(Editor’s note: The opinions expressed here are those of the author and not necessarily those of AeroSafety World or of Flight Safety Foundation.)
Europe’s air safety record is among the best in the world, and the industry’s stakeholders have succeeded in achieving a progressive reduction in the accident rate within commercial aviation operations over the past five decades.
Much of this improvement has been achieved through better understanding of human performance characteristics, improved training techniques and training devices, and massive investment in aircraft design, manufacturing and testing techniques. Likewise, substantial advances have been made in aircraft on-board equipment, especially avionics, autopilots and flight management systems.
Investment in ground facilities and satellite systems has improved navigational accuracy and infrastructure reliability and integrity, thereby facilitating better air traffic management and increased declared capacities. While the remainder of this article is about aircraft operations, many of the principles and issues discussed can be applied to other stakeholders in air safety such as air traffic management and airport ground operations.
Furthermore, the constructive parts played by Europe’s regulatory and political authorities deserve recognition. Rationalized and harmonized safety regulations, eventually to become devoid of national variants, have encouraged greater consistency of application. Legislation has given enforcement “teeth” and helped protect the interests of European citizens undertaking air travel worldwide.
However, while these improvements during the past 50 years have brought a reduction in fatalities and aircraft hull losses, there is strong evidence that substantial safety weaknesses remain in the system. The current (and perceived “acceptable”) level of safety overstates the true performance of the industry, and continued improvement is not sustainable in the longer term without further substantial effort.
Significant differences exist within Europe in the interpretation and diligence of application of existing safety regulations by national authorities. Although industry insiders would find it easy to identify countries with high and low standards, under present conditions it is not politically acceptable to do so. Such reticence does little to serve Europe’s citizens and allows substandard oversight to continue.
Poor regulatory oversight does not necessarily result in poor application of safety practices and standards by the aviation operators in the nations concerned. There are numerous instances of airlines maintaining, of their own accord, safety standards beyond those policed by their regulators.
Many regulators are finding it difficult to recruit and retain inspectors with appropriate knowledge and experience; this situation likely will become more difficult during the next decade and needs to be addressed urgently at the national and European Union (EU) level.
EU countries and their airlines generally have made demonstrable improvements in safety regulation and the application of enhanced safety cultures and procedures. The same cannot be said of all other nations, the operators from which share the same airspace, infrastructure and facilities as EU operators both within and outside the EU territories. The implementation of the EU blacklist has been a positive move in this regard, but it has not eliminated the risks faced by EU citizens traveling on EU airlines into or over countries overseen by substandard civil aviation authorities.
One obvious need for further international (and especially European) action involves arguments that are not made easily by Britain and the United States, namely the enforcement of the use of the English language by flight crews and air traffic management and airport personnel. English has been accepted by the International Civil Aviation Organization (ICAO) as the language of aviation, yet in many instances, national languages still are used by air traffic controllers and other ground personnel when communicating with crews of their own nationality.
Such practices can have a detrimental effect on air safety, as demonstrated by the number of accidents/incidents in Europe, even during the past decade, in which failure to use English has been a causal or contributing factor. Pilots operating in airspace where a mixture of English and other languages is used cannot build and maintain a mental picture of the relative positions, intentions and actions of aircraft crews around them. It is time to abandon political correctness and the avoidance of “disturbing the peace” with other nations. Reconciling conflicting national interests in international forums on the ground is infinitely preferable — for all EU air passengers — to collisions in the air!
The reduction in the overall accident rate is a welcome achievement, but it should not be assumed to be an accurate measurement of EU safety. Accidents generally are the result of a combination of factors. The absence of one factor could mean what would have been an accident becomes, at worst, an incident or an even less serious air safety event. Yet any precursors that have an adverse effect on air safety still need to be addressed vigorously within individual operators and also, where appropriate, by regulators.
