Journal of Aviation Management 2013 by Singapore Aviation Academy

Journal of Aviation Managem

ent 2013

An annual publication by the Singapore Aviation Academy

Journal of Aviation Management 2013

Journal of Aviation Management 2013

Published by Singapore Aviation Academy

A Division of the Civil Aviation Authority of Singapore

1 Aviation Drive Singapore 499867

Tel: (65) 6540 6209/6543 0433 Fax: (65) 6542 9890/6543 2778

Email: [email protected] Website: www.saa.com.sg

Copyright © 2013 Civil Aviation Authority of Singapore. All rights reserved.

No part of this Journal may be reproduced or transmitted in any form or by any means

without prior approval of the publisher, except for quotations in book reviews.

Views expressed in this Journal are the authors’ personal observations and not

necessarily the views of the Civil Aviation Authority of Singapore. While every

reasonable care has been taken in the preparation of the Journal, the publisher

is not responsible for any inaccuracies in the papers.

Cubism is an art movement that challenges visual conventions

by depicting its subjects from multiple viewpoints, allowing

subjects to be represented with greater depth. Knowledge,

like art, is strengthened by a multiplicity of perspectives. By

gathering the diverse viewpoints of the different stakeholders

from the international aviation community, the Journal of

Aviation Management strives to be a platform for a global body

of knowledge to be developed, enhanced and shared.

A Multi-faceted Exchange

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Foreword

Yap Ong HengDirector-General

Civil Aviation Authority of Singapore

As the Journal of Aviation Management enters its thirteenth year, it continues to serve as

an intellectual platform for the sharing of knowledge and experiences on developments as

well as topical issues affecting international aviation. The themes for this installment of

the Journal reflect this – accident investigation, airport emergency management, aviation

safety and security as well as human resource and training, with the papers put forward

by leading experts from Singapore and around the world.

In the section on accident investigation, highlighted are the key elements of an

accident investigation establishment and the increasing influence of media on accident

investigation which has led to a reassessment and exploration of communication

tools for greater transparency and effectiveness. The section on airport emergency

management elaborates on the new standard test protocol for compressed air foam

systems and Class B fires which is being developed by the International Civil Aviation

Organization (ICAO) to improve aircraft rescue and fire-fighting efficacy.

A dedicated section on aviation safety takes a closer look at Europe’s experience

with just culture, ICAO’s role as well as the relationship between the culture of

an organisation and the management of operational risks. The section also looks

at safety performance measurement and the collection and analysis of safety

data. The aviation security section highlights the challenges and opportunities

discussed at the High Level Conference on Aviation Security held in September

2012 as well as ways to enhance the security of civil aviation globally.

Last but not least, the section on human resource and training looks at how

competency-based training can be adapted to address the huge demand

for aircraft maintenance personnel. It also reviews the work of ICAO’s

Next Generation of Aviation Professionals (NGAP) Task Force aimed at

attracting, retaining and developing the human resource required to

deliver aviation services to the world.

To the authors and the members of the Editorial Advisory Board,

I would like to express my appreciation for their valuable contributions,

without which this publication would not be possible. To the readers,

I hope this issue of the Journal will not only serve as a useful resource,

but also inspire you to contribute more to the aviation industry.

Mr Cletus M J Packiam

Chief Airport Emergency Service

Changi Airport Group, Singapore

Mr Chiang Hai Eng

Director, Asia Pacific Affairs

Civil Air Navigation Services Organisation

Dr Michael Lim

Director, Singapore Aviation Academy

Civil Aviation Authority of Singapore

Dr Jarnail Singh

Chairman

Civil Aviation Medical Board, Singapore

Mr Mark Reeves

Director, Asia Pacific Office

Federal Aviation Administration, US

Mr Ken McLean

Director, Safety Operations & Infrastructure (Asia Pacific)

International Air Transport Association

Mr Bernard Lim

Director, International Relations & Security Division

Ministry of Transport, Singapore

Prof Henry Fan

SAA Fellow

Ms Chan Pin Pin

Ms Jasmin Ismail

Ms Addrienne Kang

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Editorial Advisory Board Members

Editorial Team

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ContentsAccident Investigation

Airport Emergency Management

Accident Investigation – In Pursuit of Safer Skies 1

Y P Tsang

Civil Aviation Department, Hong Kong SAR

AF 447 Investigation – Media Influence, Transparency and Communication 9

Ms Martine Del Bono

French Bureau of Investigation and Analysis for Civil Aviation Safety

Future Trends in Aviation Safety, Aircraft Rescue and Fire-fighting Efficacy 17

Kim Thorbjørn Olsen

Copenhagen Airport, Denmark

Aviation Safety Just Culture in Aviation: The Best of Two Worlds 23

Roderick van Dam

EUROCONTROL

Safety Performance Measurement – Quantifying Safety Performance Indicators

and an Acceptable Level of Safety 31

Teo Gim Thong

International Civil Aviation Organization

The Safety of the Flying Public is Our Top Priority – Do We Say What We Mean

and Does it Matter? 45

Capt Paul McCarthy (Retired)

Turning Data into Safety 53

Joseph Teixeira

Federal Aviation Administration, US

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Competency-based Training in Aircraft Maintenance 69

Lim Yeow Khee

President, Singapore Institute of Aerospace Engineers

Global Efforts to Address Shortage of Aviation Manpower 83

Dr Paul Bates

Griffith University, Australia

Aviation Security Aviation Security – Challenges, Opportunities and the Way Forward 63

Bernard Lim

Ministry of Transport, Singapore

Ms Patricia Reverdy

European Civil Aviation Conference

Human Resource and Training

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Accident Investigation – In Pursuit of Safer Skies

Although air transportation is widely recognised as the safest mode of transport, the aviation community, including

air accident investigators, continues to work relentlessly to make our skies even safer. Annex 13 to the Convention on

International Civil Aviation – Aircraft Accident and Incident Investigation (Tenth Edition July 2010) (hereafter referred to

as “Annex 13”) specifies that the objective of the investigation of an accident or incident is for the prevention of recurrence

and not for the purpose of apportioning blame or liability. The identification of causal factors to prevent recurrence

is best accomplished through a properly conducted investigation. To meet these international obligations and

to enable a proper investigation of accidents or incidents to be conducted, the government authority needs to put

in place an appropriate establishment. This paper highlights the key elements of an accident investigation establishment,

making reference to the experience of accident investigations conducted by the Hong Kong Civil Aviation Department (CAD)

and to showcase the new accident investigation facilities in Hong Kong.

Accident Investigation

ABSTRACT

Mr Y P Tsang is the Deputy Chief Inspector of Accidents of CAD of Hong Kong SAR.

Mr Tsang started his aviation career in 1974 with the Hong Kong Aircraft Engineering Company (HAECO) as an apprentice. He obtained his aircraft maintenance engineer qualifications in 1980. He was awarded the first International Federation of Airworthiness (IFA) scholarship the following year and worked at various customer organisations at the Boeing Commercial Airplane Company in Seattle, US for a year. Upon his return to HAECO, he was involved in a number of departments including Technical Services and Quality Assurance. In 1985, he was responsible for the design and installation of the modernised environmental control system into the Y7 aircraft manufactured by Xian Aircraft Company.

Mr Tsang joined the CAD in 1995 and was responsible for the certification of aircraft, assessment of major modifications and repairs. He was appointed the Deputy Chief Inspector of Accidents in 2003 and was the Investigator In-charge of the Eurocopter EC155 fatal accident in Hong Kong in the same year.

THE AUTHOR

Accident Investigation – In Pursuit of Safer Skies Accident Investigation

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Y P TsangCivil Aviation Department of Hong Kong SAR

INTRODUCTION

With very low accident rates in recent decades, air transportation is widely recognised as the safest mode of transport. The aviation community, including airlines, aircraft manufacturers, maintenance organisations, air navigation service providers, airport operators, and the safety regulators have been working closely to make our skies safer. Amongst all the stakeholders involved in the aviation industry, there is a particular group of aviation professional who are seldom mentioned, yet they contribute significantly to improving aviation safety. They are the air accident investigators – the people whose job is to determine the causes and circumstances of air accidents and incidents so that similar accidents can be prevented. One accident is one too many; and whenever it happens, it is bound to hit the news headlines across the globe almost instantaneously. The idealistic aspiration of zero accident, albeit statistically unachievable, keeps everyone in the aviation profession focused on building an increasingly safe aviation system.

In the international civil aviation regime, Article 26 of the Convention on International Civil Aviation (Ninth Edition 2006) stipulates that it is incumbent upon the State in which an aircraft accident occurs to institute an inquiry into the circumstances of the accident. Annex 13 further specifies that the objective of the investigation of an accident or incident is for the prevention of recurrence and not for the purpose of apportioning blame or liability. The identification of causal factors to prevent recurrence is best accomplished through a properly conducted investigation.

To meet all these international obligations and to enable a proper investigation of accidents or incidents to be conducted, an appropriate establishment needs to be put in place by the Contracting States. With continuous air traffic growth globally, such an air accident investigation establishment is essential and instrumental to support the growth and development of a safe and sustainable air transport system. It should comprise, inter alia, the following six key elements:

INDEPENDENCE IN ITS AUTHORITY TO INVESTIGATE

Independence in its authority to investigate is of utmost importance. The organisation responsible for conducting air accident investigations must be strictly objective and totally impartial, and must also be perceived to be so. It should thus be established in such a way so as to be immune from political interference or pressure.

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Some States, particularly those with a large volume of air traffic and a wide range of aviation activities, have achieved this important objective by establishing their air accident investigation authority as a separate statutory body independent of the civil aviation regulatory authority (CAA).

In many other States with relatively small scale of aviation activities, it may not be practical or economically viable to adopt such an arrangement. To achieve a certain level of independence in accident investigation, these States may set up an arrangement whereby, in the event of an accident or serious incident, the State would mobilise a normally dormant accident investigation team comprising qualified investigators, or appoint a separate commission, to conduct the investigation and report independently to the appropriate authorities.

Because of the dormant characteristics of such a setup, few, if any, of the team or commission members would be fully employed as accident investigators. Some members may be seconded from the state regulatory agencies on a need basis. In such circumstances, clear delineation of responsibilities and duty specifications must be included in the appropriate legislation emphasising the importance of independence, impartiality and objectivity of an investigation. In the course of an investigation, clear policies should also be established to ensure at least

the following:

• No conflict of interest exists between members of the investigation team and parties under investigation.

• Membersoftheinvestigationteamshalladheretotheobjectiveofaccidentinvestigation in defiance of political and commercial considerations.

• The investigation team is to reportdirectly to theheadof the investigationorganisation who should report directly to the government/administration, independent of the CAA.

• The findings and recommendations of an investigation team shall not be influenced ortampered with by any other party not involved in the investigation.

Although the above arrangement may not be ideal, there are many successful examples worldwide which demonstrate that the independence of investigation has been maintained. It is most important for States, administrators and all those who are involved in air accidents investigation to understand the objective of maintaining independence in investigation, adopt the arrangements that best suit their needs and circumstances, and implement it effectively through a sound and auditable mechanism.

SOUND LEGAL AND REGULATORY FRAMEWORK

The second key element for the establishment of a highly functional air accident investigation setup is the availability of a sound legal and regulatory framework in support of its mission, and to provide accident investigators with the required legal authority for the conduct of safety investigation in accordance with the provisions of Annex 13.

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Appropriate legislation that defines the scope of work and responsibilities of the accidents investigation establishment and those of accident investigators must be put in place. In this connection, accident investigators should be aware that air accidents may not only be subjected to technical safety investigation, but also to other judicial, statutory, administration or regulatory inquiry. Clear provisions and procedures should thus be formulated to keep the technical safety investigation separate from other proceedings.

The legislation and regulations should also clearly specify that the sole objective of the technical investigation is accident prevention and it is not to apportion blame or liability.

The legislation must also protect certain documents and information obtained during the investigation from public disclosure in accordance with Annex 13. This is particularly important as information contained in some records may include information given voluntarily by persons interviewed. Inappropriate exposure of information obtained in the course of an investigation for purposes other than the prevention of accidents would inhibit disclosure of information from witnesses in future. It would impede the work of investigators and negatively impact the thoroughness and accuracy of future investigations, at the expense of promoting safety.

QUALIFIED INVESTIGATORS

The next key element is the people actually engaged in conducting accident investigations. Even in today’s highly modernised and technology-driven society, the significant involvement and contribution of human efforts in accident investigation is indispensable.

Accident investigation is a highly specialised and time-critical task involving expertise in a wide range of aviation and non-aviation disciplines. The quality and outcome of an investigation are heavily dependent on the competence and capabilities of the investigation team. As such, accident investigation should only be undertaken by people with the right calibre and experience, and are specially trained.

Accident investigators should ideally have a professional background in aviation, such as pilot, aeronautical engineer or aircraft maintenance engineer. The possession of expert knowledge, skills and a thorough understanding of the aviation operating environment is of paramount importance to an accident investigator. Other aviation personnel who possess experience in aviation management and operations, air traffic control, meteorology and human factors could also contribute positively to accident investigation.

In addition to technical expertise, an accident investigator should also possess certain personal attributes, including integrity, impartiality, and perseverance in pursuing evidence collection, analysis, research and communication skills. An accident investigator must also be logical and methodical in thinking. He or she needs to be tactful, attentive to details and empathetic, especially in dealing with those who survived from the trauma of an air accident.

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Upon recruiting the right people, the next important step would be the provision of a structured induction training programme. This is essential to develop investigators’ ability, competence and experience for investigation tasks of various complexity. Novice investigators should be guided by experienced mentors until they are fully competent to work independently under the most taxing situation. The training programme should include rules and regulations, Annex 13 provisions, local legislation, interview and investigation techniques, latest investigation technologies, investigation procedures, on-the-job, recurrent and specialised training.

SOUND MANAGEMENT SYSTEM

To be prepared in the event of accident or serious incident, a response plan must be put in

place for the activation of the investigation processes in the most expeditious manner. The

availability of a sound management and support system is thus essential to ensure operational

readiness for the timely activation of the accident investigation process, especially in the

following areas:

• Regularreviewonsafetyregulationsandinvestigationpolicies;

• Quickresponseplan;

• Safetydataandinformationmanagement;and

• Publicrelationsmanagementandsupport.

With the continuous growth of the aviation industry and the rapidly changing technologies and safety requirements, there is a need for every aviation organisation to constantly review and update their organisational policies and operations to keep pace with the latest developments.

Quickresponseactionscanonlybeachievedthroughadequateplanning,coordinationanddrills before an accident or incident actually occurs. The setting up of quick response ‘Go-teams’ will enable the accident investigation establishment to expeditiously respond to the accident or incident for the collection of evidence, especially volatile evidence, as well as the timely coordination of the investigation process.

It isalsopertinentthataSafetyDataand InformationManagementSystembeestablishedfor the preservation of accident information and evidence and, whenever necessary, sharing of safety information within the organisation and with external parties during and after the investigation.Safetypromotionconstitutesanimportantcomponentofsafetymanagementand theState Safety Programme (SSP). It is essential that safety informationandaccidentprevention measures be promulgated widely across all spectrums of the aviation industry to achieve overall safety improvement.

Accidents or incidents often generate a high degree of interest from the public and the media. A clear public relations policy and procedure for the release of accident investigation

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information would be most helpful in managing public sentiment and undesirable speculations on the causes of the accident. Regular meetings with the media provide timely update on facts to the public without prejudice to the investigation process. Senior investigators should be given training on media management and opportunities for public speaking.

EFFECTIVE COORDINATION WITH OTHER STAKEHOLDERS

The circumstances surrounding each air accident or incident are different. To prepare for the eventuality of an air accident or incident, it is important that the accident investigation establishment set out a pre-coordinated working arrangement with other local authorities to facilitate smooth coordination and initiation of the respective emergency response in support of the investigation team.

To achieve this, the accident investigation organisation may establish formal working or cooperative arrangements with other government agencies involved in disaster response, particularly the police department, fire services department, search and rescue units, medical services and the coroner’s office. Such cooperative arrangements will foster better understanding amongst all stakeholders of the need of the investigators in the preservation of evidence.

In addition, the air accident investigation organisation may also have to seek assistance from other organisations to provide facilities, equipment and specialised services, additional manpower, e.g. heavy salvage and lifting equipment, helicopters, metal detectors, divers and surveyors during the investigation. It is thus important that arrangements be reviewed and expertise be identified in advance to ensure that resources are readily available when needed.

INTERNATIONAL AND REGIONAL COLLABORATION

The International Civil Aviation Organization (ICAO) and all of its Contracting States share a common goal of achieving safety, security, efficiency and sustainability in civil aviation. Close regional and international collaboration serves to obliterate the confines of the physical boundaries of States, and facilitates working towards achieving common standards and objectives of accident investigation amongst Contracting States.

On accident investigation matters, international and regional collaboration may include the delegation of investigation responsibilities, engagement in mutual assistance and cooperation, sharing of resources, specialised facilities, equipment and expertise in investigation. On accident investigators’ training, areas of collaboration may include the provision of investigators’ recurrent training, job attachment programmes, joint organisation of training events, etc., to facilitate and promote knowledge sharing as well as to broaden the exposure and enhance the competency of investigators.

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Through strengthened and closer cooperation between States and regional investigation authorities, the capability of air accident investigation organisations can be mutually enhanced to achieve a higher quality of investigation, thereby contributing to the good cause of aviation safety.

LATEST DEVELOPMENT IN HONG KONG

The Hong Kong CAD is presently taking proactive steps in working towards improving its accident investigation capability.

Under the current arrangement, Hong Kong has an independent investigation system under the management of the CAD. The Accident Investigation Division (AID), a normally dormant division under CAD, is responsible for the investigation of aircraft accidents and serious incidents in accordance with the Civil Aviation (Investigation of Accidents) Regulations. The conduct of air accident investigations in Hong Kong is in compliance with the Standards and Recommended Practices of Annex 13.

The AID will be mobilised in the event of an air accident or serious incident occurring in Hong Kong by drawing specially trained and qualified staff from within CAD. Currently, the AID has a pool of over 30 qualified investigators who possess considerable practical experience in aviation. They come from a wide range of professional backgrounds, and have been properly trained in areas covering:

• Flightoperations;

• Airworthiness;

• Airtrafficcontrol;

• Specialaviationsubjectssuchashumanfactors,flightdatarecorders,survivalaspects,etc.

Once the accident investigation team is activated and tasked with the responsibility to launch an investigation, the investigators are vested with the appropriate authority and are required to be entirely independent and free from any interference from other parties involved in the accident in order to maintain strict objectivity and total impartiality. Independence is firmly achieved through the provision of the Investigation Regulations, and an independent procedural and reporting arrangement within CAD.

To provide day-to-day administrative and management support to the AID, an Accident Investigation Office (AIO) was also established in 2012. The mission of the AIO is to enhance the capability and ensure the operational readiness of the AID, including regular review of the investigation procedures, quick response actions, investigators training arrangements, management of the safety information system and provision of public relations support. With the commissioning of the new accident investigation centre located in the new CAD Headquarters at the Hong Kong International Airport, the AIO also has the responsibility of managing and upkeeping the investigation facilities.

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This purpose-built accident investigation centre which occupies a floor area of about 700 m2,

provides dedicated facilities for conducting air accident investigations including:

• An accident investigation command centre to facilitate coordination during various phases of accident investigation (see Picture 1);

• A flight data recorder centre for the downloading and analysis of flight recorder data and voice recordings;

• A 200m2 fully air-conditioned hangar for the storage of evidence and critical parts of recovered wreckage; and

• Interviewrooms.

The commissioning of the new accident investigation centre in Hong Kong will provide an additional platform for the exchange of knowledge and experience with other parties and investigation agencies.

In terms of regional and international collaboration, the CAD has in recent years, signed cooperation arrangements with a number of overseas investigation agencies allowing it to share investigation skills and expertise when required. AID investigators under training also acquire knowledge and experience by participating in full-time attachment programmes with these agencies. Such arrangements have achieved positive results since its implementation. In addition, coordination arrangements with the local judicial authorities and relevant government departments have also been established to ensure common understanding of the roles and responsibilities of the investigator and the need for the preservation of evidence.

Picture 1: The Accident Investigation Command Centre

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In taking on all these challenges, AID investigators have one common goal – to continually enhance the competence in the field of air accident investigation to better serve the aviation community. The purpose is to enable proper investigation to be conducted with the objective of improving aviation safety. It is through the safety recommendations that we may avoid recurrence of similar accidents.

References

International Civil Aviation Organization. (2010). Annex 13 to the Convention on International Civil Aviation – Aircraft Accident and Incident Investigation. (Tenth Edition July 2010). Canada. International Civil Aviation Organization.

International Civil Aviation Organization. (2006). Convention on International Civil Aviation. (Ninth Edition). Canada. International Civil Aviation Organization.

AF 447 Investigation – Media Influence, Transparency and

Communication

Accident Investigation

ABSTRACT The Air France flight 447 (AF 447) accident resulted in intense media scrutiny, wild speculations, demands for transparency,

document leaks and subsequent disinformation. Various dynamics had hindered the French Bureau of Investigation

and Analysis for Civil Aviation Safety (BEA) Department of Communication’s ability to fulfill its mission. Globalisation and

the development of the internet led to a tremendous shift in the relaying and processing of information. In this context,

challenges faced by the Department of Communication in informing both relatives and the public led to a reassessment

of its communication tools. This paper highlights the benefits of social networks and suggests the importance of

an international effort. It also highlights the need to align communication media with a global online 21st century

public and increase cooperation among the Department of Communication’s international counterparts.

