Recommendations 2023
Recommandations de sécurité émises en 2023
The table below sets out the recommendations issued by the BEA in 2023 with their status:
(-) exchanges on-going
(✓) file closed with an adequate response from the addressee
(✗) file closed with an inadequate response from the addressee
To view the investigation report in which the recommendation was issued and to access the recommendation in its entirety, click on the reference number (first column).
Number | Status | Reg. | Title | Recommendations | Addressee | Date sent | Date response | Keywords |
✗ | 9H-FAM | Improvement in the crew’s situational awareness when operating in icing conditions | The ANAC in coordination with Embraer, assess the improvement to safety that would be obtained by installing an ice detector on all EMB-500 Phenom 100 aircraft and the need to impose this modification on all Phenom 100 aircraft authorised for flight in icing conditions. | ANAC | 31/01/2023 | 07/05/2024 | Aircraft systems | |
✓ | 9H-FAM | Consideration given by operators to operational constraints related to operations in icing conditions | EASA, in coordination with the national oversight authorities, in the interest of promoting safety, make operators aware of the need to give better consideration in flight planning to the landing performance of aircraft which have significant differences in performance in icing and non-icing conditions. | EASA | 31/01/2023 | 09/06/2023 | Aircraft operations | |
✗ | 9H-FAM | Consideration given to operational constraints during certification process | EASA consider revising the certification criteria (by applying special conditions, for example) when the differences between an aircraft’s performance in icing and non-icing conditions lead to operational constraints that are difficult for crews to manage. | EASA | 31/01/2023 |
| Aircraft certification | |
✓ | F-HGRE | Improvements to Cabri G2 yaw control training | Hélicoptères Guimbal provide all training organisations with further information or recommendations on how to teach yaw control on the Cabri G2 as part of theoretical and practical training. | Guimbal | 17/02/2023 | 07/07/2023 | Training / | |
✓ | F-BXEU/37AHH | Pioneer 300 airframe parachute | Alpi Aviation review the assembly of the cables connecting the airframe parachute to the structure of the Pioneer 300s already delivered and in production to ensure that this system correctly complies with the given specifications. | Alpi Aviation | 24/03/2023 | 23/05/2023 | Aircraft equipment | |
- | F-BXEU/37AHH | Interoperability of traffic detection systems | EASA promote “out signal” interoperability of electronic conspicuity systems, for example through the development of an exchange-format standard and the allocation of a dedicated aeronautical frequency in order to promote safety. | EASA | 24/03/2023 |
| Other | |
✓ | F-HMLD | Alignment of procedures and phraseology to be used in the event of a terrain alert | The DSNA, without waiting for the other actions expected from EASA and ICAO, ensure that all documents relating to phraseology and MSAW procedures are updated so that: | DSNA | 31/03/2023 | 07/07/2023 | Air navigation services | |
✗ | F-HMLD | Alignment of procedures and phraseology to be used in the event of a terrain alert | EASA, without waiting for the ICAO documents to be updated, develop Guidance Material (GM) designed to clarify in the SERA regulation, the phraseology to be used by controllers to inform crews of a MSAW and ensure that the SERA is updated so that the urgency of the situation is systematically mentioned and the crew is systematically reminded of the QNH in the controller’s message in the event of a MSAW. | EASA | 31/03/2023 |
| Air navigation services | |
✗ | F-HMLD | Alignment of procedures and phraseology to be used in the event of a terrain alert | EASA initiate international actions in conjunction with ICAO to also resolve inconsistencies and ambiguities in Doc 4444 and Doc 9432, so that they systematically specify that the urgency of the situation and the QNH information is mentioned, and move towards simple and unified phraseology, if possible. | EASA | 31/03/2023 | 24/08/2023 | Air navigation services | |
- | F-HMLD | Alignment of procedures and phraseology to be used in the event of a terrain alert | ICAO ensure that the inconsistencies between MSAW procedures and phraseology contained in Doc 4444 and Doc 9432 are removed, and ensure that these documents are updated so that the urgency of the situation is systematically mentioned and the crew is systematically reminded of the QNH in the controller’s message in the event of a MSAW. | ICAO | 31/03/2023 |
| Air navigation services | |
✓ | F-GGYC | Medical fitness criteria for performing aerobatics in a non-competition context | The DSAC, through its medical centre, raise the awareness of the approved aviation medical examiners so that they can give suitable advice corresponding to the state of health of the pilots performing aerobatics, and prescribe, if necessary, a medical examination to assess as fully as possible their ability to withstand the physiological stresses associated with this activity. | DSAC | 28/04/2023 | 05/10/2023 | Medical / | |
- | F-GGYC | Consequences of “push-pull effect” and risks associated with G-LOC | The FFA make aerobatic pilots aware of the danger of certain manoeuvres which can lead to the physiological limits of the human body being reached. | FFA | 28/04/2023 |
