The Internship

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.
Letter of Transmittal
April 30, 2014
Page | 1 Mr. Ruhual Amin
Assistant Professor
Department of Tourism and Hospitality Management
Faculty of Business Studies
University of Dhaka.
Subject: Submission of Internship Report.
Dear Sir,
It is a great pleasure and privilege for me to present the Internship report titled A critical evaluation
of aviation safety: A study on Biman Bangladesh Airlines Ltd. which was assigned to me as an
academic requirement for the completion of BBA Program.
Throughout the study I have tried my level best to accommodate as much information and relevant
issues as possible and tried to follow the instructions as you have suggested. I sincerely believe that
it will satisfy your requirements. I however sincerely believe that this report will serve the purpose of
my internship program.
I must mention here that, I am extremely grateful to you for your valuable supervision, tireless effort
and continuous attention at every step of my endeavor on this report. I shall remain deeply grateful if
you kindly take some period to go through the report and evaluate my performance.
Yours sincerely,
Ishrat Jahan
Roll: 08
3rd Batch
Acknowledgement
First of all, I wish to thank the Almighty Allah, the Supreme Authority of the universe for
immeasurable Grace and profound Kindness that he has bestowed on me for completing this valuable
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work. Successful completion of any course requires support from various persons. I have been
fortunate to get the guidance and supervision of my teacher, friends and others.
I want to express my deep sense of gratitude and sincere appreciation to my Study Supervisor Mr
Ruhual Amin, Assistant Professor, Department of Tourism and Hospitality Management, Faculty of
Business Studies, University of Dhaka, for his valuable guidance and special supervision of my work.
I feel very much lucky to get a great opportunity to carry on my internship program with such a
remarkable organization like Biman Bangladesh Airlines Ltd. I here with thankfully remember the
name Mr Abdur Rahman Faruki, Deputy General Manager, Planning Department, Biman
Bangladesh Airlines Ltd. I am also grateful to Mr Shafik Ahmed, Manager, Sales & Marketing,
Biman Bangladesh Airlines Ltd. for giving his precious time to support and guide me with knowledge
and resources.
I intend to convey my special thanks to all the employees of marketing division for giving me full
cooperation and support in preparing this report. Finally, I thank University of Dhaka, for giving me
the opportunity to have a real life experience in this field which will guide me in future.
I am also profoundly grateful to my family for providing me the moral support.
Thanks for all.
Declaration of Supervisor
This is to certify that the internship report on A critical evaluation of aviation safety: A study on
Biman Bangladesh Airlines Ltd.submitted for the award of the degree of Bachelor of Business
Page | 3 Administration from the Department of Tourism and Hospitality Management, Faculty of Business
studies, University of Dhaka, is a record of research carried out by Md. Imran Ahmad under my
supervision. No part of this internship report has been submitted for any degree, diploma, title or
recognition before.
____________________
Mr. Ruhual Amin
Assistant Professor
Declaration of the Student

I do hereby declare that this internship report has been written by me during year 2014 under the
Page | 4 valuable guidance of Mr. Ruhual Amin, Assistant Professor, Department of Tourism and Hospitality
Management, Faculty of Business studies, University of Dhaka, in fulfillment of the requirements for
the award of the degree of Bachelor of Business Administration (BBA). Im also declaring that I have
not submitted this internship report for any degree, diploma, title or recognition before.
____________________
Ishrat Jahan
Roll: 08
BBA 3rd Batch
University of Dhaka
Executive Summary
Biman is the national flag carrier, which is fully owned and operated by the Government of
Bangladesh. The corporate body of Biman, namely Bangladesh Biman Corporation, is doing
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business as Biman Bangladesh Airlines under the Ministry of Civil Aviation and Tourism. Biman
Bangladesh Airlines was formed on 4 January 1972 with 2500 skilled and unskilled manpower
without any capital and aircraft. Biman was established as of a corporation on 27 October 1972 with
a view to ensuring better operation and development of air transport service. Like many airlines, the
main concern with BIMAN and the regulatory authorities is safety because BIMAN is in a mass
transportation business.
This report is aspires to analyze aviation safety issues thoroughly by giving essential information
regarding aviation safety. Through a review of the literature within the parent disciplines, the product,
process, and customers of flying activities were identified. The four processes, the MP, the HRD,
the PM and the RS are recognized through rigorous search of the literature. The developments
of the required seven elements of skills needed for pilot performance measurement were made. Major
categories of accidents also reviewed. In the next chapter, aviation safety performance of BIMAN
was described with reliable and logical data.
Various primary and secondary sources were used to prepare this report. The core part of this report
surveying 75 respondents to collect idea about customers perception and hoe BIMAN can develop
present safety performance. The whole survey result was described in data analysis chapter.
This report found out special area in where BIMAN needs to focus much more clearly. Findings from
the field work stated clearly that support research objectves.
Table of Contents
Topic
Chapter-1
Page No.
1
1.0 Introduction
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1.1 Origin of the report

