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At the ICAO Accident Prevention and Investigation Divisional Meeting there was an awareness among the aviation authorities of many States of the need for improved accident prevention efforts. Accordingly, it reflects their work and incorporates ideas and information distilled from many sources.

It is expected that the manual will be useful to States and the aviation community for developing and maintaining accident prevention programmes. The material in this manual is not exhaustive. Users are encouraged to expand and adapt its concepts to suit their own requirements or needs. Suggestions or material for improvement are invited and should be forwarded to:. Conducting a safety survey. An example of one States guidelines for the establishment of an accident prevention programme by an operator.

Example of an aircraft manufacturers system safety programme for a new aircraft type. Examples of safety statistics. Communication skills. This is particularly true for scheduled air transport which has achieved safety levels equal to public surface transport. This approach to safety, often referred to as regulatory safety, is an essential element of aviation.

At the same time, the Meeting decided that accident prevention should be regarded in a specialized sense: it should envisage activities which complement existing safety-related procedures or organizational arrangements in States or ICAO in such fields as airworthiness, operations, personnel licensing, training, communications, etc. It was thus seen to differ from traditional regulatory safety in that it involved an active search for hazards that need to be eliminated or avoided.

That decision has guided the writing of this manual, and the philosophy it presents. Naturally there are many ways in which one can view aviation safety and accident prevention and the viewpoint expressed in this manual is but one.

Since other interpretations are possible, the intended meaning is as follows:. Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation from Annex Serious incidents are often investigated to the same extent as accidents. These definitions have been kept simple so that they can be easily used in both written and spoken communications. World War I, however, provided a stimulus for the creation of large-scale aircraft industries.

Aviation became a national resource and military criteria for performance and reliability were introduced. Large sums of money were spent acquiring aircraft and the traditions of standardization, approval and modification in the light of operational experience became part of the aviation industry. This approach to aircraft design, construction and operation largely remains today. Regulatory bodies have found it necessary to intensify the control processes governing such disciplines as design, manufacture and operation.

Throughout, ICAO has had a major role in the co-ordination and international standardization of these developments. The rapid growth of air transport indicates that it generally fulfils the publics expectations in these areas. This graph illustrates the number of passenger fatalities per million passenger kilometres in scheduled airline operations since From the passengers point of view, scheduled airline operations are much safer today than they were in However, during the period the fatality rate has levelled off, suggesting that the limits of the traditional, regulatory safety methods may have been reached.

It therefore follows that different methods and programmes, such as those presented in this manual, may be needed to further reduce the accident rate. In recent years the fatality rate for non-scheduled services has been significantly higher than that for scheduled airlines. This rate, however, includes all types and categories of non-scheduled services thus introducing the factor of significantly different operating environments.

For example, when non-scheduled operations using the same aircraft type and operating on the same routes as scheduled airlines are compared, the rates become much closer. The fatality rate for general aviation is considerably higher than either the scheduled or non- scheduled airline rate. This suggests that in many instances, the safety measures already in place may have been inadequate, circumvented or ignored.

Further advances in aviation technology will introduce new or different hazards. Accident prevention activities must therefore keep abreast of these developments if success is to be achieved in reducing the accident rate even further.

However, it is difficult to accurately assess the actual cost of aircraft accidents. Financially, they can be extremely expensive because of compensation claims, aircraft replacement costs and the effects of adverse publicity. The social costs involved are less tangible: the grief resulting from the loss of relatives or friends and the costs to society resulting from the loss of skilled and valued members are not quantifiable.

This model is a guide for its accident prevention efforts. The model examines a number of factors to determine the financial but not the social costs of an aircraft accident. These include:. However, accident prevention often leads to increased efficiency because it aims to eliminate errors and deficiencies at all levels.

As an example, one major aircraft operator found that the landing gear on some of its aircraft occasionally could not be retracted after take-off. This necessitated the dumping of fuel and return to the departure aerodrome. Investigation showed that the landing gear microswitches were malfunctioning because of moisture.

Improved microswitches reduced operating costs significantly because flights were no longer aborted for this reason. Each has a vital part to play and the absence of any one group will inevitably make the task more difficult and less successful. However, in recent years the accident record has not shown significant improvement. This has led to the belief that additional non-regulatory accident prevention measures are needed.

