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