OPERATORS SAFETY: A HOLISTIC APPROACH

1. OPERATORS SAFETY: A HOLISTIC APPROACH Presentation at the 58TH Annual International Safety Seminar (IASS) 2005 Moscow, Russia November 7-10, 2005 Presented by: Georges Rebender CJAA OPERATIONS DIRECTOR

2. CONSTANTLY CHANGING ENVIRONMENT FACED BY TRANSPORT SYSTEM (I) • Globalisation and Liberalisation, and new business models have, in the past two decades, brought about fundamental changes in the air transport industry. • These changes have frequently resulted in benefit to the industry and its customers. The increase in the number of carriers (several of which are low cost carriers) has brought with it, increased service options and, more generally, the creation of jobs.

3. CONSTANTLY CHANGING ENVIRONMENT FACED BY TRANSPORT SYSTEM (II) • The Industry, itself, is also changing as it takes advantage of new and evolving technologies. • For all parties, the challenge is to ensure the maintenance of safety whilst, at the same time, capturing the benefits of these changes in the global society.

4. CONSTANTLY CHANGING ENVIRONMENT FACED BY TRANSPORT SYSTEM (III) • The resulting growth of the air transport industry, combined with the complex arrangements that derive from the evolution of business and operating practices, may put additional pressure on the maintenance of safety standards. • In the face of these increasingly complex situations, it is essential that all parties: air operators; service providers and entities with a supervisory role have a precise understanding of their respective responsibilities and duties with regard to safety and oversight.

5. CONSTANTLY CHANGING ENVIRONMENT FACED BY TRANSPORT SYSTEM (IV) • The Operators are responsible for ensuring safe operation and, while doing so, they have a legal obligation to comply with the relevant regulatory requirements. • The States, signatories of the Chicago Convention, are responsible for continuous oversight of the Operators.

6. OPERATORS’ EFFECTIVE SAFETY (I) • JAR-OPS prescribes a structure in which the accountable manager has the responsibility of ensuring safe operation. • Post Holders, in relation to: maintenance; flight operations; ground operations and training, are responsible for implementing the safety policy in their respective fields, so as to reflect, not only the regulatory requirements, but also the Operator’s Safety Culture. • Additionally, an independent quality manager and a person accountable for the Operator’s Accident Prevention Program (reporting directly to the accountable manager) enhance the Operator’s proactive safety.

7. OPERATORS’ EFFECTIVE SAFETY (II) • The satisfactory implementation and use by the Operator of all safety measures (mandated or voluntary) is fundamental to achieving an effective safety management system. • Plans to use the full, potential of the flight data monitoring program (mandated on aeroplanes with a MTOW > 27,000 kg) are under development.

8. OPERATORS’ EFFECTIVE SAFETY (III) (1) Serious accident (15) Minor accident with damage and injury (300) incidents and near misses (15000) Observed work errors Effective SMS (FDM, ASR, safety audits…)

9. OPERATORS’ EFFECTIVE SAFETY (IV) • Operator efficiency and safety may be cross fertilised by a systemic approach. For example: • FDM/ Advanced Training Concept System, (NPA 39) • FDM/ Advanced Crew Rostering (as used by one operator). • In this way the Operator may integrate several disciplines into one single operations concept.

10. OPERATORS’ EFFECTIVE SAFETY (V) • Experience shows that a lack of appropriate management of the interface between the main areas of activity, i.e. between: maintenance; operations; training and security, can impinge on the resulting safety level. • Some operators have taken the most welcome initiative of developing, in addition of the JAR OPS requirements, Safety Management Systems (SMS) which can enhance cross discipline efficiency. • Industry initiatives in developing safety nets also show identifiable safety benefits.

11. INDUSTRY SAFETY NETS (I) EGPWS but no GPS Latest EGPWS + GPS Improper pilot response No EGPWS or Other Fatal Accidents - Worldwide Commercial Jet Fleet - 1995 Through 2004*** Courtesy Boeing 1,999 1,599 Total Fatalities = 5,828 (5,530 onboard) 2004 fatalities = 186 (186 onboard) Fatalities 420 368 339 231 348 225 155 136 119 89 25 13 3 2 0 Loss of control in flight Landing Runway incursion CFIT* Mid-air collision Takeoff config- uration In-flight fire Fuel tank explosion Takeoff Fuel exhaustion Misc. fatality Unknown Structure RTO** Turbulence Wind shear Number of fatal accidents 78 total 22 21 2 3 2 2 1 15 2 2 2 8 1 2 0 5 Accidents involving single, non-onboard fatalities are excluded Fatalities/accidents are placed in one category only. * CFIT = Controlled Flight Into Terrain ** RTO = Refused Takeoff *** 2004 is based on Preliminary Data. Note: Accidents involving multiple, non-onboard fatalities are included

12. INDUSTRY SAFETY NETS (II) Pilot Fly By Wire Airplane Other Wake-Terrain Turbulence, Icing etc Fatal Accidents - Worldwide Commercial Jet Fleet - 1995 Through 2004*** Courtesy Boeing 1,999 Total Fatalities = 5,828 (5,530 onboard) 1,599 2004 fatalities = 186 (186 onboard) Fatalities 420 368 339 231 348 225 155 136 119 89 25 13 3 2 0 Loss of control in flight CFIT* Mid-air collision Takeoff config- uration Structure Landing Takeoff Fuel exhaustion Misc. fatality Unknown In-flight fire Fuel tank explosion Runway incursion RTO** Turbulence Wind shear Number of fatal accidents 78 total 22 21 2 3 2 2 1 15 2 2 2 8 1 2 0 5 Accidents involving single, non-onboard fatalities are excluded Fatalities/accidents are placed in one category only. * CFIT = Controlled Flight Into Terrain ** RTO = Refused Takeoff *** 2004 is based on Preliminary Data. Note: Accidents involving multiple, non-onboard fatalities are included

13. REGULATORY OVERSIGHT • The complexity of the business and operating practices may warrant the attention of the State and, particularly so, in situations where more than one State is involved. • Examples can be: off-shore operations; operations involving multiple parties and, more generally, the outsourcing of operations related activities in different States.

14. CULTURAL ELEMENTS • A no blame culture is paramount – system rectification is the aim. • Culture needs to be centred on human performance – humans have their limits too. • Performance management involves both financial and safety management. • Communication must be free to be effective.

15. ICAO ADDRESS REGULATORY OVERSIGHT • ICAO State letter AN11/41/-05/83 provides findings of a study which addresses the regulatory oversight issues and makes associated recommendations.

16. A FLIGHT PLAN? • Intensive / Effective implementation along ICAO State Letter AN 11/41/-05/83; describing, in particular, the 8 critical processes. • Effective Safety Management Systems (SMS) implementation by both NAAs and Aircraft Operators. (ICAO State Letter AN 12/17-05/93). • Progress in a pragmatic way the “non-blame culture”. Reflect to the multicultural environment that is more and more phased by the European airlines. • Consider human Limitation in relation with safety nets developments. • Increase the cinergy between all the safety stakeholders.

17. THANK YOU FOR YOUR ATTENTION!