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Jim Burin Director of Technical Programs Flight Safety Foundation ASPA/ICAO 2007 Mexico City ASPA/ICAO 2007 Mexico City The Challenge of Balancing Safety,

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Presentation on theme: "Jim Burin Director of Technical Programs Flight Safety Foundation ASPA/ICAO 2007 Mexico City ASPA/ICAO 2007 Mexico City The Challenge of Balancing Safety,"— Presentation transcript:

1 Jim Burin Director of Technical Programs Flight Safety Foundation ASPA/ICAO 2007 Mexico City ASPA/ICAO 2007 Mexico City The Challenge of Balancing Safety, the Law, and the Public Interest

2 What is the Flight Safety Foundation ? Non-Profit International Founded in 1947 by Aviation Industry Independent

3 FSF Goal: Make Aviation Safer by Reducing the Risk of an Accident

4 Two Important Aspects of Safety and the Law - Protection of the sources of Safety Information Criminalization of Safety

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6 The Fleet Type Western Built Eastern Built Total Turbojets 17,609 1,839 19,548 Turboprops 4,774 1,710 6,484 Business Jets 12,724

7 Major Accidents Business Jets 1 January to 31 December 2006 DateOperatorAircraftLocationPhaseFatal 2 JanuaryAvcomHawker 700Kharkov, UkraineApproach 3 24 JanuaryGoship AirCitation VCarlsbad, CA, USALanding 4 15 FebruaryJet 2000Falcon 20Kiel, GermanyLanding 0 16 FebruaryLech AirCitation IBusckin, IraqDescent 6 2 June International Jet Charter Lear 35Groton, CT, USAApproach 2 26 JuneGreat Ideas Corp Hawker F3 Barcelona, VenezuelaLanding 0 5 JulyVigojet Saberliner Mexico City, MexicoLanding 0 19 JulyTomco II Citation Encore Cresco, IA, USALanding 2 28 AugustNetjets Hawker 800 Carson City, NV, USADescent 0 30 DecemberFact Air Saberliner Culiacan, MexicoApproach 2 Source: Ascend

8 CFIT - Touring Part 135 Hawaii - 27 Sept Navajo - 10 Fatalities

9 Major Accidents Commercial Turboprops (> 14 seats) 1 January to 31 December 2006 Source: Ascend DateOperatorAircraftLocationPhaseFatal 2 JanuaryRuenzori AirwaysAntonov 26Fataki, DR CongoClimb 0 24 JanuaryAeroliftAntonov 12 Mbuji Mayi, DR Congo Landing 0 5 FebruaryAir Cargo CarriersShorts 360Watertown, WI, USAEnroute 3 8 FebruaryTri Costal AirMetro IIParis, TN, USAEnroute 1 11 MarchAir DeccanATR 72Bangalore, IndiaLanding 0 18 MarchAmeriflightBeech 99Butte, MT, USAEnroute 2 28 MarchPhoenix AviaAntonov 12Payam, UAEClimb 0 31 MarchTEAMLet 410Saquarema, BrazilEnroute AprilTAMFokker-27 Guayaramerin, Bolivia Landing 1 24 AprilAir Million CargoAntonov 32Lashkar, AfghanistanLanding 2 27 AprilLAC SkycongoConvair 580Amisi, DR CongoLanding 8 23 MayAir Sao TomeDHC-6 Twin OtterSan Tome, AfricaApproach 4 5 JuneMerpati NusantaraCASA 212 Bandanaira, Indonesia Landing 0 21 JuneYeti AirlinesDHC-6Jumla, NepalApproach 9 7 JulyMango AirlinesAntonov 12Goma, DR CongoClimb 6 10 JulyPIAFokker 27Multan, PakistanTakeoff JulyTransAfrikLockheed HerculesKigoma, TanzaniaApproach 0

10 Major Accidents Commercial Turboprops (> 14 seats) 1 January to 31 December 2006 Cont DateOperatorAircraftLocationPhaseFatal 29 JulyAdventure AviationDHC-6Sullivan, MO, USATakeoff 6 3 AugustTracepAN-28Bukavu, DR CongoApproach 17 4 AugustAirNowEMB-110Bennington, VT, USAApproach 1 13 AugustAir Algerie Lockheed Hercules Piacenza, ItalyEnroute 3 28 August Paraguay Air Service Nomad 22BCerrillos, ArgentinaEnroute 0 17 November Trigana Air ServiceDHC-6 Puncak Jaya, Inodnesia Enroute December Sky ReliefDHC-5Nairobi, KenyaTakeoff 0 Source: Ascend

