Memorandum submitted by Dr Graham Braithwaite,
Director, Cranfield University Safety and Accident Investigation
Centre, Department of Air Transport, Cranfield University
1. OVERVIEW
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. EUROPEAN AVIATION
SAFETY AGENCY
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. CIVIL AVIATION
AUTHORITY SUCCESSES
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. SAFETY RESEARCH
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. AIR ACCIDENTS
INVESTIGATION BRANCH
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. FUTURE CHALLENGES
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. SUMMARY
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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