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Voices of Reason
5th Apr 2004, 16:37
Reprint from today’s Washington Post. Though airline focused, it might well be applied to your airspace debate. We note the use of a “per ticket cost” as was used in the Broome Study.


Airline Safety Costs a) Billions or b) Pennies. Answer Below

By David Evans

Sunday, April 4, 2004; Page B05

You hear it all the time at airline industry meetings: "If you think safety is expensive, try an accident."

Still, how one views the relative cost of airline safety -- and whether it becomes a reason to delay making improvements -- depends an awful lot on how that cost is calculated. Too often, the cost is determined through negotiations between the industry and the agency responsible for ordering improvements, the Federal Aviation Administration (FAA).

The FAA's standard method is to assess the total cost to the industry of a particular safety initiative. The resulting figures typically run into the millions or even billions of dollars -- a sure way to delay action.

I have observed air safety deliberations for nearly 10 years, and I think it's time to change the current cost-benefit approach. Discussing the cost of safety improvements in terms of the price per ticket, rather than the overall cost, would make it easier for the FAA to make the necessary fixes.

Often, the per-ticket price works out to a few dollars -- or less.

Taking this approach would help change the industry reaction from "we can't" to "why can't we?"

Besides, all costs ultimately are passed on to passengers, who have no way of knowing that a small increase in the price per ticket would dramatically improve their chances of remaining safe in flight. I'm guessing that if they did know, most would happily pay.

Instead, there's a kind of paralysis in the industry. Safety deficiencies recognized by the FAA persist for years, unnecessarily increasing the risk to air crews and the flying public.

This is precisely the case regarding three major threats to safe flight: smoke, fire and explosion. The National Transportation Safety Board (NTSB), which investigates all major accidents in the United States, has recommended that action be taken in all three areas.

For example, eliminating explosive vapors in fuel tanks has been on the NTSB's "Most Wanted" list of aviation safety improvements since May 1997.

That recommendation emerged from the investigation into the fatal July 1996 center fuel tank explosion of TWA Flight 800 over Long Island Sound, which killed all 230 aboard. A joint government-industry task force convened by the FAA said in 1998 that if nothing were done, fuel tank explosions would continue to occur at an average rate of one every 41/2 years. Almost on schedule, a tank exploded on a Thai Airways jet in Bangkok in 2001.

Fortunately, the airplane was on the ground, and only one crew member was killed. Unfortunately, the FAA panel had said, in effect, that eliminating explosive vapors in the fuel tanks would be too expensive.

Another example: Last month, U.S. carriers reported six flights with smoke in the cabin or cockpit. In each case, pilots were forced to make emergency landings. After the 1996 crash of ValuJet Flight 592 into the Everglades, the NTSB had urged the FAA to evaluate emergency vision equipment that would enable pilots to see their instruments and out the windscreen even in a smoke-filled cockpit. The FAA still has not responded to the recommendation with regulatory action.

Now consider the cargo holds in smaller jets, such as the popular Boeing 737 and DC-9. For years, these holds were not required to have an active means of detecting smoke or fire or of spraying a fire-suppressing chemical.

Cheaper fire liners were installed instead. The airlines and the manufacturers argued that, at a cost of more than $300 million to equip all the jets in service, fire protection equipment was too expensive. Then the ValuJet DC-9 crashed because of a raging fire in its forward belly hold, killing all 110 people aboard.

Using the FAA's standard $2.8 million statistical value of a life, this one accident cost more than $300 million, not including the cost of the plane. As a result of the crash, the FAA ordered fleetwide installation of fire protection equipment. The industry mobilized. The job was done in three years -- at a cost that was less than expected.

The ValuJet crash shows the folly of waiting for an accident to justify action. U.S. airlines racked up 52 accidents in 2003, an average of one per week, according to statistics published on March 22 by the NTSB. Twenty-two people were killed in two of those accidents.

To be sure, more people were killed on U.S. carriers in 1996 (342). But with an airline industry still hobbling after 9/11, the 2003 accident rate is the highest posted by the NTSB since 1984: about one accident for every 200,000 departures, or one for every 320,000 flying hours, on average.

With that in mind, let's consider the cost per ticket of addressing some of the major threats posed by smoke, fire and explosion.

