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ON COMMERCIAL AVIATION SAFETY AUTUMN 2000

This issue of focus sponsored by:

THE OFFICIAL PUBLICATION OF THE ISSUE 40 UNITED KNIGDOM FLIGHT SAFETY COMMITTEE ISSN 1335-1523 16894/Flight Safety 24pgr 29/8/08 10:40 Page 1

The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

ISSN: 1335-1523 AUTUMN 2000 ON COMMERCIAL AVIATION SAFETY

FOCUS on Commercial Aviation Safety contents is published quarterly by The UK Flight Safety Committee. Editorial 2 Editorial Office: Ed Paintin Chairman’s Column 3 The Graham Suite Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX Is My Top Management 4 Tel: 01276-855193 Fax: 855195 “Safety Management Orientated”? e-mail: [email protected] Mike Overall Web Site: www.ukfsc.co.uk Office Hours: 0900-1630 Monday-Friday Crew Resource Management 7 Advertisement Sales Office: Stalled at a Crossroads and Seeking to Interpret the Markers Andrew Phillips Pieter Hemsley Andrew Phillips Partnership 39 Hale Reeds CRM? .....It’s For The Birds! 1 0 Farnham, Surrey. GU9 9BN Tel: 01252-712434 Mobile: 0836-677377 Corporate Killing - Directors Liabilities 1 1 FOCUS on Commercial Aviation Safety is Steven Kay QC circulated to commercial pilots, flight engineers and air traffic control officers holding current licences. It is also Book Review 1 3 available on subscription to organisations Human Factors in Multi-Crew Flight Operations or individuals at a cost of £12 (+p&p) per annum. The Quality Choice 1 5 Alan Munro FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is indicated, articles may Leading the Way Towards Safer Flying 1 8 be reproduced providing that the source Dave Wright of material is acknowledged.

Publication of an advertisement, letter or One-Size-Fits-All Maintenance Problem 1 9 announcement in FOCUS does not necessarily imply that the UKFSC They Were Just Little Problems - Nothing Major 1 9 endorses any such advertisement, letter or announcement. UK Flight Safety Committee Members 2 0 Concept and Design of New Look FOCUS acknowledgement to: Legal Adviser’s Column 2 2 RAI Design Peter Martin Unit 1, Kingsmill Park London Road, Loudwater High Wycombe. HP10 9UB UKFSC Seminar - Aviation At Risk 2 3 Tel: 01494-537100 Fax: 01494-537200 email: [email protected]

Printed by Woking Print and Publicity Ltd Tel: 01483 884884 Front Cover: Embraer RJ 145 Regional Jet

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Editorial

New Millenium - New Image

The discerning reader probably noticed We will continue to change the picture on We do not intend to stop here in the that the layout of the cover of this edition the front cover for each issue and are development of FOCUS. It is our of FOCUS has changed. As you read on offering advertisers the opportunity to intention to attract more advertising in you will also see that the internal layout is sponsor an issue at very good rates. For order to improve the magazine further. A different too. No doubt you will be asking their sponsorship they will get to choose laminated cover and the use of better yourself “Why the change?” the front cover picture and have a full- quality paper would enhance its look and page advertisement on the back cover. In feel even more but these changes will be addition they will have the opportunity to subject to the amount of advertising we publish an article in the next issue of the can attract. Some time ago the United Kingdom Flight magazine on condition that it has a Safety Committee’s Communications relevant safety message and does not Sub-Committee was given the mandate blatantly advertise their product. to look at improving the magazine. We I hope you enjoy our ‘new look’ wanted to make the magazine more eye FOCUS! catching and easier to read. As a result, much discussion and investigation has You will find the inside layout more taken place and we believe that the end pleasing to the eye. This is achieved by result achieves these aims and much having a masthead across the top of the more. page that incorporates the name FOCUS and focal point (the bright star). At the bottom of the page a band in our corporate colour containing the page Some may say, “What was wrong with the number with the logo above completes old style magazine?” The answer to that the image. The text is laid out in three is simply, “Nothing”. It has served its columns (left justified) and the spacing of purpose well and has been in existence the text allows more white space making for 39 issues over a period of 10 years. At it more inviting and easier to read. the time it was a giant leap forward for the Flight Safety Committee and under the editorship of Roy Humphreyson, Executive Manager, it achieved an The UKFSC logo will replace excellent reputation. It is acclaimed by the FOCUS logo to signify some as “the best flight safety magazine the end of an article. in the world.”

The move to full colour raised the overall It was however felt that after 10 years it image of the magazine to a higher plane. was in need of a revitalisation and face- This now means that photographs and lift. I hope that the readers will feel this graphics will enhance the articles far has been achieved. more and will give a much more professional appearance.

The name of the magazine is FOCUS on Commercial Aviation Safety and over We are pleased to announce that starting the years it has become known as with this issue we will be featuring a FOCUS. In order to strengthen this we regular article by our Legal Adviser - Peter have changed the emphasis of the text in Martin. Peter hopes to use this instrument the title to highlight this. to bring to the notice of our readers, legal matters of interest and importance. Peter has a unique style of conveying the “message”. I hope that you enjoy reading them.

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Chairman’s Column

Flight Data Monitoring by Captain Tom Croke

The current development in recording lessons learned, all have an important operating procedures and safety flight data has enabled greater bearing on the way in which the system is “thresholds” laid down by the individual capabilities in the area of Operational viewed by those who use it. operators. To take these and try to apply Monitoring, Flight Operations Quality them, across the board, would be Assurance and Flight Operations Data inappropriate. However, the potential to damage, or even destroy, those systems Analysis. The software and hardware The slow development in the adoption of already operating is very real. developments have meant enormous this, probably the greatest single advance advances in the scope of the data that in safety ever, indicates the enormous can be recorded and also advanced the sensitivities and anxieties that need to be ease with which this data can now be resolved through understanding and It is to be hoped that before any such read. The cost of such a facility is now dialogue before its acceptance. When proposals are advanced, full discussion within the reach of a greater number of coupled with corporate fears about the will take place with those currently airlines. damage any leakage of such information operating these invaluable safety tools may cause, it is probably unsurprising lest unintended, but fatal, damage is that we are as far along as we are at this inflicted. However, this is only one side of the point. equation. To allow such a system to operate requires a company to commit to the culture of retribution free reporting, A recent move by one regulatory authority and adequate resources to fully exploit to obtain access to such information the benefits of such data. There must be disturbs me. The threat it poses to the absolute trust between the pilots and the advances to date far outweigh any company before such a system can gain perceived safety dividend that might the confidence of line crews. The manner accrue to the wider aviation community. in which the analysed data is used and, The reason I say this is that the more importantly, the manner in which the parameters and filters set in such crews are dealt with in implementing the systems usually reflect the standard

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Is My Top Management “Safety Management Orientated” ? by Mike Overall

Much has been said recently about air often exists in organisations which have Dangers of motherhood and apple pie operator’s safety cultures and the need weak safety management. A good safety for a more formalised approach towards ethos, based on the professionalism A safety management system is managing safety. The industry is inherent in the industry, can prevent essentially about having effective grappling with the problem of how best to accidents. It can also camouflage the management control over safety. develop aviation safety management inadequacies and sins of top systems which meet the CAA’s management. However, it is a poor and expectations. At the same time, the CAA unreliable substitute for an effective safety is trying to clarify what its expectations management system (SMS), which is One must be wary of the danger of losing mean in practical terms. driven by a competent top management sight of this objective and being misled team. by common use jargon.

Motherhood statements about “the Safety Culture commitment of management to safety”, It would be unwise to regard a sound “leadership” and “safety is paramount”, safety culture solely as some tangible although relevant, do not constitute an It is much easier to talk about the concept outcome which can be project managed, effective top management safety culture. of a safety culture than it is to identify like the introduction of a new aircraft type. A corporate “Statement of Safety Policy”, what you have to do to ensure that your It should be regarded as an outcome, a signed by the chairman and chief organisation has one that is both sound product, of good management. If an and sustainable. In the real world, it is a difficult concept to tackle head-on. Industrial history is littered with examples Principal where huge amounts of funds and effort Corporate Accountability have been pumped into trying to change Board company cultures without a sustainable result.

