Flight crews are the primary cause in two out of three accidents in the 41 states of the European Civil Aviation Conference (ECAC), according to Mike Ambrose, director general of the European Regions Airline Association (ERA). Ambrose was speaking at the March 18 to 19 European Aviation Safety Seminar jointly presented in Geneva, by the Flight Safety Foundation (FSF) and ERA. Human factors were a major theme of the seminar, entitled “Change: a Safety Challenge” and held against the backdrop of worsening economic gloom, particularly in the airline industry, as well as the opening of hostilities in Iraq.
With all the technical and operational improvements introduced over the past 15 years, Ambrose said the number of accidents had stabilized but the proportion in which human factors were a primary cause had actually grown. “Today’s high safety standards,” he said, “have been achieved by better design, testing, production and certification of aircraft, components and systems, greater reliability, new avionics, aircraft management and control system technology, more enlightened training techniques and better devices, enhanced air traffic management systems and many other factors. To some extent, the rise in human factors could be said to be a natural result of putting so much emphasis on the technical aspects of flight safety. But emerging technology must take human factors into account, and traditional safety requirements must not be overridden by new security measures.”
Non-punitive Occurrence Reporting
Blame-free occurrence reporting could also make a strong contribution to safety, said Ambrose, and was relevant to all types of personnel, including pilots, controllers, engineers and cabin crew. “This is not just a case for the cockpit,” he emphasized. A draft EU directive proposed by the European Commission with strong support from the entire industry, including air traffic management (ATM) service providers, contained two key articles offering protection not only for those who reported events but also for the reported data. The European Council of Ministers, however, apparently on the basis of judicial advice in certain member countries, had removed the two articles, effectively nullifying the purpose of the directive.
“States that cannot accept the principle of occurrence reporting without penalty, except subsequently in the case of gross negligence, are paying only lip-service to safety,” said Ambrose, “and our industry must fight to have these two most important articles reinstated.”
The same view is held at Eurocontrol (the full name of which, appropriately, is the European Organization for the Safety of Air Navigation), which is also working hard for acceptance of both the original Draft Directive and what Radu Cioponea of the organization’s Performance Review Unit called “a just culture.” This did not mean total immunity for occurrence reporters, said Cioponea, “but as much as is needed. We must try to get the useful safety information first, before questions of blame or legal liability are raised.”
Cioponea said a Eurocontrol survey and report on legal constraints to non-punitive ATM safety occurrence reporting in Europe, launched in 2001 and published last December, had shown up some stark facts, including that one-third of the Eurocontrol countries had not fully implemented the regulations in ICAO Annex 13, 5.12. “Many actually use the ICAO instruments and file an exemption, but there are a few that did not even consider it necessary to do this.”
There were, he said, significant legal and/or regulatory constraints to non-punitive reporting in many Eurocontrol countries, and “freedom-of-information legislation is particularly difficult to deal with.” Safety management was often seen as “the new kid on the block” and poor communication between the various levels of management, as well as between management and controllers, was a widespread issue. Safety regulation itself was still in its early days, he said, and there was a strong need for proper staff, legal tools and other resources.
While it was “blatantly obvious” that the just-culture concept was still unknown by a large majority of people, Cioponea said it was equally clear the professionals understood very well what it meant and the need for it. “However, the two ends must meet and this requires a vast and sustained campaign to educate the media, the public, the politicians, the managers and the last unconvinced Mohican about the need for it.” Asked whether an anonymous reporting system such as exists through NASA in the U.S. could be introduced in Europe, Cioponea explained that, as an international organization, Eurocontrol had a rather different constitution. Individual member countries should report to Eurocontrol, and several already did, but for a system such as envisioned in the Draft Directive to be effective, this implied that they should have the legal infrastructure and appropriate safety culture in place. Denmark, for example, was congratulated for having recently changed its legislation to create a non-punitive reporting environment.
Eurocontrol, in collaboration with the FAA, FSF and others, is now expanding the survey worldwide and has already sent questionnaires to about 25 countries outside its membership zone. The first responses are beginning to come in.
The FSF has also launched a new initiative at ICAO to adjust Annex 13, which usually covers air accident investigations. According to FSF president and CEO Stuart Matthews, the FSF–together with other major bodies including IFALPA, IATA and ICAO–has been increasingly concerned about the growing tendency for judicial interference in accident investigations, including in some cases the threat of criminal prosecution of those involved before the investigation has even begun. “While in some places this is a question of national law, it obviously impedes the investigation, is detrimental to establishing the causes of the accident and, as a result, does little to improve safety.”
Matthews said ICAO had responded enthusiastically to the FSF proposals on Annex 13 modification and that work was continuing to bring a definitive resolution before the 2004 ICAO General Assembly.
ALAR and CFIT
Approach and landing accident reduction (ALAR) and controlled flight into terrain (CFIT) had long been a focus of FSF attention, said Matthews, resulting in what he called “perhaps the most significant product we have ever produced,” the ALAR Tool Kit, now being introduced worldwide through a series of regional implementation workshops in Thailand, Iceland, Egypt, East Africa, South Africa, Malaysia, Australia and China, following an initial effort in South America. Many of the FSF’s ALAR recommendations, he said, have now been accepted by the FAA and European JAA (with other authorities following suit), and would form the basis of revised commercial pilot training requirements.
