The Challenge of Balancing Safety, the Law, and the Public Interest

Transcription

1 The Challenge of Balancing Safety, the Law, and the Public Interest Jim Burin Director of Technical Programs Flight Safety Foundation ASPA/ICAO 27 Mexico City

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

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

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

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6 The Fleet - 26 Type Western Built Eastern Built Total Turbojets 17,69 1,839 19,548 Turboprops 4,774 1,71 6,484 Business Jets 12,724

7 Major Accidents Business Jets 1 January to 31 December 26 Date Operator Aircraft Location Phase Fatal 2 January Avcom Hawker 7 Kharkov, Ukraine Approach 3 24 January Goship Air Citation V Carlsbad, CA, USA Landing 4 15 February Jet 2 Falcon 2 Kiel, Germany Landing 16 February Lech Air Citation I Busckin, Iraq Descent 6 2 June International Jet Charter Lear 35 Groton, CT, USA Approach 2 26 June Great Ideas Corp Hawker F3 Barcelona, Venezuela Landing 5 July Vigojet Saberliner Mexico City, Mexico Landing 19 July Tomco II Citation Encore Cresco, IA, USA Landing 2 28 August Netjets Hawker 8 Carson City, NV, USA Descent 3 December Fact Air Saberliner Culiacan, Mexico Approach 2 Source: Ascend

8 Hawaii - 27 Sept Navajo - 1 Fatalities CFIT - Touring Part 135

9 Major Accidents Commercial Turboprops (> 14 seats) 1 January to 31 December 26 Date Operator Aircraft Location Phase Fatal 2 January Ruenzori Airways Antonov 26 Fataki, DR Congo Climb 24 January Aerolift Antonov 12 Mbuji Mayi, DR Congo Landing 5 February Air Cargo Carriers Shorts 36 Watertown, WI, USA Enroute 3 8 February Tri Costal Air Metro II Paris, TN, USA Enroute 1 11 March Air Deccan ATR 72 Bangalore, India Landing 18 March Ameriflight Beech 99 Butte, MT, USA Enroute 2 28 March Phoenix Avia Antonov 12 Payam, UAE Climb 31 March TEAM Let 41 Saquarema, Brazil Enroute April TAM Fokker-27 Guayaramerin, Bolivia Landing 1 24 April Air Million Cargo Antonov 32 Lashkar, Afghanistan Landing 2 27 April LAC Skycongo Convair 58 Amisi, DR Congo Landing 8 23 May Air Sao Tome DHC-6 Twin Otter San Tome, Africa Approach 4 5 June Merpati Nusantara CASA 212 Bandanaira, Indonesia Landing 21 June Yeti Airlines DHC-6 Jumla, Nepal Approach 9 7 July Mango Airlines Antonov 12 Goma, DR Congo Climb 6 1 July PIA Fokker 27 Multan, Pakistan Takeoff July Source: Ascend TransAfrik Lockheed Hercules Kigoma, Tanzania Approach

10 Major Accidents Commercial Turboprops (> 14 seats) 1 January to 31 December 26 Con t Date Operator Aircraft Location Phase Fatal 29 July Adventure Aviation DHC-6 Sullivan, MO, USA Takeoff 6 3 August Tracep AN-28 Bukavu, DR Congo Approach 17 4 August AirNow EMB-11 Bennington, VT, USA Approach 1 13 August Air Algerie Lockheed Hercules Piacenza, Italy Enroute 3 28 August Paraguay Air Service Nomad 22B Cerrillos, Argentina Enroute 17 November Trigana Air Service DHC-6 Puncak Jaya, Inodnesia Enroute 12 3 December Sky Relief DHC-5 Nairobi, Kenya Takeoff Source: Ascend

11 Major Accidents Commercial Jets 1 January to 31 December 26 Date Operator Aircraft Location Phase Fatal 8 February UPS DC-8F Philadelphia, USA Enroute 3 May Armavia A-32 Alder-Sochi, Russia Approach July S7 Airlines A-31 Irkutsk, Russia Landing August Pulkovo Aviation TU-154 Nr. Donetsk, Ukraine Enroute August Comair CRJ-1 Lexington, KY, USA Takeoff 49 1 September Iran Air Tours TU-154 Mashhad, Iran Landing September GOL B-737 Sao Felix, Brazil Enroute October Mandala Airlines B-737 Tarakan, Indonesia Landing 1 October Atlantic Airways BAE-146 Stord-Sorstokken, Norway Landing 4 29 October ADC Airlines B-737 Abuja, Nigeria Takeoff November Aerosucre Colombia B-727 Bogota, Colombia Approach 5 Source: Ascend

12 Major Accident Rate Western-Built Commercial Jets Accident rate per million departures** Major Accident Rate (per million departures) 5 year running average Source: Ascend

13 Major Accident Rate Western-Built Commercial Jets Accident rate per million departures** Major Accident Rate (per million departures) 5 year running average Accidents Prevented Source: Ascend