Chief Comprehensive Corporate Corporate Executive Too many managers still perceive a Officer Approach to Safety Management company’s culture as being mainly, or wholly, about the company’s workplace Effective Organisation for culture. The reality is that an Delivering Safety organisation’s culture, especially as far as its safety culture is concerned, is a product of several things. Robust Systems for Assuring Safety

First, and most importantly, it is about the approach to safety taken by the Three prerequisites for successful safety manager organisation’s top management (i.e. by its corporate board and executive management team). If an organisation does not have a sound top management organisation does not have effective executive of the company, is an important safety culture, you cannot expect it to safety management, a sound safety element of an SMS. It may give have an effective workplace safety culture is unlikely to be sustainable, even encouragement to the workforce and the culture. if it appears that an improved culture has regulator, but will be no good unless it is been achieved. backed-up by rigorous management systems that facilitate top managements Safety culture, in this context, should not active and continuous involvement in be confused with safety ethos. safety management control. Top Fortunately, in the aviation industry there management “ownership of safety” can is a strong workplace safety ethos. It only be as efficient as the company’s

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safety information and management The Board of the organisation has to be an effective organisation below Board control systems allow it to be. The responsible for establishing the level to deliver safety. He, through his company’s organisational arrangements company’s corporate approach to safety. executive management team, must also for managing safety must be finely tuned It will also need to agree the Board level be responsible for making sure that the to ensure that (only) relevant safety organisational arrangements for safety right systems are in place to provide information reaches those that need to management, but it will fall to the Chief safety assurance (i.e. assurance for the know it, in a manner that enables sound Executive Officer to ensure that there is company’s management team) and that decisions to be made. Characteristics of Top Management Safety Cultures

A Hazard and Risk Management System Compliance safety culture Safety management culture is an essential core component of an SMS. However, its effectiveness will be Reliance on demonstration of Committed to and operates a limited if it exists as a relatively isolated compliance with external regulations. systematic approach to managing tool within a safety management safety. framework which lacks an integrated approach and organisational structure. Has not taken a considered view on Has decided to set company standards Care must be taken also to ensure that whether to operate at or above the at or above the regulatory minima and, the risk management process does not regulatory minima. if above, has articulated how far above. take on a narrowly focused momentum of No specific funding for SMS Board has approved specific funding for its own, which absorbs a vast amount of development project. SMS development. effort, possibly at the expense of other key elements of SMS development. Is [wholly] reactive about safety. Is proactive about safety.

Safety dealt with at Board/Top Safety demonstrably a matter in which Management level only on a reactive the Board/top management is Prerequisites for successful safety ”when necessary” basis. proactively involved in a routine and management structured manner.

Does not review safety of existing Seeks to confirm safety of existing If top management wants to design an operations unless there is a reactive operations through systematic effective SMS for controlling safety, it will reason for doing so. programme of safety assessments. help if it first focuses on the following three prerequisites for successful safety Has no specific targets for measuring Sets safety performance targets and management: safety performance. monitors their achievement.

1. A comprehensive corporate No self-generated approach to safety Has instigated a safety improvement approach to safety. improvement. programme with Board approved targets. 2. An effective organisation for delivering safety. No requirements or procedures to Requires changes to be formally routinely assess the safety impact of assessed for safety impact. 3. Robust systems to provide changes. safety assurance. No formal requirements to guide the Expects risk to be managed to ALARP Effective control of safety requires clarity assessment of risks to safety. principles/levels. and coherence in the allocation of safety responsibilities and accountabilities No standard procedures for assessing Has documented management throughout the organisation. It is vital whether unbudgeted safety procedures for deciding whether therefore to be clear where responsibility improvement proposals should be unbudgeted safety improvements rests for each of these key aspects of funded. should be funded. safety management and to ensure that the necessary management control Safety largely left to line managers, with Safety actively driven from the top. systems are in place. little involvement/oversight from top management.

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b they are working properly. The objective for a Safety Director (e.g. under FARs). safety management. of each system, how it fits within the SMS and who is accountable for delivering its Where does your company sit? objectives must be unambiguous. The reality is that the CEO cannot fulfil his The summary on page 5 of some safety safety management responsibilities culture characteristics may give you some without some dedicated senior guidance. A weakness in any one of these three management support to help him/her prerequisites will undermine the integrity ensure that the company’s SMS is of the organisation’s overall management effective and working properly. Hence the Editorial note: of safety. concept of a SMS Custodian, who acts as the guardian of the integrity of the SMS, Mike Overall currently acts as an on behalf of the CEO. For air operators, independent adviser on aviation the SMS Custodian role, depending on If an organisation is effective in all three regulation, strategy/organisation and the nature and size of the organisation, aspects, then it should also have a good safety management. He was well known would normally be vested in the Safety safety culture. On the other hand, if there to members of UKFSC in his previous role Director, Flight Safety Manager or Flight is a poor safety culture in an organisation, as Head of Licensing Standards Division Safety Officer function. Wherever the it is likely that there are weaknesses in in the CAA’s Safety Regulation Group. His Custodian function is located, it is one or more of these three key aspects of concept of the three prerequisites for essential that the person fulfilling it has an safety management. successful safety management was effective working relationship with the reflected in the UKFSC’s guidance CEO and the regulatory Accountable material on developing an aviation SMS Managers, if different. He must also have and has been adapted for similar use by How a company’s SMS is designed the inter-personal skills to operate Shell Aircraft. around the three prerequisites concept effectively at Board level and throughout will depend on the company’s nature, the organisation. The design of the size and its existing organisational company’s safety management policy structure and management systems. The and review systems and its safety bottom line is to be clear as to whom is committees and meetings will need to accountable for what - starting from the reflect these senior management Board downwards! accountabilities.

Accountability for safety What safety culture are we operating under?

The executive responsibility for safety management, on behalf of the Board, The days when an air operator’s top should rest with the Chief Executive management can be satisfied that the Officer (the CEO), or his equivalent. The demonstration of compliance with the CEO is cornerstone of the organisation’s minimum safety regulatory requirements whole safety system. He is the link is adequate are fast coming to an end. between the Board and the executive, The wider regulatory, legal and and he, more than anyone, has the power commercial world that the industry is now to deliver successful safety management. operating in will see to that. That said, This Board level responsibility must be there are still some companies which are made compatible with any regulatory operating under a top management requirements relating to the Accountable safety culture that owes more to safety Manager for safety (e.g. under JARs) or regulatory compliance than to systematic

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Crew Resource Management: Stalled at a Crossroads and Seeking to Interpret the Markers? by Pieter Hemsley

In the view of many, Crew Resource The impending requirements have raised Progress in the first two is well advanced. Management (CRM) has lost direction. genuine alarm among some operators, in Critical to the success of CRM training is After the enthusiasm of the early 1990s particular the smaller companies, that the competence of instructors, an issue for initial CRM training for flight crew, UK there are few to whom they can turn for long overdue. Competency criteria were aviation now appears less sanguine detailed advice to implement effective published in 1998 in the Guide to about embracing the subject CRM training programmes and fewer still Performance Standards for Instructors of wholeheartedly and there is the danger who can integrate such programmes with CRM Training in Commercial Aviation that a programme that offers so much technical training, the ultimate goal. produced jointly by the Royal could stall. Aeronautical Society, the Aviation Training Association and the CAA. Trainers who have examined the document have given The solution lies in three complementary enthusiastic support for the guidance fields - all addressed in the NPA - that In part this reluctance is founded on the proffered. Such informal evidence - and collectively should restore confidence: lack of precision associated with CRM; the fact that fewer than 15% of UK there are few universal truths and it - Trainer competence standards, operators appear to have received the requires an act of faith to accept its utility. Given the pessimism apparent in some - Trainer accreditation, and quarters, I should like to spell out why there is now good reason to be positive - Use of performance indicators about the future. (PI).

Non-technical Skills (NOTECHS) Framework: As a global industry, UK aviation is firmly Elements & Behaviours of Category - embedded in the wider European scene. Situation Awareness Until recently there has been no detailed supranational CRM initiative, but that has changed with the advent of the Joint Category: Aviation Authorities (JAA) Notice of Situation Awareness Proposed Amendment (NPA-OPS 16), a document negotiated between the Authorities, operators and pilot associations for more than two years. System Environmental Awareness Awareness Anticipation The NPA text has much more precision and clarity than the extant CRM wording in JAR-OPS 1 (Commercial Air Transportation (CAT) Aeroplanes), • Monitors and • Collects • Discusses reports changes information about contingent Subpart N that it will replace; much will in systems states the information strategies read across to JAR-OPS 3 (CAT Helicopters) in due course. With • Acknowledges • Contacts outside • Identifies circulation completed in April 2000, the entries and resources when possible/future NPA remains the preferred guidance of changes to necessary problems systems the JAA and could be formally adopted • Shares later this year. There is therefore some information about urgency for operators to re-examine their the environment CRM training to ensure compliance with others before the JAA Rules become UK law, feasible by 2001.

