New FSF boss urges focus on safety, not blame

 - March 8, 2007, 12:12 PM

The September 29 midair collision between an Embraer Legacy and a Gol Airlines 737 over the Amazon was a baptism by fire for Bill Voss, who took over as president of the Flight Safety Foundation (FSF) a couple of days later.

He was immediately thrown into the midst of an international incident when Brazil confiscated the passports of the two American pilots of the business jet to prevent them from leaving the country.
In the ensuing weeks,

increasing pressure was brought to bear on the Brazilian government to release the two pilots, amid outcries and consternation about what appeared to be attempts
to criminalize the accident. Even the head of Brazil’s National Pilots Union called for legislation that would prohibit charging pilots in the aftermath of accidents.

Voss and the FSF were thrust into the calls for the pilots’ release, which came from organizations as diverse as the International Air Line Pilots Association and AOPA. “The criminalization thing is turning into a fundamental issue,” he told AIN. “It’s almost like we are at a crossroads right now in the aviation safety business.”
Voss, who was director of the International Civil Aviation Organization’s Air Navigation Bureau before he took the helm of the FSF, said that criminalization is going to have a chilling effect on what has been a steadily improving safety record around most of the world.

“We have done a great job of driving down the accident rate, particularly in North America, Europe [and] some other parts of the world,” he said. “Some parts of the world still have challenges and their rate is higher, but I have to tell you their aviation safety record is a lot better than the road record.”

The question now, said Voss, is how to reach the next level of improvement. “We always thought the public listened to how many accidents there were, not what the rate was,” Voss continued. “I think when we put seven airplanes into the ground in six weeks [in summer 2005]…the whole world stood up on its back legs and said this is not acceptable, this is a problem. And so we have got to drive the rate down to keep the occurrences down with the growing amount of traffic.”

That is related to the problem of criminalization, said Voss, because to reduce the accident rate, the aviation industry has to do a better job of solving problems before they turn into accidents. The point is to learn about emerging trends by looking at incidents and normal operations to see which threats to the system are having an effect, to see how well errors are being discovered and taking action to control these errors far in advance.

“I think we’ve grown up a lot and realized that human error is never going to go away, but we can build systems that contain human error before it kills somebody if we know about the errors that are occurring,” Voss said.

Safety Investigation Paramount
According to Voss, criminalization of aircraft accidents is detrimental to safety because it invites more aggressive prosecutions. According to Voss, some of the legal systems around the world are more criminally oriented and more demanding of criminal prosecutions than others.

“But I think that all around the world we’ve seen the prosecutors becoming more aggressive and prosecuting cases that would have otherwise been left alone in years past,” he said. “And the result of that, of course, is that people start shutting up–people start worrying about whether they can actually report a problem that is occurring. And the reporting culture of the organization goes down and we have the risk of some real safety problems,” he concluded.

While the prosecutors in such cases maintain that they are speaking on behalf of those who lost their lives in a crash, Voss counters that aviation safety advocates speak for those whose lives have yet to be saved.

“They’re just as real as the people who perished,” he argues. “The curve of declining accidents shows that we’ve avoided a lot of accidents because as the rate goes down, down, down, the number of people who’ve died goes down, down, down.
“Above that curve are thousands of people who were flying along when something went wrong and nothing happened because the system was built to catch the error and solve it. If we go back to where we were years ago, those people are going to be the victims, and they could be you or me.”

Criminalization issues could also affect collection and reporting of flight information, such as the flight operations quality assurance (FOQA) programs. Voss said the study of errors in normal operations is what is going to propel the industry to the next level of safety improvements.

He said that in Annex 13 of the International Civil Aviation Organization (ICAO) standards, the international community has called for the states to legislate protections around the data, specifically trying to keep FOQA in mind. The amendment to Annex 13–Aircraft Accident and Incident Investigation–includes new provisions for the protection of safety information from inappropriate use, mainly the use of safety information in legal proceedings against operational personnel. The ICAO Council passed the annex last March 3. It took effect on November 23.

‘Big Sky’ Theory Challenged
Voss defended the amendment to the council. He noted, “It’s something we’ve been pressing here in the Flight Safety Foundation for some time.”
He characterized the amendment as a difficult one because it basically challenges countries’ legal systems, a politically incorrect thing to do within a U.N. organization. It calls for action or suggests their legal system could be better, which is a gamble for members of an international organization.

“I haven’t seen any backlash against that yet out of the Brazil crash,” said Voss, “but it makes people worry. There has been a great sense of unease. Just in the last couple of months, I’ve been talking to a lot of people in the pilot community in the United States and everybody is pretty nervous. I think this brought the issue of criminalization home… in a forceful way.”

In addition to worrying about prosecutions, pilots are also worried about the prospect of a midair itself. According to Voss, who holds an ATP license, pilots are unnerved because midairs seldom happen.

“For some reason, this one hit really close to home,” he said. “It wasn’t congested airspace, it wasn’t anything fancy going on. [The controller] had two airplanes over the middle of some non-congested airspace that managed to fly straight into each other.”

Voss asserted that improved navigation has also reduced the safety margin. “The Brazil crash clearly resonated on more than one level,” said Voss, formerly an air traffic controller in Detroit. “It got people’s attention on the criminal level and it really got people’s attention on the realities of modern ATC in a place where the sky isn’t so big any more.

“We always used to feel good about the big sky when I was an air traffic controller. You could make some pretty serious mistakes and they would never see each other, much less hit each other. To have this happen has shaken up a lot of people.”