EUROPEAN AVIATION SAFETY SEMINAR – BUCHAREST 10-12 MARCH 2008

CHIEF EXECUTIVE’S REPORT

· Click here for EASS Programme. The entire proceedings papers are only available on payment through the Flight Safety Foundation, however, the UKFSC holds a copy of the proceedings in the library and individual papers can be transmitted on request. The Key Messages and highlights from the sessions follow in this report.

· In the Opening Ceremony, Bill Voss, the CE FSF described the outcome of his review of the FSF and the way it will go about its business in future. The AeroSafety World magazine sells 2000 hard copies (FOCUS – 11000) and has now introduced a soft copy on its website with an 18000 circulation. FSF aim to influence through establishing global partnerships and exploiting the ICAO Global Air Safety Road Map. They have joined IATA in addressing the shortage of qualified aviation safety personnel, engineers and pilots and joined with Eurocontrol to sponsor an aviation safety encyclopaedia website known as ‘Skybrary’.

· Eurocontrol ATM Dep Director raised the issue of a 10% AT Controller shortage with high number of retirees approaching. The intro of CESAR was exacerbating this leading to a 20% shortfall soon. He addressed the threat of legislation on open reporting culture.

· Mike Ambrose, ERA, highlighted the need for action from the regulator on aircraft icing on supercritical wings and the unacceptable pressures being exerted on crews by airlines to fly with technical problems. He also raised concerns about multinational crews, the need to harmonise in-flight procedures and the need for protection of safety critical data and just culture. Finally, he expressed the desire for common EU-wide safety standards and aircraft registration and for emergency response plans to be strengthened

· Davis Learmount (FLIGHT) reviewed the past year in flight safety terms. Fatalities were down (744) whilst hull loss (25) was up.

· The entire afternoon of Day 1 involved a panel discussion on criminalisation and safety with a distinguished panel of legal and safety experts from a number of key nations. The discussion was based around a fictitious scenario designed to draw out the complex multinational issues that surround an aircraft accident – both in the immediate and longer term. The Key outputs from the discussion included:

o Corporate Manslaughter legislation will be introduced in the UK from 6 April 2008 which will have significant consequences for UK airline management boards. Fines of 1.5% of turnover and 4 years in prison for directors).

o A sea-change in legal attitudes – in the past a pilot was blamed for an accident, in future, the company will be blamed for not training the pilot appropriately.

o Scapegoating of aircrews involved in aircraft accidents can be expected in certain countries. Duty of care considerations for crews by airlines need to be in place for such events.

o Crews should have separate dedicated legal advice to that available to their airline.

o Evidence that an airline has a positive just and open culture on safety carries significant weight with courts of law.

o Airlines should employ a single professional spokesman to handle media in the event of accidents- and identify who in their emergency plan beforehand.

o Personal protection and counselling for those involved in an accident- both victims and families - needs prior consideration.

· The Dutch AT Safety Institute presented on an investigation into SID deviations. They found 3 significant deviations (300’ vertical/300’ horizontal) for every 100K SIDs carried out. Major factor was the wrong SID being taken by the crew. This was caused by a similar sounding name, lack of crew preparation, read-back error, late changes and crew expectation. Conclusion was that SID names should be chosen carefully and late runway changes should be avoided.

· The Head of Norwegian Air Safety described their methodology for assessing the risks involved in approaches and departures for Norwegian airfields. Through analysis of past accidents and applying knowledge of the wide number of threats – weather, terrain, obstacles, ac performance variations, nav aids and visual references - a comprehensive model has been built that can be applied to any airfield.

· The Swiss DFT Civil Aviation Safety Officer presented on his serious concerns with the lack of interoperability between ACAS and STCA, using the Uberlingen mid-air accident as his model. His major issues were that over Europe there are 30 TCAS RAs per flying day – 2 per hour and contradictory indications were common between TCAS and STCA which needed resolution. He pointed out that TCAS had been developed independently from STCA. His conclusions were that action on training and education was essential and protocols to introduce interoperability between both systems should be developed urgently.

· The presenter from the University of Texas briefed on the principles of NOSS – Normal Ops Safety Survey. The aim of NOSS was to develop a threat recognition and error management system or framework that identified threats, events and errors that occurred beyond the influence of ATC. Ultimately, the objective of NOSS is to predict the margin or point at which normal operations move to a higher threat environment. This is achieved through observing the routine error management being undertaken by the crew before the error becomes gross or significant. A LOSA is an application of NOSS principles.

· Ratan Khatwa from Honeywell presented on his findings from an investigation among airline crews about the utilisation of Weather Radar to identify CB. His pitch was that aircrew knowledge and training was inadequate. Examples of gaps included poor tilt and gain management, earth curve effect, interpretation of ground returns, radar attenuation, system limits at high altitude and poor technique generally. His recommendations were for operators to formalise initial and continuation training on fundamental concepts, system limitations, tilt management and overscan of storm cells.

· James Burin from FSF presented on the FSF Runway Safety Initiative which is aimed at addressing incursions, excursions and confusion. The former two are well documented but the latter is not. The output from the Initiative will be a catalogue of Runway Safety Products. He went on to suggest that the majority of excursions were being caused by unstable approaches and that the French were in the process of introducing regulations on approach criteria. He concluded that the lack of statistics on ‘confusion’ events around airports and airfields required attention in order to highlight and prevent confusing taxi procedures before they were introduced.

· Michel Masson from EASA covered the ESSI programme and then briefed on the establishment of the 3 main co-ordinating groups in EASA – ECAST, EHEST and EGAST. Over 150 external organisations and interest groups are now represented across these fora.

RICH JONES

CHIEF EXEC

UKFSC