Enhanced Scrutiny of Process Seen As Key To Improved Safety

Air Safety Week, Sept 28, 1998

Regulatory authorities on both sides of the Atlantic declare they are taking a more pro-active approach to safety, hoping through better analysis of trends to prevent accidents.

In Britain, the Civil Aviation Authority (CAA) is now publishing a "top ten" list of safety concerns, that will shape the agency's focus and budget. The CAA's prioritization is a product of a just- completed comprehensive review of fatal accidents worldwide. In the U.S., top Federal Aviation Administration (FAA) officials are foreswearing actions after accidents have occurred. The FAA was sharply criticized on this point recently by National Transportation Safety Board officials. For example, Chairman James Hall stated publicly the FAA's response to a spate of icing incidents and accidents was "disappointing" (see ASW, Aug. 31).

"We have been too reactive," said Monte Belger, acting deputy administrator, a veiled reference to the oft-levied charge that the FAA takes a "tombstone" approach to safety. The keynote speaker at a safety and security conference in Washington, DC, last week, Belger said two programs "represent a dramatic shift in safety strategy." One is the "Safer Skies" initiative (see ASW, April 20), which involves a more systematic analysis of data to focus on high payoff efforts, such as equipping aircraft with the latest terrain avoidance warning systems (TAWS) to lower the discouraging frequency of accidents involving controlled flight into terrain (CFIT). A notice of proposed rulemaking (NPRM) was issued August 26th calling for TAWS on all passenger-carrying aircraft.

The 'Top Ten' Safety Risk Issues for UK Aviation

"A defensible basis for justifying the level of resources needed to reduce aviation safety risks." --CAA Safety Regulation Group

* Crew and Human Factors

1. Omission of Action/Inappropriate Action

2. Flight Handling

3. Poor Professional Judgment/Airmanship

4. Failure in Crew Resource Management (CRM)

5. Lack of Positional Awareness in the Air

6. Maintenance Human Factors

* Design Related

* Regulatory Oversight

* Company Management

* Failure to Maintain Safe Separation

* Freight, Ferry and Positioning Flights

* Occupant Survivability

* Incorrect/Inadequate Procedures

* Non-JAA/FAA Operator Safety

* Failure to Adopt/Fit Best Available Technology (e.g., EGPWS)

Note: While the U.S. FAA has not yet produced a comparable list, the U.S. National Transportation Board (NTSB) has published a "Most Wanted" list for some years. On the other hand, the Air Accidents Investigation Branch in the U.K. has not published priorities comparable to the NTSB's "Most Wanted" list.

Source: CAA, Safety Regulation Group (SRG)

Shift from reacting to pre-empting

The other linchpin in the FAA's more activist approach, Belger said, is the new Air Transport Oversight System (ATOS), which goes into effect October 1st (see ASW, May 18). The birth of ATOS represents a new form of risk management, in which FAA officials will be examining carrier practices for potential hazards (as opposed to the traditional approach of citing and fining carriers for violating FAA rules).

Flight operations quality assurance (FOQA) programs are seen as vital tools for collecting trends. James Anderson, flight safety manager for Delta Air Lines [DAL], said, "If our goal is to reduce the accident rate, we must identify hazards before they become an event."

"FOQA represents a shift from analysis through snapshots to more like a running videotape," he explained. Anderson said his airline will begin its FOQA program by installing quick access (QA) data recorders on four 757s before the end of this year, and on all its new 737-800s as they are delivered.

"We want to learn how to work with the data, then we'll expand it (FOQA) out to the fleet," Anderson said.

Robert Francis, vice chairman of the National Transportation Safety Board, described ATOS as "an enormous challenge to the FAA." He explained that the flight standards culture must change "from its normal way of doing business to risk management and analysis."

The British approach

A very similar approach is being taken in Britain. Adrian Sayce, head of the CAA's Safety Analysis office, said that an 18-month internal review has led to a reformation in the CAA's approach. "We now produce an annual business plan to focus on the highest priority safety programs."

Similar to the emerging approach in the FAA, the CAA's annual plan is data-driven. Safety risks are identified by culling trends from a variety of sources. These include the Global Fatal Accident Review, Air Accidents Investigation Board (AAIB) reports, a questionnaire to extract expert judgment from safety officials, and even trends distilled from press reports. This mountain of data is processed by a Risk Assessment for Resource Evaluation (RARE) group. Its task is to identify the "Top Ten" safety issues, which in turn shape the CAA's annual business plan.

Why ten? Sayce said simply, "Ten is a manageable number."

The failure to maintain safe separation was one of the "expert issues" to emerge from this process. The last mid-air collision in Britain involving public transport aircraft occurred in 1948, but that record was not proof that the danger was minimal. "Our experts told us otherwise" about the potential danger, Sayce said. The significant increase in reported flight level deviations since 1995 was another indicator, Sayce added. "The situation is getting quite nasty."