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Jim Burin Director of Technical Programs
Flight Safety Foundation
Jim Burin Director of Technical Programs
Flight Safety Foundation
ASPA/ICAO 2007 Mexico City
ASPA/ICAO 2007 Mexico City
The Challenge of Balancing Safety, the Law, and the Public
Interest
The Challenge of Balancing Safety, the Law, and the Public
Interest
What is the Flight Safety Foundation ?
What is the Flight Safety Foundation ?
Non-Profit International
Founded in 1947 by Aviation Industry
Independent
FSF Goal:FSF Goal:
Make Aviation Safer by Reducing the Risk of an
Accident
Make Aviation Safer by Reducing the Risk of an
Accident
Two Important Aspects of Safety
and the Law
Two Important Aspects of Safety
and the Law
- Protection of the sources of Safety Information
• Criminalization of Safety
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 PhaseFata
l
2 January Avcom Hawker 700 Kharkov, UkraineApproac
h 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 F3Barcelona, Venezuela
Landing 0
5 July Vigojet Saberliner Mexico City, Mexico Landing 0
19 July Tomco IICitation Encore Cresco, IA, USA Landing 2
28 August Netjets Hawker 800Carson City, NV, USA
Descent 0
30 December
Fact Air Saberliner Culiacan, MexicoApproac
h 2
Source: Ascend
CFIT - Touring Part 135Hawaii - 27 Sept 1999 - Navajo - 10 Fatalities
Major Accidents Commercial Turboprops (> 14 seats)
1 January to 31 December 2006
Source: Ascend
Date Operator Aircraft Location PhaseFata
l
2 January Ruenzori Airways Antonov 26 Fataki, DR Congo Climb 0
24 January Aerolift Antonov 12Mbuji Mayi, DR Congo Landing 0
5 February
Air Cargo Carriers Shorts 360Watertown, 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-27Guayaramerin, Bolivia Landing 1
24 April Air Million Cargo Antonov 32Lashkar, Afghanistan
Landing 2
27 April LAC Skycongo Convair 580 Amisi, DR Congo Landing 8
23 May Air Sao TomeDHC-6 Twin Otter
San Tome, AfricaApproac
h
4
5 JuneMerpati Nusantara
CASA 212 Bandanaira, Indonesia Landing 0
21 June Yeti Airlines DHC-6 Jumla, NepalApproac
h 9
7 July Mango Airlines Antonov 12 Goma, DR Congo Climb 6
10 July PIA Fokker 27 Multan, Pakistan Takeoff 45
12 July TransAfrikLockheed Hercules
Kigoma, TanzaniaApproac
h 0
Major Accidents Commercial Turboprops (> 14 seats)
1 January to 31 December 2006 Con’t
Date Operator Aircraft Location Phase Fatal
29 JulyAdventure Aviation
DHC-6 Sullivan, MO, USA Takeoff 6
3 August Tracep AN-28 Bukavu, DR CongoApproac
h 17
4 August AirNow EMB-110Bennington, VT, USA
Approach
1
13 August Air AlgerieLockheed Hercules Piacenza, Italy Enroute 3
28 AugustParaguay 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-146Stord-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
0.00
0.40
0.80
1.20
1.60
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
5 year running average
Major Accident Rate(per million departures)
Source: Ascend
Major Accident RateWestern-Built Commercial Jets
1993 – 2006
Acc
iden
t rat
e pe
r m
illio
n de
part
ures
**
0.00
0.40
0.80
1.20
1.60
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
5 year running average
Major Accident Rate(per million departures)
Source: Ascend
Major Accident RateWestern-Built Commercial Jets
