In the commercial air-transport world, systems for sharing safety data among airlines and across borders are under construction. The military community, with its more conservative culture, is lagging behind, but there are some signs that firm foundations for pro-active safety exchanges are being laid.
Many safety-conscious and commercially astute carriers have their own internal incident databases and are preparing to network de-identified data which will expose common problems and enable pro-active safety policies to work effectively. Two fears have, however, kept the handbrake on the progress of airline-safety information exchange: in litigious countries, it is the fear of lawyers being able to subpoena such data; and in much of the world there still exists a blame-and-punish culture which prevents flightcrew and engineers from filing essential reports, according to the International Air Transport Association.
Military aviation culture is, self-evidently, different from civil, with the aura of national security influencing the way all information is treated, even when unclassified. The Republic of Singapore's Air Force Inspectorate, for example, is on the horns of a dilemma. Its chief, Col Mark Lai-Choong Wong, attends international military flight-safety seminars, but is not free to say why. When once asked to comment on the value of such conferences and explain what can be gained from them, he said that he would have to obtain clearance to speak on the subject, then had to report that he was "unable to accede to [the request] at the present time".
Brig Gen Orin Godsey, who has just retired as head of safety for the US Air Force, confirms what Wong could not, saying: "We currently exchange safety information with more than 40 foreign air forces, through memoranda of understanding. These include all the NATO nations, and others including Bangladesh, Thailand and Singapore. The exchange of information furthers all our safety programmes." Godsey explains that he is also a member of the civil-based Flight Safety Foundation (FSF), serving on two committees "-where we exchange information with manufacturers and civil airlines". One example Godsey gives of the USAF benefiting from the cross-fertilisation of ideas is the application of lessons learned from the FSF's controlled-flight-into-terrain (CFIT) studies, which led to the development of prevention programmes.
Godsey says that the new look at CFIT, plus lessons learned from the Boeing CT-43 crash at Dubrovnik, Croatia, in April 1996 and the Lockheed Martin C-130H Hercules accident in August have led to the USAF's just-announced decision to fit AlliedSignal Aerospace enhanced ground-proximity warning systems (EGPWS) in its transports. Godsey had recommended that the USAF should leapfrog ordinary GPWS in favour of the enhanced version wherever installation is planned, and this is now decided. Another key result of the Dubrovnik accident is that the USAF will install global-positioning-system (GPS) satellite navigation in all its aircraft by the turn of the century, to help with situation awareness and navigation accuracy.
The growing forum
The chairman of the European Air Forces Flight Safety Committee (EAFSC), Air Cdre Rick Peacock-Edwards of the Royal Air Force, points out that, since he took over the chair nearly three years ago, he has seen Austria, the Czech Republic, Finland, Hungary, Romania Slovakia, Sweden and Switzerland join to an organisation which formerly was purely NATO-based. Now, he comments, "-it's an expanding organisation. If it gets much bigger, we are going to have to think about where we are going to in the future."
Peacock-Edwards says that he has visions of a worldwide umbrella organisation which depends on regional committees to feed it with ideas and information. Recently, the European organisation, which meets every eight months, has started to invite a non-European military safety chief to speak on regional safety issues. Singapore's Col Wong was the latest of the non-European safety chiefs to give such a briefing.
The South African air force, which was due to hold its own internal safety congress, decided to make it completely international. It was cross-cultural as well, he reports, in that airlines were represented. Godsey was there to give a presentation on risk-management, and he reports that he was delighted to find delegates from 17 African countries, and more than 70 countries altogether, at the seminar. "We meet to steal ideas from each other," Godsey says.
The EAFSC seminars take a week. The first day and a half, says Peacock-Edwards, are used to review the progress of policies born out of the previous meeting, and to examine all the significant accidents which have happened since then. When the groundwork has been completed, each seminar follows an agreed theme. Recent themes have been technology for the year 2000, risk management, and reduced manpower following political changes.
The themes themselves are not allowed to lock out current issues or concerns, Peacock-Edwards emphasises. Human factors is always a high-profile issue, he says, adding that, at the moment, "-obviously risk-management and CRM [crew-resource management] are flavours of the day, and we make sure we cover them, whether wrapped up in the [conference] theme or as separate issues".
In addition, whichever air force is the host for a given conference invites the delegates to see something of its operations, training, or flight-safety organisation: "It is not all conducted in the lecture hall," says Peacock-Edwards.
At the next meeting, in September 1997, the theme will be flight safety in international exercises, which have been common events in NATO for many years, but now have extended well beyond the Alliance. Safety is a special consideration in any multi-national exercises, particularly where multi-lingual/multi-cultural co-operation has to play a part. Meanwhile, since 1991, the world has seen multi-national forces operating "for real" in the Gulf and in Bosnia. Forums such as the EAFSC are the only effective places, Peacock-Edwards points out, where the safety lessons learned in such operations can be reviewed and then integrated into both policy and training programmes.