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Guide - are, however, inadequate to give One set of BM is the European Union their members. But, even if the unions confidence in these standards as the NOTECHS (Non-Technical Skills) were not cautious, BM must be bedrock for the next part of the framework a PI already on trial but with as introduced with care else the weaknesses programme, accrediting CRM trainers. yet no conclusive evidence emerging of of the present system might be Therefore, a formal survey has been its validity. While NOTECHS can achieve replicated, undermining CRM programme undertaken this summer to validate the a necessary uniformity within the JAA, credibility and giving sustenance to its standards document. Such prudence in they remain in their infancy and, because critics. Accordingly, BM must be creating a suitable accreditation they rely upon bold headings only, I implemented at a measured pace and, at architecture is essential to instil believe fail to provide sufficient detail for the outset, it is appropriate to use them confidence; an embryonic structure the practitioner to apply his skills. They for CRM syllabus review only. This will should be in place in the UK next year. need maturing and embellishing, issues also create an opportunity for objective to which I will return. analysis of the instrument itself, to assure its validity and consistency in use. Despite the very powerful boost to providing quality CRM training that these The NPA, CAA Aeronautical Information measures will have, the success of such Circular 114/1998 and the Guide all refer To avoid sacrificing clarity, one of the very enterprise might be in jeopardy if greater to BM. first steps must be for all parties to agree precision regarding the efficacy of CRM activities is not fed back to organisations and crew alike, not least to appease the Non Technical Skills (NOTECHS) Framework: accountants. Historically, assessment of Categories & Elements crew in non-technical or soft skills has relied upon feedback in categories of ‘airmanship’ and ‘command’ skills. Given CATEGORIES ELEMENTS that there are no agreed definitions for these terms, the weakness of such an Team building and maintaining Consideration of others approach is its subjectivity. What then of Co-operation using observable behaviours as Supporting others indicators of performance, the third Conflict solving

element outlined above? I contend that Use of authority/assertiveness this activity is not an optional extra but an Leadership and Maintaining standards integral part of the process, to lubricate managerial skills Planning and co-operation the constituent parts and create a climate Workload management for synergy. System awareness Situation Environmental awareness awareness Anticipation By their objectivity, these behavioural markers (BM), as they are known, can Problem definition/diagnosis Option generation certainly overcome the major limitation of Decision Making current assessment models. BM lend Risk assessment/option choice greater accuracy to the analysis of Outcome review performance in a manner that promises to restore confidence in the whole CRM apparatus with customers, the line crews, who need to be ‘on side’ to provide a Despite such ubiquity, that is no reason to a terminology. In parallel, CRM trainers pool of willing advocates to assist in its rush into their use without ensuring a need to acquire the skills of accurately development. These tools certainly number of safeguards are in place. observing and recording individual and cannot be imposed to gain genuine Naturally, the pilot associations are at the crew interpersonal behaviours - many of behavioural change. forefront of wanting such protection for which are subsumed in the technical

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activity - a task not to be underestimated Workload Management given the myriad of roles already placed upon instructors, especially in the Planning: Anticipates problems and prepares for unexpected eventualities. simulator. The induction training required Planning lacks Usually plans in a logical Plans sytematically and could be protracted before instructors organisation and structure and orderly way but thoroughly, taking full and often fails to consider sometimes fails to account of task needs and reach a satisfactory level of competence. all circumstances consider all eventualities. also preparing for However, once a quorum has the skills, pertaining to the task. unforseen eventualities. BM could be used to provide feedback to training departments of the efficacy of core CRM programmes, particularly those in recurrent training. Situational awareness; Continually monitors and analyses all relevant operational factors to develop and maintain situational awareness.

Prone to becoming Usually cross-checks Not only avoids fixation but preoccupied with minor essential systems and also resolves ambiguities The next step - and this may be some tasks and often fails to instruments but and discrepancies at the years downstream - is to bring the BM to resolve conflicting or sometimes fixates on one first opportunity; always ambiguous information. aspect of the task. “ahead of the curve”. bear in whole crew assessment, prior to extending the system to individual crewmembers’ CRM skills. Such is the sensitivity of the latter that there is some unwillingness to set out on that course, Decision making; Understand and applies the elements of the but set out we must. Although I would decision-making loop. support the view that it is the crew as an Autocratic and directive, Sometimes acts over- Takes account of all even in circumstances hastily in reaching a available data; evaluates entity that operates the aircraft, where consultation would decision and fails to make different options; involves inappropriate behaviours on the part of result in a higher quality best use of all available others in the process when decision. resources. appropriate. one individual can undermine the harmony and hence the safety of the operation. It is axiomatic that all training leads to assessment in some form and thus, ultimately, individuals must receive has been used by military flight crews and provide clear goals to which those feedback on their own non-technical more recently adopted unofficially by entering the industry can also aspire. performance and the quality of their some air traffic controllers. The greater Conversely, markers could grant the contributions to the CRM equation. the effort that is invested in customising instructor of ab initio student pilots a these criteria, the greater the reward in more precise vehicle through which to terms of objectivity. The language must recourse or remove the candidate who be comprehensive and include the core has adequate technical ability but I promised to revisit the question of values of the CRM programme so that displays inappropriate and incurable embellishing NOTECHS BM headings, by specificity of comment is available. All interpersonal skills. which I mean incorporating a spectrum of will need to be trialled to ensure universal performance criteria. This is where I understanding and to hone the text. When all crewmembers exhibit the believe the necessary clarity will be Obviously, there must not be too many positive behaviours captured in BM – and achieved and confidence established. markers or too fulsome word pictures to instinctively the better ones already do – We should seek to adopt best practice overwhelm the busy instructor or confuse the psychological barriers to effective when developing these instruments, the crewmember for whom it can also be communication should be overcome, customising them to reflect local cultures, used for self-critique. The objective is to situational awareness will be enhanced be they national, company or fleet. One produce a user-friendly tool, not a burden. and the consequent, higher-quality well-tried method is to craft a spectrum of decisions made should lead to improved word pictures. operational effectiveness. In the long term, operations should be inherently The right-hand end of the spectrum safer, an outcome clearly influencing the indicates performance expected of An example that I helped advance which ‘bottom line’. experienced line crew and so BM can

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CRM?…It’s For The Birds! CRM, an acronym used vicariously in reference to Cockpit Resource Management or Crew Resource Management, has been a buzz word used in recent years by many psychologists and others to identify human factor In sum, rather than having lost its way, I limitations amongst aircrew when working together. consider CRM training has emerged from But the concept of CRM has been around for almost as long as life itself, certainly a period of uncertainty more confident. longer than the relatively new kid on the block - aviation. Consider birds for Given the impetus of the NPA, an example, in particular the humble flock of geese. unambiguous activity path ahead is evident, transparency of which is I believe assured through the use of developed BM. Eventually, CRM training could 1. In a flock of geese, as each bird flaps its wings it creates an uplift for mature to the point where behavioural the bird following. By flying in a V-formation, the whole flock adds markers become standards, comparable about 71 percent longer flying range than if each bird flew alone. to technical standards. Lesson: People who share a common direction and sense of togetherness can Now there’s a notion! go where they are going quicker, easier and safer when they travel on the thrust of one another.

The views expressed are those of the author who served 31 years as RAF 2. Whenever a goose falls out of formation, it suddenly feels the drag and aircrew and 3 years with the CAA Flight resistance of trying to fly alone, and quickly gets back into formation to Operations Department policy section, take advantage of the lifting power of the bird immediately in front. with responsibility for Crew Resource Lesson: If we have as much sense as a goose, we will stay in formation with Management issues, before becoming an those who are headed where we want to go. independent aviation consultant specialising in human factors in December 1999. He is secretary of the RAeS Accreditation Focus Group that 3. When the lead goose tires, it rotates back into the formation and produced the Guide to Performance another goose takes over as lead. Standards for Instructors of CRM Training in Commercial Aviation and Lesson: It pays to take turns doing the hard tasks and sharing leadership is progressing an accreditation framework because people, like geese, are interdependent upon each other. for CRM trainers in the UK. As secretary to the JAA Flight Crew Study Group, he was intimately involved in the development 4. The geese in formation honk from behind to encourage those up front of NPA-OPS 16 from 1997 to 1999. to maintain their speed.

© Pieter Hemsley 2000 Lesson: We need to make sure our honking from behind is one of encouragement - not something less helpful.

5. When a goose gets sick or wounded or shot down two geese drop out of formation and follow it down to help and to protect it. Then, they stay with it until it is either able to fly again or dies. Then they launch out on their own, either with another formation or to catch up with the original flock.

Lesson: If we have as much sense as the geese, we’ll stand by each other in the air like they do.

