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Select Committee on Environment, Transport and Regional Affairs Appendices to the Minutes of Evidence - Fourteenth Report

Memorandum by A F Taylor Esq, Cranfield University (AS 32)



  Thank you for the opportunity to submit comments to the Transport Sub-Committee on aspects of aviation safety. Please note that although I am responsible for much of Cranfield's work in aviation safety the comments and opinions that follow are my own and are not necessarily shared by all of my colleagues at Cranfield.

  Aviation safety may conveniently be divided into two parts: the reduction of the rate at which accidents occur and the reduction of the fatality and injury rate in those accidents that do still occur. This two pronged attack is reflected in both airworthiness requirements and accident and incident investigation procedures and is of great importance. Although my interests are wide and cover both parts most of my experience has been in the second part, that of improving the overlapping fields of crashworthiness, cabin safety and survival, passenger protection and emergency evacuation.

  The Committee will not need reminding that 10 years ago it studied Aircraft Cabin Safety, reporting1 in December 1990. One particular point that I will return to is the extremely poor response that some of that report's recommendations received from the Government and the Civil Aviation Authority (CAA).

  Another point that will be repeated throughout is that aviation safety must be considered at an international level, in few cases will a single country be able to act alone. Accident statistics have to be considered worldwide and actions, changes and improvements have to be agreed and/or made on an international basis.

1. Safety lessons

  Although it would appear that deregulation has been achieved with no loss of safety, there is no room for complacency. As usual we need to stay running fast in order to keep the number of accidents at a standstill, this however is not enough if we are to balance the anticipated increase in traffic over the next decade or two.

  My personal experience of the new low cost airlines is limited to easyJet who certainly appear not to have cut costs on safety. For example attention to cabin safety briefings and cabin checks on easyJet flights have been amongst the best I have ever observed. I am more concerned that these new airlines will be forced to use airports that are not fully equipped with navigation and approach aids. Research has shown2 that both CFIT (Controlled Flight Into Terrain) and (ALA) approach and landing accidents are much more likely to occur when such equipment is lacking. Our concern should not be confined to within the UK but should include wherever UK airlines operate, or indeed perhaps also wherever UK citizens fly.

2. Trends in aviation accidents

  Overall the level of safety throughout the world is remarkably good but there are such wide variations between different years and between different areas of the world that it can be misleading to take much notice of short-term trends. While 10 years might seem a reasonably long-term and the number of accidents and fatalities (see appendix) may be seen to have been fairly constant, there is insufficient data from too many of the accidents to ascertain all that has happened. Thus while an insignificant increase from an average of 1,365 fatalities per year from 1979 to 1988 to 1,378 per year during the last decade shows an encouraging improvement in the rate of fatalities per million flights, the forecast increases in traffic with variations between different parts of the world make useful predictions concerning future fatalities impossible. Despite the lack of firm data it may be assumed that of these some 40 per cent, or an average about 550 per year, have died in survivable accidents where cabin safety issues1 are all important.

  In the above context it is worth recalling a survivable accident that illustrates the gap that sometimes appears between the approaches of investigators and regulators, this is the DC-10 accident at Sioux City on 19 July 1989. According to the CAA3 this was an accident that typified one where "it would be unrealistic to expect that more than a very marginal increase in survival would have resulted from improved fire precautions, evacuation provisions or seating". While no-one would disagree that this was a very severe accident many investigators would consider such a categorisation as inappropriately defeatist and consequently counterproductive to the search for improved cabin safety.

  According to the NTSB there were 296 people on board of whom 111 died, the accident report4 states that "35 passengers died of asphyxia due to smoke inhalation, including 24 without traumatic blunt force injuries. The other fatally injured occupants died of multiple injuries from blunt force impact. Of the remaining 185 persons on board, 47 sustained serious injuries, 125 minor injuries, and 13 were not injured." (author's emphasis).

  Although parts of the cabin may have been totally non-survivable it is difficult to accept that only a marginal reduction in the number killed would have resulted from some of the structural and restraint system improvements under consideration at the time and since. In particular and given the above information concerning the large number with few if any injuries, what of the 24 without injuries who died of asphyxia due to smoke inhalation? Surely some of the measures discussed before and, more extensively after Manchester could have helped many of these passengers to have survived.

