Select Committee on Transport Minutes of Evidence

Memorandum submitted by Dr Graham Braithwaite, Director, Cranfield University Safety and Accident Investigation Centre, Department of Air Transport, Cranfield University


  1.1  The record for aviation safety within the United Kingdom remains good, particularly at the high-capacity, passenger end of the market. This is in no small part a consequence of the strict regulatory regime that has been fostered by the Civil Aviation Authority (CAA). However, such a safety record is not a matter of chance, but rather the result of considerable hard work which can be easily undone if complacency or ignorance is allowed to develop. Regardless of the historical safety record, safety is not a given and requires constant vigilance. Safety is negatively reported—if it is good, then we tend to hear little of it, but when safety is compromised, the matter is of considerable public and political interest.

  1.2  As the UK's role in the aviation community evolves and new technologies combine with changing commercial imperatives, so the UK's role in safety oversight must change. With the decline of elements of the aircraft manufacturing industry, but ongoing growth in the operation side, so the focus on safety oversight has had to shift more to operational matters.

  1.3  Accident statistics support the view that operational issues within the airlines and maintenance organisations continue to provide the greatest threat to safety. Human factors issues remain of considerable importance although it is the interaction of failures in several areas of the system that ultimately causes incidents and accidents.


  2.1  The launch of the European Aviation Safety Agency (EASA) in 2003 has provided some new opportunities for establishing and maintaining high, harmonised civil safety standards across the European Union. Regulatory responsibility for airworthiness (with some exclusions) has been transferred to EASA from national regulatory authorities such as the CAA.

  2.2  The transition period provides a significant challenge to the integrity of aviation safety within the UK. Any new agency will take time to establish itself and develop a sound operating culture and EASA is no exception. Recruitment, training and the development of working relationships all have the potential to distract the agency from its key tasks. The UK needs to maintain vigilance during the transition to ensure that the hard-won mantle of safety is not lost.

  2.3  CAA is an organisation with an uncertain future as its role becomes ever more absorbed into EASA. Such uncertainty is having an inevitably demotivating effect on its workforce and is leading to a loss of talent, as more secure jobs become available elsewhere. The human capital of the organisation is arguably, its single greatest asset. The experience and expertise of CAA staff, along with the relationships they have fostered with the industry is a precious resource, which cannot simply be spliced into EASA.

  2.4  Although the CAA continues to conduct many functions on behalf of EASA, its ability to drive the safety agenda is diminishing. Areas such as research and airworthiness regulation find themselves with reduced staff and reducing budgets as well as differences of philosophy compared to EASA. This notwithstanding, the considerable achievements of the CAA deserve note. It is only by understanding how we achieve success, that we can hope to preserve and improve safety levels.


  3.1  A selection of examples of successful CAA initiatives are discussed below for their contribution to improving aviation safety.

  3.2  The ongoing development of Flight Data Monitoring (FDM) has been a particular success. FDM utilises information collected from routine flights via the digital flight data recorders to allow airlines to monitor exceedences in pre-assigned criteria. For example, an aircraft on approach to an airport may exceed the predetermined approach speed—something which will then be flagged for further analysis. In this case, the act of exceeding an approach speed may seem of little significance if it is resolved and no consequences occur. However, if such an event is demonstrated to be part of a trend, then it could provide an important early-warning sign. With data collected from numerous flights and aircraft, FDM allows an operator to determine whether an event is specific to an individual, a particular aircraft or aircraft type or airport. The non-punitive system would then allow interventions—which could be engineering, procedural or training, to be put in place to rectify a problem.

  3.3  FDM is recommended by the International Civil Aviation Organisation (ICAO) and adopted into UK legislation such that operators of aircraft over 27 tonnes have been required to operate an FDM programme since 1 January 2005. The benefits for the industry are well documented in terms of both operational safety and in economic efficiency. By effectively auditing" the vast majority of flights, operators are able to ensure aircraft are operated more closely to their standard operating procedures (SOPs). This can reduce engineering and fuel expenditure as well as having a direct positive effect on safety.

  3.4  Another area in which the CAA has made a significant contribution to aviation safety has been in its work on Safety Management Systems (SMS) including the publication of guidance material (CAP 712) in 2001 and 2002. Whilst parallel work has been conducted by, in particular, the Australian and Canadian regulatory authorities, the CAA have been proactive in encouraging the aviation industry to adopt the concept of Safety Management Systems. An SMS provides a means of compliance with elements of JAR-OPS and is also advocated by ICAO through its Accident Prevention Manual. The guidance provided by CAA, which was developed in consultation with the industry, has assisted operators in developing and implementing the specifics of such a system.

  3.5  Safety Management Systems include elements such as management commitment, policies and procedures, training, audit, risk assessment, investigation, emergency planning and documentation. The key to an effective SMS is the development of a positive safety culture", a concept which developed from the reaction to key accidents such as the reactor fire at Chernobyl, the capsize of the MV Herald of Free Enterprise and the explosion on the Piper Alpha exploration platform. A positive safety culture begins with senior management commitment to safety, and defines clear policies on safety that are supported by appropriate training and equipment. The distinction between what is considered to be acceptable and what is not needs to be clear. The organisation's response to failure should be concerned with learning from the experience. Punishment should only considered where wilful violations have occurred—a so-called just" culture.

  3.6  The CAA's role in developing Safety Management Systems should not be underestimated. The safety culture of any UK aviation organisation is strongly influenced by its relationship with the regulatory authority. While there is no evidence of capture" of the CAA by the industry, there are strong working relationships which have allowed lessons learned to be shared in an atmosphere of trust. However, as the transition towards EASA continues, new relationships will need to be established. The mode of operation of EASA compared to CAA is different and the ability of the industry to innovate in safety should not become the sole domain of the regulatory agency. The CAA has worked collaboratively with the aviation industry in a number of areas where changes to standards have been proposed, and demonstrated to be appropriate by the industry itself, and subsequently endorsed by the CAA.