Reproduced with acknowledgement to ‘Spotlight’ courtesy of PIA Air Safety.

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Corporate Killing - Directors Liabilities by Steven Kay QC

The liabilities of Corporations for deaths 1. Unlawful act manslaughter itself is triable only upon indictment (jury caused as a result of commercial trial). activities is an area of criminal law that is This is when a person who causes the to be reformed and there will inevitably be death was engaged in a criminal act, an increase in the opportunities for which carried with it the risk of injury to Using modern research methods, I have prosecution of both companies and their some other person. For example, setting been able to trace only six prosecutions directors. To better understand the a fire to someone’s dustbin beside their of a corporation for manslaughter in the implications of what is to happen it is house because the smell of rubbish is history of English criminal law. Of these worthwhile to consider the law of offensive. The wind blows sparks that only two have resulted in convictions, in homicide generally and the development ignite curtains at an open window. Fire 1994 and 1999. The other cases of the concept of corporate manslaughter. spreads into the house and kills someone prosecuted which all resulted in acquittals within. This is an act of arson, or criminal were in 1927, 1965, 1991 (The Herald of damage, from which death results and Free Enterprise case aka the Zeerbrugge English law has two general forms of could be unlawful act manslaughter. Ferry disaster), 1999 (The Southall rail homicide offence - murder and crash). manslaughter. There are also some specific forms of statutory homicide, such 2. Gross Negligence Manslaughter as infanticide, but we do not need to However, there have been a number of consider those forms in this context. recent disasters, that have been This is when a death is caused by responsible for a call for a new approach extreme carelessness or incompetence. to the law. As a result the Law To be guilty of murder it has to be proved For example a Doctor negligently injecting Commission issued in 1996 a Report that the accused intended to kill or a patient with a serum that is lethal and is “Legislating the Criminal Code: intended to cause serious injury. If there the wrong drug to administer. Involuntary Manslaughter” and the Home are mitigating features within the Office have further issued in May 2000 a allegation of murder, such as provocation set of proposals for reform of the law under the title “Reforming the Law on (a temporary and sudden loss of self 3. Taking an Unreasonable Risk or Involuntary Manslaughter: The control causing the act) or diminished Recklessness Manslaughter responsibility, then the offence is one of Governments Proposals”. manslaughter. This form of manslaughter is known as voluntary manslaughter, This is when death is caused by a person because the act was intended, but who is aware that their conduct involves a Let us recall the incidents which have caused by the mitigating features. risk of causing death (or probably serious prompted the calls for reform, all of which injury) and unreasonably takes that risk. were the subject of Public Inquiries, each For example, a fun fair operator who of which was highly critical of the permits a ride to travel at speeds that If someone kills but did not intend to corporate bodies involved in the involve a risk of fracture of the metal that cause death or serious injury, but was disasters, none of which ended in a bolts the ride to a track, but continues to blameworthy in some other way, successful prosecution. operate the ride at increased speed. involuntary manslaughter is the form of homicide. It is in this area of involuntary manslaughter that we are concerned 1. November 1987 the Kings Cross when discussing corporate killing. It is within 2 and 3 that we are concerned Underground Station fire. Causing 31 with Corporate Killing or the liabilities for people to be killed and many others directors when death occurs as a seriously injured, including rescuers. Involuntary manslaughter has three consequence of an undertaking by a The report of Desmond Fenell QC was different forms: company. The punishment able to be critical of London Underground for not imposed upon a corporation for such an guarding against the unpredictability offence is a fine. Directors as individuals if of the fire and for failures within their proven also to be guilty personally, may management system by not having be liable to imprisonment or any other any person in overall charge in the sentence open to the Court. The offence event of a disaster.

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2. July 1988 the Piper Alpha oil platform because of the need to identify a The pressure for reform of the law has disaster in the North Sea in which 167 person whose gross negligence was been intense and it will arrive in the near people died and the inquest/inquiry in that of the company itself. The Judge future. The concern has been to ensure Scotland held it to be the had described the accident as being prosecutions against corporations responsibility of the platform operator. a serious fault of senior management. involved in disasters resulting in large This ruling also served as an indicator scale loss of life and to enforce Health there could be no successful and Safety at Work legislation, particularly 3. December 1988 the Clapham Rail prosecution for the recent Paddington on construction sites. However, once crash. Here, 35 people died, 500 rail crash. reformed, the law will be applied to all injured when 3 trains collided as a levels of potential offence regardless of result of signal failures. Anthony scale. Hidden QC was critical of the Let us consider now the technicalities of dangerous working practices and these prosecutions. It is possible to failure to act upon safety concerns of prosecute a company, for it is deemed in British Rail. Responsibility for what law to exist as a distinct legal entity. The The Governments proposals adopted occurred was beyond the operatives company acts through individuals who from the Law Commission are to divide at ground level, but also stretched are its servant and agents. The failure of involuntary manslaughter into separate further and higher within the the prosecution in the Herald of Free offences as follows: organisation. Enterprise case against the corporation was because of the identification doctrine. In order to convict the 1. Reckless killing: where death is The last two examples, both of which company of manslaughter, individuals caused by a person aware of a risk resulted in failed prosecutions, highlight identified as the embodiment of the that his or her conduct will cause the difficulty in the law with these cases. company would themselves have to have death or serious injury and it is been responsible and guilty of unreasonable to take the risk having manslaughter. If there is insufficient regard to the circumstances as the 4. Firstly, March 1987, the Herald of evidence to convict an individual or person knows or believes them to be. Free Enterprise car ferry disaster at individuals the case against the company the port of Zeerbrugge. There were, also fails. To successfully convict the 187 deaths which were held by the company, the acts complained of have to 2. Killing by gross carelessness: where verdicts of an inquest jury to have be committed by those identified as the death is caused by a person and the been as a result of unlawful killing. Mr. embodiment of the company itself. risk that their conduct will cause death Justice Sheen in a report for the or serious injury would be obvious to Department of Transport severely a reasonable person in his or her position, and the person is capable of criticised Townsend Car Ferries Ltd., It must be recognised that complex appreciating that risk at the material which was taken over by P&O company structures in which there is time, but did not in fact do so - and European Ferries. In June 1989, the great delegation of responsibility down either - (1) the person’s conduct falls Director of Public Prosecutions the line, causes responsibility for many far below what can reasonably brought prosecutions against P&O acts done in the company name to be too expected in the circumstances - or - and seven individuals. However, the remote from those who embody the (2) the person intends by their trial collapsed upon the ruling by company. Failure to shut the doors conduct to cause some injury, or is Mr.Justice Turner, that there was no properly on the ferry and to carry out aware of, and unreasonably takes the case to answer against the individual sloppy and dangerous practices, if there risk that it may do so and the conduct defendants and also the company. is no-one with responsibility for safety on causing ( or intended to cause ) the these matters within the body of the injury constitutes an offence. The less company avoids the company being 5. Secondly, in September 1997 the serious offence is that of failing to liable. The successful prosecutions for Southall rail crash in which 7 died and appreciate the consequences of an corporate manslaughter that have been 151 were injured. Great Western action (limb 1 of gross carelessness). brought have been against small one Trains pleaded guilty to failing to man band companies where it was ensure the public were not exposed to possible to identify the controlling mind risks to their health and safety. The 3. Death resulting from intentional or within the company, responsible for the trial Judge ruled a charge of reckless causing of minor injury: failures. manslaughter could not succeed reforming the dangerous and unlawful

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act manslaughter. This reform being immediate cause is the act or Officers of undertakings might also be motivated to deal with the situation omission of an individual. The liable for imprisonment if they have where a person causes the death of individuals within a company could contributed to the management failure. another, but the death was still be liable for the offences of unforseeable. reckless killing and killing by gross carelessness as well as the company These are proposals from the being liable for the offence of Government at this stage, but it is clear 4. Corporate Killing: an offence similar to corporate killing. that of gross carelessness. The there will be an offence of corporate offence would be committed only killing the only issue for debate is where it where the conduct of the corporation The potential class of corporate will stop. in causing death fell far below what Defendants are not limited to © Steven Kay QC could reasonably have been incorporated bodies but to those expected. The corporate offence described as:“Undertakings”. This This paper was presented at the Travel should not (unlike the individual includes corporated and unincorporated Industry Seminar - Gatwick 2 June 2000 offence in 2 supra) require that the bodies, local authorities, educational risk be obvious or that the defendant institutes, clubs, partnerships, trusts: any be capable of appreciating the risk. trade or business or other activity providing employment. Jurisdiction would be over any company doing A death should be regarded as having business in the U.K. Overseas been caused by the conduct of the incorporation or registration would not be corporation if it is caused by manage- an exemption from prosecution. ment failure by the way in which its activities are managed or organised and failed to ensure the health and Enforcement provisions against safety of persons employed in or directors for management failure would effected by its activities. include the power to disqualify from office Such a failure will be regarded as a or from acting in a managerial role. cause of a person’s death even if the

