I want to add a special welcome to new subscribers. Your readership is highly valued. It is the intention of Safety Forecast to look ahead of operations and find hazards. With this information the next intention of Safety Forecast is to encourage immediate responses to counter the hazard, interim remediations to adjust procedures and long term resolutions that through planning eliminate the hazard from impacting operations.
The goal of Safety Forecast is a more efficient, effective and robust operation through eliminating losses by Safety Planning. Yes, Safety Forecasting and Safety Planning go together.
Please feel free to contact Safety Forecast at any time with your ideas and questions. Once again, welcome to all visitors to Safety Forecast.
In my opinion, there can be no worse outcome of an aircraft disaster than to read two years later an incomplete aviation mishap investigation report. Remembering that the sole purpose of a Safety-based aircraft accident investigation report is find the cause of the mishap, so that others can prevent this same mishap from happening again, it is not clear to me how this report will satisfy that goal.Continue reading “Ethiopian Airlines 409: Lebanese Investigation Incomplete?”
Should criminalization be opposed by safety advocates and organizations? What has the ICAO Annex 13 given commercial aviation safety through the ICAO CAA investigative process?
What is the tradition of law in Western civilization? Is it seeking recompense and legal remedies for injury, death, property damage, property destruction, the expenses of treating mass casualties and the expenses of responding to an aviation disaster is part of Western culture, Western law and tradition? Is this what keeps us from “taking matters into our own hands.” Instead, in Western culture do we not we take the case to court?
Is this not the legal Western practice that is thousands of years old?
Should not Aviation Mishap (Accident) Investigations on the other hand be purely intended to QUICKLY determine the CAUSE of the Mishap (Accident) injuries, deaths, damage, destruction, mass casualties and disasters, and then determine the steps to take to IMMEDIATELY RESPOND, to come up with an INTERIM REMEDIATION and a LONG TERM RESOLUTION?
Has there been many cases where the procedures of ICAO and the actual case history of ICAO style ACCIDENT INVESTIGATIONS proceeded quickly to meet the three goals of Immediate Response, Interim Remediation and Long Term Resolution? Instead have not the legal style ICAO Accident Investigations become extensive in time and steered to determine fault and assign blame in lieu of finding cause and finding resolution?
In fact, haven’t national governmental civil aviation agencies tasked with Mishap Investigations taken years, in some cases 2-3 or more years to publish their findings, thereby failing the “Test of Quickness to Prevent a Follow-on Mishap?” Afterall, is not the main purpose stated in ICAO Aviation Mishap Investigation process quickness so as to serve the traveling public, when in fact the process seems to be serving everyone except the traveling public?
Secondly, are many of the investigation findings not actually enacted by the same governmental civil aviation agencies and as a result, are not many more mishaps of nearly identical cause left to occur, thereby costing many more unnecessary lives lost and much more destruction suffered?
Thirdly, why are involved manufacturers, involved agencies and other involved parties allowed to be members of the investigation boards instead of called as witnesses? Does this inclusion result in findings that, in my opinion, are questionable in effectiveness and questionable in logic? In fact, do not many, if not most, findings merely assign blame to the flight crew members and fail to recommend actions that would or could prevent another mishap?
Fourth, have ICAO style CAA agency investigations used a legal model of investigation and in fact are largely conducted investigations by lawyers and used the safety model and not used trained safety investigators to lead these investigations? Has the result been that many, if not most of these investigations seek and thereby assign blame and fault finding and do not accomplish the Safety task of finding cause and resolution?
In my opinion, the upshot of this incorrect Mishap Investigation and Safety Management has been that many governments have become frustrated with the unnecessary and illogical control of data and evidence exercised by CAA investigation agencies and have now begun to take over the Mishap Investigation process from ICAO style CAA agencies with stated intentions of finding recompense and remedy.They realize now that even though the stated purpose of the ICAO Annex 13 has been for safety purposes, in fact the actual purposes have been to prevent legal investigations from moving forward in court to rightfully assign blame and determine damage payments to damaged parties.
Ironically in all of these cases there is nothing actually that prevents CAA’s from conducting a Safety Investigation concurrently with a legal investigation, which in my opinion should have been the case from the beginning.