• Blinding smoke: In-flight fires have led to the catastrophic crashes of planes whose pilots couldn't maneuver simply because they could not see through the smoke. In a March 15 letter to the FAA, Nick Lacey, former FAA director of flight standards, warned about the danger of fire during a transoceanic flight, which might be hours from the nearest airport.

"Current flight deck smoke masks do not provide the ability for the pilots to see their checklists or fundamental flight instruments in the presence of dense and continuous smoke."

I've seen too many post-crash accident reports that read, "Cockpit voice recorder indicates crew unable to see instruments due to smoke." The doomed ValuJet pilots reported smoke in the cockpit.

The 1970 crash of a Swissair jet is particularly poignant. "We have fire on board," the pilots radioed, asking ground control for landing help. "I can't see anything." Twenty seconds later: "Goodbye, everybody." Investigators concluded that the otherwise flyable aircraft overshot the Zurich airport while attempting to land.

In 1993 the crew of another Swissair jet with smoke in the cockpit resorted to flapping an emergency checklist booklet back and forth to see their instruments. Unable to see anything outside the airplane during landing, the captain came to a screeching halt on a Munich runway, averting disaster.

German investigators later recommended the use of an "inflatable view channel between the crew, their instruments and the cockpit windows."

Indeed, this inflatable channel has been deployed as emergency equipment on hundreds of corporate and military aircraft worldwide. And, most telling of all, the FAA has committed to installing such equipment on its own dozens of aircraft, but it has not ordered that airlines do the same. The equipment would cost 2 or 3 cents per ticket, according to passenger advocacy groups using data supplied by the manufacturer.

• Fire: One of the biggest challenges to in-flight safety is fire in concealed spaces. Case in point: an American Airlines DC-9 that was struck by lightning on Nov. 29, 2000, while climbing out of Washington's Reagan National Airport.

The energy from the lightning bolt entered the tail cone, traveled up wires located above the overhead bins, arced in the forward area of the cabin and started a small fire between the cabin sidewall panel and the outer aluminum skin of the airplane. A flight attendant borrowed a penknife from a passenger and cut a hole through the plastic wall, into which the flight attendant was able to insert the nozzle of a portable extinguisher and douse the fire while the pilots made an emergency landing at Dulles.

As a result of this and similar incidents, the NTSB has called for improved in-flight firefighting capability in the cabin, the cockpit and inaccessible spaces.

The Fast-Port apertures offered by a small company in New York were designed specifically for aviation applications. Cost per ticket: less than 1 cent to have six of them placed strategically about the cabin. Keep in mind that in this post-9/11 era, the crash axe stored in the cockpit must remain in the cockpit, and passengers no longer have penknives on board.

• Exploding fuel tanks: After the TWA disaster, the NTSB challenged the industry's fuel system design practices. The chief designers of the fuel tanks said repeatedly in meetings that they designed the electrical fuel systems to minimize the number of heat sources that could ignite the vapors. NTSB investigators rejected this reasoning, saying that the hunt for ignition sources clearly had failed and that, instead, the explosive vapors would have to be eliminated.

The FAA convened a government-industry task force to assess technologies that might solve the problem. Its 1998 report concluded that eliminating explosive vapors could cost $5 billion to $35 billion over 10 years -- a lot more than the $2 billion cost of future accidents if the change were not made.

Wrong answer. To its credit, the FAA convened a second task force, which in 2001 reported that eliminating the vapors would cost $10 billion to $20 billion over 16 years. The internal documents of this second look showed that the panel had considered the cost on a per-passenger basis. Its conclusion? About 25 cents per ticket. Late last month, the FAA announced that it would require a partial fix to the center fuel tank. It has yet to act on the wing tanks.

In 1996, Victoria Cummock, a member of the White House Commission on Aviation Safety and Security, proposed a $4 per ticket surcharge to provide a source of funding for all safety and security initiatives then under consideration. Cummock had lost her husband in the 1988 bombing of Pan Am Flight 103 over Lockerbie, Scotland. Her proposed surcharge, which might have plugged some of the gaps in aviation security that were exploited on Sept. 11, 2001, was not endorsed.

A month after the 9/11 attacks she told me, "It breaks my heart to say it, but for a per passenger surcharge about the price of a McDonald's 'Happy Meal' this tragedy might have been prevented."

As the saying goes, one can pay a little now or a whole lot later. At a few dollars per ticket, safety is anything but expensive. And worth every penny.