Book Review

HUMAN FACTORS IN MULTI-CREW FLIGHT OPERATIONS

By Harry W.Orlady and Linda M.Orlady. contribution the authors make to the find the relevant chapter to gain an incite Forward by John K Lauber. science of understanding what Human or a reference for more detailed study. Factors entails is in the vast library of This reviewer finally found the purpose of Published by ASHGATE PUBLISHING Ltd. references they have culled in order to the book in the conclusion of chapter19, create the most up to date work thus far in which he reads: Gower House published. Many other books have been Croft Road written, throughout the world as the Aldershot subject has unfolded and they are all Hants. GU11 3HR. UK A final thought: referred to generously and accurately. List price: £59.50 A purpose of this book has been to stimulate the type of awareness that will This impressive book at over 600 pages, The book is structured in phases and it is make all members of the operating team 22 Chapters, 17 appendices and a a lengthy read to cover the whole book aware of their importance in glossary, is the long awaited even allowing an hour a day for the task. accident/incident prevention and to help compendium to the ever growing topic of The trick is to ask oneself what the ensure that members of the operating Human Factors in Airline operations problem they are analysing is and then team are not simply the victims of a published by Ashgate. The valuable

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I Thought He Was Playing Chicken!!!!

series of situations that make an accident educators and anyone thinking of taking I was reading one of your Vortex articles or incident eventually inevitable. When an up a career in any of these disciplines. the other day and it caused me to think of accident does occur, it is clear that in an incident that occurred 17 years ago In conclusion it could best be left to echo virtually all cases a total system approach that almost cost me my life. I was that in the Foreword by John Lauber, in should be used for the analysis of the working in Africa, along with a fixed wing which he writes: accident. A total system approach makes aircraft, on a spraying contract. On the it possible for the aviation system to take day of the incident, the weather was poor advantage of the lessons that may be with low visibility and I had lost contact learned. It is clear that all aspects of the “Careful reading of this book will help with the other aircraft, who was working a social environment must be considered” dispel common misconceptions of what few miles away. I had just started a spray ‘human factors’ is about, and will provide run when I saw a flash and heard the roar the reader with practical information that of an engine off my right side. I swung So many times in the past, which will no will help achieve the desired levels of my head to the right just in time to see doubt continue ad infinitum, humans human performance in the aviation the Pilatus recovering from what was o operating aircraft, both singly and in system. That this is important is amply probably a 90 high g turn. I continued teams make mistakes, not of their own reflected in the accident data: human with the spray contact but did not see or making but because of weak links in the performance and human error continue to speak to the other pilot for a couple of infrastructure or “the holes lined up” in be the leading cause of such mishaps”. days. Prof. James Reason’s ‘Cheese’ analogy. From Checklist skills to the rapidly growing human interface with the Peter G Richards I Eng MRAeS. RAeS’ When we finally got together (over a automated aircraft world, this book rep on the UK Flight Safety Committee. beer), he said he had seen me from quite exposes and explores them all. a distance but did not alter heading because he thought I was holding Courtesy of The Aerospace heading to play chicken with him. Throughout the book, the authors have Professional. Fortunately for both of us he eventually guided the reader to further study, with did the correct thing and altered heading essential forward and backward just in time to avoid a collision. He turned references and sensible footnotes. It has a light shade of white and had many a very readable style of journalism, more beers when I told him that I hadn’t though sometimes the sentences get a seen him till he had taken evasive action. bit long. They make no apology for the USA’s bias in their work, for that is the region with which they are both most Assuming that the other aircraft has you familiar. But, above all, they identify “Best visual just because you can see it could Practices”, wherever in the world they be a deadly error in judgement. originated. In the chapter entitled The Worldwide Safety Challenge they do not shirk from grasping the nettle of how to Reproduced from Aviation Safety effectively manage the emerging Vortex. programmes known as Flight Operations Quality Assurance (FOQA), or Operational Flight Data Monitoring (OFDM) in the UK.

This is a reference book, aimed at anyone who has managerial responsibilities for any level of operation involving flight operations, flight and cabin crews, ground operations and air traffic systems, especially regulators and investigators,

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The Quality Choice by Captain Alan Munro BSc(Eng) MRAeS MIQA

Quality Assurance (QA) arrived in European in one direction and in the other what is warranty claims, unplanned activities, aviation as the means by which self seen increasingly as a costly regulatory overdue accounts, downtime, stock control regulation might be achieved. Of course, burden. In other words, it is the difference problems, procedural failure, documentation Quality is in itself nothing new. Airlines and between minimal compliance and the errors, overtime, refunds and adverse maintenance organisations have always excellence which QA is capable of publicity, and most of these apply to a depended to a greater or lesser extent on producing - The Quality Choice. maintenance organisation. strong management structures, dependable What we then mean by Quality needs to be The proven ‘Quality Costs’ of a training and procedures and reliable carefully defined, for which probably the manufacturing company without QA are documentation. But at the same time the easiest version is straight ‘Customer around 25% of its turnover. regulator was always at the elbow to ensure Satisfaction’. But of course this then poses In an airline loss means ramp damage, late compliance with aviation legislation and to the question as to who the customer departures, fuel wastage, flight time ensure at least minimum safety standards actually is. Obviously this must be the airline limitation problems, damaged freight, lost on behalf of the travelling public. itself for a maintenance organisation or the bags, missed connections, unplanned passenger or the freight forwarder for an The concept of Joint Aviation Requirements activities, sub-charters and compensation. airline, but even this is not straightforward. started more than 30 years ago when the But it also means the cost of resignations, We may actually be selling to a tour cost of certification to individual national inappropriate or lack of training, retraining, operator or leasing to another airline, while specification was becoming prohibitive. For trade union activity, maintenance stock code shares or alliances may also put us in example, a new Boeing 737 certified in the control, sub-contractor performance, flight the position of delivering a customer’s United Kingdom in 1968 was required to safety, health & safety and security incidents, service to their customers. have 20 special conditions which cost in the trouble with the NAA, lost business and order of $300K per aircraft. In fact the early In this case the basic ‘product’, however, is again public loss of confidence. JARs were Joint Airworthiness relatively straightforward. At whatever level The ‘Quality Costs’ of a service company Requirements whose aim was to ensure that of comfort, for a passenger airline it means without QA may be anything up to 40% of a new aircraft’s certification was universal in a safe punctual service with luggage on the its turnover. Europe. JARs as we now know them go same aircraft. back to the Cyprus Arrangements of 1990, So in an airline, if only 10% of such wastage In the case of the regulator, the NAA is not but descend from the earlier goals of was recoverable through QA, what is 10% of so much a customer as the agent of the common certification. your turnover? And what might it mean in public, whose role is to ensure that all terms of injury and damage? The stated justification for the requirement regulations regarding safety and for QA is that active regulation of an airworthiness are met, so that ‘customer’s Of course Quality is not free. Installing a expanding complex civil aviation industry is agent’ is an appropriate definition in Quality Quality System, employing and training becoming too demanding and costly, that a terms, and the ‘product’ is then, by staff, planning, equipping and generally self-regulating Quality System allows less definition, safety and airworthiness. moving to a Quality culture all costs money, active regulation and more self-control. It but then any new project requires In other industries where QA is increasingly might be added that standardisation of investment. And that is currently where the seen as necessary for survival, the words of safety standards in a de-regulated Europe is vast majority of European airlines find Peter Drucker, the Dutch management also fundamental to aviation safety and of themselves as we speak, told to re-equip specialist well-known on both sides of the course by introducing self-regulation each with the QA tool, but unsure how to use it, Atlantic are most appropriate: nation can interpret the rules within national unaware of its potential, begrudging its cost culture and a tight set of guidelines set by “. . . . the first duty of a business is to with the only apparent benefit as doing the harmonised National Authorities (NAAs). survive, and the guiding principle of minimum QA necessary to hold a JAR-OPS business economics is not the maximisation This paper, therefore, is not about the JAAs Air Operator’s Certificate (AOC). of profit – it is the avoidance of loss . . . .” or their quite incredible achievements to We are at a stage where some of the That is what QA does, and in our industry date, or even about the problems that do European National Authorities have greater that loss is not just financial. It means exist. It is rather about the opportunities that or lesser understanding of what QA actually incident and accident, air and ground, have been handed to the leaders of our means and thus what its potential is for damage, injury and death, with industry, which have been overlooked by aviation safety, because by default a Quality commensurate loss of public confidence. many, or quite deliberately ignored. I believe System designed to assure Quality and that we stand at the crossroads with vast In a manufacturing scenario loss through a Safety is already the basis of safety opportunities for enhanced safety and profit lack of Quality means reprocessing, management. I believe that the basic