AF 447 Investigation – Media Influence, Transparency and CommunicationAccident Investigation

THE AUTHORMs Martine Del Bono is Head of Public Affairs of the French BEA. She has extensive experience in the fields of international and cross-cultural communication at the Paris Institute of Political Studies. She joined the BEA in 2002 and was subsequently promoted to her current position. Her mission includes designing and implementing communication strategies following major air accidents, ensuring appropriate access to information with media outlets, victims’ relatives and the public as well as promoting the interests of air safety within the aviation community. Since 2007, she has also been conducting crisis communication training sessions at the French National School of Civil Aviation (ENAC). Ms Del Bono has a Master’s Degree from Sorbonne University’s Graduate School of Information and Communication Sciences (CELSA), France.

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AF 447 Investigation – Media Influence, Transparency and Communication Accident Investigation

Ms Martine Del BonoFrench Bureau of Investigation and Analysis for Civil Aviation Safety

ABOUT THE AF 447 ACCIDENT

On 31 May 2009 at 22:29 Universal Time Coordinated (UTC), the Paris-bound AF 447 took off from Rio de Janeiro, Brazil. There were 228 persons on board representing 32 different nationalities – three flight crew members, nine cabin crew members and 216 passengers. The last radio communication between the crew and the Brazilian air traffic control took place at 1:35 UTC. Between 2:10 and 2:15 UTC, a position message and 24 maintenance messages were transmitted by the Aircraft Communications Addressing and Reporting System to the Air France Operations Coordination Centre in France. On Monday 1June 2009 at around 7.45 am local time, the BEA was alerted by Air France. After having established that the airplane had disappeared in international waters, and in accordance with Annex 13 (Aircraft Accident and Incident Investigation) to the Convention on International Civil Aviation, the BEA, as Investigation Authority of the State of Registry of the airplane, launched a safety investigation and a team was formed to conduct it.

INTRODUCTION

The mission of the French BEA is to improve air safety; that of the Department of Communication is to ensure an efficient relay of information from investigators to victims’ families and the public. To do so, it conducts private meetings with relatives, uses telecommunications and coordinates press conferences.

In the case of the AF 447’s accident investigation, several communication issues were encountered in the course of the investigation. Round the clock international media coverage, lengthy wreckage and flight recorders’ localisation and recovery, a carrier-manufacturer blame game, document leaks, and media speculations were all factors that contributed to a public loss of confidence not only in the Bureau’s findings and conclusions, but in its transparency and ability to remain an independent entity. The questions that needed to be raised by the Department of Communication in order to improve its ability to inform the public were determined by its experiences. Indeed, its actions and inactions had both directly and indirectly contributed to its own discredit. Challenges faced during this high-profile investigation led the Department to re-examine its current means of communication, its platform and its public exposure.

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DISINFORMATION AND TRANSPARENCY

In the few hours following announcements that AF 447’s location was unknown, a cycle of disinformation ensued. Victims’ relatives had to deal with both immense emotional crisis and intense media spotlight. Reporters “offered” an introspect into the families’ grief, provided wild speculations, featured various experts on its programmes, and tried to confront any entity it could, from the manufacturer, the carrier, the French National Pilots Union, the BEA and the European Air Safety Agency. The investigation carried on. Each time the BEA released details about the search for the wreckage or validated findings, the cycle started all over again. Families were interviewed outside the BEA or at their home; the media offered its own interpretation of the causes of the accident – as if to solve what had been labelled “the mystery of AF flight 447”; so-called experts were called back on set; and confrontations went on.

If we assume that the mission of the media is to report accurately on the progress of the investigation, sadly it often fails to do so. Viewers are implicitly taught to ignore the technical aspects of the investigation and to focus on the BEA’s “hidden agenda”. If the Bureau is not releasing new findings, then it is open season on the manufacturer and the carrier. If that option has been exhausted, then it is the turn of the pilots and the release of details about their private lives. In a nutshell, the investigation into a tragic air accident that has decimated families all over the world is treated like a public spectacle.

In this context of inadequate media coverage on a global platform, the BEA’s achievements remained grossly understated and its mission widely misunderstood. What member of the public can fully grasp the difficulties encountered in creating an international effort to both localise and recover the wreckage and flight recorders from a 3,900-metre deep mountainous seabed? Who knows about the daily phone calls in the middle of the night by journalists asking the BEA to comment on wild speculations; only to find out that the said comments had been utterly ignored in the morning’s articles and televised news reports? Or, last but not least, who can properly define the BEA’s mission? Who understands that it does not act as a penal institution, in that it does not accuse the pilots, their training or the manufacturer, but only determines the combination of factors and chain of events leading to an air accident?

Misrepresentations have drastic consequences on perceptions. For instance, ICAO’s Annex 13 (Aircraft Accident and Incident Investigation) logically recommends cooperation among the bureau of investigation, the manufacturer and the carrier to enable optimum expertise. However, when the BEA is portrayed as a penal institution working with the manufacturer and the carrier, cooperation and confidentiality raise suspicions about a potential conflict of interest. Public demand for transparency is then logical. After all, it has been told repetitively that things do not add up. This inevitably set the stage for document leaks on moral grounds, and the opportunity was seized. For example, shortly after the cockpit voice recorder was played to a restricted audience at the BEA’s headquarters, its contents were leaked and

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published in a book. The author, a flight instructor not involved with the investigation, released personal details about the flight crew’s casual conversations. The leak was then featured in various documentaries and news programmes, and the author’s actions were hailed by many as an example of investigative journalism.

A PARADOX

The media influence on the belief that the BEA had an agenda other than that of investigating was never supported by actual evidence. Unfortunately, the repetitive nature of the message combined with a large scale reach resulted in a logical demand for transparency, or “public supervision” of the investigative work the Bureau conducted. Paradoxically, news outlets seemed to be exempt from transparency. Is it not the role of the media to report based on accurate information obtained through sources with actual evidence? In the case of the BEA’s investigation and for most reports, this was not upheld. Indeed, media accountability was at a low.

What followed was a domino effect from one network to the next, to the point where the message in the headline prevailed over the veracity of the claim and the accountability of both the individual making it and the outlet reporting it. For the BEA’s Department of Communication, the battle was often lost before it began. Any comment offered with supporting evidence refuting a frivolous claim was ignored. As soon as the headline had spread like wildfire, any action by the Department was viewed as a defence strategy. To add fuel to the fire so to speak, time constraints associated with the process of validating findings did not allow the BEA to “wave evidence” which was kept confidential. This made matters worse. All in all, blowing the whistle is sometimes necessary to preserve public interest. However, blowing the whistle without evidence is merely fabrication. Most of the so-called blowing-the-case-wide-open reports found in the press were based on a simplistic approach to an extremely complex investigation and a disregard for information made available to the public by the BEA.

If transparency is the subject of many a controversy, the concept of privacy is not. Victims’ relatives do have a choice in welcoming reporters to their homes, being interviewed on network television sets and sharing their views or intimate details related to their grief. There were literally dozens of instances in which the relatives’ privacy was grossly overlooked, such as the frivolous manner in which the number of bodies recovered were reported, close-ups on body bags being unloaded in Brazil and so on. Tragically, such reports had the blueprint of a tabloid article, and did not contribute whatsoever to public understanding on the causes of the accident.

With the occurrence of such phenomena, one may feel compelled to ask: what type of transparency is expected from an investigative body? Is the need for transparency actually justified or is it the result of baseless speculations created by the media, combined with a lack of large-scale reach and informative content from the Department of Communication on

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regulations and procedures during an air accident investigation? How can the BEA be more transparent than it already is? The BEA followed procedures that are publically available. The recovery of the wreckage and that of the flight recorders were televised. Press conferences were hosted by the Director and open to all members of the press, where every single question was answered by the chief investigator and BEA technical experts. The Department of Communication took calls from reporters 24/7 and accepted to confirm or deny even the most outrageous claims. Lastly, the BEA’s website was open to all, and although its contents could be extremely technical, the Director provided explanations in layman’s terms on camera.

PUBLIC REACTION

With the ever-increasing use of the internet, getting information is as easy as entering a URL or logging into a social networking site to access a customised selection of media sources. The public can then get a better overview of available reports, and thus observe the subjectivity of some and the accuracy of others. The widespread use of comment sections or likes/dislikes (quick approval or condemnation of articles, videos and individual comments) enabled the BEA to observe some of the effects of disinformation on populations. If the message in the press is often one sided, public reaction is not.

Extensive research into the comment sections of both social networking sites and online media outlets produced five distinct categories of reactions from the public. The first focused on expressing condolences to the families of the victims. The second denoted a complete trust in media reports and the subsequent sharing of views on how the BEA could not be trusted, was incompetent and possessed a secret agenda. The third was more informed, often mentioning some professional qualifications related to either aviation, engineering or other technical fields and underlining discrepancies in the report itself. The fourth kind of reaction denounced the flip-flopping of most media outlets and their untrustworthiness. The last type consisted of approaching the release of information objectively, taking into account not only the article but also comments from readers. Fortunately, this enabled a better outlook on any report and better judgment on their veracity.

Thanks to the existence of comment sections across various online platforms, the public was given the opportunity to fight disinformation and acquire a more mitigated view of a particular event. The specific nature of social networking sites such as Facebook and YouTube also allows for a direct release of information from media outlets and/or reporters that are fully dedicated to their mission. The existence of such sites and accurate reporting by some news agencies has proven to be of paramount importance to the Department of Communication. Although a very significant percentage of the global population, companies and organisations use a variety of social networking sites, the BEA was not present on any of them. For all intent and purposes, the issue of public demand for transparency would partly solve itself if the BEA could communicate directly with the public.

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SOLUTIONS: FRAMEWORK

The press’s cooperation, or lack thereof, in relaying accurate information cannot always be predicted or assumed. The accuracy of media reports depends not only on networks, but on individual reporters as well. The BEA’s Department of Communication entertains a bittersweet relationship with the press; however taking preventive measures to alter this relationship would act against the French Republic’s core values and thus the mission of the Department of Communication. The “quick fix-do what it takes” approach would offer options that yield to rather disastrous consequences. For instance, giving exclusive access to particular reporters would infringe on the freedom of the press; blacklisting networks based on a 3-strike policy with regards to disinformation would infringe on freedom of speech; and responding to each and every inaccurate coverage and singling out reporters would not only create opportunities for sensationalised BEA versus media war but would also produce an additional basis for disinformation and accusatory statements. If solutions do not reside in altering the relationship with the press, should the Department of Communication then turn to inaction? After all, the BEA is an investigative body with a clear mission.

It can be argued, that as long as informative content is posted on its website and publically

available, its mission has been fulfilled; and that whether information is sought, altered, or

accurately reported by both the media and the public is not the Department’s primary concern,

as long as it communicates findings. However, viewed in the context of an air accident often

accompanied by a loss of life, grieving families and with a team of investigators working

relentlessly, the Department of Communication can and should, do better. Looking at the

process by which the public is misled on the BEA’s mission, misinformed on validated findings

and given unrealistic expectations in regards to the time frame of the investigation, one can

observe three elements:

• First,themediautilisesplatformsthataremoreeffectivethantheBEA’swebsite;

• Second,themediacentersitsmessageonasingleheadline;and

• Lastly,informationreleasedbytheBEAneedstobesought,contrarytomediareportsthatare delivered to the public, oftentimes through social media sites.

Should the Department of Communication turn to similar platforms to become more effective?

SOCIAL MEDIA

The answer to 21st century communication may lie in the use of social networking sites. Their use has actually been pioneered by investigative bodies such as the American National Transportation Safety Board and the Canadian Transportation Safety Board. Would this type of platform benefit the BEA’s Department of Communication during a high profile investigation such as that of AF 447? It may be so, but a number of concerns must be addressed. Indeed, any information released and publically available can be relayed and edited. This implies that

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issues encountered with sensationalism and false accusations will not disappear. Hardcopy material such as interim and final reports or video explanations provided by the chief investigator and other BEA technical experts may remain too technical and thus sometimes be misunderstood by the general public.

The creation of a more direct platform to improve communication such as a relatives’ group page raises both privacy and security concerns. Furthermore, the posting of any material on a site may result in questions related to ownership. Granted, the use of social media may bring about new challenges, but navigating through these potential issues is feasible. The great advantage of using social media is the combination of a fast release of information, which would align the BEA with the 24-hour news cycle; and reach, with a communication platform between the Bureau and the public, without any sort of intermediary. The wide array of features offered by these sites can also make the act of communicating more efficient and provide an easily accessible track record of the BEA’s statements and actions.

A non-exhaustive list highlights the following opportunities:

• Poststatementsandcommuniquésintheirentirety;

• Providelinkstositesreferencingofficialregulations;

• Postuneditedvideorecordingsofpressconferencesalongwithhighlights;

• Createeventpagesforpressconferencesandimprovelogistics;

• Createavictims’relativespagewithanSMSnotificationfeature;and

• Grantaccesstomeetingsandpressconferencesthroughafreevideoconferencingsite.

The creation of an international network through social media has the advantage to further open the door to freedom of speech. Disinformation and miscomprehension from individuals coming directly onto a BEA platform will voice their concern and thus enable the Department of Communication to further fulfill its primary mission: Inform. In addition, it has the benefit of retracing previous statements and improving their formulation, should they appear unclear to the public.

The use of social networking sites can also improve communication with victims’ relatives, who, in the case of AF 447, were most often isolated in countries abroad. The impact of any information or disinformation has a tremendous effect on their emotional state and addressing this issue with the utmost delicate care can remain a priority. This means creating not only a direct platform and taking active and/or proactive measures, but involving them in meetings and press conferences as well. Communication with both authors of accurate reports and speculators can also be improved. For the former, a social networking platform provides more precise details on the Bureau’s work and a better understanding of steps taken during the investigation. For the latter, it could redirect hypothetical statements towards more relevant aspects of the investigation…but this is just speculation!

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Lastly, the use of social networking sites can cut the mainstream media middleman that a great number of international alternative media rely on. Indeed, their lack of financial and human resources is an obstacle to their physical presence at press conferences. Instead of basing their coverage on local correspondents, they often use the “flavour of the day” reports featured in the mainstream media. Giving the alternative media an incentive to become more actively and directly involved in reporting on the investigation will, to a certain degree, diffuse disinformation and extend the BEA’s media network.

FURTHERING INTERNATIONAL COOPERATION

The question of network development applies to professionals as well. A platform used by the Department of Communication and its counterparts has the potential to further international cooperation and thus provide solutions to sometimes crippling issues. As mentioned earlier, relatives and the public are bound to get informed through either the BEA’s website or the media. However, most members of the international public do not possess the linguistic skills necessary to grasp complex issues in either French or English, and the BEA has a limited capacity to provide multilingual documents.

In the case of AF 447, with 32 nationalities on board, this issue became particularly challenging. Indeed, the technical expertise required for translation, and the risk of unauthorised and premature release of information involved with the hiring of language consultants represented serious issues. Furthering cooperation with the Department of Communication’s international counterparts in both translating and communicating locally could provide effective solutions. Advantages include confidentiality, accuracy, and reliability, which are elements necessary to ensure a secure relay of information. In addition, international cooperation would increase our understanding of public reaction and concerns abroad; and enable investigative bodies to properly respond to confusion from diverse populations. Lastly, this type of platform could be beneficial in both organising and coordinating international efforts and thus render logistical issues more manageable.

Future Trends in Aviation Safety, Aircraft Rescue and

Fire-fighting Efficacy

Airport Emergency Management

Aircraft Rescue and Fire-fighting (ARFF) is a highly specialised discipline within the Fire Services. ARFF crew must respond

quickly and with precision in order to minimise loss of life, injuries and other potential dangers. However, there are

limitations imposed by the resources available during the first response and that pre-planning and the success of the first

attack is essential for the final outcome. Fortunately, serious aircraft accidents are infrequent.

The aviation industry – our customers – always expects the Airport Fire Service to be able to cope with all emergency

situations. The operational use of a Compressed Air Foam System (CAFS) can easily be the tool that makes the difference

between life and death in a worst case scenario. New fluorine-free foams have the potential to and indeed will lessen the

environmental impact of fire service operations at airports.

The International Civil Aviation Organization (ICAO) is in the process of developing a new standard test protocol for CAFS

and Class B fires. Large-scale fire testing to ICAO Levels B and C carried out at Centre National de Prévention et de Protection

(CNPP) in France, under the auspices of the UK Civil Aviation Authority (UK CAA), have shown that a CAFS is more than 40

per cent more effective in knocking down a fully developed fuel fire than normal aspirated/non-aspirated Aqueous Film

Forming Foam (AFFF). The tests also show that Fluorine-free Foam (FFF) is just as effective as AFFF. If all goes as planned,

these will soon be implemented in future ICAO requirements.

ABSTRACT

Mr Kim Thorbjørn Olsen is Assistant Fire Chief of Copenhagen Airport, Denmark and has over 35 years of experience in the aviation industry. He is also Chief Instructor at the Copenhagen Airport Aircraft Rescue and Fire-fighting (ARFF) School. Prior to being a fire-fighter at Copenhagen Airport, he had served nine years in the Airport Police Security unit.

A member of both the International Aviation Fire Protection Association and the Aircraft Rescue and Fire-fighting Working Group (ARFFWG), Mr Olsen is Manager of Section 11 in the ARFFWG and also serves as a Liaison Officer between the two organisations. He is also an Instructor in ARFF on Incident Command at the Danish Emergency Services College.

THE AUTHOR

Future Trends in Aviation Safety, Aircraft Rescue and Fire-fighting Efficacy Airport Emergency Management

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Airport Emergency ManagementFuture Trends in Aviation Safety, Aircraft Rescue and Fire-fighting Efficacy

INTRODUCTION

Environmental issues with fluorine and the organic halogens (fluorosurfactants) in AFFF have resulted in the latter being replaced by new FFF. These FFFs are also fully ICAO Level B compliant (contrary to recent poorly founded claims by one fluorosurfactant manufacturer using faulty non-independent test procedures).

The UK CAA and other specialists from different parts of the aviation industry set up large-scale fire tests in May 2012 to compare CAFS with normal aspirated foam (using different foam products for ARFF) to ICAO Level B and Level C, including a comparison of FFF against AFFF. These tests took place at the CNPP research facilities in Vernon, France, with the participation of UK CAA regulators, manufacturers from the aviation and ARFF industries and airport fire-fighters (see Picture 1).

CAFS has been used to fight fires for many years. Traditionally, CAFS has been used to fight Class A/Structural fires and has never been used for Class B/fuel fires except under research conditions. CAFS is really a simple system in which high pressure air is injected into the water/

Kim Thorbjørn OlsenCopenhagen Airport, Denmark

Picture 1: ICAO Foam Testing in France

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Future Trends in Aviation Safety, Aircraft Rescue and Fire-fighting EfficacyAirport Emergency Management

foam solution before being pumped through the turret or hose line. Traditionally Airport Crash Tenders have operated using aspirating turrets and nozzles.

Simon Webb who led the project for the UK CAA, said, “This testing was an excellent example of the regulator, operators and manufacturers working together for the common aim of improving safety in aviation. The results of this research have delivered a key objective of the CAA Safety Plan to encourage the use of new technology in fire-fighting and will direct us on the way forward with CAFS technology.”

Industry partners who participated in the tests included the UK Airport Operators Association, Copenhagen Airport, Denmark, and Changi Airport Group, Singapore.

TEST AT CNPP AND RESULTS

On the first day, a plan was worked out by all participants on how the test procedure should best be organised in order to get good objective test results. The final plan was to combine CAFS with different foam agents which had previously not been combined. Before starting with the large-scale fire tests, the systems were optimised. CNPP staff measured the water flow rate, expansion ratio, as well as the 25 per cent and 50 per cent drainage times.

In order to measure the water flow rate, a 1,000-litre Intermediate Bulk Container (IBC) was filled for 20 seconds. This was then weighed so that the actual flow rate could be calculated. The determination of the quantity of foam used was done by weighing the difference between the filled and empty IBC container. This was done for every test.

Measurement of the foam quality was generally done according to the National Fire Protection Association (NFPA) requirements, except that the foam shield was placed at the end of the throw range instead of the usual two-third point. All measurements were performed by CNPP staff.

TEST PROCEDURE AND TACTIC

At the beginning of the tests, the pool was filled with water, so that there was at least a 10 cm water depth. Afterwards 1,500 litres of kerosene was poured into the pool and set on fire.

After the whole pool was lit up, the kerosene was left to burn for another 60 seconds before extinguishment began. The tactics to be used were discussed by the group of participants and were defined as follows: Firstly, the fire should be fought in a static way from a fixed position for two minutes, and thereafter, if the fire could not be extinguished then the fire-fighters should wait for 30 seconds and start extinguishment in a dynamic way until the fire was totally extinguished. After extinguishment, the burn-back test was done after waiting for five minutes. For this test, a burn-back pot (sleeve) was put into the pool, the foam in the pot was cleared away and 20 litres of heptane were poured into the pot and lit (see Picture 2).

The knock-down effect for the fire is essential in aviation fire-fighting. Any ICAO approved foam type has to be able to achieve this within one minute from foam application to fire is

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Picture 2: Burn-back Test

controlled. Total extinguishment has to be within three minutes from foam application to fire extinguishment. Burn-back resistance test (from burn-back pot ignition to end of test) is timed five minutes after total extinguishment. This test is a safety test which will show the foam’s ability to keep the fuel from reigniting (see Figure 1).

Figure 1: Test Result Using an ICAO Level B Compliant AFFF (Foam X)

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Figure 2 shows that the fluorine free foam passes the ICAO level B test with almost the same result as the AFFF foam (Figure 1). The environmental conditions during the two test were similar and hence did not significantly influence the two outcomes.

