AVIATION SAFETY & SECURITY

CHAPTER 3
REVIEW SAFETY
STATISTICS
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• REVIEW SAFETY STATISTICS

 SAFETY FACTORS (Causal Factor)

 Events that are associated with or influence fatality rates – a safety indicator is a measurable
safety factor

 The probability of an accident is significantly higher during takeoff or landing than any other
phases of flight

 Risk is a good indicator of probability of death due to travelling but commercial aviation
fatalities rates are poor indicators of short –term risk changes

 Accidents exceed fatalities in numbers, they are still quite small – accidents can vary
significantly from one year to the next hence accident rates are poor indicators of short term
estimates of risk trends

 Aviation accidents can vary greatly – hence the classifications of accidents as major, injury or
damage or more popular with the insurance as hull loss and non-hull loss
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ACCIDENTS AND ONBOARD FATALITIES BY PHASE OF FLIGHT, HULL-LOSS AND/OR FATAL ACCIDENT
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Source: Statistical Summary Source: Statistical Summary of Boeing

Commercial Jet Airplane Accidents, 1959 – 2008.
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Definitions of flight phases

• Parking: this phase ends and starts when the aircraft respectively begins or stops
moving forward under its own power.

• Taxi: this phase includes both taxi-out and taxi-in. Taxi-out starts when the aircraft
begins moving forward under its own power and ends when it reaches the takeoff
position. Taxi-in normally starts after the landing roll-out, when the aircraft taxis to the
parking area. It may, in some cases, follow a taxi-out.

• Takeoff run: this phase begins when the crew increases thrust for the purpose of lift-
off. It ends when an initial climb is established or the crew aborts its takeoff.

• Aborted takeoff: this phase starts when the crew reduces thrust during the takeoff
run to stop the aircraft. It ends when the aircraft is stopped or when it is taxied off the
runway.

• Initial climb: this phase begins at 35 feet above the runway elevation. It normally
ends with the climb to cruise. It may, in some instances, be followed by an approach.
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• Climb to cruise: this phase begins when the crew establishes the aircraft at a defined speed and
configuration enabling the aircraft to increase altitude for the cruise. It normally ends when the
aircraft reaches cruise altitude. It may, in some cases end with the initiation of a descent.
• Cruise: this phase begins when the aircraft reaches the initial cruise altitude. It ends when the
crew initiates a descent for the purpose of landing.
• Initial descent: this phase starts when the crew leaves the cruise altitude in order to land. It
normally ends when the crew initiates changes in the aircraft’s configuration and/or speed in view
of the landing. It may, in some cases end with a cruise or climb to cruise phase.
• Approach: this phase starts when the crew initiates changes in the aircraft’s configuration and/or
speed in view of the landing. It normally ends when the aircraft is in the landing configuration and
the crew is dedicated to land on a particular runway. It may, in some cases, end with the initiation
of an initial climb or go-around phase.
• Go-around: this phase begins when the crew aborts the descent to the planned landing runway
during the approach phase. It ends with the initiation of an initial climb or when speed and
configuration are established at a defined altitude.
• Landing: this phase begins when the aircraft is in the landing configuration and the crew is
dedicated to land on a particular runway. It ends when the aircraft’s speed is decreased to taxi
speed.
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FATALITIES BY ACCIDENT CATEGORIES, FATAL ACCIDENT 1992 -2001

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ACCIDENTS BY PRIMARY CAUSE

Human factor is clearly and consistently the most frequent cause of incidents and accidents in the
airline industry. Total contribution of human error to aviation incidents and accidents can range as
high as 80 to 90 %
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STATISTICS

Causes of Fatal Accidents by Decade (percentage)

Cause 1950s 1960s 1970s 1980s 1990s 2000s All

Total Pilot Error 58 63 44 57 55 57 53
Pilot Error 42 36 25 29 29 34 32
Pilot Error (weather related) 10 18 14 16 21 18 16
Pilot Error (mechanical related) 6 9 5 2 5 5 5
Other Human Error 3 8 9 5 8 6 6
Weather 16 9 14 14 8 6 12
Mechanical Failure 21 19 20 21 18 22 20
Sabotage 3 5 11 12 10 9 8

The table above was compiled from the PlaneCrashInfo.com accident database and represents 1,015 fatal accidents involving
commercial aircraft, world-wide, from 1950 thru 2010 for which a specific cause was known. Aircraft with 18 or less passengers
aboard, military aircraft , private aircraft and helicopters were excluded.