Western law permits suits to recover damage and there should be no impediment by safety in the name of safety that takes more than a few weeks. To impede damage suits in the name of aviation mishap investigations beyond that is illogical. Safety investigations should seek to find cause of loss and find resolution and do so quickly to determine if any other flight operations are in peril.
Legal investigations should seek to find who was at fault and who should pay? There is always plenty of time to sort that out later after the safety questions are determined. But for that Safety process to take 2-3 years is illogical and places so many more people potentially in jeopardy.
These two processes, Safety and legal, are neither mutually exclusive nor are they competitive. In my opinion they should be facilitated as concurrent investigations. The issue of criminalization of aviation disasters in my opinion has been brought about by unreasonable delays in the investigation process, by safety investigations being turned into pseudo-legal investigations and in allowing involved parties to be part of the board.
By these faults, people around the world have begun to see the fault of ICAO Annex 13 and have chosen other legal remedies for their losses.
Cargo Carriers Lawyers and the Power of Dollars Overcomes Cargo Pilots Safety Rights of One Man One Vote.
Fatigue, the greatest Human Factors problem in commercial aviation, was introduced back into the recipe of severe hazards by the work of lobbying lawyers working for the US cargo carrier industry. US Transportation officials chose to succumb to the political pressure and apparently to the financial power of lobbyists who argued that commercial cargo carriers would be subject to undue financial pressures if the cargo airlines were required to operate safely.
Instead, it appears to me that these company lawyers argued to the FAA lawyers that there is not case law that cites fatigue as causing cargo crashes that impact the public. In my opinion, no one at the FAA acts as a safety manager or safety regulator or safety administrator but rather act as lawyers and consider events related to flight operations only from the point of view of what has happened in the past. But the FEDEX B727 Tallahassee, FL fatigue related crash did not take out a neighborhood and therefore didn’t affect the public, so it appears that to an FAA lawyer only administrator, this and other similar fatigue related cargo carrier mishaps do not affect their judgment of their ability to think legally.
Did the FAA lawyers or the cargo industry lawyers look at the huge casualty costs of operating under the federal regulations as they have existed and now exist?
If, as I believe, the lawyers were trained as safety regulators, they would see the risk that fatigued cargo pilots could crash into a city such as San Diego, Philadelphia, Newark, Louisville or any number of cities overflown by cargo pilots at 5-6am at the end of a fatiguing 16 hour day of 8 or more hours of flight time.
In my opinion, the FAA is not protecting the rights of citizen pilots flying for cargo carriers. It appears to me that the FAA, the US Federal Government, is not protecting the rights of citizens living under the flight path of cargo flights arriving at 5-6am in major city hub airports. Instead, it appears to me that elected and appointed US officials are choosing to give corporation lobbying lawyers better rights than individual US citizens, so that the corporations can make more money, while the safety of the public is not protected.
The FAA Safety Policy is “One Level of Safety.” However, it appears that the FAA has dragged out some old past century bureaucrats to recreate government of the dollar, by the dollar and for the dollar, instead of “of the people, by the people and for the people,” as noted by US President Abraham Lincoln in his famous Gettysburg Address.
It is my opinion the old style bureaucrats, who have so totally screwed up the management of safety in domestic commercial aviation for so many years, should instead leave aviation safety management to people who are experienced and by this degree qualified to make decisions of regulation.
The best example is to look at the terrible mess that the FAA’s regulations have had on the US commercial airline industry. I believe that it took more than 20 years of failed regulations to institute effective wind-shear, fatigue, baggage management and TCAS standards. Now it appears that they are involved in another 20-year struggle to handle effective crew training and human factors fatigue standards.
But then we should look at all of the lives lost in the air and on the ground, the airplanes destroyed, the property destroyed year after year for the past 40 years in US domestic airline disasters? The data shows thousands of lives lost, billions of dollars destroyed, all under commercial airline operations certified and regulated by the FAA.
Can the US really afford to re-create two levels of safety in commercial aviation? Was not that FAA policy already discredited years ago?