WORKING WITH NEW TECHNOLOGY AT COPENHAGEN AIRPORT

The Copenhagen Airport’s Fire Service mission statement and vision strategy is:

“Always to keep a high level of professionalism, resourcefulness and ability to implement new technologies and replacing old ones. To ensure an efficient operation within Copenhagen Airport. To ensure a high level of satisfaction from the airlines and their passengers. To be the best-run airport fire service in the world.”

In order to maintain a leading international standing, the Fire Service will, through employee involvement and innovation, constantly develop the organisation: “By experimenting and by constantly reviewing work routines and procedures, we will seek to learn new knowledge. The aim is to develop our skills and competencies.”

The Fire Service at Copenhagen Airport has always had to deal with the challenge of low staffing levels. New techniques have always been adapted for use by the service and some amount of experimentation has always been allowed – as long as all the demands imposed by regulators are met. Examples of this approach include fighting interior aircraft fires with high pressure nozzles and one-man Crash Tenders.

Figure 2: Test Results Using an ICAO Level B Compliant FFF (Foam Z)

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Over the last five to six years, Copenhagen Airport Fire Service has worked on operational and tactical improvements. The whole fleet of Crash Tenders has been upgraded with the Rosenbauer CA-5 Panthers. One Panther is provided with FLASH™ CAFS (air bottles instead of a compressor – this works extremely well with large flow rates) on the main turret; two of the other Crash Tenders are fitted with high reach extended turrets (HRET) and the Hydro-Chem dual system.

For environmental reasons, AFFF was replaced with fluorine-free ICAO Level B foam – Solberg 3X6 RF re-healing Alcohol Type Foam Concentrate (ATC) foam. The Copenhagen Airport Environment Department has for many years had environmental concerns especially about the fluorochemicals that are in the AFFF being used at the Copenhagen Airport. This meant that there were restrictions on using this foam for testing and training. Copenhagen Airport was the first international airport to have implemented FFF for the Fire Service for operational use as early as 2009. NFPA 403 testing of all foam outlets and foam proportioning systems on all vehicles was done in conjunction with the foam manufacturer Solberg Foam and the vehicle manufacturer Rosenbauer with all vehicles and foam systems being thoroughly performance-tested before this new type of foam was put into service.

ENVIRONMENTAL PROBLEMS WITH AFFF

In 2008-09, a series of articles appeared in the Industrial Fire Journal and Fire & Rescue magazine which started to focus on the problems and concerns around the environmental issues that are associated with fluorosurfactant-containing foams such as AFFF. One of the authors, Dr Roger Klein, is amongst the world’s experts on fire-fighting foams with a background as a physical chemist, a medic and a long-term adviser to the Fire Service nationally and internationally. Klein’s article (2009) about the findings of a study in Norway really underlines the serious concerns. These articles have had a tremendous effect on a lot of European airport’s awareness of this problem. At all the major airports in Scandinavia, the fire-fighting training grounds now attract attention from the national environmental regulators. Also, the European Union Commission for Environment has become aware of the problem, resulting in a ban on the use of all fluorine-containing foams based on Perfluorooctanesulfonic acid for fire-fighting within Member States from 27 June 2011 onwards.

PERSONAL VIEWS ON THE JOB AND TASKS IN AN AIRPORT FIRE SERVICES

ARFF is a highly specialised component of the Fire Service. An aircraft accident presents different hazards that threaten the aircraft occupants, the community, the environment and the emergency responders. ARFF crew must respond quickly and with precision to minimise loss of lives, injuries and other potential dangers. Fortunately, serious accidents are fairly infrequent, but this benefit means that experience can only be accumulated through constant training. Learning from others rather than from own incident experience should be the norm. Within the Aviation Fire Services, regulations and legislation have their roots in ICAO standards

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and recommended practices (SARPs). These are usually incorporated into a country’s national legal framework. The majority of the countries comply with the international standards drawn up by ICAO.

CONCLUSION: A SAFER FUTURE FOR THE AVIATION INDUSTRY

The tests at CNPP have shown that CAFS has advantages in extinguishing fires compared to aspirated foam and this is estimated to be approximately 40 per cent more effective. These tests have also raised some very important issues such as environmental influences, tactics, etc., which have a significant impact on the extinguishment time and the amount of extinguishing agent used. The tests also showed that ICAO Level C is almost the same extinguishment time and requires a similar quantity of extinguishing agent as ICAO Level B, but contain much more fluorine which in turn has a negative impact on the environment.

From the perspective of an Assistant Fire Chief responsible for the Fire Service’s operational capability, these results “fit like a hand in a glove” and prove that at Copenhagen Airport in Denmark has made the right choices at the right time. CAFS and fluorine-free foam will no doubt improve both aviation safety and the environmental impact of fire service operations at airports.as well as the safety of the fire-fighters whom we send into the danger zone. Greater efficiency and faster control of the situation will certainly also give fire-fighters confidence in coping with the situation. A Rosenbauer Panther with CAFS on all low pressure outlets has been put into service at Copenhagen Airport in March 2013.

The UK CAA has recently put forward a proposal to the ICAO Rescue and Fire-fighting Working Group at their last meeting in Montreal, Canada for the use of CAFS on airport fire vehicles, and was accepted. If things go as planned, a new ICAO standard and procedure based on this CAFS recommendation would be implemented in the ICAO Airport Service Manual in November 2013. This would be great for the future of aviation safety.

References

Industrial Fire Journal and Fire & Rescue Magazine 2008-9.

Klein, Roger. (2009). Contaminated Water – Protecting the Environment. UK Fire & Rescue magazine, vol. 73, p. 26-29.

Just Culture in Aviation: The Best of Two Worlds

Investigation into the causes of aviation accidents and incidents is of key importance for finding solutions that

improve the safety of aviation and provide assurance to passengers for an uneventful flight. Nobody should

be immune from the law. The use of these findings in determining whether criminally reproachable behaviour

is involved forms part of the administration of justice; a function which is an integral part of any society that

respects the rule of law. The issues related to this apparent conflict between these two worlds and approaches towards

reconciling or at least balancing these activities form the basis for this paper. It introduces the notion of Just Culture,

experiences with its application in Europe and the prospects and conditions for a more global application. The role and

responsibilities of the International Civil Aviation Organization (ICAO) in this context are addressed, in particular as the

possible facilitator for introducing Just Culture-based solutions in the different ICAO regions.

This paper contains elements of two articles written by the author that were published in the Air & Space Lawyer,

Vol 2 2009 and in the IFATCA magazine 2012.

Aviation Safety

ABSTRACT

Mr Roderick van Dam is Chairman of the EUROCONTROL Just Culture Task Force. He was with EUROCONTROL since 1996 as General Counsel and retired in April 2012. Prior to that, he was Head, Legal with the Netherlands Civil Aviation Authority until 1990; he then joined ICAO as a Senior Legal Officer in the Legal Bureau.

Mr van Dam is currently a Member of the ICAO Safety Information Protection Task Force, and has participated in drafting and launching numerous ICAO instruments of international law. He is also a Rapporteur to the ICAO Legal Committee for the Montreal Protocol on Acts of Violence against International Aviation. He is also actively involved in European Union (EU) Single European Sky legislation, air traffic management (ATM) liabilities, Functional Airspace Blocks; Global Navigation Satellite System, Global Position Systems and Galileo as well as the institutional reform of ATM in Europe and of EUROCONTROL, including the reassessment of its relations between the EU and European Aviation Safety Agency.

A lecturer at Leiden University International Institute of Air & Space Law, Netherlands and member of its Advisory Board, Mr van Dam has written for numerous publications on Air and Space Law, and also participates as a moderator and speaker at aviation events. He holds a Master in International Law and Air and Space Law.

THE AUTHOR

Just Culture In Aviation: The Best of Two WorldsAviation Safety

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Just Culture in Aviation: The Best of Two WorldsAviation Safety

Roderick van DamEUROCONTROL

INTRODUCTION

Accidents and Incidents happen. They form part of our daily lives and we accept their

occurrence, even in air traffic management (ATM) and air transport, and we hope and expect

that we can avoid by far most of them by our actions, professionalism and abiding by established

rules and practices.

Ever since the investigation of aviation accidents was undertaken in a systematic manner

with the specific aim of using the findings of each accident investigation for the prevention

of other accidents, the problem of the use of these findings for purposes other than accident

prevention has manifested.

Improving aviation safety depends to a large extent on the feedback of knowledge generated

by a system of accident/incident data collection and analysis. Such a system serves the industry,

as well as its regulators, by allowing it to adapt and improve on equipment and procedures.

A high-quality output of the system very much depends on the existence of systematic record

traceability and active participation and reporting from all the aviation stakeholders involved

in safety areas. In the US and Europe, for example, well-developed accident prevention

processes are in place, including mandatory and voluntary incident reporting systems and

independent accident investigation.

From relatively early days, the ICAO which is responsible for setting international rules and

recommendations for improving safety, has been confronted by the need to protect aviation

safety interests from those parties that want access to investigation results and other safety

data with the goal of what ICAO calls apportioning blame or liability. Therefore, ICAO rules,

in the interest of an uncompromised safety investigation process, are often seen as advocating

a protection against the interests of what is often referred to as “the administration of justice.”

In a safety-critical domain such as aviation, the legal consequences of (contributory) actions

or behaviour that could result in serious personal harm, death or other damages are plentiful

and very significant, both in the private law and, increasingly, in the criminal law domain.

Criminal law forms an essential part for a sovereign State in the exercise of its responsibility

for enforcing specific domain-related norms as well as for the prevention and sanctioning of

unacceptable behaviour.

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SAFETY VERSUS JUDICIAL

The administration of justice, in particular in the criminal law domain, constitutes one of the pillars of State sovereign functions; they are usually firmly imbedded at the constitutional level. Both the Convention on International Civil Aviation (hereafter referred to as the Chicago Convention) and the EUROCONTROL Convention explicitly confirm the complete and exclusive sovereignty of a State over its territorial airspace. That certainly includes the administration of justice. States are of course free to choose to delegate or pool certain sovereign functions, as is the case with the European Union membership, but criminal jurisdiction, with only a few exceptions, generally remains firmly imbedded at the State level.

There is a growing concern in recent years on the part of aviation professionals and aviation industry about the interpretation of flight safety and aviation accidents by the general public as well as the criminal judiciary. These concerns are associated with what is seen as the increasing emphasis on legal issues in aviation safety occurrences. This has led to growing fear of litigation and the threat of criminal sanctions against individuals and organisations that are seen as partly or fully responsible for an accident or incident in which they were involved.

We need to understand the complicated relationship between the administration of justice and the safety investigation. As in a classical drama, two antagonists are involved: one with the aim of preserving justice by investigating and prosecuting possible perpetrators and the other with the aim of enhancing aviation safety through independent investigation and reporting.

The issue of criminalisation of aviation accidents or incidents illustrates the delicate relationship between the propagation of aviation safety and the administration of justice in the aviation domain. These are two distinct worlds that seldom meet. One is by nature international, dynamic and very sensitive to safety; the other is by nature national, resistant to progressive change and very sensitive to the rule of law. It is no wonder that their interaction, or perhaps the lack of it, generates difficult and often passionate discussions.

Accidents and serious incidents very often occur as the result of a series of events that in an eerie and inevitable way lead to disastrous results. When mistakes are involved they can often be labelled as “honest” mistakes that would not qualify as criminal behaviour. Controllers and pilots are professionals who are ready to realise that nobody can claim criminal immunity in any civilised country. But it is equally true that a small, but highly visible, number of cases raise questions on the relevance and motives of some criminal prosecution and court cases.

And here lies the root of the issue: Who will determine whether a mistake was made by a qualified professional acting in a responsible manner or whether this was a clear case of gross negligence, wilful misconduct or criminal intent, to use just a few of many legal terms for criminally reproachable behaviour? That person cannot be a chief pilot or a control room

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supervisor; such a call can only be made by a professional in the judiciary, a prosecutor and ultimately a court of law.

The key is what happens next: A qualified criminal investigator or prosecutor must assess whether, under the applicable criminal law, the actions leading to the accident/incident warrant further steps such as investigations and indictment. A number of high profile accidents and serious incidents did result in criminal investigations and proceedings and have raised strong concerns from the air traffic control and air transport community about the criminalisation of aviation. That is not all; events have shown that further complications could arise as a result of public and media pressures that generally accompany any crash or serious incident with the associated “search” for a guilty party.

The discussion on criminalisation of aviation incidents and accidents shows concerns on the perceived intrusion by the judiciary in the all-important effort in enhancing safety in aviation. It also shows a tendency to use “criminalisation” as the epitome of misdirected and unwarranted activities by the authorities and to argue that the safety domain should therefore be protected from any action by the prosecution.

The problem is that invoking real or alleged criminalisation of aviation incidents or accidents as a justification for fully protective legislative action does not really work. All the regional and global rules and standards related to the protection of safety data and investigative processes in aviation create an exception for the actions of a sovereign State in the exercise of the administration of justice. What is needed now is the establishment of equilibrium between two equally relevant goals: aviation safety and the administration of justice.

JUST CULTURE

Rather than trying to shut up the judiciary, focus has now shifted towards initiating a dialogue between the national authorities concerned. A better understanding of the consequences of a judicial inquiry must be the starting point. In most States, national criminal legislation provides prosecutors with a level of discretion as to how to apply those laws; a clearer appreciation of the associated safety consequences may actually influence the application of those laws.

This is where the Just Culture initiative, as developed for aviation by EUROCONTROL, enters

the equation. Attempting to describe, let alone define, Just Culture is not simple, to put it

mildly. The results may vary from one person, culture, legal system to another. The following

description of Just Culture in the aviation domain has been accepted in Europe:

“A Culture where front line operators are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”

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This description introduces the notion of gross negligence and wilful violations for qualifying criminally relevant behaviours that are not in accordance with internationally agreed definitions. And although the criteria to establish gross negligence or related legal concepts in common or civil law may be similar in most countries, their interpretation and application with respect to individual cases will ultimately lie in the hands of prosecutors and ultimately of a criminal court.

When the legal consequences of Just Culture were first discussed, the initial reaction was that most European States would need to significantly amend their laws in order to implement Just Culture in a non-punitive environment. Calls were made for changes to criminal laws and to regulate and fully protect access to information. The general feeling was that a Just Culture could not be implemented without these.

Subsequently, when the discussions became more mature, it dawned upon the participants that amending laws and principles that constitute the basis of sovereign judicial systems was, in most cases, not a realistic option. And equally important, it was not deemed essential. The issue was not necessarily the need for more legislative actions but rather the way in which those existing laws and regulations were implemented and enforced by the national judicial authorities.

Provisions which could result in a legal environment supporting a Just Culture, while taking a realistic view to the need to respect some fundamentals with regards to the administration of criminal justice, already exist. A number of relevant instruments dealing with accident investigation and incident reporting, supported in some cases by guidance material, are in place.

GLOBAL AND REGIONAL PROGRESS

Just Culture has been on the agenda for many years and it has become apparent that a key part of its successful implementation relies on a number of realistic deliverables that would stimulate further understanding and active and open coordination between the safety and judicial authorities.

In ICAO, the discussions and findings of the 36th Assembly, the Accident Investigation and Prevention Divisional meeting in 2008 and the recommendations of the ICAO High Level Safety Conference in March 2010 resulted in resolutions A37-2 and A37-3 of the 37th General Assembly on the sharing of safety information and the protection of safety data. Both resolutions, using the description of the Just Culture initiative, instructed the Council to strike a balance between the need for the protection of safety information and the need for the proper administration of justice. The Assembly furthermore noted the need to take into account the necessary interaction between safety and judicial authorities in the context of an open reporting culture. The ICAO Safety Information Protection Task Force (SIPTF) was, among other reasons, created as a result of these conclusions which to a great extent have inspired its findings and recommendations.

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In Europe, the European Union (EU) has not only formally enacted Just Culture as part of EU law with the introduction of Performance Regulation (EU) No 691/2010 , but it has also recently introduced elements of it in Regulation (EU) No 996/2010, governing air accident and incident investigation that also addresses the need to achieve a balance between the objectives of the judiciary to determine whether criminality was involved, and the need for the aviation industry to be able to run a real-time self-diagnostic system without unnecessary interference from Justice.

EU Regulation 996/2010 stipulates that its purpose is dual: to regulate both “the investigation and prevention of accidents and incidents”. It says: “An accident raises a number of different public interests such as the prevention of future accidents and the proper administration of justice. Those interests go beyond the individual interests of the parties involved and beyond the specific event. The right balance among all interests is necessary to guarantee the overall public interest.”

Although it may sound a little negative, the strength of the Just Culture Concept (or by any other name as long as it addresses the same processes) is the understanding that there is realistically no other way forward. Formal legislation fully protecting pilots or controllers or side-lining criminal prosecution is a dead-end street as demonstrated by all the existing national, regional and international legislation. Providing a reasonable expectation to, for example to a controller or a pilot, that the chances that he or she would ever be invited to be part of a preliminary criminal investigation, let alone prosecution, are very minimal, would provide a sound basis for continued incident reporting and even measured and balanced accident investigations.

Just Culture represents the fundamental recognition that both the aviation safety drive and the administration of justice would benefit from a carefully established equilibrium, moving away from criminalisation fears. It is based on the understanding that controllers and pilots can blunder and that the line between an “honest mistake” and intentional or reckless behaviour can only be drawn by a judiciary professional.

That is easier said than done, of course. But the time has come to seriously question the added value of endless and generally unsuccessful efforts at the international level to “protect” controllers and pilots against judiciary actions by creating standards, regulations and laws that are supposed to shield them against interference by justice. This is perhaps a good time to point out that this paper primarily focuses on the introduction and benefits of Just Culture at the State and International level and on the interaction between safety experts and the judiciary. At the (national) corporate level, in the interaction between management and staff of, for example airlines and air traffic service providers, Just Culture of course plays an equally important role in the acts of pilots and controllers and the application of company rules, contract and labour law.

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A lot of progress has already been made in this domain through safety management and related practices and the new ICAO Annex 19 will certainly also play an important role in this area. It is important to note that these developments will also require the recognition and perhaps harmonisation of corporate Just Culture with the criminal law requirements and policies at the State level.

DISCUSSION

The time has come to focus on the pursuance of the practical goals identified by the Just Culture activities. The first steps toward the proliferation of the model aviation prosecution policy concept have started and the first prosecutor expert courses have been held. The relevance of offering assistance and education to prosecutors and judges together with the introduction of and implementation of the model for an aviation prosecution policy in Europe and beyond is obvious. After the historic support by the full EUROCONTROL 39 State membership and the EU for these deliverables, the next step will be to submit them for global consideration at ICAO.

At the 37th General Assembly, resolutions A37-2 and A37-3 on the sharing of safety information and the protection of safety data added the instruction to the ICAO Council to strike a balance between the need for the protection of safety information and the need for the proper administration of justice; the Assembly furthermore noted the need to take into account the necessary interaction between safety and judicial authorities in the context of an open reporting culture.

As mentioned earlier, The ICAO SIPTF was tasked with analysing present ICAO rules and Standards and Recommended Practices (SARPs), National Legislation and considering enhanced communication and interaction mechanisms to improve the efficiency and credibility of data protection and occurrence reporting and the relations between safety activities and the national judiciary.

It may be expected that the SIPTF, which held its last meeting in January 2013, will come forward with realistic proposals for the enhancement of safety data protection that recognise and reconcile the existing national and international legislation and regulatory processes and their limitations. In addition to SIPTF recommendations regarding changes in positive law or ICAO SARPs, considerable progress could be made in advancing safety information protection with deliverables in the domains of training, support, education, and communication through innovative implementation tools and tactics, to balance the adequate protection of safety data with the proper administration of justice.

There is general recognition of the need to establish communication and training initiatives and advance arrangements between the aviation safety sector, regulators, law enforcement and the judiciary to avoid unnecessary interference and to build mutual trust

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and understanding. Furthermore, making high-level aviation expertise available to law

enforcement and judiciary would facilitate the exercise of their appropriate investigative

and judicial processes.

A number of States and groups of States in different ICAO regions are already organising

training and communication between safety and judicial authorities addressing implementation

tools and deliverables that would lead to a stable and successful basis for enhanced safety

data protection and a balanced interaction between safety and the administration of justice.

It is important to note that these recommendations address processes and activities that are

expected to continue well beyond the active life of the SIPTF. Training, support, cooperation,

communication and advanced arrangements form decisive conditions for an efficient and

realistic safety data protection.

The time has come for ICAO to further build on the Just Culture principles and become the

facilitator at the regional level to educate and encourage States to establish (joint) permanent

frameworks to ensure a constructive and on-going dialogue with the judiciary, to inform them

on the possibilities to establish a national aviation prosecution policy and to provide them at

their request, with dedicated and impartial aviation expertise in the exercise of their functions.

ICAO should also establish and regularly update a repository of training and education activities

related to the protection of safety data, the interaction with the judiciary and existing or new

best practices and policies. It should provide coordination and support, as well as organise

progress reporting and information on a regular basis to all Contracting States.

Just Culture is not the “magic wand” against injustice and misuse of judiciary processes. It has

been introduced to protect as much as possible the mundane but ever so important ongoing

processes of incident or occurrence reporting: literally thousands of daily events that feed

into the well-established system of using the reports for the improvement of safety and the

prevention of incidents and accidents. It represents an ongoing daily routine, certainly not as

spectacular and awesome as the aftermath of an accident, but absolutely vital for the continued

effort to improve safety by learning from mistakes and other relevant occurrences.