"Pilot error (weather related)" represents accidents in which pilot error was the cause but brought about by weather related
phenomena. "Pilot error (mechanical related)" represents accidents in which pilot error was the cause but brought about by some
type of mechanical failure. "Other human error" includes air traffic controller errors, improper loading of aircraft, fuel contamination
and improper maintenance procedures. Sabotage includes explosive devices, shoot downs and hijackings. "Total pilot error" is the
total of all three types of pilot error (in green). Where there were multiple causes, the most prominent cause was used.
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Number Of Fatal Accidents

(Civil Aircraft with 19 or More Passengers)

Source: PlaneCrashinfo.com
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Number Of Fatalities
(Civil Aircraft with 19 or More Passengers)

Source: PlaneCrashinfo.com
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Which type of flying is safer?

Type of Flight Fatalities per million flight hours

Airliner (Scheduled and nonscheduled Part 121) 4.03

Commuter Airline (Scheduled Part 135) 10.74

Commuter Plane (Nonscheduled Part 135 - Air taxi on demand) 12.24

General Aviation (Private Part 91) 22.43

Sources: NTSB Accidents and Accident Rates by NTSB

Classification 1998-2007
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Odds of being involved in a fatal accident

Odds of being on an airline flight which Odds of being killed on a single

airline flight results in at least one fatality

78 major world airlines 78 major world airlines

1 in 3.4 million 1 in 4.7 million

Top 39 airlines with the best accident rates Top 39 airlines with the best 1
in 19.8 million accident rates 1 in 10.0 million

Bottom 39 with the worst accident rates Bottom 39 with the worst
1 in 1.5 million accident rates 1 in 2.0 million

Source: OAG Aviation & PlaneCrashInfo.com accident database, 20

years of data (1993 - 2012)
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Survival rate of passengers on aircraft involved in fatal accidents carrying 10+ passengers

Decade % surviving

1930s 21
1940s 20
1950s 24
1960s 19
1970s 25
1980s 34
1990s 35
2000s 24

Survival rate of passengers on aircraft ditching during controlled flight - 53%

Source: PlaneCrashInfo.com accident database

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• ACCIDENT CAUSES AND TYPES (MODELS)

 Purpose of accident investigation – to uncover pervasive, unrecognized causal factors of accidents – the
goal is to help prevent similar accidents from occurring in the future and to recommend control measures

 To conduct a preemptive strike on the very first accident to prevent it from occurring by addressing the root cause
of the accident

 Incidents and accidents provide after-the-fact that safety was inadequate, accident modeling assists with the
understanding how accidents happen so that measures can be taken to prevent potential hazards from materializing

 Accident modeling helps us to understand the nature of accidents. Accident models:

Help explain the relationship between hazards and accidents

Assist with understanding and explaining reality

Aid in visualizing things that cannot be directly observed

Must approximate conditions that exist in reality to be useful

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• THE OFFICE OF TECHNOLOGY AND ASSESMENT MODEL (OTA)

 The OTA model outlines measurable potential safety factors/indicators that

usually related to accidents, fatalities, or injuries
 The OTA model divides its safety indicators into three categories;

Primary Safety Factors, Secondary Safety Factors and Tertiary Safety Factors

 Primary Safety Factor correlated with casual factors:

 Personnel (pilots, controllers) capabilities
 Air Traffic Environment
 Aircraft Capabilities
 Weather
 Unpredictable acts

 Secondary Safety Factors – consists of FAA operations, commercial aviation

operation and commercial aviation manufacturers that influence the primary
factors:

Airline operating, maintenance, and personnel training practices

Federal air traffic control management practice

Aviation manufacturers’ design and production practices

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 Tertiary Safety Factors – federal policies and commercial aviation industry

policies

 Federal regulatory policy influences industry policy and operating practices

 Industry philosophy and policy differ among airlines and dictate operating decisions
 Tertiary factors reflect the values of a society and its economic philosophy (e.g.
deregulation)

 FAA defines an operational error as :…an occurrence attributable to an element

of the air traffic control system that results in less than applicable separation
minima between two or more aircrafts or between an aircraft and a terrain or
obstacles …as required by FAA handbook.”