In my opinion it is now time that the FAA should be led by someone from the airline industry, someone who actually has some experience and therefore credentials as a successful aviation safety manager?
So, can anyone tell me if lawyers really study any aviation safety policy, theory or philosophy in law school? If so, I sure would like to see the law school syllabus reference, because I sure have not been able to find one.
I believe it is time for new leadership in aviation safety in America.
ICAO may be fostering bad mishap math. ICAO is stating that an increase in mishaps is attributable to an increase in flight operations. If that were so mathematically, than as any airline operated more flights and or flew more hours, their mishap rate would directly increase. But that is not the case anecdotaly, statistically, case historically or in the experience of this pilot. The author of the ICAO report is looking for the reasons for more mishaps in the wrong place. This is critically important especially if everyone is trying to achieve the goal of reducing aviation mishaps. To do so, you have to know what are the causes of mishaps in the first place It is my opinion that aviation mishaps are a direct result of unresolved hazards. The rate of mishap occurrence is reducible by resolving hazards to aviation as quickly as possible. Even though ICAO is not providing the leadership needed globally to move safety in the correct and desired direction, it is my hope that many other safety minded managers are, and are doing so by regularly working to quickly resolve hazards to safe flight operations. Best regards, Paul Miller
See ICAO Report below:
Wednesday, December 7, 2011
ICAO Issues Global Safety Report Aviation accidents around the world ticked higher last year, attributable to the resurgence in air traffic, according to ICAO’s inaugural State of Global Aviation Safety Report issued this week. The number of accidents attributed to scheduled commercial flights increased in 2010 to 121, compared to 113 in 2009, resulting in an accident rate of 4.0 per million departures. The accident rate in 2009 was 3.9 per million departures. While the overall number of fatalities in 2010 was below those in 2005 and 2006, there has been an increase in fatalities over the past three years, ICAO said, increasing from 670 in 2009 to 707 in 2010. At the same time, the number of scheduled commercial flights increased by 4.5 percent globally since 2009, which represents the first significant annual growth in the sector since 2007 and coincides with an increase of 4.2 percent in the global GDP. North America, which represents a third of global air transport traffic in terms of departures, was the only region to see a small decrease (0.6 percent) in its aggregate traffic figures. “In the context of this period of renewed growth, and in light of anticipated increases in air travel, it is imperative to maintain a very strong focus on initiatives that will further improve safety outcomes in the future. ICAO is therefore continuously developing and refining more proactive and risk-based methods to further reduce the global accident rate, enabling the safe expansion of air travel in all regions,” according to the report. “ICAO is working in partnership with the international aviation community to achieve continuous reductions in the global accident rate, with an emphasis to improve safety performance in those regions experiencing significantly higher accident rates or having specific safety challenges.”
Here are unspoken managerial safety problems. I call them:
“Miller’s Six Rules to Fail-While-Complying”
1. Many companies are run by managers who do not know their own industry well. In commercial many managers are not line pilots. Many managers do not come from the ranks of the company’s own line holders.
2. They will act as if they are trying to comply with any program placed on them by their superiors. Their work is to comply with a regulator or industry inspector, and not necessarily make their own company operation safer.
3. But they will not embrace the spirit of these regulatory programs.
4. They will not adapt these programs to be effective for their own local operation
5. They will not innovate new programs that will work for them.
6. They will suppress any person in their organization that attempts, suggests or recommends safety innovation that falls outside of the letter of the regulation or law governing their operations.
So ICAO, FAA and other government regulators can recommend or require all types of safety programs, but were not many of these programs recommended by safety organizations and safety pioneers more than 20 years ago and longer in the case of many safety programs? So, how effective are regulators themselves at being the global advocate for commercial aviation safety?
So in my opinion, if the local organization does not do everything to help themselves, are they not more or less likely to fail?
As I read the papers, watch the news, I regularly observe regulators, major airlines and aircraft manufacturers adhering to some or all of the six rules for failure?
It is critical to understand the terms risk and hazard.
A hazard is a something that causes danger such as an incomplete or outdated procedure, an object such as a equipment, a malfunction or a human factor. The hazard is real, it is perceivable and most of all discoverable BEFORE any mishap, accident or incident occurs.
