Government Insight into Airline Aviation

Specifics raised by the committee include:

a. A number of instances where airliners had arrived at Heathrow with below minimum fuel and not declared it (Malaysian Airlines).

b. 24 airliners had overflown London with one engine out to land at Heathrow (9 of these being twinjet).

c. Pilots of a lower standard would be entitled to both operate and be employed in the UK.

d. Aircraft of a lower airworthiness standard could be wet-leased by British Companies.

e. Aircrew Flight Time Limitation Standards might be subject to a "dumbing down" to less stringent JAA standards.

f. The fact that the JAA is a Club rather than a legal entity. In time the European Aviation Safety Authority would be formed.

g. The unsatisfactory situation whereby the regulator (CAA) is funded directly by a levy upon the operators.

h. Loss of experienced pilots from the Safety Regulation Group of the CAA to the industry.

i. Loss of experience levels in pilots due to the low numbers coming from the military and the retirement of large numbers of senior pilots.

(saying that 64 per cent of air accidents with a known cause were caused by aircrew and that this number could increase)

j. Reduced numbers of experienced maintenance engineers coming from military careers.

k. The effect of h, i and j being magnified by the very high growth levels in the UK airline industry.

l. Commercial pressures upon engineers and pilots to meet ATC slot times (to the detriment of safety).

m. Review of recent accidents (TWA800/VJ592/sr111 and B737 rudder-caused crashes)

"We recommend that the Safety Regulation Group re-iterates its advice to airlines that the priority in
certain emergencies, such as in-flight fires, is to land, rather than to seek to dump fuel in order to avoid an overweight landing. It
should ensure through its inspections that airlines are passing on that information to aircrews. Furthermore, we recommend that air traffic controllers be given similar advice, so that they are able to respond appropriately to such emergencies."

n. The effect of pending litigation upon open discussion and thorough investigation of airline accidents.

o. Cabin Safety Issues

"We recommend that further research be conducted by the Safety Regulation Group into the benefits
and dangers of rearward-facing seats, and by the Civil Aviation Authority generally into passengers' views of them, particularly
passengers fully informed of the benefits they might bring in the event of an accident. The results of that research should form the
basis of the Safety Regulation Group's approach, through the JAA, to the issue."

"Most of the fatalities during the Manchester disaster were the result of inhaling lethal quantities of carbon monoxide or hydrogen cyanide. Moreover, the evacuation of the aircraft was severely impeded by passengers collapsing unconscious from the effects of smoke. We recommend that the Safety Regulation Group should again conduct research into smokehoods, and the benefit which they might bring to evacuations of aircraft during fires. They should publish the results of their research within a limited timescale, and, unless there are compelling safety reasons why they should not be carried, the Safety Regulation Group should seek to make the provision of smokehoods on commercial aircraft a mandatory requirement. "

"We are extremely concerned about the delay in implementing the Transport Committee's recommendation to increase the width of the aisle through the forward bulkhead of the Boeing 737 in particular, following the accident at Manchester airport. We recommend that the Safety Regulation Group take steps to expedite the matter, and reports to us what steps it intends to take."

p. Passenger Behavioural Issues. Air Rage and Mobile phones, nicotine patches, off-loading and issue of warning cards.

q. English as the International Aviation Language. Poor English having contributed to airprox incidents and collisions.

r. The threat posed by high-speed military aircraft. Installation of collision warning systems in military jets.

s. National Air Traffic Service (NATS) changes and overcrowded airspace.

t. Difficulty in monitoring the operations of "virtual" airlines

(entities who have subcontracted out all of their functions - similar to Valujet).

Keep the shiny side up and the dirty side down

OVERALL the Committee felt that the vast majority of submissions that they received indicated that an extraordinary level of complacency prevailed within the industry. The Committee felt that it was not justified either by past performance and particularly not by expected challenges caused by shortages of experienced manpower.