Such information may be vital to a full understanding of the circumstances of an occurrence and hence to the prevention effort;. Although this may seem obvious, it needs to be clearly stated because this objective is sometimes overlooked in real life when other considerations are allowed to intrude.

There are often temptations to add legal or other considerations, such as blame or liability, to this simple objective. When this occurs, the effectiveness of accident prevention efforts is compromised. In essence, these documents reflect the safety practices of States, developed in the light of experience. It usually undertakes this by formulating regulations and procedures based on ICAO SARPs, tailored where necessary to meet local environmental or operational conditions.

Inspection and enforcement processes are then established to ensure that the aviation community complies with the national regulations. This is published by ICAO, and indicates to other States, and users, that their legislation differs from internationally agreed standards.

Most States comply with this important practice. These procedures are usually well understood. On the other hand , there is much less documentation regarding accident prevention activities outside the regulatory safety field.

This manual attempts to overcome that deficiency. For example, a State controls the licences issued to its pilots, engineers and air traffic controllers. Enforcement action may necessitate the revocation of a licence if the holder fails to comply with regulations or fails to maintain the required standards. This is an essential feature of regulatory control. Each new aircraft incorporates improvements based on the latest state of the art and operational experience.

Manufacturers produce aircraft which comply with the airworthiness regulations of domestic and foreign governments, and meet the economic and performance requirements of purchasers. In some States these may be the only guidance material available for the operation of a specific aircraft type or piece of equipment. Thus the standard of documentation provided by the manufacturer is very important.

Additionally, through their responsibilities for providing product support, training, etc. These persons are available for the investigation of accidents or incidents to aircraft of their manufacture. On the one hand, this is a spur to optimize safety, while on the other, it can act as a deterrent to the voluntary correction of faults when this could be regarded as an admission of design or manufacturing deficiencies. Where such activities do exist, they are usually carried out by a section which monitors over-all operating experience and provides independent advice to management on the preventive action needed to eliminate or avoid discovered hazards.

Such activities may also lead to economies in the airlines operation. Accident prevention programmes may tend to be oriented towards the flight operations side of the organization. Safety, however, must embrace the total organization and it is essential that a close working relationship be maintained between all parts of the organization. As a consequence, substantial benefits are to be gained from accident prevention programmes aimed at this group. In addition, general aviation operators often share facilities such as aerodromes, air traffic services, etc.

This mixing of operations with differing requirements and performance standards may introduce hazards. It includes the growing areas of corporate or business flying, often operating sophisticated aeroplanes; helicopters flown by professional pilots, through to non-professional pilots who only fly occasionally for pleasure.

Motivating an interest and awareness of safe aviation practices must be one of the first steps of an accident prevention programme aimed at this varied group. Accidents are typically a combination of several different causes. When each such cause is viewed alone, it may often appear insignificant, but in combination with other causes it can complete a sequence of seemingly unrelated events that result in an accident.

Accident prevention therefore involves identifying and eliminating these causes before the chain of events is complete. This concept is illustrated in Figure 2. In this manual, these causes or factors may also be called hazards. For simplicity, hazards have been categorized here into three groups: Man, Machine and Environment. In its widest sense, the concept should include all human involvement in aviation, such as design, construction, maintenance, operation, and management.

This is the meaning intended in this manual, since accident prevention must aim at all hazards, regardless of their origin. For example, during a pilots training he learns something of the mechanical aspects of the machine he flies, the hazards of the weather, the operating environment in which he flies, and so on. However, usually very little information is provided concerning his own behaviour, limitations, vulnerabilities and motivations.

See Figure 3. Because of this significant shift in the relationship between man and machine causes, a concensus has now emerged that accident prevention activities should be mainly directed towards the man. It is not surprising, therefore, that information on the human factor aspects of accidents or incidents is not readily forthcoming.

This is unfortunate, since it is often these areas that hold the key to the why of a mans actions or inactions. Successful accident prevention therefore necessitates probing beyond the human failure to determine the underlying factors which led to this behaviour.


Doc 9422 Accident Prevention Manual

If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user. It should be noted that SSP provisions will be incorporated into Annex 19 — Safety Management which was still under development at the time this third edition was published. This manual also provides guidance material for the establishment of safety management system SMS requirements by States as well as for SMS development and implementation by affected product and service providers. The concept underlying the manual is that of a continuous loop.


Accident prevention manual : (Doc 9422-AN/923)






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