16894/Flight Safety cover 29/8/08 10:38 Page 1

O N C O M M E R C I A L A V I A T I O N S A F E T Y AUTUMN 2000

This issue of focus sponsored by:

THE OFFICIAL PUBLICATION OF THE

ISSUE 40 UNITED KNIGDOM FLIGHT SAFETY COMMITTEE
ISSN 1335-1523
16894/Flight Safety 24pgr 29/8/08 10:40 Page 1

The Official Publication of

THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE
ISSN: 1335-1523 AUTUMN 2000 ON COMMERCIAL AVIATION SAFETY

FOCUS on Commercial Aviation Safety

is published quarterly by
contents
The UK Flight Safety Committee.
Editorial 2
Editorial Office:
Ed Paintin Chairmans Column 3
The Graham Suite
Fairoaks Airport, Chobham, Woking,
Surrey. GU24 8HX Is My Top Management 4
Tel: 01276-855193 Fax: 855195 Safety Management Orientated?
e-mail: [email protected] Mike Overall
Web Site: www.ukfsc.co.uk
Office Hours: 0900-1630 Monday-Friday
Crew Resource Management 7
Advertisement Sales Office: Stalled at a Crossroads and Seeking to Interpret the Markers
Andrew Phillips Pieter Hemsley
Andrew Phillips Partnership
39 Hale Reeds
CRM? .....Its For The Birds! 10
Farnham, Surrey. GU9 9BN
Tel: 01252-712434 Mobile: 0836-677377
Corporate Killing - Directors Liabilities 11
FOCUS on Commercial Aviation Safety is Steven Kay QC
circulated to commercial pilots, flight
engineers and air traffic control officers
holding current licences. It is also Book Review 13
available on subscription to organisations Human Factors in Multi-Crew Flight Operations
or individuals at a cost of 12 (+p&p) per
annum.
The Quality Choice 15
Alan Munro
FOCUS is produced solely for the
purpose of improving flight safety and,
unless copyright is indicated, articles may Leading the Way Towards Safer Flying 18
be reproduced providing that the source Dave Wright
of material is acknowledged.

Publication of an advertisement, letter or One-Size-Fits-All Maintenance Problem 19

announcement in FOCUS does not
necessarily imply that the UKFSC They Were Just Little Problems - Nothing Major 19
endorses any such advertisement, letter
or announcement.
UK Flight Safety Committee Members 20
Concept and Design of New Look
FOCUS acknowledgement to: Legal Advisers Column 22
RAI Design Peter Martin
Unit 1, Kingsmill Park
London Road, Loudwater
High Wycombe. HP10 9UB UKFSC Seminar - Aviation At Risk 23
Tel: 01494-537100 Fax: 01494-537200
email: [email protected]

Printed by Woking Print and Publicity Ltd

Tel: 01483 884884 Front Cover: Embraer RJ 145 Regional Jet

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16894/Flight Safety 24pgr 29/8/08 10:40 Page 2

Editorial

New Millenium - New Image

The discerning reader probably noticed We will continue to change the picture on We do not intend to stop here in the
that the layout of the cover of this edition the front cover for each issue and are development of FOCUS. It is our
of FOCUS has changed. As you read on offering advertisers the opportunity to intention to attract more advertising in
you will also see that the internal layout issponsor an issue at very good rates. For order to improve the magazine further. A
different too. No doubt you will be asking their sponsorship they will get to choose laminated cover and the use of better
yourself Why the change? the front cover picture and have a full- quality paper would enhance its look and
page advertisement on the back cover. In feel even more but these changes will be
addition they will have the opportunity to subject to the amount of advertising we
publish an article in the next issue of the can attract.
Some time ago the United Kingdom Flight magazine on condition that it has a
Safety Committees Communications relevant safety message and does not
Sub-Committee was given the mandate blatantly advertise their product.
to look at improving the magazine. We I hope you enjoy our new look
wanted to make the magazine more eye FOCUS!
catching and easier to read. As a result,
much discussion and investigation has You will find the inside layout more
taken place and we believe that the end pleasing to the eye. This is achieved by
result achieves these aims and much having a masthead across the top of the
more. page that incorporates the name FOCUS
and focal point (the bright star). At the
bottom of the page a band in our
corporate colour containing the page
Some may say, What was wrong with the number with the logo above completes
old style magazine? The answer to that the image. The text is laid out in three
is simply, Nothing. It has served its columns (left justified) and the spacing of
purpose well and has been in existence the text allows more white space making
for 39 issues over a period of 10 years. At it more inviting and easier to read.
the time it was a giant leap forward for the
Flight Safety Committee and under the
editorship of Roy Humphreyson,
Executive Manager, it achieved an The UKFSC logo will replace
excellent reputation. It is acclaimed by the FOCUS logo to signify
some as the best flight safety magazine the end of an article.
in the world.

The move to full colour raised the overall

It was however felt that after 10 years it image of the magazine to a higher plane.
was in need of a revitalisation and face- This now means that photographs and
lift. I hope that the readers will feel this graphics will enhance the articles far
has been achieved. more and will give a much more
professional appearance.

The name of the magazine is FOCUS on

Commercial Aviation Safety and over We are pleased to announce that starting
the years it has become known as with this issue we will be featuring a
FOCUS. In order to strengthen this we regular article by our Legal Adviser - Peter
have changed the emphasis of the text in Martin. Peter hopes to use this instrument
the title to highlight this. to bring to the notice of our readers, legal
matters of interest and importance. Peter
has a unique style of conveying the
message. I hope that you enjoy
reading them.

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Chairmans Column

Flight Data Monitoring

by Captain Tom Croke

The current development in recording lessons learned, all have an important operating procedures and safety
flight data has enabled greater bearing on the way in which the system is thresholds laid down by the individual
capabilities in the area of Operational viewed by those who use it. operators. To take these and try to apply
Monitoring, Flight Operations Quality them, across the board, would be
Assurance and Flight Operations Data inappropriate. However, the potential to
Analysis. The software and hardware damage, or even destroy, those systems
The slow development in the adoption of
developments have meant enormous already operating is very real.
this, probably the greatest single advance
advances in the scope of the data that in safety ever, indicates the enormous
can be recorded and also advanced the sensitivities and anxieties that need to be
ease with which this data can now be resolved through understanding and It is to be hoped that before any such
read. The cost of such a facility is now dialogue before its acceptance. When proposals are advanced, full discussion
within the reach of a greater number of coupled with corporate fears about the will take place with those currently
airlines. damage any leakage of such information operating these invaluable safety tools
may cause, it is probably unsurprising lest unintended, but fatal, damage is
that we are as far along as we are at this inflicted.
However, this is only one side of the point.
equation. To allow such a system to
operate requires a company to commit to
the culture of retribution free reporting, A recent move by one regulatory authority
and adequate resources to fully exploit to obtain access to such information
the benefits of such data. There must be disturbs me. The threat it poses to the
absolute trust between the pilots and the advances to date far outweigh any
company before such a system can gain perceived safety dividend that might
the confidence of line crews. The manner accrue to the wider aviation community.
in which the analysed data is used and, The reason I say this is that the
more importantly, the manner in which the parameters and filters set in such
crews are dealt with in implementing the systems usually reflect the standard

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Is My Top Management
Safety Management Orientated ?
by Mike Overall

Much has been said recently about air often exists in organisations which have Dangers of motherhood and apple pie
operators safety cultures and the need weak safety management. A good safety
for a more formalised approach towards ethos, based on the professionalism
inherent in the industry, can prevent A safety management system is
managing safety. The industry is
accidents. It can also camouflage the essentially about having effective
grappling with the problem of how best to
inadequacies and sins of top management control over safety.
develop aviation safety management
systems which meet the CAAs management. However, it is a poor and
expectations. At the same time, the CAA unreliable substitute for an effective safety
is trying to clarify what its expectations management system (SMS), which is One must be wary of the danger of losing
mean in practical terms. driven by a competent top management sight of this objective and being misled
team. by common use jargon.

Motherhood statements about the

Safety Culture commitment of management to safety,
It would be unwise to regard a sound
leadership and safety is paramount,
safety culture solely as some tangible
although relevant, do not constitute an
It is much easier to talk about the concept outcome which can be project managed,
effective top management safety culture.
of a safety culture than it is to identify like the introduction of a new aircraft type.
A corporate Statement of Safety Policy,
what you have to do to ensure that your It should be regarded as an outcome, a
signed by the chairman and chief
organisation has one that is both sound product, of good management. If an
and sustainable. In the real world, it is a
difficult concept to tackle head-on.
Industrial history is littered with examples Principal
where huge amounts of funds and effort Corporate Accountability
have been pumped into trying to change Board
company cultures without a sustainable
result.