  Unfortunately judgments such as those by the CAA that deny that more passengers might have survived in particular accidents have also seriously affected their estimates of the total number of lives that might be saved per year and hence the stated benefits of safety features recommended by the investigators. Consequently, the opinion of many others has been influenced. Thus incorrectly categorising other similar accidents in the same way has undoubtedly seriously and wrongly diminished the case for making cabin safety improvements.

  The high level of safety achieved in the past decade, particularly in Europe and North America, nevertheless presents the industry with a difficult problem, the cost of making aviation even safer. For example in 1993 the CAA issued a summary5 of the extensive work done on cabin water mist systems and reported upon separately. The conclusions were that they would be effective and with no insurmountable problem areas. However it was "estimated that water spray would save an average of 14 lives annually worldwide or 6 lives in the US, Canada and European countries of the JAA" ". . . giving a cost per life saved of $22 million to $32 million".

  Such costs do seem to be very high when expressed in this way but if instead one considers the cost in terms of dollars per ticket then the extra to an individual becomes trivial. It is believed that at present there are no plans to proceed further with water mist systems, thus already having decided not to proceed with smokehoods, despite the Transport Committee's arguments1 passengers are now left with no additional protection from smoke and fumes at all.

  In the UK there have been several accidents, fortuitously non-fatal, that have suggested that more attention should be given to aircraft maintenance procedures, particularly to the human factors (HF) aspects. Worldwide it is disappointing that the considerable efforts made to reduce the number of Controlled Flight Into Terrain (CFIT) accidents2 has not yet resulted in the anticipated improvement.

  No analysis of general aviation accident trends has been attempted.

3. Lessons from recent high profile accidents

  What one hopes has been learned from accidents such as the TWA 800 centre fuel tank explosion in July 1996 and the Swissair in-flight fire last September is that one should be wary about accepting past accident statistics as a pointer to the risk of similar accidents in the future. What has been discovered is that much aircraft wiring does deteriorate with age and consequently that older aircraft could now present a higher risk than that calculated from past events alone.

  A possible lesson is that emergency procedures and crew training must reflect the varying nature of emergencies and the resulting priorities. It has been suggested (we must await the accident report to confirm or deny this) that Swissair's emergency procedures called for fuel to be jettisoned to bring the weight down before landing, whereas deciding to get down as quickly as possible and to make an over-weight landing might have been preferable. This has similarities to the fatal 1977 DC-10 accident in Chicago when the crew followed procedures which allowed them to reduce speed following an engine failure after take-off (actually the engine had fallen off). Had the crew maintained their speed the aircraft would have been controllable and could probably have landed safely.

  Of major importance is the need for the world's aviation authorities, or regulatory agencies, to work together to agree worldwide safety improvements and to follow them through into airline service. Coincident with this is the need for accident investigation agencies, where appropriate, to make safety recommendations to the world's agencies and not only to their local agency. Thus the UK Air Accidents Investigation Branch (AAIB) should address not only the UK Civil Aviation Authority (CAA) but all such agencies. At present the CAA cannot react without agreement with the European Joint Aviation Authorities (JAAs) and the JAAs may feel reluctant to act without the agreement of the US Federal Aviation Administration (FAA). Awaiting such agreement may delay the introduction of safety improvements by many years, for example changes suggested by the CAA following the 1985 Manchester B737 fire have still not been implemented.

4. Other critical safety issues

  Of particular concern is the growth of traffic to and from parts of the world which have not been able to keep up with the improvements that have contributed to the very high level of safety found in Europe and North America. The Committee might consider ways in which the international aviation community could assist such parts of the world to improve their facilities and to maintain them at an acceptable level thereafter.

  No comment concerning training, congestion or pilot retirements is offered, brief reference to maintenance is made at the end of paragraph 2.

5. The adequacy of current safety oversight

  The very high level of safety in British aviation could not have been achieved without a significant input from the CAA, it therefore should be accepted that the safety oversight provided by the CAA is, at the very least, adequate and in most areas much better than adequate. However the current high level of safety both in the UK and in much of the rest of the world, coupled with the predicted increase in air traffic over the next decade, requires that we do better than just stand still so far as accident rates are concerned. The travelling public is probably must influenced by the frequency of TV and newspaper headlines concerning passenger transport aircraft accidents and is not concerned with "rates" at all. To even maintain this frequency at the current level requires a significant improvement in accident and fatality rates over the next few years and although this has been recognised by all, including the CAA, there is little evidence that very much useful action has been taken to facilitate the required improvement.