We commend all involved for their spirit of co-operation,
but we detected signs in the evidence given to us that co-operation might lead to cosiness. Most of our witnesses seemed unable or unwilling to
criticise others in the aviation sphere, other than in the most general terms. All involved in aviation should remember that openness and
criticism aid safety, and that the maintenance of safety standards is the most important factor in building a successful aviation
industry. We recommend that the Department of the Environment, Transport and the Regions maintain a careful eye on the
relationship between the Safety Regulation Group and the industry it regulates, and act firmly to ensure that the Regulation Group
remains independent and critical of the industry.

Splitting the CAA's Safety Regulation Group from the Economic
Regulation Group, through the creation of an independent Transport Safety Authority, would help to ensure that the safety regulator
maintained an appropriate distance from the industry.

We recommend
that the Government should open a dialogue with interested parties, both within the industry and outside, to consider limiting to a
sensible level the liability of manufacturers and operators in the event of aviation accidents. It should explore such matters within
relevant international fora, with the objective of limiting liability worldwide. We believe that such a step may help to encourage
greater openness about safety matters in the aftermath of accidents

unless there are compelling safety reasons why they should not be carried, the Safety Regulation Group should seek to make the
provision of smokehoods on commercial aircraft a mandatory requirement

EXTRACTS OF NOTE

21. Can you tell us why you have not insisted on smoke hoods in aeroplanes?
(Mr Profit) I shall hand that over to Mr Hunt who has a long history and knowledge of the smoke hood situation.
(Mr Hunt) I should also like to bring Mr Harper in because we have both had an involvement in this over the years. I guess the action when I
became involved started after the Manchester accident. Some research was done which led to a number of conclusions and recommendations. The
authority took the view that one of the first things we ought to do was to stop the fire from happening in the first place so that smoke hoods were
not needed at all, or any other form of protection for that matter. Then, once we had made the vehicle as safe as we could, we should address
whether or not smoke hoods would actually save lives. We did a great deal of work and concluded that there were operational disbenefits in
requiring smoke hoods to be fitted and I believe there are also technical problems with finding a smoke hood which would actually work, which
would fit the whole range of people who might wish to use it or have to use it and that would in itself create problems. That is a design aspect and
one on which I would ask Mr Harper to comment.
(Mr Harper) The problem is an operational one primarily of donning a smoke hood and the time taken to vacate the aircraft following the
donning of a smoke hood. The smoke hood itself is not necessarily an easy thing to put on.
(Mr Profit) Perhaps something needs to be understood. As I understand the current design, they carry their own air supply which has a finite
time before it exhausts itself. Therefore one has to don the hood at the critical moment before evacuating the aircraft and that is one of the key
problems.

22. What is your estimate of the number of lives saved if smoke hoods were there?
(Mr Profit) In the UK since the Manchester/Kegworth accident I would not think that it would be a significant number.
(Mr Hunt) If any. I cannot think of a case where it would have saved a life.
(Mr Harper) I do not believe there has been an accident where a smoke hood would have benefited people.

23. But it would have benefited people in Manchester.
(Mr Profit) Absolutely.

24. And probably in Seoul.
(Mr Profit) Yes, assuming they had smoke hoods which were viable, and could have been donned at the right time.
(Mr Hunt) I remember from the Manchester inquiry that the so-called challenge atmosphere was such, the atmosphere inside the cabin with all
the hydrocarbons and noxious fumes which were in the cabin at the time, that there was not then, and I am not even sure that there is now, a filter
system or whatever which would actually work in that environment. If you use the type Mr Profit referred to, which is in effect with some sort of air
supply built into it, as the crew might use, then of course the challenge atmosphere is not such a problem.

25. How many lives have been saved by life jackets in aeroplanes?
(Mr Hunt) I do not know the figure off the top of my head I am afraid. The last UK accident I can think of would be most probably the accident
in Sumburgh when an aircraft ran off the end of the runway and I seem to recall that some of the passengers in that accident used the life jackets. I
do not have an actual figure for the number of people whose lives were saved because of life jackets.