Chief Comprehensive
Corporate Corporate Executive
Too many managers still perceive a Officer Approach to Safety Management
companys culture as being mainly, or
wholly, about the companys workplace Effective Organisation for
culture. The reality is that an Delivering Safety
organisations culture, especially as far
as its safety culture is concerned, is a
product of several things. Robust Systems for Assuring Safety

First, and most importantly, it is about the

approach to safety taken by the Three prerequisites for successful safety manager
organisations top management (i.e. by
its corporate board and executive
management team). If an organisation
does not have a sound top management
organisation does not have effective executive of the company, is an important
safety culture, you cannot expect it to
safety management, a sound safety element of an SMS. It may give
have an effective workplace safety
culture is unlikely to be sustainable, even encouragement to the workforce and the
culture.
if it appears that an improved culture has regulator, but will be no good unless it is
been achieved. backed-up by rigorous management
systems that facilitate top managements
Safety culture, in this context, should not active and continuous involvement in
be confused with safety ethos. safety management control. Top
Fortunately, in the aviation industry there management ownership of safety can
is a strong workplace safety ethos. It only be as efficient as the companys

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safety information and management The Board of the organisation has to be an effective organisation below Board
control systems allow it to be. The responsible for establishing the level to deliver safety. He, through his
companys organisational arrangements companys corporate approach to safety. executive management team, must also
for managing safety must be finely tuned It will also need to agree the Board level be responsible for making sure that the
to ensure that (only) relevant safety organisational arrangements for safety right systems are in place to provide
information reaches those that need to management, but it will fall to the Chief safety assurance (i.e. assurance for the
know it, in a manner that enables sound Executive Officer to ensure that there is companys management team) and that
decisions to be made.
Characteristics of Top Management Safety Cultures

A Hazard and Risk Management System Compliance safety culture Safety management culture
is an essential core component of an
SMS. However, its effectiveness will be Reliance on demonstration of Committed to and operates a
limited if it exists as a relatively isolated compliance with external regulations. systematic approach to managing
tool within a safety management safety.
framework which lacks an integrated
approach and organisational structure. Has not taken a considered view on Has decided to set company standards
Care must be taken also to ensure that whether to operate at or above the at or above the regulatory minima and,
the risk management process does not regulatory minima. if above, has articulated how far above.
take on a narrowly focused momentum of
No specific funding for SMS Board has approved specific funding for
its own, which absorbs a vast amount of
development project. SMS development.
effort, possibly at the expense of other
key elements of SMS development. Is [wholly] reactive about safety. Is proactive about safety.

Safety dealt with at Board/Top Safety demonstrably a matter in which

Management level only on a reactive the Board/top management is
Prerequisites for successful safety
when necessary basis. proactively involved in a routine and
management
structured manner.

Does not review safety of existing Seeks to confirm safety of existing

If top management wants to design an
operations unless there is a reactive operations through systematic
effective SMS for controlling safety, it will
reason for doing so. programme of safety assessments.
help if it first focuses on the following
three prerequisites for successful safety Has no specific targets for measuring Sets safety performance targets and
management: safety performance. monitors their achievement.

1. A comprehensive corporate No self-generated approach to safety Has instigated a safety improvement

approach to safety. improvement. programme with Board approved
targets.
2. An effective organisation for
delivering safety. No requirements or procedures to Requires changes to be formally
routinely assess the safety impact of assessed for safety impact.
3. Robust systems to provide
changes.
safety assurance.
No formal requirements to guide the Expects risk to be managed to ALARP
Effective control of safety requires clarity
assessment of risks to safety. principles/levels.
and coherence in the allocation of safety
responsibilities and accountabilities No standard procedures for assessing Has documented management
throughout the organisation. It is vital whether unbudgeted safety procedures for deciding whether
therefore to be clear where responsibility improvement proposals should be unbudgeted safety improvements
rests for each of these key aspects of funded. should be funded.
safety management and to ensure that
the necessary management control Safety largely left to line managers, with Safety actively driven from the top.
systems are in place. little involvement/oversight from top
management.

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b
they are working properly. The objective for a Safety Director (e.g. under FARs). safety management.
of each system, how it fits within the SMS
and who is accountable for delivering its Where does your company sit?
objectives must be unambiguous.
The reality is that the CEO cannot fulfil his The summary on page 5 of some safety
safety management responsibilities culture characteristics may give you some
without some dedicated senior guidance.
A weakness in any one of these three management support to help him/her
prerequisites will undermine the integrity ensure that the companys SMS is
of the organisations overall management effective and working properly. Hence the
Editorial note:
of safety. concept of a SMS Custodian, who acts as
the guardian of the integrity of the SMS, Mike Overall currently acts as an
on behalf of the CEO. For air operators, independent adviser on aviation
the SMS Custodian role, depending on regulation, strategy/organisation and
If an organisation is effective in all three
the nature and size of the organisation, safety management. He was well known
aspects, then it should also have a good
would normally be vested in the Safety to members of UKFSC in his previous role
safety culture. On the other hand, if there
Director, Flight Safety Manager or Flight as Head of Licensing Standards Division
is a poor safety culture in an organisation,
Safety Officer function. Wherever the in the CAAs Safety Regulation Group. His
it is likely that there are weaknesses in
Custodian function is located, it is concept of the three prerequisites for
one or more of these three key aspects of
essential that the person fulfilling it has an successful safety management was
safety management.
effective working relationship with the reflected in the UKFSCs guidance
CEO and the regulatory Accountable material on developing an aviation SMS
Managers, if different. He must also have and has been adapted for similar use by
How a companys SMS is designed the inter-personal skills to operate Shell Aircraft.
around the three prerequisites concept effectively at Board level and throughout
will depend on the companys nature, the organisation. The design of the
size and its existing organisational companys safety management policy
structure and management systems. The and review systems and its safety
bottom line is to be clear as to whom is committees and meetings will need to
accountable for what - starting from the reflect these senior management
Board downwards! accountabilities.

Accountability for safety What safety culture are we operating

under?

The executive responsibility for safety

management, on behalf of the Board, The days when an air operators top
should rest with the Chief Executive management can be satisfied that the
Officer (the CEO), or his equivalent. The demonstration of compliance with the
CEO is cornerstone of the organisations minimum safety regulatory requirements
whole safety system. He is the link is adequate are fast coming to an end.
between the Board and the executive, The wider regulatory, legal and
and he, more than anyone, has the power commercial world that the industry is now
to deliver successful safety management. operating in will see to that. That said,
This Board level responsibility must be there are still some companies which are
made compatible with any regulatory operating under a top management
requirements relating to the Accountable safety culture that owes more to safety
Manager for safety (e.g. under JARs) or regulatory compliance than to systematic

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Crew Resource Management: Stalled at a

Crossroads and Seeking to Interpret the Markers?
by Pieter Hemsley

In the view of many, Crew Resource The impending requirements have raised Progress in the first two is well advanced.
Management (CRM) has lost direction. genuine alarm among some operators, in Critical to the success of CRM training is
After the enthusiasm of the early 1990s particular the smaller companies, that the competence of instructors, an issue
for initial CRM training for flight crew, UK there are few to whom they can turn for long overdue. Competency criteria were
aviation now appears less sanguine detailed advice to implement effective published in 1998 in the Guide to
about embracing the subject CRM training programmes and fewer still Performance Standards for Instructors of
wholeheartedly and there is the danger who can integrate such programmes with CRM Training in Commercial Aviation
that a programme that offers so much technical training, the ultimate goal. produced jointly by the Royal
could stall. Aeronautical Society, the Aviation Training
Association and the CAA. Trainers who
have examined the document have given
The solution lies in three complementary
enthusiastic support for the guidance
In part this reluctance is founded on the fields - all addressed in the NPA - that
proffered. Such informal evidence - and
lack of precision associated with CRM; collectively should restore confidence:
the fact that fewer than 15% of UK
there are few universal truths and it operators appear to have received the
- Trainer competence standards,
requires an act of faith to accept its utility.
Given the pessimism apparent in some - Trainer accreditation, and
quarters, I should like to spell out why
there is now good reason to be positive - Use of performance indicators
about the future. (PI).

Non-technical Skills (NOTECHS) Framework:

As a global industry, UK aviation is firmly
Elements & Behaviours of Category -
embedded in the wider European scene.
Until recently there has been no detailed
Situation Awareness
supranational CRM initiative, but that has
changed with the advent of the Joint Category:
Aviation Authorities (JAA) Notice of Situation Awareness
Proposed Amendment (NPA-OPS 16), a
document negotiated between the
Authorities, operators and pilot
associations for more than two years. System Environmental
Awareness Awareness Anticipation
The NPA text has much more precision
and clarity than the extant CRM wording
in JAR-OPS 1 (Commercial Air
Transportation (CAT) Aeroplanes), Monitors and Collects Discusses
reports changes information about contingent
Subpart N that it will replace; much will
in systems states the information strategies
read across to JAR-OPS 3 (CAT
Helicopters) in due course. With Acknowledges Contacts outside Identifies
circulation completed in April 2000, the entries and resources when possible/future
NPA remains the preferred guidance of changes to necessary problems
systems
the JAA and could be formally adopted
Shares
later this year. There is therefore some information about
urgency for operators to re-examine their the environment
CRM training to ensure compliance with others
before the JAA Rules become UK law,
feasible by 2001.

