Journal of Aviation Management 2013 by Singapore Aviation Academy

Journal of Aviation Management 2013
Published by Singapore Aviation Academy
A Division of the Civil Aviation Authority of Singapore
1 Aviation Drive Singapore 499867
Tel: (65) 6540 6209/6543 0433 Fax: (65) 6542 9890/6543 2778
Email: saa@caas.gov.sg Website: www.saa.com.sg

Copyright © 2013 Civil Aviation Authority of Singapore. All rights reserved.
No part of this Journal may be reproduced or transmitted in any form or by any means
without prior approval of the publisher, except for quotations in book reviews.
Views expressed in this Journal are the authors’ personal observations and not
necessarily the views of the Civil Aviation Authority of Singapore. While every
reasonable care has been taken in the preparation of the Journal, the publisher
is not responsible for any inaccuracies in the papers.
Cubism is an art movement that challenges visual conventions
by depicting its subjects from multiple viewpoints, allowing
subjects to be represented with greater depth. Knowledge,
like art, is strengthened by a multiplicity of perspectives. By
gathering the diverse viewpoints of the different stakeholders
from the international aviation community, the Journal of
Aviation Management strives to be a platform for a global body
of knowledge to be developed, enhanced and shared.
A Multi-faceted Exchange

i
Foreword
Yap Ong Heng
Director-General
Civil Aviation Authority of Singapore
As the Journal of Aviation Management enters its thirteenth year, it continues to serve as
an intellectual platform for the sharing of knowledge and experiences on developments as
well as topical issues affecting international aviation. The themes for this installment of
the Journal reflect this – accident investigation, airport emergency management, aviation
safety and security as well as human resource and training, with the papers put forward
by leading experts from Singapore and around the world.
In the section on accident investigation, highlighted are the key elements of an
accident investigation establishment and the increasing influence of media on accident
investigation which has led to a reassessment and exploration of communication
tools for greater transparency and effectiveness. The section on airport emergency
management elaborates on the new standard test protocol for compressed air foam
systems and Class B fires which is being developed by the International Civil Aviation
Organization (ICAO) to improve aircraft rescue and fire-fighting efficacy.
A dedicated section on aviation safety takes a closer look at Europe’s experience
with just culture, ICAO’s role as well as the relationship between the culture of
an organisation and the management of operational risks. The section also looks
at safety performance measurement and the collection and analysis of safety
data. The aviation security section highlights the challenges and opportunities
discussed at the High Level Conference on Aviation Security held in September
2012 as well as ways to enhance the security of civil aviation globally.
Last but not least, the section on human resource and training looks at how
competency-based training can be adapted to address the huge demand
for aircraft maintenance personnel. It also reviews the work of ICAO’s
Next Generation of Aviation Professionals (NGAP) Task Force aimed at
attracting, retaining and developing the human resource required to
deliver aviation services to the world.
To the authors and the members of the Editorial Advisory Board,
I would like to express my appreciation for their valuable contributions,
without which this publication would not be possible. To the readers,
I hope this issue of the Journal will not only serve as a useful resource,
but also inspire you to contribute more to the aviation industry.

Mr Cletus M J Packiam
Chief Airport Emergency Service
Changi Airport Group, Singapore
Mr Chiang Hai Eng
Director, Asia Pacific Affairs
Civil Air Navigation Services Organisation
Dr Michael Lim
Director, Singapore Aviation Academy
Civil Aviation Authority of Singapore
Dr Jarnail Singh
Chairman
Civil Aviation Medical Board, Singapore
Mr Mark Reeves
Director, Asia Pacific Office
Federal Aviation Administration, US
Mr Ken McLean
Director, Safety Operations & Infrastructure (Asia Pacific)
International Air Transport Association
Mr Bernard Lim
Director, International Relations & Security Division
Ministry of Transport, Singapore
Prof Henry Fan
SAA Fellow
Ms Chan Pin Pin
Ms Jasmin Ismail
Ms Addrienne Kang
ii
Editorial Advisory
Board Members
Editorial
Team

iii
Contents
Accident Investigation
Airport Emergency Management
Accident Investigation – In Pursuit of Safer Skies 1
Y P Tsang
Civil Aviation Department, Hong Kong SAR
AF 447 Investigation – Media Influence, Transparency and Communication 9
Ms Martine Del Bono
French Bureau of Investigation and Analysis for Civil Aviation Safety
Future Trends in Aviation Safety, Aircraft Rescue and Fire-fighting Efficacy 17
Kim Thorbjørn Olsen
Copenhagen Airport, Denmark
Aviation Safety
Just Culture in Aviation: The Best of Two Worlds 23
Roderick van Dam
EUROCONTROL
Safety Performance Measurement – Quantifying Safety Performance Indicators
and an Acceptable Level of Safety 31
Teo Gim Thong
International Civil Aviation Organization
The Safety of the Flying Public is Our Top Priority – Do We Say What We Mean
and Does it Matter? 45
Capt Paul McCarthy (Retired)
Turning Data into Safety 53
Joseph Teixeira
Federal Aviation Administration, US
1
2
3
4
5
6
7

iv
Competency-based Training in Aircraft Maintenance 69
Lim Yeow Khee
President, Singapore Institute of Aerospace Engineers
Global Efforts to Address Shortage of Aviation Manpower 83
Dr Paul Bates
Griffith University, Australia
Aviation Security
Aviation Security – Challenges, Opportunities and the Way Forward 63
Bernard Lim
Ministry of Transport, Singapore
Ms Patricia Reverdy
European Civil Aviation Conference
Human Resource and Training
8
9
10

– In Pursuit of Safer Skies
Although air transportation is widely recognised as the
safest mode of transport, the aviation community, including
air accident investigators, continues to work relentlessly to
make our skies even safer. Annex 13 to the Convention on
International Civil Aviation – Aircraft Accident and Incident
Investigation (Tenth Edition July 2010) (hereafter referred to
as “Annex 13”) specifies that the objective of the investigation
of an accident or incident is for the prevention of recurrence
and not for the purpose of apportioning blame or liability.
The identification of causal factors to prevent recurrence
is best accomplished through a properly conducted
investigation. To meet these international obligations and
to enable a proper investigation of accidents or incidents
to be conducted, the government authority needs to put
in place an appropriate establishment. This paper highlights
the key elements of an accident investigation establishment,
making reference to the experience of accident investigations
conducted by the Hong Kong Civil Aviation Department (CAD)
and to showcase the new accident investigation facilities
in Hong Kong.
ABSTRACT

Mr Y P Tsang is the Deputy Chief Inspector of Accidents of CAD
of Hong Kong SAR.
MrTsangstartedhisaviationcareerin1974withtheHongKong
Aircraft Engineering Company (HAECO) as an apprentice.
He obtained his aircraft maintenance engineer qualifications
in 1980. He was awarded the first International Federation
of Airworthiness (IFA) scholarship the following year and
worked at various customer organisations at the Boeing
Commercial Airplane Company in Seattle, US for a
year. Upon his return to HAECO, he was involved in
a number of departments including Technical Services
and Quality Assurance. In 1985, he was responsible
for the design and installation of the modernised
environmental control system into the Y7 aircraft
manufactured by Xian Aircraft Company.
Mr Tsang joined the CAD in 1995 and was
responsible for the certification of aircraft,
assessment of major modifications and repairs.
He was appointed the Deputy Chief Inspector
of Accidents in 2003 and was the Investigator
In-charge of the Eurocopter EC155 fatal
accident in Hong Kong in the same year.
THE AUTHOR
Accident Investigation – In Pursuit of Safer Skies

JournalofAviationManagement2013
1
Y P Tsang
Civil Aviation Department of Hong Kong SAR
INTRODUCTION
With very low accident rates in recent decades, air transportation is widely recognised as the
safest mode of transport. The aviation community, including airlines, aircraft manufacturers,
maintenance organisations, air navigation service providers, airport operators, and the safety
regulators have been working closely to make our skies safer. Amongst all the stakeholders
involved in the aviation industry, there is a particular group of aviation professional who
are seldom mentioned, yet they contribute significantly to improving aviation safety.
They are the air accident investigators – the people whose job is to determine the causes
and circumstances of air accidents and incidents so that similar accidents can be prevented.
One accident is one too many; and whenever it happens, it is bound to hit the news headlines
across the globe almost instantaneously. The idealistic aspiration of zero accident, albeit
statistically unachievable, keeps everyone in the aviation profession focused on building an
increasingly safe aviation system.
In the international civil aviation regime, Article 26 of the Convention on International
Civil Aviation (Ninth Edition 2006) stipulates that it is incumbent upon the State in which
an aircraft accident occurs to institute an inquiry into the circumstances of the accident.
Annex 13 further specifies that the objective of the investigation of an accident or incident
is for the prevention of recurrence and not for the purpose of apportioning blame or liability.
The identification of causal factors to prevent recurrence is best accomplished through
a properly conducted investigation.
To meet all these international obligations and to enable a proper investigation of accidents
or incidents to be conducted, an appropriate establishment needs to be put in place by
the Contracting States. With continuous air traffic growth globally, such an air accident
investigation establishment is essential and instrumental to support the growth and
development of a safe and sustainable air transport system. It should comprise, inter alia, the
following six key elements:
INDEPENDENCE IN ITS AUTHORITY TO INVESTIGATE
Independence in its authority to investigate is of utmost importance. The organisation
responsible for conducting air accident investigations must be strictly objective and totally
impartial, and must also be perceived to be so. It should thus be established in such a way so
as to be immune from political interference or pressure.