1993 – 2006
Acc
iden
t rat
e pe
r m
illio
n de
part
ures
**
Accidents Prevented
Safety Efforts are Data Driven
15
5
20
25
30
35
10
0
30
40
50
60
70
20100
Dep
art
ure
s (M
illi
on
s)/R
ate
Per
M
illi
on
Accid
ents
Accidents1
Traffic Growth2
Accident Rate3
1Based on current accident rate2Based on industry estimate3Based on current accident rate
Total fatalities = 7,484CFIT = Controlled Flight into TerrainRTO = Rejected takeoff
30003000
25002500
20002000
15001500
10001000
500500
00 Loss ofcontrolin flight
CFIT In-flightfire
Sabo-tage
Midaircollision
Hijack Ice/snow
LandingWindshear
Fuelexhaus-
tion
OtherRunwayincursion
RTO
2,3962,228
760607 506
306162 128 119 113 111 45 3
Accident Date Location Aircraft Accident Description Portion Intervention Name
Class Type of EGPWS CFIT TRN
Description Accident Portion of World Fleet with Intervention Implemented by (2007)
Eliminated.600 .900
Intervention Effectiveness (%/100)
CFIT 1/2/1988 IZMIR, TURKEY 737 HIT MOUNTAIN ON APPROACH .657 .950 .226CFIT 2/8/1988 LUANDA, ANGOLA 707 HIT ANTENNA ON APPROACH .586 .800 .226CFIT 2/27/1988 KYRENIA MTS, CYPRUS727 HIT MOUNTAIN ON APPROACH .657 .950 .226CFIT 3/17/1988 CUCUTA, COLUMBIA 727 HIT MOUNTAIN DURING CLIMB .657 .950 .226CFIT 6/12/1988 POSADAS, ARGENTINA MD80 CRASHED ON FINAL APPROACH .203 .000 .226CFIT 7/21/1988 LAGOS, NIGERIA 707 CRASHED ON APPROACH .203 .000 .226CFIT 10/17/1988 ROME, ITALY 707 LANDED SHORT .203 .000 .226CFIT 10/19/1988 AHMEDABAD, INDIA 737 LANDED SHORT .586 .800 .226CFIT 2/8/1989 SANTA MARIA AZORES 707 TERRAIN IMPACT/DESCENT .657 .950 .226CFIT 2/19/1989 KUALA LUMPUR, MALAYSIA747 TERRAIN IMPACT/APPROACH .657 .950 .226CFIT 6/7/1989 PARAMARIBO, SURINAMEDC8 TERRAIN IMPACT/FINAL APPROACH.203 .000 .226CFIT 7/27/1989 TRIPOLI, LIBYA DC10 TERRAIN IMPACT/FINAL APPROACH.203 .000 .226CFIT 8/25/1989 ANKARA, TURKEY 727 HIT ILS ANT. ON TAKEOFF .000 .000 .000CFIT 10/21/1989 TEGUCIGALPA, HONDURA727 TERRAIN IMPACT/APPROACH .657 .950 .226CFIT 10/26/1989 HUALIEN, TAIWAN 737 TERRAIN IMPACT/DEPARTURE .657 .950 .226CFIT 2/14/1990 BANGALORE, INDIA A320 HIT SHORT (300 FT) .203 .000 .226CFIT 6/2/1990 UNALAKLEET, ALASKA 737 HIT HILL 7 MILES OUT IN FOG .657 .950 .226CFIT 11/14/1990 ZURICH, SWITZERLANDDC9 CRASHED 5 MILES SHORT .634 .900 .226CFIT 12/4/1990 NAIROBI, KENYA 707 HIT POWER LINE ON ILS FINAL .203 .000 .226CFIT 3/5/1991 MT LA AGUADA, VENEZUELADC9 HIT MOUNTAIN/APPROACH .657 .950 .226CFIT 8/16/1991 IMPHAL, INDIA 737 A/C HIT HILL 20 MILES OUT/APPROACH.657 .950 .226CFIT 1/20/1992 STRASBOURG, FRANCE A320 IMPACTED GROUND/FINAL APPROACH.586 .800 .226CFIT 2/15/1992 KANO, NIGERIA DC8 CFIT OUT OF PROCEDURE TRN-DARK.586 .800 .226CFIT 3/24/1992 ATHENS, GREECE 707 ABANDONED APPROACH-HIT MTN .657 .950 .226CFIT 6/22/1992 CRUZEIRO DO SUL, BRAZIL737 HIT SHORT,DRK NT,DISTRACTED .203 .000 .226CFIT 7/31/1992 KATMANDU, NEPAL A310 CFIT-HIT MTN-MISSED APPROACH .657 .950 .226CFIT 9/28/1992 KATMANDU, NEPAL A300 CRASHED SHORT DURING APPROACH.657 .950 .226CFIT 11/25/1992 KANO, NIGERIA 707 LANDED SHORT MISLEADING LIGHTS.538 .700 .226CFIT 11/26/1992 MANAUS, BRAZIL 707 HIT LIGHTS ON TO/RMLG COLLAPSE.000 .000 .000CFIT 4/26/1993 AURANGABAD, INDIA 737 HIT TRUCK AFTER TAKEOFF .000 .000 .000
