of the causes are: Level Bust, Callsign Confusion, Go-around and Runway and Taxiway
Incursion/Excursion.

Language Impact on ATC Safety and Efficiency
Below, we give two incident examples related to the English language proficiency and the use of English and the national language in a
single environment on the same operational radio frequency.
EXAMPLE: Short summary of an incident with language proficiency as the contributory factor
After take off, the landing gear lever got stuck. In addition, an engine problem appeared. The pilot requested to be allowed to make a holding
pattern due to technical problems. Quality of ATC radio telephone (R/T) communications and English proficiency was quite poor. R/T communi-
cation consumed half of the entire time required to solve the technical problem! Assistance came from the company pilot on the jump seat, who
spoke the local language.
EXAMPLE: Short summary of an incident with the use of two languages in a single environment and the problem of pilot’s situational
awareness
The incident occurred with three aircraft; one just landed, the second one was ready for take off, and the third one was in the approach phase
approaching the final. The communication with the landing aircraft was in the national non-English language. After landing the a/c stayed on
the runway longer but that was not known to the non-national language speaking pilots. The departing traffic communicated with the ATC in
English and got clearance for take off, which was ATC’s mistake. Due to lack of situational awareness, the pilot of the departing traffic accepted
the clearance. Take off was aborted at a speed of 60kts. The third a/c made a Go Around since there were two a/c on the runway. The pilot of the
departing traffic stated that if he had been aware of the communication with the landing traffic he would have been in a position to warn ATC
and correct the mistake. The use of the national language reduced general awareness and possible correction of the mistake.
Worldwide common practice and operational and safety reasons have made English the Number One language in aviation, but not the
only one. On the operational frequency, as can be seen from the above incident, it is not uncommon to hear two different languages,
which could create a problem to those who do not know/understand both of them. The use of two different languages accounts for 10% of
the spoken communication problems across Europe according to the EVAIR data. The need to have only one language on the operational
frequency, when pilots and air traffic controllers communicate, opens a lot of issues amongst which the most important are: regulation,
safety and efficiency but very often followed by historical, cultural and political discussions.
Political and cultural reasons could create obstacles for the use of English as the single language in airspace designated for international
use. In a number of states across the world, the use of English in aviation communication is not regulated by national regulation or if it is,
then the national language has the same priority as English. This is the origin of various problems.
The best solution from a safety and efficiency point of view, supported very much by the airline associations, is the use of the English
language as the only one at airports and in the airspace designated for international use. Unfortunately, as previously mentioned, currently
this is not always possible due to political, cultural and historical reasons.
Improvements in the training field, refresher courses and periodic checks flexible enough to take into consideration areas of concern
identified through the reporting process, could mitigate the situation and bring positive results and ensure an appropriate level of English
language knowledge. Besides R/T phraseology, attention has to be given also to proficiency in plain language, as phraseology alone
cannot satisfy all communication requirements. This should concern both those to whom English is a foreign language but also those to
for whom English is the mother tongue.

SECTION 5 - SPECIFIC EVENTS
LASERS THREATS WIDESPREAD ACROSS EUROPE
The previous EVAIR Safety Bulletins have highlighted the growing menace to aviation caused by the misuse of hand-held laser devices
which are being used to ‘target’ aircraft and sometimes ATC facilities. In the EVAIR Safety Bulletin No 6, which covered the summer seasons
there were laser interferences at 74 different locations within 24 states. However, in this issues which covers the full years from 2008-2010,
the trend increased not only in the number of interferences but also in the number of locations. Now we have identified 100 different loca-
tions within 27 states from the reports we have received from 53 AOs.
The dramatic growth in numbers prompted the decision for EUROCONTROL to host a multi-disciplinary Laser Seminar (10-11 Oct 2011). The
aim was to gather experts from different fields to begin the search for potential answers and possible proposals to mitigate the situation at
national and international levels. It is recognised that if the fight is to be won then it will need concerted and coordinated effort by aviation
stakeholders working in conjunction with local authorities, laser manufactures, medical experts, police, prosecutors and law makers.
Landing Standing
0% 0%
Tendency of Laser interferences per 10,000 operations
Yearly development per 10,000 operations En-route Take-off
1,2 2% 6% Taxiing
EUROCONTROL
0,098 0%
1,0
0,8 0,085
0,6
0,4
0,2
0,026
0,0
-0,2
2008 2009 2010

Approach
Figure 17 - Laser interferences 2008-2010 92%
Figure 18 - Laser occurences

Callsign confusion reports per phases of flight 2008-2010
STEADES
0,6 Linear (Callsign conf. rpts per 10,000 flights) 200
Figures 17 & 18: Laser – Period 2008 - 2010 per 10.000 flights 180
0,5 160through 2008-2010. Moreover, in 2010 the increase was above the
The data show an every increasing rise in laser interference events
140
0,4 trend. The most affected phase of flight by laser is Approach with 92%. The number of Laser incidents in 2010 had a higher rate
average
120
per 0,3
10,000 operations than Level Busts and Runway Incursions combined.
100
80
0,2 60 reports concerning the misuse of lasers against aviation assets. As
EVAIR will continue to monitor the situation and welcomes additional
0,1 40
ever please send reports to: Dragica.stankovic@eurocontrol.int
20
0,0 0
2008 about lasers and
Further information 2009 2010on SKYbrary (www.skybrary.aero).
aviation is available