Author's e-mail:
[email protected]

David Evans is editor of Air Safety Week, a newsletter for the aviation industry.

Spad
6th Apr 2004, 06:22
VoR me ole mate, it may come as some surprise to you to learn that just about everyone who opens a new thread here thinks that their thread is incrediblly important, and I'm no exception to this.

However, most of us are content to let other people's reactions to our thread dictate as to whether it will stay at the top of Page 1 or sink into oblivion. I see that the moderators have removed them, but until a few days ago, your 'stickys' took up half of Page 1, and now you're starting another batch. No offence, Digger, but enough already.

Edit by this W to fix the bold print at the beginning.

tobzalp
6th Apr 2004, 07:37
VoR does not sticky them. The moderators do. Remove this post and the one above please W.

Woomera
6th Apr 2004, 08:18
This W didn't sticky it, so I'll leave it as is. :}

tobzalp
6th Apr 2004, 10:19
I bet a steak dinner I could tell you which W this is.

Woomera
6th Apr 2004, 11:40
This W also didn't sticky it, so I too will leave it as is. :}

Voices of Reason
6th Apr 2004, 17:40
To Spad and others who contribute to this forum.

We are primarily focused on the issue of aviation safety - and try to provide information and clarification whenever we can, so that safety debates can take place based on fact, and not rhetoric. We do not post simply for the sake of posting.

We did not ask for, nor set, the sticky on any threads we initiated. We were pleased to note that there were over 16,000 hits on one particular thread, which encouraged us to continue participation and exchange of information.

You might note in this thread a number of valuable points.

The first is an open admission of the value of human life in the United States, which far exceeds that shown in the Broome study, and if applied therein, would force a substantial re-evaluation of airspace change in Australia.

The second is the seeming validation of the Broome study's use of a per ticket or per capita cost-of-safety, rather than the broadbrush whole of industry approach chosen in many other cases - including assertions made by your Government in relation to NAS.

Amortised across all passengers flying each year in Australia, the purported savings of 70 million dollars would equate to something less than 50 cents per passenger per flight - for a disproportionate increase in risk.

The third is the admission that FAA, like Australian authorities, is reluctant to move from a fixed and fixated strategy - until an accident occurs. If this represents best practice, we ARE very concerned.

DirtyPierre
7th Apr 2004, 08:43
VoR,

Your posts are excellent, keep posting.

What is especially good about your posts are the clinical, logical way you completely disect the arguments of your detractors. Cold logic and sound reasoning are your steamrollers of truth.

Keep up the good work. I for one appreciate your efforts.

OverRun
7th Apr 2004, 08:56
The historian judges things on facts and not rhetoric, and at some time in the future, NAS will be judged the same way.

If the judge is ATSB, with a re-run of their 'systemic investigation into the Class G airspace demonstration' report, that will be one thing.

If the judge is ATSB with a report that ends 'the aircraft impacted the ground near ***** and was destroyed. There were no survivors.' then that will be another thing, and we don't want it.

Either way, history will judge Voices of Reason, PPRUNE and Woomera favourably for what they've done in the interests of aviation safety.

WALLEY2
7th Apr 2004, 17:37
Some 14 months prior to 9/11 we had a largely unreported incident at Broome- a pax took sticks of explosives onto an ANSETT flight bound for Perth, he also had possible detonation materials.

He was caught as he stumbled on the apron and an alert hostie spotted the sticks in his open carry bag, ground crew using a rouse got him of the aircraft.

He was arrested and charged. Why little press exposure? he killed himself before it came to trial. We(the airport) then decided to go secure at Broome and got verbal egreement from AN, QF and DoTRS.

After we installed the equiptment and trained the staff QF and DoTRS backed out and later AN followed. We continued to screen pax as the fight on who had the right to impose screening raged.It was a $150,000 fight as it took about 6 months to get QF and AN to agree.

As a last resort we said "lets ask the users directly" we surveyed them over one week, about 80% of all enplaining pax. We gave them the facts including the incident that prompted our installation of security equiptment and procedures, we advised them the cost was $3.75 per return flight.

The result of the survey was 97% of pax said they were happy to pay and wanted the security, only then did the airlines agree to put the charge on the tickets and reinburse us starting the next month.

We now sit across the table with some of the same people deciding whether batteries need to be removed from laptops etc.I don't go to the meetings as I would not cope with these "after the horse has bolted" experts.

