Aviation Safety - The Year In Review Aviation Safety in 1998 Presented at the 51st Flight Safety Foundation International Air Safety Seminar Cape Town, South Africa 17-19 November 1998 - PowerPoint PPT Presentation

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Aviation Safety - The Year In Review Aviation Safety in 1998 Presented at the 51st Flight Safety Foundation International Air Safety Seminar Cape Town, South Africa 17-19 November 1998

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The Challenge of Balancing Safety, the Law, and the Public Interest Jim Burin Director of Technical Programs Flight Safety Foundation – PowerPoint PPT presentation

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Title: Aviation Safety - The Year In Review Aviation Safety in 1998 Presented at the 51st Flight Safety Foundation International Air Safety Seminar Cape Town, South Africa 17-19 November 1998


1
The Challenge of Balancing Safety, the Law,
and the Public Interest
Jim Burin Director of Technical
ProgramsFlight Safety Foundation
ASPA/ICAO 2007
Mexico City

2
What is the Flight Safety Foundation ?
  • Independent
  • Non-Profit
  • International
  • Founded in 1947 by Aviation Industry

3
FSF Goal
Make Aviation Safer by Reducing the Risk of
an Accident
4
Two Important Aspects of Safety and the Law
  • Criminalization of Safety

- Protection of the sources of
Safety Information
5
(No Transcript)
6
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
7
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
8
CFIT - Touring Part 135
Hawaii - 27 Sept 1999 - Navajo - 10 Fatalities
9
Major Accidents Commercial Turboprops (gt 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 Lockheed Hercules Kigoma, Tanzania Approach 0
Source Ascend
10
Major Accidents Commercial Turboprops (gt 14
seats) 1 January to 31
December 2006 Cont
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
11
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
12
Major Accident Rate Western-Built Commercial Jets
1993 2006
Accident rate per million departures
Source Ascend
13
Major Accident Rate Western-Built Commercial Jets
1993 2006
Accident rate per million departures
Accidents Prevented
Source Ascend
14
(No Transcript)
15
Safety Efforts are Data Driven
16
Africa 2003
81
17
Information Driven
  • Accident Data
  • Incident Data
  • Flight Data Monitoring
  • Non-Punitive Reporting
  • Line Observed Safety Audit
  • Cooperative Data Sharing

18
(No Transcript)
19
(No Transcript)
20
The Aviation Safety Approach
1. Who made errors ?
2. Why were the errors made ?
3. How do we prevent the errors from
happening again ?
21
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.
22
Safety Challenges
The greatest enemy of safety is blame.
- Dan Maurino
23
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

24
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

25
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

26
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
27
Examples of Success
  • New Zealand CVR Case/Law

Canada Protection Actions
EU Council Directive
US FAR Part 193
Denmark National Law
28
(No Transcript)
29
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.
30
(No Transcript)
31
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
32
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
33
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.. d. Swiss prosecutors in
August 2006 charged eight Swiss Skyguide air
traffic controllers with negligent homicide.
34
e. the Swiss Federal Prosecutors 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
35
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 sanctionsBeing 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
36
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
37
Joint Resolution Regarding Criminalization of
Aviation Accidents
BE IT THEREFORE RESOLVED, that the below
organizations1. 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..
38
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
39
William Voss, President and CEO Flight
Safety Foundation
___________________________________ Alexander ter
Kuile, Secretary General Civil Air Navigation
Services Organisation

Jean-Claude Bück, President Académie
Nationale de l Air et de l Espace
Keith Mans, Chief ExecutiveRoyal Aeronautical
Society
40
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41
Hull Loss Accidents Western Built Commercial
Jets (gt60,000 lbs) 1960 thru 2005
Hull Loss Rate in losses per million departures


Source Boeing, AvSoft
42
Hull Loss Accidents Western Built Commercial
Jets (gt60,000 lbs) 1960 thru 2005
Lives Saved !!
Hull Loss Rate in losses per million departures


Source Boeing, AvSoft
43
Safety Information
Less
More
Criminalization
44
(No Transcript)
45
The Public Interest
Safety
The Law
46
FSF Goal
Make Aviation Safer by Reducing the Risk of
an Accident
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