  As will be known to members of the Transport Committee, the Air Accidents Investigation Branch (AAIB) of the Department of the Environment, Transport and the Regions is responsible for investigating accidents and incidents, establishing causal factors and safety deficiencies and making safety recommendations with the objective of preventing (or making less likely) future accidents, fatalities and injuries. In the past most of these recommendations have been addressed to the CAA and the CAA has been obliged to respond, setting out whether or not it accepts the recommendations. In addition the CAA publishes an annual Progress Report6 describing the current situation with respect to all of the AAIB's safety recommendations that are still "open". However as recommendations are almost invariably of a general nature so as to leave the CAA to decide, for example, how best to reduce or eliminate the safety deficiency, there have been many occasions7 when recommendations have been accepted only for no action to be taken, that is there has been a review or some research has been commissioned but these have led to no changes being made to regulations or procedures. Consequently the high level of acceptance of safety recommendations often quoted is totally meaningless, not only that but no record has been kept of those that have in fact led to changes.8

  As stated just two years ago9 "The CAA, along with airworthiness authorities elsewhere, has the unenviable task of explaining to the media why it is not always possible to produce the `instant fix' called for. It can be extremely difficult to get across to the media why we have to be so careful before we introduce changes, perhaps because of this a rather defensive attitude may have been adopted. In general, although of course we must heed Murphy in that `every solution breeds new problems', I would suggest that the CAA, rather than being on the defensive, should be seen to be striving to overcome the problems often associated with new safety features in order to introduce them as soon as is practicable."

  Since writing the above, and in particular since the events that caused it to be written, there have been many changes at the CAA which may render criticism of the CAA's actions, or lack of actions, less appropriate than then. However in the past it is believed that in some areas the CAA has fallen well short of the standard that the industry and the travelling public expect. To some extent this may be due to the CAA's own charter which makes the CAA responsible for both the safety of passengers and for the economic regulation of British aviation, thus the CAA may sometimes face something of a dilemma when trying to decide "what is best". What is best for the passenger may not seem to be what is best for the aviation industry. My view is that passenger safety should come first but to make real improvements in air safety without financially penalising the UK industry requires that improvements are made internationally and not just locally. This means carrying Europe with us and then the USA, if this is done then all other countries will follow. This too is recognised by the CAA and improvements are supposedly being sought through various international bodies and joint committees.

  For the CAA to take a lead in these matters first requires that it gets its own house in order. It is hoped that appropriate changes have already occurred or are in progress but for the problem that has existed in the past to be understood it has been considered necessary to quote some examples7 and that some be repeated here. The Transport Committee's report on Aircraft Cabin safety1 and the Government's response10 provides two examples, another is taken from an AAIB report11 and the final one from my personal experience.

  In view of these examples the present Committee may care to note that following the Government's response in 1991 there was not, so far as I am aware, an opportunity for the Committee to meet and consider this. My personal view is that, if this was the case, it would have been better if the Committee could have met, discussed the responses and either resolved differences prior to publication or been able to note any differences. If appropriate the present Committee may care to review the procedures relevant to the current enquiry.

5.1 Guidelines concerning fuel tank integrity

  Initially in response to concerns expressed following the B737 fire at Manchester Airport in 1985 the House of Commons Transport Committee took evidence on aspects of Aircraft Cabin Safety from many sources near the end of 1989 and throughout much of 1990. During this period the Kegworth accident, also to a B737 and highly relevant to cabin safety, occurred. Although these two accidents were central to much of the discussion the Committee took a much wider view of cabin safety; many other relevant accidents from around the world were discussed and the recommendations were intended to be general and not to relate only to these two UK accidents.

  One general point made by the Committee was this:

    A post-impact fire is most unlikely to occur without there first being an external fuel fire. Even without a cabin fire, an external fuel fire may penetrate the cabin and generate sufficient heat and fumes to kill passengers. To combat this danger, the likelihood of fuel being spilled needs to be reduced and its properties altered to reduce the likelihood of it catching fire.