Just Culture requires understanding and appreciation of the different processes and

commitments by both safety people and the judiciary. And let there be no mistake: Just Culture

also implies that misuse of criminal processes or ignorance from the part of the judiciary is

equally unacceptable! There is still a long way to go, both in Europe as well as at ICAO, but most

of the signs are outright encouraging, as witnessed by the deliverables of the Just Culture Task

Force and those expected from the SIPTF and reactions from third parties.

Finally, as good concepts often are in essence simple ones, I would submit that the summary

of Just Culture, of reconciling safety and justice interests, can be reflected as follows: IT TAKES

TWO TO TANGO!

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References

Commission regulation (EU) No 691/2010 of 29 July 2010 laying down a performance scheme for air navigation services and network functions and amending Regulation (EC) No 2096/2005 laying down common requirements for the provision of air navigation services; OJ L 201, 03.08.2010.

Resolutions adopted by the 37th Session of the ICAO General Assembly held in September/October 2010, see: http://legacy.icao.int/icao/en/assembl/A37/Docs/a37_res_prov_en.pdf

Regulation (EU) No 996/2010 of the European Parliament and of Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC, OJ L 295, 12.11.2010.

The term ‘Safety Performance Measurement’ highlights the need for an objective and quantifiable mechanism to facilitate

safety performance interpretation. Without a quantifiable mechanism, safety performance measurement will likely

remain in the domain of subjective narration.

A quantitative approach to performance interpretation of conventional safety or quality occurrence trending indicators

can be achieved by incorporating quantitative performance boundaries into them – such as Alert and Target markers.

The Yes-No triggering of these markers forms the basis for an objective and quantifiable interpretation of the indicator’s

performance (within a given monitoring period).

With this mechanism in place, the summary performance of a package of safety performance indicators (SPIs) can accordingly

be quantified by their summary Alert and Target outcomes. This summary Alert and Target outcome would be a fair

reflection of the organisation or system’s safety performance, to the extent as represented by the scope and nature of the

selected package of SPIs.

Safety Performance Measurement – Quantifying Safety Performance Indicators and an Acceptable Level of Safety

ABSTRACT

Aviation Safety

Safety Performance Measurement – Quantifying Safety Performance Indicators and An Acceptable Level Of Safety Aviation Safety

Mr Teo Gim Thong is the Safety Management Consultant on secondment to the International Civil Aviation Organization (ICAO) Air Navigation Bureau’s Integrated Safety Management Section since 1st Mar 2010. He is currently involved in the development of a ICAO Standardised Training Package for safety management using the TRAINAIR PLUS method and had been the main coordinator and developer of the 3rd Edition (2012) of ICAO’s Safety Management Manual (SMM, Doc 9859).

Mr Teo joined the Civil Aviation Authority of Singapore (CAAS) as an Airworthiness Manager in 2004 after working in the airline and the Maintenance, Repair and Overhaul industry for 32 years. Prior to his current appointment, he was Senior Manager in Rulemaking, CAAS responsible for Safety Policy and Rulemaking and has been the main coordinator of CAAS’ State Safety Programme implementation taskforce since 2007. He is also a subject matter expert for state Safety Programme and Safety Management System. Mr Teo is a qualified Licenced Aircraft Maintenance Engineer since 1976.

THE AUTHOR

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Safety Performance Measurement – Quantifying Safety Performance Indicators and an Acceptable Level of Safety Aviation Safety

Teo Gim ThongInternational Civil Aviation Organization

INTRODUCTION

‘Safety Performance Measurement’ in the context of this paper essentially refers to the process of measuring safety related outcomes associated with a given operational system or organisation. Specifically, it is written in the context of today’s State Safety Programme (SSP) and Safety Management System (SMS) environment.

WHY MEASURE SAFETY PERFORMANCE

Safety management Standards and Recommended Practices (SARPs) had been progressively

introduced by ICAO since 2001. The main framework of these safety management SARPs

are the SSP and SMS. Amongst other requirements, Annex 19 (Safety Management) has the

provision for States to achieve an acceptable level of safety performance:

“Each State shall establish an SSP for the management of safety in the State, in order to achieve an acceptable level of safety performance in civil aviation.” (ICAO, 2013a, Chapter 3)

The active verb here is “to achieve”. The next immediate clause says:

“The acceptable level of safety performance to be achieved shall be established by the State.” (ICAO, 2013a, Chapter 3)

So, that “acceptable level” which States are supposed to achieve is based on that which States are going to establish themselves.

Objectively speaking, the expected bottom line (most onerous outcome) from these two clauses

can possibly result in a theoretical scenario like this:

“Show me (a safety management Auditor quoting ICAO Annex 19, Chapter 3) whether you have achieved (or not achieved) your acceptable level of safety performance. We will just take it that your own quantum of acceptable level of safety performance (which has been determined by your State) is reasonable. Now, just show me whether you have achieved it, or not…”

Even if such a bottom-line question is not coming from your SSP or SMS auditor, any discerning Accountable Executive or Safety Committee Chairman would probably ask anyway, sooner or later.

“You cannot manage what you cannot measure” is a well-known sage advice. So, obviously we must be able to manage and measure safety performance, before anyone can expect us to achieve it (to whatever level)!

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HOW TO MEASURE SAFETY PERFORMANCE

To achieve an acceptable level (or any level) of safety performance, an organisation will firstly need to establish a mechanism to measure its safety performance. After that, it will then decide on the acceptable level of safety to be achieved, within a given monitoring period.

Taking into consideration ICAO Annex 19 expectations, we will need to ensure a few characteristics of the safety performance measurement mechanism and indicators which are to

be developed:

• Theyshouldbequantitativeandmeasurable.

• Theyshouldbeanexpressionofthesafetyperformancestatusoftheaviationsystemoroperational areas.

• Theyshouldhaveprovisionformonitoringperformance inrelationtocertaindata-basedperformance markers.

• Theyshouldcollectivelybeabletogiveabottomlinemeasurableperformancestatus.

• Thisbottomlineperformancestatusshouldbeabletotellwhethertheplannedacceptablelevel of safety performance has been achieved or not, at the end of a monitoring period.

Now, do we need to start from scratch to search for such safety performance measurement mechanisms or indicators? Apparently not. Some aviation quality management systems or reliability control systems (especially large commercial air operators) have been traditionally known to utilise technical or reliability related indicators to track the performance of specific system processes. Examples include engine in-flight shut down rate, component failure rate, technical delay rate, etc. Hence, the existence of such technical indicators is a good place to start our appreciation of safety indicator models for SSP and SMS. Thus, within the large commercial air operators and their Approved Maintenance Organisation and Design & Manufacturing Organisation sectors, development of SSP-SMS safety indicators is a matter of starting with the adaptation of certain existing technical or reliability related indicators to meet the higher level SSP-SMS expectations.

As for the other service provider sectors (Aerodrome, Air Navigation Services, Approved Training Organisation, International General Aviation) where they may have no prior experience with ReliabilityorQualityControlsystemsindicators;theymaythenneedtofamiliarisethemselveswith fundamental data trending charts for the purpose of developing SSP-SMS SPIs. Figures 1 and 2 provide an illustration of a common basic data chart and a continuous data trending chart respectively.

The two figures show a one-time status of reportable incidents for each aircraft type (Figure 1) and a continuing incidents trending of the airline’s entire fleet (Figure 2). However, these two charts cannot serve as SSP-SMS SPI candidates yet, because they have no built-in performance measures – such as Alert and Target settings. Without such safety metrics performance measuring pointers or markers, there is no provision for interpretation and collation of the

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Figure 2: A Continuous Trending Chart

performance of each indicator (and ultimately the package of indicators) at the end of a given monitoring period.

We need to convert the (otherwise) qualitative performance of a data trending chart into a quantitative outcome, by means of measuring (counting) two key safety metrics markers – Alert avoidance and Target achievement status. It is like interpreting the health of a patient by just two key parameters – heart rate (low rate achievement) and blood pressure (high pressure avoidance).

Thus, an SPI has to be more than just a basic data chart, more than just a continuous data trending chart. It must have the capability for building in planned Targets to be achieved as well as Alert levels to be avoided. These two complementary and parallel markers will then serve to transform a common data trending chart into an SPI. By means of these two observable

Figure 1: A Basic Data Analysis Chart

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and countable markers, the performance of a safety indicator is made quantifiable. This quantification process (at end of monitoring period) is achieved by asking two basic questions:

1) Has the indicator breached its Alert level? [Yes/ No]; and

2) Has the indicator achieved its planned Target performance level? [Yes/ No]

These two safety metrics performance markers are somewhat like those little built-in green pips and red warning flags within the various indicators in an aircraft cockpit. They will serve to tell the pilot whether he has not achieved his Target Engine Pressure Ratio (required power) or whether he has an Exhaust Gas Temperature Alert (potential engine fire) during his take-off run; either of which event can mean aborting the take-off altogether. These aircraft systems safety indicators are the origin of this terminology that we use for our SSP-SMS safety performance measurement mechanism today.

ALERT LEVELS

Besides serving as one of the two data trending performance quantifiers, an alert level is fundamentally the caution light or alarm bell of an SPI. Its common safety metrics terminology is called ‘Out of Control Criteria’ (Janicak 2003, p. 47). Breaching an Alert level implies that a data set has trended into an abnormal/undesirable region (in relation to its historical performance). In the case of a safety (occurrences) indicator it would mean an abnormal escalation of the occurrence type being tracked, implying a high risk situation of subsequent “out of control” occurrence rates. The determination of such an Alert boundary or level is associated with the recent historical data trending behaviour of the same indicator. The rationale for this is to ensure that a safety indicator’s current Alert setting has taken into consideration its own recent historical performance or behaviour. The historical data performance is specifically measured by means of two characteristics of the historical data set:

a) Average value; and

b) Standard Deviation (SD) value

From these two values (Average and SD), the Alert level for the current (or next) monitoring period of the safety indicator chart is derived and plotted as follows:

1) Average + 1 SD;

2) Average + 2 SD; and

3) Average + 3 SD.

Figure 3 depicts the typical three Alert level lines as derived from the above three [Average + 1/ 2/ 3 SD] values. The “Preceding Year” is the historical data set whilst the “Current Year” is where the three Alert lines have been plotted, based on the preceding data set.

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Figure 3: Alert Levels Based on Historical Average and SD Values (Source: ICAO 2013b)

The formula for calculating SD value (part of most spreadsheet software, eg Excel) is “=STDEVP”.

For manual calculation purpose, this SD (Population) formula can be sighted in the Safety

Management Manual (ICAO 2013b).

ALERT TRIGGER

An Alert (abnormal/unacceptable trend) is indicated if ANY of the conditions below are met for

the current monitoring period:

a) Any single point is above [Average + 3 SD] line;

b) Two (or more) consecutive points are above [Average + 2 SD] line; and

c) Three (or more) consecutive points are above [Average + 1 SD] line.

These three separate Alert lines establish an equitable set of criteria to ensure that only a valid

Alert situation is captured as such.

Criterion (a) captures a situation where the occurrence rate during the data point update period

(one month, in the case of Figure 3) is more than three times the historical standard deviation

(from the Average value). This is obviously unacceptable and hence warrants an Alert to be

triggered, even though only one data point is involved.

Criteria (b) and (c) are complementary graduated Alert levels to capture a relatively lower quantum

of data point deviation beyond the 2 standard deviation and 1 standard deviation Alert levels

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respectively. In conjunction with their respective lower deviation quantum, the (b) and (c) Alert conditions of “two (or more) consecutive points” and “three (or more) consecutive points” are hence provided for. Refer to Figure 4 below for an illustration of these 3 Alert conditions .

Armed with such a package of three complementary alert levels, a safety indicator is poised to trigger a genuine Alert condition based on valid statistical criteria. It will effectively capture any sudden (single data point) high risk spike as well as any sustained high occurrence rate deviations, which are equally unacceptable.

Figure 4-1, Alert (a): Single Point Above 3 SD

Figure 4-2, Alert (b): Two (or more) Consecutive Points Above 2 SD

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FOLLOW UP ACTIONS TO AN ALERT

SPIs are normally reviewed by a scheduled Safety Review Committee or appropriate platform.

Where an Alert has been triggered for any given indicator, an enquiry or investigation should

be conducted to explain or determine the reason for the Alert condition. The Safety Office

concerned would preferably have anticipated the Committee’s enquiry and should be prepared

to account for the Alert level breach. This may involve prior liaison with service providers or

operational areas concerned.

There is a logical connection between a safety indicator Alert mechanism and an organisation’s

occurrence investigation as well as Hazard Identification and Risk Mitigation (HIRM) processes.

Where an SPI pertaining to certain type or category of incident has triggered an Alert, it implies

that there is an abnormally high occurrence of that type or category of incidents. In order to

arrest such an abnormal incident rate, necessary analysis of all the relevant incidents’ records

(such as incident notification or incident investigation reports) would be necessary. This is to

identify potential issues such as significant recurrence of a particular incident type (whether

due to one particular equipment or the same series of equipment), or that there was a series

of multiple (connected or unconnected) incidents for that period concerned. The evaluation of

such occurrence investigation reports can also determine if adequate and effective corrective

actions have indeed been taken or recommended by the relevant investigators to address the

causes of those incidents, and hence ensure their non-recurrence. If investigations performed

Figure 4-3, Alert (c): Three (or more) Consecutive Points Above 1 SD

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are not sufficiently thorough to address root cause or latent conditions, then recurrence of the same incident type can be expected. Thus, there is a connection between inadequate incident investigation processes and subsequent sustained high incident rates, because actions taken or recommended from previous investigations were off the mark or did not address underlying issues or hazards.

Where there should be any hazards identified in the course of incident investigation records review, and found to have been inadequately addressed, this can then bring in the organisation’s HIRM process. Thus in an SSP-SMS environment, there should be a constant connection between its safety performance monitoring, occurrence investigation and HIRM processes.

In the case of a lower consequence SPI, say Runway-Apron Foreign Objects Debris reports, a triggered Alert would imply that there is a high likelihood of seeing a subsequent Alert in its related higher consequence SPIs, e.g. Aircraft Foreign Objects Damage incidents, or Engine Foreign Object Damage incidents. This would invariably be so, if no timely and effective corrective actions were taken in relation to the lower consequence SPI’s Alert.

TARGET SETTING

Target setting is a less structured process than Alert setting. It is essentially a desired or planned percentage improvement over the preceding period’s Average occurrence rate. The Target level is represented by the dotted line in Figure 3. In this case it is five percentage points below (better) than the preceding data period. This Target level is meant to be compared with the current monitoring period’s Average value (which is to be calculated at the end of the current monitoring period). If the current period’s Average value should be below (better) than this Target line (preceding year’s Average) then the Target performance has been achieved. If the current period’s Average is above (worse) than the Target line, then the Target has not been achieved.

There should be an objective rationale for determining the Target quantum of a given SPI, whether it should be 1 per cent, 5 per cent or 10 per cent. Primarily, it should be correlated to the nature, scope and aggressiveness of actions taken or planned with regard to the purpose of improving the safety and reliability performance of the operational process underlying that SPI.

SPI DATA TABLE AND CHART GENERATION

In order to generate a SPI trending chart shown in Figure 3, it will be necessary to collate and annotate the preceding and current data sets on an Excel spreadsheet shown in Figure 5.

Such an Excel data sheet is to be annotated with all the necessary data pertaining to the SPI concerned, namely its preceding and current period’s occurrence numbers, flight hours/cycles/ movements as applicable. The required formulae for Average, Standard Deviation (STDEVP), Alert and Target settings are built-in as indicated. The completed table can then generate the required SPI chart (Figure 3) automatically, with the Excel charting function.

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ALERT AND TARGET VALIDITY PERIOD

Alert and Target settings are based on an SPI’s recent historical behaviour. With this rationale in

mind, it is apparent that Alert level and Target settings should be updated between appropriate

monitoring periods. This would be especially important where there has been significant change

in the volatility of past data sets (Higher SD value will result in bigger margins in-between Alert

lines and vice versa). Theoretically, Alert level and Target settings can be recalculated at the

end of each monitoring period, say yearly. However, this may not be the case, depending on

factors such as the number of data points per monitoring period and the volatility of those

data points. Any major operational environment changes such as new equipment or additional

service providers may deserve a review of Alert levels, Targets or even SPI validity. In any case, the

validity of Alert levels and Target settings should preferably not exceed the period of its related

historical data points.

WHAT SPIs PACKAGE DO WE NEED

For the purpose of SSP-SMS safety performance measurement, an organisation will need

to distinguish a special package of strategic and pertinent SPIs from other normal business

Figure 5: SPI Data Table (Source: ICAO 2013b)

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indicators. The normal business indicators or key performance indicators (KPIs) will continue to

be maintained by the organisation for its specific business purposes and should not be mixed

with their SSP-SMS SPIs. The fundamental reason is that SSP-SMS interaction expects the service

provider’s SMS SPIs to be congruent to the SSP SPIs and hence be subject to the civil aviation

authority’s agreement and oversight. Thus, a service provider’s SMS documentation should

address its specific SMS SPIs only.

Selection of a package of SSP-SMS SPIs should be preceded by collating a list of all the

organisation’s existing indicators (including any technical or reliability indicators and KPIs).

Such a document will afford the SPIs selection team a good overview of the current available

indicators and their respective data sources.

A package of selected SPIs will need to include High consequence safety related outcome

indicators (accidents, serious/mandatory incidents). This should then subsequently (later

phase) be supported by Lower consequence indicators (e.g. routine incidents, specific

process/system/ area indicators, etc). Such High and Lower consequence SPIs are sometimes

termed as lagging and leading indicators. Thereafter, the organisation may also consider

supplementary indicators to monitor safety-related organisational behaviour and activity

where appropriate.

When considering the selection of supplementary behaviour and activity related indicators, an

organisation should be well aware of their constraints. These would include measurement or

quantification viability as well as the possibility of encouraging unwarranted activities or bias,

for the sake of attaining certain targets. Notwithstanding this, there is no doubt that adopting

a mechanism to measure, and hence encourage positive organisational behaviour or safety

culture is something which can be considered as a frontier behavioural SPI in a fully matured

SSP-SMS environment. Further discussion on such a possible organisational safety culture (risk

profile) measurement concept can be found in the Safety Management Manual (ICAO 2013b).

If such an organisational risk profile (ORP) is adopted by a State, it can be a comprehensive

measurement of its service providers’ organisational risk profile. The aggregate outcome from

such an ORP measurement mechanism can then be a comprehensive behaviour/activity

indicator, to supplement the primary SPIs.

MEASURING PERFORMANCE OF A SSP- SMS SPIs PACKAGE

Once a package of selected SPIs is in place, their individual as well as summary performance

can be measured. The outcomes of each SPI’s Alert and Target markers can be in the form of

“YES/NO” answers, or to be more quantitative, allocation of positive points for achievement of

a Target and avoidance of an Alert. The points system can facilitate weighting between High

consequence, Lower consequence and possibly supplementary indicators. An illustration of

a quantitative performance measure for a package of SSP SPIs is in Figure 6.

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Hence, a SMS or SSP overall safety performance can be manifested by the summary Alert avoidance and Target achievement outcomes of its package of selected SPIs by tracking and counting their Target achievement and Alert avoidance outcomes respectively.

Figure 6: SSP SPIs Package Performance Measure(Source: ICAO 2013b)

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ACCEPTABLE LEVEL OF SAFETY PERFORMANCE

With reference to Figure 6, the quantitative summary performance of the package of SPIs is self-evident at the bottom-line titled “Overall SSP Acceptable Level of Safety Performance (ALoSP)”.

In this illustration it is “58.3 per cent”. Does this 58.3 per cent percentage meet the minimum overall performance expectation of the State (SSP)?

As per ICAO Annex 19 (2013a), “The acceptable level of safety performance to be achieved shall be established by the State.” If the State (in this Figure 6 illustration) had established its ALoSP at say, 50 per cent, then it would have achieved its ALoSP.

CHARACTERISTICS OF AN EFFECTIVE AND VIABLE PACKAGE OF SPIs

Some questions which an effective package of SPIs should be able to answer positively are as follows:

• Dowehaveabalancedpackageofsafetyindicators,measuringHighandLowerconsequencesafety/quality outcomes primarily?

• DoeseachsafetyindicatorhaveanobjectivehighriskorundesirabletrendAlerttriggercriteria?

• Doeseachsafetyindicatorhaveanobjective(desired/planned)Targetsettingcriteria?

• Wouldanyoftheseindicators,byvirtueofitstargetoralertsettings,inadvertentlyresultinthe creation of unexpected or unwarranted organisational activities or behaviour?

• Doeseachsafetyindicatorprovideuswithacontinuousperspectiveofitscurrenttrendingin relation to its recent historical performance?

• Dowehavesupplementaryindicatorsmeasuringorganisationalsafety-relatedbehaviouroractivities which are pertinent to the organisation’s safety culture or risk profile measurement?

• Canourpackageofsafetyindicatorsprovideuswithabottomlinequantitativemeasureofour overall organisation safety performance?

• Willwebeabletocompareorbenchmarktheperformanceofourindividualorpackageofindicators internally or externally?

• Areweabletoaccountfortheperformanceofanaggregatesafetyindicatortoitsvariousindividual contributing sources or service providers, when necessary?

BENEFITS OF HARMONISED SAFETY PERFORMANCE MEASUREMENT

Some apparent benefits of adopting objective safety performance measurement mechanisms as

illustrated in this paper, which are also addressed in ICAO Doc 9859 (2013b) are as follows:

• Muchlesssubjectivitytotheissueof“whatismyacceptablelevelofsafetyperformance”;

• HarmonisedSPIsAlertandTargetsettingcriteriabasedonobjectivesafetymetricsprinciples;

• NomorepluckingofanSPIAlertleveloutofthinair,orusinga“grandfather”alertlevel;

• Allowinter-organisationsharing/benchmarkingofSPIperformance;and

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• Facilitatetheoverallconsolidated(bottomline)safetyperformancemeasureofapackageofSMS or SSP SPIs.