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Some States, particularly those with a large volume of air traffic and a wide range of
aviation activities, have achieved this important objective by establishing their air accident
investigation authority as a separate statutory body independent of the civil aviation regulatory
authority (CAA).
In many other States with relatively small scale of aviation activities, it may not be practical or
economically viable to adopt such an arrangement. To achieve a certain level of independence
in accident investigation, these States may set up an arrangement whereby, in the event
of an accident or serious incident, the State would mobilise a normally dormant accident
investigation team comprising qualified investigators, or appoint a separate commission, to
conduct the investigation and report independently to the appropriate authorities.
Because of the dormant characteristics of such a setup, few, if any, of the team or commission
members would be fully employed as accident investigators. Some members may be seconded
from the state regulatory agencies on a need basis. In such circumstances, clear delineation
of responsibilities and duty specifications must be included in the appropriate legislation
emphasising the importance of independence, impartiality and objectivity of an investigation.
In the course of an investigation, clear policies should also be established to ensure at least
the following:
• No conflict of interest exists between members of the investigation team and parties
under investigation.
• Members of the investigation team shall adhere to the objective of accident investigation
in defiance of political and commercial considerations.
• The investigation team is to report directly to the head of the investigation organisation
who should report directly to the government/administration, independent of the CAA.
• The findings and recommendations of an investigation team shall not be influenced or
tampered with by any other party not involved in the investigation.
Although the above arrangement may not be ideal, there are many successful examples
worldwide which demonstrate that the independence of investigation has been maintained.
It is most important for States, administrators and all those who are involved in air accidents
investigation to understand the objective of maintaining independence in investigation, adopt
the arrangements that best suit their needs and circumstances, and implement it effectively
through a sound and auditable mechanism.
SOUND LEGAL AND REGULATORY FRAMEWORK
The second key element for the establishment of a highly functional air accident investigation
setup is the availability of a sound legal and regulatory framework in support of its mission,
and to provide accident investigators with the required legal authority for the conduct of safety
investigation in accordance with the provisions of Annex 13.

3
Appropriate legislation that defines the scope of work and responsibilities of the accidents
investigation establishment and those of accident investigators must be put in place. In this
connection, accident investigators should be aware that air accidents may not only be subjected
to technical safety investigation, but also to other judicial, statutory, administration or regulatory
inquiry. Clear provisions and procedures should thus be formulated to keep the technical safety
investigation separate from other proceedings.
The legislation and regulations should also clearly specify that the sole objective of the technical
investigation is accident prevention and it is not to apportion blame or liability.
The legislation must also protect certain documents and information obtained during the
investigation from public disclosure in accordance with Annex 13. This is particularly important
as information contained in some records may include information given voluntarily by persons
interviewed. Inappropriate exposure of information obtained in the course of an investigation
for purposes other than the prevention of accidents would inhibit disclosure of information
from witnesses in future. It would impede the work of investigators and negatively impact the
thoroughness and accuracy of future investigations, at the expense of promoting safety.
QUALIFIED INVESTIGATORS
The next key element is the people actually engaged in conducting accident investigations. Even
in today’s highly modernised and technology-driven society, the significant involvement and
contribution of human efforts in accident investigation is indispensable.
Accident investigation is a highly specialised and time-critical task involving expertise in a wide
range of aviation and non-aviation disciplines. The quality and outcome of an investigation are
heavily dependent on the competence and capabilities of the investigation team. As such, accident
investigation should only be undertaken by people with the right calibre and experience, and
are specially trained.
Accident investigators should ideally have a professional background in aviation, such as pilot,
aeronautical engineer or aircraft maintenance engineer. The possession of expert knowledge,
skills and a thorough understanding of the aviation operating environment is of paramount
importance to an accident investigator. Other aviation personnel who possess experience in
aviation management and operations, air traffic control, meteorology and human factors could
also contribute positively to accident investigation.
In addition to technical expertise, an accident investigator should also possess certain personal
attributes, including integrity, impartiality, and perseverance in pursuing evidence collection,
analysis, research and communication skills. An accident investigator must also be logical and
methodical in thinking. He or she needs to be tactful, attentive to details and empathetic,
especially in dealing with those who survived from the trauma of an air accident.

4
Upon recruiting the right people, the next important step would be the provision of a structured
induction training programme. This is essential to develop investigators’ ability, competence
and experience for investigation tasks of various complexity. Novice investigators should be
guided by experienced mentors until they are fully competent to work independently under
the most taxing situation. The training programme should include rules and regulations, Annex
13 provisions, local legislation, interview and investigation techniques, latest investigation
technologies, investigation procedures, on-the-job, recurrent and specialised training.
SOUND MANAGEMENT SYSTEM
To be prepared in the event of accident or serious incident, a response plan must be put in
place for the activation of the investigation processes in the most expeditious manner. The
availability of a sound management and support system is thus essential to ensure operational
readiness for the timely activation of the accident investigation process, especially in the
following areas:
• Regular review on safety regulations and investigation policies;
• Quick response plan;
• Safety data and information management; and
• Public relations management and support.
With the continuous growth of the aviation industry and the rapidly changing technologies and
safety requirements, there is a need for every aviation organisation to constantly review and
update their organisational policies and operations to keep pace with the latest developments.
Quick response actions can only be achieved through adequate planning, coordination and
drills before an accident or incident actually occurs. The setting up of quick response ‘Go-
teams’ will enable the accident investigation establishment to expeditiously respond to the
accident or incident for the collection of evidence, especially volatile evidence, as well as the
timely coordination of the investigation process.
It is also pertinent that a Safety Data and Information Management System be established
for the preservation of accident information and evidence and, whenever necessary, sharing
of safety information within the organisation and with external parties during and after the
investigation. Safety promotion constitutes an important component of safety management
and the State Safety Programme (SSP). It is essential that safety information and accident
prevention measures be promulgated widely across all spectrums of the aviation industry to
achieve overall safety improvement.
Accidents or incidents often generate a high degree of interest from the public and the
media. A clear public relations policy and procedure for the release of accident investigation

5
information would be most helpful in managing public sentiment and undesirable speculations
on the causes of the accident. Regular meetings with the media provide timely update on facts
to the public without prejudice to the investigation process. Senior investigators should be
given training on media management and opportunities for public speaking.
EFFECTIVE COORDINATION WITH OTHER STAKEHOLDERS
The circumstances surrounding each air accident or incident are different. To prepare for
the eventuality of an air accident or incident, it is important that the accident investigation
establishment set out a pre-coordinated working arrangement with other local authorities to
facilitate smooth coordination and initiation of the respective emergency response in support
of the investigation team.
To achieve this, the accident investigation organisation may establish formal working or
cooperative arrangements with other government agencies involved in disaster response,
particularly the police department, fire services department, search and rescue units, medical
services and the coroner’s office. Such cooperative arrangements will foster better understanding
amongst all stakeholders of the need of the investigators in the preservation of evidence.
In addition, the air accident investigation organisation may also have to seek assistance
from other organisations to provide facilities, equipment and specialised services, additional
manpower, e.g. heavy salvage and lifting equipment, helicopters, metal detectors, divers
and surveyors during the investigation. It is thus important that arrangements be reviewed
and expertise be identified in advance to ensure that resources are readily available
when needed.
INTERNATIONAL AND REGIONAL COLLABORATION
The International Civil Aviation Organization (ICAO) and all of its Contracting States share
a common goal of achieving safety, security, efficiency and sustainability in civil aviation.
Close regional and international collaboration serves to obliterate the confines of the physical
boundaries of States, and facilitates working towards achieving common standards and
objectives of accident investigation amongst Contracting States.
On accident investigation matters, international and regional collaboration may include the
delegation of investigation responsibilities, engagement in mutual assistance and cooperation,
sharing of resources, specialised facilities, equipment and expertise in investigation.
On accident investigators’ training, areas of collaboration may include the provision of
investigators’ recurrent training, job attachment programmes, joint organisation of training
events, etc., to facilitate and promote knowledge sharing as well as to broaden the exposure
and enhance the competency of investigators.

6
Through strengthened and closer cooperation between States and regional investigation
authorities, the capability of air accident investigation organisations can be mutually enhanced
to achieve a higher quality of investigation, thereby contributing to the good cause of
aviation safety.
LATEST DEVELOPMENT IN HONG KONG
The Hong Kong CAD is presently taking proactive steps in working towards improving its
accident investigation capability.
Under the current arrangement, Hong Kong has an independent investigation system under
the management of the CAD. The Accident Investigation Division (AID), a normally dormant
division under CAD, is responsible for the investigation of aircraft accidents and serious
incidents in accordance with the Civil Aviation (Investigation of Accidents) Regulations. The
conduct of air accident investigations in Hong Kong is in compliance with the Standards and
Recommended Practices of Annex 13.
The AID will be mobilised in the event of an air accident or serious incident occurring in Hong
Kong by drawing specially trained and qualified staff from within CAD. Currently, the AID
has a pool of over 30 qualified investigators who possess considerable practical experience in
aviation. They come from a wide range of professional backgrounds, and have been properly
trained in areas covering:
• Flight operations;
• Airworthiness;
• Air traffic control;
• Special aviation subjects such as human factors, flight data recorders, survival aspects, etc.
Once the accident investigation team is activated and tasked with the responsibility to launch
an investigation, the investigators are vested with the appropriate authority and are required
to be entirely independent and free from any interference from other parties involved in
the accident in order to maintain strict objectivity and total impartiality. Independence is
firmly achieved through the provision of the Investigation Regulations, and an independent
procedural and reporting arrangement within CAD.
To provide day-to-day administrative and management support to the AID, an Accident
Investigation Office (AIO) was also established in 2012. The mission of the AIO is to enhance
the capability and ensure the operational readiness of the AID, including regular review of
the investigation procedures, quick response actions, investigators training arrangements,
management of the safety information system and provision of public relations support.
With the commissioning of the new accident investigation centre located in the new CAD
Headquarters at the Hong Kong International Airport, the AIO also has the responsibility of
managing and upkeeping the investigation facilities.