Approach and landing is the flight regime in which about half of all accidents occur, said Matthews, adding: “Regrettably, in the past year, the CFIT scourge has reappeared with a vengeance, with most accidents [13 out of 18 worldwide, according to another speaker, involving five turbofans, 10 turboprops and three piston aircraft] happening during approach and landing…We must renew our efforts to ensure full awareness of the problem, together with the many preventive measures we have developed to reduce it.”
But Matthews was concerned as to why it was that not everyone in the industry appeared to take note and learn even when there were accidents. “Patently,” he said, “the industry as a whole does not pay sufficient attention and not only do accidents continue to happen, the same types of accident continue to happen.” Was it complacency, he asked, or was it an economic problem? None of the recent CFIT accident aircraft had been fitted with a terrain awareness and warning system (TAWS), he noted. “My call to the airline industry is ‘wake up.’ You may have significant economic problems and you may be preoccupied with security issues but, important though security is, nothing on the safety front has changed and it is important that there should be no relaxation of the safety defenses built up over many years to produce the incredibly low accident rate that the industry enjoys today.”
At the JAA, meanwhile, chief executive Klaus Koplin told the seminar that eight CFIT action plans had been agreed on by the JAA management as part of its Joint Safety Strategy Initiative, launched in 1998 and producing deliverables such as research studies, training kits, advisory circulars and changes to requirements. Among the eight plans are, for example, TAWS, precision-like approach implementation, minimum safe-altitude warning and flight-data monitoring. Five approach and landing action plans have also been agreed on, including flight-deck equipment upgrades and installation, flight crew training and promotion of a safety culture. While the TAWS actions are essentially complete and the ICAO/FSF CFIT Training Tool is already on the JAA Web site, said Koplin, all the plans are currently being reviewed to identify what is covered by JAR-OPS and ongoing work, to integrate ICAO initiatives and to identify top priorities.
According to Koplin, the aggregated action plans, which cover several other safety issues beyond CFIT and ALAR, are due for final approval in the fall of this year. As this timescale coincides with the planned September 28 establishment of the new European Aviation Safety Agency (EASA), Koplin said the JAA work would be passed on to EASA, which he assumed would continue with the JSSI from then.
Runway Incursion: A Growing Problem
Reported runway incursions per flight had increased no less than fivefold since 1998, according to ERA’s Ambrose, and JAA’s Koplin said that, in Europe, there was an incursion every three or four days and a near-collision every two or three months. Incursions now account for some 26 percent of all runway safety issues. The FSF’s Matthews calculated that airlines and business aircraft operators worldwide annually suffer as much as $5 billion in losses as a result of the whole range of incidents that occur on airport ramps, and that resulting fatalities on the ground are running as high as 200 a year.
Controversy Mounts as JAA Transitions to EASA
Differences in safety culture are causing some concern as ECAC and JAA membership expands eastwards, according to JAA chief executive Klaus Koplin. Responsibility for European type certification and rulemaking for both airworthiness and maintenance is due to transition on September 28 from the JAA to the new European Aviation Safety Agency (EASA) set up by an EU regulation published last September 7. The transfer of responsibility for operations and licensing is currently foreseen during 2005.
Koplin said the JAA is actively preparing for the changes, using the so-called Option 3 transition model under which EASA will take on all “technical” work, with the JAA governing bodies adopting EASA decisions for the JAA. The central JAA will subsequently disappear, possibly as early as next year. All EASA regulations and procedures are in fact being drafted by JAA experts and are now under legal review before a public comment period in early summer. The timescale is therefore tight, since they must be in place at the start of EASA operations on September 28, and as Koplin told the seminar, “the EASA executive director has not yet been chosen.”
Flight Crews at Fault Most Often
Pilots may be surprised to learn that, according to a recent study by the Netherlands National Aerospace Laboratory, flight crew error was the primary causal factor in 53 percent of the air traffic management (ATM)-related commercial aircraft accidents worldwide between 1981 and 2001. ATC was the primary causal factor in 28 percent of such accidents, the study showed, the remainder being attributed to environmental factors (13 percent) and aircraft systems (6 percent). “ATM-related” accidents in the analysis were defined as those involving two or more aircraft; one aircraft and one or more ground vehicles; problems with landing aids such as ILS, MLS, PAR, PAPI, VASI or approach lights; and wake vortex-induced accidents.
The overwhelming proportion of the accidents, just over two-thirds, happened during taxiing and the majority of events concerned collisions with vehicles (33 percent), followed by collisions with stationary (22 percent) or moving (21 percent) aircraft. The top 10 most frequently identified causal factors in all the accidents were, in descending order, low visibility (16 percent); flight crew lack of positional awareness on the ground; incorrect or inadequate ATC instructions; flight crew look out failure; flight crew non-adherence to procedures; flight crew omitting to act or acting inappropriately; ATC failure to provide separation on the ground; aircraft system failure affecting controllability; flight crew failure to cross-check or coordinate; and malfunction or unavailability of an ATC ground aid (5 percent).
Overall, the study showed that 213 (8 percent) of all accidents in the 20-year period were ATM-related. Of these, 29 were fatal, or 4.4 percent of all fatal accidents; perhaps unsurprisingly, collisions and near-collisions between two aircraft caused the majority of the 984 fatalities in ATM-related accidents. The overall worldwide ATM-related accident rate is 0.44 per million flight hours.