1.2 Rational of the study
1.3 Aim and Objectives of the report
Chapter-2
2.0 Review of Related Literature
2.1 Political issues
2.2 Economic Issues
2.3 Social issues
2.4 Technology issue
2.5 Parent Discipline One: Safety Management
2.5.1 An Inspection Era
2.5.2 The Unsafe Act and Condition Era
2.5.3 The Industrial Hygiene Era
2.5.4 The Noise Era
2.5.5 The Safety Management Era
2.5.6 The Occupational Safety and Health Act
(OSHA) Era
2.5.7 The Active Failure-Latent Condition Era
2.6 PARENT DISCIPLINE TWO: AVIATION
SAFETY MANAGEMENT
2.6.1 Management Practice
2.6.2 Human Resource Development
2.6.3 Performance Measurement
2.6.3.1 The Importance of Information for

Decision Making
2
2
3
5
7
8
10
10
11
12
12
12
13
13
13
14
15
20
22
26
26
2.6.4 Reporting Systems (RS)

2.7 A review of major accident categories and
risk areas
2.7.1 Controlled flight into terrain (CFIT)
2.7.2 Approach and landing accidents
2.7.3 Loss of control in-flight
2.7.4 Fire (Post-Impact and In-Flight)
2.7.5 Runway excursions
2.7.6 Runway incursions
2.7.7 Other Significant Accident Categories
Chapter-3
3.0 Safety performance of Biman Bangladesh
Airlines
3.1 Accidents and incidents by Biman
Bangladesh Airlines Ltd.
27
28
3.2 Reasons of previous accidents and

incidents
38
28
29
29
30
31
32
33
35
37
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3.3 A brief comparison between Biman

Bangladesh Airlines and the safest airlines based
on safety rating criteria
39
Chapter-4
4.0 Methodology
4.1 Steps in the Research Methodology
4.2 Research Objectives
4.3 Methods Available For Business Research
4.3.1 Exploratory Research
4.3.2 Descriptive Research
4.3.3 Causal/Experimental Research
4.4 Research Design
4.5 The Research Method: The Selection of Data
Sources
4.6 Data Collection Methods
4.6.1 Primary data collection method: Focus
Groups
4.6.2 Primary data collection method:
Questionnaires
4.6.3 Primary data collection method:
Unstructured Observation
4.6.4 Secondary Data collection method
Chapter-5
5.0 Data Analysis
5.1 Sampling
5.1.1 The Population
43
5.1.2 Sample size

5.2 Questionnaire for Respondents
5.3 Analysis of survey Results by Questions
Chapter-6
Findings
Chapter-7
Conclusion
Appendices
References
43
44
44
45
45
45
46
47
47
48
48
48
51
51
51
51
52
54
59
61
63
65
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Chapter-
Background of the Study.
1.0 Introduction
Since the first power driven flight was performed by the Wright brothers at Kitty Hawk, North
Carolina on 17 December 1903, our way of life has been changed forever (Orlady and Orlady, 1999).
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Air transport has become a worldwide industry in which facilitation of rapid transition has taken
place. Aviation industry has expanded greatly during the last decade due to the growth of air
transportation demand which is induced by the growth of the world economy.
Aviation accidents have become the center of attention of the public especially the media. Air
accidents occupy the headlines of the newspapers and other information agents. This is because air
accidents bring about great losses in terms of monetary units and human well-being.
In the Gulf War in the 1990s, aviation losses through air accidents and misidentification were
more than losses caused by enemy fire. Wood (1991) mentions in his book titled: Aviation
Safety Program: A Management Handbook, that apart from the obvious costs, for example
liability losses, accidents, especially air accidents, bring about hidden costs such as uninsured costs.
Uninsured costs will be elaborated in Chapter Two.
One of the contributing factors of the likelihood of air accidents is that the airlines do not
seem to learn from each others safety shortcomings despite provision of a wide array of global
information networks. Accident reports are vital for future preventions.
Aviation safety is now one of the most priority given issues by airline industry throughout the world.
Biman Bangladesh Airlines, the national flag carrier of Bangladesh, is also giving importance to the
matter of airline safety.
More players had entered into the market with improved airlines safety and some others were
preparing for entry into the same. As increasing number of customers were considering the safety
measures of airlines, various airlines had stepped up marketing efforts to retain and enhance their
market. The policy planners have found a showing growth of airline with the sound safety and security
initiatives; the business has become intensely competitive.
This report basically deals with A critical evaluation of aviation safety: A study on Biman
Bangladesh Airlines.
This report will inform and support a practical application with the development and implementation
of safety cultures and guidelines in airline industry. It explains how safety improvement strategies on
reaction to individual accidents as they occurred, policy formulation is able, for the first time, to be
driven by hard data gathered over extended periods of time. So precise areas of risk could be
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identified, quantified and prioritized for detailed treatment.

