Improving Flight Safety Through Accident/Incident - Scsi

Improving Flight Safety Through Accident/Incident - Scsi

Improving Flight Safety Through
Accident/Incident Investigation,
The Taiwanese Way
By : Kay Yong, Ph.D.
Aviation Safety Council
February, 2001
!
Taiwan’s Civil Aviation Environment
!
Responsibilities and Organization of
Aviation Safety Council
!
What we have done
!
Conclusion
The Civil Aviation
Environment
of
Taiwan
Two International Airlines (China Airlines,
EVA)
! Four Domestic Airlines (Far Eastern,
TransAsia, UIA, Mandarin)
! Seven GA operators
! Total Registered Airplanes – 178
! Types of Aircrafts
!
– B747-400, -200, B737, B757, B767, MD11,
MD80, MD90, A340(in Spring, 2001), A320,
Fokker-50, -100, Dash8, ATR72, Helicopters
Taiwan’s Civil Aviation
Number of Take Offs (1991~2000)
400000
350000
300000
250000
D om estic
200000
Internat'l
150000
Total
100000
50000
0
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00
Statistics in the Last Decade (1991~2000)
(Accidents Only)
No. of Accidents
GA
No. of
Fatalities
Type of AC
Operators Involved
1
1
6
B742, UH-12E
CAL,Yun-Hsin
92
1
0
2
BN-2A
Taiwan
93
3
0
6
DO-228, MD82, B744
Yun-Hsin, FAT, CAL
94
2
1
264
AB6, HU-12E, Learjet35
CAL, Yun-Hsin, Golden
Eagle
95
1
2
5
ATR-72,Bell-206,
Schweizer300C
Transasia, Asia Pacific,
Taipei
96
1
0
6
DO-228
Formosa
97
1
1
16
Bell-206, DO-228
Asia Pacific, Formosa
98
2
1
219
AB6,Saab340,Bell-412
CAL, Formosa, Daily
99
3
2
7
MD11, MD90,UH-12E,
BK117, B747SP
CAL(2), UIA, Daily,
EPAir
00
1
1
83
B744, Bell-430
SIA, Daily
614
AB6(2),B742,B744,MD11,
MD90, MD82, DO228(3),
Saab340, BN-2A, ATR-72,
Learjet35, Helo(8)
CAL(6), TransAsia(1),
SIA(1), Formosa(3),
UIA(1), Yun-Hsin(3),
Daily(3), Others (7)
Year
Passenger
/ Cargo
91
Total
16
9
!
Average Accident Rate in the Past Decade
≅5.9 per million T.O. (PAR 121 only)
!
Average Accident Rate in the Past Three
Years ≅6.6 per million T.O. (PAR 121 only)
Responsibilities &
Organization of Aviation
Safety Council
- ASC -
In The Past
!
!
!
!
!
!
CAA (FSD) handled all accident investigations, and paid
virtually no attention to any kind of “incident” investigation.
Even in the investigation of accidents, investigators were
part time with little training, and usually was handled by one
person.
There were no data base of any kind to provide information
for improvement.
The purpose of the investigations then was to find the guilty
party, not to improve safety.
Paid little attention to the Human Factors, especially
organizational safety issues.
Cabin Safety very seldom a safety issue.
After the CAL Tauyuan accident (AB6), people
recognized that in order to improve air safety, an
independent aviation accident/incident investigation
organization was necessary.
- Hence, the birth of ASC (in May 25, 1998)
Responsibilities
!
An independent government organization responsible for all
aircraft accident and serious incident investigation
!
Flight safety improvement recommendations directly to the
Premier and follow ups.
!
Collaboration with international flight safety organizations on
accident / major incident investigation and flight safety
improvements.
!
Pro-active (preventive) measures for safety improvement.
Aviation Safety Council
BOARD
BOARD
Chairman
Chairman
Council Member (4 Members)
Council Member (4 Members)
Managing Director
Managing Director
Consultant Group
(when required)
Office Manager
Flight Safety
Department
(Director)
Technical Section
(Chief)
Investigation
Department
(Director)
Administrative &
Legal Affairs
Section
(Chief)
Personnel
Accounting
(Acting)
Flight Safety
Investigator(1)
Aviation Accident
Investigator(1)
Aerodynamics
Flight Safety
Investigator(2)
Aviation Accident
Investigator(2)
Information
Flight Safety
Investigator(3)
Aviation Accident
Investigator(3)
Cashier
Flight Safety
Investigator(4)
Aviation Accident
Investigator(4)
Library
Systems
CVR/FDR LAB
Simulation /
Analysis
Recorders
¡° Hire part-time workers when required
Total of 18 staff members
General Affairs
Transportation
What We Have Done
The Track Records
!
