Aviation Safety The Year In Review Aviation Safety in ICAO by jennyyingdi

VIEWS: 14 PAGES: 46

									The Challenge of Balancing
 Safety, the Law, and the
      Public Interest
              Jim Burin
   Director of Technical Programs
      Flight Safety Foundation
           ASPA/ICAO 2007
            Mexico City
    What is the Flight Safety
         Foundation ?
   Independent

   Non-Profit

   International


Founded in 1947 by Aviation Industry
    FSF Goal:
Make Aviation Safer by Reducing
    the Risk of an Accident
    Two Important
  Aspects of Safety and
        the Law

• Criminalization of Safety
     - Protection of the sources
       of Safety Information
            The Fleet - 2006


Type        Western Built Eastern Built   Total

Turbojets    17,609         1,839         19,548
Turboprops      4,774       1,710          6,484
Business Jets                             12,724
                               Major Accidents
                                Business Jets
                         1 January to 31 December 2006
    Date                Operator             Aircraft             Location          Phase     Fatal
2 January     Avcom                       Hawker 700        Kharkov, Ukraine       Approach     3
24 January    Goship Air                  Citation V        Carlsbad, CA, USA      Landing      4
15 February   Jet 2000                    Falcon 20         Kiel, Germany          Landing      0
16 February   Lech Air                    Citation I        Busckin, Iraq          Descent      6
2 June        International Jet Charter   Lear 35           Groton, CT, USA        Approach     2
26 June       Great Ideas Corp            Hawker F3         Barcelona, Venezuela   Landing      0
5 July        Vigojet                     Saberliner        Mexico City, Mexico    Landing      0
19 July       Tomco II                    Citation Encore   Cresco, IA, USA        Landing      2
28 August     Netjets                     Hawker 800        Carson City, NV, USA   Descent      0
30 December   Fact Air                    Saberliner        Culiacan, Mexico       Approach     2




  Source: Ascend
Hawaii - 27 Sept 1999 - Navajo - 10 Fatalities

            CFIT - Touring Part 135
                                 Major Accidents
                    Commercial Turboprops (> 14 seats)
                     1 January to 31 December 2006

   Date            Operator            Aircraft              Location           Phase     Fatal
2 January    Ruenzori Airways      Antonov 26          Fataki, DR Congo         Climb       0
24 January   Aerolift              Antonov 12          Mbuji Mayi, DR Congo    Landing      0
5 February   Air Cargo Carriers    Shorts 360          Watertown, WI, USA      Enroute      3
8 February   Tri Costal Air        Metro II            Paris, TN, USA          Enroute      1
11 March     Air Deccan            ATR 72              Bangalore, India        Landing      0
18 March     Ameriflight           Beech 99            Butte, MT, USA          Enroute      2
28 March     Phoenix Avia          Antonov 12          Payam, UAE               Climb       0
31 March     TEAM                  Let 410             Saquarema, Brazil       Enroute      19
16 April     TAM                   Fokker-27           Guayaramerin, Bolivia   Landing      1
24 April     Air Million Cargo     Antonov 32          Lashkar, Afghanistan    Landing      2
27 April     LAC Skycongo          Convair 580         Amisi, DR Congo         Landing      8
23 May       Air Sao Tome          DHC-6 Twin Otter    San Tome, Africa        Approach     4
5 June       Merpati Nusantara     CASA 212            Bandanaira, Indonesia   Landing      0
21 June      Yeti Airlines         DHC-6               Jumla, Nepal            Approach     9
7 July       Mango Airlines        Antonov 12          Goma, DR Congo           Climb       6
10 July      PIA                   Fokker 27           Multan, Pakistan        Takeoff      45
12 July      TransAfrik
    Source: Ascend                 Lockheed Hercules   Kigoma, Tanzania        Approach     0
                               Major Accidents
                    Commercial Turboprops (> 14 seats)
                   1 January to 31 December 2006                                            Con’t
   Date            Operator              Aircraft              Location            Phase      Fatal
  29 July     Adventure Aviation     DHC-6               Sullivan, MO, USA        Takeoff       6
 3 August     Tracep                 AN-28               Bukavu, DR Congo         Approach     17
 4 August     AirNow                 EMB-110             Bennington, VT, USA      Approach      1
13 August     Air Algerie            Lockheed Hercules   Piacenza, Italy          Enroute       3
28 August     Paraguay Air Service   Nomad 22B           Cerrillos, Argentina     Enroute       0
17 November   Trigana Air Service    DHC-6               Puncak Jaya, Inodnesia   Enroute      12
30 December   Sky Relief             DHC-5               Nairobi, Kenya           Takeoff       0