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Guide - are, however, inadequate to give One set of BM is the European Union their members. But, even if the unions
confidence in these standards as the NOTECHS (Non-Technical Skills) were not cautious, BM must be
bedrock for the next part of the framework a PI already on trial but with as introduced with care else the weaknesses
programme, accrediting CRM trainers. yet no conclusive evidence emerging of of the present system might be
Therefore, a formal survey has been its validity. While NOTECHS can achieve replicated, undermining CRM programme
undertaken this summer to validate the a necessary uniformity within the JAA, credibility and giving sustenance to its
standards document. Such prudence in they remain in their infancy and, because critics. Accordingly, BM must be
creating a suitable accreditation they rely upon bold headings only, I implemented at a measured pace and, at
architecture is essential to instil believe fail to provide sufficient detail for the outset, it is appropriate to use them
confidence; an embryonic structure the practitioner to apply his skills. They for CRM syllabus review only. This will
should be in place in the UK next year. need maturing and embellishing, issues also create an opportunity for objective
to which I will return. analysis of the instrument itself, to assure
its validity and consistency in use.
Despite the very powerful boost to
providing quality CRM training that these The NPA, CAA Aeronautical Information
measures will have, the success of such Circular 114/1998 and the Guide all refer To avoid sacrificing clarity, one of the very
enterprise might be in jeopardy if greater to BM. first steps must be for all parties to agree
precision regarding the efficacy of CRM
activities is not fed back to organisations
and crew alike, not least to appease the Non Technical Skills (NOTECHS) Framework:
accountants. Historically, assessment of Categories & Elements
crew in non-technical or soft skills has
relied upon feedback in categories of
airmanship and command skills. Given
CATEGORIES ELEMENTS
that there are no agreed definitions for
these terms, the weakness of such an Team building and maintaining

approach is its subjectivity. What then of Consideration of others

Co-operation
using observable behaviours as Supporting others
Conflict solving
indicators of performance, the third
element outlined above? I contend that Use of authority/assertiveness
this activity is not an optional extra but an Maintaining standards
Leadership and
integral part of the process, to lubricate managerial skills Planning and co-operation
the constituent parts and create a climate Workload management
for synergy.
System awareness
Situation
Environmental awareness
awareness
Anticipation
By their objectivity, these behavioural
markers (BM), as they are known, can Problem definition/diagnosis
certainly overcome the major limitation of Option generation
Decision Making
current assessment models. BM lend Risk assessment/option choice

greater accuracy to the analysis of Outcome review

performance in a manner that promises

to restore confidence in the whole CRM
apparatus with customers, the line crews,
who need to be on side to provide a
Despite such ubiquity, that is no reason to a terminology. In parallel, CRM trainers
pool of willing advocates to assist in its
rush into their use without ensuring a need to acquire the skills of accurately
development. These tools certainly
number of safeguards are in place. observing and recording individual and
cannot be imposed to gain genuine
Naturally, the pilot associations are at the crew interpersonal behaviours - many of
behavioural change.
forefront of wanting such protection for which are subsumed in the technical

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activity - a task not to be underestimated Workload Management

given the myriad of roles already placed
upon instructors, especially in the Planning: Anticipates problems and prepares for unexpected eventualities.
simulator. The induction training required Planning lacks Usually plans in a logical Plans sytematically and
could be protracted before instructors organisation and structure and orderly way but thoroughly, taking full
and often fails to consider sometimes fails to account of task needs and
reach a satisfactory level of competence. all circumstances consider all eventualities. also preparing for
However, once a quorum has the skills, pertaining to the task. unforseen eventualities.
BM could be used to provide feedback to
training departments of the efficacy of
core CRM programmes, particularly those
in recurrent training. Situational awareness; Continually monitors and analyses all relevant
operational factors to develop and maintain situational awareness.
Prone to becoming Usually cross-checks Not only avoids fixation but
preoccupied with minor essential systems and also resolves ambiguities
The next step - and this may be some tasks and often fails to instruments but and discrepancies at the
years downstream - is to bring the BM to resolve conflicting or sometimes fixates on one first opportunity; always
ambiguous information. aspect of the task. ahead of the curve.
bear in whole crew assessment, prior to
extending the system to individual
crewmembers CRM skills. Such is the
sensitivity of the latter that there is some
unwillingness to set out on that course, Decision making; Understand and applies the elements of the
but set out we must. Although I would decision-making loop.
support the view that it is the crew as an Autocratic and directive, Sometimes acts over- Takes account of all
even in circumstances hastily in reaching a available data; evaluates
entity that operates the aircraft, where consultation would decision and fails to make different options; involves
inappropriate behaviours on the part of result in a higher quality best use of all available others in the process when
decision. resources. appropriate.
one individual can undermine the
harmony and hence the safety of the
operation. It is axiomatic that all training
leads to assessment in some form and
thus, ultimately, individuals must receive has been used by military flight crews and provide clear goals to which those
feedback on their own non-technical more recently adopted unofficially by entering the industry can also aspire.
performance and the quality of their some air traffic controllers. The greater Conversely, markers could grant the
contributions to the CRM equation. the effort that is invested in customising instructor of ab initio student pilots a
these criteria, the greater the reward in more precise vehicle through which to
terms of objectivity. The language must recourse or remove the candidate who
be comprehensive and include the core has adequate technical ability but
I promised to revisit the question of
values of the CRM programme so that displays inappropriate and incurable
embellishing NOTECHS BM headings, by
specificity of comment is available. All interpersonal skills.
which I mean incorporating a spectrum of
will need to be trialled to ensure universal
performance criteria. This is where I When all crewmembers exhibit the
understanding and to hone the text.
believe the necessary clarity will be positive behaviours captured in BM and
Obviously, there must not be too many
achieved and confidence established. instinctively the better ones already do
markers or too fulsome word pictures to
We should seek to adopt best practice the psychological barriers to effective
overwhelm the busy instructor or confuse
when developing these instruments, communication should be overcome,
the crewmember for whom it can also be
customising them to reflect local cultures, situational awareness will be enhanced
used for self-critique. The objective is to
be they national, company or fleet. One and the consequent, higher-quality
produce a user-friendly tool, not a burden.
well-tried method is to craft a spectrum of decisions made should lead to improved
word pictures. operational effectiveness. In the long
term, operations should be inherently
The right-hand end of the spectrum safer, an outcome clearly influencing the
indicates performance expected of bottom line.
An example that I helped advance which
experienced line crew and so BM can

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CRM?Its For The Birds!

CRM, an acronym used vicariously in reference to Cockpit Resource
Management or Crew Resource Management, has been a buzz word used in
recent years by many psychologists and others to identify human factor
In sum, rather than having lost its way, I limitations amongst aircrew when working together.
consider CRM training has emerged from
But the concept of CRM has been around for almost as long as life itself, certainly
a period of uncertainty more confident.
longer than the relatively new kid on the block - aviation. Consider birds for
Given the impetus of the NPA, an
example, in particular the humble flock of geese.
unambiguous activity path ahead is
evident, transparency of which is I believe
assured through the use of developed
BM. Eventually, CRM training could 1. In a flock of geese, as each bird flaps its wings it creates an uplift for
mature to the point where behavioural the bird following. By flying in a V-formation, the whole flock adds
markers become standards, comparable about 71 percent longer flying range than if each bird flew alone.
to technical standards.
Lesson: People who share a common direction and sense of togetherness can
Now theres a notion! go where they are going quicker, easier and safer when they travel on
the thrust of one another.

The views expressed are those of the

author who served 31 years as RAF 2. Whenever a goose falls out of formation, it suddenly feels the drag and
aircrew and 3 years with the CAA Flight resistance of trying to fly alone, and quickly gets back into formation to
Operations Department policy section, take advantage of the lifting power of the bird immediately in front.
with responsibility for Crew Resource
Lesson: If we have as much sense as a goose, we will stay in formation with
Management issues, before becoming an
those who are headed where we want to go.
independent aviation consultant
specialising in human factors in
December 1999. He is secretary of the
RAeS Accreditation Focus Group that 3. When the lead goose tires, it rotates back into the formation and
produced the Guide to Performance another goose takes over as lead.
Standards for Instructors of CRM
Training in Commercial Aviation and Lesson: It pays to take turns doing the hard tasks and sharing leadership
is progressing an accreditation framework because people, like geese, are interdependent upon each other.
for CRM trainers in the UK. As secretary
to the JAA Flight Crew Study Group, he
was intimately involved in the development 4. The geese in formation honk from behind to encourage those up front
of NPA-OPS 16 from 1997 to 1999. to maintain their speed.

Pieter Hemsley 2000 Lesson: We need to make sure our honking from behind is one of
encouragement - not something less helpful.

5. When a goose gets sick or wounded or shot down two geese drop out
of formation and follow it down to help and to protect it. Then, they
stay with it until it is either able to fly again or dies. Then they launch
out on their own, either with another formation or to catch up with the
original flock.

