ICAO may be fostering bad mishap math. ICAO is stating that an increase in mishaps is attributable to an increase in flight operations. If that were so mathematically, than as any airline operated more flights and or flew more hours, their mishap rate would directly increase.
But that is not the case anecdotaly, statistically, case historically or in the experience of this pilot. The author of the ICAO report is looking for the reasons for more mishaps in the wrong place. This is critically important error on the part of ICAO, especially if everyone is trying to achieve the goal of reducing aviation mishaps. ICAO math would have us reducing flight operations in order to reduce the commercial mishap rate.
But is not our goal to solve the mathematical problem of mishaps and rates by finding methods of prevention? To do so, wouldn't you have to know what are the causes of mishaps in the first place?
It is my opinion that aviation mishaps are a direct result of unresolved hazards. The rate of mishap occurrence is therefore reducible by resolving hazards to aviation as quickly as possible. As the factors affecting the rate are reduced through Safety Procedures, the numbers of mishaps will be reduced. That in my opinion is the correct Safety Math.
Accident are therefore a mathematical function of unresolved hazards and are not a mathematical function of hours flown, nor of take-offs or other related operational factors. In my opinion ICAO is using bad math to address the issue of safety hazards and accident rates.
The correct safety math is therefore a function of how quickly we can eliminate hazards. As the rate of hazard occurrence and the actual numbers of hazards are reduced, then the rate of aviation mishaps disasters will be reduced. In fact, it is actually how rapidly we eliminate hazards that also counts, since a hazard over time results in heightened mishaps. Accident Rate is a direct function of unresolved hazards and nothing else.
Even though ICAO is not providing the mathematical or safety leadership needed globally to move commercial aviation safety in the correct and desired direction, it is my hope that many other safety minded managers are, and are doing so by regularly working to quickly resolve hazards to safe flight operations.
Best regards, Paul Miller
Wednesday, December 7, 2011
ICAO Issues Global Safety Report
Aviation accidents around the world ticked higher last year, attributable to the resurgence in air traffic, according to ICAO's inaugural State of Global Aviation Safety Report issued this week.
The number of accidents attributed to scheduled commercial flights increased in 2010 to 121, compared to 113 in 2009, resulting in an accident rate of 4.0 per million departures. The accident rate in 2009 was 3.9 per million departures. While the overall number of fatalities in 2010 was below those in 2005 and 2006, there has been an increase in fatalities over the past three years, ICAO said, increasing from 670 in 2009 to 707 in 2010.
At the same time, the number of scheduled commercial flights increased by 4.5 percent globally since 2009, which represents the first significant annual growth in the sector since 2007 and coincides with an increase of 4.2 percent in the global GDP. North America, which represents a third of global air transport traffic in terms of departures, was the only region to see a small decrease (0.6 percent) in its aggregate traffic figures.
"In the context of this period of renewed growth, and in light of anticipated increases in air travel, it is imperative to maintain a very strong focus on initiatives that will further improve safety outcomes in the future. ICAO is therefore continuously developing and refining more proactive and risk-based methods to further reduce the global accident rate, enabling the safe expansion of air travel in all regions," according to the report.
"ICAO is working in partnership with the international aviation community to achieve continuous reductions in the global accident rate, with an emphasis to improve safety performance in those regions experiencing significantly higher accident rates or having specific safety challenges."
Thursday, December 8, 2011
Sunday, December 4, 2011
To my readers from across the globe
Welcome:
If you are a safety manager for a commercial airline, I want to extend a welcome to you. I want to offer my ideas to you to help you make your own airline safer. I know that being a Safety Manager is a very hard job. You either have the choice of doing very little and waiting until a mishap (accident) happens and then you have 2-3 years of mishap investigating to do.
OR
You can work very hard long hours to prevent mishaps from occurring in the first place.
In either case, you will work very hard. The big difference?
In the case of prevention, you will enjoy the holidays with your family, your company will be profitable and all of the employees will enjoy happy careers.
In the case of mishap investigation, you will work so very hard and in the end, realize that all of this pain, suffering, damage and all this waste could have been and should have been prevented and you will have a stack of photographs, a larger stack of papers, a huge smoking hole and a lifetime of regret.
Please follow my blog so that I can give you some ideas on how to be a successful Safety Manager.
All my best regards, Paul Miller
If you would like to send me an email to ask a question or clarify the English language part of all of this, please do.
http://paulmiller@safetyforecast.com and I will answer you individually.
If you are a safety manager for a commercial airline, I want to extend a welcome to you. I want to offer my ideas to you to help you make your own airline safer. I know that being a Safety Manager is a very hard job. You either have the choice of doing very little and waiting until a mishap (accident) happens and then you have 2-3 years of mishap investigating to do.
OR
You can work very hard long hours to prevent mishaps from occurring in the first place.