SECTION 6 - ACAS REPORTING
EVAIR ACAS monitoring aims to ensure the continued safe and effective operation of ACAS by identifying and measuring issues associated
with RAs and their trends and taking preventive measures where necessary.
ACAS is the generic term for Airborne Collision Avoidance Systems, of which TCAS II is the only example of implementation so far. ACAS
is intended to improve air safety by acting as a ‘last-resort’ method of preventing mid-air collisions or near collisions between aircraft.
Although ACAS II implementation was completed in 2005, ACAS monitoring continues to improve safety by identifying technical and
procedural deficiencies.
ACAS data have been collected either automatically via the Automated Safety Monitoring Tool (ASMT) developed by EUROCONTROL, or
manually thanks to airlines and ANSPs reporting.
It should be noted that ACAS / TCAS statistics from manual reporting rely on pilots’ and controllers’ perceptions and memories of
the events rather than measured or calculated values. Therefore care is needed when comparing manually collected data and data
that are captured automatically. Messages about typical performance should generally be taken from the Automatic recording
of events. Manual reporting tends to give emphasis to more significant events and insights into perception of the ACAS II system.
In 2010 through the automatic data collection from twelve radars a total of 8152 events with valid RAs were recorded in the EVAIR data-
base. Among them there were 203 complex events that had more than two different RAs. To ensure consistent continuity of the statistical
analysis, data from only one of the radars covering a busy airspace is compared with previous years. The reason to compare the previous
period with data from only one radar is because the other 11 were not previously included in the system. It is unfortunate that monitoring
for that one radar was not continuous for the whole period in 2010 that has approximately one month worth of missing data.
Part One - Manual ACAS Reporting
Through all phases of flight, except take-off, the

number of manually provided ACAS RAs in 2010
decreased versus 2009 and more or less is at the
level of 2008. In total in 2010 there were about
2.5 ACAS RA incidents daily, which is slightly
2010
less than in 2009 when according to the EVAIR 2009
Approach
data there were at least 3 RAs incidents across 2008
Europe daily. Interestingly still within the manual
En-route
reporting, the highest number of RAs occurred
within En-route airspace, which contrasts with
Take-off
the data collected automatically, where the
highest number of RAs occur within the TMAs. It 0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8
is difficult to say what the reasons for this differ-
ence are and further investigations will be done Incidents rate per 10.000 flights
through the contacts with ANSPs and airlines Figure 19 - Manually reported ACAS incidents
and their pilots. by phase of flights 2008 – 2010

ICAO ADREP definitions of types of RAs are shown below. The extent to which pilots and controllers correctly follow these classifications
when filling out their reports is unknown. The assessment of events (e.g. severity, usefulness) is based on subjective assessment of those
who were involved in the incident. Nevertheless, these values arguably provide a general measure of the current operational acceptability
of ACAS.
l Useful RA - The ACAS II system generated an advisory in accordance with its technical specifications in a situation where there
was or would have been a risk of collision between the aircraft.
l Unnecessary (Nuisance) RA - The ACAS II system generated an advisory in accordance with its technical specification in a situa-
tion where there was not, or would have not been, a risk of collision between the aircraft.
l Unclassifiable RA - The ACAS II system generated an advisory that cannot be classified because the manual report contained
insufficient data.
All three types of the RA incidents decreased

Useful RA
in 2010 versus 2009. The majority of RAs
that occurred during the summer 2010
Nuisance 2010
have been classified by pilots as ‘Useful’ RAs
2009
making a rate of about 0.2 incidents per
2008
Unclassifiable RA
10.000 flights in 2010. It seems that every
fourth RA provided manually was classified 0,0 0,1 0,2 0,3 0,4 0,5 0,6
by pilots as Useful.
Figure 20 - ACAS RA Classification 2008 - 2010
RA INSTRUCTIONS 2008-2010
Within EVAIR manually collected data, ACAS reports have decreased in 2010 and have lower levels than in 2009 and 2008. We believe
that the reasons behind this are the number of initiatives taken by the aviation community to improve ACAS operational performance.
EUROCONTROL contributions amongst the others in this regard, are very wide and well accepted across the aviation community. ‘Reduce/
Adjust’ RA is in general the RA that occurs with the greatest frequency. In 2010 the ‘Reduce/Adjust’ RA decreased by 11% versus 2009.
The 2nd most frequent RA instruction is ‘Climb’ RA, which decreased by 6% for the whole 2010 versus 2009. However during the summer
season this reduction in 2010 versus 2009
was 28%; with the available information it is
difficult to explain the reasons behind. One Climb RA
of the areas for the improvement is within
training. Training regimes have the flexibility Crossing RA
to continuously adapt programs following

Descend RA
identified problems and to find the best way
to spread the messages and awareness to Increase RA
pilots and controllers about these problems 2010
and how to avoid them. Maintain vertical speed RA 2009
2008
Monitor vertical speed RA
Reduce/Adjust RA
0,00 0,05 0,10 0,15 0,20 0,25 0,30 0,35