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Testimony by HEAD of UKAAIB (mr Smart)

I heard the discussion on smoke hoods. Let me say that I carry a smoke hood. I have one in my
bag here, but I expect to have to use it more often in an hotel than ever on an aircraft. If I did, in the very, very rare event, have to use it on an
aircraft, I know how to use it. I accept the regulatory authorities' arguments that after a lot of research which was done, which was what we asked
for, we did not recommend that smoke hoods should be fitted. I think there is a misconception about the recommendation which we actually made.
We asked the regulatory authority to consider whether a twin-track approach, smoke hoods and/or water spray systems, could save lives
effectively. They spent a lot of time and money in researching that particular recommendation and they came to the conclusions they came to. I can
accept in certain circumstances that it could well delay egress from the aircraft. It is a very complex subject, because if you are going to introduce
smoke hoods you have to introduce training of people to use them in a very meaningful way, which would mean it would not cause a delay. To
come back to your original question, no, smoke hoods would not be one of the things which was top of my particular list of recommendations
which I felt ought to be implemented.

71. May I ask the same question about the Swissair accident at Nova Scotia?
(Mr Smart) The fire which caused the loss of the Swissair aircraft is thought to be associated with a wiring problem; the wiring is thought to be
associated. These are not definitive causes for the accident by any means because all the wreckage in the area of the seat of the fire has not been
recovered yet. It is thought to be associated with the inflight entertainment system wiring. The spread of the fire is thought to be associated with the
insulation blankets on the aircraft. That is as far as the Canadian Transportation Safety Board has got with their examination.

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Testimony by Cranfield University Rep (Mr Taylor)

One point I should like to make concerning the cost of safety features and so forth is that I actually did the sums on the water mist system which was the system which was recommended in parallel with smoke hoods by the AAIB after Manchester. There the CAA came up with a figure which I have no reason to doubt at all of something like $22-32 million per year per life saved, so about 14 lives saved. If you do those sums it comes out to a lot of money. However, if you take into account that every year something like 1,600 million passengers fly, then the total cost of saving those 14 lives—I believe it would be more than 14—would be approximately 50 cents per return ticket. That puts a different complexion on the costs which are involved in some of the safety features which have been recommended by the AAIB, by NTSB in the States and by other organisations.

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Testimony by Guild of Air Pilots and Navigators (GAPAN) and BALPA

(Miss Evans) Our concern there is that the CAA does sometimes have its hands tied. This goes back a little to the previous question as well: that
an airline from another JAA state is accepted to have the same standards as a United Kingdom airline and be subjected to the same regulatory
oversight. We do not believe this is the case. The airline that was grounded for three or four days last year comes from a JAA state but never goes
near its own JAA state and never receives, in our opinion, satisfactory regulatory oversight. That is a good example of where the CAA is
constrained.

BALPA does noBALPA does not think that the CAA are proactive enough in looking at the certification standards of other JAA state
aircraft. That is perhaps where they are constrained.t thin

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Testimony by the Royal Aeronautical Society (RAS)

Then in what measure and in what manner should we alter the checking in order to ensure that the regulatory regime remains rigorous?
(Captain Lowe) I think that the audit process is the key to this and there are two elements to it. One is auditing the management structure and
the processes which are at work, including who is finally accountable. If you look at the case where someone might have a sub-leased engine on a
sub-leased aeroplane done by a third-party maintenance organisation, there needs to be in place an accountable structure to say who is responsible
for the aeroplane.

