AMT 324 – ADAPTAR

BASIC SAFETY CONCEPTS

SAFETY is the state in which the possibility of harm to persons or damage to property is reduced to, and
maintained at or below, an acceptable level through a continuing process of hazard identification and
safety risk management

Things to consider:
(the weaknesses in the notion of perfection)

 The elimination of accidents (and serious incidents) is unachievable.

 Failures will occur, despite the most accomplished prevention efforts
 No human endeavor or human-made system can be free from risk and error.
 Controlled risk and controlled error are acceptable in an inherently safe system.
 Safety is a concept that must encompass relatives rather than absolutes, safety risks arising
because of the hazards in the operational context must be acceptable.
 If safety risks and operational errors are kept under a degree of reasonable control, a system as
dynamic as the commercial civil aviation is considered safe.

The evolution of safety thinking

1950 –First age of safety (TECHNOLOGY)
1970- Ergonomics, Organizational factors—Second age of safety (HUMAN)
1990s-2020s – Third age of safety (ORGANIZATIONAL MANAGEMENT)
TRADITIONAL APPROACH- PREVENTING ACCIDENTS
● Focuses on outcomes/ causes

● Unsafe acts by operational personnel

● Attach blame/punish for failures to “perform safely”

● Address identified safety concern exclusively

IDENTIFIES: WHAT? WHO? WHEN?

BUT DOES NOT ALWAYS DISCLOSES: WHY? HOW?

THE SHELL MODEL

S- SOFTWARE

H- HARDWARE

E- ENVIRONMENT

L- LIVEWARE

 Software- the rules, procedures, written documents etc., which are part of the standard operating
procedures.
 Hardware- the Air Traffic Control suites, their configuration, controls and surfaces, displays and
functional systems
 Environment- the situation in which the L-H-S system must function, the social and economicA
climate as well as the natural environment.
 Liveware (individual)- the human beings
 Liveware (group)- the controller with other controllers, flight crews, engineers and maintenance
personnel, management and administration people - within in the system.

PEOPLE AND SAFETY

○ Aviation workplaces involves complex interrelationships among its many components.

○ To understand operational performance, we must understand how it may be affected.

SAFETY MANAGEMENT:
● In order to achieve its production objectives, the management of any aviation organization requires the
management of many business process.

● Managing safety is one such business process.

● Safety management is a core business function just as financial management, HR management, and etc.

● This bring a potential dilemma for management

HAZARD IDENTIFICATION & RISK MANAGEMENT

● Hazard- It is a condition, object or activity with the potential of causing injuries to personnel, damage
to equipment or structures, loss of material, or reduction of ability to perform a prescribed function.

● Consequence - Potential outcome(s) of the hazard. A wind of 15 knots blowing directly across the
runway is a hazard The potential that a pilot may not be able to control the aircraft during take-off or
landing is one of the consequences of the hazard.
UNDERSTANDING HAZARDS

● There are three (3) types of hazards:

1. Natural
2. Technical
3. Economic

Examples of Natural Hazards:

 Severe weather or climatic events; Hurricanes, drought, tornadoes, thunderstorms, and wind shear.

 Adverse weather conditions; Icing, freezing, precipitation, heavy rain, snow, winds, and restrictions to
visibility

Geophysical events; Earthquakes, volcano eruptions, tsunamis, floods, landslides.

TECHNICAL HAZARDS

○ Deficiencies regarding;

E.g. aircraft and aircraft components, systems, subsystems, and related equipment.

E.g. an organization’s facilities, tools, and related equipment.

E.g. facilities, systems, sub-systems, and related equipment that are external to the organization.

ECONOMIC HAZARDS
● Major trends related to:

 Growth

 Recession

 Cost of materials or equipment

 Etc.

In order to identify the hazards, consider the following:

○ Design factors, including equipment and task design.

○ Procedure and operating practices, including documentation and checklists. ○ Communications,

including means, terminology and language.

○ Organizational factors, such as company policies for recruitment, training, remuneration and
allocation of resources.

○ Work environment factors, such as ambient noise and vibration, temperature, lighting and protective
equipment and clothing.
Sources for Hazard Identification

● Internal

1. Flight Data Analysis

2. Company voluntary reporting system
3. Audits and surveys

Sources for Hazard Identification

● External

1. Accident reports
2. State mandatory occurrence system

● By whom?