Figure 21 - ACAS RA Instructions 2008-2010

ACAS FL DISTRIBUTION
140
120 2010
2009
100 2008
80
60
40
20
0
50
60
70
80
90
98
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
310
320
330
340
350
360
370
380
390
410
Rate of incidents - absolute figures
Figure 22 - ACAS Flight Level Distribution 2008-2010
Statistics related to the FL distribution of the manually collected ACAS incidents show that the ACAS incidents are located in clusters
of FLs. For the period 2008 – 2010 absolute figures, the ACASAS RAs are grouped in 3 big areas: FLs between 50-170; 180 – 250; and
330-370. In general, the largest number of RAs occurred between FL 50 – 130. However, in 2010 there was an overall decrease in the
number of RAs and the most affected levels were between FL230 and FL 250 and FL 310 and FL 350. Geographical location of incidents
and comparison with the route network structure as well as sectorisation could give more information whether some of these incidents
have been generated by the airspace design and sectorisation structure or some other reasons. In the next issue, more attention will
be dedicated to this type of analysis.

PART TWO - ACAS RAs COLLECTED AUTOMATICALLY FROM MODE S RADAR STATION
Tim Baldwin
Analysis of Automatically provided Garfield Dean
ACAS RAs ACAS Expert
Tim.baldwin@eurocontrol.int Garfield.Dean@eurocontrol.int
ACAS RAs COLLECTED AUTOMATICALLY FROM MODE-S RADAR
Automatic monitoring of ACAS RA downlink messages has been expanded in the last 12 months to cover larger numbers of radars in
Europe. The procedures for monitoring have been changed by using the Automated Safety Monitoring Tool (ASMT) to monitor Radar LAN
recordings rather than being connected on line. Standard radar LAN recordings are transferred to ASMT on a daily basis and the detection
process in ASMT is run once for each ModeS radar source storing detected events in a dedicated radar community database. This process
is now used by two ASNP’s.
The total numbers of RA downlink events recorded by ASMT attached to 12 radars in Europe is shown below:
All radars
Events with valid Events with Erroneous Complex

Year Totals
RA RA messages RA events
2010 8152 18589 203 26944
Events with valid RA messages = RA downlink messages which a valid RA downlink code.
Events with erroneous RA messages = RA downlink messages which are empty or contain only a stop bit.
Complex RA events = Events where more than two different RAs are detected for one aircraft during the encounter.
Note: many of the events are seen by up to 7 radars and so result in multiple recordings.
Comparison of statistics for 2007, 2008, 2009 and 2010.
ASMT is being used to record and analyze all ACAS downlink messages. The set of data presented below covers one radar head, to enable
comparison of statistics through 2007-2010. The data has been collected by ASMT from the same ModeS radar in European airspace.
NUMBER OF EVENTS RECORDED
Events with valid Events with Erroneous Complex

Year Totals
RA RA messages RA events
2007 1516 7743 30 9289
2008 1912 6064 38 8014
2009 1070 1925 30 3025
2010 1071 1939 16 3026

The figures show a significant drop in the number of RAs over the 3 years a drop of 29% from 2007 to 2009. Note: - The numbers for 2009
and 2010 are very similar.
During 2007 the monitoring was not continuously available due to radar maintenance and a change to the ASMT monitoring machine.
In 2008 automatic filtering of erroneous messages from selected airframes was also introduced. In 2009 additional filtering of erroneous
messages was introduced to reject all continuous downlink transmissions of messages with only the stop bit set hence a large reduction
in numbers of erroneous downlink messages in 2009 and 2010 (downlink anomalies).
Although there are many erronous downlink messages these appear to be generated by a small number of aircraft fitted with Honeywell
TCAS units and Honeywell Enhanced ModeS transponders that continuously report RAs. With the addition of a new ANSP providing data
a new group of airframes has been detected exhibiting the same phenomena. There is a much larger group of aircraft that generate a
downlink message with only the RA stop bit set. With these aircraft it is a set of three erroneous messages sent once or twice per flight and
we have not yet found a common factor.
Detection and correction of RA downlink anomalies is now being handled by the ModeS monitoring team.
Downlink anomalies
In summary, a small number of aircraft are non- compliant with the SARPS and ‘pollute’ the RF environment. Corrective action is underway
with the operators and manufacturers concerned.
Aircraft reporting RAs
For the 10 radars the graph below indicates the number of aircraft reporting RA downlink to one or more radars. Some military actually
flew through the coverage of more than one radar and reported RAs in different geographic locations. The numbers here are filtered using
ModeS code and therefore represent a clearer picture of total events but still include duplicate counts for coordinated events;
200
186
180
164 167
160
143 144
140 131
120
100 97
80
60
42
40
20 11
1
0
1 2 3 4 5 6 7 8 9 10
Figure 23 - Radars detecting RAs

Aircraft Reporting Days
Data from the year was analysed and some aircraft were detected as reporting a valid RA on more than one occasion, the Modes S code
was looked at for those reporting on multiple days and all reporting on 4 or more days were identified as military. It is very unlikely that
commercial airframes will get more than one RA in a year.
900
793
800
700
600
500
400
300
200
157
100
49
28 18 12
0 5 5 1 1 1 1 1 1 0 0 4 0 1 2 1 1 0 1 2 0 0 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Figure 24 - Days reporting by airframe
RA DISTRIBUTION BY FLIGHT LEVELS
Figure 25 below shows the number of RAs by Flight Level and compares 2007, 2008, 2009 and 2010. All recorded RAs with a valid down-
link message (not blank and not stop only) have been counted even if the intruding aircraft has not been identified. FLs in this report are
rounded to the nearest FL. There is no major trend difference between the 2007, 2008, 2009 and 2010 distributions except for a reduction
in higher level RAs.
500
400 2010
2009
300 2008
200
100
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
310
320
330
340
350
360
370
380
390
400
410
420
Figure 25 - Advisories by Flight Level