CONCLUSION

Employing basic safety metrics principles to monitor and measure safety performance is an

objective and reasonable way to go. Without an underlying SPIs quantification mechanism, an

organisation’s safety performance report may just consist of subjective accounts, interpretations

and promises.

References

ICAO (2013a). Annex 19 to the Convention on International Civil Aviation. Montreal. International Civil Aviation Organization.

ICAO (2013b). Document 9859, Safety Management Manual (3rd edn), Montreal. International Civil Aviation Organization.

Janicak, C.A. (2003). Safety Metrics: Tools and Techniques for Measuring Safety Performance. Lanham, Maryland. Government Institutes.

The Safety of the Flying Public is Our Top Priority – Do We Say What

We Mean and Does it Matter?

Aviation Safety

The relationship between the culture of an organisation and the management of operational risk is one that

can be easily overlooked by managers and regulators. A management structure that is very hierarchical and

focused on accountability may inhibit the functioning of an otherwise sound safety management system. In order

for risk management to perform its intended function, the organisation must accumulate sufficient data to predict

potential risks and determine how they can be mitigated or avoided. Once identified, the mitigation strategy must

be successfully implemented in a timely fashion. Both of these steps are predicated on an organisational culture that

facilitates rather than impedes the process.

All too often the risk management process is seriously compromised by an organisational culture that relies on

a safety slogan rather than on actual change. It is not enough to implement a safety management system; there has to be a

cultural adaptation. Only then will the safety slogan become reality.

ABSTRACT

Capt Paul McCarthy was the Representative to International Civil Aviation Organization (ICAO) and Technical Director, International

Federation of Air Line Pilots’ Association (IFALPA) from January 2006 to December 2012. He was responsible for executing IFALPA’s technical policy through the ICAO process and responding to all technical

initiatives brought before ICAO. He has held positions of increasing responsibility within IFALPA, such as Council 9 Safety Representative,

Boston Airport Liaison Representative, Vice Chairman of the National Noise Abatement Committee, Chairman of the IFALPA Accident Analysis Board and ALPA Accident Investigation Board and IFALPA

Principal Vice President for Technical Standards, before culminating with service as the Executive Air Safety Chairman for the association.

He was also a member of numerous groups including CVR/FDR, FOQA/ASAP, Criminal Liability of Pilots, CAST and

GAIN, as well as an ALPA Accredited Accident Investigator and Chief Investigator for Delta MEC. Prior to this, he was a pilot with Delta Air Lines for 32 years retiring as a

777 Captain, and was also a pilot with the US Navy for six years before that. Capt McCarthy was also a licensed

attorney in Massachusetts and Florida and practiced in Boston for 18 years in Admiralty Law.

THE AUTHOR

The Safety of the Flying Public is Our Top Priority – Do We Say What We Mean and Does it Matter?Aviation Safety

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INTRODUCTION

The public is constantly being reassured by the various players in the aviation arena. Pilots, managers, CEOs and government officials are very fond of public statements meant to convince the flying public that flying is a safe means of travel. How often have you heard something along these lines? “Safety is Job One”; “Safety is our First Priority”; “Schedule with Safety”; “We Always Put Safety First” and so on.

We can all appreciate that such statements do in fact support the broader message to the flying public that they should fly as a first choice. Perhaps such statements serve the intended purpose in much the same way that “man in the street” interviews seem to support the concept that intrusive security checks “make us safer”. Let’s face it; many people are less than comfortable with the concept of air travel. They do it because of the convenience, not because of the pleasant experience. Potential passengers need reassurance and we in the industry are more than happy to give it to them, neatly contained in statements of our overriding goal, which is safety.

While such statements may be good public relations, they have a way of migrating into the fundamental policy statements meant for internal consumption in the organisation. Are such public relations slogans the best way to communicate important goals to members of an operational enterprise? Probably not. In fact, such “safety” statements could be destructive to the overall operational culture of an organisation.

Does any enterprise really put “Safety First”? Can it? It is well established that the first job of any management is the accomplishment of the mission of the organisation with an acceptable level of risk. It is an observation bordering on the absurd but if we really wanted to put “safety first” we would not fly an aircraft. No one can guarantee that any given flight would be safe. It stands to reason then, that safety cannot be our first priority.

WHAT IS SAFETY?

Safety is perhaps the most overused and least understood concept in aviation or for that matter in any endeavour in the industrialised world. What is safety? A quick check of the internet yields the following: “the condition of being protected from or unlikely to cause danger, risk, or injury.”

Protection from the risk of injury, danger or loss, which could be referred to as risk avoidance,

must always be balanced with the need to efficiently accomplish a given task. Going back to

Capt Paul McCarthy (Retired)

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the dictionary, we find the definition of efficient as “achieving maximum productivity with

minimum wasted effort or expense.” Efficiency is the state of being efficient. Every manager

must balance risk and efficiency with every decision that is made. This is not to say that the

requirements of the enterprise must trump avoidance of risk; in fact it is quite the contrary.

The requirements of risk avoidance and efficiency must be balanced.

Effective risk management is critical in the furtherance of the organisation’s key objectives.

It has been suggested that corporate success and social welfare are interdependent. A business

needs a healthy, educated workforce, sustainable resources and adept government to

compete effectively. For society to thrive, profitable and competitive businesses must

be developed and supported. The same public that is reassured by the statement that

“Safety is Job One” is in a way dependent on safety not really being “Job One”. In an airline

context it would seem that the prime objective might be characterised as profit for the

shareholders (admittedly an elusive goal). This will of necessity include employment for the

stakeholders, value for the customers and good citizenship in the form of utility to society in

the provision of transportation, employment at many ancillary enterprises and environmental

responsibility in many different ways.

RISK MANAGEMENT

Conceptually, every aspect of the management of an aviation enterprise is about management

of risk. There is a risk that a prospective passenger is unable to determine the price of

a particular flight and books with another carrier. This risk can be managed by monitoring the

various platforms used to fulfill the marketing function and empowering the management

structure to respond to adverse trends on a near real-time basis. There is a risk that insurance

coverage for ground-handling incidents would be priced at an unaffordable level. This risk

could be managed by determining the reason for the increase in premiums, the state of the

insurance market and the loss experience of the particular enterprise. There is a risk that the

carrier will be unable to obtain governmental permission to outsource heavy maintenance.

This risk can be managed by understanding the requirements of the various governmental

agencies involved and ensuring that the maintenance provider is fully compliant prior to

applying for authorisation. The list really is endless. Every management decision involves some

element of risk management.

While the consequences differ, a governmental enterprise faces the same challenges to

manage risk. Certificate holders may be involved in operations which the regulator cannot

effectively oversee. Type designs may prove to be improperly issued. The public may demand

a response to a particular event that is contrary to perceived best operational practice.

How does the government manage such risk? It can be argued that management in any

aviation context is all about risk and reward. A balance must be struck by the appropriate level of management between the level of risk of an action and the value of that action.

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This is a concept that is fundamental to every aspect of an enterprise. In fact, The International Standards Organisation (ISO) has a specific standard, ISO 31000, that deals with enterprise risk management. Generally it holds that a risk is defined as a possible event or circumstance that can have negative influences on the enterprise in question. Its impact can be on the very existence, the resources (human and capital), the products and services, or the customers of the enterprise, as well as external impacts on society, markets, or the environment.

For international aviation enterprises, there are specific requirements to formally manage risk in several areas as defined by ICAO: Annex 1 (Personnel Licensing), Annex 6 (Operation of Aircraft), Annex 8 (Airworthiness of Aircraft), Annex 11 (Air Traffic Services), Annex 13 (Aircraft Accident and Incident Investigation) and Annex 14 (Aerodromes) (soon to be replaced by a dedicated Annex 19). This requirement is collected under the terms of the ICAO Safety Management System (SMS). There is also a requirement for a State Safety Programme to ensure that the certificate holder properly implements an SMS. This seems to make sense in the broader context of the requirement of risk management discussed above.

EFFECTIVENESS OF SMS

With many regulations and standards, there is a requirement to act and a need for documentation. SMS is no different. It is quite possible to establish a very impressive SMS on paper with very little actual implementation. It is entirely possible that senior management may feel that the articulation of a safety goal adopted from a public relations statement coupled with a system for operational risk management which is formalised on paper and staffed would discharge their responsibilities for risk management. The odd thing is that the same senior management would not stand for their marketing, insurance or maintenance departments making risk management without adequate information. Nor would senior management fail to give line managers in these departments sufficient responsibility to carry out their particular mission. Yet, without a robust implementation of an SMS, the operational end of the enterprise would be in that exact position. Train and equip the crew, dispatch them and hope for the best. That is not risk management. Does that situation exist at an enterprise you are familiar with?

Pose the following hypothetical questions to your enterprise. An aircraft is released from maintenance after a visit of less than 24 hours. It is placed in operation and dispatched on a revenue flight. Following take-off, a pressurisation malfunction forces the crew to return to the departure airport. Upon inspection it is determined that an essential component of the system was removed during the maintenance visit and not reinstalled. There was a shift change during the performance of the work card. It is subsequently determined that the handover procedures in use were inadequate to prevent such an error.

Under the SMS in force, does the safety officer have direct access to the chief operating officer concerning this system failure? If not, is the safety officer compelled to follow the chain

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of command from the shop floor to discuss the results of an investigation into the event? Can the safety officer require immediate change to certain operating procedures? If not, who has control over how to manage the risk and when the new procedure or process is to be completed? If the chain of command must be followed, are they technically qualified to assess both the risk and any proposed mitigation measures? It seems obvious that shop procedures that do not appropriately compensate for shift change issues during completion of a job card present a significant risk, particularly in systems that cannot be fully checked by line engineers or the operating crew prior to departure. In a large operation, many aircraft cycle through a maintenance facility during the course of any given week. This would seem to present a significant risk requiring immediate attention. Bureaucratic inaction can easily cause corrective measures to be significantly delayed or deferred.

“No” answers to the questions in the above hypothetical are possible under a fully approved SMS plan. The chief executive officer may feel fully justified in stating that “Safety is Job One” because that is an articulated goal to the employees and an approved SMS has been provided to assist them in achieving that goal. The existing management culture may resist delegation of any significant authority to a support function such as the group that administers the SMS. The management culture may require that line managers be given time to study the alleged risk and the proposed mitigation and fully analyse the financial impact of any mitigation. This is probably a good idea when the risk in question cannot have catastrophic consequences. Hypothetically, failure of pressurisation systems is not typically catastrophic. However, failure to properly complete a job card on any one of the components of an aircraft could easily be catastrophic. The risk identified is the job card procedure itself. In such a culture the effectiveness of the SMS may be seriously questioned. In short, the articulated safety goal may in fact lead to preservation of an overly rigid managerial hierarchy which in turn may lead to an inappropriate response from the SMS to a significant risk.

PROACTIVE SAFETY MANAGEMENT

The impact of existing management culture on the functioning of the SMS extends to both the balancing of risk and efficiency and the more basic problem of identification of risk. It is clear that an accident or serious incident at any organisation that requires State investigation will highlight certain common risks that must be addressed by the industry. The recent Boeing 787 Lithium Ion Battery issue provides an excellent example. If such risks are the only ones applied to the analysis of an SMS, there would be very little to analyse and even less to mitigate. This is best characterised as reactive safety management. It would identify and respond to yesterday’s risks. Hopefully, it would prevent a reoccurrence of past accidents but would do little to prevent existing but undocumented risks from becoming the next accident.

Events which do not rise to the level of an accident or incident can impact day-to-day

operational efficiency. They should require investigation, analysis and action as though they

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were accidents. For an SMS to be effective, this would seem to be a basic requirement.

An obvious example would be an aircraft declaring a fuel emergency. Any prudent manager

would investigate the circumstances connected with such a low fuel state on a given flight.

The same manager would hopefully be aware of the need to minimise fuel consumption and

hence cost caused by the carriage of excess fuel. Would the manager be aware of other incidents

of low fuel states, particularly if they did not result in the declaration of a fuel emergency?

If not, could the manager have sufficient information to enable an accurate assessment of the

need to amend the company’s fuel carriage procedures balanced with the need to operate

with the maximum efficiency? Can an effective SMS be of any value?

Daily use of a procedure can cause operational personnel to become error tolerant, the

so-called “practical drift”. An example here is the requirement that approach controllers

sequence arriving aircraft to a horizontal and vertical position from which they can

comfortably intercept approach guidance and complete the approach. During periods of high

traffic, the controllers have learned that pilots will accept approach clearance when well

outside of these established parameters. They have informally observed that the number of

aborted approaches does not appear to be related to such out-of-parameter clearance and

so have adopted the technique as acceptable. Pilots can cope with such clearances but may

be required to exceed the requirements for a stabilised approach to successfully complete

the approach. Over time, both pilots and controllers utilise the technique during periods of

increasingly adverse weather. Can either group accurately predict the consequences of this

practice for a particular flight? Can the risk be identified by investigation of a single event?

Can the risk be managed by either the air traffic service management or the flight operations

management? Can an effective SMS be of any value?

CULTURE AND ITS EFFECT ON SAFETY

Most importantly, in each of the above examples, the events depicted could serve as indicators

of risk when voluntarily reported to an SMS. There has been quite a bit written on the concept of

culture and its relation to risk management. In an excellent article on culture and risk resilience

in the Singapore Straits Times, Professor Siddiqi noted that “[f]ailure to tap onto the wisdom

of rank and file employees is wastage of shareholder value”. For an SMS to function it must

have raw data, a system to analyse that data and a process in place to act on the analysis.

The culture of the organisation would have a dramatic effect on each of these elements.

We know that we can train behaviour. The famous dog experiments of Pavlov demonstrated

a conditioned reflex that is a response to a particular stimulus. It has been shown to apply

equally to humans. It is fair to say that if an individual reports an event and is subsequently

punished for causing the event, the individual will refrain from reporting any future events.

Further, in a social environment, the associates of the individual will quickly learn not to report

events for fear of punishment. If much of the data for an effective SMS is obtained through

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voluntary reports, it may be fair to say that an organisational culture that routinely punishes

reporters may seriously impede the operation of an SMS.

Air New Zealand has published guidelines in its SMS policy, setting out the organisational

response to a report. “Console the error; Coach those at risk; Discipline the reckless”.

This is a very clear statement of a culture which seems to underlie almost all successful voluntary

reporting schemes. As a preliminary observation, it must be noted that of course all reports are

properly logged and feedback is always given to the reporter.

Where a violation of a rule or a policy is indicated in the report, there must be a process to

determine if the event can be classified as an error (or lapse or mistake) that does not indicate

a lack of qualification. If so, no further action is warranted.

Where a lack of qualification or proficiency is indicated by the investigation, appropriate non-

punitive corrective action is required before the matter can be closed. Such action generally

involves additional training and checking for operational personnel.

Where intent to violate a rule or a reckless disregard of the consequences of an action

is shown by the investigation of the event, discipline is appropriate. The integrity of the

accountability of both certificate holder and regulator is maintained by this formal process.

The operational employees know that the consequences of reporting an event are both

predictable and fair. This has sometimes been referred to as a just culture.

As Professor Siddiqi noted, “The boss sets the tone for a culture of risk resilience… Within

appropriate guardrails, timely feedback and clear executive direction, employees are seen as

self-directing and self-correcting.” Saying “Safety is Job One, etc. etc.” is simply not enough.

The culture of the organisation must be adapted to complement the goals of the SMS.

The organisation must make certain that an environment which encourages full reporting of

non-standard events is fully implemented throughout the management hierarchy. In fact, not

only encouraged but explained and if necessary demonstrated. Front line employees will not

initially trust safeguards built into an SMS programme. It may well have to be sold in all but the most exceptional organisations.

CONCLUSION

It is fair to say that an effective management would manage risk by establishing a culture which encourages full and detailed event reporting and feedback to the reporters; analyse risk by a scientific investigation of both individual events and the collected events stored in the data base, including possible alleviation strategies and their projected cost; and manage the risk by taking all required action at the time most appropriate to the level of risk. SMS is simply the tool that enables management to manage. Without the full understanding and acceptance of the SMS processes and outcomes at all levels of management, SMS will not

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realise its potential. Without the full cooperation of front line employees, it will be denied the basic ingredient for success, that is data. It is not a one-time exercise but rather a way of operating. It is not simply adopting a slogan and funding an office. It is a commitment from top to bottom of an aviation organisation to proactively manage the risk of injury, damage or loss. Only then can the CEO say that “Safety is Job One” because it really will be.

References

D Wood, ‘Corporate Social Performance Revisited’ (1991) 16(4) The Academy of Management Review

EU Directive 2003/42

ICAO Doc 9859, Safety Management Manual (3rd edn) 2012 p. 13

J.B. Watson Address to American Psychological Association 1916

Kang Huei Wang (2011) Safety Culture and Safety Management Systems – Enhancing the Heartware of Managing Aviation Safety. Journal of Aviation Management, Singapore Aviation Academy, p. 62.

Oxforddictionaries.com

The Straits Times February 25, 2013 p. A20

US Federal Aviation Administration Advisory Circular AC 120-66B, November 2002

Turning Data into Safety

The US Federal Aviation Administration (FAA) is proactively collecting and analysing safety data in order to identify risks

and enhance safety procedures long before those risks lead to aircraft incidents or accidents. The FAA has implemented

or is testing multiple programmes that empower air traffic controllers, front line managers, technical specialists, other

employees and airlines to report safety risks. An automated system at dozens of terminal radar facilities also helps detect

losses of aircraft separation for further investigation. To turn these valuable but ever-increasing stockpiles of data into

actions that will improve safety, the FAA is participating in global efforts to standardise how the information can be

categorised. The agency is also developing an analytics tool capable of better handling the larger volume of data so that

officials can get the best use of it.

ABSTRACT

Aviation Safety

Mr Joseph Teixeira has been the Vice President for Safety and Technical Training for the FAA Air Traffic Organisation (ATO) since 2011. He is responsible for integrating a safety management system and safety standards into the ATO as well as organisational efforts to manage risk, assure quality standards, instill an open culture of disclosure, educate employees and promote continuous improvement. Mr Teixeira also leads the agency’s technical training and certification of air traffic controllers and technicians. Prior to this, Mr Teixeira was the Executive Director for Safety where he was responsible for the daily monitoring of operational safety performance and the development of safety policy and programmes. He also oversaw the development and implementation of voluntary reporting systems and the integration of human factors, employee safety, fatigue risk and safety culture. Under his leadership, the ATO now operates the largest aviation voluntary safety reporting programme in the world.

THE AUTHOR

Turning Data into SafetyAviation Safety

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INTRODUCTION

Thanks to a proactive safety culture, the US FAA has been collecting more safety data in recent years than at any other time in its history, and the agency is using that information to reduce risks to aircraft. Because more than 99.998 per cent of air traffic operations in the US occur under the FAA’s exacting guidelines, the agency now roots out hazards that lead to risk rather than just reacting to incidents and accidents.

Using voluntary safety reporting programmes, operations reviews and automated tracking

systems, the FAA is gathering information on previously unknown issues. That data empowers

agency officials to identify and eliminate minor risks long before they grow into major

safety incidents, and they are measuring success by what the agency fixes. The FAA Safety

Management System works on four key strategies:

• Valueemployeeinput;

• Usetechnologytogatherdata;

• Analysedata,identifyissuesandmakerecommendationsforcorrectiveactions;and

• Learnandembracechangethatwillmakethenationalairspacesystemsafer(see Figure 1).

The effort already has proven its value. Thanks to the collection and analysis of safety data, the FAA identified the five most serious hazards that contribute to risk in the national airspace system in 2012. It has addressed those risks with changes to policies, procedures and training, and a study on modifying radar systems. This year, the FAA has used the data to identify the next five most serious hazards, and efforts are under way to address them. The ‘Top 5’, as the programme is known, is an ongoing effort to focus resources and attention on

Joseph TeixeiraFederal Aviation Administration, US

Figure 1: The FAA Safety Management System

REPORT COMPILE ANALYZE IDENTIFY IMPROVE

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the most threatening hazards in the system. The effort is based on a process that provides

a standardised scoring system for events that can be used to identify the areas of highest risk.

FAA officials then compare events objectively to decide which ones pose the most pressing

risks to safety.

But that is just one way the FAA is using data to push safety forward. The agency is also

developing more robust systems to classify and analyse the immense amount of safety

information it is collecting.

COLLECTING DATA

The FAA operates the largest voluntary aviation safety reporting programme in the world.

Known as the Air Traffic Safety Action Programme, it collects reports from air traffic controllers

and front line managers at 332 facilities across the country.

More than 67,800 reports have been filed since the programme was first implemented in

2008, and more than 77 per cent of eligible personnel have submitted at least one report.

Controllers are filing more than 1,580 reports each month. About 78 per cent of them

describe specific events; the rest provide insights into policies, procedures and equipment

issues.

That level of participation demonstrates that the FAA’s front line employees see the

programme’s non-punitive approach as an incentive for people to share information that

reduces risk in the national airspace system. Their participation is essential to making the

system even safer.

Because controllers handle air traffic every day using the FAA’s systems and procedures,

they often see safety risks before managers become aware of them. The safety reporting

programme gives controllers the power to report those risks. The most serious reports go to

a committee of management and labour representatives that is set up to resolve safety issues.

