Plenary meeting of the Aviation Study Group at Linacre College, Oxford University, 16 February 2001 
  

 
I am truly delighted to be here with you today for this plenary session of the Aviation Study Group. Since the last meeting, substantial progress has been made by the Group towards the establishment of the Chair of Aviation Safety and the Institute of Aviation Safety Management at Linacre College, Oxford University. I congratulate all of you for your hard work and I am sure you join me in paying a special tribute to Dr. James Vant, Chairman of the Aviation Study Group, and to Mr. Derek Dempster for their exemplary determination to turn an exciting vision into a timely and much-needed reality.
 
I have followed with great personal interest the creation of the Chair of Aviation Safety and I support its primary aim, that of "creating a new impetus to improve the safety of flight and to establish an international culture of system safety in all aspects of aviation". All of us in this room share a noble cause, that of saving and preserving lives. As I have said many times, aviation safety is a global challenge that requires a global commitment to finding global solutions. Through the Chair of Aviation Safety, you will become full-fledged participants in this global effort. I can assure you that ICAO looks forward to collaborating with you in all projects and activities.
 
In anticipation of soon celebrating the official inauguration of the Chair of Aviation Safety, I thought it appropriate to review with you certain highlights in the evolution of aviation safety over the years and to describe the major actions currently being taken by ICAO to further enhance air safety. I will conclude this brief tour d'horizon with an expanded definition of aviation safety for the 21st century, one that I feel reflects the new priorities of modern-day travellers.
 
In 1947, on airline scheduled services there were 21 million passengers, of which 590 were killed in 34 fatal accidents. This produced an accident rate of 3.12 passenger fatalities per 100 million passenger-kilometres. In 1999, there were some 1.6 billion passengers and, of those, 489 lost their lives in 20 accidents, for an accident rate of .02. In short, there were fewer accidents and fatalities in 1999 than there were in 1947, in spite of a dramatic increase in traffic. This is a truly remarkable achievement, made possible through constant and methodical improvements in safety that, year after year, albeit with fluctuations, resulted in lowering accident and fatality statistics. Air transport remains an extremely safe mode of mass transportation and it can, I believe, be made even safer.
 
This, however, will not be easy. Over the past half century, we have been very successful in finding and implementing specific solutions for most categories of accidents. We have seen the number of fatal accidents and those involving hull losses steadily go down. What we are now left with, therefore, are random causes of accidents. There is no clearly discernable pattern to accidents today and this makes it much more difficult to manage. And yet, with an average annual increase in traffic of 5 per cent predicted for the present decade, we must keep on reducing the accident rate if we want to continue reducing the absolute number of accidents and fatalities. I would suggest a two-fold approach. First, we must remain vigilant in implementing the effective solutions we have identified already for known causes of accidents. Second, we need to adopt new ideas to operate a paradigm shift about safety. That is why the establishment of a Chair of Aviation Safety at Oxford is so vital. The formidable wealth of knowledge, expertise and imagination of this eminent institution can play a pivotal role in shaping this new way of thinking so that we may one day succeed in our drive to perfect safety. For perfect safety, as lofty as it may seem, is the goal we should set for ourselves. For me, as for you I am sure, even one loss of life is one too many.
 
As we strive in that direction, I believe it is useful to reflect on the road travelled, to benefit from lessons learned and to build on a good understanding of what has worked and what has not. Let me take you back a few years. You may recall that ICAO was established by the Convention on International Civil Aviation signed in Chicago on 7 December 1944 to ensure the safe and orderly development of international civil aviation. In keeping with that mandate, we have, over the years, formulated and updated hundreds of Standards and Recommended Practices (SARPs) covering all aspects of air transport. This global, uniform set of regulations provides the basic framework underpinning safety excellence in civil aviation. Such standardization has without a doubt been key in achieving the objectives reflected in Article 44 of the Convention, the most important of which is to ensure the safe and orderly growth of international civil aviation so as to meet the needs of the peoples of the world for safe, regular, efficient and economical air transport.
 
Another reason for our enviable safety record is the incessant pursuit of new ways of increasing safety. In the early days of aviation, we quite naturally addressed our safety concerns from the technical perspective. As a fledgling industry, we directed our attention and resources first to meeting the many challenges of emerging yet imperfect technologies. We basically sought engineering solutions to engineering problems. For more than half a century, we pursued this technical approach and were extremely successful in steadily improving the safety and reliability of civil aviation.
 