There is a large proportion of RAs between FL10 and 30. They are mostly the result of VFR traffic in uncontrolled airspace. (Figure below
shows the high number of Mode C Intruders at these levels, but note the increase in Mode S equipped intruders in 2008 compared with
2007 indicating a greater number of GA aircraft fitted with Mode S transponders)
Intruder equipage by flight bands
The diagram below shows the number of RAs events recorded on both aircraft and the number of events where only one aircraft reported
an RA.
Events shown as an RA with a Mode S intruder are to a very large extent ACAS equipped. ACAS does not symmetrically generate RAs.
There are many events where only one aircraft receives an RA, even though both are ACAS equipped. In 2010 both aircraft reported an RA
in 11% of the recorded events. RA with intruder Mode C are confirmed as Mode C intruders by the Own RA downlink. In the lower levels
there is an increased percentage of aircraft identified as Mode S intruders and a reduction in Mode C intruders, which may be due to the
increase in the number of General Aviation aircraft fitting Mode S transponders.
2010 Below 3000

2009 Below 3000
2008 Below 3000
2007 Below 3000
2010 FL 30-100
2009 FL 30-100
2008 FL 30-100
2007 FL 30-100
2010 FL 100-180
2009 FL 100-180
2008 FL 100-180 Both RA
2007 FL 100-180 Intruder ModeS
2010 FL 180-290 Intruder Mode C
2009 FL 180-290
2008 FL 180-290
2007 FL 180-290
2010 AboveFL 290
2009 AboveFL 290
2008 AboveFL 290
2007 Above FL 290
0 100 200 300 400 500
RA by FL and YEAR
Figure 26 - TCAS equipage in Encounters
Note: The number of events at each level is lower than the number of RAs because more than one RA can exist for each event.
At lower flight levels, the majority of RAs are against Mode C intruders, whereas at higher levels, most RAs are against intruders with Mode
S or are coordinated ACAS encounters. A significant reduction of level off RAs in upper flight levels is possibly due to the increased use of
25ft reporting Mode S transponders.

Hot Spots
Plotting XY distributions of RAs at different altitude ranges allows “RA hotspots” to be identified. Frequently these are related to airspace
design and airspace classification issues, e.g. where climbing aircraft level off just below a flight level where descending aircraft level off
too. As an example, a hot spot diagram is shown below. Better conclusions would have been given if the route network had been shown.
200
150
100
50
0
-200 -150 -100 -50 0 50 100 150 200
-50
-100
-150
-200
Figure 27 - Example of Hot Spot Diagram using 2010 data only
250
200
150
100
50
0
Head-on Acute Crossing Obtuse Chasing Changing
Figure 28 - Horizontal Geometry (2010 only)
Definitions of geometry are included in Annex 2
As expected this shows that the majority of RAs occur with acute and crossing tracks with 60% in this area. The low number of head on
geometry could be due to the fact that head on traffic is not normally climbing or descending to within 1000ft in close proximity, when on
the same airway in opposite directions. However it is usual to have aircraft aiming for 1000ft separation at airway crossing points.

50%
40%
30%
20%
69% 27% 4%
10% 58% 29% 13%
0%
Normal High Level
Pilot response 2010
For an RA that does not change for at least 2 radar cycles, i.e. 10 seconds ASMT automatically calculates compliance with the RA. We see that
81% of pilots have at least adequately responded to the RA. There were 73% achieving the requested vertical rate and 8% exceeding the
requested rate. 19% of responses were not satisfactory from a safety perspective with 12% either slow or failing to achieve the requested rate
and 7% were calculated to have made opposite responses. These are similar numbers to 2009. The numbers here are for all RA’s from a single
900
radar and include those from Military training and transport aircraft. Most of the military will fall in the short RA sample in the diagrams below.
811
800
731
Opposite Excessive
700 Followed
655 7% 8% 2008
27%
600 2007 Below
Partial required rate
Followed 25%
500 followed 73%
468
12%
419
400
351
300
236
200 192
100
33 27
Excessive
13 10 13 13 20
0 0 9 8 1 9 5 6 10%
MVS KVS AVS CL ICL CCL RCL DE IDE CDE RDE
Opposite
38%
Figure 29 - Response to standard RAs Figure 30 - Response to short RAs
For short RAs (353 events - 39%), where the RA is observed to change after one radar cycle (changes in less than 10 seconds), compli-
ance with the RA is not as good, even though ACAS expects a quicker response from pilots. The ACAS logic expects an initial response
to an RA in 5 seconds and only if the RA exists for less than 6 seconds do the responses here appear to be reasonable.
The high level of opposite responses to changing RAs is a cause for concern and re-emphasizes the need for pilots to be trained to follow
the full sequence of RAs that they receive.
VERTICAL RATES AT THE TIME OF THE RA
On 20th November 2008 PANS-OPS was changed to