7
This purpose-built accident investigation centre which occupies a floor area of about 700 m2
,
provides dedicated facilities for conducting air accident investigations including:
• An accident investigation command centre to facilitate coordination during various
phases of accident investigation (see Picture 1);
• A flight data recorder centre for the downloading and analysis of flight recorder data
and voice recordings;
• A 200 m2
fully air-conditioned hangar for the storage of evidence and critical parts of
recovered wreckage; and
• Interview rooms.
The commissioning of the new accident investigation centre in Hong Kong will provide an
additional platform for the exchange of knowledge and experience with other parties and
investigation agencies.
In terms of regional and international collaboration, the CAD has in recent years, signed
cooperation arrangements with a number of overseas investigation agencies allowing it to
share investigation skills and expertise when required. AID investigators under training also
acquire knowledge and experience by participating in full-time attachment programmes with
these agencies. Such arrangements have achieved positive results since its implementation.
In addition, coordination arrangements with the local judicial authorities and relevant
government departments have also been established to ensure common understanding
of the roles and responsibilities of the investigator and the need for the preservation
of evidence.
Picture 1: The Accident Investigation Command Centre

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In taking on all these challenges, AID investigators have one common goal – to continually
enhance the competence in the field of air accident investigation to better serve the aviation
community. The purpose is to enable proper investigation to be conducted with the objective
of improving aviation safety. It is through the safety recommendations that we may avoid
recurrence of similar accidents.
References
International Civil Aviation Organization. (2010). Annex 13 to the Convention on International Civil Aviation –
Aircraft Accident and Incident Investigation. (Tenth Edition July 2010). Canada. International Civil Aviation
Organization.
International Civil Aviation Organization. (2006). Convention on International Civil Aviation. (Ninth Edition).
Canada. International Civil Aviation Organization.

AF 447 Investigation – Media
Influence, Transparency and
Communication
ABSTRACT The Air France flight 447 (AF 447) accident resulted in intense
media scrutiny, wild speculations, demands for transparency,
document leaks and subsequent disinformation. Various
dynamics had hindered the French Bureau of Investigation
and Analysis for Civil Aviation Safety (BEA) Department of
Communication’s ability to fulfill its mission. Globalisation and
the development of the internet led to a tremendous shift in
the relaying and processing of information. In this context,
challenges faced by the Department of Communication in
informing both relatives and the public led to a reassessment
of its communication tools. This paper highlights the
benefits of social networks and suggests the importance of
an international effort. It also highlights the need to align
communication media with a global online 21st
century
public and increase cooperation among the Department of
Communication’s international counterparts.

AF 447 Investigation – Media Influence, Transparency and Communication
THE AUTHOR
Ms Martine Del Bono is Head of Public Affairs of the
French BEA. She has extensive experience in the fields of
international and cross-cultural communication at the Paris
Institute of Political Studies. She joined the BEA in 2002
and was subsequently promoted to her current position.
Her mission includes designing and implementing
communication strategies following major air accidents,
ensuring appropriate access to information with media
outlets, victims’ relatives and the public as well as
promoting the interests of air safety within the
aviation community. Since 2007, she has also been
conducting crisis communication training sessions at
the French National School of Civil Aviation (ENAC).
Ms Del Bono has a Master’s Degree from Sorbonne
University’s Graduate School of Information and
Communication Sciences (CELSA), France.

9
Ms Martine Del Bono
French Bureau of Investigation and Analysis for Civil Aviation Safety
ABOUT THE AF 447 ACCIDENT
On 31 May 2009 at 22:29 Universal Time Coordinated (UTC), the Paris-bound AF 447 took
off from Rio de Janeiro, Brazil. There were 228 persons on board representing 32 different
nationalities – three flight crew members, nine cabin crew members and 216 passengers. The
last radio communication between the crew and the Brazilian air traffic control took place at
1:35 UTC. Between 2:10 and 2:15 UTC, a position message and 24 maintenance messages
were transmitted by the Aircraft Communications Addressing and Reporting System to
the Air France Operations Coordination Centre in France. On Monday 1June 2009 at around
7.45 am local time, the BEA was alerted by Air France. After having established that the
airplane had disappeared in international waters, and in accordance with Annex 13 (Aircraft
Accident and Incident Investigation) to the Convention on International Civil Aviation, the
BEA, as Investigation Authority of the State of Registry of the airplane, launched a safety
investigation and a team was formed to conduct it.
INTRODUCTION
The mission of the French BEA is to improve air safety; that of the Department of Communication
is to ensure an efficient relay of information from investigators to victims’ families and the
public. To do so, it conducts private meetings with relatives, uses telecommunications and
coordinates press conferences.
In the case of the AF 447’s accident investigation, several communication issues were
encountered in the course of the investigation. Round the clock international media coverage,
lengthy wreckage and flight recorders’ localisation and recovery, a carrier-manufacturer blame
game, document leaks, and media speculations were all factors that contributed to a public
loss of confidence not only in the Bureau’s findings and conclusions, but in its transparency
and ability to remain an independent entity. The questions that needed to be raised by the
Department of Communication in order to improve its ability to inform the public were
determined by its experiences. Indeed, its actions and inactions had both directly and indirectly
contributed to its own discredit. Challenges faced during this high-profile investigation led
the Department to re-examine its current means of communication, its platform and its
public exposure.

10
DISINFORMATION AND TRANSPARENCY
In the few hours following announcements that AF 447’s location was unknown, a cycle of
disinformation ensued. Victims’ relatives had to deal with both immense emotional crisis
and intense media spotlight. Reporters “offered” an introspect into the families’ grief,
provided wild speculations, featured various experts on its programmes, and tried to confront
any entity it could, from the manufacturer, the carrier, the French National Pilots Union, the
BEA and the European Air Safety Agency. The investigation carried on. Each time the BEA
released details about the search for the wreckage or validated findings, the cycle started all
over again. Families were interviewed outside the BEA or at their home; the media offered
its own interpretation of the causes of the accident – as if to solve what had been labelled
“the mystery of AF flight 447”; so-called experts were called back on set; and confrontations
went on.
If we assume that the mission of the media is to report accurately on the progress of the
investigation, sadly it often fails to do so. Viewers are implicitly taught to ignore the technical
aspects of the investigation and to focus on the BEA’s “hidden agenda”. If the Bureau is not
releasing new findings, then it is open season on the manufacturer and the carrier. If that
option has been exhausted, then it is the turn of the pilots and the release of details about
their private lives. In a nutshell, the investigation into a tragic air accident that has decimated
families all over the world is treated like a public spectacle.
In this context of inadequate media coverage on a global platform, the BEA’s achievements
remained grossly understated and its mission widely misunderstood. What member of the
public can fully grasp the difficulties encountered in creating an international effort to both
localise and recover the wreckage and flight recorders from a 3,900-metre deep mountainous
seabed? Who knows about the daily phone calls in the middle of the night by journalists
asking the BEA to comment on wild speculations; only to find out that the said comments
had been utterly ignored in the morning’s articles and televised news reports? Or, last but not
least, who can properly define the BEA’s mission? Who understands that it does not act as a
penal institution, in that it does not accuse the pilots, their training or the manufacturer, but
only determines the combination of factors and chain of events leading to an air accident?
Misrepresentations have drastic consequences on perceptions. For instance, ICAO’s Annex
13 (Aircraft Accident and Incident Investigation) logically recommends cooperation among
the bureau of investigation, the manufacturer and the carrier to enable optimum expertise.
However, when the BEA is portrayed as a penal institution working with the manufacturer
and the carrier, cooperation and confidentiality raise suspicions about a potential conflict of
interest. Public demand for transparency is then logical. After all, it has been told repetitively
that things do not add up. This inevitably set the stage for document leaks on moral grounds,
and the opportunity was seized. For example, shortly after the cockpit voice recorder was
played to a restricted audience at the BEA’s headquarters, its contents were leaked and