    Design regulations require that, in an impact, wing engines and undercarriages should break off without rupturing the fuel tanks. Despite this, ruptures have occurred which suggest a lack of compliance with regulations. We believe that closer monitoring of this aspect of crashworthiness is called for and suggest that additional guidelines concerning compliance with the appropriate regulations would benefit both the manufacturers and the certificating authority. We recommend that additional guidelines be formulated to ensure the structural integrity of the aircraft during "emergency alighting" conditions. Particular attention should be given to minimising damage to the fuel tanks and to the passenger's cabin caused by, or as a result of, undercarriage collapse.

  The Government response (supplied by the CAA)10 to this totally missed the point that the Committee had made no comment, adverse or otherwise, concerning the actual requirements, only that not all aircraft appeared to comply with them. Furthermore the context was general and the recommendation was not made in connection with any particular accident. Nevertheless the response was:

    The existing requirements have been reviewed and are considered satisfactory. From the reported evidence of the Kegworth accident it is noted that the landing gear attachment failed as intended. The engine pylon also failed in such a way as to satisfactorily prevent damage to the fuel tanks.

  If this was not a deliberate attempt to avoid the points being raised it was certainly totally unhelpful and not in the spirit of sensible and constructive discussion necessary when dealing with safety issues. Because of such negative replies and the time it takes to get them, many people give up trying to get any sense out of government departments. This may be of no great concern in some areas but given the unforgiving nature of heavier than air flight the "aviation safety system" must do better than this.

5.2 Airport safety centres

  Some years ago it was suggested that the time that many passengers at present tend to waste in the departure lounges could be put to good use if, under supervision, they were encouraged to inspect and use various safety items that are to be found in the aircraft cabin. This could be achieved by having in the lounge a mock-up of a small section of aircraft cabin fitted with appropriate equipment. In addition to seats and seat belts, life jackets, oxygen masks, etc., the mock-up could be fitted with doors and hatches typical of those likely to be encountered in several aircraft types. An important point being that the mock-up could be "general purpose" and not representative of only one aircraft type.

  The House of Commons report1 contained the following paragraph, the last sentence which was in bold type was repeated, omitting only the word "therefore", in the final list of recommendations:

    We believe that this suggestion deserves serious consideration. In the longer term design differences between aircraft could be reduced. A cabin mock-up could prove useful not only to the passenger but to airlines and the airworthiness authorities by helping them to establish exactly what difficulties the passengers have in following the instructions provided. We therefore recommend that research should be undertaken to establish whether a small cabin mock-up, installed in the airport departure lounge and enabling passengers to actually use safety equipment, could be of overall benefit to the travelling public and to the industry as a whole.

  This idea, although it has subsequently been shown to improve passengers' awareness and performance,12 has not yet found favour. This may in part be due to the totally negative response from the government,10 namely:

    The Authority believes that it would be impracticable to provide training that represented the vast range of cabin configurations that passengers might encounter. Inappropriate demonstrations could be dangerously misleading.

  This response suggests that the recommendation had actually been to introduce such Centres without any proper study, whereas even a superficial reading shows this not to have been the case; the difficulties, even dangers, had been recognised and the actual wording carefully chosen to reflect this. Thus the response was either excessively careless or missed the point quite deliberately.

  Of course members of the CAA and of other such agencies have every right to offer an opinion, usually of course an expert opinion, and it might turn out that it would indeed prove to be impracticable to provide training in this way. Nevertheless to totally disregard the careful deliberations of Members of Parliament, all regular travellers by air and advised by two experienced members of the aviation industry, one an ex-Chief Inspector of Accidents with the AAIB, is hard to excuse.

5.3 Communication between firemen

  Another potentially important point relevant to the discussion of safety recommendations concerned the problems firemen have in communicating with each other while fighting an aircraft fire. Within the analysis section of the Manchester report11 it was stated:

    It is evident that poor communications were a major handicap throughout the period of firefighting activity. In particular, there was no means for the officer in charge to contact RFF personnel outside his immediate vicinity, preventing him from re-directing resources to provide a more unified effort should he have considered that necessary, and no means for him to obtain feedback on the progress of, or to process requests from, individual teams. This was illustrated graphically by the variety of individual instructions issued and actions taken during attempts to obtain water from the hydrants, all of which were carried out in isolation and without the individuals concerned being aware of the actions of others.