In either case, you will work very hard. The big difference?
In the case of prevention, you will enjoy the holidays with your family, your company will be profitable and all of the employees will enjoy happy careers.
In the case of mishap investigation, you will work so very hard and in the end, realize that all of this pain, suffering, damage and all this waste could have been and should have been prevented and you will have a stack of photographs, a larger stack of papers, a huge smoking hole and a lifetime of regret.
Please follow my blog so that I can give you some ideas on how to be a successful Safety Manager.
All my best regards, Paul Miller
If you would like to send me an email to ask a question or clarify the English language part of all of this, please do.
http://paulmiller@safetyforecast.com and I will answer you individually.
Tuesday, November 29, 2011
Safety Tools vs Safety Managers (RevA): Which Works Best?
All safety programs are only tools. So, to do the work of Safety your company needs someone who knows how to use the tools.
The Safety Manager has to be a "skilled works-man in the trade of Safety." Programs from "on-high" in and of themselves do not Safety make.
The mistake many airlines make is to approach Safety with a not-too-smart manager, who is both excels at "bureaucratic compliance" and intimidating flightcrew, but most often someone who does not have original thoughts nor innovative thinking.
To use all of the Safety tools provided by various Safety advocate organizations a company needs a skilled Safety person, someone who knows how to use the tools to create safety. It is not enough just to dress up in the clothes and look the part, you actually have to do the work or no safety is achieved.
The Safety Manager has to be a "skilled works-man in the trade of Safety." Programs from "on-high" in and of themselves do not Safety make.
The mistake many airlines make is to approach Safety with a not-too-smart manager, who is both excels at "bureaucratic compliance" and intimidating flightcrew, but most often someone who does not have original thoughts nor innovative thinking.
To use all of the Safety tools provided by various Safety advocate organizations a company needs a skilled Safety person, someone who knows how to use the tools to create safety. It is not enough just to dress up in the clothes and look the part, you actually have to do the work or no safety is achieved.
Friday, November 25, 2011
Six Rules for Failure?
Here are unspoken managerial safety problems. I call them:
"Miller's Six Rules to Fail-While-Complying"
1. Many companies are run by managers who do not know their own industry well. In commercial aviation many managers are not line pilots. Many managers do not come from the ranks of the company's own line holders.
2. They will act as if they are trying to comply with any program placed on them by their superiors. Their work is to comply with a regulator or industry inspector, and not necessarily make their own company operation safer.
3. But they will not embrace the spirit of these regulatory programs.
4. They will not adapt these programs to be effective for their own local operation
5. They will not innovate new programs that will work for them.
6. They will suppress any person in their organization that attempts, suggests or recommends safety innovation that falls outside of the letter of the regulation or law governing their operations.
So ICAO, FAA and other government regulators can recommend or require all types of safety programs, but were not many of these programs recommended by safety organizations and safety pioneers more than 20 years ago and longer in the case of many safety programs? So, how effective are regulators themselves at being the global advocate for commercial aviation safety?
So in my opinion, if the local organization does not do everything to help themselves, are they not more or less likely to fail?
As I read the papers, watch the news, I regularly observe regulators, major airlines and aircraft manufacturers adhering to some or all of the six rules for failure?
Examples? Crew fatigue.
"Miller's Six Rules to Fail-While-Complying"
1. Many companies are run by managers who do not know their own industry well. In commercial aviation many managers are not line pilots. Many managers do not come from the ranks of the company's own line holders.
2. They will act as if they are trying to comply with any program placed on them by their superiors. Their work is to comply with a regulator or industry inspector, and not necessarily make their own company operation safer.
3. But they will not embrace the spirit of these regulatory programs.
4. They will not adapt these programs to be effective for their own local operation
5. They will not innovate new programs that will work for them.
6. They will suppress any person in their organization that attempts, suggests or recommends safety innovation that falls outside of the letter of the regulation or law governing their operations.
So ICAO, FAA and other government regulators can recommend or require all types of safety programs, but were not many of these programs recommended by safety organizations and safety pioneers more than 20 years ago and longer in the case of many safety programs? So, how effective are regulators themselves at being the global advocate for commercial aviation safety?
So in my opinion, if the local organization does not do everything to help themselves, are they not more or less likely to fail?
As I read the papers, watch the news, I regularly observe regulators, major airlines and aircraft manufacturers adhering to some or all of the six rules for failure?
Examples? Crew fatigue.
Saturday, November 19, 2011
Safety Manager Tool for Accident Prevention
To understand how to prevent a mishap, it is critical to understand the terms Risk and Hazard.
A hazard is a something that causes danger such as an incomplete or outdated procedure, an object such as a equipment, a malfunction or a human factor. The hazard is real, it is perceivable and most of all discoverable BEFORE any mishap, accident or incident occurs.