include the following recommendation:
1000
900
“Pilots should use appropriate procedures by which an aero-
800
plane climbing or descending to an assigned altitude or flight
700
level, especially with an autopilot engaged, may do so at a
600
rate less than 8 m/s (or 1 500 ft/min) throughout the last 300
500
m (or 1 000 ft) of climb or descent to the assigned altitude or
400 flight level when the pilot is made aware of another aircraft
300 at or approaching an adjacent altitude or flight level, unless
5 6
200 otherwise instructed by ATC. These procedures are intended to
RDE
100 Normal avoid unnecessary airborne collision avoidance system (ACAS
High
0 Level II) resolution advisories in aircraft at or approaching adjacent
2007 2008 2009 2010 altitudes or flight levels. For commercial operations, these
Figure 31 - Own vertical rates procedures should be specified by the operator.”

At the time of the first RA reports, 2010 analysis shows 27 % of aircraft had a vertical rate exceeding 1500fpm. A drop of 9 % in 2009
compared to 2007 was mostly reversed in 2010.
Pilots should be reminded of the provision in PANS-OPS shown above.
ADVISORIES ISSUED
The number of RAs is greater than the number of events for two reasons: more than one RA can be issued to an aircraft during an event;
and both own aircraft and intruder can issue an RA. The table below shows the breakdown of advisories issued in the collected data.
The reduction in the number and percentage of MVS (monitor vertical speed) RAs is probably due to the increased use of ModeS by
general aviation aircraft at lower flight levels.
Code Advisory 2007 2008 2009 2010

AVS Adjust Vertical Speed 36% 40% 38% 39%
MVS Monitor Vertical Speed 33% 23% 25% 23%
CL Climb 17% 21% 23% 20%
DE Descent 10% 12% 12% 12%
KVS Maintain Vertical Speed 2% 1% 1% 2%
ICL Increase Climb 0,6% 0,5% 1,5% 0,5%
ICD Increase Decent 0,6% 0,6% 1,1% 1%
RCL Reversal Climb 0,4% 0,0% 0,7% 0,9%
CCL Crossing Climb 0,0% 0,4% 0,4% 0,6%
RDE Reversal Descent 0,2% 0,3% 0,3% 0,6%
CDE Crossing Descent 0,4% 1,0% 1,0% 1%
MUL Multiple 0,0% 0,0% 0,1% 0%
The ACAS advisories AVS and MVS do not require deviation from ATC clearance unless ATC requests a specific vertical rate. They correspond to
62% of RAs in 2010 similar to 2008 and 2009 but a drop of 4% from 2007.
900
811
800
731
700 2010
655
2009
600 2008
2007
486
500
468
420
419
400
351
282
278
300
242
236
205
192
200
147
130
100
33
27
17
19
13
10
17
13
13
12
20
17
11
12
9
8
8
8
11
9
11
0
6
0
5
5
6
7
0
0
1
0
MVS KVS AVS CL ICL CCL RCL DE IDE CDE RDE MUL
Figure 32 - Distribution by RA Type

ACAS RAs COLLECTED AUTOMATICALLY FROM Recorded radar LAN containing data from TEN MODE-S RADAR STATIONS
To obtain the statistics presented below all RA downlink messages from all Radars were merged into a single table and sorted on time.
These were then filtered to eliminate duplication by selecting only the first message from a series collected from the same ModeS address.
350
300
250
200
150
100
50
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
310
320
330
340
350
360
370
380
390
400
Figure 33 - Events by Flight Level
Due to the method of extracting the statistics, the results here represent the number of events rather than the number of RA’s as shown
in figure 4 above covering four years.
Time of RA downlink before Horizontal CPA
Times were extracted for one of the radars to get an estimate of warning time that a controller might expect from RA downlink. The
measurement was taken from receipt of first downlink to calculated Horizontal Closest Point of Approach (CPA) and is shown at one
second intervals.
200
180
160
140
120
100
80
60
40
20
0
1
13
17
21
25
29
33
37
41
45
49
53
57
Time in seconds
Figure 34 - RA downlink to horizontal CPA

Selection of Possible Save the Day events
The ASMT database was interrogated with a Query that selected all events with a horizontal CPA of 0.2nM and vertical separation of less
than 700ft. This set was individually assessed using InCAS to check what the separation might have been if the aircraft had continued
with its vertical rate rather than responding to ACAS advisory.
One of the events between GA aircraft is described below showing that following the RA increased vertical separation.
One example of save the day event
AC1 was a CESSNA C560 Simulation from radar data indicates 240 knots at FL 21.5 and AC2 was a PA32on a reciprocal heading at 170 knots FL 21.
Simulation suggests that AC 1 received a Traffic Advisory at 08:32:01 when AC2 was 2.8nm head-on with a closing speed of 410mph. Simu-
lation suggests that at 08:32:11 AC1 received a Resolution Advisory to climb when AC 2 was now 1.7nm ahead, still on reciprocal heading.
At 08:32:14 the radar received a downlink message from AC1 reporting a climb advisory. The simulation suggests that AC1 started to climb
at 1500fpm as requested by ACAS at 08:32:18 and the intruder AC 2 passed 223ft below with 0.04nm horizontal separation.
Figure 35
RA downlink Messages from AC1
Own Threat Threat Multi- Comple- Intruder

Time SSR Code Callsign Advisory Message
Address Info Stop Intruder ment Address
08:32:14 7041 AC 1 400??? Mode S No No CL - 400??? C2.00.05.00.??.??