This report deals with the policies, procedures and processes of Aviation Safety. It also highlights the
establishment of a good safety culture to encourage safe behavior and minimize the risk of accident
occurrence in the context of Biman Bangladesh Airlines.
1.1 Origin of the report
This Internship report is prepared as a requirement for the conclusion of the BBA program of Faculty
of Business Studies, University of Dhaka. The organization which this report represents is Biman
Bangladesh Airlines (BBA). The internship program at BBA was done in the Marketing Division for
organization attachment period for three-month. As an intern of Biman Bangladesh Airlines, I was
asked by my honorable faculty Mr. Ruhual Amin to conduct a report on A critical evaluation of
aviation safety: A study on Biman Bangladesh Airlines.
1.2 Rational of the study
In any industry, satisfying the customer is the ultimate goal or objective of any marketer. Excellent
passenger satisfaction is one of the greatest assets for air business in todays competitive environment.
Passenger satisfaction arises when an industry can provide passengers with safe, secure, efficient and
environmentally sustainable operations at the global, regional and national levels.
With more planes in the air and more total time spent in the air during travel, aviation safety is more
important than ever. While air safety has been important since the very beginning of flight for man,
in todays technological world with many complicated systems in operation during a flight paying
attention to the details is important. So aviation safety proved to be a challenging research task.
Biman Bangladesh Airlines is certified as safe to fly in Europe by the European Aviation Safety
Agency. It also successfully passed the IATA Operational Safety Audit and since then, the airline has
resumed flights to some of its previous destinations in Asia and Europe.
On the other hand, it is not considered among the safest airlines. It also faced some fatalities during
its operational time. As of November 2013, Aviation Safety Network records 11 accidents/incidents
for Biman Bangladesh Airlines, two of them leading to fatalities. However, these major aviation
accidents, when considered together, can illustrate where process improvements can be made.
The reason of doing this report is to discuss safety concerns in more detail and to identify possible
improvements. There have been too many reports made earlier on Biman Bangladesh Airlines.
However, no report has been done on safety issues of Biman Bangladesh Airlines. So making report
in this crucial issue will be helpful to Bangladesh Aviation Industry as well as developing countries
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aviation sector.
For the aviation industry, being safe is the right thing to do, and it is the law, too. Therefore, it is clear
that the research is needed to better understand the significant elements that determine safety issues
of aviation industry. In addition, discussions with various sectors of safety issues can be a practical
tool to measure aviation safety. It may assist passenger-carrying operators in identifying areas where
safety improvements are required.
1.3 Aim and Objectives of the report
Aim
The main objective of this study is to find out the safety issues in the context of the Biman Bangladesh
Airlines in order to know its Aviation safety hazards, Accident survivability, Accidents and incidents,
Safety Improvement Initiatives and Regulations.
This will be a theoretical contribution for better understanding of the Airline Safety Issues. This report
also analyzes the factors that are threatening the lives and growth of the airline industry, and will
discuss the challenges faced by the management in detail. This will enable Biman Bangladesh
Airlines to identify the most effective ways of managing the safety standards and choose which to
focus on.
The specific objectives of the report include
To get an overview of Biman Bangladesh Airlines.