11 Major Accidents Commercial Jets 1 January to 31 December 2006 DateOperatorAircraftLocationPhaseFatal 8 FebruaryUPSDC-8FPhiladelphia, USAEnroute0 3 MayArmaviaA-320Alder-Sochi, RussiaApproach113 9 JulyS7 AirlinesA-310Irkutsk, RussiaLanding AugustPulkovo AviationTU-154Nr. Donetsk, UkraineEnroute AugustComairCRJ-100Lexington, KY, USATakeoff49 1 SeptemberIran Air ToursTU-154Mashhad, IranLanding28 29 SeptemberGOLB-737Sao Felix, BrazilEnroute154 3 OctoberMandala AirlinesB-737Tarakan, IndonesiaLanding0 10 OctoberAtlantic AirwaysBAE-146Stord-Sorstokken, NorwayLanding4 29 OctoberADC AirlinesB-737Abuja, NigeriaTakeoff96 18 NovemberAerosucre ColombiaB-727Bogota, ColombiaApproach5 Source: Ascend

12 Major Accident Rate Western-Built Commercial Jets 1993 – 2006 Accident rate per million departures**

13 Source: Ascend Major Accident Rate Western-Built Commercial Jets 1993 – 2006 Accident rate per million departures** Accidents Prevented

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15 Safety Efforts are Data Driven Departures (Millions)/Rate Per Million Accidents Accidents 1 Traffic Growth 2 Accident Rate 3 1 Based on current accident rate 2 Based on industry estimate 3 Based on current accident rate Total fatalities = 7,484 CFIT = Controlled Flight into Terrain RTO = Rejected takeoff Loss of control in flight CFITIn-flight fire Sabo- tage Midair collision HijackIce/ snow LandingWind shear Fuel exhaus- tion OtherRunway incursion RTO 2,396 2,

16 Africa

17 Incident Data Flight Data Monitoring Non-Punitive Reporting Line Observed Safety Audit Information Driven Cooperative Data Sharing Accident Data

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20 1. Who made errors ? The Aviation Safety Approach 2. Why were the errors made ? 3. How do we prevent the errors from happening again ?

21 Accident Investigation Safety: Annex 13 - The sole objective of the investigation of an accident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability. Legal: The sole objective of legal proceedings is to apportion blame or liability.

22 The greatest enemy of safety is blame. - Dan Maurino Safety Challenges

23 The Basics of Safety an the Law Safety Investigations must be independent - Unhindered by judiciary authorities - Safety Information must be freely available to safety investigators Safety Investigations must be independent - Unhindered by judiciary authorities - Safety Information must be freely available to safety investigators Significant challenges exist in some countries - Legal systems - Cultures Significant challenges exist in some countries - Legal systems - Cultures First Step - Protection of the Sources of Safety Information is required

24 2004 Situation Accident/incident investigation records Accident/incident investigation records - Protected somewhat by ICAO provisions - Protected somewhat by ICAO provisions - Protected by few domestic legislations - Protected by few domestic legislations Voluntary reporting systems & FDA programs - Not explicitly protected by ICAO provisions Voluntary reporting systems & FDA programs - Not explicitly protected by ICAO provisions - Protected by few domestic legislations - Protected by few domestic legislations Inconsistent International Picture Inconsistent International Picture

25 Basic Principles Existing international and national laws were inadequate to protect many sources of safety information No Group or Workforce above the Law Goal: To protect safety information, but not deny the right to prosecute Evidence other than from sources of safety information can be used in prosecuting The public interest requires a balance between the protection of safety information and the availability of evidence in judicial actions

26 Assembly Resolution A35-17 Protecting information from safety data collection systems in order to improve aviation safety The Assembly: 1. Instructs the Council to develop appropriate legal guidance that will assist States to enact national laws and regulations to effectively protect information from safety data collection systems, both mandatory and voluntary, while allowing for the proper administration of justice in the State; 2. Urges all Contracting States to examine their existing legislation and adjust as necessary, or enact laws and regulations to effectively protect information from safety data collection systems based, to the extent possible, on the legal guidance developed by ICAO; and 3. Instructs the Council to provide a progress report to the next ordinary Session of the Assembly on this matter

27 * New Zealand CVR Case/Law Examples of Success * Denmark National Law * Canada Protection Actions * EU Council Directive * US FAR Part 193

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29 New Annex 13 – Appendix E Info …a review by an appropriate authority determines that the release of the safety information is necessary for the proper administration of justice, and that its release outweighs the adverse domestic and international impact such release may have on the future availability of safety information.