VoR please keep posting on NAS you are helping and guiding many to forsee the danger and the proper procedures that are being ignored by some of our agencies. We need to stop and force assessments of dangers before they occur. We needed the AN bomb scare to alert us to security action and the DoTRS needed 9/11 before they finally saw the issue.

You help alert us to the fault prevention procedures that may result in proper assessment of airspace changes before a mid-air collision which appears to be the only stimulus some officials and pilots need to see the errors,shortfalls and dangers of certain aspects of the the NAS.

No matter how scientifically we approach the NAS2c we are a player and are seen as self interested you are not and the hits on your posts show the respect your postings deserve.

Thank you

Spad
8th Apr 2004, 11:49
VoR, getting back to my first post. I've got no complaints about the merits of your posts nor of their importance. But I stand by my original request. Most people think that the thread they introduce is important - or why post in the first place?

If everyone made every thread they thought to be important a Sticky, no one would know if or when a new thread was posted. Last week, your 'stickies' took up half my screen when I opened D&G.

DirtyPierre
8th Apr 2004, 22:04
Spad,

Flogging and dead horses spring to mind.

Move on.

Woomera
9th Apr 2004, 00:59
The W that did.

Spad old chap, no one and that includes the V o R, except a moderator can sticky a thread.

The use of the "sticky" by mods, is to keep a thread "at the top" that he/she/they think is of sufficient importance/interest for all to see. How long it stays depends on the response, posts or views.

Some PPRuNers don't get to the boards every day or even week due to their rosters or work pattern.

It's also why we have more than one W.

If it doesn't or stops "flying" it will go.

We have no idea beyond the registration email address who the V o R, or any other PPRuNer for that matter, is or may purport to be.
Sometimes we, like you guys, wish we did so we could send the bruvvers around to have a bit of a chat wiv em like, around the back of the bike shed :E :p. We, like everybody else have our theories but that is all. :(

Our 9 or so years experience around here, yeah verily since the beginning of PPRuNe, tells us that they are worth listening to.

This is a subject exciting National interest.

We always support calm rational discussion about all and any important aviation matters, something not always evident around here.

Given that is the case what other objections do you then have? :)

W

trafficwas
9th Apr 2004, 12:21
The posts of VoR have been timely. articulate and sage.
They are another argument for or against NAS.
Who can now decide who,what or which argument is reasonable?
Which splinter group do you heed? The ATC "henny penny" argument? The good of aviation Australia wide argument? God forbid there is common ground. Government departments to decide this? How as an industry can we find a way forward?
There must be a way.
We are professionals, all of us.
Sort it

Voices of Reason
9th Apr 2004, 16:00
TCAS and Safety


(cross-posted from the TCAS thread)


We agree that TCAS is a valuable safety tool – and where it is cost effective and justifiable to fit, it should be fitted. We also support the carriage and operation of secondary surveillance radar transponders – Mode C or mode S – to support the operation of TCAS.

BUT we DO NOT support the use of TCAS and adjunct transponders as an airspace design tool. We have enunciated this more forcefully in other threads.

TCAS is acknowledged by ALL leading aviation States, and by ALL leading aviation organizations and authorities, as a LAST LINE OF DEFENCE – not an aid to separation or traffic information. It is meant to be independent of the air traffic system – not a supporting concept.

Carriage and operation of transponders in the United States should NOT be assumed to be a fundamental support to TCAS and aircraft based traffic information to IFR aircraft – it is principally related to the extensive radar coverage in the continental United States – primary and secondary. The carriage and operation of transponders allows air traffic control to provide traffic information and collision avoidance advice as a part of the design of airspace in the United States.

Ask any expert in the United States if TCAS is a design tool, or if TCAS resolution is a good design and safety aid, and the answer would be a resounding NO!

We cannot stress strongly enough – if your airspace system is being “rescued” on a regular basis by TCAS observation and reaction, your airspace deign is fatally flawed, and it is only a matter of time (or statistics) until the ultimate sanction.

FlexibleResponse
9th Apr 2004, 16:14
Statistically we are probably overdue for another fire/smoke accident. So I think it is a good and timely post from Voices of Reason.

Talking of Safety in terms of price per ticket, didn’t thre Aus Govt put a “sticky” of $10 on the price of all Aus pax tickets to help the payout of the retirement benefits of the Ansett staff who lost their jobs and due to their company going broke? That seemed to be a worthy cause.