| Safety promotion | |
- | F-HBXK/OO-SNE |
| The DSNA revise the demonstration of compliance with regulatory requirement ATS.TR.255 of Regulation (EU) No 2017/373, in particular the point relating to the minimum distance between runway centrelines and the divergence between departure and go-around paths for specialised simultaneous operations, so that it takes into account the observations highlighted by this incident. | DGAC | 31/05/2023 |
| Air navigation services | |
- | F-HBXK/OO-SNE |
| The DSAC reassess its decision to approve the AltMOC submitted by the DSNA on the specific issue of the alternative means of compliance to AMC4 ATS.TR.255. | ICAO | 31/05/2023 |
| Aircraft operations | |
- | F-HBXK/OO-SNE |
| ICAO assess the appropriateness of recommending the adaptation of specialised simultaneous operations when certain meteorological conditions prescribed by the appropriate ATS authorities (windshear, turbulence, downdrafts, crosswind or other significant meteorological conditions such as thunderstorms) might cause an increase in deviations from the published flight paths to the extent that safety may be impaired. | ICAO | 31/05/2023 |
| Air navigation services | |
✓ | F-HGPG/F-HBXG | Maintenance documentation published by Textron Aviation | Textron Aviation supplement the maintenance documentation to specify the actions to be taken in the event of an air data system anomaly for all versions of the Cessna 525, including those modified by SB525-34-41. | Textron Aviation | 10/07/2023 | 09/10/2023 | Aircraft maintenance | |
✓ | F-HGPG/F-HBXG | Notification of technical faults at the operator, Valljet | Valljet review its organisation, procedures and practices so that captains are encouraged, in accordance with requirement CAT.GEN.MPA.105 of the consolidated European regulation No 965/2012 known as "Air Ops", to immediately record themselves in the TLB, at the end of each flight, the faults observed, without having to obtain prior validation by an operations manager or by an expert pilot, and without being concerned that restrictive measures will be taken against them. | Valljet | 10/07/2023 | 28/02/2024 | Training / | |
✓ | F-HGPG/F-HBXG | Notification of technical faults at the operator, Valljet | The DSAC ensure that the Valljet operator remains in full compliance with paragraph CAT.GEN.MPA.105 of the consolidated European regulation (EU) No 965/2012 known as "Air Ops", under requirement ARO.GEN.300 of the same regulation, by actively seeking all useful information, such as crew reports, data collected by OSAC as part of the oversight of the operator's CAMO and Part 145 maintenance workshop, and exchanges and correspondences between flight operations, the CAMO, as well as the Part 145 maintenance workshop(s) used by the operator. | DSAC | 10/07/2023 | 21/11/2023 | Audits / | |
✓ | F-HGPG/F-HBXG | Quick reference card for controller | The DSNA ensure that the emergency procedure relating to a pilot's doubt about the altitude of his flight is the subject of an quick reference card, made available to controllers at their control position and is accompanied by recurrent training on a simulator. | DSNA | 10/07/2023 | 12/12/2023 | Air navigation services | |
- | F-HGPG/F-HBXG | Information transmitted by CNOA | The CNOA determine the limitations of its systems and the data at its disposal in order to provide relevant information to air navigation partners. | CNOA | 10/07/2023 |
| Air navigation services | |
- | F-HGPG/F-HBXG | Analysis of risk posed by an air data system fault | EASA continue and complete the analysis of the risk posed by a fault on the air data system, taking into account the system as a whole, and draw, as applicable, any conclusions regarding safety actions. | EASA | 10/07/2023 |
| Management of safety risk | |
| 59DUJ |
| The DSNA review the organisation of the flight information service, the positioning of this service in relation to all the air services provided by the DSNA and the training of the agents providing this service in French airspace, paying particular attention to the following subjects: | DSNA | 11/08/2023 |
| Air navigation services | |
- | OE-INE/F-GTZY |
| The DSNA equip the control centres with an automatic and nominative system to record the presence of controllers in position and at the workplace, and ensure that this information can be used by the DSNA services, in particular to ensure the appropriateness of staffing levels and to enable the analysis of safety events. | DSNA | 19/12/2023 |
| Training / Proficiency / Control | |
- | Oxygen fire in cockpit study | Further work taking into consideration the effects of overpressure in the oxygen system | 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 should be analysed with regard to the potential factors explaining the scenario of flight MS804. These analyses may require additional testing as part of a research program. | EASA | 29/12/2023 |
| Aircraft equipment | |
- | Oxygen fire in cockpit study | Propagation of a fire fed by an oxygen leak | 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 of the oxygen supply in this case, and if applicable, review the requirements for
| EASA | 29/12/2023 |
| Aircraft operations | |
- | Oxygen fire in cockpit study | Risks linked to the use of cigarettes in the cockpit | EASA ensure that: | EASA | 29/12/2023 |
| Aircraft operations / |