Aerospace Insight Blog

As massive growth in civil aviation continues, is the real threat to aviation safety the criminalisation of aircraft accidents? CAROLINE MALTBY reports on whether a worldwide Just Culture is achievable.

This is a full article published in Aerospace International: December 2012

The 2005 Helios Airways crash resulted in criminal charges being brought against the airline’s staff. (Skybary)

It is widely accepted that flying is one of the safest forms of transport.According to the National Transportation Safety Board, of the US’ 34,925 transportation-related fatalities through 2010, the aviation sector accounted for 472 deaths. Though roughly equating to slightly under 1·4% of all fatalities within the transportation sector in the US, aviation can however be further broken down into its various components; as opposed to general aviation which was attributable for 1·28% of the total, the results reveal that commercial airlines accounted for 0·0057% of mortalities across the entire transportation network within the US in 2010.

In its 2011 State of Global Aviation Safety review, the International Civil Aviation Organization’s (ICAO) statistics state that, in 2010, the world accident rate for scheduled commercial air transport, of maximum takeoff weights greater than 2250kg, stood at a rate of 4·0 per million departures. Of 30,556,513 scheduled commercial flights, this rate reflects 121 accidents globally, of which 19 proved fatal.

A need for change

Can justice and safety co-exist?

Taking into account industry projections, stakeholders of the aviation industry have recognised the necessity to reduce the global accident rate. Upon the assumption that Boeing’s market forecast for the subsequent two decades is realised, i.e. the world’s commercial jet fleet is set to almost double from the 19,890 aircraft in service in 2011 to 39,780 by 2031, it can be supposed that maintaining today’s accident rate will similarly result in a near twofold increase in the number of global accidents which, at best, translates to slightly under 40 fatal airline accidents per year, or an average of almost one per week. In reality however, this calculation merely reflects an oversimplified global projection that fails to consider a vast number of variables; acknowledging this fact alone would imply that, essentially, the industry is dealing with an unknown quantity by which an annual figure of 40 fatal accidents would instead likely reflect a minimum.

A significant factor contributing to the uncertainty relates, in part, to the rapid emergence of markets, coupled with the levels of growth that are anticipated within these regions in forthcoming years. Whilst more mature markets have gathered and maintained a wealth of knowledge and experience throughout their rich aeronautical histories, evolving markets do not have this asset upon which to rely.

Notwithstanding mild year-on-year fluctuations, in recent years there has been an overall decline in the global accident rate as compared to those of the past. It has, however been argued that, as a fundamental constituent of human nature, all man-made systems, irrespective of their complexity, are subject to potential human error. On this assumption, it has also been argued, and indeed widely accepted, that the total eradication of aviation accidents is not possible. Yet despite this, the industry’s attention to safety has never been so paramount.

A safety culture

Core to its activities, safety represents an area that ICAO has played a key role in developing. Safety Management Systems (SMS), defined by ICAO as ‘a systematic approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures’, are being progressively mandated across the industry’s sectors as an obligatory constituent of an organisation’s safety programme. In a similar respect to other management functions, safety is becoming increasingly viewed as a necessary component of the respective organisation’s operation. As opposed to merely outlining requirements from a regulatory perspective, SMS are intended to provide the tools with which an organisation may expand and grow in accordance with industry best practice; international standards and requirements for such systems are set out within ICAO’s Safety Management Manual (Doc 9859).

Aviation safety evolved throughout the latter-half of the 20th Century and, as such, may be divided into three eras:

• The Technical era under which the focus of aviation safety was primarily attributed to technological factors and failures.
• The Human Factors era whereby greater consideration was given to the man/machine interface upon which commercial air transportation is based.
• The Organisational era in which safety has become progressively viewed from a systematic perspective that encompasses both technical and human factors from an organisational standpoint.

Arising in the mid-1990s, the Organisational era continues to endure today. Differentiating it from previous eras, the Organisational era gives consideration to the impact of organisational culture and policies on the safety performance of that institution. Also distinguishing it from eras past, today’s rationale gives credence to an increasingly proactive approach to safety. In essence, a safety culture must endure; the values, beliefs and behaviours exhibited by personnel within an organisation will contribute to the fundamental foundations upon which safety management systems are built.

Central to Organisational era-thinking is Professor James Reason’s Accident Causation model. The model suggests that accidents occur subsequent to the successive breach of a system’s multiple defences, i.e. active failures may typically arise only after latent conditions have allowed them to do so. Within an organisational context, an example may refer to an error attributable to the work of a maintenance technician; the consequent investigation revealed that the technician made this error due to the provision of incorrect tools with which to conduct the task itself.