 An operational deviation is”…an occurrence where applicable separation

minima were maintained but loss in separation minima existed between an
aircraft and protected airspace, an aircraft penetrated airspace that was
delegated to another aircraft …without prior approval.”

 A pilot deviation is “…the action of a pilot that results in the violation of a

Federal Aviation Regulation tolerance.”
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THE 5-M MODEL

 The man, machine, medium, mission and management represent a valuable

model for examining the nature of accidents

 The circles intertwined a means of checklist for fact-finding and analysis to

ensure that all factors are considered

 All five factors are closely interrelated with management plays a predominant role
with mission serves as the target or objective to emphasize

 Initially introduced with 3-M (man-machine-medium) terminology by T.P Wright

of Cornell U-1940

 The 4th-M (management) was introduced at USC in 1965

 The 5h-M (mission factor) introduced by E.A. Jerome in 1976 introduced at

military-oriented USC
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• MAN:

 Include all human involvement in aviation : flight crew, ground

crew, ATC, meteorologist, aircraft designer, construction,
maintenance, operation and management

 Very little study of man (human factors) was conducted although

he/she learns something on mechanical aspects of the aircraft,
the hazards of the weather, the operating environment etc BUT
not on his/her behaviour, limitations, vulnerabilities and
motivations

 Due to lack of study of human factors – over the years the number
of accidents caused by the machine has declined – those caused
by man have risen proportionally
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 A consensus has now emerged that accident prevention activities

should be mainly directed towards the human
 To study the “why” of a person’s actions or inactions

 People reluctant to admit to their limitations – loss of face among

peers, self-incrimination, fear of job loss, consideration of blame
and liability

 Necessitate to probe beyond human failures – was the individual

physically and mentally capable of responding properly? Did the
failure derive from a self-induced state such as fatigue or alcohol
intoxication?

 Earlier, most of the blame on accident directed towards pilot (pilot

error) and the use of common question as to WHAT happened
BUT now the investigation team would use more WHY it
happened which would include all those human that handles
the aircraft
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• MACHINE: (Aviation Technology)

 History pointed out to the hazards found in the design, manufacture,

or maintenance of aircraft despite aviation technology has made
substantial advances

 A number of accidents can be traced to errors in the conceptual,

design, and development phase

 A fail-safe features and redundancy in critical components or system

must be employed by the designers

 Designer must attempt to minimize the possibility of a person using

or working on the equipment committing errors or mistakes based on
the Murphy’s law: “If something can go wrong, it will.”
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 Modern design must take into account the limitation inherent in

humans – by designing some system that make human’s task easier
with the aim to prevent mistakes and errors

 GPWS – Ground Proximity Warning System is a good example. Has

significantly reduced the number of accidents in which airworthy
aircraft collide with the ground or water while under the control of
the pilot

 Failures most common in:

 Initial failures – caused by inadequate design or manufacture
 Random failures – modification to components reduce these
failures to minimum during main/useful life period
 Increased failures – happen towards near the end of the life of a
component due to wearing out .(“the bathtub” curve) helps to
illustrate further
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• MACHINE: “Bath-tub” model

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• MEDIUM: (Environment):

 Where the aircraft operations take place, equipment used, and personnel work
directly affect safety

 Comprise two parts : the natural environment and the artificial environment

 Natural environment – weather, topography and other natural phenomena

such as temperature, wind, rain, ice, lightning, mountains and volcanic
eruptions. Since they cannot be eliminated – they must be avoided or
allowance must be made for them

