Article citation information:
Chruzik, K., Wiśniewska, K., Fellner, R. Analysis of internal sources of
hazards in civil air operations. Scientific
Journal of Silesian University of Technology. Series Transport. 2017, 94,
27-35. ISSN: 0209-3324. DOI: https://doi.org/10.20858/sjsutst.2017.94.3.
Katarzyna CHRUZIK[1],
Karolina WIŚNIEWSKA[2],
Radosław FELLNER[3]
ANALYSIS OF INTERNAL SOURCES
OF HAZARDS IN CIVIL AIR OPERATIONS
Summary.
International air law imposes an obligation on the part of transport operators to
operationalize risk management, and hence develop records of hazards and
estimate the level of risk in the respective organization. Air transport is a
complex system combining advanced technical systems, operators and procedures.
Sources of hazards occur in all of these closely related and mutually
interacting areas, which operate in highly dispersed spaces with a short time
horizon. A highly important element of risk management is therefore to identify
sources of danger, not only in terms of their own internal risks (the source of
threats and activation of threats within the same transport organization), but
also in the area of common risk (sources of threats beyond the transport system
to which the activation of the hazard is related) and external risks (sources
of threats outside the transport system). The overall risk management of a
transport organization should consider all three risk areas. The paper presents
an analysis of internal sources of threats to civil air operations and the
resulting main risk areas. The article complements a previous paper by the same
authors entitled “Analysis of external sources of hazards in civil air
operations”.
Keywords:
air traffic safety, risk management, risk analysis, sources of hazards, air
transport, airport
1. INTRODUCTION
Risk and safety management in
practice is often implemented by examining the causes of incidents and
accidents, identifying critical initiating events, estimating the risks
associated with them, and establishing corrective and preventive actions.
Polish and European air law, for practical reasons, has narrowed the number of
categories to three events: accident, incident and serious incident [3, 4]:
1. “Accident” refers to an occurrence
associated with the operation of an aircraft: in the case of a manned aircraft,
this takes place between the time any person boards the aircraft with the
intention of flying until such time as all such persons have disembarked; or,
in the case of an unmanned aircraft, this takes place between the time the
aircraft is ready to move with the purpose of flying until such time when it
comes to rest at the end of the flight and the primary propulsion system is
shut down. In either case, an accident will occur when:
(a) a person is fatally or seriously injured as a result of:
- being
in the aircraft; or
- being
in direct contact with any part of the aircraft, including parts that have
become detached from the aircraft; or
- being
direct exposed to jet blast, except when the injuries are from natural causes,
self-inflicted or inflicted by other persons, or when the injuries are to
stowaways hiding outside the areas normally available to the passengers and
crew; or
(b) the aircraft sustains damage or structural failure, which adversely
affects the structural strength, performance or flight characteristics of the
aircraft, and would normally require major repair or replacement of the
affected component, except for engine failure or damage, when the damage is
limited to a single engine (including its cowlings or accessories), propellers,
wing tips, antennas, probes, vanes, tyres, brakes, wheels, fairings, panels,
landing gear doors, windscreens, the aircraft skin (such as small dents or
puncture holes), minor damage to the main rotor blades, tail rotor blades,
landing gear, or damage resulting from hail or bird strike (including holes in
the radome); or
(c) the aircraft is missing or completely inaccessible.
2. “Incident” refers to an occurrence,
other than an accident, associated with the operation of an aircraft, which
affects or could affect the safety of operation.
3. “Serious incident” refers to an
incident involving circumstances that indicate that there is a high probability
that an accident occurred, associated with the operation of an aircraft: in the
case of a manned aircraft, this takes place between the time any person boards
the aircraft with the intention of flying until such time as all such persons
have disembarked; or, in the case of an unmanned aircraft, this takes place
between the time the aircraft is ready to move with the purpose of flying until
such time when it comes to rest at the end of the flight and the primary
propulsion system is shut down.
For statistical purposes, “fatal
injury” means an injury sustained by a person in an accident, which results in his
or her death within 30 days of the date of the accident.
Analysing safety levels made on the
basis of reports of civil air operations in 2003-2009, records on incidents
kept by the Civil Aviation Authority and reports of the State Commission on
Aircraft Accidents Investigation (2,973 reported events) (see Fig. 1) allows us
to identify the main groups of hazards. As can be seen from the data, 1,009
causes of the events were classified as involving a “human factor”, which
accounts for 34% of all events. Meanwhile, 936 events, or 31% of the total,
were classified as resulting from a “technical factor”. Steadily increasing is
the number of reported incidents involving an “environmental factor”: in
2003-2009, 618 of these kinds of hazards occurred, representing 21% of all
events. Other factors are: “organizational factor” (179 events or 6%),
“cancelled investigation/discontinued cases” (112 or 4%) and “unidentified”,
i.e., an event for which the data are insufficient for it to qualify under any
specific group (119 or 4% of the total) [2].