1. By anybody
2. By designated personnel

● How?

1. Through formal processes

2. Depends on the organization

ACCIDENT vs. INCIDENT

ACCIDENTS are defined as an unexpected event that may either result in property damage or an injury
or illness to an employee.

For example:

-There was a bad car accident on the highway.

-A drunk driver runs his car into a group of people killing 8 and injuring 16 people.

The first aircraft accident in which 200 or more people died occurred on March 3, 1974, when 346 died
in the crash of Turkish Airlines Flight 981. Investigation ruled that the cargo door failed due to aircraft
design flaw leading to explosive decompression, destruction of control

On March 27, 1977, two Boeing 747 passenger jets, operating KLM Flight 4805 and Pan Am Flight 1736,
collided on the runway at Los Rodeos Airport on the Spanish island of Tenerife. Resulting in 583
fatalities, this accident is the deadliest in aviation history.

The sudden fog greatly limited visibility. The control tower and the crews of both planes were unable to
see one another.

● Interference from simultaneous radio transmissions, with the result that it was difficult to hear the
message.
INCIDENTS on the other hand, are an unexpected event that may result in property damage but does
not result in an injury or illness. Incidents are also called, "near misses," or "near hits.“

For example: -A Pacific Airlines aircraft safely performed an emergency landing in Seoul en route to the
Philippines after its avionics system malfunctioned.

So both Accidents and Incidents are unplanned but can both present a clear damage to a place object or
person. However, only accidents result in illness or injury to a person. Basically, by definition, all
accidents are incidents, but not all incidents are accidents

● Why learn from incidents?

Many organizations have problems in reducing the number of incidents and this can be partly attributed
to the failure to learn the lessons from incidents that had occurred. Incident prevention is strongly based
on learning from previous incidents. When incidents occur they raise awareness and understanding of
things that went wrong, and perhaps can go wrong again

● Reducing Workplace Incidents and Accidents

Ultimately, every incident that occurs provides the potential for a future near miss or accident. To
reduce the number of incidents and accidents that take place, we need to implement a health and
safety program that:

○ Identifies hazards – by reviewing employees, tasks, tools and the environment, it is possible to identify
hazards and risks within a workplace.

○ Implements controls – by implementing controls, it is possible to minimize the occurrence of incidents

and accidents.

○ Investigates incidents – the importance of incident reporting shouldn’t be underestimated. When an

incident is correctly reported and investigated, it ensures the root cause is found and that additional
measures can be put in place to avoid a recurrence.

In over one hundred years of implementation, aviation safety has improved considerably. [Controlled
Impact Demonstration by NASA and the FAA, December 1984]

In modern times, two major manufacturers still produce heavy passenger aircraft for the civilian market:
Boeing in the United States, and the European company Airbus.

Both of these manufacturers place a huge emphasis on the use of aviation safety equipment, now a
billion-dollar industry in its own right; safety is a key selling point for these companies, as they recognize
that a poor safety record in the aviation industry is a threat to corporate survival.

Some major safety devices now required in commercial aircraft are:

● Evacuation slides, to aid rapid passenger exit from an aircraft in an emergency situation.

● Advanced avionics, incorporating computerized auto-recovery and alert systems

● Turbine engines with improved durability and failure containment mechanisms.

● Landing gear that can be lowered even after loss of power and hydraulics.

Measured on a passenger-distance calculation, air travel is the safest form of transportation

available.

“Airline operations are among the safest anywhere. When compared to all other modes of transport, on
a 'fatality per mile basis', air transport is the safest — six times safer than traveling by car; twice as safe
as rail.“

In an effort to prevent incidents such as the haance of Malaysia Airlines Flight MH370, a new standard
has been issued requiring all commercial aircraft to report their position every 15 minutes to air traffic
controllers regardless of the country of origin.

FIRST AVIATION ACCIDENT & INVESTIGATION

An aviation accident is defined by the Convention on International Civil Aviation Annex 13 as an
occurrence associated with the operation of an aircraft, which takes place from the time any person
boards the aircraft with the intention of flight until all such persons have disembarked and in which:

a) a person is fatally or seriously injured,

b) the aircraft sustains significant damage or structural failure, or

c) the aircraft goes missing or becomes completely inaccessible.

