ICAO Safety Information Protection Task Force Listening Session Washington 5ht December 2012
ICAO Safety Information Protection Task Force Listening Session
Washington, DC 5th December 2012
THE IMPORTANCE OF COLLECTING, SHARING, AND PROTECTING SAFETY SENSITIVE INFORMATION IN AVIATION
Good morning.
My name is Paolo Pettinaroli. I am currently serving as President of 8 Ottobre Fondazione, which is a Foundation set up in Italy to honor the memory of those 118 people who lost their lives in the tragic Milan Linate crash on 8 October 2001. An SAS MD-80 aircraft was taking off on the departure runway in heavy fog, and a confused Cessna business jet wrongly taxied onto the active runway, with controllers who were also confused about location of the aircraft with imperfect aircraft situational displays. Eleven people were charged, including airport managers, civil aviation officials, air navigation officials, airport managers, and the controller.
A long process of criminal charges ensued, with really no resolution satisfactory to anyone. Convictions, appeals, suspended sentences, acquittals. None of us want to see some one else suffer unless they are active wrongdoers, but all of us want a sense of accountability, of making sure it doesn’t happen again. Much as the unfortunate criminal charges in the Concorde case, after an over 10 year investigation and prosecution, have generally left everyone with a bad taste in their mouth, whether you won or lost. Absent willful misconduct or gross negligence, criminal prosecutions and charges, with long, expensive trials, and mixed verdicts, don’t really help anyone, and often only add to the victims.
Allow me to begin by commending this Task Force and to you for holding this Listening Session. Too often governments go behind closed doors, either before or after a crash, and talk only to themselves or a select industry insiders—“parties to an investigation”—only to emerge later with either probable cause determinations from a crash or rules based on voluntary disclosures. Yet, we the passenger, the traveling public, are those with the biggest stake in what you are doing. We can and should have a place at the table. We deserve to be consulted, not just to ask how you might be of “assistance” after a crash or “briefed” at your progress along the way, but part of the process for arriving at corrective fixes, so that we not only know our loved ones have not died in vain, but incidents and accidents are reduced drastically.
So I again commend you for holding this listening session, and encourage ICAO and all of my friends in the aviation industry—regulators, accident investigators, lawyers, insurers, aerospace manufacturers, and airlines—to seek our input as you study and consider safety problems and solutions. You might be surprised that we can offer you unique and balanced perspectives, and be very helpful in ensuring that safety information is used only for safety related purposes.
As you might expect, in the wake of a crash where one of your loved ones just died, you are very upset. You not only seek answers. You seek accountability. You not only seek compensation. You seek justice. But as the weeks and months and years pass, you come to accept the fact that so long as human beings are involved, as they must, in the design, flying, maintaining, and controlling of aircraft, with imperfect technology, people will make mistakes. Bad mistakes. Mistakes that lead to catastrophic consequences.
So what do we do? Add to the victims of terrible tragedy by putting others in the cross hairs of prosecutors? Put a dark cloud over aviation professional’s careers for over a decade for something they did or did not do? These people, nearly all of them well intentioned, probably got up in the morning just as our loved ones on a fateful day, and did not mean to cause anyone harm. In fact, virtually all of the people that I know in aviation—like the great people in this room—wake up every day trying to make an extraordinarily safe aviation system even safer. They put themselves often in the cockpit. Their lives are just as much at risk as our loved ones were. They did not intend to do harm. They intended to get people to where they wanted to go, on time, and hopefully without losing their bag.
Having made this point, this Task Force should not suggest immunity for aviation professionals. All too often, in the wake of tragedies, we see unacceptable conduct, cutting corners, taking risks that should not have been taken, putting people in harm’s way. If an aviation mechanic puts down that he or she did something when they did not, there can be no free pass for falsification, or “pencil-whipping.” If a pilot or company knows they are too fatigued for safe flight, or God help us, under the influence of drugs or alcohol, then there should be no mercy. Criminal laws, prosecutors, and judges are there to protect us, and when someone is wrongdoing, hold them accountable. Criminal sanction can be an effective deterrent to doing the wrong thing.
One of the existing problems in the circulation of reports and anonymous reports-- which are fundamental for encouraging the flow of information necessary for “Risk Management” and “Risk Assessment” reports that are needed to improve and implement the system -- is the often difficult relationship between technical and judicial investigations, despite the continuous and constant call for a “just culture” made by all pertinent professionals and experts in the sector.
"Collection of the largest amount of the most diverse data is essential for identifying new paths in the implementation of Flight Safety.”
Accidents and incidents are becoming rare, that to identify new threats, safety professionals must analyze vast of operational safety data. Often this data much be consolidated from sources in multiple countries who are subject to widely varying laws.
Therefore, it is increasingly important to identify a place, method and procedures that can encourage the flow of information and protect people with useful information who are hesitant or concerned about possible consequences, especially in contexts where maintaining anonymity is difficult.
Despite the continuous commitment of all professionals in the sector to affirm and promote the principles of “just culture” and the increasing number of unfavorable temporary employment contracts in all sectors of air transportation, the greater presence of the Magistracy in the event of air crashes to guarantee and protect users and to reaffirm their importance (as in the cases of Air France 447, Mangalore, and Windjet Palermo) further inhibits and discourages the flow of data and weakens the determination of the people who wish to provide this information.
In this perspective, the Technical Task Force of Fondazione 8 ottobre 2001 has found a solution: identifying an impartial, charismatic, independent, non-profit international organization that is recognized and respected worldwide, which can collect and process data and information and ensure anonymity.
This organization should reside in a country whose laws guarantee the anonymity of the person providing the information with the aim of improving safety and identifying the cause of accidents to prevent all types of problems on every level.
I believe that the FSF has all these qualities, including its location, to be this association.
If we could reach an agreement with ICAO (and also FAA, EASA, Eurocontrol, etc.) for the purpose of providing specific information to countries to encourage this path, it would be easy to make it possible, on a local level, for air transportation workers to use special forms to send their information to a specially formed Task Force with specific expertise. This Task Force would analyze and interpret the information and compile a document in a completely anonymous format that would nevertheless provide information about existing or emerging critical aspects based on the application of the various known “risk matrices” and, if requested, even supply possible suggestions or advice for the prevention of these aspects.
The same problems also exist with technical flight data monitoring and air traffic data.
All this data is most valuable and useful for prevention when collected in large and significant amounts over a long period of time.
Sharing data across borders, without constrictions from local criminal laws, is imperative for safety.
Furthermore, many countries are unable or too small or are not structured to have an organization to collect enough data to detect emerging threats.
The Flight Safety Foundation could be the independent, impartial and unbiased organization that is the valuable “gatekeeper” for this data.
Of course, financial support would be needed to create this system, study and implement these procedures to ensure the correct flow of information in an anonymous form, opportunely distribute and promote this project on all levels in the various countries, also through specific conferences, and maintain this service in the future.
There could be a sort of “subscription” to this service, which I believe is extremely useful for the entire aeronautics industry, starting with the authorities of Civilian Aviation, Service Providers, Professionals, and so on.
I believe this project could “revitalize” and help give the FSF a new and important role in its mission to ensure safety, to which it has been committed since 1947.”
In Italy this project has already received an important political and specific support and the Centro Studi DEMETRA shares it with us.