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problem is the manner in which the JAR- system for company excellence where QA is and commercial issues which at first glance OPS Quality requirement has been stated. used to produce safety, airworthiness and have no place in an Operations Quality continual business improvement. System. And yet safety issues are quite After all, a Quality System is only a fundamental, starting with stress on the documented business management system The companies which have gone for operating air and ground crews and ending constructed for maximum business minimum QA compliance, the vast majority, with flight time limitation problems, so that effectiveness. General Electric’s own Six have thus imposed a burden on themselves the solution is probably simply one of Sigma QA is exactly that, customised to with none of the potential advantages, while presentation. If we write our operational and what the corporation considers vital for those who have grasped the challenge are maintenance manuals in such a way that customer approval. now visibly pulling away. And even where the NAA regulator can see compliance with meaningful QA is attempted, all too often So let us now take a passing glance at the all QA requirements, there is no reason why senior management simply fails to see QA ISO 9000 Quality Standard. We are looking we should not at the same time make these as a management responsibility which quite simply at a model of a manufacturing a part of a greater company QA initiative. needs daily visible commitment from the top or service delivery which has been made and indeed a cultural change in There are after all few operational issues universally acceptable, and I am well aware management style. without a commercial impact and even of its limitations when misused. We are fewer commercial issues which do not simply making a comparison. The Internal Quality Audit itself, for example, impact directly on Operations and is a powerful tool by which management The ISO 9000 standard model of a business Maintenance. The helicopter operators flying can receive accurate information on organisation has 20 clauses and in the order for oil companies have recognised these anything they want to know, but too often it of 170 actual requirements for a Quality simple truths for years, working operational is viewed as a check that all regulatory delivery, and of course many Quality minded Quality as part of a documented Quality and requirements have been satisfied rather companies go much further than this basic Safety System, usually within an ISO 9000 than a check of overall management model. Of these 20, about 14 are identifiable registration demanded by their employers. requirements. An example of this might be a in JAR-145, and about 7 in JAR-OPS 1 and cabin audit which reports on serviceability, a So it is a matter of commitment and then 3. Both are unacceptable as substitute regulatory requirement, but not on cabin presentation, offering each sub-part of Quality standards (although interestingly cleanliness which is not. company QA to the respective regulator, all JAR-21 is acceptable). Roughly speaking working within an overall Quality System, these are the requirements for management, (The Wootton report, investigating the designed to deliver everything that the process control, internal auditing and Quality Control incident where a Boeing 737 company is trying to do with maximum corrective action, with elements of landed after 10 minutes flight with no engine proactivity and minimum loss. And of purchasing, document & record control and oil remaining, made the recommendation course a number of different regulators may little else. But it is not even that good. that there should be compulsory Quality be involved, with security, health and safety, Management training for senior managers, Corrective action is not required to eliminate company law and the environment all now accepted by the UK CAA.) root cause, the handling ‘non-compliance’ making individual demands on a hard receives almost no direction and Quality should be a consensual method by pressed management, not to mention ‘preventative action’ is arguably just touched which the entire company is involved in specialist medical, veterinary and other on. And yet the purpose of QA, enshrined in management strategy, carefully devolved exceptional needs. ISO, is always to be preventative and where through a Quality System where everyone We have not so far mentioned the role of the things do go wrong, to eliminate the root knows what to do and is doing exactly what airline or maintenance sub-contractor. It is a cause quickly and totally. management wants of them. rule of life that what we purchase we pass JAR-OPS go on to compound the problem I believe that the solution initially lies in on in the final product, which has always by splitting its minimal QA requirements management understanding of what is been recognised by maintenance. In from its requirements of management which being asked of them, of careful definition of operations our frequent dependence on are as ever comprehensive and demanding, the issues which drive their company sub-contractors is now making a significant but these almost entirely form the conditions business, and then of formulating the impact. JAR-OPS 1 and 3 actually remind us for holding an AOC. The result is the current policies necessary to give full concentration that the final product is correctly and wisdom that “Quality is reactive and nothing on each of the areas of critical concern and invariably the responsibility of the operator, to do with Safety”. “Trust us, we’re the Safety the procedures necessary to achieve a nowhere more so than in ground operations. experts” and so on. And regrettably too Quality product. In the past, however, we have put total faith many regulators agree, only wanting to see An example of this is perhaps that of on- in the Standard Ground Handling the documented minimum rather than a time departures, a mixture of operational Agreement, based on the IATA AHM 810,

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putting matters to right well after something by company QA and a culture which should minimum acceptable QA we saddle a has gone wrong, and as we all know to our be designed to support flight safety monster. If we choose the harder road, as cost, this can range from very expensive proactively. Quality, like safety, must become other industries already have, the combined aircraft damage to the occasional fatality. everyone’s concern, so that when we talk rewards in terms of business and safety safety then Quality and Safety have to be one excellence are immeasurable. Increasingly as the operator is forced to and the same. Increasingly as we move demonstrate a minimum degree of QA The Quality Choice. towards a Safety Management System, and compliance, auditing has become the only risk auditing becomes the order of the day, recognised tool in the Quality box for then the management aims inevitably merge. checking on a sub-contractor’s Alan Munro flew for 40 years, serving as an performance, while it is not actually the Beyond our first steps into QA is the road to RAF pilot and FSO, instructing for many years specific JAR-OPS requirement. The result is Total Quality; the often misquoted TQM, in GA, flying commercially as an A320 Captain severe over-auditing and a heavy drain on always in the distance but just out of sight; and working as an airline safety officer. operator and sub-contractor resources for the land of brilliant management, happy He now runs Airstaff Associates, an airline which the official solution is now audit customers, sub-contractors working as Quality & Safety consultancy and training pooling and horse trading of audit results, business partners, delighted shareholders, organisation in the United Kingdom on the vague assumption that all operator harmony with the environment, contented specialising in airline QA, (www.airstaff.co.uk), requirements are identical. workers and delighted regulators, where and is Director of the UK arm of AviaQ, an safety and airworthiness are absolute. An It has all been tried before. As a result, the aviation auditing company (www.aviaq.com). impossibility? I don’t think so. In fact a TQM motor industry developed QS 9000, a Quality approach could even become essential for The views expressed in this paper are his own super-standard where all the specific needs future survival as a more discerning public and do not necessarily reflect the policies or of car manufacturers are independently and regulator increasingly demand it. views of GE Capital Aviation Services. audited periodically by a specialist company, with a resulting accreditation being In the JAAs I think that we have arrived at a internationally acceptable. And of course at cross-roads, where if we choose to do the the end of the road this will hopefully one day become the norm for our own industry. Others have already followed, for example Airstaff Associates the AS 9000 standard for Aerospace, but we in association with seem to be at least 20 years behind in our Nigel Bauer & Associates own approach. QUALITY MANAGEMENT FOR OPERATORS * Long before then, there are many other JAR-OPS Quality Systems, documentation & auditing Quality tools for the control of the sub- 5 days - ARN - 28 Aug, LGW - 18 Sep, 20 Nov, 22 Jan contractor, starting with performance SAFETY MANAGEMENT SYSTEMS evaluation on Quality grounds. All the advice SMS course for air & ground operators 2 days - LGW - 18 Oct needed is in the ISO 9000 standard which is AUDITING IN AN OPERATIONAL ENVIRONMENT * in fact the only Quality check list in existence. Air & ground operations auditing 3 days - LGW - 06 Dec Then there is the matter of the airline which AUDIT IMPROVEMENT WORKSHOP undergoes rapid expansion in size, fleets, Experience sharing & improvement of audit process 2 days - LGW - 16 Oct bases, personnel and so on, where a highly QUALITY FOR SENIOR MANAGEMENT motivated close knit body working together NEW FOR 2000 - JAR Quality Management 2 days - ‘in-company’ only becomes increasingly dysfunctional through lack of planning, resource and solid * Incorporating Nigel Bauer & Associates IRCA certificated Internal Auditor Training course sensible communication; otherwise known as a documented Quality System. For further details including In-Company courses and consultancy services please contact: The Quality Manager is not, however, a Airstaff Associates: Tel +44 (0) 1780 721223 e-mail: [email protected] substitute flight safety officer (FSO), and Fax +44 (0) 1780 720032 www.airstaff.co.uk indeed the QM’s role described in JARs is really that of an Audit Manager. The FSO will Nigel Bauer & Associates: Tel +44 (0) 1243 778121 e-mail: [email protected] always remain the safety champion, Fax +44 (0) 1243 789121 www.nb-a.demon.co.uk frequently acting intuitively but now backed