11
published in a book. The author, a flight instructor not involved with the investigation, released
personal details about the flight crew’s casual conversations. The leak was then featured in
various documentaries and news programmes, and the author’s actions were hailed by many
as an example of investigative journalism.
A PARADOX
The media influence on the belief that the BEA had an agenda other than that of investigating
was never supported by actual evidence. Unfortunately, the repetitive nature of the message
combined with a large scale reach resulted in a logical demand for transparency, or “public
supervision” of the investigative work the Bureau conducted. Paradoxically, news outlets
seemed to be exempt from transparency. Is it not the role of the media to report based on
accurate information obtained through sources with actual evidence? In the case of the BEA’s
investigation and for most reports, this was not upheld. Indeed, media accountability was at
a low.
What followed was a domino effect from one network to the next, to the point where the
message in the headline prevailed over the veracity of the claim and the accountability of both
the individual making it and the outlet reporting it. For the BEA’s Department of Communication,
the battle was often lost before it began. Any comment offered with supporting evidence
refuting a frivolous claim was ignored. As soon as the headline had spread like wildfire, any
action by the Department was viewed as a defence strategy. To add fuel to the fire so to
speak, time constraints associated with the process of validating findings did not allow the
BEA to “wave evidence” which was kept confidential. This made matters worse. All in all,
blowing the whistle is sometimes necessary to preserve public interest. However, blowing the
whistle without evidence is merely fabrication. Most of the so-called blowing-the-case-wide-
open reports found in the press were based on a simplistic approach to an extremely complex
investigation and a disregard for information made available to the public by the BEA.
If transparency is the subject of many a controversy, the concept of privacy is not. Victims’
relatives do have a choice in welcoming reporters to their homes, being interviewed on
network television sets and sharing their views or intimate details related to their grief. There
were literally dozens of instances in which the relatives’ privacy was grossly overlooked, such
as the frivolous manner in which the number of bodies recovered were reported, close-ups
on body bags being unloaded in Brazil and so on. Tragically, such reports had the blueprint of
a tabloid article, and did not contribute whatsoever to public understanding on the causes of
the accident.
With the occurrence of such phenomena, one may feel compelled to ask: what type of
transparency is expected from an investigative body? Is the need for transparency actually
justified or is it the result of baseless speculations created by the media, combined with a
lack of large-scale reach and informative content from the Department of Communication on

12
regulations and procedures during an air accident investigation? How can the BEA be more
transparent than it already is? The BEA followed procedures that are publically available. The
recovery of the wreckage and that of the flight recorders were televised. Press conferences
were hosted by the Director and open to all members of the press, where every single
question was answered by the chief investigator and BEA technical experts. The Department
of Communication took calls from reporters 24/7 and accepted to confirm or deny even the
most outrageous claims. Lastly, the BEA’s website was open to all, and although its contents
could be extremely technical, the Director provided explanations in layman’s terms on camera.
PUBLIC REACTION
With the ever-increasing use of the internet, getting information is as easy as entering a URL
or logging into a social networking site to access a customised selection of media sources. The
public can then get a better overview of available reports, and thus observe the subjectivity
of some and the accuracy of others. The widespread use of comment sections or likes/dislikes
(quick approval or condemnation of articles, videos and individual comments) enabled the
BEA to observe some of the effects of disinformation on populations. If the message in the
press is often one sided, public reaction is not.
Extensive research into the comment sections of both social networking sites and online
media outlets produced five distinct categories of reactions from the public. The first focused
on expressing condolences to the families of the victims. The second denoted a complete
trust in media reports and the subsequent sharing of views on how the BEA could not be
trusted, was incompetent and possessed a secret agenda. The third was more informed, often
mentioning some professional qualifications related to either aviation, engineering or other
technical fields and underlining discrepancies in the report itself. The fourth kind of reaction
denounced the flip-flopping of most media outlets and their untrustworthiness. The last type
consisted of approaching the release of information objectively, taking into account not only
the article but also comments from readers. Fortunately, this enabled a better outlook on any
report and better judgment on their veracity.
Thanks to the existence of comment sections across various online platforms, the public was
given the opportunity to fight disinformation and acquire a more mitigated view of a particular
event. The specific nature of social networking sites such as Facebook and YouTube also
allows for a direct release of information from media outlets and/or reporters that are fully
dedicated to their mission. The existence of such sites and accurate reporting by some news
agencies has proven to be of paramount importance to the Department of Communication.
Although a very significant percentage of the global population, companies and organisations
use a variety of social networking sites, the BEA was not present on any of them. For all intent
and purposes, the issue of public demand for transparency would partly solve itself if the BEA
could communicate directly with the public.

13
SOLUTIONS: FRAMEWORK
The press’s cooperation, or lack thereof, in relaying accurate information cannot always be
predicted or assumed. The accuracy of media reports depends not only on networks, but on
individual reporters as well. The BEA’s Department of Communication entertains a bittersweet
relationship with the press; however taking preventive measures to alter this relationship
would act against the French Republic’s core values and thus the mission of the Department
of Communication. The “quick fix-do what it takes” approach would offer options that yield
to rather disastrous consequences. For instance, giving exclusive access to particular reporters
would infringe on the freedom of the press; blacklisting networks based on a 3-strike policy
with regards to disinformation would infringe on freedom of speech; and responding to each
and every inaccurate coverage and singling out reporters would not only create opportunities
for sensationalised BEA versus media war but would also produce an additional basis for
disinformation and accusatory statements. If solutions do not reside in altering the relationship
with the press, should the Department of Communication then turn to inaction? After all, the
BEA is an investigative body with a clear mission.
It can be argued, that as long as informative content is posted on its website and publically
available, its mission has been fulfilled; and that whether information is sought, altered, or
accurately reported by both the media and the public is not the Department’s primary concern,
as long as it communicates findings. However, viewed in the context of an air accident often
accompanied by a loss of life, grieving families and with a team of investigators working
relentlessly, the Department of Communication can and should, do better. Looking at the
process by which the public is misled on the BEA’s mission, misinformed on validated findings
and given unrealistic expectations in regards to the time frame of the investigation, one can
observe three elements:
• First, the media utilises platforms that are more effective than the BEA’s website;
• Second, the media centers its message on a single headline; and
• Lastly, information released by the BEA needs to be sought, contrary to media reports that
are delivered to the public, oftentimes through social media sites.
Should the Department of Communication turn to similar platforms to become more effective?
SOCIAL MEDIA
The answer to 21st
century communication may lie in the use of social networking sites.
Their use has actually been pioneered by investigative bodies such as the American National
Transportation Safety Board and the Canadian Transportation Safety Board. Would this type of
platform benefit the BEA’s Department of Communication during a high profile investigation
such as that of AF 447? It may be so, but a number of concerns must be addressed. Indeed,
any information released and publically available can be relayed and edited. This implies that

14
issues encountered with sensationalism and false accusations will not disappear. Hardcopy
material such as interim and final reports or video explanations provided by the chief
investigator and other BEA technical experts may remain too technical and thus sometimes
be misunderstood by the general public.
The creation of a more direct platform to improve communication such as a relatives’ group page
raises both privacy and security concerns. Furthermore, the posting of any material on a site may
result in questions related to ownership. Granted, the use of social media may bring about new
challenges, but navigating through these potential issues is feasible. The great advantage of using
social media is the combination of a fast release of information, which would align the BEA with the
24-hour news cycle; and reach, with a communication platform between the Bureau and the public,
without any sort of intermediary. The wide array of features offered by these sites can also make
the act of communicating more efficient and provide an easily accessible track record of the BEA’s
statements and actions.
A non-exhaustive list highlights the following opportunities:
• Post statements and communiqués in their entirety;
• Provide links to sites referencing official regulations;
• Post unedited video recordings of press conferences along with highlights;
• Create event pages for press conferences and improve logistics;
• Create a victims’ relatives page with an SMS notification feature; and
• Grant access to meetings and press conferences through a free video conferencing site.
The creation of an international network through social media has the advantage to further
open the door to freedom of speech. Disinformation and miscomprehension from individuals
coming directly onto a BEA platform will voice their concern and thus enable the Department
of Communication to further fulfill its primary mission: Inform. In addition, it has the benefit of
retracing previous statements and improving their formulation, should they appear unclear to
the public.
The use of social networking sites can also improve communication with victims’ relatives,
who, in the case of AF 447, were most often isolated in countries abroad. The impact of any
information or disinformation has a tremendous effect on their emotional state and addressing
this issue with the utmost delicate care can remain a priority. This means creating not only a
direct platform and taking active and/or proactive measures, but involving them in meetings
and press conferences as well. Communication with both authors of accurate reports and
speculators can also be improved. For the former, a social networking platform provides more
precise details on the Bureau’s work and a better understanding of steps taken during the
investigation. For the latter, it could redirect hypothetical statements towards more relevant
aspects of the investigation…but this is just speculation!

15
Lastly, the use of social networking sites can cut the mainstream media middleman that a great
number of international alternative media rely on. Indeed, their lack of financial and human
resources is an obstacle to their physical presence at press conferences. Instead of basing their
coverage on local correspondents, they often use the “flavour of the day” reports featured in
the mainstream media. Giving the alternative media an incentive to become more actively and
directly involved in reporting on the investigation will, to a certain degree, diffuse disinformation
and extend the BEA’s media network.
FURTHERING INTERNATIONAL COOPERATION
The question of network development applies to professionals as well. A platform used by the
Department of Communication and its counterparts has the potential to further international
cooperation and thus provide solutions to sometimes crippling issues. As mentioned earlier,
relatives and the public are bound to get informed through either the BEA’s website or the
media. However, most members of the international public do not possess the linguistic skills
necessary to grasp complex issues in either French or English, and the BEA has a limited capacity
to provide multilingual documents.
In the case of AF 447, with 32 nationalities on board, this issue became particularly challenging.
Indeed, the technical expertise required for translation, and the risk of unauthorised and
premature release of information involved with the hiring of language consultants represented
serious issues. Furthering cooperation with the Department of Communication’s international
counterparts in both translating and communicating locally could provide effective solutions.
Advantages include confidentiality, accuracy, and reliability, which are elements necessary to
ensure a secure relay of information. In addition, international cooperation would increase
our understanding of public reaction and concerns abroad; and enable investigative bodies to
properly respond to confusion from diverse populations. Lastly, this type of platform could be
beneficial in both organising and coordinating international efforts and thus render logistical
issues more manageable.