I wonder if Safety will also get a look-in sometime soon?

Wizofoz
9th Apr 2004, 16:34
Spad,

Your previous posts have made you seem like an arrogant, self important know-it-all.

Your efforts here confirm this, plus make it obvious that you can't grasp simple concepts (Like it's the MODERATORS who make things stickies- always been obvious to me!!)

VOR- Well done, informative and timely as always.

Spad
10th Apr 2004, 01:38
I most humbly eat crow, Mr Moderator. As for Mr Wizofoz, I think it will be obvious to many why he finds me to be so disagreeable. Ooops! Hijacking the thread alert!!!

trafficwas
10th Apr 2004, 13:26
The most stident examples of TCAS resolution have been the public displays of NAS failures. In LT,CANTY, AY and MC all have been TCAS resolutions. What does that say about a system which according to ICAO requires no such back-up?
This has to be a sad joke and who is going to be the punch line?

Kaptin M
12th Apr 2004, 14:14
IMHO, Safety has been - and still is - ALWAYS the singular, most important decision making criteria for pilots, whether they be PPL's or ATPL's.

Unfortunately, pilots are not directly responsible for overseeing precisley HOW the levies collected in the name of "Safety/security" are spent.

Whilst the (recent) scenario you describe was obviously life-threatening, WALLEY2, would you be at all surprised to learn that a DC9 was hi-jacked out of Coolangatta Airport some 30 years ago, by a pax carrying a shotgun under his overcoat?
That something similar happened three decades later, indicates - to me, at least - that most governments treat aviation security as a token "given".

Personally, I am EXTREMELY "bemused" at the amateurish levels afforded commercial airline aviation today, at the undoubtedly ludicrous prices they are charged!
The gaping holes have been pointed out to my company, but with no response - perhaps because it's a case of "We've always done it this way", and to include the EXTRA security means re-balancing the budget.

Without a doubt, the "user pays" system is the most simple, cost-effective method - and matter-of-factly is the one that the company "beanies" will eventually utilise ANYWAY!
Companies no longer "absorb" costs - they are always passed on to the end user (together with suitable "add-ons"), and usually with great fanfare indicating that it was all out of managements' control!! :eek:

FlexibleResponse
13th Apr 2004, 13:39
Chris Jones reporting on the ATSB
Last year alone there were three serious incidents – a near-miss over Tasmania, a large airliner running off the runway on landing in Darwin, and one instance where both pilots on a Boeing 737 were overcome by smoke caused by an electrical fault in the cabin.
From lame’s thread “Close Calls Point To Air Safety Time Bomb” http://www.pprune.org/forums/showthread.php?threadid=126418

It’s a shame that the impact of VOR’s topic has been somewhat diluted by extraneous chatter.

The ATSB’s report for last year has a chilling message for the senior and experienced aviators amongst us.

I am sure that nobody would disagree that Kaptin M's observation stated in his first line says describes the basic tenet of our profession.

Unfortunately, we also realise that while pilots have the responsibility for ensuring Safety of their passengers and aircraft, pilots are very often denied the authority to make the changes necessary to "make it so".

WALLEY2
13th Apr 2004, 15:40
Kaptim M

Yikes! No I did not know. Thankyou it is useful to know when dealing with DoTRS safety "guru-s"

Voices of Reason
13th Apr 2004, 21:24
The following is an extract of the Executive Summary from a recent [2003] report by the United States Department of Transportation – Office of the Inspector General – into Operational Errors and Runway Incursions within the United States. An “Operational Error”, in the context of this report, is effectively a serious loss of separation by air traffic controllers – one where two aircraft were within 12 seconds of collision. Note that there were 1194 reported operational errors in the United States in 2001 – i.e., 1194 instances of aircraft within 12 seconds of collision.

In the extract, though important, we have removed references to Runway Incursions – however the full report is available from http://www.oig.dot.gov/

The reason we have provided this information is two-fold. The first is to caution that to refer to the United States as a best-practice model may in fact belie the fact of your own good safety record or practices – that is, your own system may be substantially better than that in place in the United States.

If a proponent of airspace change is to be believed, the United States handles 20 times as much traffic as is handled by controllers in your country. That would seem to say that 1194/20 – or 60 very near miss incidents per year - is an acceptable level of safety for Australia. We think not.