Africa 2003 Africa 2003 8181
• Incident Data
• Flight Data Monitoring
• Non-Punitive Reporting
• Line Observed Safety Audit
Information Driven
• Cooperative Data Sharing
• Accident Data
1. Who made errors ?
The Aviation Safety Approach
2. Why were the errors made ?
3. How do we prevent the errors from happening again ?
Accident InvestigationAccident InvestigationSafety: 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.
The greatest enemy of safety is blame.
- Dan Maurino
Safety Challenges
The Basics of Safety an the LawThe Basics of Safety an the Law
• Safety Investigations must be independent
- Unhindered by judiciary authorities - Safety Information must be freely available to safety investigators
• 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
• Significant challenges exist in some countries- Legal systems- Cultures
• First Step - Protection of the Sources of Safety Information is required
• First Step - Protection of the Sources of Safety Information is required
2004 Situation 2004 Situation
Accident/incident investigation recordsAccident/incident investigation records
- - Protected somewhat by ICAO provisionsProtected somewhat by ICAO provisions - Protected by few domestic legislations- Protected by few domestic legislations
Voluntary reporting systems & FDA programsVoluntary reporting systems & FDA programs
- - Not explicitly protected by ICAO provisionsNot explicitly protected by ICAO provisions - Protected by few domestic legislations- Protected by few domestic legislations
Inconsistent International PictureInconsistent International Picture
Basic PrinciplesBasic 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 A35-17Assembly Resolution A35-17Protecting information from safety data collectionsystems 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
* New Zealand CVR Case/Law
Examples of Success
Examples of Success
* Denmark National Law
* Canada Protection Actions
* EU Council Directive
* US FAR Part 193
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
AccidentsRecognizing 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
AccidentsRecognizing 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
AccidentsNoting 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…….
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
AccidentsRecognizing 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
AccidentsConsidering 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
AccidentsBE 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
Accidents3. 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 CEOFlight Safety Foundation
Keith Mans, Chief ExecutiveRoyal Aeronautical Society
Jean-Claude Bück, PresidentAcadémie Nationale de l’ Air et de l’ Espace
___________________________________Alexander ter Kuile, Secretary GeneralCivil Air Navigation Services Organisation
Hu
ll L
oss R
ate
in
losses p
er
million
d
ep
art
ure
s 5.64
2.161.47 1.29 0.89
0.00
2.00
4.00
6.00
8.00
10.00
60's 70's 80's 90's 2000's
Hull Loss Accidents Western Built Commercial Jets (>60,000 lbs)
1960 thru 2005
Source: Boeing, AvSoft
Hu
ll L
oss R
ate
in
losses p
er
million
d
ep
art
ure
s
0.00
2.00
4.00
6.00
8.00
10.00
60's 70's 80's 90's 2000's
Hull Loss Accidents Western Built Commercial Jets (>60,000 lbs)
1960 thru 2005
Source: Boeing, AvSoft
Lives Saved !!
Criminalization
More
Safe
ty
Info
rmati
on
Less
The Public Interest
Safety
The Law
FSF Goal:FSF Goal:
Make Aviation Safer by Reducing the Risk of an
Accident
Make Aviation Safer by Reducing the Risk of an
Accident
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