Lesson: If we have as much sense as the geese, well stand by each other in
the air like they do.

Reproduced with acknowledgement to Spotlight courtesy of PIA Air Safety.

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Corporate Killing - Directors Liabilities

by Steven Kay QC

The liabilities of Corporations for deaths 1. Unlawful act manslaughter itself is triable only upon indictment (jury
caused as a result of commercial trial).
activities is an area of criminal law that is
This is when a person who causes the
to be reformed and there will inevitably be
death was engaged in a criminal act,
an increase in the opportunities for Using modern research methods, I have
which carried with it the risk of injury to
prosecution of both companies and their been able to trace only six prosecutions
some other person. For example, setting
directors. To better understand the of a corporation for manslaughter in the
a fire to someones dustbin beside their
implications of what is to happen it is history of English criminal law. Of these
house because the smell of rubbish is
worthwhile to consider the law of only two have resulted in convictions, in
offensive. The wind blows sparks that
homicide generally and the development 1994 and 1999. The other cases
ignite curtains at an open window. Fire
of the concept of corporate manslaughter. prosecuted which all resulted in acquittals
spreads into the house and kills someone
within. This is an act of arson, or criminal were in 1927, 1965, 1991 (The Herald of
damage, from which death results and Free Enterprise case aka the Zeerbrugge
English law has two general forms of could be unlawful act manslaughter. Ferry disaster), 1999 (The Southall rail
homicide offence - murder and crash).
manslaughter. There are also some
specific forms of statutory homicide, such
2. Gross Negligence Manslaughter
as infanticide, but we do not need to However, there have been a number of
consider those forms in this context. recent disasters, that have been
This is when a death is caused by responsible for a call for a new approach
extreme carelessness or incompetence. to the law. As a result the Law
To be guilty of murder it has to be proved For example a Doctor negligently injecting Commission issued in 1996 a Report
that the accused intended to kill or a patient with a serum that is lethal and is Legislating the Criminal Code:
intended to cause serious injury. If there the wrong drug to administer. Involuntary Manslaughter and the Home
are mitigating features within the Office have further issued in May 2000 a
allegation of murder, such as provocation set of proposals for reform of the law
(a temporary and sudden loss of self under the title Reforming the Law on
3. Taking an Unreasonable Risk or
control causing the act) or diminished Involuntary Manslaughter: The
Recklessness Manslaughter
responsibility, then the offence is one of Governments Proposals.
manslaughter. This form of manslaughter
is known as voluntary manslaughter, This is when death is caused by a person
because the act was intended, but who is aware that their conduct involves a Let us recall the incidents which have
caused by the mitigating features. risk of causing death (or probably serious prompted the calls for reform, all of which
injury) and unreasonably takes that risk. were the subject of Public Inquiries, each
For example, a fun fair operator who of which was highly critical of the
permits a ride to travel at speeds that corporate bodies involved in the
If someone kills but did not intend to
involve a risk of fracture of the metal that disasters, none of which ended in a
cause death or serious injury, but was
bolts the ride to a track, but continues to successful prosecution.
blameworthy in some other way,
operate the ride at increased speed.
involuntary manslaughter is the form of
homicide. It is in this area of involuntary
manslaughter that we are concerned 1. November 1987 the Kings Cross
when discussing corporate killing. It is within 2 and 3 that we are concerned Underground Station fire. Causing 31
with Corporate Killing or the liabilities for people to be killed and many others
directors when death occurs as a seriously injured, including rescuers.
Involuntary manslaughter has three consequence of an undertaking by a The report of Desmond Fenell QC was
different forms: company. The punishment able to be critical of London Underground for not
imposed upon a corporation for such an guarding against the unpredictability
offence is a fine. Directors as individuals if of the fire and for failures within their
proven also to be guilty personally, may management system by not having
be liable to imprisonment or any other any person in overall charge in the
sentence open to the Court. The offence event of a disaster.

11
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2. July 1988 the Piper Alpha oil platform because of the need to identify a The pressure for reform of the law has
disaster in the North Sea in which 167 person whose gross negligence was been intense and it will arrive in the near
people died and the inquest/inquiry in that of the company itself. The Judge future. The concern has been to ensure
Scotland held it to be the had described the accident as being prosecutions against corporations
responsibility of the platform operator. a serious fault of senior management. involved in disasters resulting in large
This ruling also served as an indicator scale loss of life and to enforce Health
there could be no successful and Safety at Work legislation, particularly
3. December 1988 the Clapham Rail prosecution for the recent Paddington on construction sites. However, once
crash. Here, 35 people died, 500 rail crash. reformed, the law will be applied to all
injured when 3 trains collided as a levels of potential offence regardless of
result of signal failures. Anthony scale.
Hidden QC was critical of the Let us consider now the technicalities of
dangerous working practices and these prosecutions. It is possible to
failure to act upon safety concerns of prosecute a company, for it is deemed in
British Rail. Responsibility for what law to exist as a distinct legal entity. The The Governments proposals adopted
occurred was beyond the operatives company acts through individuals who from the Law Commission are to divide
at ground level, but also stretched are its servant and agents. The failure of involuntary manslaughter into separate
further and higher within the the prosecution in the Herald of Free offences as follows:
organisation. Enterprise case against the corporation
was because of the identification
doctrine.. In order to convict the 1. Reckless killing: where death is
The last two examples, both of which company of manslaughter, individuals caused by a person aware of a risk
resulted in failed prosecutions, highlight identified as the embodiment of the that his or her conduct will cause
the difficulty in the law with these cases. company would themselves have to have death or serious injury and it is
been responsible and guilty of unreasonable to take the risk having
manslaughter. If there is insufficient regard to the circumstances as the
4. Firstly, March 1987, the Herald of evidence to convict an individual or person knows or believes them to be.
Free Enterprise car ferry disaster at individuals the case against the company
the port of Zeerbrugge. There were, also fails. To successfully convict the
187 deaths which were held by the company, the acts complained of have to 2. Killing by gross carelessness: where
verdicts of an inquest jury to have be committed by those identified as the death is caused by a person and the
been as a result of unlawful killing. Mr. embodiment of the company itself.. risk that their conduct will cause death
Justice Sheen in a report for the or serious injury would be obvious to
Department of Transport severely a reasonable person in his or her
criticised Townsend Car Ferries Ltd., position, and the person is capable of
It must be recognised that complex
which was taken over by P&O appreciating that risk at the material
company structures in which there is
European Ferries. In June 1989, the time, but did not in fact do so - and
great delegation of responsibility down
Director of Public Prosecutions either - (1) the persons conduct falls
the line, causes responsibility for many
brought prosecutions against P&O far below what can reasonably
acts done in the company name to be too
and seven individuals. However, the expected in the circumstances - or -
remote from those who embody the
trial collapsed upon the ruling by (2) the person intends by their
company. Failure to shut the doors
Mr.Justice Turner, that there was no conduct to cause some injury, or is
properly on the ferry and to carry out
case to answer against the individual aware of, and unreasonably takes the
sloppy and dangerous practices, if there
defendants and also the company. risk that it may do so and the conduct
is no-one with responsibility for safety on
causing ( or intended to cause ) the
these matters within the body of the
injury constitutes an offence. The less
company avoids the company being
5. Secondly, in September 1997 the serious offence is that of failing to
liable. The successful prosecutions for
Southall rail crash in which 7 died and appreciate the consequences of an
corporate manslaughter that have been
151 were injured. Great Western action (limb 1 of gross carelessness).
brought have been against small one
Trains pleaded guilty to failing to
man band companies where it was
ensure the public were not exposed to
possible to identify the controlling mind 3. Death resulting from intentional or
risks to their health and safety. The
within the company, responsible for the reckless causing of minor injury:
trial Judge ruled a charge of
failures. reforming the dangerous and unlawful
manslaughter could not succeed

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act manslaughter. This reform being immediate cause is the act or Officers of undertakings might also be
motivated to deal with the situation omission of an individual. The liable for imprisonment if they have
where a person causes the death of individuals within a company could contributed to the management failure.
another, but the death was still be liable for the offences of
unforseeable. reckless killing and killing by gross
carelessness as well as the company
These are proposals from the
being liable for the offence of
4. Corporate Killing: an offence similar to Government at this stage, but it is clear
corporate killing.
that of gross carelessness. The there will be an offence of corporate
offence would be committed only killing the only issue for debate is where it
where the conduct of the corporation The potential class of corporate will stop.
in causing death fell far below what Defendants are not limited to
Steven Kay QC
could reasonably have been incorporated bodies but to those
expected. The corporate offence described as:Undertakings. This This paper was presented at the Travel
should not (unlike the individual includes corporated and unincorporated Industry Seminar - Gatwick 2 June 2000
offence in 2 supra) require that the bodies, local authorities, educational
risk be obvious or that the defendant institutes, clubs, partnerships, trusts: any
be capable of appreciating the risk. trade or business or other activity
providing employment. Jurisdiction
would be over any company doing
A death should be regarded as having business in the U.K. Overseas
been caused by the conduct of the incorporation or registration would not be
corporation if it is caused by manage- an exemption from prosecution.
ment failure by the way in which its
activities are managed or organised
and failed to ensure the health and
Enforcement provisions against
safety of persons employed in or
directors for management failure would
effected by its activities.
include the power to disqualify from office
Such a failure will be regarded as a
or from acting in a managerial role.
cause of a persons death even if the