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31 Joint Resolution Regarding Criminalization of Aviation Accidents Recognizing the importance in civil aviation accident investigations in securing the free flow of information to determine the cause of accidents and incidents and to prevent future accidents and incidents; Recognizing the actions taken recently by the International Civil Aviation Organization in promoting amendments to Annex 13 – Aircraft Accident and Incident Investigations to the Convention on International Civil Aviation, encouraging Contracting States to adopt by November 2006 certain actions to protect the sources of safety information; Recognizing the importance of preventing the inappropriate use of safety information, including the increasing use of such information in criminal proceedings against operational personnel, managerial officers, and safety regulatory officials;

32 Joint Resolution Regarding Criminalization of Aviation Accidents Recognizing that information given voluntarily by persons interviewed during the course of safety investigations is valuable, and that such information, if used by criminal investigators or prosecutors for the purpose of assessing guilt and punishment, could discourage persons from providing accident information, thereby adversely affecting flight safety; Recognizing that under certain circumstances, including acts of sabotage and willful or particularly egregious reckless conduct, criminal investigations and prosecutions may be appropriate; Concerned with the growing trend to criminalize acts and omissions of parties involved in aviation accidents and incidents;

33 Joint Resolution Regarding Criminalization of Aviation Accidents Noting that: a. law enforcement authorities in the September 29, 2006 mid-air collision between an Embraer Legacy 600 executive jet and a Gol Linhas Aéreas Intelligentes B have opened a criminal investigation….. b the French Supreme Court on September 20, 2006 rejected a request to dismiss charges in the July 2000 Air France Concorde crash……….. c. a French court is expected to issue its verdict soon in the 1992 Air-Inter crash………….. d. Swiss prosecutors in August 2006 charged eight Swiss Skyguide air traffic controllers with negligent homicide…….

34 e. the Swiss Federal Prosecutors Office has an ongoing criminal investigation for negligent manslaughter of the former chief executive of Swiss International Airlines… f. an Italian court on July 7, 2006 affirmed the convictions for manslaughter of five aviation officials……… g. an ongoing Greek quasi-judicial investigation exists of the 2005 Helios B crash near Athens…….. h. U.S. federal and Florida state prosecutors brought criminal charges, including 220 counts of murder and manslaughter, against a maintenance company, several mechanics, and a maintenance manager arising out of the 1996 ValuJet flight 592 crash………… f. Greek prosecutors brought negligent manslaughter, negligent bodily injury, and disrupting the safety of air services charges against the captain and first officer………

35 Joint Resolution Regarding Criminalization of Aviation Accidents Recognizing that the sole purpose of protecting safety information from inappropriate use is to ensure its continued availability to take proper and timely preventative actions and to improve aviation safety; Considering that numerous incentives, including disciplinary, civil, and administrative penalties, already exist to prevent and deter accidents without the threat of criminal sanctions; Being mindful that a predominant risk of criminalization of aviation accidents is the refusal of witnesses to cooperate with investigations, as individuals invoke rights to protect themselves from criminal prosecution, and choose not to freely admit mistakes in the spirit of ICAO Annex 13 for the purpose of preventing recurrence;

36 Joint Resolution Regarding Criminalization of Aviation Accidents Considering that the vast majority of aviation accidents result from inadvertent, and often multiple, human errors; Being convinced that criminal investigations and prosecutions in the wake of aviation accidents can interfere with the efficient and effective investigation of accidents and prevent the timely and accurate determination of probable cause and issuance of recommendations to prevent recurrence;

37 Joint Resolution Regarding Criminalization of Aviation Accidents BE IT THEREFORE RESOLVED, that the below organizations: 1. Declare that the paramount consideration in an aviation accident investigation should be to determine the probable cause of and contributing factors in the accident, not to punish criminally flight crews, maintenance employees, airline or manufacturer management executives, regulatory officials, or air traffic controllers….. 2. Declare that, absent acts of sabotage and willful or particularly egregious reckless misconduct (including misuse of alcohol or substance abuse), criminalization of aviation accidents is not an effective deterrent or in the public interest……………..

38 Joint Resolution Regarding Criminalization of Aviation Accidents 3. Urge States to exercise far greater restraint and adopt stricter guidelines before officials initiate criminal investigations or bring criminal prosecutions in the wake of aviation disasters………. 4. Urge States to safeguard the safety investigation report and probable cause/contributing factor conclusions from premature disclosure………… 5. Urge National aviation and accident investigating authorities to: (i) assert strong control over accident investigations, free from undue interference from law enforcement authorities………….. DATED: October 17, 2006

39 William Voss, President and CEO Flight Safety Foundation Keith Mans, Chief Executive Royal Aeronautical Society Jean-Claude Bück, President Académie Nationale de l Air et de l Espace ___________________________________ Alexander ter Kuile, Secretary General Civil Air Navigation Services Organisation

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41 Hull Loss Rate in losses per million departures Hull Loss Accidents Western Built Commercial Jets (>60,000 lbs) 1960 thru 2005 Source: Boeing, AvSoft

42 Hull Loss Rate in losses per million departures Hull Loss Accidents Western Built Commercial Jets (>60,000 lbs) 1960 thru 2005 Source: Boeing, AvSoft Lives Saved !!

43 Criminalization More Safety Information Less

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45 The Public Interest Safety The Law

46 FSF Goal: Make Aviation Safer by Reducing the Risk of an Accident


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