Lessons Not Learned
The implementation of safety management systems (SMS) may partly address the shortfall in “accident lore,” the accumulation of lessons learned traditionally from accidents, but SMS implementation remains variable throughout the industry. In some cases, there is a risk of creating a negative effect on safety as a result of safety managers becoming overstretched in meeting their regulator’s latest concept of SMS requirements and distracted from other aspects of their work.
It also can be argued that the reduction in the accident rate has had, counterintuitively, an adverse effect on crew safety culture. During the 1960s, it was quite usual for national carriers in Europe to lose one aircraft per year in an accident. Accident awareness within airlines and crews was understandably high. Today, accidents are exceedingly rare and flying tends to be assumed to be inherently safe. Pilots entering the industry today, while arguably better trained than their predecessors, often do not have the same level of accident awareness as did previous generations. Furthermore, if today’s pilots pursue their careers primarily for the lifestyle, status and long-term monetary rewards, misplaced priorities could override the long-prevalent culture of dedication first to air safety.
As noted, the reduction in the accident rate tends to reduce practical insights from “accident lore” in aircraft operations. Lessons learned in past accidents thus are not readily transferred to new generations of pilots, and consequently, past accident types are frequently and tragically repeated.
From what I have seen, no module typically exists within current pilot training requirements that would help to educate new pilots about past accidents and other serious safety occurrences. It would be comparatively easy to create an interactive, web-based training module (based on material within official accident reports and using new-technology graphics) to educate pilots to help prevent them from falling into a “same accident, different location” situation. Recent accidents, for instance Colgan Air Flight 3407, Air France 447 and others, might have been prevented, or at least mitigated, had such training existed.
Sadly, many accidents still occur as a result of, or are influenced by, the operating crew’s failure to adhere to the standard operating procedures (SOPs) developed for the protection of the flight. Time and again, deviations from SOPs lead to a properly trained and qualified crew flying a perfectly serviceable aircraft into an accident situation. While other risk factors have been researched and solutions put in place, it seems that comparatively little research has been undertaken to understand (and prevent) reasons why crews deviate from their company’s SOPs.
Increased reliability and integration of aircraft management and control systems have made a significant contribution toward lowering the accident rate. Perversely, these also have had a negative effect that cannot be ignored, namely a reduction in “hands on” flying experience, especially among younger pilots. SOPs that routinely result in the engagement of autopilot systems soon after takeoff and maintain this control method until minutes before landing prevent the practice of aircraft handling skills. In normal operations, this is not a problem, but in abnormal operations this inexperience has been exposed with tragic results. The proportion of hand flying time to total flying for air carrier pilots perhaps needs to be reviewed, and means of achieving a better balance might have to be considered.
Rested or Restless?
Duty and rest time limitations generally should ensure that crewmembers are adequately rested. However, it is assumed that crewmembers will act responsibly in using periods devoid of any duties to ensure that they have proper rest. The majority do, but past accidents have demonstrated that some crewmembers misused rest opportunities, with adverse effects on air safety and, in some instances, tragic consequences. To my knowledge, no reporting obligations typically exist among European operators regarding crewmembers’ use of rest time.
Often there is insufficient airline pressure on crews to ensure they report fit for the longest possible duty period for that reporting time, plus a contingency. Unexpected extended duty days are usually due to complications (technical, weather or security delays or any combination), and under these conditions, optimal alertness is required.
Since 2007, airlines worldwide have been obliged to adapt to new, more challenging market and economic conditions. The inevitable consequence has been that all budgets, including those concerned with operations and safety, have come under intense scrutiny with persistent pressure to reduce expenditures. Typically, airlines have been successful in maintaining the safety integrity of their operations, but it has become progressively more difficult for them to ensure adherence to all safety requirements and standards.
In today’s difficult economic conditions, regulation, legislation and taxation that in recent years have imposed additional cost burdens on the industry without serious consideration of consequential effects on operators have, at the margin, had an adverse effect on air safety.