Annex 13 defines an aviation incident as an occurrence, other than an accident, associated with the
operation of an aircraft that affects or could affect the safety of operation

FIRST AVIATION ACCIDENT

Jean-François Pilâtre de Rozier 30 March 1754 – 15 June 1785 was a French chemistry and physics
teacher, and one of the first pioneers of aviation. He and François Laurent d'Arlandes made the first
manned free balloon flight on 21 November 1783, in a Montgolfier balloon.

The first fatal aviation accident was the crash of a Rozière balloon near Wimereux, France, on June 15,
1785, killing the balloon's inventor, JeanFrançois Pilâtre de Rozier, and the other occupant, Pierre
Romain. He also risked himself while researching the flammability of hydrogen which proves that
hydrogen is indeed explosively combustible.

The first involving a powered aircraft was the crash of a Wright Model A aircraft at Fort Myer, Virginia, in
the United States on September 17, 1908, injuring its co-inventor and pilot, Orville Wright, and killing
the passenger, Signal Corps Lieutenant Thomas Selfridge.

FIRST AVIATION ACCIDENT INVESTIGATION

Frank P. Lahm

● November 17, 1877 – July 7, 1963 was an American aviation pioneer, the "nation's first military
aviator", and a general officer in the United States Army Air Corps and Army Air Forces.
The deadliest aviation-related disaster of any kind, considering 2, 996 fatalities on both the aircraft and
the ground, was the destruction of the World Trade Center in New York City on September 11, 2001.

Annex 13 of the Chicago Convention provides the international Standards And Recommended Practices
that form the basis for air accident and incident investigations by signatory countries, as well as
reporting and preventive measures. The International Civil Aviation Organization (ICAO) is specifically
focused on preventing accidents, rather than determining liability.

The investigation team consists of a permanent core group and outside scientific experts who are called
on when needed. They respond immediately to the accident and go to the accident site. Each member
will carry flashlights, tape recorders, camera and film, as well as any specialist tools.

The history of the flight and the crewmembers' duties leading up to the accident are noted. Careful
documentation is made of the wreckage and accident scene, with calculation of the impact angles so
that the pre-accident flight path can be determined.

Crew-members are interviewed to look at possible human error factors, such as medical history, fatigue,
training , workload, working environment, and drug and alcohol abuse.

A vital part of the aircraft accident investigation in the case of larger planes is recovery and examination
of the flight recorder, also known as the black box. Airplanes usually have two types of flight recorders:
A: Flight Data Recorder (FDR)

B: Cockpit Voice Recorder (CVR).

Cockpit Voice Recorder (CVR) - a device used to record the audio environment in the flight deck for
accidents and incident investigation purposes. The CVR records and stores the audio signals of the
microphones and earphones of the pilots’ headsets and of an area microphone installed in the cockpit

Flight Data Recorder (FDR) - device used to record specific aircraft performance parameters. The
purpose of an FDR is to collect and record data from a variety of aircraft sensors onto a medium
designed to survive an accident.

An FDR has historically been one of two types of"flight recorder" carried on aircraft, the other being a
cockpit voice recorder. Where both types of recorder are fitted, they are now sometimes combined into
a single unit
 NOTABLE LOCAL & INTERNATIONAL ACCIDENTS
Air Philippines Flight 541 was a scheduled domestic flight operated by Air Philippines from Ninoy Aquino
International Airport in Manila to Francisco Bangoy International Airport in Davao City. On April 19,
2000, the Boeing 737-2H4 crashed in Samal, Davao del Norte while on approach to the airport, killing all
124 passengers and 7 crew members. It remains the deadliest air disaster in the Philippines.

Pilot error was determined to be the cause of the accident. Flight 541 began to climb and re-entered the
clouds due to occupied runway. The correct procedure would have been to climb to 4,000 feet on
instruments and circle around to pick up the guide slope. Instead the crew attempted to fly VFR in
instrument conditions at a lower altitude.

Cebu Pacific Flight 387 was a domestic Cebu Pacific flight from Manila's Ninoy Aquino International
Airport to Lumbia Airport in Cagayan de Oro City on Mindanao. On 2 February 1998, the 31-year-old
McDonnell Douglas DC-9-32 crashed on the slopes of Mount Sumagaya in Gingoog City, Misamis
Oriental. The incident resulted in the deaths of all 104 passengers and crew on board the aircraft

● Investigations found out that the Air Transportation Office maps used by the pilots listed the elevation
of Mt. Sumagaya at 5,000 feet above sea level, while the mountain actually is 6,000 feet above sea level.
This error might have misled the pilots to believe that they were clear of terrain, while in fact they were
flying dangerously low. The ATO, on the other hand, pointed out in its official report deficiencies in the
training of the pilots

The 1957 crash of a Douglas C-47 plane named Mt. Pinatubo on the slopes of Mount Manunggal, Cebu,
Philippines, killed the seventh President of the Philippines, Ramon Magsaysay, and 24 other passengers.
The crash was estimated to have occurred at 1:40 a.m., March 17, 1957.