230. I have to say, Captain Lowe, the operation of safety cases in other transport industries when there is an extension by the use of contractors
and sub-contractors is not a good example to use, because the further away that the actual job gets from the person who has the safety case
responsibility, the greater is the possibility that it will not be of the standard required?
(Captain Lowe) Indeed. That is what I am saying. I think there must be a case for oversight from the regulator to see that the management
processes are in place to ensure that they can trace accountability if need be. So it is actually looking in an audit process at the management
structure, I am saying, rather than at the detail, but I think there will continue to need to be a review of some of the detailed operations in an
inspection process, which goes on now, and I think that must continue. Perhaps I could add a third point, though, which I think is crucial. Both
Stewart John and I, from opposite sides of the world, have come to exactly the same conclusion and that is that the use of quick access data
recorders, flight data recorders, is the key to both safe operation and to regulation, in that these quick access recorders, which record thousands of
parameters a second, if the data is correctly analysed, can tell both the airline management and the operators, be it pilot or engineers, and the
regulatory authority just what is going on. In other words, if we use the modern equipment which is available and is used by some airlines, the
oversight of the regulator becomes much easier.

231. Yes. Of course, though, that would be a reactive process?
(Captain Lowe) No, it would be very much a proactive one because the use of these recorders allows you to look, over a long period of time
and many sectors, at both trends and deviations from the norm, rather than simply waiting for an accident to occur. This should give you the
information well before and we both relied on it very heavily.

Is there more they could do? The answer again is yes, and as you have already heard me reference, I find it very difficult to understand why the use of quick access flight data recorders and the subsequent analysis is not made a mandatory piece of equipment because it is a quality control system which is second to none. Many airlines do use it anyway voluntarily, and I think that in part explains why some of the JAA airlines and one or two others, certainly in the Far East, have got now statistically better performance, both in terms of incidents and safety events.

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Peter Martin. (the Solicitor and the Honorary Legal Adviser to the Flight Safety Committee)

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Wearing another hat I am the Honorary Solicitor to the Royal Aeronautical Society and we are aware on the council that there is an
appalling skills shortage in maintenance engineers, great and growing. There is a whole range of reasons. One is low professional status, another has
to do with diminishing numbers coming from the armed services, a whole range of reasons, and the Royal Aeronautical Society is doing what it can in
trying to improve recruitment by finding a way of improving their professional status through membership of the Royal Aeronautical Society. It is a
huge issue and there is a specialist committee operating at the Royal Aeronautical Society with oversight of this and perhaps you should invite them to
address you.

(Captain Kerr) One of the concerns of the overall concept of JAA that we have is that it is a bit like the camel train, it is as quick as the slowest
camel in the train and likewise in the area of self-regulation what we are alluding to there is that under the self-regulatory aspects of JAA the airline
very much regulates itself with an oversight from the Authority. In doing so we feel that the day of the experienced flight operations inspector who
could go in and see a developing problem because he had seen it before because he had been doing the job for donkeys' years could be——

797. Does that mean, Captain Kerr, that your Committee is concerned that the process could lead to what is popularly called "dumbing down" rather
than not only maintaining but ensuring that the high safety standards in the United Kingdom are spread throughout the whole of the JAA's activities?
(Captain Kerr) Our concern is that it is essential that the high standards of regulation and safety standards in this country must be maintained and
that we must not find ourselves working to the lowest common denominator.

798. Do you think there is a danger of that?
(Captain Kerr) I believe there is unless we regulate very strongly.

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Mr Bennett (MP)

817. If you convince us with a bit of passion and we put it in the report we might have a chance of convincing our colleagues but, come on,
smokehoods and cabin water-misting systems?
(Mr Humphreyson) Chairman, the Manchester air disaster sparked several studies one recommendation of which was smokehoods and evolving
out of that was water sprays. There is no doubt that these things are advantageous, however the studies that have been done, the cost-benefit
analyses, have said it would be too costly for industry, it is not mandated worldwide and therefore it would make the playing field unlevel and those
mandates would put us at a commercial disadvantage and of course the bottom line is What price do you place on a human life? The CAA study said
that they were not going to mandate smokehoods in United Kingdom aircraft but suffice to say that I and most of the AAIB and all the insurance assessors that I know would not fly without one and I carry one wherever I go.