Simply put, the FAA trusts front line employees to be its greatest resource to eliminate risk in

the airspace. Their efforts are vital to success.

The National Air Traffic Controllers Association (NATCA), the FAA’s largest labour union,

agrees. “The [FAA] now has more and better detailed safety data than before,” NATCA Safety

Committee Chairman Steven Hansen recently told The Washington Post. “The high levels of

participation shows controllers see the programme as a way to improve safety.”

As a result of reports the controllers are submitting through the programme, the FAA

has expedited the elimination of safety problems such as trees degrading radar signals,

condensation on tower windows obscuring controllers’ views and an automation system

glitch that rerouted unauthorised flights through restricted airspace.

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After reviewing the reports, safety panels that comprised representatives from the FAA’s ATO, Air Traffic Safety Oversight Service and NATCA have asked for corrections that have been implemented in 200 cases. Since the programme’s implementation, no other safety programme has been used to identify and fix more local and system issues.

TECHNICAL OPERATIONS SAFETY ACTION PROGRAMMES

As the controllers’ programme makes the national airspace system even safer, the FAA is implementing a similar programme for employees who maintain the FAA’s air traffic control equipment. Called the Technical Operations Safety Action Programme, it has been put in place in one of the FAA’s three service areas and will be deployed in the other two soon.

This second programme is already showing positive results. More than 2,200 employees are eligible to submit reports, and 164 reports have been submitted so far. Fifty-six corrective action requests have been issued to resolve safety problems identified in those reports.

One report alerted officials that computer screen savers could interfere with the monitoring of airport surface detection equipment used by air traffic controllers. The problem could delay a technician’s response to a malfunctioning system, increasing the chances of a runway incursion. A maintenance alert was issued, allowing sites to set up the screen savers properly, and a national change proposal was submitted to disable automatic screen savers.

AVIATION SAFETY ACTION PROGRAMME

The FAA realises that it cannot reduce risk in the national airspace system by itself, so it has agreements in place with 12 airlines to share data collected through the voluntary reporting programmes for controllers and the airlines’ voluntary safety reporting programmes, known as the Aviation Safety Action Programme. An additional programme – Confidential Information Sharing Programme, gives the FAA and the airlines access to information they otherwise would not have, elevating managers’ awareness of safety issues and providing a more complete picture of safety incidents.

FAA analysts review an average of 155 reports from the airlines each week, and the agency is organising data in an effort to study issues raised by pilot reports on tailwind landings and security measures around special events, such as major sports events and VIP travel. To date, more than 9,750 reports have been shared.

TRAFFIC ANALYSIS REVIEW PROGRAMME

In addition to those manual reporting programmes, the FAA has implemented an automated safety reporting system called the Traffic Analysis Review Programme (TARP). This tracks operations at 174 terminal air traffic control radar facilities and 22 air route traffic control centers. The software automatically detects losses of aircraft separation.

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When losses are detected, the programme generates electronic occurrence reports that are used strictly for trend analysis and are non-punitive. The application that detects losses of separation begins the analysis by finding pairs of aircraft that have less than the required vertical and lateral separation. This forms the FAA’s base data set on which TARP then applies other applicable separation standards. It is this application of these other applicable standards where part of the reduction occurs, such as diverging courses or visual separation. Upon analysis, more than 99 per cent of those events turn out to be safe situations with positive separation that required human interpretation. But the automated reports still provide a robust set of data for the analysts working to identify safety trends.

ELECTRONIC DATA ANAYSIS AND REPORTING PROGRAMME

The FAA also collects a considerable amount of safety data through employee occurrence reports, which are required whenever a serious incident is observed. Both manual and electronic occurrence reports are gathered by the Comprehensive Electronic Data Analysis and Reporting Programme. After being in place for a year under new FAA orders that guide safety reporting, this programme now has more than 848,500 records on file.

When an incident that is reported manually or electronically involving a loss of separation between two aircraft of more than 34 per cent, the FAA classifies it as a Risk Analysis Event. That triggers a Review Analysis Process involving a panel of experts on the type of facility where the event occurred, an airline transport pilot and often a NATCA representative. They examine the event using criteria including proximity, closure rate, repeatability and severity. Data from those events are compared to determine the five most serious hazards in the national airspace system mentioned above.

With the various reporting programmes in place, the FAA now has nearly a million reports. That is a lot of data which the agency is turning all of this information into safer skies.

CLASSIFYING DATA

The first step is classifying the information such that data from separate incidents can be compared and studied together. The rapid expansion in both the quantity and quality of information the FAA captures on safety incidents in the national airspace system has required agency officials to reconfigure how they classify the features of those incidents.

Before 2013, the Air Traffic Quality Assurance database was the FAA’s principal source ofinformation regarding air traffic control safety incidents. It contained about 100 causal and contributory factor codes, but as some of these codes overlap, there were actually fewer than 100. That may sound like a lot, but the Review Analysis Process and the voluntary reporting programme for controllers contain more than 500 causal and contributory factors each. This multitude of factors enables analysts to explore the causes of safety incidents at a much finer level of detail.

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That is a big step forward in eliminating hazards that lead to risk, but the implementation of the data collection efforts has introduced a challenge for the FAA’s data analysts. Because the programmes were, for the most part, developed independently, the systems used to classify their respective causal and contributory factors are very different.

Moreover, those two FAA classification systems are different from other major classification schemes, such as the National Transportation Safety Board (NTSB)’s accident incident database system and the National Aeronautics and Space Administration’s Aviation Safety Reporting System. The lack of a common classification scheme makes it difficult to analyse information from multiple data systems using common analytical framework.

AIR TRAFFIC MANAGEMENT COMMON TAXONOMY

In response to this circumstance, the FAA has initiated an effort to meet the challenges of having diverse classifications. The agency is participating in an international effort to standardise causal and contributory factors in these systems. In the first phase of this effort, begun in September 2011, the FAA completed an element-by-element mapping for causal factors related to the Review Analysis Process and the voluntary reporting programme for controllers. This new merged classification system is called Air Traffic Management Common Taxonomy version 1, more commonly known as ACT v.1.

The key contribution of ACT v.1 is the creation of a system-wide classification framework for understanding causal and contributory factors. In other words, rather than just focusing on the pilot or the air traffic controller, ACT v.1 considers interactions among all agents operating in the airspace system, including pilots, controllers, and organisational and environmental factors and combines information from multiple reporting systems (see Figure 2). Each causal factor is fully further divided into contributing factors (see Figure 3).

ACT v.1 also relates similar elements in the two FAA reporting programmes, even if they use different terms for the same concept. For example, “Auditory or Visual Information Misinterpreted” in the controllers’ programme is equivalent to “Perception” in the Review Analysis Process.

ACT v.1 was a product of months of extensive meetings. Subject matter experts from each programme convened to discuss their respective terminologies and definitions. A useful by-product of this process is that ACT v.1 provides, for the first time, a data dictionary with definitions and examples for each element.

While ACT v.1 is an internal product designed primarily as an analytical aid to FAA safety analysts, this year the agency is collaborating with various international organisations in order to develop a common global classification framework. The partners in the effort are the Commercial Aviation Safety Team-International Civil Aviation Organization Common Taxonomy Team (CICTT), the Civil Air Navigation Services Organisation, EUROCONTROL and the European Aviation Safety Agency.

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The international system will form the basis for ACT v.2, which will be an internal product featuring an improved classification structure, an improved human factors section that is based on a substantial body of CICTT human factors work, and an improved fatigue factors section designed by fatigue experts in the FAA’s ATO.

The international effort to create common classifications is a high-level effort aimed at building the first two or three tiers of a hierarchy. CICTT wants to give each member organisation some latitude to design its own lower-level tiers. Having common top tiers, however, would enable CICTT and other groups to study data gathered by multiple air traffic management organisations in an “apple-to-apple” comparison.

Additionally, ACT v.2 will incorporate mappings to other major aviation classification systems, including the NTSB accident/incident database. The FAA plans to make the detailed classification system of ACT v.2 available for use by any country or organisation.

ANALYSING DATA

The classification process will help the FAA organise the safety data it collects. But the sheer quantity of the data makes it difficult to study using existing labour-intensive methods.

Figure 2: Common Top Tiers of Causal Factors

AJS MERGED TAXONOMY

A INDIVIDUAL FACTORS

B SUPERVISORY AND ORGANIZATIONAL FACTORS

C FATIGUE

D ATC/PILOT COMMUNICATIONS/CLEARANCE

E COORDINATION

F AIRSPACE AND PROCEDURES

G AIRCRAFT PERFORMANCE OR PILOT ACTIONS

H WEATHER

I SECTOR, POSITION AND ENVIRONMENT

jEQUIPMENT

K TRAINING AND EXPERIENCE

L FLIGHT DATA, DISPLAY PROBLEMS AND AIRCRAFT OBSERVATION

M AIRPORT AND SURFACE

N EMERGENCY SITUATIONS AND SPECIAL EVENTS

O TRAFFIC MANAGEMENT

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Until recently, analysis of event data relied on traditional analytical techniques, such as manually reading event narratives, viewing radar replays, and using tables, charts and trending graphs. While these types of tools will always be an important part of the analytical process, they require too much effort to manage the tens of thousands of reports the FAA is now collecting. FAA analysts could never process that many event reports under the same time constraints using existing tools.

The FAA has long had a substantial amount of radar track data available, and analysing that data has been a challenge. The agency puts considerable effort and resources into transforming that radar data into information so that it can be process efficiently, and recent efforts have shown positive results. But while huge amount of radar data have existed for a while, the explosion in the quantity of event data – like that gleaned from some of the safety reporting systems – is relatively new.

The new data collection efforts and advances in classifying that information have given FAA analysts an abundance of data, and the FAA is investing proportionately in resources to fully exploit this increased stream of information.

Figure 3: Common Contributory Factors

AJS MERGED TAXONOMY B SUPERVISORY AND ORGANIZATIONAL FACTORS

C FATIGUE

A.a CONTROLLER ACTIONS

A.b WORK AREA INFLUENCES

A.c CONTROLLER INFLUENCES

A.d OUTSIDE INFLUENCES

A.e EXPECTATION BIAS

A.f INTERRUPTION

A.g UNSAFE ACTS

A.h RECOVERY

A.i MEMORY

A.j NON-CONFORMANCE

A.k PERSONAL FACTORS

A.l PILOT FACTORS (DISTRACTION)

A.m PERSONNEL

A.n CONTEXTUAL FACTORS

A INDIVIDUAL FACTORS

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The long-term vision for safety analysis is defined in a recently completed “concept of operations” for a future Safety Analysis System. It includes new information technology infrastructure to accommodate much larger quantities of data – including voice and radar data – and new analytics capabilities that the FAA is in the process of identifying.

In the near-term, the agency is developing a prototype safety analytics tool to test analytical tools and methods in a working environment. The results of the prototype testing will be used to further define the long-term requirements.

In broad terms, the prototype suite consists of six components. The FAA hopes to have these components fully developed in 12 months:

Taxonomy Mapping

The prototype safety analytics tool is designed to accommodate new data streams and the associated classifications that will be continuously added to the system. The classification interface allows users to search and explore the Air Traffic Management Common Taxonomy and the various aviation classification schemes to which it is mapped using both text-based and interactive graphical representations.

Because the classification system is evolving and is subject to continual revision and improvement, the interface will include a function to manage proposed changes to the components, organisation and definitions of the system.

Data Retrieval and Basic Data Exploration

The prototype will also significantly upgrade the ability of users to access and manipulate data. Current FAA systems offer very limited options for data access to basic users – for example, retrieving a few records at a time based on simple filtering criteria. If users want to access data with more advanced options, a training course is necessary so they can learn how to use a more sophisticated tool.

The prototype suite will allow users with little or no training to explore the data with a wide array of user-friendly filtering options, table-generation functions, graphics and charting features, and simple statistical testing capabilities, such as ordinary least squares. This component will also generate standardised reports on a regularly scheduled timetable or upon user demand. Those reports are currently produced manually.

System Monitoring

Featuring a full suite of user-customisable monitoring displays or “dashboards,” the prototype would offer an at-a-glance picture of risks and resolutions. The dashboards would include maps of events and anomalies with various analytical functions; color-coded heat maps

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on which the intensity of colors indicates the degree of potential safety risks; risk matrix

representations based on FAA Safety Management System definitions; the system risk error

rate; and seasonally adjusted performance.

Each of these functions would enable users to examine data in fine detail by making use of

statistical algorithms that could, for example, offer clustering to identify similar facilities for

comparative analysis.

Resource Allocation

The fourth component would serve as a test bed for applying risk-based methods and

procedures to the allocation of resources. This functionality would help managers decide

where a runway safety action team could have the biggest impact or help them determine

which facilities should be audited.

Basic research in this area has already been completed by the University of Virginia’s School

of Engineering Centre for Risk Management, and a stand-alone, personal computer version

of the tool has been built. The next phase would involve transferring the tool to a web-based

environment for testing and evaluation by FAA managers across the country.

Mitigation Performance

Another feature of the prototype tool would enable users to analyse incident data in

combination with information on safety-related activities. This builds on work already done

by the FAA.

The agency has produced a prototype process to assess how effective various runway safety action

items have been in reducing the frequency of runway incursions. The current prototype focuses

on aggregate incursion rates and overall levels of activity. Future versions of the tool would allow

users to focus on specific types of runway hazards and the impact of particular interventions,

which already are identified by types in the runway safety action team tracking system.

As additional mitigation tracking systems are implemented, they can be incorporated into

the prototype. Users would be able to apply the prototype to monitor risks and interventions

throughout the national airspace system, not just issues tackled by runway safety action teams.

Quality Control

In addition to its role as a tool test bed, the prototype analytics suite would serve as a platform

to study how safety analysts do their jobs, what tools they require to be more productive

and, potentially, to re-organise the safety analysis process by replacing manual input with

automated input.

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For example, based on the FAA’s research, anomaly detection methods show promise as a means of continuously monitoring vast quantities of data without human intervention. That would save a significant number of man-hours, and an analyst or decision-maker would only need to be notified when certain alert parameters are attained. He or she could then study the incident further or initiate corrective action.

CONCLUSION

The FAA operates the safest airspace system in the world. But safe is never safe enough. As new technologies, airframes and systems are introduced, complexity in the aviation system will continue to increase. By collecting data through new safety reporting systems, collaborating with international partners, analysing new processes and applying that new knowledge to reduce risk, the agency is measuring success by the things it fixes and moving aviation safety to the next level.

Aviation Security – Challenges, Opportunities

and the Way Forward From 12 to 14 September 2012, the International Civil Aviation

Organization (ICAO) held a High Level Conference on Aviation Security (HLCAS) in Montreal, Canada. The HLCAS was

a timely event that brought together top level aviation security leaders who collectively gave their strong support to the

ICAO for its efforts in addressing the challenges faced on the aviation security front.

The HLCAS witnessed the agreement by the delegates in various critical areas. The ICAO also issued a Communique mapping

out its commitment to further enhance the level of global aviation security. A number of challenges and opportunities

including finding sustainable and practical approaches to deal with aviation security challenges, enhancing international

co-operation, and searching for innovative solutions that move towards an outcome-based approach to security were

identified. New opportunities in identifying new and emerging aviation security threats, streamlining of security approaches

internationally, and opening up more avenues for capacity building and assistance were also achieved. The ICAO, its

Member States, industry, and other stakeholders, would be expected to collaborate closely to ride these challenges and

explore these opportunities to enhance the level of global civil aviation security.

ABSTRACT

Aviation Security

Mr Bernard Lim is Director (International Relations and Security) with the Ministry of Transport, Singapore. His key responsibilities include formulating and managing policy matters concerning international relations, transport security and transport emergency preparedness in Singapore. He is currently Chairman of the ICAO Aviation Security Panel and Vice-Chairman of the Asia-Pacific Economic Co-operation Aviation Security Experts Sub-Group. He had also led the ICAO Aviation Security Panel Working Group that developed the Comprehensive Aviation Security Strategy (2011 - 2016).

Prior to this, Mr Lim had held various positions in areas such as airport management and ground operations, air transport and air services negotiations, international relations as well as aviation security and emergency preparedness at the Civil Aviation Authority of Singapore.

Bernard holds a Master’s Degree in Public Administration from the University of Liverpool, UK. He was trained in crisis management at the Emergency Planning College in York, UK, and in Leadership at the John F Kennedy School of Government, Harvard University, US.

Ms Patricia Reverdy is Deputy Executive Director of the European Civil Aviation Conference (ECAC). Her responsibilities cover a wide ambit on civil aviation policies and development, including air transport, training and aviation security matters.

She joined the ECAC in September 2001 as an Aviation Security Audit Officer and was responsible for the development of aviation security policies, management and implementation of the ECAC Audit and Capacity Building Programme, and various efforts to provide technical and operational expertise to ECAC’s 44 Member States, in order to attain and maintain full compliance with the European aviation security standards. Prior to joining ECAC, Ms Reverdy was security manager with the Federal Office for Civil Aviation in Berne, Switzerland, from 1995.

THE AUTHORS

Aviation Security – Challenges, Opportunities and the Way Forward Aviation Security

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Bernard LimMinistry of Transport, Singapore

Ms Patricia ReverdyEuropean Civil Aviation Conference

INTRODUCTION

The ICAO convened a HLCAS from 12 to 14 September 2012, in Montreal, Canada. More than 800 delegates from 132 Member States, 32 international organisations, as well as industry associations attended theConference. ACommuniquéwas issued at the end ofthe Conference, capturing the key thrusts and directions which ICAO and its Member States intended to go forward in enhancing the level of aviation security at a global level. This Conference represented a unique opportunity to set political priorities in the field of aviation security for the coming years, especially in view of the fact that the last time ICAO had held a similar conference was the Ministerial Conference on Aviation Security in 2002, following the tragic events of 9/11.

BACKGROUND

The HLCAS was a timely event. Since September 2001, ICAO, its Member States, international organisations and industry had undertaken many new measures and developed new Standards and Recommended Practices (SARPs) in ICAO Annex 17 to the Chicago Convention to enhance the level of security for international air travel, and the benefits for the travelling public. For example, enhanced measures were introduced on the screening of baggage, passenger, cargo and mail. Despite these new measures being introduced, the threat from international terrorist groups against civil aviation continued unabated. Aviation remains an attractive target for terrorist groups. For instance, there were terrorist attacks at Glasgow Airport, UK in 2007; Mumbai, India in 2008; Moscow, Russia in 2011 and against flights such as the “underwear bomber” from Amsterdam, The Netherlands to Detroit, US in 2009, and on a domestic flight in China in 2012. In 2010, there was also an alleged plot by terrorists to detonate explosives hidden in printer cartridges flown as air cargo consignments on civilian aircraft, from Yemen to Chicago, US via Europe and the Middle East. Thankfully, the improvised explosive devices were discovered by intelligence sources and intercepted before the terrorists could use them to cause any fatalities.

For those who may have doubted the need for security in aviation, these incidents provided clear evidence that civil aviation operations continued to be at risk. ICAO and the international air transport community have to maintain their focus and determination to combat such threats to the security of international air transport, whilst facilitating the continued growth of the air transport sector, and the movement of millions of passengers and high volumes of air cargo, in the most expedient and cost-efficient manner. It was timely that a high level political forum be

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convened by ICAO, to seek high level political commitment and support from its Member States and industry, and to identify some important steps forward which ICAO, its Member States and industry could take. The HLCAS was convened, following a series of regional aviation security conferences held in 2011 and 2012, to provide that needed platform to give aviation security the much needed attention and focus at the highest levels. Another aim of the HLCAS was to galvanise common steps amongst all stakeholders in moving forward with various initiatives and efforts to enhance the level of aviation security globally.

THE KEY OUTCOMES

Given the multiple global developments and continued concerns regarding the security of international civil aviation operations, the HLCAS’ deliberations focused on several major items that were of global significance. The key outcomes were as follows:

Focus on implementation: There was a unanimous call by the Conference for all ICAO Member States to strengthen their efforts to ensure compliance with the SARPs of Annex 17 (Security), and security-related SARPs of Annex 9 (Facilitation) of the Chicago Convention, as well as other relevant security conventions.

Risk-based approach to security: The Conference supported that ICAO and all stakeholders adopt a risk-based approach towards aviation security. This includes taking on an outcome-based approach with regard to the implementation of aviation security measures that would best suit the circumstances faced by States, with the flexibility to decide on the exact methods of security measures to be put in place, whilst achieving the same security outcome/objective defined in Annex 17 SARPs. In relation to the risk-based approach to security, the Conference welcomed the development of a Risk Context Statement by ICAO, which could be used as a reference by States seeking guidance for conducting their own risk assessment.

Insider threats: The threats potentially presented by “insiders”, those who work every day in aviation, and have both privileged access and specific knowledge, were recognised by the Conference. In this regard, the Conference recommended the adoption by the Council of a Standard for 100 per cent screening of non-passengers entering a security-restricted area at the airport.

Cargo security: The Conference endorsed the new SARPs that were developed by the ICAO Aviation Security Panel for the strengthening of measures applicable to cargo and mail shipments. Further work on air cargo security are in progress as new guidance material, as well as a strategy towards achieving further security outcomes were welcomed by the Conference.

Acknowledging the multi-discipline nature of cargo security, the Conference welcomed ICAO’s efforts to strengthen its collaboration with the World Customs Organisation and the Universal Postal Union with the objective to streamline and examine steps towards strengthening

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and harmonising air cargo security processes and measures. Such collaboration would have significant benefits for all States and industry stakeholders.