There were initial speculations that sabotage had caused the plane crash. On April 27, 1957, the chief of
the Philippine Constabulary, General Manuel F. Cabal, testified that the crash had been caused by metal
fatigue, which had broken a drive shaft that caused a power failure on board the plane shortly after
takeoff.

Ukraine International Airlines Flight 752 (PS752) was a scheduled international passenger flight from
Tehran to Kiev operated by Ukraine International Airlines (UIA). On 8 January 2020, the Boeing 737-800
operating the route was shot down shortly after takeoff from Tehran Imam Khomeini International
Airport by the Iranian Islamic Revolutionary Guards Corp.

Malaysia Airlines Flight 370 (also known as MH370 or MAS370) was a scheduled international passenger
flight operated by Malaysia Airlines that disappeared on 8 March 2014 while flying from Kuala Lumpur
International Airport to its planned destination, Beijing Capital International Airport.

The aircraft last communicated with air traffic control (ATC) around 38 minutes after takeoff when the
flight was over the South China Sea. The aircraft was lost from ATC radar screens minutes later but was
tracked by military radar for another hour, deviating westwards from its planned flight path. With all
227 passengers and 12 crew aboard presumed dead, the disappearance of Flight 370 was the deadliest
incident involving a Boeing 777
American Airlines Flight 587 was a regularly scheduled international passenger flight that departed on
November 12, 2001 from John F. Kennedy International Airport to Las Américas International Airport in
Santo Domingo, the capital of the Dominican Republic.

The Airbus A300B4-605R flying the route crashed into the neighborhood of Belle Harbor, on the
Rockaway Peninsula of Queens, New York City shortly after takeoff. All 260 people aboard the plane.
According to the NTSB, the aggressive use of the rudder controls by the first officer stressed the vertical
stabilizer until it snapped off the plane. The plane's two engines also separated from the aircraft before
impact due to the intense forces.

Aircraft Accident Investigation & Inquiry Board

AAIIB- Aircraft Accident Investigation & Inquiry Board

CAAP’S AAIIB is directly under the Office of the Director General of the Civil Aviation Authority of the
Philippines. The Head of the AAIIB is responsible to The Director General for the management of all
aircraft accident/incident investigations conducted by the AAIIB

CAPTAIN JIM C. SYDIONGCO - DIRECTOR GENERAL Civil Aviation Authority of the Philippines

The AAIIB is responsible for the investigation of air accidents and incidents involving civil aircraft
occurring within the Republic of the Philippines; or occurring outside the Republic of the Philippines
involving a Republic of the Philippines registered aircraft or aircraft operated by a Republic of the
Philippines Air Operator Certificate (AOC) holder.

The investigation conducted by AAIIB is independent of the investigations by judicial authorities and of
enforcement and legal entities that apportions blame and liability in the Republic of the Philippines.

AOC - “Air Operator Certificate (AOC)” refers to a certificate authorizing an operator to carry out
specified commercial air transport operations.

ATO - “Approved Training Organization” refers to an organization staffed, equipped and operated in a
suitable environment offering approved flying training, and/or synthetic flight instruction and/or
theoretical knowledge instruction for specific flight training programs.

AMO - “Approved Maintenance Organization” refers to an organization that may perform maintenance,
preventive maintenance, or alterations on an aircraft, airframe, aircraft engine, propeller, appliance,
component, or part thereof only for which it is rated and within the terms, conditions, and
authorizations placed in its operations specifications.

The key functions of the AAIIB are:

● To implement the Standards and Recommended Practices contained in Annex 13 to the

Convention on International Civil Aviation (Chicago Convention).

-Annex 13: Aircraft Accident and Incident Investigation contains the international Standards and
Recommended Practices for aircraft accident and incident Investigation
Subsequent to several studies initiated by the United States, as well as various consultations it
undertook with its Major Allies, the U.S. government extended an invitation to 55 States to attend an
International Civil Aviation Conference in Chicago in 1944.