Human
factor Transients Organizational
factor Environmental
factor Technical factor Forfeited
Fig. 1.
Classification of aviation events (safety investigations) in 2003-2009
according
to specific groups of causal factors
[2]
The data show that, during the
analysed period, the number of safety investigations increased more than four
times: from 175 in 2003 to 702 in 2007. This increase relates specifically to
incidents in the categories of “human factor” (from 31 to 106), “environmental
factor” (from four to 100) and “technical factor” from 30 to 200 events. The number
of events in the category of “organizational factor” is maintained at a
constant level. The above analysis shows that the number of reported incidents
is constantly increasing. This is due to increased awareness of the role of
reporting in the management of aviation safety, which is highly important from
the point of view of flight safety because it allows for appropriate preventive
measures to be taken in order to avoid incidents in the future [2].
Causes in the category of “human
factor” only refer to the crew. However, aspects of this category can also
refer to technical, environmental and organizational areas. For instance,
factor H2 (“lack of qualifications”) may be a consequence of deficiencies in
training or standards, controls and audits. Similarly, H5 (“inability”) may be
a consequence of deficiencies in safety management or standards, controls and
audits [1]. Within the “human factor” category, there are five groups of causes
[1]:
H1 - intentional conduct
H2 - lack of professional
qualifications
H3 - errors in communication
H4 - procedural errors
H5 - inability
Figure 2 shows the classification of
the different groups of causes of events reported in 2005-2009. As can be seen
from the data, of the 626 incidents reported in this period, 339 were
categorized in the “procedural errors” group, which accounts for 53% of all
events. Furthermore, 201 events or 32% were classified into the category of “no
qualifications”, 48 or 7% as “errors in communication”, 39 or 6% as resulting
from “intentional conduct” and 10 events or 2% of the total assigned to
“inability” [2].
H1: intentional conduct H2: lack of qualifications H3: errors in communication H4: procedural errors H5: inability
Fig. 2. Summary
of events in 2005-2009 for the “human factor” groups of causes [2]
The groups of causes in the “technical”
category refer specifically to systems and components of specific aircraft in
terms of their airworthiness and efficiency. In this category, there are 12
groups [1]:
T1 - serious engine failure, engine fire
T2 - damage to the engine, malfunction, alarm
fire, damage to the balloon
T3 - chassis and tyres
T4 - control systems
T5 - structural damage
T6 - fire, smoke (cabin crew, passenger, in the
hold)
T7 - unauthorized modification, non-genuine
spare parts
T8 - equipment and radio equipment (avionics)
T9 - design and manufacturing errors
T10 - autopilot
T11 - damage of the system
T12 - other
Figure 3 shows the classification of the
different groups of causes of events reported in 2005-2009. As can be seen from
the data, of the 436 incidents reported in this period, 96 were related to
“accessories and radio”, representing 22% of all events. Meanwhile, 79 events
or 18% were classified under the “chassis and tyres” category, and 66 or 15%
were classified as “other”, i.e., damage not included in groups relating to
specific causes. For “engine damage”, there were 58 events or 13% of the total,
whereas “damage to hydraulic systems” represented 54 events or 13% of the
total. “Other” or “design errors” accounted for 24 events or 6%, “serious
engine failure” for 23 events of 5%, “structural failure” for 15 events or 4%,
“control systems” for seven events or 2%, and “fire, smoke” or “autopilot and
flight management systems” for five events or 1% of the total [2].
The groups of causes in the
“organizational factor” category refer to flight safety management systems in
the workplace organizational unit of aviation. In this category, there are 12
groups [1]:
O1-
security management
O2
- training system
O3
- standards, controls and audits
O4
- operation of cabin crew
O5
- operation of ground handling
O6
- technology and equipment
O7
- operational planning
O8
- change management
O9
- selection system
O10
- service and maintenance
O11
- shipping, forwarding
O12
- other
T1: serious engine failure, engine fire, damage to the balloon
envelope or canopy parachute harness T2: engine damage, failure, signalling a fire, damage to the
balloon T3: chassis and tyres T4: controls T5: structural damage T6: fire, smoke (cabin crew, passenger, cargo)
Fig. 3. Summary
of events in 2005-2009 for the “technical factor” groups [2]
Figure 4 presents the individual
group causes of air events reported in 2005-2009. As can be seen from the data,
of the 138 incidents reported in this period, 90 were related to “maintenance”,
which makes up 65% of all events. Meanwhile, 19 events or 14% were classified
under the category of “operation of ground handling”, 12 events or 9% under
“standards, inspections and audits”, and 11 events or 8% under “training
system”. A further three events or 2% of the total could be classified under
“operation of cabin crew” or “other” [2].