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Leading The Way Towards Safer Flying by Dave Wright

By using information from every flight UK As part of this process, on the 28th June, number of operators shared recent operators show the world how to improve a second very successful OFDM lessons learnt with the audience and this flight safety. The pioneering 1970’s co- workshop was held at the Gatwick Europa highlighted the potential benefits of a operative research project of SRG and Hotel. One hundred people attended this Web based OFDM user group that was British Airways has become an important workshop that was aimed at assisting UK proposed earlier in the day. A wide tool to help improve safety in the new operators implement the pro-active range of issues were raised that will be millennium. analysis of FDR data to improve safety. followed up by both industry and SRG. w The eighteen UK and five Foreign w operators (plus twenty other organisations) learnt from advanced Comments received after the event By routinely running flight data recorder users such as British Airways, British included..... information through analysis programs Midland and Bristow Helicopters; operators are able to detect departures watched technical presentations on Quick “found the event thoroughly stimulating from standard operating procedures or Access Recorders (QARs) for regional and it gave us renewed confidence to find unusual situations that may have safety aircraft from BAES and SAGEM; listened so many other operators at the same implications. Once detected, these are intently to a presentation on legal aspects stage as ourselves” ..... w assessed and, where necessary, remedial by CAA’s Legal Adviser’s Office; and saw action is taken. This may involve demonstrations by a number of leading “It was good to see such a healthy changes in procedures, technical action software and hardware companies. dialogue between the operators and the or crew education and retraining. This regulator” process is known in the UK as Operational Flight Data Monitoring “we need a forum where we can (OFDM). The workshop was organised by SRG’s exchange views, information and lessons Safety Analysis Unit assisted by Flight learnt, and a means for the Regulator to Operations Policy and International update operators” Services. SRG have been instrumental in encouraging and advising operators in w this area and today over sixty percent of Contact Dave Wright at W all UK jet airliners are monitored by such Discussions were opened into [email protected] programs and this proportion is growing international developments, legal issues, rapidly. organisational methods and operational experience. In the latter session a

A

w

w

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One-Size-Fits-All Maintenance Problem

In the past year several incidents have absolutely no indication on the takeoff roll covered with grease. Unless been reported to ASRS in which Boeing that the wheel had failed. In fact, when maintenance technicians take time to 737-100 and –200 wheel bearings were the errant wheel was located, it too was verify the B737 part numbers, the wrong incorrectly installed on the series –300 intact and even still inflated. bearing may be installed on the wheel. aircraft. Now here’s a Captain’s report that describes the installation of a B-757 The B737-300 wheel apparently will From the NASA Aviation Safety wheel bearing on a B737-300 wheel – accept B737-100, 200 and B757 bearings Reporting System CALLBACK. with potentially catastrophic results: and look like a correct installation. The underlying problem is that part numbers Shortly after departure from Runway 34L are on the bearing race are normally the Tower controller informed us we had lost a wheel on the takeoff. In a very short period of time we were told we had They Were Just Little Problems – Nothing Major lost either the right outboard main gear The investigator was carefully picking problems?” the investigator asked. wheel, the right inboard main gear wheel, over the pieces of what had once been a or even both right main gear wheels. I “Lots of little ones; none of them seemed well-designed and well-constructed elected to stay in the local area and to be really enough to cause us to aircraft. Little remained that looked reduce fuel to an acceptable level complain. The only one that scared me worthwhile. There was no obvious reason (weight) for landing. The B737-300 does was the time the electric’s all went off, but for the crash, and the detective work was not have fuel dumping capabilities. they came back on again almost going to take some effort. That’s what he immediately. In fact, they came back on got paid for, he mused. before I had time to do anything about Since I did not know the integrity or even A bystander at the perimeter of the roped- the problem.” existence of the remaining wheel on the off area had been standing there quietly right side, I wanted to reduce the aircraft “Had this happened to anyone else that for some time, and the investigator noted weight as much as possible for landing. you know of on this aircraft?” the a reasonably relaxed, but slightly nervous, We held outside the [airport] area for two inspector asked, doing his best to keep air – not your normal gawker. hours. I realized that if we held for an his voice calm and level. extended period, we would be making an When the investigator left the crash site “Never mentioned it to anyone else, and emergency landing, and quite possibly a for a moment, the bystander approached they didn’t say anything to me either. passenger evacuation after sunset. With him, not anxiously but with a purpose. Well, glad if any of this helped,” he said, this consideration, I held until the time we then he turned and walked away. could make a low pass, get a visual After a few pleasantries, the bystander shuffled slightly and said “I don’t know inspection from the Tower and return for The investigator shook his head. The how to put this, whether I should say landing just prior to sunset. accident happened at night in poor anything or not, or if it might help. I don’t weather to a pilot brand new to the want to be named or held responsible for operation and this aircraft. The low pass was conducted and the anything.” ATC personnel, as well as company mechanic, reported the right outboard Assured that anything might help in the wheel was intact, the inboard was crash and that there was no danger of Reproduced from Aviation Safety missing. After the visual inspection, we getting in trouble, the bystander relaxed Vortex. returned for landing…..The approach and slightly and continued. landing were uneventful…The aircraft was “I flew this aircraft a lot, you know, over towed to the maintenance hangar where it the last few years, and it had some was discovered that the main wheel peculiar habits. Everyone just put it down bearing on the right inboard wheel had The least experienced press on while to being different, and no one ever failed. The wheel departed the airplane, the more experienced turn back to join formally wrote it up – we all knew about leaving the axle and the brake assembly the most experienced, who never left the problems.” “Oh? What sort of intact on the landing gear…There was the ground in the first place.

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Members of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

Full members British Airways GAPAN Capt. Chris Tiffin Capt. Chris Hodgkinson Chairman Aer Lingus British European Airways GATCO Capt. Tom Croke Stuart McKie-Smith Richard Dawson

Vice-Chairman British Mediterranean GB Airways Airclaims Capt. Peter Chinneck Capt. Mike Smith John Dunne British Midland Gill Airways Treasurer Capt. Mel Grievson Capt. Ben Hastings CAA Tony Ingham British Midland Commuter GO FLY Ltd Capt. Steve Saint Capt. Michael Orr Communications Officer RAeS British Regional Airlines HeavyLift Cargo Peter Richards Capt. Ed Pooley Capt. Mike Jenvey

Aerostructures Hamble British World Airlines Irish Aviation Authority Dr. Marvin Curtis Capt. Shireen McVicker Capt. Bob Tweedy

Airtours International Brymon Airways JMC Airlines Capt. Tim Cheal Capt. Martin Jezard Capt. Graham Clarke

Air Contractors CAA KLM uk Capt. Tony Barrett-Jolley Chrys Hadjiantonis - Safety Data Dept Peter Walton Keith Wilson - Intl . Services Air Foyle Brian Synnott - Flight Ops. Libyan Arab Airlines Capt. Chris Fox Eng.Mahmud Ali Tekali CargoLux Air Mauritius Capt. David Martin Lloyds Aviation Roy Lomas Martin Matthews Cathay Pacific Air Seychelles Capt. David Mawdsley Maersk Air Capt.Alasdair Liddle Capt. Robin Evans Channel Express Air Transport Avionics Rob Trayhurn Manchester Airport Plc Colin Buck Peter Hampson City Flyer Express Air 2000 Capt. Andy Walker Manston Airport Capt. Martin Pitt Wally Walker CityJet ALAE Capt. Sean Burke-Daly MoD John Sawyer Gp. Capt. Bill Cope - RAF Delta Airlines Cdr. D.J. Lilley - RN BAA plc Evan Parsons Sqn Ldr Jeff Collier - HQSTC Francis Richards EasyJet Monarch Airlines BAC Express Capt. John Broomfield Capt. Gavin Rowden Capt. David Smith Emerald Airways NATS BALPA Capt. Roley Bevan Paul Jones Carolyn Evans EVA Airways PrivatAir Bristow Helicopters Alex Reid Capt.Francisco Agullo Capt. Derek Whatling Ford Air Ryanair Britannia Airways Capt. John Sarris Capt. Gerry Conway Peter Naz GAB Robins Aviation Sabre Airways British Aerospace Reg. A/C Rob Burge Peter Kelly Dan Gurney