Around the mid-seventies, it was becoming obvious that human error was capable of circumventing even the best designed technical safety defences. We consequently shifted our thinking to the human perspective. Two points are worth noting from this era. First, our human factors endeavours at that time were focused on the individual; they were aimed at improving individual performance, mainly through training and regulations. Second, a substantial part of our human factors efforts attempted to eliminate error through design, to replace human functions with machine functions, thus seeking to minimize human intervention and, therefore, opportunities for error. Addressing human error and its negative effect on safety from an individual perspective was an important step. It had to be taken, and yet it was not enough.
 
This realization came in the nineties, when we understood that human performance does not take place in a vacuum but rather within social contexts. Individual human behaviour is modelled after behaviour that organizations foster and expect from their members. We therefore began to address safety concerns from the organizational perspective. In this way, we acquired a systemic view of aviation safety, including the interactions not only among people, but also between people and technology, and between people and the organizations to which they belong. Most importantly, and for the first time, we began to scrutinize the role of, and the relationship between, management and safety.
 
I suggest to you today that it is through the organizational perspective that we will break the current safety impasse in which we find ourselves. I strongly believe that the contribution of the aviation system's management towards enhancing safety is paramount. Regulators and airline management alike define the environment within which individuals conduct their tasks. They define the policies and procedures that individuals must follow and respect. They allocate the critical resources which individuals need in order to achieve the system's safety and production goals. Lastly, when the system fails, they must thoroughly investigate these failures and take all needed remedial action to avoid repetition. Simply put, managers play a fundamental role in defining and sustaining the safety culture of their organizations.
 
One crucial aspect of an organization's safety culture is the ability to deal with human error. From an organizational perspective, human error should become a warning flag for regulators and managers, a possible symptom that individual workers have been unable to achieve the system goals because of difficult working environments, flaws in policies and procedures, inadequate allocation of resources, or other deficiencies in the architecture of the system. We must face the fact that because of human error, unwanted, un-willful deviations from the norms will take place. However, deviations in and of themselves are not the problem. The danger lies not in experiencing operational deviations, but rather in not having an adequate process of managing these deviations.
 
Effective deviation management results from the free exchange of information about operational errors which lead to deviations. We must create, therefore, an operational environment where anyone can feel secure in coming forward and sharing information concerning deviations. In other words, humans must be part of the solution and not part of the problem. This is a non-punitive environment, which nevertheless retains individual and organizational accountability.
 
That may well be the final frontier of aviation safety, the last hurdle on our way to perfect safety. A combination of all we have learned in the past, plus a context where problems in the system will be brought in the open, so they can be quickly and confidently addressed by all parties. Where accountability, both individual and organizational, and not punishment and blame, is the driving force. System managers can take the reform action necessary to address the root causes of these deficiencies by considering human factors from the organizational perspective.
 
The increased focus on human factors complements extraordinarily well the normative approach put into place with the Chicago Convention. It also recognizes that aviation safety cannot be entirely pre-specified through standards and regulations, primarily because of the fact that humans will always be an integral part of the process, and as long as humans are part of the process, the possibility of error exists. It is clear to me that what we need is a balance between the human dimension of safety and the regulatory framework that has served aviation safety so well for more than half a century.
 
ICAO is well sensitized to such a balanced approach and will devote the necessary resources to both sides of the equation, as evidenced by one of our major systemic safety initiatives we call the Global Aviation Safety Plan (GASP). This Plan was developed by the ICAO Air Navigation Commission in 1997 to coordinate and to provide a common direction to the efforts of ICAO's Contracting States and the aviation industry. GASP is a tool that allows ICAO to focus its resources and to prioritize its activities on those that provide the best safety dividends. Worthy of note is that three of the six major activities comprising GASP are management-oriented.
 