    It is considered that the lack of a helmet mounted communications system is a serious handicap which limits the potential effectiveness of both the aerodrome RFF services and the local authority fire services which attend. It is considered necessary that a requirement for suitable communication systems be introduced as part of the licensing requirements for all major airports, and that these requirements include provision for communication on the same system by (at least) the officer in charge of any local authority fire service having standing arrangements to attend aircraft emergencies at such aerodromes. It is further considered necessary that the recruitment and training of airport fire officers be amended to facilitate a more command orientated approach (emphasis added).

  This was emphasised as one of the "findings" thus:

    The potential for an officer in charge of airport firefighting crews to mange resources effectively is compromised by a lack of helmet-mounted communication (emphasis added).

  The resulting safety recommendation followed:

    A requirement should be introduced for an effective communication system for Rescue and Fire Fighting personnel as part of the licensing requirements for all major airports. That requirement should include provision for communication on the same system by the officer in charge of the units deployed by any local authority fire service having standing arrangements to attend such airports.

  Nobody reading these paragraphs can be left in any doubt that what the AAIB thought was lacking was communication between the officer in charge and his firefighting crews, not between appliances and the fire station. Thus the response from the CAA must have been disappointing and perplexing:

    The Authority accepts this recommendation. CAP 168 . . . already calls for an effective communication system between the Aerodrome Fire Service appliances and a suitable ground station preferably the control tower. Also, where more than one aerodrome fire appliance has radio equipment there should be two-way communications between these appliances.

    A new edition of CAP 168, due out in October 1990 will require that at Aerodrome RFF category 5-9 radio facilities to enable the Airport Fire Service to communicate with responding Local Authority Fire Services are provided. Consultation has taken place . . .

  There was no mention or acknowledgement of the safety issue actually raised in the accident report at all! When the matter was raised with the CAA the reply made it clear that their policy was to deal strictly with the recommendations without putting them into the context to be found in earlier sections. At the same time it was made clear that, nevertheless, they were pursuing the question of helmet mounted radios, which makes one wonder why they didn't accept the spirit of the recommendation in the first place. This appeared to be evidence of "points scoring" going beyond that consistent with a healthy approach to safety!

  More recently practicable helmet-mounted communications systems have come into service at some airports but their cost probably prohibits their wider use. However as with much equipment of this nature the development of better and less expensive models depends on the potential market size. If all fire services were called upon to use them then the cost would come tumbling down! This is an example of a subject that should be re-opened for discussion.

5.4 Evacuation trials at Cranfield

  Following the 1985 Manchester accident the CAA sponsored Cranfield to conduct a series of evacuation trials to help evaluate the effects on evacuation rates of different widths of passageway through bulkheads and different seating arrangements by overwing, Type III exits since both of these had caused concern to the AAIB, to the Manchester fire service and to the passengers themselves. A disturbing and at the time surprising feature revealed at the start of the first Cranfield trials, while the AAIB's investigation into the accident was still in progress, was the reluctance by one of the leading members of the CAA to allow the AAIB investigators dealing with evacuation issues to witness the trials. It was as if the AAIB were the nuisance and not the accident! This, it was felt, went beyond the healthy rivalry that may occur between two such independent agencies. Fortunately this reluctance was overcome and the trials helped everyone, including the AAIB, to understand a great deal about what probably went on in the cabin at Manchester. Survivors of the Manchester accident who witnessed evacuations from a position at the back of the cabin, confirmed that in their opinion the real evacuation had been very similar.

  My worry was that if senior CAA personnel were quite open in expressing their reluctance to co-operate with the AAIB then they presumably could not see that such behaviour was not in the best interests of improving safety, particularly as they might well encourage such behaviour in their junior colleagues. It is believed that relations between the AAIB and the CAA are now, over 10 years later, distinctly better but this should not be left to chance.