 Artificial environment – physical and nonphysical

 Physical – air traffic control, airports, navigation aids, landing aids

 Nonphysical – (system software) national and federal legislation,

associated orders and regulations, SOP, training syllabi
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 Setbacks – despite of knowing of the hazard – today many people responsible

of the environment:

 do not want to become involved in change

 consider that nothing can be done
 insufficiently motivated to take the necessary actions

 Examples – obstructions near runways, malfunctioning or nonexistent

airport equipment, errors or omission on aeronautical charts, faulty
procedures

All the above examples have direct effect/impact on

aviation safety
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• MISSION: (THE PURPOSE OF THE MISSION)

 Risks associated with different types of operation vary considerably

 A commuter airline operating out of many small airports during winter months has
a completely different mission than the all-cargo carrier flying from New York to
Los Angeles

 Each category of operation )mission has certain intrinsic hazards that have to be
accepted

 This fact is reflected in the accident rates of the different categories of operation
and is the reason why such rates are usually calculated separately
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• MANAGEMENT:

 Management given the responsibility for safety – thus accident

prevention rests with management

 Why? – because only management controls the allocation of

resources – selects the type of aircraft to buy, personnel to fly and
maintain them, routes to operate, training and operating
procedures used

 Management is responsible for fostering basic motivation to

the staff so that the slogan “Safety is everybody’s business” will be
a success by giving adequate training and supervision, proper
working environment and the right facilities/tools and equipment
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 Management must not only say the slogan but must be seen
applying it and clearly visible to the staff- although it cost money but
it not only improve the performance of staff but it is cost effective,
reduce waste and increase efficiency of the organization

 By getting involved in accident prevention programs in the

company, management would be able to not only know who was
responsible for an accident or incident BUT its investigation would
also reveal what had caused the human error. (this would also
indicate faults in management's own policies & procedures

 Management’s attitude and behaviour will have an impact to the

staff – saving cost by cutting corners, lowering standard of
maintenance result in low morale, self interest in retaining their jobs
which ultimately lead to ‘welcoming' hazards
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• REASON’S MODEL

• Introduced by Dr.James Reason’s - focuses on understanding incidents and

accidents and their contributing factors

 Widely used in aviation industry especially by FAA in investigating the role of

management policies and procedures in aircraft accidents

 Reason’s model traces the root causes of accidents to errors that occur in
the higher management levels of an organization – these errors are
referred to as latent errors

 Reason also feels that any models that show individual operator performance
that attributes to the accident is grossly inadequate. He proposes that
human error is the end result rather than the cause of incidents or accidents
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 Some salient (prominent) features of Reason’s model:

 Systems are protected by multiple layers of defenses designed to

prevent hazards or system failures from cascading (leading to) into
accidents

 Each layer of protection, can develop ‘holes’ or flaws through safety

deficiencies, resembling Swiss cheese

 As number and size of holes in the defense increases, the chances of

accident also increase

 When the holes in each of he layers of defenses line up, an accident

occurs

 Fallible decisions made by high-level decision makers may be the latent

failures that permit active failures to occur
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RISK MANAGEMENT

 A concept that stems largely from financial concerns and a realization that losses from
different areas in a business must be either reduced or accepted

 Safety losses stems from costs of accidents that result in fatalities, illness, injuries,
product damage and lost employee and production time

 Aircraft accident prevention attempts to minimize the risk posed by safety hazards

 The overall process of identifying, evaluating, controlling or reducing, and accepting risk
where management decisions about risk have been identified and analyzed.

 It involves conserving assets and minimizing exposure to losses. It means looking ahead
to detect hazards before they lead to losses and taking appropriate action when these risks
cannot be eliminated.

 Categorized into three areas they threaten – assets, income and legal liability. In
Aviation accident industry, accidents usually involve all three areas

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Risk is the combination of the probability of occurrence of the hazard (or loss
potential) and the severity of its effects.

Accidents can be considered involuntary and unscheduled expenditures,

managers are obliged to established policies and procedures to attempt to
eliminate or minimize them

 Risk assessment is the process of evaluating risk. If it want to be

successful, they have to be integrated into the various business functions
within the organization

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