Known then and today more commonly as the ‘Chicago Convention’, this landmark agreement laid the
foundation for the standards and procedures for peaceful global air navigation. It set out as its prime
objective the development of international civil aviation “…in a safe and orderly manner”, and such that
air transport services would be established “on the basis of equality of opportunity and operated
soundly and economically.”

To conduct independent and objective investigation of accidents and incidents in accordance with the
Republic of the Philippines’ law and international best practices.

To promote aviation safety through the investigation of accidents and incidents and the identification of
safety deficiencies so that accidents may be avoided in the future.

To administer a voluntary and non-punitive confidential aviation incident reporting system.

To educate the industry and the public on ICAO’s philosophy of investigation.

To maintain the confidence of the aviation industry and the public in aviation safety through the
investigation of accident and incidents.

AIRCRAFT ACCIDENT INVESTIGATION TRAINING

Accident investigation is a systematic process whereby all of the possible causes of an adverse event are
evaluated and eliminated until the remaining causes are identified as applicable to that investigation.

Why do we Investigate?

• To effectively discover and identify hazard/s that led to the accident and provide recommendations
which will prevent occurrence or recurrence.

• Identify other hazards that increased the level of injury/damage, but were not accident cause factors

What is the purpose of an Investigation?

• To be able to preserve human and material resources.

• To eliminate hazards, and if completely successful, the subsequent reduction of accidents.

• To be able to simply describe WHAT happened?

• Prevent another accident or incident

INVESTIGATION REQUIREMENTS
Prior to an accident, an organization must determine who will conduct an investigation, establish
guidelines on how it will be done, and provide the tools and authority necessary to conduct the task.
● Accident/Incident Plans

Must be developed and practiced BEFORE an accident occurs. They must be easy to use and provide the
necessary information to notify appropriate personnel, initiate the investigation, and document
essential data such as time of incident and location.

• Investigation Kit:

It For a successful conduct of an investigation, you will need a few simple tools. Accident kits should be
compact and portable. The following items may be useful: Surgical gloves (may be worn under work
gloves) to prevent fuel, biological fluids, chemical contact; work gloves; writing tools; tape recorder;
camera; tape measure; labels; accident/incident forms; knife; small hand tools; magnifying glass, etc.

The Investigator in Charge (IIC)

must have the authority to conduct the investigation, acquire resources, and have access to an
organization’s leadership. The Investigator in Charge should be senior in authority to the person directly
involved in the accident to eliminate influence over the reported outcome of the investigation

Investigation Teams, etc:

Depending upon the level of accident and the size of an organization, safety investigations may be
conducted by a team of personnel from various departments or by one or two individuals. Your
organization must choose, plan, and train according to their requirements and abilities.

Investigation Phases
I. Accident Response and Evidence Gathering

II. Critical Examination

III. Preliminary Analysis

IV. Validation of Finding

ACCIDENT RESPONSE & EVIDENCE GATHERING:

The first few minutes (up to a couple of days at a major accident) are used to get a quick understanding
of the magnitude of the accident and the response required to control conditions. Things to consider
during this “walk through” include the safety of the site, whether the number of rescue and investigative
personnel are sufficient.

After noting the “big picture” and ensuring that additional support is on the way (if needed),
investigators can turn their attention to collecting and preserving evidence. Photographs, accident site
sketches, recording switch/gauge information, note taking, witness identification/interviews, etc. occur
at this time.
II. Critical Examination:

After all the evidence is under your control, individual aircraft and equipment systems can be traced,
evaluated, and possibly subjected to mogtogineering investigations. Data/documentation on equipment
and personnel performance are scrutinized for errors and organizational shortcomings. This methodical
approach requires patience and an eye for discovery. You are examining puzzle pieces without knowing
for sure what the final picture is going to be.

III. Preliminary Analysis:

Investigators should ensure that ALL available evidence is gathered and analyzed FIRST, then you can
formulate and test theories. Use the process of elimination to discount factors this system.

IV. Validation of Findings:

When the investigation team believes they have determined some likely factors, they should verify that
they fit within all of the information known about the accident. Reexamine the entire accident sequence
to ensure that your theory actually “works” and that it doesn’t f other evidence (you can mistakenly
make ANY theory work if you ignore a little evidence here or there)