This is a CRITICAL part of safety theory. A Hazard is a real thing and certain people with a good safety eye can see it ahead of any accident. Some do not, but many do and can report that hazard to the safety manager, who if he or she is smart enough, can take steps to eliminate that hazard.
Why is it important to eliminate hazards?????
Safety theory says that mishaps, accident and incidents are the result of unresolved hazards. That is the sole purpose of safety investigations: identify the hazard and eliminate them.
But if you seek mishap free operations, then you have to go seek out hazards and eliminate them ahead of time. If you do that, you will enjoy mishap free operations.
A risk is defined as a product of two factors. First factor is the likelihood of the event occurring on a sliding scale from zero to 100. Think of this as a per cent of probability which could be measured from a low of very unlikely, at or near zero per cent, then all the way up to very likely, that is at or near 100%.
The second factor is the severity of the event if it occurs. This means if the hazard does occur, what are the consequences? How badly will a plane be destroyed if it crashes, how seriously will a person be injured or will they die, how severely will equipment be damaged or destroyed? You could assign a numerical value to severity as well on a sliding scale of zero to 100 percentage, meaning that none, some or all of the aircraft, person, property or equipment is damaged, injured, destroyed or killed.
When you multiply the two factors of probability per cent and severity per centage together, the product becomes RISK, which is a real number. Risk is a product of two factors, meaning that each is factor is multiplied together to form a number. As when multiplying any two numbers between zero and 100 together, the product increases rapidly and in a hyperbolic fashion.
So I have written a mathematical formula to describe this and it is called, MILLER’S FORMULA FOR RISK. RIsk is labled Z, Probability is labeled X and Severity is labeled Y. When you multiply probability by severity you come up with risk. So the formula looks like this Z=XY. Plotting this function gives you a three dimensional display of the full range of risks. Factor in several more factors such as time and resources devoted to mishap investigations, called factor N and take into account some level of periodocity by looking at the trigonometric sine function and MILLER’S FORMULA FOR RISK becomes Z= sine |X| N(Y).
There is more in my paper published in the Flight Safety Foundation Proceedings of the 2003 Corporate Aviation Safety Seminar, entitled “Forecasting Hazards and Charting a Safe Course: How to Plan Changes in Flight Safety Programs to Meet Future Safety Issues, Decisions and Attitudes, and Keep Your Business Profitable!” copyrighted 2003.
If you have any problem getting a copy or a copy of the accompanying Powerpoint or would like me to come to your organization to speak more on this subject, contact me by Paulmiller@safetyforecast.com.
Really it is the experience of the commercial aviation industry about which I speak.
Airline operations today should be safe so that mishaps are a rarity, when in fact, not only do we see continued commercial aviation mishaps continuing unabated, but we see mishaps that are 100% preventable.
Safety is being absurdly left behind in virtually every investigation for the purpose of blaming a party and seeking damages.
The concept of prevention today is about as foreign to most managers as east is from west. And yet, when a mishap occurs, there are expressions of incredulity that belie the understanding of hundreds of years of tort law.
BEA’s investigation of AF 447 is an example of that, but I digress.
Name me one fact or idea in the September Yak 42 mishap report that was either not already known, or should have been known?
Pilots should be trained in the aircraft that they are flying? What? We didn’t already know that? Managers should keep correct records and maintain certified training? What? Is that a new idea? Customers should be protected by a layer of aviation safety regulatory bureaucracy? What, is that something new?
What occurred that was not already known to be a problem, prior to starting engines? How can we move forward as a commercial industry, when so many want to move backwards? Is this the Unregulated Three Step Dance, one step forward, two steps back?
More questions have been raised by fellow safety minded pilots regarding AF Flight 447. Here are several:
1. Why were they flying through that nasty convective weather?
2. Why did the captain leave the cockpit just prior to the flight’s arrival to this area?
With respect to the questions asked, here is my take.