This is a CRITICAL part of safety theory. A Hazard is a real thing and certain people with a good safety eye can see it ahead of any accident. Some do not, but many do and can report that hazard to the safety manager, who if he or she is smart enough, can take steps to eliminate that hazard.
Why is it important to eliminate hazards?????
Safety theory says that mishaps, accident and incidents are the result of unresolved hazards. That is the sole purpose of safety investigations: identify the hazard and eliminate them.
But if you seek mishap free operations, then you have to go seek out hazards and eliminate them ahead of time. If you do that, you will enjoy mishap free operations.
A risk is defined as a product of two factors. First factor is the likelihood of the event occurring on a sliding scale from zero to 100. Think of this as a per cent of probability which could be measured from a low of very unlikely, at or near zero per cent, then all the way up to very likely, that is at or near 100%.
The second factor is the severity of the event if it occurs. This means if the hazard does occur, what are the consequences? How badly will a plane be destroyed if it crashes, how seriously will a person be injured or will they die, how severely will equipment be damaged or destroyed? You could assign a numerical value to severity as well on a sliding scale of zero to 100 percentage, meaning that none, some or all of the aircraft, person, property or equipment is damaged, injured, destroyed or killed.
When you multiply the two factors of probability per cent and severity per centage together, the product becomes RISK, which is a real number. Risk is a product of two factors, meaning that each is factor is multiplied together to form a number. As when multiplying any two numbers between zero and 100 together, the product increases rapidly and in a hyperbolic fashion.
So I have written a mathematical formula to describe this and it is called, MILLER'S FORMULA FOR RISK. RIsk is labled Z, Probability is labeled X and Severity is labeled Y. When you multiply probability by severity you come up with risk. So the formula looks like this Z=XY. Plotting this function gives you a three dimensional display of the full range of risks. Factor in several more factors such as time and resources devoted to mishap investigations, called factor N and take into account some level of periodocity by looking at the trigonometric sine function and MILLER'S FORMULA FOR RISK becomes Z= sine |X| N(Y).
There is more in my paper published in the Flight Safety Foundation Proceedings of the 2003 Corporate Aviation Safety Seminar, entitled "Forecasting Hazards and Charting a Safe Course: How to Plan Changes in Flight Safety Programs to Meet Future Safety Issues, Decisions and Attitudes, and Keep Your Business Profitable!" copyrighted 2003.
If you have any problem getting a copy or a copy of the accompanying Powerpoint or would like me to come to your organization to speak more on this subject, contact me by Paulmiller@safetyforecast.com.
See other safety discussions on my web site: http://safetyforecast.com
Be safe. Remember that $afetyPay$
A hazard is a something that causes danger such as an incomplete or outdated procedure, an object such as a equipment, a malfunction or a human factor. The hazard is real, it is perceivable and most of all discoverable BEFORE any mishap, accident or incident occurs.
This is a CRITICAL part of safety theory. A Hazard is a real thing and certain people with a good safety eye can see it ahead of any accident. Some do not, but many do and can report that hazard to the safety manager, who if he or she is smart enough, can take steps to eliminate that hazard.
Why is it important to eliminate hazards?????
Safety theory says that mishaps, accident and incidents are the result of unresolved hazards. That is the sole purpose of safety investigations: identify the hazard and eliminate them.
But if you seek mishap free operations, then you have to go seek out hazards and eliminate them ahead of time. If you do that, you will enjoy mishap free operations.
A risk is defined as a product of two factors. First factor is the likelihood of the event occurring on a sliding scale from zero to 100. Think of this as a per cent of probability which could be measured from a low of very unlikely, at or near zero per cent, then all the way up to very likely, that is at or near 100%.
The second factor is the severity of the event if it occurs. This means if the hazard does occur, what are the consequences? How badly will a plane be destroyed if it crashes, how seriously will a person be injured or will they die, how severely will equipment be damaged or destroyed? You could assign a numerical value to severity as well on a sliding scale of zero to 100 percentage, meaning that none, some or all of the aircraft, person, property or equipment is damaged, injured, destroyed or killed.
When you multiply the two factors of probability per cent and severity per centage together, the product becomes RISK, which is a real number. Risk is a product of two factors, meaning that each is factor is multiplied together to form a number. As when multiplying any two numbers between zero and 100 together, the product increases rapidly and in a hyperbolic fashion.
So I have written a mathematical formula to describe this and it is called, MILLER'S FORMULA FOR RISK. RIsk is labled Z, Probability is labeled X and Severity is labeled Y. When you multiply probability by severity you come up with risk. So the formula looks like this Z=XY. Plotting this function gives you a three dimensional display of the full range of risks. Factor in several more factors such as time and resources devoted to mishap investigations, called factor N and take into account some level of periodocity by looking at the trigonometric sine function and MILLER'S FORMULA FOR RISK becomes Z= sine |X| N(Y).