08:32:18 7041 AC 1 400??? Mode S No No CL - 400??? C2.00.05.00.??.??
08:32:22 7041 AC 1 400??? Mode S No No CL - 400??? C2.00.05.00.??.??
08:32:26 7041 AC 1 400??? Mode S No No CL - 400??? C2.00.05.00.??.??
08:32:30 7041 AC 1 400??? Mode S No No CL - 400??? C2.00.05.00.??.??
08:32:34 7041 AC 1 400??? Mode S Yes No CL - 400??? C2.00.25.00.??.??

ANNEXES
ANNEX 1 - EUROPEAN ACTION PLANS
THE EUROPEAN ACTION PLAN FOR THE PREVENTION OF LEVEL BUST
Reducing Level busts is one of EUROCONTROL’s highest priorities. EUROCONTROL began raising awareness of the Level Bust issue in 2001,
organised series of workshops, and established a Level Bust Task Force to define the recommendations and to formulate an action plan to
reduce level busts.
The level bust action plan is the product of work carried out by EUROCONTROL’s cross-industry Level Bust Task Force, which was set up
in 2003. The Task Force reviewed the evidence available, identified the principal causal factors, and listened to the Air Navigation Service
Providers and aircraft operators with experience in reducing level busts.
The Action Plan contains recommendations for Air Traffic Management, Air Traffic Controllers, and Aircraft Operators. It designed to reduce
the frequency of level busts and reduce the risks associated with level busts. Implementation of the Action Plan will be monitored by the
Task Force monitoring group reporting to the EUROCONTROL Safety Improvement Sub Group (SISG).
http://skybrary.aero/index.php/Solutions:Level_Bust
THE EUROPEAN ACTION PLAN FOR THE PREVENTION OF RUNWAY INCURSIONS (EAPRI)
Although runway safety includes issues such as foreign objects, debris and wildlife straying onto the runway and other technical deficien-
cies, this action plan specifically addresses the subject of runway incursion prevention.
EAPRI is the result of the combined efforts of organisations representing all areas of aerodrome operations that are totally committed
to enhancing the safety of runway operations by advocating the implementation of the recommendations that it contains in the ECAC
area. The ICAO secretariat has lent its strong support to the work of this group and urges all States to fully implement the ICAO provisions
relevant to runway safety.
The version 2.0 of EAPRI came to light n April 2011 and contains more than 56 recommendations. When implemented, it will enhance
runway safety by the consistent and harmonised application of existing ICAO provisions, improving controller - pilot - vehicle driver
communications and working procedures at the aerodrome, and by the subsequent increase in situational awareness.
http://www.eurocontrol.int/runwaysafety/public/standard_page/EuropeanAction.html
CALL SIGN SIMILARITY (CSS)
The European Action Plan for Air Ground Communication Safety (conceived inter alia by EUROCONTROL, aircraft operators (AOs) and the
Flight Safety Foundation) identified Call Sign Similarity (CSS) as a significant contributor to air-ground communication issues. Analysis of
ATC reported events shows that 5% involve incidences where CSS is involved. Some aircraft operators are trying to find solutions; the only
known ANSP actively operating a service to de-conflict call signs is France’s DSNA.
Research and CBA studies show that the most cost efficient way of providing a long-lasting, Europe-wide solution is to create a central
management service to de-conflict ATC call signs. This strategy provides economies of scale and rapid pay back of investment (3 years).
More importantly, it is calculated that it will eliminate over 80% of the CSS incidences and thus improve safety.
http://www.eurocontrol.int/safety/public/standard_page/Callsign_Similarity_project.html

ANNEX 2 - DEFINITIONS
Following definitions are extracted from the HEIDI and/or HERA Taxonomies.
HEIDI (Harmonisation of European Incident Definitions Initiative for ATM) intends to finalise a harmonised set of definitions (taxonomy)
for ATM related occurrences.
HERA (Human Error in European Air Traffic Management) develops a detailed methodology for analysing human errors in ATM, including
all error forms and their causal, contributory and compounding factors.
More information can be found at:

HEIDI: http://www.eurocontrol.int/src/public/standard_page/esarr2_heidi.html
HERA: http://www.eurocontrol.int/humanfactors/public/site_preferences/display_library_list_public.html#5
ATC clearance/instruction (HEIDI): Related to incorrect or wrong aircraft action. Authorisation for an aircraft to proceed under conditions
specified by an air traffic control unit and deviations from the clearance which cause runway incursions, taxiway incursions, apron incur-
sions, level bust, unauthorised penetration of airspace etc.
Coordination (HEIDI): Internal coordination encompassing coordination with sectors within the same unit, and sectors within the ATC
suite; external coordination, civil/civil and civil/military; and special coordination, covering expedite clearance, prior permission required,
revision and other special coordination.
Call sign confusion: The major cause for aircraft taking a clearance not intended for them.
Call sign similarity: The use of similar call signs by aircraft.”
Contributory factors (HEIDI): A part of the chain of events or combination of events which has played a role in the occurrence (either
by easing its emergence or by aggravating the consequences thereof ) but for which it cannot be determined whether its non existence
would have changed the course of events.
Decision-Making (HERA): Cover incorrect, late or absence of decision.
Failure to Monitor (HERA): Failure to monitor people, information or automation.
Judgement (HERA): Mainly associated to separation.
Lapses (HEIDI): Psychological issues encompassing: Reception of information, Identification of information, Perception of information,
Detection, Misunderstanding, Monitoring, Timing, Distraction, Forgetting and Loss of awareness.
Level bust (HEIDI): Any unauthorised vertical deviation of more than 300 feet from an ATC flight clearance Departing from a previously
maintained FL, overshooting, undershooting, levelling-off at a different level than cleared level.
Mental/Emotional/Personality issues (HERA): include the following items.
l Mental capacity: loss of picture or Safety Awareness;