RISK MANAGEMENT
"All nations are thinking about risk management far more," maintains Peacock-Edwards. For example, Singapore has a risk-management policy, he reveals, and the USAF has instituted what it calls "operational risk-management," which was a concept developed by the US Army (Flight International, 24-20 April 1996, Military flight safety review, P34). The US Army studied the accidents for particular types to determine on what kind of operation and at what stage accidents most often happen. This gave it an ability to assess the level of risk involved in any given operation so that measures could be taken to reduce the risk. The system worked for US Army helicopter operations, so it is extending the concept to other areas.
Peacock-Edwards points out that the RAF's definition of flight safety is based on the concept of maximising operational capability by minimising the risk, but that the RAF has not implemented a formal risk-management programme as such. He has, he says, talked to Singapore and the USA about their risk-management programmes and, in due course, this will probably lead to an RAF policy. This, he says, is the sort of benefit which international military seminars bring.
Next steps
Peacock-Edwards comments that experiences across all the air forces tend to be similar in that they have seen a general downward trend in accident rates, but that the improvement now appears to have "bottomed out" and, since costs are going up, the significance of individual accidents is heightened. "We are now focusing our attention on what we can do to get the accident rates to start going down again," he says.
CRM is seen increasingly as one of the means of driving accident rates down. Peacock-Edwards prefers to call it TRM, or team resource management, and it is being implemented by the Australians, Dutch, Norwegians and several of the USAF commands. The RAF has now not only completed its studies on how to use CRM, but has made it an integral part of its whole training system from the start. Peacock-Edwards comments that "people aren't even aware that they're getting it as such". Martin Henshaw, formerly with the RAF and now a consultant taken on by the RAF to help design CRM into the system, explains why the military have apparently lagged behind the airlines in its implementation.
"It is not a question of the RAF being laggardly. Teamwork and leadership have always been very much more a part of air force training than it was in airline training," he says. Peacock-Edwards sees TRM as a means of making people more interactive, so that if an error-chain starts to build up, it becomes more likely that someone will not only see it but act to interrupt the chain.
The USAF has reported that in 1996 it suffered 27 "Class A mishaps", including 20 aircraft destroyed, the lowest number ever. A Class A mishap involves fatalities, damage of over $1 million, or destruction of the aircraft. The mishap rate was 1.25 per 100,000 flying hours, the second-best behind the surprising 1.11 rate in 1991, a year which included the Gulf War. In the fighter/attack class, there were 16 Class As and a mishap rate of 2.16, significantly down on 1995's rate of 2.56. In comparison, the USAF Class A mishap total for 1995 was 32, with aircraft destroyed in 29 of the cases, and 1995's overall mishap rate was 1.4.
In 1996, however, there were several high-visibility aircraft losses, including the CT-43A (military Boeing 737) crash on 3 April, 1996, in Croatia which took 35 lives, the loss of a Lockheed U-2R in Oroville, California, on 7 August 1996, and the crash of a Lockheed Martin C-130H Hercules in Wyoming in which nine were killed.
Lockheed Martin F-16s had the most Class A mishaps during 1996, and all were destroyed. Godsey ascribes the high F-16 losses to the fleet size, mission numbers and the single-engine configuration. He says that safety measures put in place include CRM and a leadership safety initiative in which commanders are made accountable for accidents. "People held accountable for their actions will think twice before they allow deviations from rules they are supposed to be following," explains Godsey, who has also initiated an F-16 fleet operational-risk management (ORM) programme to be in place by 1 October 1998.
The crash of a Fairchild A-10 attack aircraft based at Davis-Montham AFB, Arizona, in April is not listed on the Class A mishap list for this year. This was an aircraft which had left its formation and disappeared for some weeks, until it was found crashed into a snow-covered mountainside. "That was not an aircraft accident," Godsey says. "The evidence we have so far-the change in altitude, the manoeuvring-allows us to stop a safety investigation and open a legal investigation-We believe this was an illegal act [on the part of the pilot]. We have highly reliable witnesses who saw the aircraft manoeuvring. An unconscious pilot could not have done those things."
LESSONS FROM CROATIA
Godsey points out that the Croatian CT-43A CFIT accident near Dubrovnik was a lesson in how not to do almost everything, providing a list of errors, including failure to get proper clearance for the flight, inadequate flight-planning, inadequate on-board navigational aids, a crew whose instrument flying skills were found wanting, and disregard of basic safety rules about minimum safe altitudes, minimum descent heights and making preparations for a missed-approach.
Godsey concludes: "We have rules and regulations that people are ignoring, and we need to take a new look at instrument training procedures." The USAF has now commissioned an independent group to examine its instrument training at all levels from basic to biennial recurrent courses.
Godsey is a firm believer in pooling knowledge and exchanging views at all levels. Poor communication, Godsey believes, was a factor in the Dubrovnik accident. The CT-43's operating command, USAF (Europe), had not instituted a CRM programme at that time. "They have now," says Godsey, emphasising: "If it had been in place it would have helped because it is obvious that the two pilots in the cockpit were not working together."
Perhaps CRM and TRM should be elevated to GRM: global-resource management. Godsey sums up the communications issue neatly: "We're doing a lot, we're learning a lot from other people, but we're also sharing what we're doing with other people.
Source: Flight International