There is more in my paper published in the Flight Safety Foundation Proceedings of the 2003 Corporate Aviation Safety Seminar, entitled "Forecasting Hazards and Charting a Safe Course: How to Plan Changes in Flight Safety Programs to Meet Future Safety Issues, Decisions and Attitudes, and Keep Your Business Profitable!" copyrighted 2003.
If you have any problem getting a copy or a copy of the accompanying Powerpoint or would like me to come to your organization to speak more on this subject, contact me by Paulmiller@safetyforecast.com.
See other safety discussions on my web site: http://safetyforecast.com
Be safe. Remember that $afetyPay$
Sunday, October 16, 2011
Friday, October 14, 2011
Air France 447: Critique of Otelli's French book
Heard about the book today. Jean-Pierre Otelli who specializes in aviation safety, publishes his book "Piloting Error, Volume 5" today.
But in my opinion, he only re-analyses the facts collected in BEA's report. I believe that the BEA's report is seriously flawed and the book adds little to mishap prevention.
Read my many articles in my other safety blogs to learn more.
http://safetyforecasts.com/
http://bettersafeaviation.blogspot.com/
Would you like proof that BEA's investigation is flawed?
Simple: there is little if any recommended corrective action contained in the report, that, if followed, would have prevented this mishap. Rather, the book and report appears to center on finding fault, assigning blame and extracting tribute for damages. So, the investigation is really a legal investigation and not a Safety Investigation. I have explained in the blog that the only value to a Safety investigation is to find ways to prevent a recurrence.
It appears to me training is weak at AF as well. So, that is a managerial responsibility and regulatory duty. Remember that this crew was certified by the airline's training dept and national aeronautical regulators before they were assigned to operate this flight. If their performance as a crew and as individuals was substandard, as alleged in the BEA's report, then that would be a direct indictment of the training and certification authority credibility, would it not?
From my background training experience, when we first learned basic and radio instrument procedures in basic jet training, an important segment of that training were procedures to employ when some of the instruments failed. Some of this training focuses on the failure of attitude and/or directional gyro equipment and is called partial panel procedures. Some other procedures focused on loss of pitot-static instruments, some or all and teach you to remain in stable flight using attitude instruments and standard engine power settings. Other procedures cover magnetic and/or directional gyro or heading instrument failures, still others cover what to do if part of your navigation instrumentation fails.
We practiced all of these procedures this right from the beginning. Along the way with every new aircraft, with every new organization, these procedures remained a significant part of regular training. At my last sim/training session a year before retirement, we practiced these procedures and focused especially on the loss of pitot-static instruments. We trained heavily on this.
So, were these AF447 crew members trained by AF in this area? There certainly appears to be a question here. However, does the report by BEA or the book by Otelli investigate this?
But in my opinion, he only re-analyses the facts collected in BEA's report. I believe that the BEA's report is seriously flawed and the book adds little to mishap prevention.
Read my many articles in my other safety blogs to learn more.
http://safetyforecasts.com/
http://bettersafeaviation.blogspot.com/
Would you like proof that BEA's investigation is flawed?
Simple: there is little if any recommended corrective action contained in the report, that, if followed, would have prevented this mishap. Rather, the book and report appears to center on finding fault, assigning blame and extracting tribute for damages. So, the investigation is really a legal investigation and not a Safety Investigation. I have explained in the blog that the only value to a Safety investigation is to find ways to prevent a recurrence.
It appears to me training is weak at AF as well. So, that is a managerial responsibility and regulatory duty. Remember that this crew was certified by the airline's training dept and national aeronautical regulators before they were assigned to operate this flight. If their performance as a crew and as individuals was substandard, as alleged in the BEA's report, then that would be a direct indictment of the training and certification authority credibility, would it not?
From my background training experience, when we first learned basic and radio instrument procedures in basic jet training, an important segment of that training were procedures to employ when some of the instruments failed. Some of this training focuses on the failure of attitude and/or directional gyro equipment and is called partial panel procedures. Some other procedures focused on loss of pitot-static instruments, some or all and teach you to remain in stable flight using attitude instruments and standard engine power settings. Other procedures cover magnetic and/or directional gyro or heading instrument failures, still others cover what to do if part of your navigation instrumentation fails.
We practiced all of these procedures this right from the beginning. Along the way with every new aircraft, with every new organization, these procedures remained a significant part of regular training. At my last sim/training session a year before retirement, we practiced these procedures and focused especially on the loss of pitot-static instruments. We trained heavily on this.
So, were these AF447 crew members trained by AF in this area? There certainly appears to be a question here. However, does the report by BEA or the book by Otelli investigate this?
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