l Confidence in self, in others, in information, in equipment, in automation;
l Complacency;

l Motivation/Morale;
l Attitudes to others;
l Personality traits: aggressive, assertive, under-confident, risk taking;
l Emotional status: stressed, post incident;
l Miss-stored or insufficient learned information;
l Planning: insufficient, incorrect or failed;
l Recall of information: ailed, inaccurate, rare information, past information;
l Violations: routine, exceptional.
Mistakes (HEIDI): Psychological issues encompassing: Information wrongly associated, Workload issues, Information not detected,
Failure to monitor, Recall of information, Misunderstanding or insufficiently learned information, Judgement, Planning, Decision mak-
ing, Assumptions and Mindset.
Missed approach/Go-around (HEIDI): The operating phase where the aircraft flies the procedure to be followed if the approach cannot
be continued.
Operational communication (HEIDI): Air-Ground, Ground-Ground and Use of equipment verification testing. Air-Ground communica-
tion encompasses hear back omitted, pilots’ read back, standard phraseology, message construction, R/T monitoring including sector
frequency monitoring and emergency frequency monitoring, handling of radio communication failure, unlawful radio communications
transmission. Ground-Ground communication refers to the standard phraseology, speech techniques, message construction, standard
use of equipment like, radio frequency, telephones, intercoms, etc.
RA geometry between two Aircraft (ASMT)
Crossing Crossing
Limit Limit
Crossing
Chasing -Head-On
Obtuse Acute
Limit Limit
Chasing Head-On
Chasing -Head-On
Obtuse Acute
Limit Limit
Crossing
Crossing Crossing
Limit Limit

Runway Incursion (ICAO): Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the pro-
tected area of a surface designated for the landing and take-off of aircraft.
Spoken communication (HEIDI): Human/human communication encompassing air-ground and ground-ground communications but
also call sign confusion, noise interference and other spoken information provided in plain language. Air-ground communication refers to
language/accent, situation not conveyed by pilots, pilot’s breach of radio telephony (R/T), workload, misunderstanding/misinterpretation,
and other pilot problems. Ground-ground communication refers to misunderstanding/misinterpretation, poor/no coordination.
Taxiway Incursion (HEIDI): Any occurrence unauthorized presence on a taxiway of an aircraft, vehicle, person or object that creates a
collision hazard or results in a potential loss of separation.
Traffic & Airspace problems (HEIDI): There are four set of causal factors under this element.
l Traffic load & complexity, encompassing excessive and fluctuating load, unexpected traffic demand, complex mix of traffic,
unusual situations (emergency, high risk, other), Abnormal time pressure, underload and call signs confusion;
l Airspace problems composed of flights in non controlled and controlled air space, Airspace design characteristics(complexity,
changes, other) and temporary sector activities(military, parachuting, volcanic activity, training);
l Weather problems such as poor or unpredictable(snow, slush, ice, fog, law cloud, thunderstorm, wind shear);
l Pilot problems concerning language, culture and experience aspects.
Traffic Information (HEIDI): Essential and local traffic information provided by an air traffic controller to the pilot. Essential information is
related to the provision of traffic information containing:
a. direction of flight of aircraft concerned;

b. type and wake turbulence category (if relevant) of aircraft concerned;
c. cruising level of aircraft concerned; and
d. estimated time over the reporting point nearest to where the level will be crossed; or
e. relative bearing of the aircraft concerned in terms of the 12-hour clock as well as distance from the conflicting traffic; or
f. actual or estimated position of the aircraft concerned.
Local traffic in this context consists of any aircraft, vehicle or personnel on or near the runway to be used, or traffic in the take-off and
climb-out area or the final approach area, which may constitute a collision hazard to the other aircraft and about which the information
has to be provided.
Workload issues (HERA): Concern both minimal and excessive workload.