To give a brief idea of Aviation Safety and Safety culture.
To analyze Safety Management era.
To focus on Bimans safety model.
To describe Aviation Safety Management.
To investigate current accidents record.
To know about Safety Cultures and Guidelines for airline industry.
To focus on the safety performance of Biman Bangladesh Airlines.
To highlight the difference of safety performance between Worlds Safest Airlines and Biman
Bangladesh Airlines.
To know the safety problem facing by the passengers of Biman Bangladesh Airlines.
To identify reasons of previous accidents and incidents of Biman Bangladesh Airlines.
To understand the view of customers of Biman about how they evaluate its safety measures.
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Chapter-
Review of Related Literature.
2.0 Review of Related Literature

A Safety Culture is something that is striven for but rarely attained (James Reason, Managing the
risks of organizational accidents). According to James Reason safety begins at top of airline industry
Page | 5 .The safest airlines have more effectively committed themselves to controlling the risks that may arise
from mechanical or organizational failures, environmental conditions and human error.

The management collects and analyzes the right kind of data to keep it informed of the safety health
of the industry collects, analyzes and disseminates information on incidents and near-misses, as
well as proactive safety checks.
The recent focus on the influential role of management in accident causation has led to considerable
interest in the concept of safety culture. In the aviation industry, a number of accident reports
(Moshansky, 1992; Bureau of Air Safety Investigation, 1994; 1995) have implicated operators and
regulators for failing to foster an effective safety culture. Recent papers on the subject (Reason, 1997;
Hudson, 1997; Ginnett, 1997; Edkins, 1998a) suggest that the establishment of a good safety culture
will encourage safe behavior and minimize the risk of accident occurrence.
Attempts to more clearly understand the concept of safety culture can be broadly categorized into two
different approaches. The first approach may be called the industrial view of safety culture, which
relies on industry experience and accident statistics to identify what elements distinguish good from
poor safety cultures. The second approach is more academic and is based on conducting empirical
research in an attempt to develop methods that can measure the concept.
The industrial view of safety culture suggests that the concept involves more than simply encouraging
employees to change their attitudes toward safety. Rather, it is equally important to implement
strategies that motivate employees to gather and assess potentially dangerous hazards. For example,
the International Civil Aviation Organization (ICAO, 1992) suggests that a good safety culture is
made up of the following attributes:
Senior management placing a strong emphasis on safety;
Staff having an understanding of hazards within the workplace;
Senior managements willingness to accept criticism and openness to opposing views;
Senior management fostering a climate that encourages feedback;
Emphasize on the importance of communicating relevant safety information;
The promotion of realistic and workable safety rules; and
Ensuring staff are well educated and trained so that they understand the consequences of
unsafe acts.
In the academic arena, there have been many attempts to develop methods to measure safety culture.
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However, there is still considerable debate about whether the concept is generated by specific
workplace characteristics or by employee attitudes about safety (Williamson, Feyer, Cairns &
Biancotti, 1997).
Zohar (1980), who in reviewing the literature, conducted the first reported research in the area of
safety culture and accident rate statistics, attempted to determine what factors distinguish
organizations with good and poor safety performance. Zohar identified eight factors, and
subsequently developed a 49-item questionnaire to assess safety performance. These factors included
perceived importance of training programs, perceived management attitudes to safety, perceived
effects of safe conduct on promotion, perceived level of risk within the workplace, perceived effects
of required work pace on safety, perceived status of the safety officer, perceived effect of safe conduct
on social status and perceived status of the safety committee. Nine items were removed from the
original 49-item scale and a revised 40-discussion with experts in the field suggests that there is very
little that distinguishes one from the other.
Questionnaire was administered to 20 production workers within a number of different workplaces.
The results demonstrated that organizations have quite distinct safety cultures with two factors being
most important for identifying workplace differences: perceived relevance of safety to job behavior;
and perceived management attitude to safety.
Since Zohars initial work, a number of researchers (Glennon, 1982; Brown and Holmes, 1986;
Dedobbeleer and Beland, 1991; Seppala, 1992; Glen don, Stanton and Harrison, 1994; Cooper, 1995;
DeJoy, Murphy & Gershon, 1995) have developed additional safety culture instruments. However,
results have differed widely on the number (2-11) and types of factors identified. For example,
Dedobbeleer and Beland (1991) identified the following two broad factors: management commitment
to safety and employee involvement in safety. In contrast, Glendon, Stanton and Harrison (1994)
identified eleven factors that are representative of much more specific employee workplace
perceptions such as work pressure, procedures, relationships, investigations and personal protective
equipment.
Other studies (Cox and Cox, 1991; Donald, Cantaer and Chalk, 1991; Niskanen, 1994) utilizing
attitudinal survey methods have produced disparate results in attempting to identify the important
elements that constitute safety culture. Results have ranged from three (Donald et al 1991) to four
factor solutions for management and employees (Niskanen, 1994).
According to Williamson et al (1997) two factors, appear to be reflected consistently across the
majority of studies undertaken: management attitude toward safety; and employee involvement
and/or attitudes to safety. Despite this finding, no further agreement exists regarding the dimensions
that comprise safety culture. Niskanen (1994) suggests that this is due, in part, to relatively little cross
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matching of data from previous studies and a lack of studies, which base their work on established
theory.
Dissimilar results of this kind are not surprising considering the different aims of various studies and
varying types of response formats used. For example, the work of Cox and Cox (1991) and Donald
et al (1991) was concerned with general employee attitudes about safety, whereas Brown and Holmes
(1986) focused on specific employee perceptions about the state of safety within a workplace. Various
types of scales used include the visual 9-point analogue scale with descriptors of never,
sometimes or always (Glendon, Stanton and Harrison, 1994), to a combination of 3-5 point liker
scale formats (Zohar, 1980; Dedobbeleer and Beland, 1991).
From the studies reviewed above, it is clear that further safety culture research is needed to better
understand the significant elements that determine this concept. In addition, discussions with various
sectors of the Australian aviation industry suggests that a practical tool to measure airline safety
culture may assist passenger carrying operators in identifying areas where safety improvements are
required (Edkins & Brown, 1996).
2.1 Political issues
In 1997, a strategic partnership among five airlines, namely, United Airlines, Lufthansa German
Airlines, Air Canada, SAS and THAI, was formed and named Star Alliance.
From a fatality rate perspective, accident records show that aviation safety standards among
various airlines are not the same <http://www.airsafe.com/airline.hotmail>. Code sharing among
partner airlines, therefore, causes some concern about the differing degrees of safety for
passengers among the authorities under which these partner airlines are operating.
This concern causes some authorities, especially the Federal Aviation Administration (FAA),
to impose stricter regulations upon US code share partners. Because of the strict regulations
imposed by authorities, a Star Alliance Safety Review Team (SA-SRT) was formed, under a joint
agreement, to ensure all partner airlines meet a set safety standard of requirements. The team
consists of representatives from partner airlines. The SA-SRT performs safety auditing on all
partner airlines every two years. As a result, THAI Safety and Quality Policy were explicitly
articulated (THAI Safety and Quality Manual, TSQM, 2000).
Another example of the impact of aviation accidents at a political level is the International Civil
Aviation Organizations (ICAOs) application of its policy of Safety Oversight which many
member states are using as standard measures for operation practices and procedures of airlines
under their jurisdictions (ICAO Safety Oversight Assessment Handbook, 1996).
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2.2 Economic Issues