5.5 Civil Aviation Safety Advisor

  It has also been pointed out9 that until a few years ago the Department of Transport had maintained the post of "Civil Aviation Safety Advisor" in order to provide a link between Her Majesty's Government and the day to day operation of air transport. For reasons of which I am ignorant this post appears now to be either vacant or to have been lost. An important duty incumbent upon the holder of this post had been to draft replies to parliamentary questions that relate to safety issues and to provide other relevant information to the Government spokesperson, for example to the Secretary of State for Transport. This good, practical system has been complicated by the fact that civil aircraft safety and air transport safety are the responsibility of the CAA; it has therefore often been the practice for the answers to parliamentary questions to be prefaced with a remark to that effect.

  An element relevant to this point has been that the Civil Aviation Safety Advisor has, for as long as I can remember, been an ex-member of the CAA. Thus, it being extremely difficult to totally dissociate oneself from past affiliations, this may have led to answers being biased to give the view of the CAA rather than that of the Department of Transport, which of course contains the AAIB. Should a Member require only the view of the CAA then of course he or she can write directly to the CAA; this surely is not what is intended when a question is put to the Secretary of State. It is therefore suggested that the Government reinstate the post of Civil Aviation Safety Advisor and appoint a person who can convince the selection panel of his or her independence of mind. Any suitable candidate would know the responsibilities and workings of both the CAA and the AAIB and would appreciate the need for and the value of their independent rôles (no suitable candidate could truthfully claim to have been totally independent of both!). He or she should also be aware of the problems of the manufacturing and air transport industry but have no financial interests in either. Having such a person in what I believe to be a very important position should, as far as is possible, ensure that answers to parliamentary questions are properly balanced, perhaps more so than they have sometimes appeared to have been in the past. After all the government is elected by the public and in this, as in other matters, government should, above all else, have the interests of the public at heart.

6. Conclusions and recommendations

    —  Despite attempts to reduce the number of CFIT (Controlled Flight Into Terrain) accidents little impression has so far been made, particularly outside Europe and North America. This problem should remain high on the safety agenda.

    —  The number of fatalities per year has only risen slightly over the past two decades, showing a slight improvement in accident rates. However the forecast increase in traffic means that we must make more than a "slight" improvement over the next decade, this will not be easy and will require close international co-operation.

    —  Cabin safety remains a major concern still requiring urgent international attention. Little has been changed on aircraft since the 1985 Manchester accident despite considerable research and, in some cases, strong CAA backing. Previous proposals should be reconsidered.

    —  The cost of introducing safety improvements should be quoted in terms of the extra cost of a single ticket rather than the usually enormous total cost per fleet.

    —  Safety recommendations made by investigating agencies should, when appropriate, be considered internationally.

    —  The present charter of the CAA may sometimes cause members to face something of a dilemma when trying to decide "what is best" since the CAA is responsible for both the safety of passengers and for the economic regulation of British aviation. This situation should be reviewed.

    —  In the past the CAA has, in its responses to safety recommendations, on some occasions missed the point behind them. Whatever the reasons for this in the past, steps should be taken to prevent it from happening again.

    —  It is recommended that the Government's responses to such recommendations as the Transport Committee may make following the present enquiry are studied with care and, if not already provided, there should be the opportunity for further discussion of the responses before publication.

7. References

  1. "Aircraft Cabin Safety", House of Commons Transport Committee, Session 1990-91, First Report, HMSO, 1990.

  2. "Airport safety: a study of accidents and available approach-and-landing aids", Ratan Katwan et al, Flight Safety Foundation, Flight Safety Digest, March 1996 and reprinted February 1999.

  3. "Minutes of evidence by the UK Civil Aviation Authority (CAA) to the House of Commons Transport Committee, "Aircraft Cabin Safety", Session 1990-91, HMSO, 1990.

  4. "United Airlines Flight 232 McDonnell Douglas DC-10-10 Sioux Gateway Airport Sioux City, Iowa July 19, 1989", National Transportation Safety Board (NTSB), Aircraft Accident Report NTSB/AAR-90/06, 1990.

  5. "International cabin water spray research management group—conclusions of research programme", Civil Aviation Authority, CAA Paper 93012, 1993.

  6. "Progress Report 1997: CAA and DoT Responses to Air Accidents Investigation Branch (AAIB) Safety Recommendations", CAP 674, CAA, July 1997.