Latent conditions are described as such due to their very nature; they have potential to lay dormant and unnoticed for significant periods of time, indeed if not indefinitely. Yet under Reason’s model, and under specific circumstances, a combination of the latent condition(s) in question and active failure(s) may result in a fatal accident. A key issue therefore arising relates to how exactly these latent conditions can be identified.

Proactivity is key

As previously noted, a key feature differentiating today’s thinking from that of the past relates to the fact that both reactive and proactive approaches to safety are considered integral to the industry’s overall progression.

Reacting to an event alone is no longer considered adequate. The industry must instead seek to identify and mitigate those hazards posing an unacceptable risk, achieved through a continuing process of hazard identification and risk management. However, a further consideration of this approach refers back to Reason’s model; while it may be supposed that an organisation will have a genuine awareness of those hazards considered to be unacceptable, how can latent failures be identified?

As per ICAO requirement, States are obligated to establish mandatory occurrence reporting systems. The procedure relates to the timely reporting of ‘accidents, serious incidents, incidents and other reportable occurrences by relevant stakeholders’ as a mechanism by which data may be gathered and exchanged with specific regard to actual events or serious deficiencies within an organisation’s defences, therefore fulfilling not only legal and insurance purposes but also contributing towards the hazard identification aspect of safety management. As such, those organisations maintaining a positive safety culture will consider the benefits of reporting systems not only as a means of identifying how specific events have arisen but also as a tool by which operational safety may be improved for the future.

Voluntary reporting systems, however,have become increasingly prevalent throughout the industry as a means of data collection across both individual organisations and the industry’s wider spectrums. Distinguishing it from the former system, voluntary reports seek to confidentially attain data that may not otherwise be reported. In the US, the Federal Aviation Administration’s (FAA) Aviation Safety Reporting System (ASRS) and the UK’s Confidential Human Factors Incident Reporting Programme (CHIRP) are prime examples of such systems, each providing industry feedback in the form of regular newsletters such as ASRS’s Callback and CHIRP’s Feedback.

The objective underpinning voluntary reporting systems is to prevent safety occurrences, not attribute blame or liability. Correspondingly, fundamental to the success of this system is the prerequisite that the identity of the individual submitting the report should remain confidential so as to prevent disciplinary action or prosecution in consequence to an unintentional error or mistake. Evidently however, there is undoubtedly a clear distinction between that of an error or mistake and that of a violation. As such, this is a distinction that must be drawn from the outset.

A ‘Just’ Culture

This piece of metal from a Continental Airlines DC-10 was the key evidence that led to a mechanic being found guilty of manslaughter for his part in the 2000 Concorde crash. (BEA)

Central to the establishment of a safety culture, and with particular regard to reporting systems, is the underlying requirement for a ‘Just Culture’. A Just Culture has been described as ‘an atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour’.

Marx identified four behaviours as giving potential for unsafe acts to arise:

• Human error
• Negligent conduct
• Reckless conduct
• Intentional ‘wilful’ violations

Under the assumptions of Reason’s model once more, within the majority of circumstances, it is the sequence of events that will ultimately give rise to an accident as opposed that of an isolated event alone. It is therefore imperative that the boundary as to what constitutes ‘acceptable’ and ‘unacceptable’ behaviour be drawn. Accordingly, it is equally imperative that both individuals and organisations should understand the role to be played if this culture is to develop and succeed. It is therefore generally accepted that to discipline the perpetrators responsible for the vast majority of unintentional unsafe acts would not be beneficial; instead such acts would require alternative methods, such as retraining, to eradicate their occurrence. Wilful acts or those of gross negligence however must not be tolerated and may not expect impunity from prosecution.

Criminalisation of acts

In accordance with a number of bodies, the International Air Transport Association (IATA) has recently expressed its concerns with respect to an increasing trend toward the criminalisation of accidents, either subsequent to or concurrent with the safety investigation itself. Ironically, the nature of these parallel investigations is often of potentially conflicting agendas. According to IATA: ‘The sole aim of the safety investigation is to find out what went wrong and to use this information to prevent a similar accident happening again. The criminal investigation, on the other hand, tries to find out who is to blame for an accident and then punish those concerned.’

Evidently, an increasing trend of this nature has potential to significantly impact one of the core foundations upon which the safety culture is built: the Just Culture. With open reporting systems proving key to the realisation of the Just Culture, the use of data contained within voluntary occurrence reports to prosecute or to attribute blame represents a sizeable barrier to the generation and submission of reports in the first place.

By no means affecting such countries exclusively, IATA has identified those countries with strong civil law cultures as those that are particularly susceptible to this movement. France, Italy and Japan were cited as countries in which it is more likely that judges and courts will attempt to override accident investigators through the acquisition of safety information reported prior to the accident as evidence in court.