The second is to challenge readers – and in particular your airspace designers – that as was done in the United States, evaluating the contention that you operate a safe system, and then underpinning that safety (or rectifying identified deficiencies) – is a far better use of resource than blindly implementing a new airspace system “simply because someone believes it is better”.

We apologize for the length of this extract – however we believe you should note the detailed findings and recommendations, as a caution on your own system. We are also NOT targeting air traffic controllers – as much information can be provided of pilot errors. This information is provided as a warning that safety should NEVER be taken as a given.



Operational Errors and Runway Incursions

After several years of continuous increases in operational errors and runway incursions, FAA has made progress in reducing these incidents in FY 2002. From FY 1998 through FY 2001, operational errors increased 35 percent from 885 to 1,194. This past year FAA has begun to reverse this trend. In FY 2002, operational errors decreased 11 percent to 1,061. FAA’s success was due in part to the implementation of FAA and industry initiatives. In addition, we found that there was a statistical correlation between the decrease in these incidents and the reduction in air traffic operations.

Despite FAA’s progress in reducing the number of operational errors and runway incursions in FY 2002, the number of these incidents is still too high considering the potential catastrophic results of a midair collision or a runway accident.

In FY 2002, on average, three operational errors and one runway incursion occurred each day. FAA records showed that the most serious operational errors (those rated as high risk) occurred, on average, ONCE EVERY 8 DAYS. ON AVERAGE, IN FY 2002, AT LEAST ONE COMMERCIAL AIRCRAFT WAS INVOLVED IN A SERIOUS RUNWAY INCURSION OR OPERATIONAL ERROR ONCE EVERY 10 DAYS.

In our opinion, FAA’s severity rating system understates the number of serious operational errors. For example, our analysis of operational errors that occurred from May 1, 2001, when FAA established its severity rating system, through May 31, 2002, showed that the most serious operational errors occurred, on average, once every 3 days, when we included operational errors rated moderate i.e., that were within 30 seconds of a midair collision.

In the first 5 months of FY 2003, the number of operational errors rated high risk increased from 21 to 24. While the progress in reducing serious runway incursions is encouraging, it is important that FAA take additional actions to further reduce the number and safety risk of operational errors and runway incursions, especially since FAA projects that air traffic operations will return to pre-September 11th growth patterns between 2005 and 2007.
……

FAA considers many operational errors as moderate severity when in fact some of these errors are very serious. For example, FAA rated an error as moderate that was less than 12 seconds from a midair collision. FAA needs to modify its rating system to more accurately identify the most serious operational errors, focus its resources on reducing them, and ensure that controllers receive the appropriate training for high risk errors.

FAA procedures do not require training when controllers have multiple operational errors or for controllers who have operational errors that pose a moderate or high safety risk. The procedures state only that skill enhancement training “may” be provided and, therefore, are open to interpretation.

NTSB has expressed concerns over these procedures. Under these procedures, for example, a controller had three operational errors within a 2-year period, but did not receive any training after the second and third errors because these two errors were categorized as low severity. In addition, our review of 85 moderate and high severity operational errors disclosed that the controllers involved did not receive any formal training for 18 (21 percent) of these errors. FAA needs to revise its procedures to ensure that controllers are trained to reduce the risk of future errors.

In December 2000, we reported that FAA needed to approach reducing operational errors with a sense of urgency and provide stronger national oversight to ensure efforts to reduce these errors are effective. FAA initiated actions to improve its oversight efforts and, together with the National Air Traffic Controllers Association (NATCA), established a system to identify the severity, or collision hazard, of operational errors and to focus resources on preventing the most severe errors.

The rating system uses a 100-point scale to rate the severity of errors into three risk categories - low (39 and below), moderate (40 to 89), and high (90 and above). Points are assigned based on vertical and horizontal separation distances, flight paths, closure rate, and level of air traffic control involvement (controlled: controller was aware an error was about to occur, or uncontrolled: controller was not aware an error was about to occur).

Those operational errors rated as low are not considered a safety risk and are categorized as technical violations.
The reduction in air traffic operations and FAA initiatives contributed to FAA’s progress in reducing operational errors. Most of the decrease in FY 2002 occurred at three facilities.