The most important one is the ICAO Universal Safety Oversight Audit Programme. Launched on 1 January 1999, the Programme consists of regular, mandatory, systematic and harmonized safety audits carried out by ICAO in all of its Contracting States. The objective of these safety audits is to determine the potential of civil aviation authorities to discharge their oversight obligations in accordance with international standards. In this way, States can better identify and correct deficiencies in the implementation of ICAO Standards and Recommended Practices (SARPs) and relevant associated procedures, guidance material and safety-related practices. It also provides for action plans to address identified deficiencies and direct assistance, when required, to carry out corrective measures. This is a safety initiative based entirely on an organizational perspective and, like all organizational strategies, is a long-term investment. The current scope of the Programme is limited to legislation, civil aviation organization, procedures and practices as they relate to personnel licensing, and the operation and airworthiness of aircraft. Subject to a decision by the 33rd Session of the ICAO Assembly next September, the Programme may be expanded to cover air traffic services, aerodromes and possibly aircraft accident and incident investigation.
 
Another component of the GASP is the ICAO Flight Safety and Human Factors Programme. This one seeks to further the understanding of the root causes of both human and organizational error and, therefore, of the relationship between management and safety. Our objective is to turn this understanding into prevention strategies. The Flight Safety and Human Factors Programme has a close relationship with, and a fundamental supporting role in, the Universal Safety Oversight Audit Programme, through one of its main components dealing with cross-cultural issues in aviation safety.
 
The third programme I would like to mention is the ICAO Controlled Flight Into Terrain, or CFIT, Prevention Programme. The CFIT Programme moves away from the simplistic notion that CFIT accidents are simply caused by sub-standard human performance. CFIT accidents are truly systemic accidents. I have no doubt that flaws in managerial safety oversight and the improper allocation of resources, including lack of adequate training and available technology, are among the root causes. This is the reason why a substantial part of the ICAO CFIT message is directed at decision-makers in the aviation system.
 
In addition to these programmes I have just outlined, I am happy to report that the ICAO Council has approved in principle a proposal by the Air Navigation Commission concerning the formation of proactive regional flight safety groups. The role of these groups would be to review the implementation of various global safety initiatives, to systematically review regional accident and incident data and identify repetitive causes, to develop and recommend regional aviation safety plans to supplement the Global Aviation Safety Plan, and to exchange aviation safety data with corresponding groups in other regions. Each group would consist of flight safety experts from States, international organizations and industry, supported by the ICAO Regional Offices with assistance from our Air Navigation Bureau.
 
I am sure that the Chair of Aviation Safety and the Institute of Safety Management will find the work of these groups quite useful. In fact, your underlying aims and objectives are very closely aligned with the work of ICAO and all of its partners. You indicate a profound desire to seek fresh insights for application in practical ways which will enhance air safety, by focussing research on structural and systemic problems, conditioned by underlying technological and human factor constraints and regulatory environments. And you wish to accomplish this in close cooperation with other members of the world aviation community, in a spirit of finding global solutions to global challenges. I am confident that you will help aviation reach new heights and new horizons in the area of safety and I am proud to be associated with this inspired notion of linking the oldest and most prestigious university in the English-speaking world with the most modern form of mass transportation.
 
With more than one billion six hundred million human beings travelling by air every year, and the entry into service in 2006 of the super jumbo jet A-380, with more than 650 passengers, I wonder whether issues such as cabin air quality should not now be on our list of preoccupations. ICAO has developed standards, procedures and manuals dealing with a host of safety issues. And yet, we have never produced operational provisions for such vital health issues as air quality, nor have we produced public health limits for contaminants and pollutants in cabin air. The time may have come to focus on these inherently human issues.
 
I feel the same way about survivability in case of accident. The widely held perception is that an airliner crash is always a catastrophically fatal one, even if there are survivors. Crucial problems still exist in safety procedures and equipment. Safety briefings are commonly ignored by passengers. Aircraft actually in service and in particular the super jet aircraft with a larger capacity pose serious problems in case of an emergency evacuation. Procedures need to be updated and streamlined. ICAO and the rest of the aviation community should study cabin safety so as to increase the number of survivors in case of an accident. Let us widen the scope of our thinking, as we have done so successfully in the past, and keep abreast of the needs and wants of those who are the prime object of our dedication, people, human beings like you and me.
 
I hope that my presentation has raised sufficiently challenging questions that we may continue to seek forever better answers to creating a safer and better aviation system for the benefit of all of mankind.