In this respect, the recent proposal (put forward within the planned revision of EU Regulation 261/2004) to compel payments to passengers on diverted flights is particularly egregious. It would, if accepted, apply a wholly unnecessary and otherwise avoidable commercial pressure on aircraft crews to “get in” at a destination airport when experience, prudence and good practice would dictate diverting.
Rulings by the European Court of Justice concerning compensation to passengers in the event of flights cancelled for safety reasons are inexcusable and a potential threat to safety. Decisions on the safety of an operation should be made by the aircraft commander with no economic pressure.
The Executive Factor
In some respects, we have seen that the influence of those senior executives within a company who are responsible for the safety of operations has diminished during the past four decades. Whereas, in the 1960s and 1970s, it was quite common for chief executive officers (CEOs) to have a background in operations, today’s airlines frequently are managed by executives whose primary experience is focused on commerce or finance. In itself, this shift is not undesirable provided that adequate safeguards exist to ensure that executives responsible for operational safety have sufficient authority to prevent the introduction of policies and actions that might adversely affect the company’s safety performance. While it is normal practice for the CEO to be the accountable manager, a CEO can be part of a safety problem! For example, budgetary constraints imposed by the CEO can have latent or direct impact on risk management performance.
While most European company structures provide for the post of an air safety officer/manager, comparatively few airlines implement policies in which the reporting line of the post holder guarantees that his or her concerns can be raised at board level without fear of such expression of concern being career-limiting. Consider, for example, a situation in which the air safety officer (ASO) reports to the director of operations (DoO). An issue raised by the ASO that reflects badly on the DoO is unlikely to be raised by the latter to the CEO and board. Alternatively, the DoO might support the ASO’s views but be reluctant to go against, for example, budgetary constraints imposed by the CEO.
When accidents or major incidents occur, Europe’s citizens and other industry stakeholders are frequently ill-served by the present investigatory system. Although it is not politically correct to say so, all too often, commercial pressures to blame someone else, combined with a determination to protect national interests and company reputations, reduce the objectivity of the investigation, the determination of cause and the means to prevent recurrence.
In parallel, the prime focus of European ministries of justice, urged on by some self-interested members of the legal profession, has seemed to be the allocation of blame. Little consideration may be given to the science of human fallibility — aviation professionals simply making a mistake. It is no wonder that EU airlines have to put so much effort into developing a blame-free reporting structure. Crews know that misuse of reported data in any criminal prosecution could still find them liable. (Editor’s note: FSF in 2006 issued a joint resolution condemning the criminalization of accident investigations. The text of the resolution can be found on the Foundation’s website at <flightsafety.org>.) Indeed, the safety occurrence-reporting situation in some companies has deteriorated to the point that voluntary reports go first to the staff member’s employee organization, and only thereafter might the report reach the ASO, and ultimately, the CEO.
What Might Be Done
When Joint Aviation Requirements (JAR) Part 145 (concerning the approval of companies engaged in repair and maintenance) was implemented, the regulation required in part the creation of maintenance standardisation teams comprising experts from different national authorities. These teams were to ensure the consistent implementation and application of JAR145. There is a pressing need for a similar vehicle to be created to ensure consistency in the application of EU OPS. The European Aviation Safety Agency, already operating with budget constraints, is unlikely to have the resources to undertake such an effort. Furthermore, it is important that such teams, rather than a national authority, choose the company or companies that they believe warrant a visit.
I believe the creation of an EU accident investigation authority equivalent to the U.S. National Transportation Safety Board is long overdue. Many European accident investigation organizations have neither the resources nor the experience to undertake complex and extended investigations by themselves. An EU authority could easily be established if the political will existed without the impediment of state self-interest. It would need to be a ruthlessly atypical EU organization — instead of every member nation having a representative, only the brightest and the best would be recruited — and be built around objectivity and technical expertise.
The current situation can be summarized as “much has been done, significant improvements have been achieved, but much remains to be done — and under challenging economic and operational circumstances.”
Mike A. Ambrose is an independent air transport consultant. From 1987 to 2012, he was director general of the European Regions Airline Association.