Book Review
HUMAN FACTORS IN MULTI-CREW
FLIGHT OPERATIONS
By Harry W.Orlady and Linda M.Orlady.contribution the authors make to the find the relevant chapter to gain an incite
Forward by John K Lauber. science of understanding what Human or a reference for more detailed study.
Factors entails is in the vast library of This reviewer finally found the purpose of
Published by ASHGATE PUBLISHING Ltd. references they have culled in order to the book in the conclusion of chapter19,
create the most up to date work thus far in which he reads:
Gower House
published. Many other books have been
Croft Road
written, throughout the world as the
Aldershot
subject has unfolded and they are all
Hants. GU11 3HR. UK A final thought:
referred to generously and accurately.
List price: 59.50 A purpose of this book has been to
stimulate the type of awareness that will
This impressive book at over 600 pages, make all members of the operating team
The book is structured in phases and it is
22 Chapters, 17 appendices and a aware of their importance in
a lengthy read to cover the whole book
glossary, is the long awaited accident/incident prevention and to help
even allowing an hour a day for the task.
compendium to the ever growing topic of ensure that members of the operating
The trick is to ask oneself what the
Human Factors in Airline operations team are not simply the victims of a
problem they are analysing is and then
published by Ashgate. The valuable

13
16894/Flight Safety 24pgr 29/8/08 10:40 Page 14

I Thought He Was
Playing Chicken!!!!
series of situations that make an accident educators and anyone thinking of taking I was reading one of your Vortex articles
or incident eventually inevitable. When an up a career in any of these disciplines. the other day and it caused me to think of
accident does occur, it is clear that in an incident that occurred 17 years ago
virtually all cases a total system approach In conclusion it could best be left to echo
that almost cost me my life. I was
should be used for the analysis of the that in the Foreword by John Lauber, in
working in Africa, along with a fixed wing
accident. A total system approach makes which he writes:
aircraft, on a spraying contract. On the
it possible for the aviation system to take day of the incident, the weather was poor
advantage of the lessons that may be with low visibility and I had lost contact
learned. It is clear that all aspects of the Careful reading of this book will help with the other aircraft, who was working a
social environment must be considered dispel common misconceptions of what few miles away. I had just started a spray
human factors is about, and will provide run when I saw a flash and heard the roar
the reader with practical information that of an engine off my right side. I swung
So many times in the past, which will no will help achieve the desired levels of my head to the right just in time to see
doubt continue ad infinitum, humans human performance in the aviation the Pilatus recovering from what was
operating aircraft, both singly and in system. That this is important is amply probably a 90o high g turn. I continued
teams make mistakes, not of their own reflected in the accident data: human with the spray contact but did not see or
making but because of weak links in the performance and human error continue to speak to the other pilot for a couple of
infrastructure or the holes lined up in be the leading cause of such mishaps. days.
Prof. James Reasons Cheese analogy.
From Checklist skills to the rapidly
growing human interface with the Peter G Richards I Eng MRAeS. RAeS When we finally got together (over a
automated aircraft world, this book rep on the UK Flight Safety Committee. beer), he said he had seen me from quite
exposes and explores them all. a distance but did not alter heading
because he thought I was holding
Courtesy of The Aerospace heading to play chicken with him.
Throughout the book, the authors have Professional. Fortunately for both of us he eventually
guided the reader to further study, with did the correct thing and altered heading
essential forward and backward just in time to avoid a collision. He turned
references and sensible footnotes. It has a light shade of white and had many
a very readable style of journalism, more beers when I told him that I hadnt
though sometimes the sentences get a seen him till he had taken evasive action.
bit long. They make no apology for the
USAs bias in their work, for that is the
region with which they are both most Assuming that the other aircraft has you
familiar. But, above all, they identify Best visual just because you can see it could
Practices, wherever in the world they be a deadly error in judgement.
originated. In the chapter entitled The
Worldwide Safety Challenge they do not
shirk from grasping the nettle of how to
Reproduced from Aviation Safety
effectively manage the emerging
Vortex.
programmes known as Flight Operations
Quality Assurance (FOQA), or Operational
Flight Data Monitoring (OFDM) in the UK.

This is a reference book, aimed at anyone

who has managerial responsibilities for
any level of operation involving flight
operations, flight and cabin crews,
ground operations and air traffic systems,
especially regulators and investigators,

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16894/Flight Safety 24pgr 29/8/08 10:40 Page 15

The Quality Choice

by Captain Alan Munro
BSc(Eng) MRAeS MIQA

Quality Assurance (QA) arrived in European in one direction and in the other what is warranty claims, unplanned activities,
aviation as the means by which self seen increasingly as a costly regulatory overdue accounts, downtime, stock control
regulation might be achieved. Of course, burden. In other words, it is the difference problems, procedural failure, documentation
Quality is in itself nothing new. Airlines and between minimal compliance and the errors, overtime, refunds and adverse
maintenance organisations have always excellence which QA is capable of publicity, and most of these apply to a
depended to a greater or lesser extent on producing - The Quality Choice. maintenance organisation.
strong management structures, dependable What we then mean by Quality needs to be The proven Quality Costs of a
training and procedures and reliable carefully defined, for which probably the manufacturing company without QA are
documentation. But at the same time the easiest version is straight Customer around 25% of its turnover.
regulator was always at the elbow to ensure Satisfaction. But of course this then poses
compliance with aviation legislation and to In an airline loss means ramp damage, late
the question as to who the customer
ensure at least minimum safety standards departures, fuel wastage, flight time
actually is. Obviously this must be the airline
on behalf of the travelling public. limitation problems, damaged freight, lost
itself for a maintenance organisation or the
bags, missed connections, unplanned
The concept of Joint Aviation Requirements passenger or the freight forwarder for an
activities, sub-charters and compensation.
started more than 30 years ago when the airline, but even this is not straightforward.
But it also means the cost of resignations,
cost of certification to individual national We may actually be selling to a tour
inappropriate or lack of training, retraining,
specification was becoming prohibitive. For operator or leasing to another airline, while
trade union activity, maintenance stock
example, a new Boeing 737 certified in the code shares or alliances may also put us in
control, sub-contractor performance, flight
United Kingdom in 1968 was required to the position of delivering a customers
safety, health & safety and security incidents,
have 20 special conditions which cost in the service to their customers.
trouble with the NAA, lost business and
order of $300K per aircraft. In fact the early In this case the basic product, however, is again public loss of confidence.
JARs were Joint Airworthiness relatively straightforward. At whatever level
Requirements whose aim was to ensure that The Quality Costs of a service company
of comfort, for a passenger airline it means
a new aircrafts certification was universal in without QA may be anything up to 40% of
a safe punctual service with luggage on the
Europe. JARs as we now know them go its turnover.
same aircraft.
back to the Cyprus Arrangements of 1990, So in an airline, if only 10% of such wastage
but descend from the earlier goals of In the case of the regulator, the NAA is not
was recoverable through QA, what is 10% of
common certification. so much a customer as the agent of the
your turnover? And what might it mean in
public, whose role is to ensure that all
The stated justification for the requirement terms of injury and damage?
regulations regarding safety and
for QA is that active regulation of an airworthiness are met, so that customers Of course Quality is not free. Installing a
expanding complex civil aviation industry is agent is an appropriate definition in Quality Quality System, employing and training
becoming too demanding and costly, that a terms, and the product is then, by staff, planning, equipping and generally
self-regulating Quality System allows less definition, safety and airworthiness. moving to a Quality culture all costs money,
active regulation and more self-control. It but then any new project requires
might be added that standardisation of In other industries where QA is increasingly
investment. And that is currently where the
safety standards in a de-regulated Europe is seen as necessary for survival, the words of
vast majority of European airlines find
also fundamental to aviation safety and of Peter Drucker, the Dutch management
themselves as we speak, told to re-equip
course by introducing self-regulation each specialist well-known on both sides of the
with the QA tool, but unsure how to use it,
nation can interpret the rules within national Atlantic are most appropriate:
unaware of its potential, begrudging its cost
culture and a tight set of guidelines set by . . . . the first duty of a business is to with the only apparent benefit as doing the
harmonised National Authorities (NAAs). survive, and the guiding principle of minimum QA necessary to hold a JAR-OPS
business economics is not the maximisation Air Operators Certificate (AOC).
This paper, therefore, is not about the JAAs
of profit it is the avoidance of loss . . . .
or their quite incredible achievements to We are at a stage where some of the
date, or even about the problems that do That is what QA does, and in our industry
European National Authorities have greater
exist. It is rather about the opportunities that that loss is not just financial. It means
or lesser understanding of what QA actually
have been handed to the leaders of our incident and accident, air and ground,
means and thus what its potential is for
industry, which have been overlooked by damage, injury and death, with
aviation safety, because by default a Quality
many, or quite deliberately ignored. I believe commensurate loss of public confidence.
System designed to assure Quality and
that we stand at the crossroads with vast In a manufacturing scenario loss through a Safety is already the basis of safety
opportunities for enhanced safety and profit lack of Quality means reprocessing, management. I believe that the basic