  7. "Airworthiness requirements: accidents investigation and safety recommendations", A F Taylor, ISASI '98 seminar, Barcelona, October 1998.

  8. Answer by Ms Glenda Jackson to question 37856 by Mr Brake, Hansard for 8 April 1998.

  9. "Up in the air", A F Taylor, PACTS conference, "Transport Safety: What do we want from an incoming government?", May 1997.

  10. "Government observations on the First Report of (Transport) Committee, Session 1990-91 (Aircraft Cabin safety)", Second Special Report, House of Commons Transport Committee, HMSO, 1991.

  11. "Report on the accident to Boeing 737-236 series 1, G-BGJL at Manchester International Airport on 22 August 1985", AAIB, Air Accident Report No. 8/88, 1989.

  12. "The contribution of Airport Safety Centres to passengers' attitudes and performance", B A Mitchell, Cranfield University MSc thesis, 1992.

Cranfield Aviation Safety Centre

March 1999

Figure 1: Fatalities in Aviation Accidents
19761977 197819791980 198119821983 198419851986 1987
January271135 23342147 1710150 65218109 67
February3185 1048913 86322 02012150
March144625 19118787 26653 3252221 21
April77147 1257250 3311237 192213 34
May9483 21303677 2504 7519216
June1039 515158 53324018 34951156
July7628 999179 113236141 1282595
August7111 37321342 1972297 95722137 238
September423143 2249545 54108392 34977 5
October21311 69968 21033190 2113994
November164183 24343251 12037368 15600 332
December140276 14011972 19593142 151263150 133
Total1,8071,736 1,2881,8551,358 9201,1641,355 6242,362926 1,351
10 year moving average—fatalities 1,7671,7441,691 1,5521,4741,328 1,4471,3591,320
5 year moving average1,951 1,7871,6171,572 1,6091,4311,317 1,3301,0841,285 1,2861,324
3 year moving average1,688 1,5721,6101,626 1,5001,3781,147 1,1461,0481,447 1,3041,546

19881989 199019911992 199319941995 199619971998
January18554 151191 4513775 038683,381
February73194 1077747 1464510 34824309 2,868
March19633 4411154 918276 369873,470
April447 353970 1332844 3320532,232
May4428 552690136 1527179 411032,442
June29303 342571 4320572 2330112,909
July309202 0292354 19215553 2728340 4,246
August61138 5081112 1085294 156246130 4,751
September140419 3669182 136221103 34328323 4,534
October251292 1522683 171588 1897444 3,048
November14152 99131238 1531567 680026 4,133
December38813 1840250 75124578 28273131 5,229
Total1,7341,855 7811,1611,552 1,2751,4931,167 1,9451,2261,325
10 year moving average—fatalities 1,3651,3651,307 1,3311,3701,362 1,4491,3301,431 1,4191,378
5 year moving average1,399 1,6461,3291,376 1,4171,3251,252 1,3301,4861,421 1,431
3 year moving average1,337 1,6471,4571,266 1,1651,3291,440 1,3121,5351,446 1,499

Figure 2: Number of fatal accidents
19761977 197819791980 198119821983 198419851986 1987
January84 564 3426 733
February43 464 3410 332
March36 7912 443 163
April46 3154 132 414
May43 5424 201 326
June42 2562 451 364
July15 2737 321 331
August43 484 4326 633
September78 864 2332 331
October63 632 3044 474
November64 576 3242 106
December68 1072 3556 245
Total5755 616943 40353534 404142
10 year moving average—fatal accidents 615857 53504847 4544
5 year moving average60 57565857 545044 37373738
3 year moving average54 54586258 513937 35363841

19881989 199019911992 199319941995 199619971998
January73 513 7350 43137
February67 253 4328 24112
March55 3463 431 45117
April42 5357 323 3197
May35 5702 253 22105
June48 2563 555 21117
July75 0487 656 75126
August54 236 3354 35120
September510 494 4962 44146
October56 539 3428 13128
November54 364 5448 03114
December72 343 5874 54158
Total6361 395457 53545152 3740
10 year moving average—fatal accidents 444343 44474850 525352 50
5 year moving average44 49495255 535154 534947
3 year moving average49 55545150 555553 524743

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