   Source: Ascend
                                Major Accidents
                        Commercial Jets
                  1 January to 31 December 2006
    Date             Operator        Aircraft            Location           Phase     Fatal
8 February     UPS                  DC-8F       Philadelphia, USA          Enroute     0
3 May          Armavia              A-320       Alder-Sochi, Russia        Approach   113
9 July         S7 Airlines          A-310       Irkutsk, Russia            Landing    126
22 August      Pulkovo Aviation     TU-154      Nr. Donetsk, Ukraine       Enroute    170
27 August      Comair               CRJ-100     Lexington, KY, USA         Takeoff     49
1 September    Iran Air Tours       TU-154      Mashhad, Iran              Landing     28
29 September   GOL                  B-737       Sao Felix, Brazil          Enroute    154
3 October      Mandala Airlines     B-737       Tarakan, Indonesia         Landing     0
10 October     Atlantic Airways     BAE-146     Stord-Sorstokken, Norway   Landing     4
29 October     ADC Airlines         B-737       Abuja, Nigeria             Takeoff     96
18 November    Aerosucre Colombia   B-727       Bogota, Colombia           Approach    5




   Source: Ascend
                                                                Major Accident Rate
                                                              Western-Built Commercial Jets
                                                                      1993 – 2006
Accident rate per million departures**




                                         1.60
                                                                                                        5 year running average


                                         1.20



                                         0.80
                                                                Major Accident Rate
                                                              (per million departures)
                                         0.40



                                         0.00
                                                1993   1994   1995   1996   1997   1998   1999   2000     2001   2002   2003     2004   2005   2006




                                    Source: Ascend
                                                                Major Accident Rate
                                                              Western-Built Commercial Jets
                                                                      1993 – 2006
Accident rate per million departures**




                                         1.60
                                                                                          5 year running average


                                         1.20
                                                                                                                          Accidents
                                                                                                                          Prevented
                                         0.80
                                                                Major Accident Rate
                                                              (per million departures)
                                         0.40



                                         0.00
                                                1993   1994   1995   1996   1997   1998    1999   2000   2001      2002   2003   2004   2005   2006




                                    Source: Ascend
Safety Efforts are Data Driven
   3                                                                                   7            Accident        Date        Location     Aircraft       Accident Description   Portion Intervention Name
                                                                                                      Class                                    Type                                   of   EGPWS     CFIT TRN
   5                                                                                   0
(Millions)/Rate Per




   3                                                                                   6           Description                                                                     Accident Portion of World Fle
                                                                                                                                                                                   Eliminated.600      .900
   0                                                                                   0
    Departures




                                                                                                                                                                                             Intervention Effecti




                                                                                       Accidents
   2                                                                                   5
       Million




                                                                                                      CFIT         1/2/1988 IZMIR, TURKEY       737     HIT MOUNTAIN ON APPROACH     .657 .950         .226
   5                                                                                   0
   2                                             Accidents1                            4              CFIT
                                                                                                      CFIT
                                                                                                                   2/8/1988 LUANDA, ANGOLA      707
                                                                                                                  2/27/1988 KYRENIA MTS, CYPRUS727
                                                                                                                                                        HIT ANTENNA ON APPROACH
                                                                                                                                                        HIT MOUNTAIN ON APPROACH
                                                                                                                                                                                     .586 .800
                                                                                                                                                                                     .657 .950
                                                                                                                                                                                                       .226
                                                                                                                                                                                                       .226
   0
   1                                                                            0                     CFIT        3/17/1988 CUCUTA, COLUMBIA 727        HIT MOUNTAIN DURING CLIMB    .657 .950         .226
                                                                                3                     CFIT        6/12/1988 POSADAS, ARGENTINA MD80     CRASHED ON FINAL APPROACH    .203 .000         .226
   5                                   Traffic Growth2                          0                     CFIT        7/21/1988 LAGOS, NIGERIA      707     CRASHED ON APPROACH          .203 .000         .226
   1                                                                            2                     CFIT       10/17/1988 ROME, ITALY         707     LANDED SHORT                 .203 .000         .226
   05                                                         Accident          0
                                                                          Rate3 1                     CFIT       10/19/1988 AHMEDABAD, INDIA 737        LANDED SHORT                 .586 .800         .226
                                                                                                      CFIT         2/8/1989 SANTA MARIA AZORES 707      TERRAIN IMPACT/DESCENT       .657 .950         .226