Evolution of the Universal Aviation Security Audit Programme (USAP): The Conference supported the proposal for the evolution of ICAO’s USAP towards a Continuous Monitoring Approach to ensure compliance with ICAO’s security SARPs. This would allow ICAO to better focus the use of its resources on States that have major deficiencies. Further work would be pursued to encourage States to collaborate, and for ICAO to use the USAP results to identify weak areas where specific States could benefit from the assistance from other States to address these gaps.

Capacity building: There was strong support for widening the provision of aviation security capacity building and assistance, especially to States that would benefit significantly to level up their aviation security standards. These included initiatives to enhance capacity building for air cargo security, as well as improving the quality of aviation security personnel entrusted with the responsibilities of carrying out aviation security measures.

Liquids, aerosols and gels (LAGs): Recognising the threats posed by liquid explosives, the Conference called for further efforts to address security concerns and restrictions currently in place, such as the carriage of LAGs in cabin baggage by air travellers. The aim is to find practical, effective and sustainable procedures and measures that could be universally implemented across all airports to facilitate the carriage of LAGs items, thus improving passenger facilitation whilst still meeting security needs. A transition from a restriction regime to an effective screening regime was favoured.

Equivalence of security measures: The Conference supported the call for initiatives and steps that can be taken by ICAO, States and stakeholders towards greater harmonisation of aviation security measures which could lead to the recognition of equivalent security measures, and possibly “one-stop security” agreements. There was also unanimous support for the strengthening of international co-operation amongst all States towards mutual recognition of each other’s security regimes. Such efforts would optimise the use of limited resources, enhance passenger facilitation, as well as remove redundancies and unnecessary costs, thereby raising the efficiency of security measures applied across States.

Innovation: The Conference also welcomed steps forward in the use of security technology and innovation, as well as initiatives to improve security screening processes for passengers and cargo.

CHALLENGES AND OPPORTUNITIES

Despite it being a success, the Conference was only one step in the right direction. More measures are now needed to transform the conclusions of the Conference into practical improvements. The Conference gave aviation security timely and critical high level political support and

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attention that was needed at the global level. This provided for consensus on the various key areas of focus and gave directions to ICAO, Member States and all stakeholders, on a number of important steps to be taken in the way ahead towards enhancing aviation security in a collective manner.

Some of the key challenges that can arguably be said to have come out of the ICAO HLCAS include:

(a) ICAO, its Member States and all stakeholders should work in unison to move away from the “one-size-fits-all” approach to aviation security. In this regard, ICAO and its Member States should recognise that, while all stakeholders share a common objective and vision towards creating a secure global environment that can support the growth and development of international civil aviation, States have different domestic and local circumstances, and resource limitations that could prevent them from implementing identical security measures. Instead, choosing a risk-based and outcome-based approach to aviation security should be strongly supported so that the most practical and cost-effective security measures can be applied, optimising the use of resources and harnessing the security measures already provided for by other entities within the State (e.g. customs authorities, border control authorities etc) and international partners.

(b) Promoting international collaboration amongst States and stakeholders is indeed a win-win approach for all partners involved. This is consistent with ICAO’s constant call for harmonisation of security approaches, as well as pursuing mutual recognition of security measures between States. This would avoid duplications, improve security and operational efficiencies, and enhance passenger and cargo movements, and facilitation between/across States and continents. This would also serve to avoid States imposing unilateral security measures and requirements on other States and/or their air carriers, which can lead to inefficient, costly, unsustainable and uneven application of security measures globally.

This is especially the case when many States have already established their national aviation security regimes and implemented measures to ensure the security of the aircraft, passengers, baggage and cargo, to achieve the same security outcome – i.e., the aircraft takes off and lands safely at its destination without any security breach, incident or act of unlawful interference being committed throughout its journey.

(c) The search for innovative solutions to address security concerns, such as new methods to overcome the restrictions on the carriage of LAGs, and for more efficient ways to screen passengers and cargo, represents a challenge for all stakeholders. These challenges include the willingness and capability to move away from traditional and deep-rooted mindsets, and to adopt a risk-based and outcome-based approach to security.

There is also the challenge of developing, investing in and deploying the use of security screening technology that can deliver the desired outcomes for both security and

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facilitation. For many States and stakeholders, these can be financially costly from the capital investment and operational aspects, which makes it difficult for such technology to be universally applied.

However, there are also opportunities for all stakeholders arising from the conclusions of the ICAO HLCAS. These include:

(a) The Conference has created a momentum for international collaborations, which should be further pursued by ICAO, its Member States and all stakeholders. Such collaborations would bring about benefits in terms of streamlining security approaches, and the resulting efficiency to enhancing security and facilitation. Stronger international collaborations will also enable ICAO and all stakeholders to develop aviation security SARPs that are sensible, practical, acceptable and universally sustainable.

(b) The Conference clearly stated the importance of capacity building activities. Capacity-building opportunities should be explored and undertaken to help States that require such assistance to level up their security measures, which will collectively raise the bar across the world. Such capacity-building efforts will also help States to jointly resolve impediments to aviation security, learn from each other’s experiences, tackle both common and unique challenges that may be prevalent in certain regions or in individual States, build greater understanding and open up avenues for more innovative security measures that can be adopted by all entities.

(c) Collectively, these efforts present new opportunities to identify new and emerging threats to the security of global civil aviation. These would help in the early development of awareness, as well as practical approaches and capabilities – including the use of technology and other innovative methods, to mitigate these threats. States that have the ability to lead in such developments can then help other States to shorten the learning curve and work towards jointly dealing with such new threats collectively and sustainably.

CONCLUSION: THE WAY FORWARD

Security threats to global civil aviation operations will continue to pose challenges to all stakeholders. It is imperative that ICAO, its Member States and all stakeholders, enhance efforts to cooperate with each other to address these threats and challenges through practical and cost-effective ways. The sharing of information and best practices, within and across regions, and the use of international forums to develop new approaches and security SARPs should be further encouraged. The use of advanced security technology and innovative measures, using risk-based and outcome-based approaches, would certainly enhance security and facilitation. Stakeholders and decision-makers should also be urged to adopt a greater level of security culture and awareness, where security forms an integral part of their overall

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spectrum of deliberations and decisions, when addressing civil aviation issues, developments and operations.

ICAO has a critical and central role to play and needs to show its leadership in the field of aviation security. The 38th ICAO Assembly presented an opportunity to do so and to materialise the decisions taken at the HLCAS into concrete and practical actions for the next three years.

Competency-based Training in Aircraft Maintenance


Training aircraft engineers and technicians has been a challenge as aircraft touch-time for trainees is getting

scarce. This paper looks at the history of Competency-based Training (CBT) and how the aviation industry can adapt CBT

to mitigate the huge demand for training in the coming years. The theoretical foundation of CBT is discussed and its

applicability to aviation training explored. Some efforts by the aviation industry are listed, including Singapore’s Workforce

Skills Qualification system which has shown encouraging results. The paper concludes with a scenario of pressure to

produce large numbers of skilled workers as similar to the 1960s when CBT was formulated.

ABSTRACT


Mr Lim Yeow Khee is President of the Singapore Institute of Aerospace Engineers (SIAE); Managing Director, LYK Aerospace (S) Pte Ltd; Associate Professor (Adjunct) of the Nanyang Technological University, Singapore; Chairman, Singapore Aerospace Workforce Skills Qualification (Aero WSQ) Technical Committee and Authority Member, Civil Aviation Authority of Singapore.

Mr Lim started his aerospace engineering career with Malaysia-Singapore Airlines in 1968 and continued with the airline [which became Singapore Airlines (SIA) in 1972] for 38 years. He has served in various technical and management positions in SIA and SIA Engineering Company covering base maintenance, technical services, workshops, technical projects, inflight entertainment, line maintenance, quality & safety and productivity & engineering training.

As Chairman of Singapore Aero WSQ, he is responsible for formulating and validating 55 skills modules for the Higher Certificate in Aerospace Maintenance.

He holds a Bachelor of Science (Engineering) Honours from University of Leeds, UK. He is a Fellow of the Royal Aeronautical Society (UK) and Honorary Fellow of the SIAE.

THE AUTHOR

Competency-based Training in Aircraft Maintenance

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Competency-based Training in Aircraft MaintenceHuman Resource and Training

Lim Yeow KheeSingapore Institute of Aerospace Engineers

INTRODUCTION

Since the turn of the millennium, there have been growing concerns about the shortage of aircraft maintenance engineers and technicians. Projections by various organisations indicate worldwide demand for 650,000 aircraft maintenance jobs by 2030. The Asia Pacific region alone will need 250,000 people resulting in demands for 24,000 training places for aircraft maintenance engineers and technicians per year up to 2030.

This global challenge for the aviation industry to produce sufficient well trained and experienced maintenance personnel demands innovative training methods and new systems of certifying maintenance personnel. The industry needs to create attractive job propositions and career paths which appeal to skilled and motivated people.

CBT appears to be a viable solution. In contrast to traditional time-based training, CBT allows the student to learn at his own pace and progress is measured by achievement of specific learning objectives. CBT has tremendous potential to improve training efficiency, maximise the training dollar, as well as optimise the period in which personnel can be operationally ready. With that, trainees will see themselves productive and contributing to their organisations earlier, and in the perspective of companies, it could help in the attraction and retention of new talents.

CBT sounds effective and economical, but is CBT the only solution and what do we need to make it sustainable? Let us look at some basic concepts of learning with CBT and the potential difficulties in implementing CBT.

HOW IT BEGAN

Many commentaries on the origins of CBT pointed to concerns about inadequate teacher training and poor student achievement in America in the mid-1960s. CBT was then promoted as competency-based teacher education by the Education Professions Development Act of 1970 (McKenna, 1992 as cited in McCowan 1998).

Interestingly, the impetus to develop CBT had its origins in the launch of “Sputnik I” by the Soviet Union on 4 October 1957. Hodge (2007) stated that the launch of the first artificial satellite by the Soviet Union caught the US by surprise and Americans started to ask how America could have lost their technological superiority – the education system was obviously at

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fault! America started to look critically at its education system which led to Congress passing

the National Defence Education Act in 1958.

This Federal intervention on education and training resulted in large funding available for

science and vocational education, providing the resources for the development of CBT.

Meanwhile, with the political climate in the John F Kennedy administration with Secretary for

Defence, Robert S McNamara pushing for cost effective management methods and objective

planning, the stage was set for the implementation of competency-based education and

training in America.

THEORETICAL ORIGINS

The foundations of CBT are derived from psychological behaviourism and scientific measurement.

They were forged in the US military during World War II and the Cold War when they were

faced with the problem of training a large number of people for combat as well as to operate

the rapidly evolving technologically advanced weapon systems.

By the time of the Sputnik crisis, the US military was already well advanced in developing

a scientifically-grounded solution for fast and effective training methodologies.

According to Hodge (2007), the theory of behaviourism was inspired by the 17th century

philosophical notion expounded by Hobbs and Locke, often referred to as British Empiricism.

Its main premise is that our sensory experience is the only source of knowledge. Though

controversial by today’s knowledge of the mind, it did lay the foundation for the experiential

learning part of CBT. Dewey gave it a twist, that the real question is not so much as how our

knowledge is derived, but how our action is shaped by experience.

CBT’s strong emphasis on the expression of competencies in behavioural terms and the

assessment on the observable behaviours of the student are clearly influenced by behavioural

psychology.

The emphasis in CBT on relevance to industry has its roots in viewing training as a sub-system

where the training design is orientated to the systemic needs of the parent system i.e. the

organisation which it serves.

THEORETICAL CONTRIBUTIONS TO CBT

Thorndike who dominated the field of learning theory and behaviourism in the early 1900s

had great influence in establishing the foundation of CBT in the areas of quantification,

measurement and assessment of outcomes (McCowan, 1998).

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The use of task analysis in CBT can be attributed to Taylor’s scientific management. Taylor had used scientific methods to analyse job performance and introduced time-motion and cost-benefit studies which had exerted a major influence on American society. He stipulated that detailed specification of a task was essential to scientific measurement on the performance of the task. Together with his quantification of performance standards and evaluation of workers based on job-related competencies, his contribution to CBT was extensive (McCowan, 1998).

Hodge (2007) added that this understanding was further enhanced by Tyler and Bloom. While their works were mainly focused on education rather than training, Bloom’s hierarchy of learning levels provided an important foundation in defining competency levels and standards in the development of CBT.

Development of CBT

One of the most distinctive characteristics of CBT is the emphasis on identification of learning objectives. Tyler (1949 as cited in Hodge, 2007) said that the main problem with education during his time was the failure to clearly state the purpose of curricula which were often focused on the content of areas of knowledge. The goals of education then were expressed as what the instructor would do, rather than what the students were supposed to do.

Tyler asserted that curriculum should be designed with explicit objectives expressed in terms of the changes the learning was supposed to produce in the behaviour of students.

Miller’s (1962) comprehensive methods to determine training objectives were influenced by Taylor’s principle of scientific measurement as applied to the workplace. Taylor noted that one of the difficulties in designing efficient workplaces was the inconsistency of skills displayed by different qualified tradesmen. The wide variation of proficiency in workers’ skills was a result of the traditional apprenticeship system with its rule-of-thumb principles.

Taylor called for the breakdown of jobs into definable tasks to form the basis for a scientific approach to design efficient workflow, in order to improve productivity.

Miller noted that the use of task analysis was an important breakthrough in the 1950s when the US Air Force was developing and deploying high technology equipment at such a pace that training of personnel had to be done before the production model was ready. Under that situation, close cooperation between engineers and training designers was essential.

Miller also identified three areas of information needed for task design:

1) Performance requirements for the system in which the task was embedded, ideally expressed in terms of context and time limits;

2) The direct observation of tasks being performed; and

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3) Interviews with operators and supervisors who could help determine both outstanding and ineffective behaviours.

The functional requirements of tasks need to specify the types and amount of output required. Input variables and conditions also need to be specified, along with the equipment the operator is expected to use to transform inputs into outputs.

Miller also recommended that task description include what the operator is expected to do in the event of overload or equipment failures.

Hence, learning objectives have to be derived from operational requirements in the form of task analyses. Miller’s analysis of task description requirements has been pivotal to the way competency standards are structured and expressed in CBT.

EDUCATION AND TRAINING

It is important to note the distinction between education and training. Training involves a specific behavioural end-product while education does not normally have well-defined end-products. Training teaches individuals to exhibit similar behaviors, while education seeks to develop behaviours in individuals. Also, training is something arranged and funded by the parent system or organisation to develop human components in operating systems, while education is generally funded by the individual.

Bloom (2013) set out to codify the educational goals of learning, known as Bloom’s Taxonomy, which defines the different levels of learning. While there is limited use to training, as they are meant for education, it was an important step to CBT as it stressed the importance of communicability of goals and had structured the goals into cognitive, affective and psychomotor domains. These are closely related to the concept of competency.

Bloom’s six levels of skills in the cognitive domain of learning are particularly useful in helping to define competency at various levels in the competency map. The six levels are: Knowledge, Comprehension, Application, Analysis, Synthesis and Evaluation in that order. Later revisions of Bloom’s Taxonomy have put Synthesis above Evaluation, but some critics suggested that the three higher levels of Analysis, Evaluation and Synthesis should be parallel.

Bloom’s other two aspects of learning, Affective Skills and Psychomotor Skills are also useful in CBT development.

Affective objectives are typically stages of development of attitude, emotion and feeling. The five stages of development in attitude to learning are particularly useful. They are classified as: Receiving, Responding, Valuing, Organising and Characterising.

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Psychomotor skills describe the ability to manipulate a tool. Psychomotor objectives focus on

changes or stage of development in behavior in the performance of physical activities. The

seven stages are:

• Perception – the ability to use sensory cues to guide motor activity.

• Set – Readiness to act. Mental, physical and emotional dispositions in responding to different situations.

• Guided Response – Early stage in learning complex skills by imitation and trial & error.

• Mechanism – The intermediate stage in learning complex skills when learned responses have become habitual.

• Complex Overt Response – Skillful performance of physical activities with complex movement patterns. Proficiency is indicated by quick, accurate and highly coordinated actions with minimum energy.

• Adaptation – Well-developed skills with ability to modify actions to fit special requirements.

• Origination – Create new activities to fit particular situation or solve specific problem.

Bloom’s Taxonomy has gone through many revisions, but its contributions to the development of CBT remain profound. Some of the hierarchical levels have been reviewed and changed according to specific situations. For example, in the field of problem-based learning, application is placed before comprehension of the concept.

Some critics even suggest that the categorisations are artificial as a cognitive task often involves a number of processes and the classification could undermine the holistic nature of cognition.

WHAT IS CBT?

The fundamental driving force in a training programme is the curriculum and the

underlying value orientation of the curriculum will determine the output characteristics

of the training programme. McNeils (1977) classified curriculum into the following four

value orientations:

• Humanistic – Concerned with people achieving self-actualisation. The educational experience should result in liberating the person.

• Social – Stress society over individual. Focus on providing a better future for people, thus building a more egalitarian society.

• Technology – Structured and rational methods to achieve goals demanded by policy-makers.

• Academic – Traditional university structure. Knowledge as an end in itself.

Most educational and training programmes carry a mixture of these four orientations, but there will be one dominant orientation in every programme. Technical training programmes in aviation

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clearly fall into the Technology category. They are technical in nature and are characterised by being rational, objective and efficient. There are well-defined goals set by regulators and business corporations. CBT is clearly most suited to be applied to training programmes in the Technology value orientation category.

Managers should understand the underlying philosophy on which the training programmes are based as it has profound impact on the outcome of the training. CBT is a training methodology based on specific, measurable objectives related to instructional activities. Trainees are assessed for the mastery of essential attitude, skill and knowledge. It is widely believed that CBT will be a more efficient and effective training method compared to the traditional time-based learning methods.

The first step in CBT development is to identify clear goals of the training and trainees are assessed in the course of the instruction.

With CBT, trainees advance when they have demonstrated mastery of a competency needed to perform a task. Assessment is embedded in every step of the learning process so that trainees are guided and supported towards mastery.

A CBT system is student-centered as compared to traditional time-based teacher-centered training where progress is measured in time units. The emphasis is on performing rather than just knowing. Trainers must know what skills and knowledge need to be provided and organisations must identify the competencies required of their personnel.

Traditional education systems prepare course syllabi by identifying content and readings. With the CBT approach, the opposite prevails; you identify competencies, then select the content, readings and assignment to support student attainment of those competencies.

CBT needs to be embedded in the HR development framework of an organisation. While it may be unavoidable to include required minimum academic qualifications and prior relevant work experience in job advertisements, what is critical is to include competency-based job descriptions which define the key knowledge, skills and abilities required of the candidate.

A CBT programme thus must have the following characteristics:

• Clearjobdescriptionsandprogrammeoutcomes;

• Needassessmentsbasedonjob-relatedcompetencies;

• Instructionbasedonspecificbehaviouralobjectiveswithopportunitiestoapplynewskillsand knowledge and adjust learning attitudes;

• Assessmentusingclearperformancecriteria;and

• Remedial training and On-the-job mentoring to assure trainees’ mastery of essentialmaterials.

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CBT IN AVIATION

The new ICAO Training Policy stresses on CBT. While CBT has been implemented in pilot training with significant adoption of the Multi-crew Pilot License (MPL), its application to maintenance personnel has attracted interest only in recent years.

In 2010, ICAO issued two State Letters:

• AN12/1.1.15-10/52–toamendAnnex1ofChapter4toincludeCBTforMaintenance.

• AN 12/48-10/50 – Proposal for the amendment of PANS-TRG, Doc 9868 regarding “Training” – introduction of CBT to be applicable to Maintenance mechanics / technicians / engineers for aircraft and engines, components and structural repairs. It will cover line, base and workshops maintenance for large turbine engine powered aeroplanes.

They detail that the establishment of detailed competencies for each aviation function (and its related training requirements) is crucial to improving safety and efficiency.

“Establishing competency-based training in aviation is only a mid-term goal that is dependent on the establishment of detailed competency frameworks for specific aviation related positions. This requires clearer descriptions for all jobs across the aviation industry, in addition to improved standardisation of professional employment. Competency frameworks are performance-based provisions rather than prescriptive benchmarks and should be employed in a constructive, rather than restrictive manner,” said Capt Mostafa Hoummady, Chief, Aviation Safety Training Section of ICAO Air Navigation Bureau.

Several international groups started to support the concept by producing several documents. The IATA Maintenance Personnel Selection Criteria Guidance Material provides guidance for specific competencies useful to aviation.

Basic-mental competencies

- following instructions - verbal ability - numerical ability - abstract reasoning - spatial ability - mechanical reasoning - diagrammatic thinking - fault diagnosis - data checking - managerial competencies like - leadership - concern for task - concern for people

Psycho-motor competencies

- aim - arm-hand steadiness - control precision - finger dexterity - manual dexterity - multi-limb coordination - rate control - reaction time - response orientation - speed of arm movement - wrist-finger speed

Personality profile including competencies and attitudes

- stability - self-discipline - flexibility - team orientation - independence - adherence to procedures - helpfulness - ambition - openness - assertiveness - perseverance

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Air Transport Association of America (ATA) Specification 104 Guidelines for Airplane Maintenance

Training are also being revised to cater to CBT. Changes include:

• Clearlyidentifiesasetofobjectivesandcompetence(CBT)

• Includesmeasurementofstudentperformanceandfeedback

• Useavarietyofmethodologiesasappropriate(blendingteachingmethods)

Short syllabus for:

• Enginestart,run-upandtaxi

• Rigging

• Compositeandmetallic(damageassessmentandrepair)

• Fuelling

• Deice/anti-icing

• Componentmaintenancetraining

There will be significant changes to ATA 104 in the following issues which will be introduced in

an appropriate manner:

• Coursedevelopmentmethodology;

• Populationanalysis;

• Competencyunit,competencyelementandperformancecriteria;

• Assessmentandexaminationprocessversuscompetenceandtrainingobjectives;

• Assessorsandexaminers:trainingandqualification;

• Performancecriteria;and

• Evaluationoftheeffectivenessofthetraining.