Expense is bound to become an important issue in having to comply with stricter safety
regulations, which involves expenses on training, technological improvement and other areas
which add up to a substantial amount.
Thus, the general statement: An accident is a very expensive business holds true, because, if an
accident is allowed to occur, great costs will surface.
Costs incurred in an accident can be divided into two broad categories, insured and uninsured costs.
Insured costs are costs incurred covered by an insurance policy. Uninsured costs are hidden costs
not usually covered by an insurance policy. The operator absorbs this uninsured cost burden,
which is of great concern.
According to Wood (1991) and Cox and Cox (1996), hidden uninsured costs account for insurance
deductibles, lost time and overtime, cost of investigation, cost of hiring and training replacement
personnel, lost productivity of injured personnel, cost of cleanup and restoration of order, loss
of use of equipment and damage to premises, cost of rental of replacement equipment, goods and
services, increased operating costs of remaining equipment, loss of spares or specialized
equipment, fines and citations, legal fees, liability claims in excess of coverage, increased
insurance premiums, loss of commitment and motivation of personnel involved, loss of good
workers as a result of post-accident trauma, loss of business and damage to image and reputation, and
cost of corrective actions (Williams and Heins, 1989, Wood, 1991, pp.6-10, Cox and Cox,
1996).
The above statements show that safety poses an economical problem. There is a cost to safety. Chase
and Aquilano (1995) state that, just like the cost of quality, maintenance of safety can be costly,
depending on its degree because in THAI flight operations, safety is considered a part of quality (THA
I Operations Safety and Quality Manual, OSQM, 2000).
Wilbur Wright, one of the Wright brothers who flew the worlds first powered flight at Kitty Hawk,
North Carolina on 17 December 1903, noted that: If you are looking for a perfect safety, you would
do well to sit on a fence and watch the bird (Campbell and Bagshaw, 1991, p.133).
This statement is confirmed by Wood (1991) when he notes in his book titled: Aviation Safety
Management that in every operation there is a certain degree of risk. He also notes that a safe
operation is an operation in which a degree of risk is accepted. Risk can be defined as the opposite
end of the safety spectrum. Safety can be demonstrated in terms of risk and Figure 2.2 shows the
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Risk vs. Safety concept.