      0                                                                                0
                                                                                       0
                                                                                                      CFIT        2/19/1989 KUALA LUMPUR, MALAYSIA
                                                                                                                                                747     TERRAIN IMPACT/APPROACH      .657 .950         .226
                                             1Based                                                   CFIT                                      D
                                                                                                                   6/7/1989 PARAMARIBO, SURINAMEC8      TERRAIN IMPACT/FINAL APPROACH.203 .000         .226
                                                    on current accident rate                          CFIT        7/27/1989 TRIPOLI, LIBYA     DC10     TERRAIN IMPACT/FINAL APPROACH.203 .000         .226
                                             2Based on industry estimate                              CFIT        8/25/1989 ANKARA, TURKEY      727     HIT ILS ANT. ON TAKEOFF      .000 .000         .000
                                             3Based on current accident rate
                                                                                                      CFIT                                      7
                                                                                                                 10/21/1989 TEGUCIGALPA, HONDURA27      TERRAIN IMPACT/APPROACH      .657 .950         .226
                                                                                                      CFIT       10/26/1989 HUALIEN, TAIWAN     737     TERRAIN IMPACT/DEPARTURE     .657 .950         .226
3000                                                                                                  CFIT        2/14/1990 BANGALORE, INDIA A320       HIT SHORT (300 FT)           .203 .000         .226
                                                                                                      CFIT         6/2/1990 UNALAKLEET, ALASKA 737      HIT HILL 7 MILES OUT IN FOG .657 .950          .226

2500 2,396                                  Total fatalities = 7,484                                  CFIT       11/14/1990 ZURICH, SWITZERLANDDC9      CRASHED 5 MILES SHORT        .634 .900         .226
                       2,228                                                                          CFIT        12/4/1990 NAIROBI, KENYA      707     HIT POWER LINE ON ILS FINAL .203 .000          .226
                                            CFIT = Controlled Flight into Terrain                     CFIT                                      DC9
                                                                                                                   3/5/1991 MT LA AGUADA, VENEZUELA     HIT MOUNTAIN/APPROACH        .657 .950         .226
2000                                        RTO = Rejected takeoff                                    CFIT        8/16/1991 IMPHAL, INDIA       737                                  .657
                                                                                                                                                        A/C HIT HILL 20 MILES OUT/APPROACH.950         .226
                                                                                                      CFIT        1/20/1992 STRASBOURG, FRANCE A320                                  .586
                                                                                                                                                        IMPACTED GROUND/FINAL APPROACH .800            .226
1500                                                                                                  CFIT        2/15/1992 KANO, NIGERIA       DC8                                  .
                                                                                                                                                        CFIT OUT OF PROCEDURE TRN-DARK586 .800         .226
                                                                                                      CFIT        3/24/1992 ATHENS, GREECE      707     ABANDONED APPROACH-HIT MTN .657 .950           .226
                                                                                                      CFIT                                      737
                                                                                                                  6/22/1992 CRUZEIRO DO SUL, BRAZIL     HIT SHORT,DRK NT,DISTRACTED .203 .000          .226
1000                           760                                                                    CFIT        7/31/1992 KATMANDU, NEPAL A310        CFIT-HIT MTN-MISSED APPROACH .657 .950         .226
                                     607
                                           506                                                        CFIT        9/28/1992 KATMANDU, NEPAL A300        CRASHED SHORT DURING APPROACH.657 .950         .226
 500                                             306                                                  CFIT       11/25/1992 KANO, NIGERIA       707                                  .
                                                                                                                                                        LANDED SHORT MISLEADING LIGHTS538 .700         .226
                                                       162 128 119 113 111
                                                                              45   3                  CFIT       11/26/1992 MANAUS, BRAZIL      707                                  .
                                                                                                                                                        HIT LIGHTS ON TO/RMLG COLLAPSE000 .000         .000
       0 CFIT     of
             Loss In-flight
                         Sabo-    Hijack Ice/
                             Midair         Landing
                                                  Wind Fuel Other
                                                               Runway
                                                                    RTO
                                                                                                      CFIT        4/26/1993 AURANGABAD, INDIA 737       HIT TRUCK AFTER TAKEOFF      .000 .000         .000
                                      collision
                      control fire tage                snow     shear
                                                                   exhaus- incursion
                      in flight                                       tion
Africa 2003   81
 Information Driven
• Accident Data
• Incident Data
• Flight Data Monitoring
• Non-Punitive Reporting
• Line Observed Safety Audit
• Cooperative Data Sharing
The Aviation Safety Approach

1. Who made errors ?
2. Why were the errors
   made ?
3. How do we prevent the
   errors from happening
   again ?
    Accident Investigation
Safety: Annex 13 - “The sole
objective of the investigation of an
accident shall be the prevention of
accidents and incidents. It is not the
purpose of this activity to apportion
blame or liability.”


