Guidance for Operators -

Guidance for Operators - Implement an Accident Prevention Program

1. Purpose: The Egyptian Aviation Accident Prevention Program is a cooperative venture of the Minister of Transportation, the ECAA, the aviation industry, and the general aviation community with the common goal of effectively reducing the aviation accident rate. In order for the ECAA to fulfill its role in meeting this objective, they must rely on the critical safety data that is being generated by the aviation community from the various safety and quality programs now required in Egypt. This EAC is intended to provide operators with a general discussion of the elements of a successful and compliant accident prevention program.

2. General: When an accident or incident occurs in our air transportation systems, it means that some Part of that system has failed. If an aircraft does not takeoff and land uneventfully, some program, policy, procedure or regulation failed to achieve its purpose. When a cabin crewmember, a cockpit crewmember, a maintenance engineer, a cargo loading supervisor, a dispatcher or any other individuals who play a critical role in air transportation fail, then some Part of the air transportation system fails. When we arrive at this point we begin the problem solving process in an effort to identify the safety deficiency so we can improve the process and allow the system to operate safely. This after the fact identification of a safety deficiency and the implementation of the corrective action is a Part of a successful accident prevention program. Another integral Part of a successful accident prevention program is the training programs and analysis that provide information that produces before the fact, proactive change that results in avoiding incidents and accidents. The primary method for establishing an on-going safety initiative is by continuously analyzing information and recognizing disturbing trends, making changes, and thereby avoiding failures that could result in an incident or accident. For clarification in this document we will be referring to “after the fact” response as corrective action and “before the fact” changes as safety enhancements.

The following text provides the Egyptian Operators with the key elements of a successful and compliant accident prevention program. Additional support can be provided by the ECAA under the Egyptian Civil Aviation Supervisory Authority "Safety and Accident Prevention Program," upon request.

3. The Program: Each Operator is required to develop and implement and Accident Prevention and Safety Program. The following information is provided as guidance to assist the operator in the development of that program. The program must be submitted to ECAA for acceptance and any other Policy and Procedures or Operating Manuals that are affected by this program must be amended to reflect the changes in processes or procedures.

(a) Senior Management: Accident prevention starts at the top. Senior Management must be fully committed to the principles of the accident prevention program, the people involved and be willing to invest in the corrective action and enhancement process. The operator’s senior management is the group or person responsible for accident prevention. The senior management must:

1. Specify the Company’s standards.

2. Ensure every employee knows the standards and accepts them.

3. Ensure there is a system in place so that failures to maintain the standards are recognized, reported and corrected.

4. Include safety responsibility in each manager’s job description and performance review.

(b) The Director of Safety: This is a mandatory position for all certificate holders and the experience and qualifications are outlined in Part 121. This person is responsible for the administration of the safety-related programs and also responsible for assuring that senior management is fully informed of all safety related issues. The accident prevention program must be the administrative responsibility and the primary focus of the Director of Safety and must include the following program principles:

1. The establishment of specific safety performance measurements and audits by each operating division.

2. Naming of specific individuals responsible to achieve divisional/departmental safety initiatives.

3. Requiring each location within an operational division to develop maintains and implements a written Departmental Safety Plan.

4. Establishing procedures that address the operator’s contractor safety exposures.

5. Establish and administer a Corporate Hazard Reporting System.

6. Establish and administer a Corporate Accident and Incident Reporting and Investigation System.

7. Establishing a continuous improvement process, which utilizes a safety team or safety improvement team formats within each operational division. This safety process may be done in parallel with other required quality programs.

8. Establish and maintain an on-going safety training program for all employees assigned corporate safety responsibilities.

4. Corrective Action: Remember, corrective action is the result of a failure. The ability of an operator to discover, communicate, and then fix these failures will generally determine the effectiveness of their accident prevention program. There are several required programs that are designed to give operators this ability. The quality control program required for airworthiness, competency checks for cabin crew and dispatchers, and proficiency checks for pilots and flight engineers are some key activities through which operators can determine deficiencies. These programs also provide an excellent source for statistical information that can be used to analyze trends.