SINGAPORE AERO WSQ

In 2004, the Singapore Workforce Development Agency set up a committee comprising representatives from industry, professional associations and institutions of higher learning to study and develop a set of competency standards for the aerospace maintenance, repair and overhaul (MRO) industry.

The effort led to the launch of the national training framework for aerospace, known as the

AerospaceWorkforceSkillsQualifications(AeroWSQ)in2007.Today, ithas55Competency

Units,anddeliversworkforceskillsqualificationsuptoSpecialistDiplomaLevel.TheWSQhas

also been adopted into internal training systems within aerospace organisations, showing the

extent of industry input and content in the modules, and the robustness of the by-industry-for-

industry system.

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TheAeroWSQisprimarilyaContinuingEducationandTraining(CET)frameworkfortraining

technical personnel in the aerospace industry. This alludes to it being focused on ‘training’

rather than ‘education’, which was mentioned earlier, and identifies that it is “something

arranged and funded by the parent system or organisation to develop human components in

operating systems”. It does not encroach into Pre-employment Training (PET), where education

and the earlier identified humanistic, social and academic value orientations take precedence.

The line begins to blur where vocational training and PET coincide, which in Singapore, is best

exemplified in our Institute of Technical Education (ITE) system which combines the best in

vocational and academic training.

TheWSQisdesignedforexistingworkerswithintheindustrywhointendtoupgradetheirskills

as well as people who want to move into the aerospace industry.

Figure1showsthesixspecialisationtracksinAeroWSQ:

1) Aircraft Maintenance (Mechanical)

2) Aircraft Maintenance (Avionics)

3) Component Repair & Overhaul (Mechanical)

4) Component Repair & Overhaul (Avionics)

5) Engine/Engine Component Repair & Overhaul

6) Engine Build

The modular system provides a ‘menu’ of competency units (CUs), which when combined in

prescribedformats,formqualificationsrangingfromCertificatestoSpecialistDiplomas.InWSQ

nomenclature, completion of each module’s or CU’s training followed by an assessment in

which the trainee is deemed competent, will see the trainee awarded with a modular certificate

or a “Statement of Attainment.” Industry compulsory units are called the “Common Core”,

followed by sectoral compulsory units called the “Sectoral Core”. Add-on units are titled

“Electives”, and a prescribed number of electives units combine with the sectoral and common

core to form a full qualification.

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Figure 1: Aero WSQ Framework with 55 Competency UnitsSource: Workforce Development Agency

For the training areas which are regulated, the modules or CUs incorporate the necessary requirements under the Singapore Airworthiness Requirement 66 (SAR 66, CAAS, 2011). Beyond CBT, the WSQ system also promotes two other pathways to secure recognition,through “Recognition of prior learning” as well as “Assessment-only Pathway”. This allows a type of articulation where the trainee of prior knowledge and experience can display his/her competency through producing evidence through prior employment records and certification, or he/she can undergo direct assessment, by-passing the re-training, through the “assessment-only pathway”. Figure 2 shows the pathways to various jobs in the MRO sector.

To date, nearly 4,000 people have attended Aero WSQ courses and more than 8,000Statements of Attainment (SOA) have been awarded. About 800WSQCertificates havebeen issued (Figure 3 and Figure 4).

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Figure 2: Pathways to Various Categories of Aircraft Maintenance Licenses and Aviation Technical Management Jobs.Source: Workforce Development Agency

Figure 3: Total of 3,825 personnel have been trained on Aero WSQSource: Workforce Development Agency

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THE OPPORTUNITIES AND THE CHALLENGES

The development of CBT has gone back more than half a century and was accelerated by crises of shortage of skilled manpower to support the American society during the 1960s. The fundamental ideas drawn from behavioural psychology and empiricist philosophy went even further back to the 17th Century.

Today, CBT is still far from achieving its potential to deliver efficient training programmes. This shows the complexity of education and training. Understanding the human mind and its interaction with the environment has been one of the most challenging tasks of mankind.

With the advent of modern psychology aided by advances made in neural science and high technology methods and equipment, we should be in a much better position than the people in the 1960s and 1970s to realise the potential of CBT.

However, technology itself will not be enough. We are dealing with generations of people who have been used to the traditional ways of education, training and learning. The social and psychological barriers to implementing CBT are formidable.

There must be very strong incentives, like the Sputnik which hurt the American pride or the challenge of operating and maintaining the huge military machine during the Cold War era. The incentives are here. 24,000 people need to be trained a year up to 2030 to maintain the growing fleet of aircraft in the Asia Pacific region. And unlike other industries, it cannot afford

Figure 4: Total of 8,387 Statements of Attainment issuedSource: Workforce Development Agency

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to fail. Failure in the sense that the training cannot deliver the safety standards the aviation industry demands.

Hence, intense research and prudent experimentations must be initiated immediately. CBT appears to be a viable solution, other options must be explored too.

Other solutions are likely to be products of information technology. An extension of computer simulation into games could be an excellent learning tool.

An evolving branch of learning system, referred to as “serious games” is gaining popularity in training operational staff based on projected scenarios. Here, the learning objectives are built into electronic games and assessments can be done off-line from recordings of the actions of trainees. Rewards and penalties scoring system can be used as incentives as well as assessment results.

The emergence of competency-based training and serious games can be seen as products of the information technology revolution and is a revolution in itself that could parallel the information technology revolution.

Seen as a “disruptive innovation”, they would require serious rethinking of industry standards for reliability, quality and safety and define how the industry operates and supports traditional products and services.

References

ATA 104 (2001) Guidelines for Aircraft Maintenance Training. Airlines for America (Formerly Air Transport Association of America).

Bloom, B.S. (n.d) Retrived: Wikipedia ( May 2013)

Hodge, S. (2007). ‘The origins of competency-based training’, Australian Journal of Adult Learning, volume 47 (2) p.180-206.

Miller, R.B. (1962). ‘Analysis & specification of behavior for training’, in Glaser, R. (ed),

Training research & education, Pittsburg: University of Pittsburg Press, p. 31-62.

McCowan, R.J. (1998). ‘Origins of competency-based training’. SUNY Research Foundation/Centre for Development of Human Services. New York: State University of New York.

McNeil, J.D. (1977). Curriculum: A comprehensive introduction. Boston: Little, Brown.

Singapore Airworthiness Requirements. Part 66 Aircraft Maintenance Licensing, 2011. Civil Aviation Authority of Singapore.

Global Efforts to Address Shortage of Aviation Manpower


The aviation industry is rapidly and deeply affected by world events, be they natural such as volcanic ash

plumes or the result of human factors including war and global financial issues. This is also an industry that rapidly

recovers and moves on. Despite the vagaries of the world financial situation and natural disasters, the growth of this

industry continues unabated in many regions of the world. While some regions are expanding very, very rapidly and

others are experiencing less growth, in general, there will be continued global growth into the foreseeable future.

This growth clearly brings with it the imperative to attract, retain and train the human resources required to safely

deliver aviation services to the world. This paper reviews the International Civil Aviation Organization’s (ICAO’s) Next

Generation of Aviation Professionals (NGAP) Task Force, which has been developed to address these human resource issues.

ABSTRACT

Dr Paul Bates has held the position of Head, School of Aviation at Griffith University, which has recently been renamed “Griffith Aviation”, since 1994. An associate professor, Dr Bates also teaches Aviation Medicine to Bachelor of Aviation students and has introduced Degrees for Pilots and Aviation managers at the graduate and postgraduate level. He is currently a member of the Education and Research committee and The Council of Associates of the International Air Cargo Association and Chairs the Outreach Committee of ICAO’s Next Generation of Aviation Professionals Task Force. He is also a Director of the Wide Bay Australia International Air Show.

Dr Bates has published research papers and presented research findings at international conferences. He is Managing Editor of the Aviation Journal “Aeronautica” and a Member of the Editorial Board of the International Journal of Aviation Management.

THE AUTHOR

Human Resource and Training Global Efforts to Address Shortage of Aviation Manpower

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Global Efforts to Address Shortage of Aviation ManpowerHuman Resource and Training

Dr Paul BatesGriffith University, Australia

INTRODUCTION

Over the last decade, various organisations have generated statistics and conducted studies on the status of aviation manpower worldwide. All the results of these studies have clearly pointed to the same conclusion: there will be a real shortage of qualified and competent personnel which will seriously impact the safe, secure and efficient operation of the air transportation system in the near future if the problem is not addressed immediately. The conclusions of these studies also showed that, while the severity of the problem varies from region to region, this issue must be treated on a global level and requires State involvement. Therefore, these organisations approached ICAO in 2008 and 2009 to request that it facilitated the coordination of a global effort to address this strategic issue.

THE ESTABLISHMENT OF NGAP

The Director and staff of the Air Navigation Bureau of ICAO had also analysed these various studies and had come to the same conclusion: the number of qualified personnel that were going to be required for the safe, secure and efficient operation of the aviation industry over the coming decades would exceed the number of people available to be trained at the current rates. In 2009, ICAO invited interested parties from across the globe to a roundtable meeting at ICAO Headquarters in Montreal, Canada to brainstorm on these issues, and encouraged the industry to become engaged with what came to be called the NGAP concept.

Approximately 100 members of the aviation community from regulatory authorities, universities and colleges, airlines, associations and the wider industry gathered to discuss the issues and ways forward to ensure that the aviation industry would be able to meet future staffing demands. This meeting concluded that the ICAO-NGAP Task Force be established to “attract, train and retain the best and brightest staff for the aviation industry”.

NGAP TASK FORCE MEETING

The first official meeting of the NGAP Task Force was held in October 2009 in Montreal to define the needs of the industry and to ensure the Task Force was able to define deliverables and adhere to timelines for deliverables for the industry. To this end, it was decided that four committees of the Task Force would be created to address specific needs. These committees were the Flight Crew Committee, the Air Traffic Management (ATM) Committee, the Accreditation Committee

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and the Outreach Committee. Each of these committees would meet at scheduled intervals outside the formal meetings in Montreal to ensure that the NGAP agenda was addressed and progressed. All committees had specific deliverables that were agreed upon at the Task Force Meeting and the groups returned to their home States to begin the work.

GLOBAL ICAO-NGAP SYMPOSIUM

The First Global ICAO-NGAP Symposium was held on 10 February 2010 at the ICAO Headquarters in Montreal to allow the Task Force to meet and discuss the deliverables of each of the committees as well as to encourage wider participation by the industry. The event was a tremendous success with broad participation and almost 100 students in attendance. The importance of the student interest in the Symposium cannot be overstated as, without them, a full understanding of what will attract and retain them and those following them into the industry can only be speculated by current administrators who may or may not understand the ways in which the next generation thinks and works. It is also important for the next generation students to be involved from across the globe because the skills shortages that exist today or will be with us soon are most certainly different from region to region and nation to nation.

OUTREACH INITIATIVES

In recognition of this, the Outreach Committee suggested that regional conferences be held in 2011 to gather intelligence on what was actually happening in the various regions of the world, and to garner information on what the issues were from regulators, employers and students in those regions. It was also intended to find out from students from the various regions what tools they believed would be useful to attract others to follow in their footsteps. This information was then to be collated and reported back to the NGAP Task Force and the wider community. The other main ideas to reach out to the aviation and wider community for NGAP were a website, promotion of International Civil Aviation Day on 7 December, and promotional videos and facts kits for university/college students and high school students.

The global community found this to be an exciting proposal and several offers to run the regional conferences arose. The first conference was held in the Republic of Korea from 29 March to 1 April 2011. This Conference was attended by 486 people from 36 ICAO Member States. There were 118 students in attendance from the region. This was an amazing feat and well and truly proved that the concept of NGAP regional conferences was very high on the list of the needs of the aviation community. The Secretary General of ICAO formally opened this Conference along with high-level officials from Korea, including the Minister of Transport.

The first conference was very successful, with presentations on the issues facing the globe and the specific issues of the region. It was clear that the very idea of the regional conference

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had galvanised a focus on the NGAP issues and that various governments and the industry in general had launched a variety of initiatives to address NGAP issues. While there are many great initiatives in the region, the Civil Aviation Authority of Singapore deserves special mention in showing insight and commitment to addressing the staffing issues in Singapore. Three other regional conferences were held in 2011 and each was highly successful for those regions and also for data collection.

REVIEW OF TASK FORCE

The Management Group of NGAP met in December 2012 to review the work of the Task Force and to prepare papers for the Fourth Task Force Meeting in January 2013. At this meeting, it was decided that a new work structure was required to meet the new challenges to be encountered by the Task Force. Thus, the various working groups were replaced by three new working groups, namely the Research Working Group, the Outreach Working Group which includes the Partnerships Sub-group, and the Technical Competencies Working Group which includes the ATM Sub-group.

The Task Force will now meet twice each year (once in person and once electronically) while the NGAP Management Group, consisting of the Chairman of the Task Force and the three new working group chairs, sub-group leaders and ICAO, will hold discussions quarterly to ensure that the Task Force is meeting the approved work schedule.

The Outreach Working Group will continue to support regional Symposia in 2013. The first of these was held in Jamaica in February and covered the Americas. It showed a great commitment from officials and industry of this region. Another symposium was held in Indonesia in late April that covered Asia Pacific. This was followed by another event in Turkey in June covering Europe and the Middle East and the series of Symposia will conclude in December in South Africa for the African region. ICAO and the NGAP Outreach Committee received many offers from States and organisations to host an NGAP symposium, thus showing the growing interest and great commitment of the aviation community to the ICAO-NGAP concept.

DEVELOPING ACCREDITATION PROCESSES

The Accreditation Committee of NGAP has effectively completed its task and has made recommendations to the NGAP Task Force, to maintain a watching brief on accreditation. The Committee investigated the multitude of accreditation processes around the world. There are numerous different education systems in various countries and regions and the approaches to education and accreditation are so divergent that it is impossible to set a standard at this point in time that each region or even a majority of regions would find acceptable. Many areas have accreditation systems that work well in their respective environments but none that is, at this stage, universally acceptable.

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It should be noted that this is not an issue that is faced by the aviation community alone. There are almost no internationally portable professions that can be internationally accredited. For example, law, dentistry, medicine, pharmacology, and most other professions are not portable professions without significant levels of restudy. The Accreditation group has recommended that this not be pursued at this stage and it will maintain a watching brief on the system as time passes.

INTERNATIONAL PILOT TRAINING CONSORTIUM

The Flight Crew Committee of the NGAP Task Force has changed rather significantly and has been disbanded. This has come about through the development of the International Pilot Training Consortium (IPTC). This consortium comprises representatives from The Royal Aeronautical Society (RAeS), ICAO, the International Air Transport Association (IATA) and the International Federation of Airline Pilots’ Associations (IFALPA). It became evident that a number of organisations around the world had embarked upon similar interests in pilot training at much the same time. When this became evident, it was clear that much could be gained by the various lead organisations working together on pilot, instructor and evaluator qualification in the international air transport sector.

The IPTC is governed by a steering committee with members selected from each of the four partner organisations. The Executive Chairman of the IPTC is provided by the RAeS. The chairs of each of the work streams are subject matter experts and are full members of the steering committee. The IPTC will be focusing on multi-crew pilot licence; evidence-based training and standardisation of the use of flight training devices as a starting point. Further activities may be developed over time. This is a truly new concept in the aviation industry and has the potential to deliver great results for the industry. To ensure that results are delivered on time, the steering committee has developed a series of work schedules and deliverable timelines that it guarantees will be met.

IPTC has also invited civil aviation authorities (CAAs) to work with the various work groups to assist in meeting these deadlines. It is anticipated that ICAO and subsequently CAAs will formalise the agreed outputs of IPTC’s work groups into regulatory frameworks. IPTC has developed a website for this purpose, and applications to join the site can be made through [email protected].

AIR TRAFFIC MANAGEMENT (ATM) COMMITTEE

The final committee of the initial NGAP Task Force is the ATM group. This group has been working very effectively and, like the Accreditation Committee, has found that significant variations in training and regulatory frameworks exist around the world. This group continues to work on developing internationally agreed approaches to ATM training and regulatory processes.

The Airports Council International is also working with its members and ICAO to address the NGAP issues facing the world’s airports in the 21st century and beyond.

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At its last meeting in January 2013, the Task Force voted to adopt a new approach to NGAP and introduced two new working groups, namely the Research Sub-group and the Partnerships Work Groups. Finalisation of all the activities of the NGAP Task Force into the future is being arranged at the time of writing.

CONCLUSION

The ICAO NGAP Task Force has transitioned from its initial phase into a highly focused and active group of representatives from industry, academia, training institutions and regulatory authorities from across the globe. New groups have been formed and re-invigorated work schedules are being developed. One of the most visible and essential activities of the Task Force will be the NGAP Global Symposium to be held in 2014. At this symposium, representatives from around the world will gather to review the progress of the Task Force, make decisions on how to move forward to the next stage and provide guidance to ICAO and the aviation community in dealing with NGAP issues.

JOURNAL OF AVIATION MANAGEMENT 2014CONTRIBUTOR GUIDELINES

The Journal of Aviation Management is an annual publication by the Singapore Aviation Academy (SAA), the training arm of the Civil Aviation Authority of Singapore (CAAS). It aims to provide an intellectual forum for the sharing of views and experiences on new developments and topical management issues in civil aviation amongst leading experts from Singapore and around the world.

It is distributed to a worldwide audience of experts and professionals in the field of civil aviation on a complimentary basis. Journal papers are also made available on SAA website. We welcome contributions of papers and feedback from members of the aviation community.

Selection and Review of Contribution

The Editorial Team and Editorial Advisory Board reserve the right to select, edit and publish papers according to the Journal’s editorial policy. Contributors may be asked to revise their paper before a final decision is made as to whether it is suitable for publication. Contributors will have an opportunity to review the paper prior to publishing. Corrections, if any, should be limited to typographical errors only.

Copyright, Proprietary Rights and Confidential Content

Authors submitting papers for publication must ensure that they have obtained all necessary consent for the use and publication of any information in the papers. By submitting any paper for publication, the author is deemed to warrant that no part of that paper infringes any copyright, proprietary or other rights of any person, or violate any confidentiality obligation on the author’s part, or contain any defamatory or offensive material.

Where a paper submitted by an author is published, the author is deemed to have agreed to indemnify CAAS against any loss, liability, action, proceeding, expenses or claim for damages made by any person arising from any alleged or actual infringement of any third party copyright, proprietary or other right, or from any alleged or actual breach of confidentiality on the author’s part, or from any alleged or actual defamatory or offensive material in the paper.

Authors must indicate if their paper has been presented/published elsewhere. If he/she does not do so, it will be assumed that the paper is an original contribution. The copyright in any papers published shall vest in CAAS unless otherwise agreed.

Preparation of Paper

Length: Preferred length is between 3,000 and 4,000 words.

Title: Should identify the subject matter as briefly and clearly as possible.

Abstract: Authors are requested to provide an abstract of about 150 words.

Figures and Tables: Should be typed separately from the text, and numbered and captioned clearly.

Illustrations: Where possible, provide high resolution jpeg or digital files. High quality black and white and colour transparencies, slides or prints are also acceptable.

Footnotes: To be used as sparingly as possible. Footnotes should be numbered consecutively (1, 2, 3) and appear on the page they are referred to.

Narrative Mode: Should be written in third-person narration.

Referencing

References to other works should be presented according to the APA Referencing Style as follows:

• Referencestoarticles

Author (surname followed by initials). Year of publication in brackets. Title of article. Name of the publication in which it appears, volume, issue (in brackets), page reference, date of issue.

Example: Bells, W G. (1993). Guidelines for emergency management in fixed site installations. Journal of Disaster Prevention and Management, 2, (4), pp. 6-16.

• Referencestobooksorreports

Author (surname followed by initials). Year of publication in brackets. Book title, including subtitle (underlined). Edition (in brackets). Place of publication. Publisher.

Example: Wells, A T. (1996). Airport Planning and Management (3rd edn). New York. McGraw-Hill.

• ReferencestowebsitesoraWWWdocument

Author (surname followed by initials). Year of publication in brackets. Document title (underlined). Format [WWW]. URL including filename extension. Date accessed in brackets

Example: Lee, J. (1999). Salvador Dali. [WWW] http://dali.kores.ac.kr/SalvadorDali_biography.html (30 July 2001).

• Listreferenceschronologicallyinalphabeticalorder.

• Wherenecessary,in-textreferencingshouldbeincluded.

- When quoting, referencing should be reflected in brackets immediately after the quote, as (author’s surname, year, page reference).

Example: (Wallington, 1997, p. 84).

- When paraphrasing, referencing should be reflected as author’s surname (year, page reference).

Example: Wallington (1997, p. 84) argued that…

Biography and Photograph

Authors are requested to submit a brief biography (50-100 words) outlining their current title/position, qualifications and relevant career highlights, as well as a photograph of themselves. The photograph should be in color with a resolution of at least 300 dpi.

Submission of Paper

Authors are requested to submit a softcopy via email, preferably in Microsoft Word format by 30 June 2014. Papers should be submitted to:

The EditorJournal of Aviation Management

Singapore Aviation Academy1 Aviation Drive

Singapore 499867Fax: (65) 6542 9890/6543 2778

Email: [email protected]

A Publication by the Singapore Aviation Academy