!
!
!
!
!
!
!
Sept 2, 1998 Swiss Air #111 as an observer.
April 21, 1999 Daily Air Helicopter (SK117) CFIT near Taipei.
(report published)
August 22, 1999 China Airlines CAL642 (MD11) accident in Hong
Kong Cip-Lap-Kwok Airport.
August 24, 1999 UNI Air UIA873 (MD90) explosion on landing roll
in Hualien Airport. (report published)
Sept 2, 1999 China Airlines B747-SP training run off runway after
landing. (report published)
Oct 31, 2000 Singapore International Airlines B747-400 accident at
CKS International Airport, Taiwan (under investigation).
Jan 15, 2001 UNI Air Dash8-300 accident at Gin-Man Airport (under
investigation).
Plus 3 GA accidents (helicopters), 4 serious incident investigations,
and one state aircraft.
Published 6 reports and issued 65 recommendations.
Daily Airlines B55502 Crash Site
China Airlines CAL642 Crash Site
UNI Air UIA873 Accident Site
CKS GROUND MAP
NP!N1!05R GROUND PHOTO
View of entrance into Runway 05R/23L
from taxiway N1
NP!N1!05R AERIAL PHOTO
SIA006 GROUND TRAJECTORY
SIA006 GROUND TRAJECTORY
(CONT.)
SIA006 GROUND TRAJECTORY
(CONT.)
SIA006 GROUND TRAJECTORY
(CONT.)
AERIAL VIEW OF MAIN WRECKAGE
1ST JERSEY BLOCK
1ST EXCAVATOR IN NO.5 PIT
WRECKAGE & GROUND EQUIPMENT
IN NO.4 PIT
WRECKAGE & GROUND EQUIPMENT
IN NO.11 PIT
WRECKAGE IN NO.11 PIT
WRECKAGE (NOSE GEAR) & GROUND
EQUIPMENT IN NO.11 PIT
WRECKAGE & GROUND EQUIPMENT
IN NO.11 PIT
BULLDOZER IN NO.11 PIT
NO.1 ENGINE
NO.2 ENGINE
NO.3 ENGINE
NO.4 ENGINE
REAR PORTION OF THE FUSELAGE
REAR PORTION OF THE FUSELAGE
LEFT WING
RIGHT WING
FRONT FUSELAGE
NOSE
Establishment of Capability
In Accident Investigation
! FDR,CVR readout laboratory and analysis
(operational since August 10, 1999)
- 12 different cases this far.
! Training programs for accident investigators
- NTSB,FAA,Cranfield,ATSB, SCSI Courses.
! Active collaboration with international accident
investigation organizations
- ATSB (Australia)
- NTSB (U.S.A.) - TAB (Canada)
- BEA (France)
- AAIB (U.K.)
Establishment of Capabilities (Cont’)
Pro-Active Flight Safety Improvement
! Confidential Aviation Safety Reporting System since Feb,
2000(TACARE) – Have received 33 reports.
! Accident,incident and anomaly Date Base and Flight Safety
Trend Analysis (FSDB, August, 1999)
! Applied research in Human Factor
– CRM and Management Culture
!
!
!
!
Aviation Safety Information System/Library (Jan, 2000)
International and domestic flight safety conferences (May
29~30, 1999, December 4~5, 2000), include a Cabin Safety
session in the December conference.
Held two Cabin Safety Discussions at ASC to emphasize the
importance of this ignored issue.
Will host 2002 ISASI conference in Taipei (Sept, 2002)
Conclusion
!
Serious Incident investigation is even more important
than accident investigation from safety improvement
prospective. Must share information to the community as
quickly as possible.
!
Timely dissemination of data/information of a government
investigation is vitally important.
!
Investigation should be done in a transparent
environment, should not be held as the event of a secret
society.
!
Must elevate the importance of the cabin crew in safety
prevention and training. Prevention is always more
important and effective than re-active post-accident
investigation.