Future Trends in Aviation
Safety, Aircraft Rescue and
Fire-fighting Efficacy
Aircraft Rescue and Fire-fighting (ARFF) is a highly specialised
discipline within the Fire Services. ARFF crew must respond
quickly and with precision in order to minimise loss of life,
injuries and other potential dangers. However, there are
limitations imposed by the resources available during the first
response and that pre-planning and the success of the first
attack is essential for the final outcome. Fortunately, serious
aircraft accidents are infrequent.
The aviation industry – our customers – always expects the
Airport Fire Service to be able to cope with all emergency
situations. The operational use of a Compressed Air Foam
System (CAFS) can easily be the tool that makes the difference
between life and death in a worst case scenario. New fluorine-
free foams have the potential to and indeed will lessen the
environmental impact of fire service operations at airports.
The International Civil Aviation Organization (ICAO) is in the
process of developing a new standard test protocol for CAFS
and Class B fires. Large-scale fire testing to ICAO Levels B and
C carried out at Centre National de Prévention et de Protection
(CNPP) in France, under the auspices of the UK Civil Aviation
Authority (UK CAA), have shown that a CAFS is more than 40
per cent more effective in knocking down a fully developed
fuel fire than normal aspirated/non-aspirated Aqueous Film
Forming Foam (AFFF). The tests also show that Fluorine-free
Foam (FFF) is just as effective as AFFF. If all goes as planned,
these will soon be implemented in future ICAO requirements.
ABSTRACT

Mr Kim Thorbjørn Olsen is Assistant Fire Chief of
Copenhagen Airport, Denmark and has over 35 years
of experience in the aviation industry. He is also Chief
Instructor at the Copenhagen Airport Aircraft Rescue
and Fire-fighting (ARFF) School. Prior to being a fire-
fighter at Copenhagen Airport, he had served nine
years in the Airport Police Security unit.
A member of both the International Aviation Fire
Protection Association and the Aircraft Rescue and
Fire-fighting Working Group (ARFFWG), Mr Olsen
is Manager of Section 11 in the ARFFWG and
also serves as a Liaison Officer between the two
organisations. He is also an Instructor in ARFF on
Incident Command at the Danish Emergency
Services College.
THE AUTHOR
Future Trends in Aviation Safety, Aircraft Rescue and Fire-fighting Efficacy

17
INTRODUCTION
Environmental issues with fluorine and the organic halogens (fluorosurfactants) in AFFF
have resulted in the latter being replaced by new FFF. These FFFs are also fully ICAO Level B
compliant (contrary to recent poorly founded claims by one fluorosurfactant manufacturer
using faulty non-independent test procedures).
The UK CAA and other specialists from different parts of the aviation industry set up large-
scale fire tests in May 2012 to compare CAFS with normal aspirated foam (using different
foam products for ARFF) to ICAO Level B and Level C, including a comparison of FFF against
AFFF. These tests took place at the CNPP research facilities in Vernon, France, with the
participation of UK CAA regulators, manufacturers from the aviation and ARFF industries and
airport fire-fighters (see Picture 1).

CAFS has been used to fight fires for many years. Traditionally, CAFS has been used to fight
Class A/Structural fires and has never been used for Class B/fuel fires except under research
conditions. CAFS is really a simple system in which high pressure air is injected into the water/
Kim Thorbjørn Olsen
Copenhagen Airport, Denmark
Picture 1: ICAO Foam Testing in France

18
foam solution before being pumped through the turret or hose line. Traditionally Airport
Crash Tenders have operated using aspirating turrets and nozzles.
Simon Webb who led the project for the UK CAA, said, “This testing was an excellent example
of the regulator, operators and manufacturers working together for the common aim of
improving safety in aviation. The results of this research have delivered a key objective of the
CAA Safety Plan to encourage the use of new technology in fire-fighting and will direct us on
the way forward with CAFS technology.”
Industry partners who participated in the tests included the UK Airport Operators Association,
Copenhagen Airport, Denmark, and Changi Airport Group, Singapore.
TEST AT CNPP AND RESULTS
On the first day, a plan was worked out by all participants on how the test procedure should
best be organised in order to get good objective test results. The final plan was to combine
CAFS with different foam agents which had previously not been combined. Before starting
with the large-scale fire tests, the systems were optimised. CNPP staff measured the water
flow rate, expansion ratio, as well as the 25 per cent and 50 per cent drainage times.
In order to measure the water flow rate, a 1,000-litre Intermediate Bulk Container (IBC) was
filled for 20 seconds. This was then weighed so that the actual flow rate could be calculated.
The determination of the quantity of foam used was done by weighing the difference between
the filled and empty IBC container. This was done for every test.
Measurement of the foam quality was generally done according to the National Fire Protection
Association (NFPA) requirements, except that the foam shield was placed at the end of the throw
range instead of the usual two-third point. All measurements were performed by CNPP staff.
TEST PROCEDURE AND TACTIC
At the beginning of the tests, the pool was filled with water, so that there was at least a 10 cm
water depth. Afterwards 1,500 litres of kerosene was poured into the pool and set on fire.
After the whole pool was lit up, the kerosene was left to burn for another 60 seconds before
extinguishment began. The tactics to be used were discussed by the group of participants and
were defined as follows: Firstly, the fire should be fought in a static way from a fixed position
for two minutes, and thereafter, if the fire could not be extinguished then the fire-fighters
should wait for 30 seconds and start extinguishment in a dynamic way until the fire was totally
extinguished. After extinguishment, the burn-back test was done after waiting for five minutes.
For this test, a burn-back pot (sleeve) was put into the pool, the foam in the pot was cleared
away and 20 litres of heptane were poured into the pot and lit (see Picture 2).
The knock-down effect for the fire is essential in aviation fire-fighting. Any ICAO approved
foam type has to be able to achieve this within one minute from foam application to fire is

19
Picture 2: Burn-back Test
controlled. Total extinguishment has to be within three minutes from foam application to
fire extinguishment. Burn-back resistance test (from burn-back pot ignition to end of test) is
timed five minutes after total extinguishment. This test is a safety test which will show the
foam’s ability to keep the fuel from reigniting (see Figure 1).
Figure 1: Test Result Using an ICAO Level B Compliant AFFF (Foam X)

20
Figure 2 shows that the fluorine free foam passes the ICAO level B test with almost the same
result as the AFFF foam (Figure 1). The environmental conditions during the two test were
similar and hence did not significantly influence the two outcomes.
WORKING WITH NEW TECHNOLOGY AT COPENHAGEN AIRPORT
The Copenhagen Airport’s Fire Service mission statement and vision strategy is:
“Always to keep a high level of professionalism, resourcefulness and ability to implement new
technologies and replacing old ones. To ensure an efficient operation within Copenhagen
Airport. To ensure a high level of satisfaction from the airlines and their passengers. To be the
best-run airport fire service in the world.”
In order to maintain a leading international standing, the Fire Service will, through employee
involvement and innovation, constantly develop the organisation: “By experimenting and by
constantly reviewing work routines and procedures, we will seek to learn new knowledge.
The aim is to develop our skills and competencies.”
The Fire Service at Copenhagen Airport has always had to deal with the challenge of low
staffing levels. New techniques have always been adapted for use by the service and some
amount of experimentation has always been allowed – as long as all the demands imposed by
regulators are met. Examples of this approach include fighting interior aircraft fires with high
pressure nozzles and one-man Crash Tenders.
Figure 2: Test Results Using an ICAO Level B Compliant FFF (Foam Z)

21
Over the last five to six years, Copenhagen Airport Fire Service has worked on operational
and tactical improvements. The whole fleet of Crash Tenders has been upgraded with the
Rosenbauer CA-5 Panthers. One Panther is provided with FLASH™ CAFS (air bottles instead
of a compressor – this works extremely well with large flow rates) on the main turret; two of
the other Crash Tenders are fitted with high reach extended turrets (HRET) and the Hydro-
Chem dual system.
For environmental reasons, AFFF was replaced with fluorine-free ICAO Level B foam – Solberg
3X6 RF re-healing Alcohol Type Foam Concentrate (ATC) foam. The Copenhagen Airport
Environment Department has for many years had environmental concerns especially about the
fluorochemicals that are in the AFFF being used at the Copenhagen Airport. This meant that
there were restrictions on using this foam for testing and training. Copenhagen Airport was
the first international airport to have implemented FFF for the Fire Service for operational use
as early as 2009. NFPA 403 testing of all foam outlets and foam proportioning systems on all
vehicles was done in conjunction with the foam manufacturer Solberg Foam and the vehicle
manufacturer Rosenbauer with all vehicles and foam systems being thoroughly performance-
tested before this new type of foam was put into service.
ENVIRONMENTAL PROBLEMS WITH AFFF
In 2008-09, a series of articles appeared in the Industrial Fire Journal and Fire & Rescue
magazine which started to focus on the problems and concerns around the environmental
issues that are associated with fluorosurfactant-containing foams such as AFFF. One of
the authors, Dr Roger Klein, is amongst the world’s experts on fire-fighting foams with
a background as a physical chemist, a medic and a long-term adviser to the Fire Service
nationally and internationally. Klein’s article (2009) about the findings of a study in Norway
really underlines the serious concerns. These articles have had a tremendous effect on a lot of
European airport’s awareness of this problem. At all the major airports in Scandinavia, the fire-
fighting training grounds now attract attention from the national environmental regulators.
Also, the European Union Commission for Environment has become aware of the problem,
resulting in a ban on the use of all fluorine-containing foams based on Perfluorooctanesulfonic
acid for fire-fighting within Member States from 27 June 2011 onwards.
PERSONAL VIEWS ON THE JOB AND TASKS IN AN AIRPORT FIRE SERVICES
ARFF is a highly specialised component of the Fire Service. An aircraft accident presents
different hazards that threaten the aircraft occupants, the community, the environment and
the emergency responders. ARFF crew must respond quickly and with precision to minimise
loss of lives, injuries and other potential dangers. Fortunately, serious accidents are fairly
infrequent, but this benefit means that experience can only be accumulated through constant
training. Learning from others rather than from own incident experience should be the norm.
Within the Aviation Fire Services, regulations and legislation have their roots in ICAO standards