  3.7  Since 1999, the CAA has required helicopter health monitoring systems (HMS) to be fitted to UK registered helicopters issued with a Certificate of Airworthiness in the Transport Category (Passenger) with seats for greater than nine passengers. Also known as Helicopter Usage Monitoring Systems (HUMS), this form of FDM has made a major contribution to fault detection and hence accident prevention. The work that the CAA has done in this area, again in collaboration with the industry, has far reaching effects in an area of the aviation industry which experiences higher operational threats.


  4.1  The UK Civil Aviation Authority's Safety Regulation Group has a very proud history of conducting and supporting research. Its positive effect has not just been on the UK industry, but on the worldwide aviation industry and is a major factor in establishing the level of esteem that the CAA has been held in until now. Recent research successes have included:

    —  The establishment of a Flight Operations Research Centre of Excellence (FORCE), based at Cranfield University. This is a world-first collaboration of industry and academia to focus on the flight operations side of aviation with projects in areas such as checklists, type-rating syllabi, risk assessment, and required navigation performance (RNP).

    —  Work on safety of helicopter operations in the high-risk North Sea environment including flight data monitoring, lighting, ditching and crashworthiness, turbulence, and GPS reception projects.

    —  Research into aircraft icing including ground de-icing and techniques to reduce incidence of carburettor icing in piston engine aircraft.

    —  The development of a tool for measuring safety culture within maintenance organisations.

    —  Mid-air collision risk modelling.

    —  The development of a model to properly assess GPS approaches proposed by the aviation industry.

  4.2  With the development of EASA and commensurate reduction of direct income to the CAA, the funding for research has diminished accordingly. Currently in the region of £1 million per annum and due to drop by two-thirds, the budget pales compared to other safety-critical industries. For example, in 2001, the Rail Safety and Standards Board (RSSB) launched a £70 million research budget over five years. However, DfT figures published in 2004 indicate an equal UK relative fatality risk (per billion passenger km) for both air and rail transport. Without funding for continued research, the aviation industry cannot expect to maintain its current level of safety performance as new challenges present themselves.

  4.3  Although EASA is forming a wish list" for research, it is, as yet, unpublished and unfunded. Meanwhile the present state within the UK CAA is one of declining capacity. The uncertainty within the CAA makes it difficult for other funding bodies such as the Engineering and Physical Sciences Research Council (EPSRC) to commit to longer-term collaborative funding. However, the UK aviation industry has in some cases been proactive enough to support what it considers to be useful work by the CAA. Examples include easyJet, MyTravel and the helicopter industry. Whilst an encouraging sign, this depends on the ability of a particular industry sector to fund research—something which may not necessarily equate with risk. In other words, although the general aviation sector may have a higher accident rate, its ability to fund research is very limited.


  5.1  The Air Accidents Investigation Branch (AAIB) exists as an independent agency within the Department for Transport (DfT), reporting directly to the Secretary of State for Transport. Its reputation within the aviation industry for conducting no-blame safety investigations, in accordance with the standards and recommended practices laid out in ICAO Annex 13, is a strong one. AAIB does not have legislative powers, but instead makes formal recommendations to the industry and its regulators through its reports and bulletins. Many of these recommendations are made directly to the CAA and although not all are acted upon by them, this has been a generally effective relationship. Indeed, the UK has released a significant number (approximately 3,000) of Additional Airworthiness Directives (AADs), which are not necessarily required by other states. With the assumption of airworthiness responsibility by EASA, it was proposed that these AADs were scrapped. Whilst some have become obsolete (such as where aircraft types have ceased to be operated) others are very important (such as HUMS) and should be adopted by EASA. This is an ongoing issue and should be carefully monitored to ensure that hard-won safety initiatives are not lost to harmonisation".

  5.2  The relationship between AAIB, CAA and EASA needs to be carefully monitored to ensure that recommendations are made and acted upon in a timely fashion. Whilst the AAIB is encouraged by EASA's intention to work more closely with the national investigation agencies to develop a unified approach to the making of, and response to recommendations, this is not something that has yet developed into a tangible process.


  6.1  In addition to the transition to EASA, the regulation of safety within UK aviation will need to cope with a variety of new challenges. Although aviation has matured as an industry, new developments continue and active regulation is important in order to maintain standards. Developments such as ultra-long range aircraft, ultra large aircraft, increased use of composite and other new materials, very light jets (VLJs), fractional ownership and so on, demand a regulator which is able to keep pace.

  6.2  If CAA is allowed to wind down" before EASA has reached maturity, there is a significant risk that it will not be able to adequately execute its regulatory function. Already, there are examples of where operators of advanced equipment are unable to gain regulatory approval for new safety-critical equipment because of the CAA's inability to keep up. Arguably, the economies of scale that EASA may offer will allow a greater capacity to deal with the certification of new technology. However, in the meantime the risk that operators decide to move from the UK register or operate equipment without approval needs to be managed.


  7.1  The Civil Aviation Authority has developed an excellent reputation amongst the World's aviation community for its commitment to regulating and enhancing safety. However, as the European Aviation Safety Agency continues to develop and the CAA reduces its own role, there is a risk that the high levels of safety achieved thus far may be compromised. Whilst the system may not necessarily be described as unsafe", the operating and political environments are notoriously unforgiving of lapses of attention. Past successes and an apparently good accident record should not allow complacency to develop.

  7.2  Particular attention should be paid to monitoring the transition, including areas such as staffing, research capacity and funding, Additional Airworthiness Requirements, the relationship with the Air Accidents Investigation Branch, and the certification of new technologies.

13 January 2006

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