As a degree of risk increases, a degree of safety decreases.
Figure 2.2.1: Risk-Safety Spectrum
The term Accident prevention is subjective because accidents cannot be totally prevented.
In this context, Accident prevention simply means Least-risk operation (Wood, 1991). Figure 2.3
demonstrates how the cost of safety maintenance increases with an increased degree of safety or
reduced degree of risk.
Figure 2.2.2: Safety Cost Model

Source: Adapted for the Report from Pindyck and Rubinfeld, 1995, pp. 183-184.
As shown in Figure 2.3, in addition to the cost incurred in having to comply with safety regulations,
an operator has to bear extra costs if it is to further elevate its level of safety. The level of safety,
when risk is acceptable, reaches a point where the marginal return is reduced. This occurs when the
curve starts to flatten out and the law of diminishing returns applies (Pindyck and Rubinfeld, 1995).
2.3 Social issues

In a fatal air accident, the loss of life brings grievance and suffering to society, especially where the
next of kin of the perished and injured live. This is true when children are left orphans, wives are left
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widows and husbands are left widowers. Ill feelings can grow among next of kin and relatives when
compensation is perceived to be inadequate and where, often, settlements end in court. Compensation
won from the court case cannot replace human dissatisfaction and sufferings caused by disabilities
and loss of lives of the victims. The company image is tarnished especially if the compensation
is not considered to be fair. It is obvious that the impact of an accident on society has huge
implications.
2.4 Technology issues
Apart from losses induced by an accident, industry also has to bear costs of improvement in
technology, because, in the long run, costs of accidents will surpass costs of technology improvement.
The aviation industry has been driven by technology for many years (Garland, Wise and Hopkin,
1999, Orlady and Orlady, 1999). Due to problems with the man machine interface caused by the
failure of human operators to completely understand the design concept of an aircraft, the human
factor has also become a part of core technology (Reason, 1997, Garland, Wise and Hopkins,
1999, Orlady and Orlady, 1999, McAllistair, 2001).
Technology is also driven by some accident causal factors that result in the requirement of
improvement in equipment to minimize the chances of future occurrence. The development
of the Enhanced Ground Proximity Warning System (EGPWS) is a good example of technology
development driven by Controlled-Flight Into-Terrain type accidents, which constitute the leading
category of worldwide air transport accidents (Orlady and Orlady, 1999). An EGPWS is the further
development of the normal Ground Proximity Warning System (GPWS), a warning system capable
of facilitating terrain collision avoidance (THAI Aircraft Operating Manual AOM, Vol. Two, 2000,
Orlady and Orlady, 1999).
A GPWS which is the basis for the development of the EGPWS (Orlady and Orlady, 1999) is an aural
and visual warning system incorporated in an aircraft made mandatory on commercial aircraft of
certain size by some regulatory bodies such as the FAA.
THAIs Airbus A310, retrofitted with a normal GPWS, accident in KTM demonstrates this
case well. The EGPWS was designed to give ample time for a pilot to avoid terrain collision while
a normal GPWS in some cases would not (THAI Aircraft Operating Manual AOM, 2000, Vol.
Two), as in the case of THAIs accident in Kathmandu, Nepal. In this case, the flight had to
climb some 4500 feet in 30 seconds to avoid collision with the mountain when the GPWS was
activated (Meyer, J, 1995). To climb 4500 feet in 30 seconds was impossible even with todays
high performance aircraft technology. Had the aircraft been retrofitted with an EGPWS (that
had not then been developed), a chance of survival would have been better because an EGPWS
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facilitates warnings including terrain closure much earlier.