22
and recommended practices (SARPs). These are usually incorporated into a country’s national
legal framework. The majority of the countries comply with the international standards
drawn up by ICAO.
CONCLUSION: A SAFER FUTURE FOR THE AVIATION INDUSTRY
The tests at CNPP have shown that CAFS has advantages in extinguishing fires compared
to aspirated foam and this is estimated to be approximately 40 per cent more effective.
These tests have also raised some very important issues such as environmental influences,
tactics, etc., which have a significant impact on the extinguishment time and the amount
of extinguishing agent used. The tests also showed that ICAO Level C is almost the same
extinguishment time and requires a similar quantity of extinguishing agent as ICAO Level B,
but contain much more fluorine which in turn has a negative impact on the environment.
From the perspective of an Assistant Fire Chief responsible for the Fire Service’s operational
capability, these results “fit like a hand in a glove” and prove that at Copenhagen Airport in
Denmark has made the right choices at the right time. CAFS and fluorine-free foam will no
doubt improve both aviation safety and the environmental impact of fire service operations at
airports.as well as the safety of the fire-fighters whom we send into the danger zone. Greater
efficiency and faster control of the situation will certainly also give fire-fighters confidence in
coping with the situation. A Rosenbauer Panther with CAFS on all low pressure outlets has
been put into service at Copenhagen Airport in March 2013.
The UK CAA has recently put forward a proposal to the ICAO Rescue and Fire-fighting
Working Group at their last meeting in Montreal, Canada for the use of CAFS on airport fire
vehicles, and was accepted. If things go as planned, a new ICAO standard and procedure
based on this CAFS recommendation would be implemented in the ICAO Airport Service
Manual in November 2013. This would be great for the future of aviation safety.
References
Industrial Fire Journal and Fire & Rescue Magazine 2008-9.
Klein, Roger. (2009). Contaminated Water – Protecting the Environment. UK Fire & Rescue magazine, vol. 73,
p. 26-29.

Just Culture in Aviation:
The Best of Two Worlds
Investigation into the causes of aviation accidents and
incidents is of key importance for finding solutions that
improve the safety of aviation and provide assurance
to passengers for an uneventful flight. Nobody should
be immune from the law. The use of these findings in
determining whether criminally reproachable behaviour
is involved forms part of the administration of justice;
a function which is an integral part of any society that
respects the rule of law. The issues related to this apparent
conflict between these two worlds and approaches towards
reconciling or at least balancing these activities form the
basis for this paper. It introduces the notion of Just Culture,
experiences with its application in Europe and the prospects
and conditions for a more global application. The role and
responsibilities of the International Civil Aviation Organization
(ICAO) in this context are addressed, in particular as the
possible facilitator for introducing Just Culture-based
solutions in the different ICAO regions.
This paper contains elements of two articles written by the
author that were published in the Air & Space Lawyer,
Vol 2 2009 and in the IFATCA magazine 2012.
Aviation Safety
ABSTRACT

Mr Roderick van Dam is Chairman of the EUROCONTROL Just Culture
Task Force. He was with EUROCONTROL since 1996 as General Counsel
and retired in April 2012. Prior to that, he was Head, Legal with the
Netherlands Civil Aviation Authority until 1990; he then joined ICAO as
a Senior Legal Officer in the Legal Bureau.
Mr van Dam is currently a Member of the ICAO Safety Information
Protection Task Force, and has participated in drafting and
launching numerous ICAO instruments of international law. He is
also a Rapporteur to the ICAO Legal Committee for the Montreal
Protocol on Acts of Violence against International Aviation. He is
also actively involved in European Union (EU) Single European Sky
legislation, air traffic management (ATM) liabilities, Functional
Airspace Blocks; Global Navigation Satellite System, Global
Position Systems and Galileo as well as the institutional reform
of ATM in Europe and of EUROCONTROL, including the
reassessment of its relations between the EU and European
Aviation Safety Agency.
A lecturer at Leiden University International Institute of Air & Space
Law, Netherlands and member of its Advisory Board, Mr van Dam
has written for numerous publications on Air and Space Law, and
also participates as a moderator and speaker at aviation events.
He holds a Master in International Law and Air and Space Law.
THE AUTHOR
Just Culture In Aviation: The Best of Two Worlds
Aviation Safety

23
Just Culture in Aviation: The Best of Two Worlds
Aviation Safety
Roderick van Dam
EUROCONTROL
INTRODUCTION
Accidents and Incidents happen. They form part of our daily lives and we accept their
occurrence, even in air traffic management (ATM) and air transport, and we hope and expect
that we can avoid by far most of them by our actions, professionalism and abiding by established
rules and practices.
Ever since the investigation of aviation accidents was undertaken in a systematic manner
with the specific aim of using the findings of each accident investigation for the prevention
of other accidents, the problem of the use of these findings for purposes other than accident
prevention has manifested.
Improving aviation safety depends to a large extent on the feedback of knowledge generated
by a system of accident/incident data collection and analysis. Such a system serves the industry,
as well as its regulators, by allowing it to adapt and improve on equipment and procedures.
A high-quality output of the system very much depends on the existence of systematic record
traceability and active participation and reporting from all the aviation stakeholders involved
in safety areas. In the US and Europe, for example, well-developed accident prevention
processes are in place, including mandatory and voluntary incident reporting systems and
independent accident investigation.
From relatively early days, the ICAO which is responsible for setting international rules and
recommendations for improving safety, has been confronted by the need to protect aviation
safety interests from those parties that want access to investigation results and other safety
data with the goal of what ICAO calls apportioning blame or liability. Therefore, ICAO rules,
in the interest of an uncompromised safety investigation process, are often seen as advocating
a protection against the interests of what is often referred to as “the administration of justice.”
In a safety-critical domain such as aviation, the legal consequences of (contributory) actions
or behaviour that could result in serious personal harm, death or other damages are plentiful
and very significant, both in the private law and, increasingly, in the criminal law domain.
Criminal law forms an essential part for a sovereign State in the exercise of its responsibility
for enforcing specific domain-related norms as well as for the prevention and sanctioning of
unacceptable behaviour.

24
Aviation Safety
SAFETY VERSUS JUDICIAL
The administration of justice, in particular in the criminal law domain, constitutes one of the
pillars of State sovereign functions; they are usually firmly imbedded at the constitutional
level. Both the Convention on International Civil Aviation (hereafter referred to as the Chicago
Convention) and the EUROCONTROL Convention explicitly confirm the complete and exclusive
sovereignty of a State over its territorial airspace. That certainly includes the administration of
justice. States are of course free to choose to delegate or pool certain sovereign functions, as
is the case with the European Union membership, but criminal jurisdiction, with only a few
exceptions, generally remains firmly imbedded at the State level.
There is a growing concern in recent years on the part of aviation professionals and aviation
industry about the interpretation of flight safety and aviation accidents by the general public
as well as the criminal judiciary. These concerns are associated with what is seen as the
increasing emphasis on legal issues in aviation safety occurrences. This has led to growing fear
of litigation and the threat of criminal sanctions against individuals and organisations that are
seen as partly or fully responsible for an accident or incident in which they were involved.
We need to understand the complicated relationship between the administration of justice and
the safety investigation. As in a classical drama, two antagonists are involved: one with the aim
of preserving justice by investigating and prosecuting possible perpetrators and the other with
the aim of enhancing aviation safety through independent investigation and reporting.
The issue of criminalisation of aviation accidents or incidents illustrates the delicate relationship
between the propagation of aviation safety and the administration of justice in the aviation
domain. These are two distinct worlds that seldom meet. One is by nature international,
dynamic and very sensitive to safety; the other is by nature national, resistant to progressive
change and very sensitive to the rule of law. It is no wonder that their interaction, or perhaps
the lack of it, generates difficult and often passionate discussions.
Accidents and serious incidents very often occur as the result of a series of events that in an
eerie and inevitable way lead to disastrous results. When mistakes are involved they can often
be labelled as “honest” mistakes that would not qualify as criminal behaviour. Controllers and
pilots are professionals who are ready to realise that nobody can claim criminal immunity in
any civilised country. But it is equally true that a small, but highly visible, number of cases raise
questions on the relevance and motives of some criminal prosecution and court cases.
And here lies the root of the issue: Who will determine whether a mistake was made by
a qualified professional acting in a responsible manner or whether this was a clear case of
gross negligence, wilful misconduct or criminal intent, to use just a few of many legal terms
for criminally reproachable behaviour? That person cannot be a chief pilot or a control room