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SBAC City Flyer Express Co-opted advisers Peter Holtby - Secretariat John Park Bryan Cowin - BAE SYSTEMS AAIB Vic Lockwood -FR Aviation Ford Motor Co. Richard Whidborne Stuart Yeomans Scotia Helicopters CHIRP Capt. Jide Adebayo GB Airways Peter Tait Terry Scott Servisair GASCo Eric Nobbs Gill Aviation John Campbell Warren Storey Shell Aircraft Legal Adviser Cliff Edwards MOD EIFS RAF Peter Martin Wg.Cdr.Dave McCormick The Boeing Co. Royal Met. Society Edward Berthiaume RAeS Dr.John Stewart Jack Carter TRW Aeronautical Systems Keith Joyner Scotia Helicopters Ian Davies TransAer Capt. Mick O’Connor TransAer Noel Madigan Virgin Atlantic Airways Capt.Jason Holt

Willis Aerospace Ian Crowe FOCUS Subscription Application Group members UK Flight Safety Committee Eurocypria Airlines The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey. GU 24 8HX Cyprus Airways Tel: 01276-855193 Fax: 855195 Capt. Nick Kotsapas email: [email protected]

FLS Aerospace (Ireland) Name FLS (UK) Frank Buggie Job Title

Lufthansa Cargo Lufthansa AG Company Name Lufthansa Cityline Condor Address Condor Berlin Capt. Nigel Ironside

Maintenance members Tel/Fax No

Britannia Airways email Peter Pope

British Airways Nature of Business Colin Evered Please enter my subscription to FOCUS from the next issue. I enclose a sterling cheque made payable to Flight Safety Committee British European Technical Services or invoice me for the annual Subscription Rate of £12.00 for 4 issues. Chris Clark Plus P & P £2.60 for UK - overseas P & P on application.

British Midland Airways Signature Peter Horner

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Legal Adviser’s Column

Is Turning The Lights Down Low At Night A Safe Procedure? by Peter Martin

Decisions of the US Courts of Appeals compensation! To have made good her crew to retreat to the galley for a few interpreting the Warsaw Convention do claim she would have to demonstrate that hours of rest and recreation of their own. not bind the English courts but can be of the assault was an “accident” for the If liberty comes only at the price of eternal persuasive authority in cases where the purposes of the Warsaw Convention vigilance, so also does freedom from English courts have not yet themselves since, without there being an accident sexual assault in today’s libertine world. considered a particular issue. For this there can be no claim. In an earlier case Airlines must be even more watchful, not reason, an unusual case decided recently the court had reasoned that sexual least if alcohol may also be a factor. by the Second Circuit (New York) Court of assault was not “a risk characteristic of air Appeals is of particular interest to airlines. travel” and therefore did not constitute an “accident” as that term is generally 1Wallace v Korean Air 27 Avi 17, 869 understood. On this basis, KAL successfully denied the claim in the Two male passengers sat between a Miss District Court, the Federal court of first Wallace and the aisle on a Korean Airlines instance, and Miss Wallace appealed. night flight from Seoul to Los Angeles on 17 August 1997. It being the middle of summer, Miss Wallace wore a Tee shirt 1 and jean shorts with a belt. Initially the The Court of Appeals held that the flight passed uneventfully and Miss characteristics of air travel increased Miss Wallace fell asleep in the darkened Wallace’s vulnerability to Mr Park’s aircraft after finishing her meal. She had assault. She was cramped into a confined no conversation with her neighbours and, space beside two strange men, one of in particular, a Mr Park who sat beside whom turned out to be a sexual predator. her. About three hours into the flight, Miss The lights were turned down and the Wallace awoke to find that Mr Park had predator was left unsupervised. Mr Park’s unbuckled her belt, unzipped and behaviour was not a five-second unbuttoned her shorts and had placed his operation, and could not have been hands into her knickers to fondle her. entirely inconspicuous. Yet, not a single Miss Wallace awoke with a start, turned flight attendant noticed what was her body towards the window causing Mr happening. What is more, when Miss Park to withdraw his hands. When Mr Wallace awoke, she could not get away at Park resumed his unwelcome attentions, once but had to endure a renewed Miss Wallace recovered from her shock assault before clambering to safety in the and hit him hard. She then climbed out of aisle. The event was, therefore, an her seat, jumped over the sleeping man accident, namely, “ an unexpected or in the aisle seat and made good her unusual event or happening external to escape. the passenger.” As such it gave rise to a legitimate claim against the airline which could not escape liability for it. The case was remitted to the District Court where, After reporting the matter to a flight no doubt, it will be or has been settled on attendant who allocated her another seat, payment of agreed compensation as it Miss Wallace reported also to the police seems most unlikely KAL would risk a full on arrival. Mr Park was arrested and trial and a jury award of damages in a pleaded guilty to a charge of engaging in case of this kind. unwelcome sexual conduct, an offence in the US, in the Federal District court in Los Angeles. Subsequently, Miss Wallace sued KAL alleging sexual assault not by Lessons for airlines? It is no longer a safe the airline but on board its aircraft and, procedure for airlines to turn the lights therefore, its responsibility in terms of down low on night flights and for cabin

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UNITED KINGDOM FLIGHT SAFETY COMMITTEE SEMINAR 2000

AVIATION AT RISK

3rd OCTOBER 2000

RENAISSANCE LONDON HEATHROW HOTEL, LONDON

SEMINAR OBJECTIVE Safe Flight is based on a knowledge and control of a wide variety of competing areas of Risk. This Seminar will provide management with robust tools and strategies to enable them to increase their knowledge and control. PROGRAMME MONDAY 2nd OCTOBER 2000

1530 - 1830 Registration 2000hrs Seminar Dinner This will take place in the Hotel Foyer Sponsored by Willis After Dinner Speaker - Rt Hon Lord Trefgarne, PC

TUESDAY 3rd OCTOBER 2000

0730 - 0845 Registration

Session Chairman - Ed Paintin UKFSC 1130 - 1200 Airport Influence on Flight Safety Risk Factors 0900 - 0910 Opening Remarks Paul Fox - BAA - Capt.Tom Croke Chairman UKFSC 1200 - 1245 DISCUSSION

0910 - 0920 Keynote Speech 1245 - 1400 Lunch Gwyneth Dunwoody MP 1400 - 1430 Managing Safety Management 0920 - 0940 Disaster Vs Risk Mike Overall Jacques Berghmans - DuPont 1430 - 1500 Risk Management & Regulation 0940-1000 Regulatory Style Richie Profit - UK CAA Clive Norris - HSE 1500 - 1530 Corporate Killing 1000 - 1030 Failures & Shortcomings of Peter Martin Current Risk Management Matthew Day - Willis 1530 - 1615 DISCUSSION

1030 - 1100 Refreshment Break 1615 Closing Remarks Chairman UKFSC 1100 - 1130 Risk Management in Relation to NATS Business Plan Euan Black - NATS

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AVIATION AT RISK SEMINAR INFORMATION

• Hotel Accommodation Hotel Accommodation is not included in the Seminar Registration Fee. A rate of £104 (room only) has been negotiated with the Renaissance Hotel. If you require a hotel booking form, please request one.

• Seminar Dinner Dress for Dinner – Lounge Suits

• Cancellations/Refunds Cancellations received prior to 18th September 2000 will incur a 50% cancellation fee. Refunds after this date will not be given.

If you are unable to attend why not nominate a colleague to take your place. If so, please advise the UKFSC Fairoaks office of any changes prior to the Seminar. ✂ SEMINAR REGISTRATION FORM

Please complete one registration form per person (photocopies accepted).

REGISTRATION INFORMATION (Please print clearly)

First Name: Surname:

Company: Job Title:

Address:

Tel No: Fax No: e-mail:

PAYMENT INFORMATION

Seminar Fee: £100 UKFSC Member £150 Non-Member

This includes Dinner on the evening 2nd October, lunch, refreshments and car parking. This does not include hotel accommodation – please see above Seminar Information.

Payment is by sterling cheque only. No credit cards are accepted. Bank transfer is available, details on request (please note an additional cost of £6 will be added to cover handling charges). The UKFSC is not VAT Registered.

Sterling cheques should be made payable to UK Flight Safety Committee.

• Do you plan to attend the Seminar Dinner on Monday 2nd October? Yes No • Do you require a Vegetarian alternative? Yes No

PLEASE SEND YOUR COMPLETED REGISTRATION FORM WITH YOUR CHEQUE TO:

UK Flight Safety Committee, Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey, GU24 8HX. Tel No: 01276 855193 Fax No: 01276 855195 e-mail: [email protected] Confirmation of your registration will be faxed to you on receipt of your Registration Form and payment.

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