A prime example being that of the criminal investigation which followed the crash of an Air France Concorde in Paris in July of 2000 and in which 113 people lost their lives. Whilst the conviction was ultimately overturned on appeal in November 2012, it was the verdict of a French court in 2010 that a single mechanic be found guilty of manslaughter after it was discovered that a small titanium strip of metal, having fallen from a departing Continental Airlines DC-10 he had previously worked on, had shredded the tyres of the supersonic airliner during its take-off roll and ultimately ruptured the aircraft’s fuel tank. The charges against Air France and Concorde’s designers were dropped and the operator of Charles de Gaulle, Aéroports de Paris, was not held accountable further to its failure to perform an inspection of the runway.

Unfortunately, the accident and subsequent investigation outlined here is by no means an isolated example, the loss of a Helios Airways 737-300 in 2005 and a ValuJet MD-80 in 1996 serving as two other high profile illustrations. Society’s need to seek out those responsible, attribute blame and ultimately sentence those deemed accountable for the actions giving rise to an event is not unusual; we must however question the applicability and indeed validity of this practice in relation to aviation accidents. The prosecution of frontline employees will not prevent similar accidents in the future due to the fact that it does not address the underlying safety issue; nor indeed does the prosecution of the managers of frontline employees, a focus, according to IATA, commonly exemplified in Japan.

Although the benefits of a Just Culture with regard to an organisation’s overall safety culture are tangible, these advantages are threatened by a lack in policy concerning a global standard in relation to the permissibility of the safety information previously generated through reporting systems in terms of its use as evidence within a criminal investigation. According to IATA’s Gary Doernhoefer: “It is simply counter-productive to global aviation safety if lawyers can freely mine data gathered for safety analysis and use it as evidence in a criminal court case resulting from an accident”. To grant free access to this data would be to erode the foundations of a Just Culture, ultimately serving to obstruct the influx of safety-related information and, as a result, instead pose what is perhaps the greatest threat to aviation safety.

A global challenge

Recovery of AF447s flight data recorder. (BEA)

Whilst the aviation industry does indeed maintain an enviable safety record, the figures portrayed previously represent an industry average only. It is not unnoticed that the statistics presented at the outset of this article referred to that of the US. Had they instead referred to Africa, however, the data would have painted an altogether different picture.

In 2010, there were 17 accidents in Africa, three of which proved fatal. While the number of accidents in itself contrasts positively to that of other regions such as North America, Europe and Asia which accounted for 35, 24 and 24 accidents respectively, it is Africa’s accident rate which gives rise to the greatest concern. When considering accident statistics, it is also necessary to consider the significant variation in traffic volume that is attributable to each region. Of the six global regions identified by the United Nations, Africa accounted for the lowest traffic volume (1,013,063) in 2010, roughly one-tenth of that witnessed in the US which played host to the greatest volume (10,624,134). Despite this, Africa maintained an accident rate of 16·8 per million departures. This compares to an accident rate of 3·3 per million departures in North America, 3·3 in Europe and 3·1 in Asia. Although Africa represents what maybe the most troubling statistic, at rates of 5·4 and 4.8 per million departures respectively, the regions of Latin America & the Caribbean and Oceania also gave rise to a somewhat concerning number of accidents relative to the volume of traffic that they witnessed.

While the implementation of voluntary reporting systems represents a valuable tool with which a proactive industry may gather key data as a means of eliminating unsafe conditions and preclusion of avoidable accidents and incidents, to truly reduce the industry’s accident rate at both a regional and a global level, the industry must share the information it has gathered. The exchange of safety information is a means of facilitating the continuous improvement of an industry whose very core is reliant upon safe operations. To succeed however, the reporting system itself must be confidential and non-punitive; equally, the system must maintain the support and backing of the industry that utilises it.

The criminalisation of accidents serves only to damage the relationship of trust which underpins the Just Culture and to undermine all that the aviation industry has achieved thus far; can the industry afford to play host to almost one fatal accident per week?

Aerospace International Contents - December 2012

News Roundup – p 4

Star chamber - p 11
Report on the 2012 Internatioanl Astronautical Congress

The criminalisation of aircraft accidents – p 14
Is Just Culture achieveable in aircraft accidents?

Empowering military air safety - p 18
Has the UK Military Aviation Authority encouraged a new safety culture?

Partnerships – learning lessons?- p 22
Government, industry and military co-operation

Fuel for thought - p 26
What will aircraft use for fuel in 2050 and will it be environmentally friendly?

The F-35 – getting nearer - p 30
Update on the JSF fighter programme

The last word – p 34
Keith Hayward on implications of the EADS/BAE Systems failed merger

 

This is a full article published in Aerospace International: December 2012. As a member, you receive two new Royal Aeronautical Society publications each month – find out more about membership.