Legal: The sole objective of legal
proceedings is to apportion blame or
liability.
    Safety Challenges


  The greatest enemy of safety
is blame.
               - Dan Maurino
      The Basics of Safety an the Law

• Safety Investigations must be independent
           - Unhindered by judiciary authorities
           - Safety Information must be freely
             available to safety investigators


• Significant challenges exist in some countries
           - Legal systems
           - Cultures


• First Step - Protection of the Sources of Safety
               Information is required
              2004 Situation

 Accident/incident investigation records
    - Protected somewhat by ICAO provisions
    - Protected by few domestic legislations



   Voluntary reporting systems & FDA programs
    - Not explicitly protected by ICAO provisions
    - Protected by few domestic legislations



   Inconsistent International Picture
             Basic Principles
 Existing international and national laws were
  inadequate to protect many sources of safety
  information

 No Group or Workforce above the Law

 Goal: To protect safety information, but not deny the
  right to prosecute

 Evidence other than from sources of safety
  information can be used in prosecuting

 The public interest requires a balance between the
  protection of safety information and the availability of
  evidence in judicial actions
          Assembly Resolution A35-17
Protecting information from safety data collection
systems in order to improve aviation safety

The Assembly:
1. Instructs the Council to develop appropriate legal guidance that
    will assist States to enact national laws and regulations to
    effectively protect information from safety data collection
    systems, both mandatory and voluntary, while allowing for the
    proper administration of justice in the State;

2. Urges all Contracting States to examine their existing legislation
    and adjust as necessary, or enact laws and regulations to
    effectively protect information from safety data collection
    systems based, to the extent possible, on the legal guidance
    developed by ICAO; and

3. Instructs the Council to provide a progress report to the next
    ordinary Session of the Assembly on this matter
 Examples of Success

* New Zealand CVR Case/Law

* Canada Protection Actions
* EU Council Directive
* US FAR Part 193
* Denmark National Law
New Annex 13 – Appendix E Info

 …a review by an appropriate authority
 determines that the release of the
 safety information is necessary for
 the proper administration of justice,
 and that its release outweighs the
 adverse domestic and international
 impact such release may have on the
 future availability of safety
 information.
      Joint Resolution Regarding
  Criminalization of Aviation Accidents
Recognizing the importance in civil aviation
accident investigations in securing the free flow
of information to determine the cause of accidents and incidents and to
prevent future accidents and incidents;
Recognizing the actions taken recently by the
International Civil Aviation Organization in
promoting amendments to Annex 13 – Aircraft Accident
and Incident Investigations to the Convention on International Civil Aviation,
encouraging Contracting States to adopt by November 2006 certain actions to protect
the sources of safety information;
Recognizing the importance of preventing the
inappropriate use of safety information, including
the increasing use of such information in criminal
proceedings against operational personnel,
managerial officers, and safety regulatory officials;
      Joint Resolution Regarding
  Criminalization of Aviation Accidents
Recognizing that information given voluntarily by
persons interviewed during the course of safety
investigations is valuable, and that such
information, if used by criminal investigators or
prosecutors for the purpose of assessing guilt
and punishment, could discourage persons from
providing accident information, thereby
adversely affecting flight safety;
Recognizing that under certain circumstances, including acts of sabotage and willful
or particularly egregious reckless conduct, criminal investigations and prosecutions
may be appropriate;
Concerned with the growing trend to criminalize
acts and omissions of parties involved in aviation
accidents and incidents;
     Joint Resolution Regarding
 Criminalization of Aviation Accidents
Noting that:
a. law enforcement authorities in the September
29, 2006 mid-air collision between an Embraer
Legacy 600 executive jet and a Gol Linhas Aéreas
Intelligentes B-737-800 have opened a criminal
investigation…..

b the French Supreme Court on September 20,
2006 rejected a request to dismiss charges in the
July 2000 Air France Concorde crash………..