O2:
training system O3:
standards, controls and audits O4:
operation of cabin crew O5:
operation of ground handling O10:
service and maintenance O12: other
Fig. 4.
Summary of events in 2005-2009 for the “organizational factor” groups [2]
Groups of causes in the
“environmental factor” category refer to the physical world, in which flights
are made by particular aircraft, and to equipment infrastructure that is necessary
to ensure flight safety. In this category, there are eight groups [1]:
E1 - meteorological
E2 - air traffic management, radio
communication or air traffic confusion
E3 - birds, animals and other objects
E4 - airport services and ground handling
E5 - communication, navigation and surveillance
aids
E6 - protection (transport security)
E7 - supervising the application of the rules
E8 - other
Figure 5 shows the classification of the
different groups of causes reported in 2005-2009 [2].
As can be seen from the data, of the
544 incidents reported in this period, 333 were related to “birds, animals and
other objects”, which makes up 52% of all events. Meanwhile, 62 events or 12%
were classified under the “air traffic management, radio communication or air traffic
confusion” category, 37 events or 7% under the “meteorological” category, 40
events or 7% under “other”, 36 events or 7% under “airport services and ground
handling”, 11 events or 2% under “protection” and 15 events or 3% under
“communication, navigation and surveillance aids” [2].
E1: meteorological E2: air traffic management, radio communication or air traffic
confusion E3: birds, animals and other objects E5: communication, navigation and surveillance aids E8: other
E4:
airport services and ground handling
E6:
protection (transport security)
Fig. 5. Summary
of events in 2005-2009 for the “environmental factor” groups of causes [2]
In the model process approach, risk
management in aviation is related to a cycle comprising the following steps:
the identification of sources of threats, developing areas of risk, risk
assessment, the communication of risks within and outside the organization,
corrective and preventive actions, and monitoring changes in security. The
primary purpose of active safety management strategy involves constant
monitoring and obtaining knowledge on the basis of a variety of information,
which may highlight threats and signal the appearance of early symptoms of
potential problems relevant to safety (including the analysis of flight events
or safety investigations). As such, the aforementioned approach could be a
useful basis from which to identify the source of hazards that pose a potential
threat to flight safety.
2. SOURCES OF INTERNAL HAZARDS IN CIVIL AIR OPERATIONS
A registry of external hazards and
the corresponding risk areas has previously been published by the Department of
Aviation Technologies at the Silesian University of Technology. In order to
maintain compatibility with the classification of hazard sources, the publication set out divisions on the basis of
possible group effects of hazards in accordance with [1], as well as a group
headings relating to causes of hazards in civil air operations (Table 1) and
the possible scenarios involving a combination of hazards (Table 2).
Table 1. Internal sources of hazards in
airports
|
Human factor (H) |
|
|
Intentional (HI) |
16.
Mental
illness 17.
Alcohol 18.
Drugs and
stimulants 19.
Bravado |
|
Unintentional (HN) |
10.
Panic 11.
Fatigue 12.
Inadequate
training 13.
Lack of
sufficient experience 14.
Ignorance of
procedures 15.
“Burns”
professional 16.
Errors in
communication 17.
Low awareness
of hazards 18.
Failure to
communicate threats |
|
Technical factor (T) |
6.
Unauthorized
access to the ground-based facilities 7.
Unauthorized
access to the aircraft 8.
Errors in the
construction of technical measures 9.
Accumulation
of flammable substances 10.
Unsuitable
means of screening 11.
Failures of
computer systems 12.
Ergonomic
positions 13.
Improper
repair 14.
Improper
inspections 15.
Errors in the
construction of technical measurements |
|
Environmental factor (E) |
9.
Stress 10.
Social
environments 11.
Errors in the
work of handling companies 12.
Inadequate
maintenance of the state of the runway, signage or information |
|
Organizational factor (O) |
6.
Lack of
operational procedures 7.
Errors in
operating procedures 8.
Errors in
training programmes 9.
Errors during
loading 10.
Errors during
refuelling 11.