(a) Absolute compliance with all regulations may also require corrective action on the Part of the operators. Regulations are a derivative of our laws that have been enacted to ensure that the aviation industry in Egypt operates as safely as possible. The Internal Evaluation Program (IEP) is a mandatory program designed to provide operators with a system of continuous evaluation with regard to regulatory compliance. The IEP has a sister program that has been established to provide operators the ability to disclose their findings to the ECAA without penalty. The program is called the Voluntary Disclosure Program and is now available to all operators with an approved IEP. The IEP is an excellent source for assimilating data that can be used in trend analysis and can be used as a component of an effective accident prevention program. In fact, for small operators, the functions of the IEP can be combined with the required position of the Director of Safety, thus gaining efficiency for the small operator and creating a single point for the administration of these critical programs.

(b) An accident and incident reporting and investigation system is a requirement for the operator and is a key element in the corrective action side of the safety equation. First, all operators must know what is going on with regard to safety failures. Then, they must have the trained personnel to investigate the incident or accident and report the findings to the responsible personnel who will design and implement the corrective action. These reports are required to be forwarded to the following government agencies. Numbers and addresses, within x days of the incident or accident.

(c) Emergency response planning is also a required element of the operator’s accident prevention program. This planning function must be completed to ensure that operators are prepared in the event a major accident does occur.

(d) Communication and/or training are always the last steps in the corrective action process. After the operator is convinced of the need for corrective action, they must then ensure that all of the employees in the safety critical positions are informed of the corrective action and, if necessary, this new procedure may be added to or revised in the applicable training programs.

5. Safety Enhancement is another element of the accident prevention program that results in the implementation of before the fact proactive change. There are several integral parts of the operators required programs that can be used to derive the required data that can be used in the trend analysis that identify problems looming on the horizon. Some of these programs have already been mentioned in the discussions on corrective action and operators can use this same information in a forward looking form of analysis rather than a reaction to failure. There are two areas that are critical to the viability of the operator’s safety enhancement efforts, and they will be discussed separately.

(a) A Hazard Reporting System is a requirement for all operators. This is a key element of the carriers accident prevention program and the development of safety enhancements. In order for the hazard reporting system to be successful it must be accessible to all employees. This program must be under the supervision of the Director of Safety. The program must be totally free of all punitive actions that may be exercised against an employee who reports a hazard and this fact must be stated in the program and be a reality in practice. All hazards that are reported must be documented and must be processed through the system with a response to the reporting individual and a description of the safety enhancement that resulted or an explanation as to why no change was necessary. Additionally, there must be provisions to report and involve government agencies if the hazard requires a government-controlled solution.

(b) Flight Operations Quality Assurance Program (FOQA) is the most advanced form of safety enhancement tool that is being used in the industry today. Thanks to advancements in aircraft equipment, the flight recorder data can be easily collected and analyzed for trends that could point to deficiencies in training programs and to pilot or aircraft performance issues. Airlines that have implemented FOQA have also used the information to change procedures that have resulted in improved efficiency and reduced costs. Again, as in the IEP, operators can use the voluntary disclosure program to communicate problems to the ECAA without any form of penalty. FOQA is the most important information-gathering tool used in establishing a proactive accident prevention program.

(c) Human factors training are other safety enhancement tool and a key element in the accident prevention program. Statistics show that 80% of all accidents result for human error. The reason for human factors training is to provide all people working in safety related jobs training in teamwork and communication. This includes maintenance engineers, pilots, cabin crew, dispatchers and even includes methods to produce operations and maintenance manuals in a way that make them easier to read and understand. This training should also apply to all levels of management in the chain of authority. Human factors training is a requirement for all Egyptian operators.

6. Summary: The elements of a successful Accident Prevention Program:

(a) Required: An active and compliant Internal Evaluation Program.

(b) Strongly Recommended: Analysis and evaluation of all failures with corrective action adopted as a change in the corporate culture through communication and training.

(d) Strongly Recommended: Using the Voluntary Disclosure Program for solicitation of all solutions for a failure to comply with regulations.

(e) Strongly Recommended: Establishing a Flight Operations Quality Assurance Program that will result in a database that can be used to formulate and implement safety enhancements.

(f) Required: Develop a well-equipped and highly qualified safety staff lead by a strong and respected Director of Safety. Establish this department as the focal point of data collection and communication for all safety related programs and information.

(g) Required: An operator hazard reporting system.

(h) Required: An operator incident and accident reporting and investigation system.

(i) Required for Success: Develop a corporate culture that establishes senior management as the accident prevention leaders who fully support the Director of Safety, the Safety Staff, and the programs they administer.