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820. What is your view of the suggestion there is something wrong with the rudder of the Boeing 737?
(Mr Humphreyson) One of the problems that affects the aviation industry is an accident that has no solution. I think it is the Committee's view that
improved flight data recording in the case of the two Boeing rudder incidents that resulted in fatalities may have been better investigated with better
flight data recorders, cockpit recorders and the like. Not just better in terms of the technical recording that is done, the number of parameters
recorded, but also the length of time that they record and I think our Committee would like to see better and longer recording to enable investigators to get to the root cause of problems such as the 737 rudder problem more easily. That applies not only to the 737 rudders but others. I am delighted to say that the NTSB has recently made a recommendation on modifications to 737 rudders which hopefully will come forward. The two accidents I
allude to did not happen in the UK. Another aspect of the investigation of course is the admission of liability by the manufacturer particularly in the
United States where litigation is such a major problem.

821. Of course, the fact it happened in America really has no bearing on the facts because there are so many Boeing products in this country and so
many of them are flown by British airlines.
(Mr Humphreyson) The point I am making is——

822. —— is a legal one.
(Mr Humphreyson) Is that our system would enable us perhaps to get to the root cause more quickly.

823. Faster.
(Mr Humphreyson) Because the manufacturer does not face the same litigation problems.

824. Can I then finally ask you, particularly to the man carrying a smokehood in his pocket, how important is it we go for survivability of crashes
rather than improving the reliability of aircraft?
(Mr Humphreyson) I think I am in the hot seat on this one.

825. You have drawn the short straw all round this afternoon.
(Mr Humphreyson) I am asked this question I usually quote the Kegworth accident where survivability would have been better——British Midland
Airways fitted 16 G seats into that aeroplane. They were not mandated at the time but they fitted them because they thought there would be better
survivability. Unfortunately, of course, they retro-fitted them into 8 G flooring and therefore the 16 G seats did not improve survivability. Therefore, it
is a very complicated problem where you have aeroplanes with grandfather rights evolved where some of the systems do not meet or it is not
economical to update them to the safety standards that would be survivable.

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Capt Vivian (OIC Flt Ops Dept CAA -Safety Regulation Div)

933. Alright. Then let us ask something else. What advice have you issued to operators and air traffic controllers in respect of overweight landings
following the Swissair accident?
(Captain Vivian) Insofar as it is available to people flying, for example Boeing or Airbus aircraft, it is already written into the flight manuals and the
operating manuals that in an emergency people can land overweight and face the consequences afterwards. By the consequences I mean the damage
to the aircraft that may ensue. There is nothing new in that. What is new is that people recognise that they may have a serious situation and that fuel
dumping is not the top priority. The top priority is to divert and land and to that extent that is being emphasised by training companies at the present
time. It is a balance between whether you dump fuel and land afterwards or whether you land immediately. The sort of time when we would expect
someone to land immediately would be a fire.

934. British Airways specifically mentioned fires, "cabin fires in the air, especially the advice on overweight landings".
(Captain Vivian) The advice is you land, you do not hesitate, you do not hang about, you do not waste time burning off fuel and aircraft are able to
land overweight. There is no magic there. They will not fail.

935. So you have not felt the need to put in any specific change in your advice?
(Captain Vivian) What we have done is made sure that airlines reinforce this advice and that is what we looked at through our inspection
programme, to make sure people are not conditioned in taking one action at the expense of another, they weigh up the consequences.

CABIN SAFETY

Chairman

961. I want to bring you back even further to one of the original reports done by this Committee. You will remember we talked to the CAA then not only about the emergency methods for evacuating aircraft but we did talk to you about smokehoods following Manchester. Some of the things we recommended at that time, the floor lights, the various other changes, the suggestion that people sitting in seats next to emergency exits should be able to handle the weight of the door in an emergency, a lot of these things were actually carried out but I have to say the CAA took the view there was no justification for smokehoods and they gave a number of reasons. You have announced a very expensive new simulator. Is that going to conduct further research into smokehoods or cabin water-misting systems?
(Mr Profit) Not smokehoods specifically. The main aim of the new simulator is to meet a requirement we just cannot meet at the moment. For the current simulator is Boeing 737 size, a relatively small aircraft. For the new generation of European aircraft coming into service there is no suitable simulator for simply exercising the evacuation drills and optimum processes. This new simulator at Cranfield will have this capability. It is larger and it is also more flexible so far as its attitude can be changed and it can be reconfigured quite quickly. For a whole spectrum of new aircraft types coming on to the market over coming years we have now got a more realistic simulator.