ICAO Annex 13of the Chicago Convention indicates that the only purpose of the investigation of an
accident or incident is to enable future prevention, not blame apportioning (ICAO Annex13, 1994,
Garland, Wise and Hopkin, 1999, Orlady and Orlady, 1999). The Annex 13 of this Convention
also states that an investigation commission for an air accident should comprise accredited
representatives of the country of registry, the country of the operator, the country of manufacturing
and the country of design of major components of the aircraft (ICAO Annex 13, 1994).
Generally, recommendations made by the investigation commission, both in technical and human
factor areas are well received by the regulatory bodies considering the costs of development of new
technology and chances of accident reoccurrence.
One US National Transportation Safety Board (NTSB) member indicated in a meeting that
more than 80 per cent of recommendations made by the NTSB were well accepted by the regulatory
body, the FAA. The NTSB is responsible for accident investigation on the following modes of
transportation, air, sea, road, railroad, and pipeline, within the U.S.A.
Thus, safety has become the main concern of the airline business simply because of the total
costs of an accident when assessed in terms of political, social, economic and technological
impacts.
2.5 Parent Discipline One: Safety Management
Reason (1997), states in his book, Managing the Risks of Organizational Accidents, that most
accidents are brought about by sacrificing protective benefits for productive gains. Unless there are
legal or regulatory requirements which demand otherwise, cutting corners in safety maintenance and
enhancement is common practice (Oster Jr., Strong and Zorn, 1992).
Prior to the 1900s, safety movements in the US were almost non-existent. Only in the early
1900s progress in safety was beginning to take place. This was due to the lack of workmens
compensation laws. Workmens compensation states that no matter whose fault is it, the injured
employee will be compensated for the injuries received on the job (Petersen, 1975, p.7). Industrial
injuries were then handled under common law. It was almost certain that the management of the
industry did not have to pay for the injuries (Williams and Heins 1989, Greenberg and Barron,
1997). According to Petersen (1975), the workmens compensation laws were passed in 1911 which
marked the beginning of industrial safety management. The industrial management found that
paying compensation for injuries was more expensive than paying for a certain degree of safety
improvement which prompted the start of serious industrial safety movements.
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Due to the fact that the U.S.A. is the leader in aviation safety field because of the millions of dollars
invested in aviation accident investigations and analysis, especially on the TWA 800 accident at
Long Island, New York in 1996 (Orlady and Orlady, 1999), together with the fact that safety data in
the U.S.A. is readily available through electronic displays and hard copies, it prompts the
researcher to select the coming of safety movements in the U.S.A. as the start of this study. Safety
movements in the U.S.A. have been developed over time in the following chronological order. Not
so long after or about the same time, safety in other countries, such as Great Britain, Australia, New
Zealand, Canada and some other European countries has also been seriously developed.
2.5.1 An Inspection Era
In the beginning period of safety movements, management concentrated mostly on cleaning
up poor physical conditions. This method alone reduced the number of deaths from an estimated
18,000 to 21,000 in 1912 to about 14,500 in 1933 (Petersen, 1975, p.8). In terms of death rates, the
figure would yield a better outcome if presented in percentage terms, because the number of workers
in industry increased while industry expanded.
Petersen (1975) indicates that in 1931, H.W. Heinrich published a book titled: Industrial Accident
Prevention: A Human Approach, in which the principles set by him, laid the foundation for
most of todays safety program elements. From a safety perspective, as a result of Heinrichs
Industrial Accident Prevention publication, safety management has developed to its present standard.
2.5.2 The Unsafe Act and Condition Era
Heinrich indicated that more accidents are caused by human factors than by conditions. He
suggested that accidents are caused by unsafe acts more than by unsafe conditions. As a result, the
safety professional of the 1930s and the1940s thought of industrial accident prevention
simultaneously in two ways. One was to clean up conditions and the other was to promote safe ways
of working (Petersen, 1975, p.8).
2.5.3 The Industrial Hygiene Era
Diseases related to occupations have long been acknowledged. In the late 1920s and the early
1930s,
interest
in
occupational
diseases
intensified
since
they became the subject of
compensatory actions. Safety personnel of the 1930s and the 1940s treated industrial safety in three