c. a French court is expected to issue its verdict
soon in the 1992 Air-Inter crash…………..
e. the Swiss Federal Prosecutor’s Office has an ongoing
criminal investigation for negligent manslaughter of the
former chief executive of Swiss International Airlines…

f. an Italian court on July 7, 2006 affirmed the convictions
for manslaughter of five aviation officials………

g. an ongoing Greek quasi-judicial investigation exists of
the 2005 Helios B-737-300 crash near Athens……..

h. U.S. federal and Florida state prosecutors brought
criminal charges, including 220 counts of murder and
manslaughter, against a maintenance company, several
mechanics, and a maintenance manager arising out of the
1996 ValuJet flight 592 crash…………

f. Greek prosecutors brought negligent manslaughter,
negligent bodily injury, and disrupting the safety of air
services charges against the captain and first officer………
     Joint Resolution Regarding
 Criminalization of Aviation Accidents
Recognizing that the sole purpose of protecting safety
information from inappropriate use is to ensure its
continued availability to take proper and timely
preventative actions and to improve aviation safety;
Considering that numerous incentives, including
disciplinary, civil, and administrative penalties, already
exist to prevent and deter accidents without the threat of
criminal sanctions;

Being mindful that a predominant risk of criminalization
of aviation accidents is the refusal of witnesses to
cooperate with investigations, as individuals invoke
rights to protect themselves from criminal prosecution,
and choose not to freely admit mistakes in the spirit of
ICAO Annex 13 for the purpose of preventing recurrence;
     Joint Resolution Regarding
 Criminalization of Aviation Accidents

Considering that the vast majority of aviation
accidents result from inadvertent, and often
multiple, human errors;

Being convinced that criminal investigations and
prosecutions in the wake of aviation accidents
can interfere with the efficient and effective
investigation of accidents and prevent the timely
and accurate determination of probable cause
and issuance of recommendations to prevent
recurrence;
     Joint Resolution Regarding
 Criminalization of Aviation Accidents
BE IT THEREFORE RESOLVED, that the below organizations:
1. Declare that the paramount consideration in an
aviation accident investigation should be to determine
the probable cause of and contributing factors in the
accident, not to punish criminally flight crews,
maintenance employees, airline or manufacturer
management executives, regulatory officials, or air traffic
controllers…..

2. Declare that, absent acts of sabotage and willful or
particularly egregious reckless misconduct (including
misuse of alcohol or substance abuse), criminalization of
aviation accidents is not an effective deterrent or in the
public interest……………..
     Joint Resolution Regarding
 Criminalization of Aviation Accidents
3. Urge States to exercise far greater restraint and adopt
stricter guidelines before officials initiate criminal
investigations or bring criminal prosecutions in the wake
of aviation disasters……….

4. Urge States to safeguard the safety investigation
report and probable cause/contributing factor
conclusions from premature disclosure…………

5. Urge National aviation and accident investigating
authorities to: (i) assert strong control over accident
investigations, free from undue interference from law
enforcement authorities…………..

DATED: October 17, 2006
William Voss, President and CEO                      ___________________________________
                                                     Alexander ter Kuile, Secretary General
Flight Safety Foundation
                                                     Civil Air Navigation Services Organisation




                                  Jean-Claude Bück, President
                                  Académie Nationale de l’ Air et de l’ Espace
Keith Mans, Chief Executive
Royal Aeronautical Society
                                                                   Hull Loss Accidents
                                                        Western Built Commercial Jets (>60,000 lbs)
                                                                     1960 thru 2005
  Hull Loss Rate in losses per million departures




                                                    10.00


                                                    8.00

                                                            5.64
                                                    6.00


                                                    4.00
                                                                     2.16
                                                                            1.47     1.29
                                                    2.00                                      0.89
                                                    0.00

                                                            60's     70's    80's     90's   2000's
Source: Boeing, AvSoft
                                                                   Hull Loss Accidents
                                                        Western Built Commercial Jets (>60,000 lbs)
                                                                     1960 thru 2005
  Hull Loss Rate in losses per million departures




                                                    10.00

                                                    8.00
                                                                       Lives Saved !!
                                                    6.00

                                                    4.00


                                                    2.00

                                                    0.00

                                                            60's     70's    80's     90's   2000's

Source: Boeing, AvSoft
 Safety Information




Less
                                        More
                      Criminalization
   The Public   Interest




Safety                 The Law
    FSF Goal:
Make Aviation Safer by Reducing
    the Risk of an Accident

								
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