25
Aviation Safety
supervisor; such a call can only be made by a professional in the judiciary, a prosecutor and
ultimately a court of law.
The key is what happens next: A qualified criminal investigator or prosecutor must assess
whether, under the applicable criminal law, the actions leading to the accident/incident warrant
further steps such as investigations and indictment. A number of high profile accidents and
serious incidents did result in criminal investigations and proceedings and have raised strong
concerns from the air traffic control and air transport community about the criminalisation of
aviation. That is not all; events have shown that further complications could arise as a result
of public and media pressures that generally accompany any crash or serious incident with the
associated “search” for a guilty party.
The discussion on criminalisation of aviation incidents and accidents shows concerns on
the perceived intrusion by the judiciary in the all-important effort in enhancing safety in
aviation. It also shows a tendency to use “criminalisation” as the epitome of misdirected
and unwarranted activities by the authorities and to argue that the safety domain should
therefore be protected from any action by the prosecution.
The problem is that invoking real or alleged criminalisation of aviation incidents or accidents
as a justification for fully protective legislative action does not really work. All the regional and
global rules and standards related to the protection of safety data and investigative processes
in aviation create an exception for the actions of a sovereign State in the exercise of the
administration of justice. What is needed now is the establishment of equilibrium between
two equally relevant goals: aviation safety and the administration of justice.
JUST CULTURE
Rather than trying to shut up the judiciary, focus has now shifted towards initiating a dialogue
between the national authorities concerned. A better understanding of the consequences of
a judicial inquiry must be the starting point. In most States, national criminal legislation provides
prosecutors with a level of discretion as to how to apply those laws; a clearer appreciation of the
associated safety consequences may actually influence the application of those laws.
This is where the Just Culture initiative, as developed for aviation by EUROCONTROL, enters
the equation. Attempting to describe, let alone define, Just Culture is not simple, to put it
mildly. The results may vary from one person, culture, legal system to another. The following
description of Just Culture in the aviation domain has been accepted in Europe:
“A Culture where front line operators are not punished for actions, omissions or decisions
taken by them that are commensurate with their experience and training, but where gross
negligence, wilful violations and destructive acts are not tolerated.”

26
Aviation Safety
This description introduces the notion of gross negligence and wilful violations for qualifying
criminally relevant behaviours that are not in accordance with internationally agreed
definitions. And although the criteria to establish gross negligence or related legal concepts
in common or civil law may be similar in most countries, their interpretation and application
with respect to individual cases will ultimately lie in the hands of prosecutors and ultimately
of a criminal court.
When the legal consequences of Just Culture were first discussed, the initial reaction was that
most European States would need to significantly amend their laws in order to implement Just
Culture in a non-punitive environment. Calls were made for changes to criminal laws and to
regulate and fully protect access to information. The general feeling was that a Just Culture
could not be implemented without these.
Subsequently, when the discussions became more mature, it dawned upon the participants that
amending laws and principles that constitute the basis of sovereign judicial systems was, in most
cases, not a realistic option. And equally important, it was not deemed essential. The issue was
not necessarily the need for more legislative actions but rather the way in which those existing
laws and regulations were implemented and enforced by the national judicial authorities.
Provisions which could result in a legal environment supporting a Just Culture, while taking
a realistic view to the need to respect some fundamentals with regards to the administration
of criminal justice, already exist. A number of relevant instruments dealing with accident
investigation and incident reporting, supported in some cases by guidance material, are in place.
GLOBAL AND REGIONAL PROGRESS
Just Culture has been on the agenda for many years and it has become apparent that a key
part of its successful implementation relies on a number of realistic deliverables that would
stimulate further understanding and active and open coordination between the safety and
judicial authorities.
In ICAO, the discussions and findings of the 36th
Assembly, the Accident Investigation and
Prevention Divisional meeting in 2008 and the recommendations of the ICAO High Level Safety
Conference in March 2010 resulted in resolutions A37-2 and A37-3 of the 37th
General Assembly
on the sharing of safety information and the protection of safety data. Both resolutions, using
the description of the Just Culture initiative, instructed the Council to strike a balance between
the need for the protection of safety information and the need for the proper administration of
justice. The Assembly furthermore noted the need to take into account the necessary interaction
between safety and judicial authorities in the context of an open reporting culture. The ICAO
Safety Information Protection Task Force (SIPTF) was, among other reasons, created as a result
of these conclusions which to a great extent have inspired its findings and recommendations.

27
Aviation Safety
In Europe, the European Union (EU) has not only formally enacted Just Culture as part of
EU law with the introduction of Performance Regulation (EU) No 691/2010 , but it has also
recently introduced elements of it in Regulation (EU) No 996/2010, governing air accident
and incident investigation that also addresses the need to achieve a balance between the
objectives of the judiciary to determine whether criminality was involved, and the need for
the aviation industry to be able to run a real-time self-diagnostic system without unnecessary
interference from Justice.
EU Regulation 996/2010 stipulates that its purpose is dual: to regulate both “the investigation
and prevention of accidents and incidents”. It says: “An accident raises a number of different
public interests such as the prevention of future accidents and the proper administration of
justice. Those interests go beyond the individual interests of the parties involved and beyond
the specific event. The right balance among all interests is necessary to guarantee the overall
public interest.”
Although it may sound a little negative, the strength of the Just Culture Concept (or by
any other name as long as it addresses the same processes) is the understanding that there
is realistically no other way forward. Formal legislation fully protecting pilots or controllers
or side-lining criminal prosecution is a dead-end street as demonstrated by all the existing
national, regional and international legislation. Providing a reasonable expectation to, for
example to a controller or a pilot, that the chances that he or she would ever be invited to
be part of a preliminary criminal investigation, let alone prosecution, are very minimal, would
provide a sound basis for continued incident reporting and even measured and balanced
accident investigations.
Just Culture represents the fundamental recognition that both the aviation safety drive and
the administration of justice would benefit from a carefully established equilibrium, moving
away from criminalisation fears. It is based on the understanding that controllers and pilots can
blunder and that the line between an “honest mistake” and intentional or reckless behaviour
can only be drawn by a judiciary professional.
That is easier said than done, of course. But the time has come to seriously question the added
value of endless and generally unsuccessful efforts at the international level to “protect”
controllers and pilots against judiciary actions by creating standards, regulations and laws
that are supposed to shield them against interference by justice. This is perhaps a good time
to point out that this paper primarily focuses on the introduction and benefits of Just Culture
at the State and International level and on the interaction between safety experts and the
judiciary. At the (national) corporate level, in the interaction between management and staff
of, for example airlines and air traffic service providers, Just Culture of course plays an equally
important role in the acts of pilots and controllers and the application of company rules,
contract and labour law.

28
Aviation Safety
A lot of progress has already been made in this domain through safety management and related
practices and the new ICAO Annex 19 will certainly also play an important role in this area.
It is important to note that these developments will also require the recognition and perhaps
harmonisation of corporate Just Culture with the criminal law requirements and policies at the
State level.
DISCUSSION
The time has come to focus on the pursuance of the practical goals identified by the Just
Culture activities. The first steps toward the proliferation of the model aviation prosecution
policy concept have started and the first prosecutor expert courses have been held. The
relevance of offering assistance and education to prosecutors and judges together with
the introduction of and implementation of the model for an aviation prosecution policy
in Europe and beyond is obvious. After the historic support by the full EUROCONTROL
39 State membership and the EU for these deliverables, the next step will be to submit them
for global consideration at ICAO.
At the 37th
General Assembly, resolutions A37-2 and A37-3 on the sharing of safety
information and the protection of safety data added the instruction to the ICAO Council to
strike a balance between the need for the protection of safety information and the need for
the proper administration of justice; the Assembly furthermore noted the need to take into
account the necessary interaction between safety and judicial authorities in the context of
an open reporting culture.
As mentioned earlier, The ICAO SIPTF was tasked with analysing present ICAO rules and
Standards and Recommended Practices (SARPs), National Legislation and considering enhanced
communication and interaction mechanisms to improve the efficiency and credibility of
data protection and occurrence reporting and the relations between safety activities and
the national judiciary.
It may be expected that the SIPTF, which held its last meeting in January 2013, will come
forward with realistic proposals for the enhancement of safety data protection that
recognise and reconcile the existing national and international legislation and regulatory
processes and their limitations. In addition to SIPTF recommendations regarding changes
in positive law or ICAO SARPs, considerable progress could be made in advancing safety
information protection with deliverables in the domains of training, support, education,
and communication through innovative implementation tools and tactics, to balance the
adequate protection of safety data with the proper administration of justice.
There is general recognition of the need to establish communication and training
initiatives and advance arrangements between the aviation safety sector, regulators, law
enforcement and the judiciary to avoid unnecessary interference and to build mutual trust