962. You are wiping out reference to smokehoods altogether, are you?
(Mr Profit) No, we are not.

963. Or water-misting systems or backward facing seats? Are all of these included in your new simulator?
(Mr Harper) In fact, they are not, Chairman, but the simulator will have the capability of looking at cabin evacuation with smoke in the cabin as an item.

964. That is not quite the question I asked you, Mr Harper, is it?
(Mr Harper) I thought it was of interest, Chairman.

965. Of considerable interest and we have established that the reason for the new simulator is that it will be able to deal with this question of
smoke-filled cabins.
(Mr Harper) It will as part of the improvement of requirements for cabin evacuation and will be slanted towards new large aeroplanes with wide
bodies such as the new Airbus 3XX, a very large transport aeroplane.

966. So you are certainly looking at the whole business of the speed of evacuation, efficiency and the various other elements. Can we take it then that the CAA has made a value judgement that survivability of crashes is the most important factor? Is that the line that you are following?
(Mr Harper) It is a very important factor, Chairman, and it features as a major item in the SRG business plan and it is worth noting that since
Manchester we have made 20 safety improvement introductions as part of the follow-up, from floor path lighting right through to increased strength seats to different materials in the cabin. We have put in place 20 safety improvement requirements post-Manchester.

967. So apart from the actual physical spaces in which people have to be evacuated what do you expect to get from your new simulator, what extra research do you expect it to throw up?
(Mr Harper) It is a bit iterative but it is mainly aimed at new requirements for cabin evacuation under varying conditions for large aeroplanes.

968. Does that include rearward facing seats?
(Mr Harper) It would not specifically include rearward facing seats but it would be possible to do work on reward facing seats and we did look at that post-Manchester.

969. But you rejected it as far as I remember on the basis that the general public would not be impressed. I have to say if it was explained to the general public as a difference in survivability they might take more of an active interest.
(Mr Harper) We look wider, Chairman, and one of the issues was if a passenger is facing rearwards and the aircraft crashes there is a risk of
projectiles coming down the cabin and seriously injuring the person sitting in a rearward facing seat.

Mr Stringer

970. Is that not a question of the design of overhead locker compartments? It is not a fundamental issue. The design of overhead compartments can be changed or things can be stored under seats.
(Mr Harper) They certainly can be, Mr Stringer, but they are not the only thing that is left loose in the cabin. Cabin debris is quite a common thing. If an aircraft comes to a halt quickly it would not be unusual for bits to come down the cabin and injure those sitting in the seats. There are some associated comfort things and with modern high performance aircraft certainly there is a passenger comfort issue because the aircraft is taking off steeply and people tip forward.

Chairman

971. The Committee has heard these arguments in some detail before but you will understand that we want to be assured if you are spending this degree of money on a simulator there will be some very positive results, some new research, a different angle on things which have been looked at before and rejected. If you will forgive me for saying so, I think we are still talking about the speed of evacuation of a cabin.
(Mr Profit) We have got a particular problem which can only be addressed by the new generation of simulators that comes along with the next
version of the Boeing Airbus.

972. Would you expect to make recommendations about the size of bulkhead exits, about seating? What is the purpose?
(Mr Profit) I do not know what the research programme will be at the moment. What this simulator will do is enable us to consider any sort
research because it is that much more flexible. One of the problems with the next generation of aircraft is evacuation from what will now be the upper deck and that is another angle that does require a lot of work, particularly evacuation down chutes because there is concern that chutes will not be a safe way of evacuating that aircraft. For reasons such as this it has not been designed specifically to re-examine old issues although obviously they can be with the simulator.