1. The captain had at least a 2 hour-old satellite pix by the time he started engines. The thunderstorm encounter occurred somewhere after about the second or third hour of flight, meaning that the AF 447 entered the thunderstorm area about four to five hours minimum after the satellite picture was taken. This means that it is very possible that the satellite picture that the captain received did not resemble the convective weather area that the flight eventually encountered enroute. This is assuming of course that the crew got a satellite pix at all out of Rio. This is a very common pre-flight briefing problem for all airlines operating oceanic flights. Making the problem worse is that Flight Control is not required to resend the latest satellite shots to the crew during the flight. Why is that? Why do we have rules that not only do not provide important weather information, but do allow the provision of somewhat inaccurate weather information? Why is that?
A. Let’s say that the captain was a cautious fellow and planned well. So he gets up a few hours before the hotel pickup, has a shower, checks his email, gets packed, dressed and meets the crew in the lobby. At the airport or maybe even at the hotel, he sees the satellite picture prepared and sent by AF Flight Control Dispatch Offices.
I have not seen a satellite pix or a weather observation from the time from 4-5 hours before the mishap, but if I was investigating this incident, that is the first place that I would look. Why? Well satellite picture is the information that will inform the captain as to what lies ahead of him and will inform his game plan, sleep strategy, crew switch strategy for the flight. So my money is on a sat shot that shows widely scattered storms if any at all given to the captain during pre-flight briefings. He doesn’t see a threat at this time and doesn’t see any reason not to use his normal strategy of getting the oceanic clearance, getting the plane out onto the transoceanic tracks and then retiring to get some rest, letting the other crew members handle the routine of the crossing. This will allow him to get some sleep and be fresh when they get close to Europe and have to start their let down at CDG for landing. Maybe this is his normal routine. Based on this supposed scenario, it is a reasonable one.
B. Alternative scenario: The captain is a “show me” kind of guy; unless he sees the lightning flashes and is face to face with a thunderstorm, he doesn’t worry about the metro stuff, because it is all 4-5 hours old data by the time they get out onto the tracks for crossing.
Either way, I do not think that the captain foresaw that 60,000 ft+ inter tropical convergence zone storms in his path would be a real possibility.
Additionally, we might consider this: thunderstorms anywhere rise rapidly in height, developing at 2000-4000 feet per minute, even as much as 6000 feet per minute. Therefore, information such as “the previous flight got through this path” is not really all that valid information for following flights, especially flights following 10 to 15 minutes later. The fact that another flight transited this area 10-15 minutes prior is certainly and in my opinion most definitely not an endorsement for safe flight in an area of active thunderstorm activity. Thunderstorms by their very nature are unstable. That is what makes them so dangerous to flight. Thunderstorms violate the very first principle of aerodynamics, which says, “assume a homogeneous airmass.” For sure a thunderstorm is not a homogeneous airmass!
Thunderstorm development in the inter-tropical convergence zone (ITCZ) is even more dynamic than at other places on the globe. This means that even more caution needs to be exercised in the ITCZ by commercial airline operations. Yet remember that this mishap occurred on a flight planned and operated regularly in the ITCZ by this airline.
C. Third scenario is this. This is the kind of fellow that does his own thing. He does the takeoff, then he does his nap, then he does his arrival. This is the way that he does things and this is his thing. This is how he does every oceanic flight and he figures the other crew can handle things. That is just the way he is.
D. Fourth possible scenario: The Air France Dispatch Office in CDG does not consider it their responsibility to update Air France flights with Air France passengers on board of dangerous weather that has developed and is now in the path of an Air France flight. They consider it their responsibility only to get the pre-flight paper work prepared and delivered and then do no further duties other than to stay awake and answer any questions that come up during the flight.
My guess is that AF Dispatch Flight Control Standard Operating Procedure SOP is not to initiate any inflight communications unless directed to do so by “higher authority” or some similar version of that idea. The second place that I would look were I doing the BEA investigation would be the AF Flight Control Log for AF 447, the AF Flight Control SOP and all of the metro data that was available to AF Flight Control before the mishap.
I would further examine just exactly how AF Flight Control does business every day and night with respect to how much info is passed to airborne flights concerning dangerous weather occurring ahead of any AF flight.