29
Aviation Safety
and understanding. Furthermore, making high-level aviation expertise available to law
enforcement and judiciary would facilitate the exercise of their appropriate investigative
and judicial processes.
A number of States and groups of States in different ICAO regions are already organising
training and communication between safety and judicial authorities addressing implementation
tools and deliverables that would lead to a stable and successful basis for enhanced safety
data protection and a balanced interaction between safety and the administration of justice.
It is important to note that these recommendations address processes and activities that are
expected to continue well beyond the active life of the SIPTF. Training, support, cooperation,
communication and advanced arrangements form decisive conditions for an efficient and
realistic safety data protection.
The time has come for ICAO to further build on the Just Culture principles and become the
facilitator at the regional level to educate and encourage States to establish (joint) permanent
frameworks to ensure a constructive and on-going dialogue with the judiciary, to inform them
on the possibilities to establish a national aviation prosecution policy and to provide them at
their request, with dedicated and impartial aviation expertise in the exercise of their functions.
ICAO should also establish and regularly update a repository of training and education activities
related to the protection of safety data, the interaction with the judiciary and existing or new
best practices and policies. It should provide coordination and support, as well as organise
progress reporting and information on a regular basis to all Contracting States.
Just Culture is not the “magic wand” against injustice and misuse of judiciary processes. It has
been introduced to protect as much as possible the mundane but ever so important ongoing
processes of incident or occurrence reporting: literally thousands of daily events that feed
into the well-established system of using the reports for the improvement of safety and the
prevention of incidents and accidents. It represents an ongoing daily routine, certainly not as
spectacular and awesome as the aftermath of an accident, but absolutely vital for the continued
effort to improve safety by learning from mistakes and other relevant occurrences.
Just Culture requires understanding and appreciation of the different processes and
commitments by both safety people and the judiciary. And let there be no mistake: Just Culture
also implies that misuse of criminal processes or ignorance from the part of the judiciary is
equally unacceptable! There is still a long way to go, both in Europe as well as at ICAO, but most
of the signs are outright encouraging, as witnessed by the deliverables of the Just Culture Task
Force and those expected from the SIPTF and reactions from third parties.
Finally, as good concepts often are in essence simple ones, I would submit that the summary
of Just Culture, of reconciling safety and justice interests, can be reflected as follows: IT TAKES
TWO TO TANGO!

30
Aviation Safety
References
Commission regulation (EU) No 691/2010 of 29 July 2010 laying down a performance scheme for air
navigation services and network functions and amending Regulation (EC) No 2096/2005 laying down
common requirements for the provision of air navigation services; OJ L 201, 03.08.2010.
Resolutions adopted by the 37th
Session of the ICAO General Assembly held in September/October 2010,
see: http://legacy.icao.int/icao/en/assembl/A37/Docs/a37_res_prov_en.pdf
Regulation (EU) No 996/2010 of the European Parliament and of Council of 20 October 2010 on the
investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC,
OJ L 295, 12.11.2010.

The term ‘Safety Performance Measurement’ highlights the
need for an objective and quantifiable mechanism to facilitate
safety performance interpretation. Without a quantifiable
mechanism, safety performance measurement will likely
remain in the domain of subjective narration.
A quantitative approach to performance interpretation of
conventional safety or quality occurrence trending indicators
can be achieved by incorporating quantitative performance
boundaries into them – such as Alert and Target markers.
The Yes-No triggering of these markers forms the basis for
an objective and quantifiable interpretation of the indicator’s
performance (within a given monitoring period).
With this mechanism in place, the summary performance of a
package of safety performance indicators (SPIs) can accordingly
be quantified by their summary Alert and Target outcomes.
This summary Alert and Target outcome would be a fair
reflection of the organisation or system’s safety performance,
to the extent as represented by the scope and nature of the
selected package of SPIs.
Safety Performance Measurement
– Quantifying Safety Performance
Indicators and an Acceptable
Level of Safety
ABSTRACT
Aviation Safety

Safety Performance Measurement – Quantifying Safety Performance Indicators and An Acceptable Level Of Safety
Aviation Safety
Mr Teo Gim Thong is the Safety Management Consultant on
secondment to the International Civil Aviation Organization (ICAO)
Air Navigation Bureau’s Integrated Safety Management Section
since 1st
Mar 2010. He is currently involved in the development of
a ICAO Standardised Training Package for safety management
using the TRAINAIR PLUS method and had been the main
coordinator and developer of the 3rd
Edition (2012) of ICAO’s
Safety Management Manual (SMM, Doc 9859).
Mr Teo joined the Civil Aviation Authority of Singapore
(CAAS) as an Airworthiness Manager in 2004 after
working in the airline and the Maintenance, Repair and
Overhaul industry for 32 years. Prior to his current
appointment, he was Senior Manager in Rulemaking,
CAAS responsible for Safety Policy and Rulemaking
and has been the main coordinator of CAAS’ State
Safety Programme implementation taskforce since
2007. He is also a subject matter expert for state
Safety Programme and Safety Management
System. Mr Teo is a qualified Licenced Aircraft
Maintenance Engineer since 1976.
THE AUTHOR

31
Safety Performance Measurement – Quantifying Safety Performance Indicators and an Acceptable Level of Safety
Aviation Safety
Teo Gim Thong
International Civil Aviation Organization
INTRODUCTION
‘Safety Performance Measurement’ in the context of this paper essentially refers to the
process of measuring safety related outcomes associated with a given operational system or
organisation. Specifically, it is written in the context of today’s State Safety Programme (SSP)
and Safety Management System (SMS) environment.
WHY MEASURE SAFETY PERFORMANCE
Safety management Standards and Recommended Practices (SARPs) had been progressively
introduced by ICAO since 2001. The main framework of these safety management SARPs
are the SSP and SMS. Amongst other requirements, Annex 19 (Safety Management) has the
provision for States to achieve an acceptable level of safety performance:
“Each State shall establish an SSP for the management of safety in the State, in order to achieve
an acceptable level of safety performance in civil aviation.” (ICAO, 2013a, Chapter 3)
The active verb here is “to achieve”. The next immediate clause says:
“The acceptable level of safety performance to be achieved shall be established by the State.”
(ICAO, 2013a, Chapter 3)
So, that “acceptable level” which States are supposed to achieve is based on that which States
are going to establish themselves.
Objectively speaking, the expected bottom line (most onerous outcome) from these two clauses
can possibly result in a theoretical scenario like this:
“Show me (a safety management Auditor quoting ICAO Annex 19, Chapter 3) whether you
have achieved (or not achieved) your acceptable level of safety performance. We will just take it
that your own quantum of acceptable level of safety performance (which has been determined
by your State) is reasonable. Now, just show me whether you have achieved it, or not…”
Even if such a bottom-line question is not coming from your SSP or SMS auditor, any discerning
Accountable Executive or Safety Committee Chairman would probably ask anyway, sooner or later.
“You cannot manage what you cannot measure” is a well-known sage advice. So, obviously
we must be able to manage and measure safety performance, before anyone can expect us to
achieve it (to whatever level)!

32
Aviation Safety
HOW TO MEASURE SAFETY PERFORMANCE
To achieve an acceptable level (or any level) of safety performance, an organisation will firstly
need to establish a mechanism to measure its safety performance. After that, it will then decide
on the acceptable level of safety to be achieved, within a given monitoring period.
Taking into consideration ICAO Annex 19 expectations, we will need to ensure a few
characteristics of the safety performance measurement mechanism and indicators which are to
be developed:
• They should be quantitative and measurable.
• They should be an expression of the safety performance status of the aviation system or
operational areas.
• They should have provision for monitoring performance in relation to certain data-based
performance markers.
• They should collectively be able to give a bottom line measurable performance status.
• This bottom line performance status should be able to tell whether the planned acceptable
level of safety performance has been achieved or not, at the end of a monitoring period.
Now, do we need to start from scratch to search for such safety performance measurement
mechanisms or indicators? Apparently not. Some aviation quality management systems or
reliability control systems (especially large commercial air operators) have been traditionally
known to utilise technical or reliability related indicators to track the performance of specific
system processes. Examples include engine in-flight shut down rate, component failure rate,
technical delay rate, etc. Hence, the existence of such technical indicators is a good
place to start our appreciation of safety indicator models for SSP and SMS. Thus, within
the large commercial air operators and their Approved Maintenance Organisation and
Design & Manufacturing Organisation sectors, development of SSP-SMS safety indicators
is a matter of starting with the adaptation of certain existing technical or reliability
related indicators to meet the higher level SSP-SMS expectations.
As for the other service provider sectors (Aerodrome, Air Navigation Services, Approved Training
Organisation, International General Aviation) where they may have no prior experience with
Reliability or Quality Control systems indicators; they may then need to familiarise themselves
with fundamental data trending charts for the purpose of developing SSP-SMS SPIs. Figures
1 and 2 provide an illustration of a common basic data chart and a continuous data trending
chart respectively.
The two figures show a one-time status of reportable incidents for each aircraft type (Figure 1)
and a continuing incidents trending of the airline’s entire fleet (Figure 2). However, these two
charts cannot serve as SSP-SMS SPI candidates yet, because they have no built-in performance
measures – such as Alert and Target settings. Without such safety metrics performance
measuring pointers or markers, there is no provision for interpretation and collation of the

33
Aviation Safety
Figure 2: A Continuous Trending Chart
performance of each indicator (and ultimately the package of indicators) at the end of a given
monitoring period.
We need to convert the (otherwise) qualitative performance of a data trending chart into
a quantitative outcome, by means of measuring (counting) two key safety metrics markers –
Alert avoidance and Target achievement status. It is like interpreting the health of a patient
by just two key parameters – heart rate (low rate achievement) and blood pressure (high
pressure avoidance).
Thus, an SPI has to be more than just a basic data chart, more than just a continuous data
trending chart. It must have the capability for building in planned Targets to be achieved as well
as Alert levels to be avoided. These two complementary and parallel markers will then serve
to transform a common data trending chart into an SPI. By means of these two observable
Figure 1: A Basic Data Analysis Chart

Journal of Aviation Management 2013 by Singapore Aviation Academy

Journal of Aviation Management 2013 by Singapore Aviation Academy

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Journal of Aviation Management 2013 by Singapore Aviation Academy