15
16894/Flight Safety 24pgr 29/8/08 10:40 Page 16

problem is the manner in which the JAR- system for company excellence where QA is and commercial issues which at first glance
OPS Quality requirement has been stated. used to produce safety, airworthiness and have no place in an Operations Quality
continual business improvement. System. And yet safety issues are quite
After all, a Quality System is only a
fundamental, starting with stress on the
documented business management system The companies which have gone for
operating air and ground crews and ending
constructed for maximum business minimum QA compliance, the vast majority,
with flight time limitation problems, so that
effectiveness. General Electrics own Six have thus imposed a burden on themselves
the solution is probably simply one of
Sigma QA is exactly that, customised to with none of the potential advantages, while
presentation. If we write our operational and
what the corporation considers vital for those who have grasped the challenge are
maintenance manuals in such a way that
customer approval. now visibly pulling away. And even where
the NAA regulator can see compliance with
meaningful QA is attempted, all too often
So let us now take a passing glance at the all QA requirements, there is no reason why
senior management simply fails to see QA
ISO 9000 Quality Standard. We are looking we should not at the same time make these
as a management responsibility which
quite simply at a model of a manufacturing a part of a greater company QA initiative.
needs daily visible commitment from the top
or service delivery which has been made
and indeed a cultural change in There are after all few operational issues
universally acceptable, and I am well aware
management style. without a commercial impact and even
of its limitations when misused. We are
fewer commercial issues which do not
simply making a comparison. The Internal Quality Audit itself, for example,
impact directly on Operations and
is a powerful tool by which management
The ISO 9000 standard model of a business Maintenance. The helicopter operators flying
can receive accurate information on
organisation has 20 clauses and in the order for oil companies have recognised these
anything they want to know, but too often it
of 170 actual requirements for a Quality simple truths for years, working operational
is viewed as a check that all regulatory
delivery, and of course many Quality minded Quality as part of a documented Quality and
requirements have been satisfied rather
companies go much further than this basic Safety System, usually within an ISO 9000
than a check of overall management
model. Of these 20, about 14 are identifiable registration demanded by their employers.
requirements. An example of this might be a
in JAR-145, and about 7 in JAR-OPS 1 and
cabin audit which reports on serviceability, a So it is a matter of commitment and then
3. Both are unacceptable as substitute
regulatory requirement, but not on cabin presentation, offering each sub-part of
Quality standards (although interestingly
cleanliness which is not. company QA to the respective regulator, all
JAR-21 is acceptable). Roughly speaking
working within an overall Quality System,
these are the requirements for management, (The Wootton report, investigating the
designed to deliver everything that the
process control, internal auditing and Quality Control incident where a Boeing 737
company is trying to do with maximum
corrective action, with elements of landed after 10 minutes flight with no engine
proactivity and minimum loss. And of
purchasing, document & record control and oil remaining, made the recommendation
course a number of different regulators may
little else. But it is not even that good. that there should be compulsory Quality
be involved, with security, health and safety,
Management training for senior managers,
Corrective action is not required to eliminate company law and the environment all
now accepted by the UK CAA.)
root cause, the handling non-compliance making individual demands on a hard
receives almost no direction and Quality should be a consensual method by pressed management, not to mention
preventative action is arguably just touched which the entire company is involved in specialist medical, veterinary and other
on. And yet the purpose of QA, enshrined in management strategy, carefully devolved exceptional needs.
ISO, is always to be preventative and where through a Quality System where everyone
We have not so far mentioned the role of the
things do go wrong, to eliminate the root knows what to do and is doing exactly what
airline or maintenance sub-contractor. It is a
cause quickly and totally. management wants of them.
rule of life that what we purchase we pass
JAR-OPS go on to compound the problem I believe that the solution initially lies in on in the final product, which has always
by splitting its minimal QA requirements management understanding of what is been recognised by maintenance. In
from its requirements of management which being asked of them, of careful definition of operations our frequent dependence on
are as ever comprehensive and demanding, the issues which drive their company sub-contractors is now making a significant
but these almost entirely form the conditions business, and then of formulating the impact. JAR-OPS 1 and 3 actually remind us
for holding an AOC. The result is the current policies necessary to give full concentration that the final product is correctly and
wisdom that Quality is reactive and nothing on each of the areas of critical concern and invariably the responsibility of the operator,
to do with Safety. Trust us, were the Safety the procedures necessary to achieve a nowhere more so than in ground operations.
experts and so on. And regrettably too Quality product.
In the past, however, we have put total faith
many regulators agree, only wanting to see
An example of this is perhaps that of on- in the Standard Ground Handling
the documented minimum rather than a
time departures, a mixture of operational Agreement, based on the IATA AHM 810,

16
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putting matters to right well after something by company QA and a culture which should minimum acceptable QA we saddle a
has gone wrong, and as we all know to our be designed to support flight safety monster. If we choose the harder road, as
cost, this can range from very expensive proactively. Quality, like safety, must become other industries already have, the combined
aircraft damage to the occasional fatality. everyones concern, so that when we talk rewards in terms of business and safety
safety then Quality and Safety have to be one excellence are immeasurable.
Increasingly as the operator is forced to
and the same. Increasingly as we move
demonstrate a minimum degree of QA The Quality Choice.
towards a Safety Management System, and
compliance, auditing has become the only
risk auditing becomes the order of the day,
recognised tool in the Quality box for
then the management aims inevitably merge.
checking on a sub-contractors Alan Munro flew for 40 years, serving as an
performance, while it is not actually the Beyond our first steps into QA is the road to RAF pilot and FSO, instructing for many years
specific JAR-OPS requirement. The result is Total Quality; the often misquoted TQM, in GA, flying commercially as an A320 Captain
severe over-auditing and a heavy drain on always in the distance but just out of sight; and working as an airline safety officer.
operator and sub-contractor resources for the land of brilliant management, happy
He now runs Airstaff Associates, an airline
which the official solution is now audit customers, sub-contractors working as
Quality & Safety consultancy and training
pooling and horse trading of audit results, business partners, delighted shareholders,
organisation in the United Kingdom
on the vague assumption that all operator harmony with the environment, contented
specialising in airline QA, (www.airstaff.co.uk),
requirements are identical. workers and delighted regulators, where
and is Director of the UK arm of AviaQ, an
safety and airworthiness are absolute. An
It has all been tried before. As a result, the aviation auditing company (www.aviaq.com).
impossibility? I dont think so. In fact a TQM
motor industry developed QS 9000, a Quality
approach could even become essential for The views expressed in this paper are his own
super-standard where all the specific needs
future survival as a more discerning public and do not necessarily reflect the policies or
of car manufacturers are independently
and regulator increasingly demand it. views of GE Capital Aviation Services.
audited periodically by a specialist company,
with a resulting accreditation being In the JAAs I think that we have arrived at a
internationally acceptable. And of course at cross-roads, where if we choose to do the
the end of the road this will hopefully one day
become the norm for our own industry.
Others have already followed, for example Airstaff Associates
the AS 9000 standard for Aerospace, but we in association with
seem to be at least 20 years behind in our Nigel Bauer & Associates
own approach.
QUALITY MANAGEMENT FOR OPERATORS *
Long before then, there are many other JAR-OPS Quality Systems, documentation & auditing
Quality tools for the control of the sub- 5 days - ARN - 28 Aug, LGW - 18 Sep, 20 Nov, 22 Jan
contractor, starting with performance SAFETY MANAGEMENT SYSTEMS
evaluation on Quality grounds. All the advice SMS course for air & ground operators 2 days - LGW - 18 Oct
needed is in the ISO 9000 standard which is AUDITING IN AN OPERATIONAL ENVIRONMENT *
in fact the only Quality check list in existence. Air & ground operations auditing 3 days - LGW - 06 Dec

Then there is the matter of the airline which AUDIT IMPROVEMENT WORKSHOP
undergoes rapid expansion in size, fleets, Experience sharing & improvement of audit process 2 days - LGW - 16 Oct
bases, personnel and so on, where a highly QUALITY FOR SENIOR MANAGEMENT
motivated close knit body working together NEW FOR 2000 - JAR Quality Management 2 days - in-company only
becomes increasingly dysfunctional through
* Incorporating Nigel Bauer & Associates
lack of planning, resource and solid
IRCA certificated Internal Auditor Training course
sensible communication; otherwise known
as a documented Quality System. For further details including In-Company courses and consultancy services please contact:

