Improvements in Aviation Safety:
Potential Impact on Safety Investigation Environment
Ms Nancy Graham,
Director, Air Navigation Bureau of International Civil Aviation Organization (ICAO),
Capt Kevin Hiatt,
President and CEO of Flight Safety Foundation (FSF),
Ladies and Gentlemen,
A very good morning. It is a pleasure for me to join you today at the 2nd International Accident Investigation Forum. I would like to extend a warm welcome to all delegates.
We are encouraged by the significant presence of international participants. It reflects not just the importance of the topic, but the strong ties and partnership within the accident investigation community.
Commendable Safety Record of Air Transport Industry
We meet today against a backdrop of continued, strong growth in air travel. According to ICAO, the number of air passengers increased by more than five per cent in 2012, hitting 2.9 billion. The number of aircraft departures reached a record 31 million, one million more than in 2011.
Yet, despite the high volume of air travel, air safety has never been better. According to the International Air Transport Association (IATA), last year's global accident rate for western-built passenger jets was the lowest in aviation history, with just three fatal crashes on such aircraft – and none among any of IATA’s 240 members.
The strong safety record of the air transport industry can be attributed to the hard work and dedication of many stakeholders, including the meticulous work of accident investigators and safety regulators, where every accident, including potential accidents, incidents and “near-misses”, are thoroughly investigated for safety lessons. Through these investigations, defects are identified and corrected, procedures changed, and human errors addressed, to prevent recurrences.
In this regard, we must also commend ICAO’s leadership for promoting policies and initiatives that advance aviation safety and I am pleased that Singapore has been able to play a role in supporting them.
In particular, three years ago, thanks to the strong support of ICAO, the Flight Safety Foundation, the European Civil Aviation Conference and the International Society of Air Safety Investigators, Singapore’s Air Accident Investigation Bureau was privileged to host the inaugural IAI Forum. This year’s Forum builds on the inaugural Forum, with an even more significant line-up of speakers and topics. Singapore hopes, through hosting this Forum, to make a contribution to advancing aviation safety and accident investigation cooperation.
Challenges for Safety Investigation
While the improvements in aviation safety call for celebration, we must not take them for granted. Air France’s Airbus 330 Flight 447 crash into the Atlantic Ocean almost four years ago is a sombre reminder that when air accidents happen, they are often highly tragic events.
And paradoxically, the improvement in air safety poses challenges for aviation safety and consequently for safety investigations. Let me elaborate.
Lack of Practical Experience
The aviation system is getting more sound, with safer aircraft, better-trained pilots and engineers, as well as more sophisticated air traffic control. However, with fewer accidents, not many of us gathered here can be involved in actual accidents often enough to become highly proficient. It is hard to accumulate experience, and the challenge then lies in finding the means to go beyond theoretical knowledge, to gain practical experience in various aspects of investigative work, including organisation and management of search and recovery operations. So, whenever possible, allowing partner investigation agencies to send observers or to be attached to investigation teams, as well as more realistic training and simulation exercises, must increasingly be the way forward.
Increasing System Complexity
Indeed, rapid changes in air transport technology such as satellite-based navigation systems, high efficiency engines, the increased use of composite materials and, more recently, the extensive use of lithium-ion batteries to power key aircraft functions, underscore the importance of training. To sustain the relevance and usefulness of accident investigations to the aviation industry, as the industry evolves, it is imperative for accident investigators to keep pace with the changes and the technological advances.
Moreover, aircraft systems have become ever so sophisticated and automated. They are designed to aid the flight crew during normal operations. However, they can also complicate the cockpit environment during unusual circumstances. Over-reliance on automation can detract from basic airmanship. And the level of system sophistication may be beyond the ability of the crew to quickly make sense of the signals that are supposed to warn them of system malfunctions.
Here again, we can learn from Flight 447. The event may have started as a “simple” problem of unreliable airspeed indication. But when the appropriate response procedure for such airspeed indication problem was not undertaken, the situation deteriorated to a degree where the crew could not understand anymore. The French investigators have in their report highlighted the need for pilot training to ensure that crews have the capacity to understand a deteriorating situation.
A much more fortunate outcome happened some 17 months later, in November 2010. The five-man Qantas crew of a modern Airbus 380 aircraft was bombarded with automated warning messages after an engine had failed in-flight soon after taking off from Singapore. The combined wisdom and experience of the highly trained crew allowed them to diagnose the deteriorating situation effectively and bring the crippled aircraft safely back to Singapore.
15 It is clear that for both the system designers and accident investigators, a deeper understanding of the risks associated with failure of complex systems, and a better appreciation of the human factors when confronted with such unexpected failures, would be issues that have to be looked into.
Insufficient Protection of Safety Data
Another major challenge for investigators is the protection of safety information. For years, investigation agencies have been stressing that safety investigations do not seek to determine blame or liability; rather, they are conducted for the sole objective of improving aviation safety. This is important so that those involved will freely provide complete and accurate information, which is essential in identifying safety deficiencies and reducing accidents. Indeed, the collection and use of safety data allow us to draw safety lessons from previous accidents to avert future ones. Therefore, the fundamental reason for protecting safety data – to improve aviation safety – must be driven home time and time again, to prevent the inappropriate use or unauthorised release of the data, to the detriment of aviation safety.
In this regard, I am glad that ICAO has formed a Safety Information Protection Task Force to look into the issue, and Ms Nancy Graham will be updating the Forum on the outcome of this task force.
Let me conclude. It is a no-brainer that aviation safety must remain a top priority for all of us in the aviation community. 2012 has been a good year for aviation safety. We must take advantage of such clear skies to learn, improve and work together in close cooperation to further improve safety and investigation processes. Singapore is committed to contributing and working with our partners towards this end.
I wish all of you an enjoyable and fruitful Forum, and for our overseas guests, an enjoyable stay in Singapore. Thank you.