Specifically:

We analyzed the 11 percent decrease in operational errors from FY 2001 to FY 2002 (1,194 to 1,061) and found that the decrease was due in part to the 3 percent reduction in air traffic operations (about 4.2 million operations) during FY 2002. We performed a statistical correlation analysis between air traffic operations and operational errors on a monthly basis for FY 2001 and FY 2002 and concluded there was a positive correlation. In other words, as operations decreased, errors also decreased.

We also performed the same statistical correlation analysis for 24 facilities that had decreases in operations in FY 2002 and concluded that there was also a positive correlation on a facility basis.

There is no question that FAA has made improvements since we issued our report in December 2000; however, we found that much work remains in reducing operational errors.


For FY 2002, FAA changed its goal from reducing the total number of operational errors to reducing the most serious incidents. However, FAA missed its FY 2002 goal of having no more than 568 operational errors with less than 80 percent of required separation between aircraft with 617 such errors.

Seventy-eight percent of the 1,103 operational errors that FAA rated during the 13-month period from May 1, 2001, to May 31, 2002, posed a moderate or high safety risk.

FAA's rating system understates the safety risk of the most serious operational errors. Only 61 of 1,103 operational errors were rated high risk (90 and above out of 100 points). However, we found another 65 errors rated in the high end of moderate. (70 to 89 points) that, in our opinion, were also very serious (within 30 seconds of a midair collision).

On average, operational errors that scored between 70 and 89 points had only 50 percent of the required separation between aircraft. Depending on the closure rate of the aircraft involved, these errors can be only seconds away from an accident. For example, a controller directed two commercial airliners head-on at a closure rate of 460 miles per hour. The two aircraft had only 43 percent of the required 3-mile horizontal separation and were less than 12 seconds from a midair collision. The incident was rated as moderate scoring 87 points. In our opinion, this operational error was very serious, and FAA should consider errors such as this one to be high risk.

FAA does not identify and monitor statistics on the number of operational errors that involve commercial aircraft, general aviation aircraft, and military aircraft. This is important in measuring the overall safety impact of operational errors. For example, operational errors that involve commercial aircraft should be identified and monitored because they can place hundreds of passengers at risk.

FAA procedures do not require training when controllers have multiple operational errors or for controllers who have operational errors that posed a moderate or high safety risk. This occurred because, in 2001, FAA and NATCA signed a Memorandum of Understanding establishing new procedures for the types of actions that can be taken when operational errors occur, in part, to change the controller’s belief that actions taken as a result of an operational error were punitive. In the past, supervisors could decertify a controller and provide remedial training even if the error was the controller’s first operational error and did not pose a safety risk. We agree with FAA's decision to eliminate the perception that actions taken after an operational error are punitive.

However, we do not consider training to be punitive. As a result of FAA’s new procedures, some controllers with multiple errors or errors that posed a moderate or high safety risk did not receive training. Specifically: FAA procedures set no limit on the number of low severity errors a controller could have before training is required; therefore, a controller can have multiple errors and not receive training.

The procedures state that training will not be provided to controllers who have low severity errors that are controlled (i.e., the controller was aware the error was about to occur). For low severity errors that are uncontrolled, training “may” be provided but is not mandatory.

For example, a controller had three operational errors within a 2-year period, but did not receive any training after the second and third errors because these two errors were categorized as low severity. Less than 1 year later, the controller had a fourth operational error that was rated in the high end of moderate. While the controller did receive training after the fourth error, training provided after the second or third error possibly could have prevented the fourth error. Our review of 85 moderate and high severity operational errors disclosed that the controllers involved did not receive any formal training for 18 (21 percent) of these errors.

Voices of Reason
14th Apr 2004, 00:21
Having re-read our previous post, we feel we should provide some clarification.

There was absolutely no intent to malign air traffic controllers - neither was there an intent to imply that controllers are in any way responsible for the safety implications associated with your current airspace reform debate - nor pilots, for that matter.

We are also very well aware that controllers cannot significantly influence the safety issues relating to your recent incidents in Class E and Class G airspace - they are a product of faulty airspace design.

Our post was meant to show that whilst certain assertions are being made about the "best practice" status of the United States airspace system, appearances can be deceptive.

Our post was meant to say that before a State embarks on a change of the nature of NAS, it had better be certain that the internal foundation upon which that change is built is robust - and that the external system on which it is modeled truly is "better" than that it replaces.

We are reasonably confident in stating that no such studies were carried out. Should an accident result from such incompetence, the architects and proponents of change might well then be judged to be criminal negligent.