Airstaff Associates:
The Quality Manager is not, however, a
Tel +44 (0) 1780 721223 e-mail: [email protected]
substitute flight safety officer (FSO), and Fax +44 (0) 1780 720032 www.airstaff.co.uk
indeed the QMs role described in JARs is
really that of an Audit Manager. The FSO will Nigel Bauer & Associates:
Tel +44 (0) 1243 778121 e-mail: [email protected]
always remain the safety champion, Fax +44 (0) 1243 789121 www.nb-a.demon.co.uk
frequently acting intuitively but now backed

17
16894/Flight Safety 24pgr 29/8/08 10:40 Page 18

Leading The Way Towards Safer Flying

by Dave Wright

By using information from every flight UK As part of this process, on the 28th June, number of operators shared recent
operators show the world how to improve a second very successful OFDM lessons learnt with the audience and this
flight safety. The pioneering 1970s co- workshop was held at the Gatwick Europa highlighted the potential benefits of a
operative research project of SRG and Hotel. One hundred people attended this Web based OFDM user group that was
British Airways has become an important workshop that was aimed at assisting UK proposed earlier in the day. A wide
tool to help improve safety in the new operators implement the pro-active range of issues were raised that will be
millennium. analysis of FDR data to improve safety. followed up by both industry and SRG. w
The eighteen UK and five Foreign w
operators (plus twenty other
organisations) learnt from advanced
By routinely running flight data recorder Comments received after the event
users such as British Airways, British
information through analysis programs included.....
Midland and Bristow Helicopters;
operators are able to detect departures watched technical presentations on Quick found the event thoroughly stimulating
from standard operating procedures or Access Recorders (QARs) for regional and it gave us renewed confidence to find
unusual situations that may have safety aircraft from BAES and SAGEM; listened so many other operators at the same
implications. Once detected, these are intently to a presentation on legal aspects w
stage as ourselves .....
assessed and, where necessary, remedial by CAAs Legal Advisers Office; and saw
action is taken. This may involve demonstrations by a number of leading It was good to see such a healthy
changes in procedures, technical action software and hardware companies. dialogue between the operators and the
or crew education and retraining. This regulator
process is known in the UK as
Operational Flight Data Monitoring we need a forum where we can
(OFDM). The workshop was organised by SRGs exchange views, information and lessons
Safety Analysis Unit assisted by Flight learnt, and a means for the Regulator to
Operations Policy and International update operators
Services.
SRG have been instrumental in
encouraging and advising operators in w
this area and today over sixty percent of Contact Dave Wright at W
all UK jet airliners are monitored by such Discussions were opened into [email protected]
programs and this proportion is growing international developments, legal issues,
rapidly. organisational methods and operational
experience. In the latter session a

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One-Size-Fits-All Maintenance Problem

In the past year several incidents have absolutely no indication on the takeoff roll covered with grease. Unless
been reported to ASRS in which Boeing that the wheel had failed. In fact, when maintenance technicians take time to
737-100 and 200 wheel bearings were the errant wheel was located, it too was verify the B737 part numbers, the wrong
incorrectly installed on the series 300 intact and even still inflated. bearing may be installed on the wheel.
aircraft. Now heres a Captains report
that describes the installation of a B-757
The B737-300 wheel apparently will From the NASA Aviation Safety
wheel bearing on a B737-300 wheel
accept B737-100, 200 and B757 bearings Reporting System CALLBACK.
with potentially catastrophic results:
and look like a correct installation. The
underlying problem is that part numbers
Shortly after departure from Runway 34L are on the bearing race are normally
the Tower controller informed us we had
lost a wheel on the takeoff. In a very
short period of time we were told we had They Were Just Little Problems Nothing Major
lost either the right outboard main gear problems? the investigator asked.
wheel, the right inboard main gear wheel,
The investigator was carefully picking
over the pieces of what had once been a
or even both right main gear wheels. I Lots of little ones; none of them seemed
well-designed and well-constructed
elected to stay in the local area and to be really enough to cause us to
aircraft. Little remained that looked
reduce fuel to an acceptable level complain. The only one that scared me
worthwhile. There was no obvious reason
(weight) for landing. The B737-300 does was the time the electrics all went off, but
for the crash, and the detective work was
not have fuel dumping capabilities. they came back on again almost
going to take some effort. Thats what he
immediately. In fact, they came back on
got paid for, he mused.
before I had time to do anything about
Since I did not know the integrity or even
A bystander at the perimeter of the roped- the problem.
existence of the remaining wheel on the
off area had been standing there quietly
right side, I wanted to reduce the aircraft Had this happened to anyone else that
for some time, and the investigator noted
weight as much as possible for landing. you know of on this aircraft? the
a reasonably relaxed, but slightly nervous,
We held outside the [airport] area for two inspector asked, doing his best to keep
air not your normal gawker.
hours. I realized that if we held for an his voice calm and level.
extended period, we would be making an When the investigator left the crash site
Never mentioned it to anyone else, and
emergency landing, and quite possibly a for a moment, the bystander approached
they didnt say anything to me either.
passenger evacuation after sunset. With him, not anxiously but with a purpose.
Well, glad if any of this helped, he said,
this consideration, I held until the time we
After a few pleasantries, the bystander then he turned and walked away.
could make a low pass, get a visual
inspection from the Tower and return for shuffled slightly and said I dont know
The investigator shook his head. The
landing just prior to sunset. how to put this, whether I should say
accident happened at night in poor
anything or not, or if it might help. I dont
weather to a pilot brand new to the
want to be named or held responsible for
operation and this aircraft.
The low pass was conducted and the anything.
ATC personnel, as well as company
mechanic, reported the right outboard Assured that anything might help in the
wheel was intact, the inboard was crash and that there was no danger of Reproduced from Aviation Safety
missing. After the visual inspection, we getting in trouble, the bystander relaxed Vortex.
returned for landing..The approach and slightly and continued.
landing were uneventfulThe aircraft was
I flew this aircraft a lot, you know, over
towed to the maintenance hangar where it
the last few years, and it had some
was discovered that the main wheel
peculiar habits. Everyone just put it down The least experienced press on while
bearing on the right inboard wheel had
to being different, and no one ever the more experienced turn back to join
failed. The wheel departed the airplane,
formally wrote it up we all knew about the most experienced, who never left
leaving the axle and the brake assembly
the problems. Oh? What sort of the ground in the first place.
intact on the landing gearThere was

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16894/Flight Safety 24pgr 29/8/08 10:40 Page 20

Members of
THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

Full members British Airways GAPAN

Capt. Chris Tiffin Capt. Chris Hodgkinson
Chairman
Aer Lingus British European Airways GATCO
Capt. Tom Croke Stuart McKie-Smith Richard Dawson
Vice-Chairman British Mediterranean GB Airways
Airclaims
Capt. Peter Chinneck Capt. Mike Smith
John Dunne
British Midland Gill Airways
Treasurer
Capt. Mel Grievson Capt. Ben Hastings
CAA
Tony Ingham
British Midland Commuter GO FLY Ltd
Capt. Steve Saint Capt. Michael Orr
Communications Officer
RAeS
British Regional Airlines HeavyLift Cargo
Peter Richards
Capt. Ed Pooley Capt. Mike Jenvey

Aerostructures Hamble British World Airlines Irish Aviation Authority

Dr. Marvin Curtis Capt. Shireen McVicker Capt. Bob Tweedy

Airtours International Brymon Airways JMC Airlines

Capt. Tim Cheal Capt. Martin Jezard Capt. Graham Clarke

Air Contractors CAA KLM uk

Capt. Tony Barrett-Jolley Chrys Hadjiantonis - Safety Data Dept Peter Walton
Keith Wilson - Intl . Services
Air Foyle Brian Synnott - Flight Ops. Libyan Arab Airlines
Capt. Chris Fox Eng.Mahmud Ali Tekali
CargoLux
Air Mauritius Capt. David Martin Lloyds Aviation
Roy Lomas Martin Matthews
Cathay Pacific
Air Seychelles Capt. David Mawdsley Maersk Air
Capt.Alasdair Liddle Capt. Robin Evans
Channel Express
Air Transport Avionics Rob Trayhurn Manchester Airport Plc
Colin Buck Peter Hampson
City Flyer Express
Air 2000 Capt. Andy Walker Manston Airport
Capt. Martin Pitt Wally Walker
CityJet
ALAE Capt. Sean Burke-Daly MoD
John Sawyer Gp. Capt. Bill Cope - RAF
Delta Airlines Cdr. D.J. Lilley - RN
BAA plc Evan Parsons Sqn Ldr Jeff Collier - HQSTC
Francis Richards
EasyJet Monarch Airlines
BAC Express Capt. John Broomfield Capt. Gavin Rowden
Capt. David Smith
Emerald Airways NATS
BALPA Capt. Roley Bevan Paul Jones
Carolyn Evans
EVA Airways PrivatAir
Bristow Helicopters Alex Reid Capt.Francisco Agullo
Capt. Derek Whatling
Ford Air Ryanair
Britannia Airways Capt. John Sarris Capt. Gerry Conway
Peter Naz
GAB Robins Aviation Sabre Airways
British Aerospace Reg. A/C Rob Burge Peter Kelly
Dan Gurney