Errors in
security controls 12.
Insufficient
monitoring processes 13.
Errors in
crisis management 14.
Lack of
control and threat assessments 15.
Improper
planning 16.
Inadequate
funding 17.
Political
situation 18.
Lack of legal
regulations |
Table 2. Identified groups of hazards
(own study based on the European Aviation Safety Plan and the Polish Civil
Aviation Authority communications)
|
No. |
Group of hazards |
|
Runway incursions |
|
|
Runway excursions |
|
|
Mid-air collisions |
|
|
Controlled flight into terrain |
|
|
Loss of in-flight control |
|
|
Controlled airspace violation |
|
|
Fire, smoke and fumes |
|
|
Unlawful intrusion into restricted area of the airport |
|
|
Unlawful intrusion into restricted area of the airport with prohibited
items |
|
|
Placing explosives in facilities and equipment of the airport |
|
|
Placing explosives on board the aircraft |
|
|
Hostages in the area of airport |
|
|
Seizure of aircraft with passengers |
|
|
Seizure of aircraft without passengers |
|
|
Landing at the airport with seized aircraft |
|
|
Acts of sabotage/diversion |
|
|
Disturbance of public order, vandalism |
|
|
Disaster unrelated to human activities (weather anomalies) |
|
|
Damage of technical equipment with consequences |
3.
SELECTED SOURCES OF HAZARDS IN BRIEF
The groups of hazards as described in Table 2
highlight many possible combinations of hazards sources. All the mentioned
groups are conditioned by factors resulting from internal threats. Airports
have either a limited or no influence on such threats. Some sources of hazards
are described below:
1.
HN6: lack of awareness of consequences
Risks arising from the lack of adequate
knowledge among passengers about aviation security. An example would be when
luggage containing prohibited items left by a terrorist is tampered with by
unaware passengers, resulting in a threat generated by their lack of awareness
of civil aviation security.
2.
HI7: possession of prohibited items
Items that are prohibited from being brought on
board the aircraft by passengers in cabin baggage are defined in Annex 4-C of
the EU Commission Implementing Regulation 2015/1998 of 5 November 2015, which
sets out detailed measures for the implementation of common basic standards on
aviation security. The list of prohibited items in this context is attached in
Annex 5-B of the aforementioned regulation. In addition, assembled explosives
and incendiary devices, which are not carried in accordance with the applicable
safety rules, are also prohibited in consignments of cargo and mail.
3.
O1: lack of awareness of safety culture
An effective safety culture involves mutual
cooperation in order to ensure the highest level of safety. In the case of
noticing any risk, threats and hazards should be reported to the appropriate
authorities. In the absence of this awareness, the risk of danger increases
significantly.
4.
T4: design errors in technical equipment and constructions
Defects in technical constructions,
equipment (terminal, ATM, conveyor belt, tanks, roofing) may pose a direct
threat to aviation. The presence of fuel tanks and other sensitive technical
materials at the airport means that mistakes in construction could lead to
disaster.
4. CONCLUSIONS
International air law imposes an obligation on the part of transport
operators to operationalize risk management, and hence develop recording
systems of hazards and estimate the level of risk in an organization. Air
transport is a complex system combining advanced technical systems, operators
and procedures. Sources of hazards occur in all of these closely related and
mutually interacting areas, which operate in a highly dispersed environment
with a short time horizon. A very important element of risk management is
therefore to identify sources of danger, not only in terms of the internal risk
involved (the source of threats and activation of threats within the same
transport organization), but also in the area of common (sources of threats
beyond the transport system to which the activation of the hazard is related)
and external risks (sources of threats outside the transport system). The
overall risk in a transport organization should consider all three risk areas.
The paper presented an analysis of internal sources of threats in civil air
operations and the resulting main risk areas.
References
1.
Appendix to Order No. 14 of the President of the Civil Aviation
Authority of 14 December 2006 (Pos. 43)”. Official
Journal of the Civil Aviation Office, No. 10, Warsaw, Poland, 29 December
2006.
2.
Materials Civil Aviation Authority. Qualification
of Aircraft Accident 2003-2009.
3.
Regulation (EU)
No. 996/2010 of the European Parliament and of the Council of 20 October 2010
on the Investigation and Prevention of Accidents and Incidents in Civil
Aviation and Repealing the Directive 94/56/EC (Text with EEA Relevance) OJ L
295, 12 November 2010: 35-50.
4.
Act of 3 July 2002. Aviation Law.
Received 11.12.2016;
accepted in revised form 15.02.2017
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