Sorry to say this but more than a few commercial flight crew members are like B and C. I am even more sorry to say that more often than not, many flight control offices are like D. They send company flights on flight paths that intersect dangerous weather and do not change plans along the way. My guess is that this most likely remains “the way things are” at many airlines. How about yours? Are you in a position to make some changes at your airline?
So that is some thoughts on question one. But if you are a good captain and a good communicator, my guess is that you also have a few ideas and I would be very interested in hearing from you and reading your thoughts on this same question.
Now for question two, here is what I think. I do not think that the captain was fully aware of what was ahead of him. I also do not think that the captain expected a failure on the pitot static system due to icing to occur if the flight did go into clouds.
Remember that the pitot static equipment manufacturer, France’s CAA, Airbus and AF all denied that the equipment was faulty, even though there had be several incidents of failure previously of this same equipment in this same scenario and that it had been reported in the industry press.
So that captain may have allowed himself to be informed by the “authorities” in lieu of informing himself through reading industry incident reports.
Again, there are plenty of crew members who allow themselves to be informed this same way, at airlines all over the world, pilots who do the same thing.
Those of us who doubt “authority” are few, probably less than 1/3 of all. My guess is that real doubters are even fewer than 1/3, more like 1/10!
So, here is a third question: Why didn’t the captain jump back into his seat and take control as soon as he arrived back up front? I know that I would have. You? Sure things were confusing, alarms going off, icing, thunderstorms, panic-what better time for the captain to be in charge of the flight deck and the controls?
I hope that this mishap is eventually re-investigated by some board other than the BEA, a board that knows that they are doing a Safety Investigation and not a Legal Investigation for some future court proceedings.
In the meantime, I am blogging my thoughts to allow local safety managers around the world to think deeper about keeping their operation safe. That is my intent.
Heard about the book today. Jean-Pierre Otelli who specializes in aviation safety, publishes his book “Piloting Error, Volume 5” today.
But in my opinion, he only re-analyses the facts collected in BEA’s report. I believe that the BEA’s report is seriously flawed and the book adds little to mishap prevention.
Would you like proof that BEA’s investigation is flawed?
Simple: there is little if any recommended corrective action contained in the report, that, if followed, would have prevented this mishap. Rather, the book and report appears to center on finding fault, assigning blame and extracting tribute for damages. So, the investigation is really a legal investigation and not a Safety Investigation. I have explained in the blog that the only value to a Safety investigation is to find ways to prevent a recurrence.
It appears to me training is weak at AF as well. So, that is a managerial responsibility and regulatory duty. Remember that this crew was certified by the airline’s training dept and national aeronautical regulators before they were assigned to operate this flight. If their performance as a crew and as individuals was substandard, as alleged in the BEA’s report, then that would be a direct indictment of the training and certification authority credibility, would it not?
From my background training experience, when we first learned basic and radio instrument procedures in basic jet training, an important segment of that training were procedures to employ when some of the instruments failed. Some of this training focuses on the failure of attitude and/or directional gyro equipment and is called partial panel procedures. Some other procedures focused on loss of pitot-static instruments, some or all, and teach you to remain in stable flight using attitude instruments and standard engine power settings. Other procedures cover magnetic and/or directional gyro or heading instrument failures, still others cover what to do if part of your navigation instrumentation fails.
We practiced all of these procedures right from the beginning of our training. Along the way with every new aircraft, with every new organization, these procedures remained a significant part of regular training. At my last sim/training session a year before retirement, we were required to practice these procedures and focus especially on the loss of pitot-static instruments. We trained heavily on this. After more than 40 years of flying and training, we were reviewing the basics and training on written procedures for loss of instrumentation.
So, were these AF447 crew members trained by AF in this area? There certainly appears to be a question here. However, does the report by BEA or the book by Otelli investigate this?
So, read over my various blog postings and let me know what comes to your mind.
In my opinion, there can be no worse outcome of an aircraft disaster than to read two years later an incomplete aviation mishap investigation report. Remembering that the sole purpose of a Safety-based aircraft accident investigation report is find the cause of the mishap, so that others can prevent this same mishap from happening again, it is not clear to me how this report will satisfy that goal.
Safety Forecast 