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16894/Flight Safety 24pgr 29/8/08 10:40 Page 21

SBAC City Flyer Express Co-opted advisers

Peter Holtby - Secretariat John Park
Bryan Cowin - BAE SYSTEMS AAIB
Vic Lockwood -FR Aviation Ford Motor Co. Richard Whidborne
Stuart Yeomans
Scotia Helicopters CHIRP
Capt. Jide Adebayo GB Airways Peter Tait
Terry Scott
Servisair GASCo
Eric Nobbs Gill Aviation John Campbell
Warren Storey
Shell Aircraft Legal Adviser
Cliff Edwards MOD EIFS RAF Peter Martin
Wg.Cdr.Dave McCormick
The Boeing Co. Royal Met. Society
Edward Berthiaume RAeS Dr.John Stewart
Jack Carter
TRW Aeronautical Systems
Keith Joyner Scotia Helicopters
Ian Davies
TransAer
Capt. Mick OConnor TransAer
Noel Madigan
Virgin Atlantic Airways
Capt.Jason Holt

Willis Aerospace
Ian Crowe

FOCUS Subscription Application

Group members
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The Graham Suite, Fairoaks Airport,
Eurocypria Airlines Chobham, Woking, Surrey. GU 24 8HX
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Capt. Nick Kotsapas email: [email protected]

Name
FLS Aerospace (Ireland)
FLS (UK)
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Maintenance members Tel/Fax No

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Colin Evered Please enter my subscription to FOCUS from the next issue.
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16894/Flight Safety 24pgr 29/8/08 10:40 Page 22

Legal Advisers Column

Is Turning The Lights Down Low At Night A Safe Procedure?

by Peter Martin

Decisions of the US Courts of Appeals compensation! To have made good her crew to retreat to the galley for a few
interpreting the Warsaw Convention do claim she would have to demonstrate that hours of rest and recreation of their own.
not bind the English courts but can be of the assault was an accident for the If liberty comes only at the price of eternal
persuasive authority in cases where the purposes of the Warsaw Convention vigilance, so also does freedom from
English courts have not yet themselves since, without there being an accident sexual assault in todays libertine world.
considered a particular issue. For this there can be no claim. In an earlier case Airlines must be even more watchful, not
reason, an unusual case decided recently the court had reasoned that sexual least if alcohol may also be a factor.
by the Second Circuit (New York) Court of assault was not a risk characteristic of air
Appeals is of particular interest to airlines. travel and therefore did not constitute an
accident as that term is generally 1Wallace v Korean Air 27 Avi 17, 869
understood. On this basis, KAL
successfully denied the claim in the
Two male passengers sat between a Miss District Court, the Federal court of first
Wallace and the aisle on a Korean Airlines instance, and Miss Wallace appealed.
night flight from Seoul to Los Angeles on
17 August 1997. It being the middle of
summer, Miss Wallace wore a Tee shirt
and jean shorts with a belt. Initially the The Court of Appeals held1 that the
flight passed uneventfully and Miss characteristics of air travel increased Miss
Wallace fell asleep in the darkened Wallaces vulnerability to Mr Parks
aircraft after finishing her meal. She had assault. She was cramped into a confined
no conversation with her neighbours and, space beside two strange men, one of
in particular, a Mr Park who sat beside whom turned out to be a sexual predator.
her. About three hours into the flight, Miss The lights were turned down and the
Wallace awoke to find that Mr Park had predator was left unsupervised. Mr Parks
unbuckled her belt, unzipped and behaviour was not a five-second
unbuttoned her shorts and had placed his operation, and could not have been
hands into her knickers to fondle her. entirely inconspicuous. Yet, not a single
Miss Wallace awoke with a start, turned flight attendant noticed what was
her body towards the window causing Mr happening. What is more, when Miss
Park to withdraw his hands. When Mr Wallace awoke, she could not get away at
Park resumed his unwelcome attentions, once but had to endure a renewed
Miss Wallace recovered from her shock assault before clambering to safety in the
and hit him hard. She then climbed out of aisle. The event was, therefore, an
her seat, jumped over the sleeping man accident, namely, an unexpected or
in the aisle seat and made good her unusual event or happening external to
escape. the passenger. As such it gave rise to a
legitimate claim against the airline which
could not escape liability for it. The case
was remitted to the District Court where,
After reporting the matter to a flight no doubt, it will be or has been settled on
attendant who allocated her another seat, payment of agreed compensation as it
Miss Wallace reported also to the police seems most unlikely KAL would risk a full
on arrival. Mr Park was arrested and trial and a jury award of damages in a
pleaded guilty to a charge of engaging in case of this kind.
unwelcome sexual conduct, an offence in
the US, in the Federal District court in Los
Angeles. Subsequently, Miss Wallace
sued KAL alleging sexual assault not by Lessons for airlines? It is no longer a safe
the airline but on board its aircraft and, procedure for airlines to turn the lights
therefore, its responsibility in terms of down low on night flights and for cabin

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16894/Flight Safety 24pgr 29/8/08 10:40 Page 23

UNITED KINGDOM FLIGHT SAFETY COMMITTEE

SEMINAR 2000

AVIATION AT RISK
3rd OCTOBER 2000

RENAISSANCE LONDON HEATHROW HOTEL, LONDON

SEMINAR OBJECTIVE
Safe Flight is based on a knowledge and control of a wide variety of
competing areas of Risk. This Seminar will provide management with robust
tools and strategies to enable them to increase their knowledge and control.
PROGRAMME
MONDAY 2nd OCTOBER 2000

1530 - 1830 Registration 2000hrs Seminar Dinner

This will take place in the Hotel Foyer Sponsored by Willis
After Dinner Speaker -
Rt Hon Lord Trefgarne, PC

TUESDAY 3rd OCTOBER 2000

0730 - 0845 Registration

Session Chairman - Ed Paintin UKFSC 1130 - 1200 Airport Influence on Flight

Safety Risk Factors
0900 - 0910 Opening Remarks Paul Fox - BAA
- Capt.Tom Croke
Chairman UKFSC 1200 - 1245 DISCUSSION

0910 - 0920 Keynote Speech 1245 - 1400 Lunch

Gwyneth Dunwoody MP
1400 - 1430 Managing Safety Management
0920 - 0940 Disaster Vs Risk Mike Overall
Jacques Berghmans - DuPont
1430 - 1500 Risk Management & Regulation
0940-1000 Regulatory Style Richie Profit - UK CAA
Clive Norris - HSE
1500 - 1530 Corporate Killing
1000 - 1030 Failures & Shortcomings of Peter Martin
Current Risk Management
Matthew Day - Willis 1530 - 1615 DISCUSSION

1030 - 1100 Refreshment Break 1615 Closing Remarks

Chairman UKFSC
1100 - 1130 Risk Management in Relation
to NATS Business Plan
Euan Black - NATS

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16894/Flight Safety 24pgr 29/8/08 10:40 Page 24

AVIATION AT RISK
SEMINAR INFORMATION

Hotel Accommodation
Hotel Accommodation is not included in the Seminar Registration Fee. A rate of 104 (room only) has
been negotiated with the Renaissance Hotel. If you require a hotel booking form, please request one.

Seminar Dinner
Dress for Dinner Lounge Suits

Cancellations/Refunds
Cancellations received prior to 18th September 2000 will incur a 50% cancellation fee. Refunds after
this date will not be given.

If you are unable to attend why not nominate a colleague to take your place. If so, please advise the
UKFSC Fairoaks office of any changes prior to the Seminar.

SEMINAR REGISTRATION FORM
Please complete one registration form per person (photocopies accepted).

REGISTRATION INFORMATION
(Please print clearly)

First Name: Surname:

Company: Job Title:

Address:

Tel No: Fax No: e-mail:

PAYMENT INFORMATION

Seminar Fee: 100 UKFSC Member 150 Non-Member

This includes Dinner on the evening 2nd October, lunch, refreshments and car parking. This does not include hotel
accommodation please see above Seminar Information.

Payment is by sterling cheque only. No credit cards are accepted. Bank transfer is available, details on request
(please note an additional cost of 6 will be added to cover handling charges). The UKFSC is not VAT Registered.

Sterling cheques should be made payable to UK Flight Safety Committee.

Do you plan to attend the Seminar Dinner on Monday 2nd October? Yes No

Do you require a Vegetarian alternative? Yes No

PLEASE SEND YOUR COMPLETED REGISTRATION FORM WITH YOUR CHEQUE TO:

UK Flight Safety Committee, Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey, GU24 8HX.
Tel No: 01276 855193 Fax No: 01276 855195 e-mail: [email protected]
Confirmation of your registration will be faxed to you on receipt of your Registration Form and payment.

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