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15 Safety Efforts are Data Driven Departures (Millions)/Rate Per Million ,396 2,228 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 CFITLoss In-flight of Sabotagecollision Midair Hijack Ice/ LandingWind FuelOtherRunway RTO control fire in flight snow shear exhaus- tion incursion Accidents Accident Date Location Aircraft Accident Description Portion Intervention Name Class Type of EGPWS CFIT TRN Description Accident Portion of World Fle Eliminated.6.9 Intervention Effecti CFIT 1/2/1988 IZMIR, TURKEY 737 HIT MOUNTAIN ON APPROACH CFIT 2/8/1988 LUANDA, ANGOLA 77 HIT ANTENNA ON APPROACH CFIT 2/27/1988 KYRENIA MTS, CYPR 727 HIT MOUNTAIN ON APPROACH CFIT 3/17/1988 CUCUTA, COLUMBIA 727 HIT MOUNTAIN DURING CLIMB CFIT 6/12/1988 POSADAS, ARGENTIN MD8 CRASHED ON FINAL APPROACH CFIT 7/21/1988 LAGOS, NIGERIA 77 CRASHED ON APPROACH CFIT 1/17/1988 ROME, ITALY 77 LANDED SHORT CFIT 1/19/1988 AHMEDABAD, INDIA 737 LANDED SHORT CFIT 2/8/1989 SANTA MARIA AZORE 77 TERRAIN IMPACT/DESCENT CFIT 2/19/1989 KUALA LUMPUR, MAL 747 TERRAIN IMPACT/APPROACH CFIT 6/7/1989 PARAMARIBO, SURIN DC8 TERRAIN IMPACT/FINAL APPRO CFIT 7/27/1989 TRIPOLI, LIBYA DC1 TERRAIN IMPACT/FINAL APPRO CFIT 8/25/1989 ANKARA, TURKEY 727 HIT ILS ANT. ON TAKEOFF... CFIT 1/21/1989 TEGUCIGALPA, HOND 727 TERRAIN IMPACT/APPROACH CFIT 1/26/1989 HUALIEN, TAIWAN 737 TERRAIN IMPACT/DEPARTURE CFIT 2/14/199 BANGALORE, INDIA A32 HIT SHORT (3 FT) CFIT 6/2/199 UNALAKLEET, ALASK 737 HIT HILL 7 MILES OUT IN FO CFIT 11/14/199 ZURICH, SWITZERLA DC9 CRASHED 5 MILES SHORT CFIT 12/4/199 NAIROBI, KENYA 77 HIT POWER LINE ON ILS FINA CFIT 3/5/1991 MT LA AGUADA, VEN DC9 HIT MOUNTAIN/APPROACH CFIT 8/16/1991 IMPHAL, INDIA 737 A/C HIT HILL 2 MILES OUT/ CFIT 1/2/1992 STRASBOURG, FRANC A32 IMPACTED GROUND/FINAL APP CFIT 2/15/1992 KANO, NIGERIA DC8 CFIT OUT OF PROCEDURE TRN CFIT 3/24/1992 ATHENS, GREECE 77 ABANDONED APPROACH-HIT MTN CFIT 6/22/1992 CRUZEIRO DO SUL, 737 HIT SHORT,DRK NT,DISTRACTE CFIT 7/31/1992 KATMANDU, NEPAL A31 CFIT-HIT MTN-MISSED APPROA CFIT 9/28/1992 KATMANDU, NEPAL A3 CRASHED SHORT DURING APPRO CFIT 11/25/1992 KANO, NIGERIA 77 LANDED SHORT MISLEADING LI CFIT 11/26/1992 MANAUS, BRAZIL 77 HIT LIGHTS ON TO/RMLG COLL... CFIT 4/26/1993 AURANGABAD, INDIA 737 HIT TRUCK AFTER TAKEOFF...

16 Africa 23 81

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

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20 The Aviation Safety Approach 1. Who made errors? 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 Safety Challenges The greatest enemy of safety is blame. - Dan Maurino

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 Significant challenges exist in some countries - Legal systems - Cultures First Step - Protection of the Sources of Safety Information is required

24 24 Situation Accident/incident investigation records - Protected somewhat by ICAO provisions - Protected by few domestic legislations Voluntary reporting systems & FDA programs - Not explicitly protected by ICAO provisions - Protected by few domestic legislations 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 Examples of Success * New Zealand CVR Case/Law * Canada Protection Actions * EU Council Directive * US FAR Part 193 * Denmark National Law

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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 26 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, 26 mid-air collision between an Embraer Legacy 6 executive jet and a Gol Linhas Aéreas Intelligentes B have opened a criminal investigation.. b the French Supreme Court on September 2, 26 rejected a request to dismiss charges in the July 2 Air France Concorde crash.. c. a French court is expected to issue its verdict soon in the 1992 Air-Inter crash..

34 e. the Swiss Federal Prosecutor s Office has an ongoing criminal investigation for negligent manslaughter of the former chief executive of Swiss International Airlines f. an Italian court on July 7, 26 affirmed the convictions for manslaughter of five aviation officials g. an ongoing Greek quasi-judicial investigation exists of the 25 Helios B crash near Athens.. h. U.S. federal and Florida state prosecutors brought criminal charges, including 22 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, 26

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

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41 Hull Loss Accidents Western Built Commercial Jets (>6, lbs) 196 thru 25 Hull Loss Rate in losses per million departures 's 7's 8's 9's 2's Source: Boeing, AvSoft

42 Hull Loss Accidents Western Built Commercial Jets (>6, lbs) 196 thru 25 Hull Loss Rate in losses per million departures Lives Saved!! 6's 7's 8's 9's 2's Source: Boeing, AvSoft

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