ANNEX 3 - ACRONYMS
ACAS Airborne Collision Avoidance System

ANSP Air Navigation Services Provider
AO Aircraft Operator
ASMT ATM Safety Monitoring Tool
ATC Air Traffic Control
ATM/CNS Air Traffic Management/Communication, Navigation, Surveillance
CFMU Central Flow Management Unit
CSS Call Sign Similarity
ECAC European Civil Aviation Conference
EVAIR EUROCONTROL Voluntary ATM Incidents Reporting
FL Flight Level
GAT General Air Traffic
HEIDI Harmonisation of European Incident Definitions Initiative for ATM
HERA Human Error in European Air Traffic Management
LAN Local Area Network
Mode C Altitude Reporting Mode of Secondary Radar (ICAO)
Mode S SSR selective mode of interrogation
NATS National Air Traffic Services (UK)
OPS Operations
PAN-OPS Procedures for Air Navigation - Operations
RA Resolution Advisory
RF Radio Frequency
RWY Runway
SARPS Standard And Recommended Practices
SISG Safety Improvement Sub-Group
SSR Secondary Surveillance Radar
TCAS Traffic Collision Avoidance System

ANNEX 4 - IATA Explanations of categories
Category Definition / Note
Altitude Deviation Unintentional deviation from the assigned altitude/flight level
Call Sign Confusion Two or more aircraft on frequency with similar Call Signs creating confusion
Go-Around Go-Around or missed approach procedure carried out
Other Aircraft - Runway/Taxiway Another aircraft made an unauthorised entry into a runway or taxiway
Incursion
Runway Incursion by Ground Vehicle A ground vehicle entering an active runway or taxiway without ATC permission
creating an unsafe situation
Runway/Taxiway Incursion The aircraft made an unauthorised entry into a runway or taxiway

EUROCONTROL
October 2011 - © European Organisation for the Safety of Air Navigation (EUROCONTROL)
This document is published by EUROCONTROL for information purposes. It may be copied in

whole or in part, provided that EUROCONTROL is mentioned as the source and it is not used for
commercial purposes (i.e. for financial gain). The information in this document may not be modified
without prior written permission from EUROCONTROL.
www.eurocontrol.int

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EVAIR Safety Bulletin

EVAIR Function Manager’s Perspective 4

Introduction to EVAIR Statistical Data 7

Section 1 - Phases of Flights 7

Section 2- ATM events and support to European action plans 8

l Training – The solution for contributors to ATM occurrences 9

Section 3 - EVAIR Support to Call Sign Similarity Implementation Project 13

l Call Sign Confusion Summer 2008-2010 Trend 15

Section 4 - Air – Ground Communication 16

Section 5 - Specific events Laser Treats widespread across Europe 18

Section 6 - ACAS Reporting 19

l Part one – Manual ACAS Reporting 19

l Annex 1 - European Action Plans 33

EVAIR SAFETY BULLETIN N°7 - 2008-2010 3 EUROCONTROL

EUROCONTROL 4 EVAIR SAFETY BULLETIN N°7 - 2008-2010

Main trends: Laser Interference

EVAIR SAFETY BULLETIN N°7 - 2008-2010 5 EUROCONTROL

EUROCONTROL 6 EVAIR SAFETY BULLETIN N°7 - 2008-2010

SECTION 1 - PHASES OF FLIGHTS

INCIDENTS PER PHASE OF FLIGHT: PERIOD 2008 - 2010

Figure 2: Incident distribution per phases of

EVAIR SAFETY BULLETIN N°7 - 2008-2010 7 EUROCONTROL

Figure 3 and 3a: ATM Events 2008 - 2010

ACAS RAs not possible to be continued. It is interesting that

Runway incursion reports

EUROCONTROL 8 EVAIR SAFETY BULLETIN N°7 - 2008-2010

Comm. Operational & Spoken

Trafffic and Airspace problems

0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6

Incidents rate per 10.000 flights

EVAIR SAFETY BULLETIN N°7 - 2008-2010 9 EUROCONTROL

Yearly development per 10,000 operations

10 reserved. No part of this

recast, reformatted or trans-

which saw growth is ‘Other parties’ which Coordinations Issuies 2010

EUROCONTROL 10 EVAIR SAFETY BULLETIN N°7 - 2008-2010

Runway incursion reports

graph may be reproduced, 200

Oper. Comm. Issue

EVAIR SAFETY BULLETIN N°7 - 2008-2010 11 EUROCONTROL

Altitude deviation reports

Altitude deviation reports Figure 9a - Altitude Deviation reports 2008-2010

0,00 0,02 0,04 0,06 0,08 0,10

Incidents rate per 10.000 flights

EUROCONTROL 12 EVAIR SAFETY BULLETIN N°7 - 2008-2010

CSS Tool WP1 CSS Tool WP1 CSS Tool WP2

CSS Tool Initial CSS Tool WP1 Continued

April April 2010 - March 2010 - Summer Spring Summer September

Work Package Release Date

EVAIR SAFETY BULLETIN N°7 - 2008-2010 13 EUROCONTROL

EUROCONTROL 14 EVAIR SAFETY BULLETIN N°7 - 2008-2010

CALL SIGN CONFUSION 2008 – 2010 TREND

Callsign confusion reports

0,00 0,02 0,04 0,06 0,08 0,10

Incidents rate per 10.000 flights

EVAIR SAFETY BULLETIN N°7 - 2008-2010 15 EUROCONTROL

Figure 14 – Contributors to ATM Incidents

Transfert of Call sign confusion

EUROCONTROL 16 EVAIR SAFETY BULLETIN N°7 - 2008-2010

EVAIR SAFETY BULLETIN N°7 - 2008-2010 17 EUROCONTROL

LASERS THREATS WIDESPREAD ACROSS EUROPE

Incidents rate per 10.000 flights

Figure 18 - Laser occurences

EUROCONTROL 18 EVAIR SAFETY BULLETIN N°7 - 2008-2010