ways by looking at the physical conditions, the behavior of workers and the environmental conditions
(Petersen, 1975, p.9).
2.5.4 The Noise Era
Page | 13 In 1951, compensation commenced for the loss of hearing or related damages caused by noise in the
workplace (Petersen, 1975). This marked the Noise Era when safety managers spent time on noise
problems as well as other problems mentioned earlier.
2.5.5 The Safety Management Era
In the 1950s and the 1960s safety engineers emphasized the management side of safety such as
setting policy, defining responsibilities and authorities (Petersen, 1975). They also looked at
human factors in engineering. Petersen (1975)indicates that statistical tools were brought into use
in safety management as well as other management terms and concepts.
Safety management did not only look into the on the-job injuries of the workers, it also addressed
fleet safety, control of property damage, off-the-job safety, etc. In this era, records show that from
1961 to 1971, the frequency rates of accidents that had been improved since the 1930s era
began to worsen but the severity rates of injury were lessened (Petersen, 1975, p.11). The
reasons could be that the development of machines went ahead of that of human elements
causing more frequency of mishaps. Improvement in protective gear, such as safety belts, safety
goggles, etc., could explain the reduction in severity. Approaches to safety were then re-examined.
This re-examination would lead to the evolution of safety programs.
2.5.6 The Occupational Safety and Health Act (OSHA) Era
In 1970, according to Petersen (1975), an Occupational Safety and Health Act was passed which
marked a new era of safety management where the safety professional is required by law to
focus on two things:
(i) The requirement to remove physical conditions that are mentioned in the federal standards.
(ii) The requirement to record everything carried out.
Since the passing of Workmens Compensation laws in 1911, operators in industry, including
the aviation industry, would rather outlay on accident prevention than on compensation, because
costs of prevention are lower than costs of compensation and other hidden costs (Pertersen,
1975, Wood, 1991, Garland, Wise and Hopkin, 1999, Orlady and Orlady, 1999).
Despite most third-party compensation, higher costs on insurance premiums and deductibles will be
imposed whenever accidents happen. The increase will also depend on the amount of liability limits.
2.5.7 The Active Failure-Latent Condition Era
Page | 14 Reason (1997) states that there are two major kinds of accidents: individual and organizational
accidents. Individual accidents are greater in number. The reason for individual accident to be
greater in number may be because financial and other support for structured accident prevention
program is inferior. He goes on to say that individual accidents are accidents that happen to
individuals, who are either the agents or the victims.
Organizational accidents, according to Reason (1997), are accidents that happen to organizations.
These kinds of accidents have many causes involving many people at different levels of the
organizations. They can have devastating effects on the environment or properties or people who
are not even directly involved. Reason (1997) also indicates that organizational accidents often
are a product of new technological innovations, which have changed the relation between systems
and their human operators as mentioned in Section 2.2.2.4.
One of typical problems is the
inherent man-machine interface difficulty (Garland, Wise and Hopkin, 1999).

In many instances, the users of a system are not the designers. Many man-machine interface problems
have led to catastrophic accidents. Such interface problems occur when there is nothing wrong with
the human operators and the machines. Mismanagement of automation due to lack of understanding
of the design concept of complex systems is found to be a leading cause. Air France Airbus 320
and Air Inter Airbus 320 accidents at Mullhouse-Habshiem and Strasbourg in France, in which
pilots misinterpreted aircraft performance caused by the changing of automation mode in a go-around
attempt and in which pilots possibly misinterpreted a digital instrument display, are two of many
examples of man-machine-problem induced accident.
Reason (1997) has clearly pointed out those human actions and decisions cause organizational
accidents. Human beings can contribute to the breakdown of the defenses in two ways: by committing
errors and violations.
Defenses, in this case, according to Reason (1997), are referred to as the means by which the goal of
ensuring the safety of people and properties is achieved. The commitment of errors and violations is
in fact the unsafe acts as mentioned in Section 2.5.2 and due to the immediacy of their adverse
effects; these acts are termed active failures (Reason, 1997, p.10).
Within the last 20 years or so, unsafe acts or active failures have been seen more as symptoms
or consequences than causes (Reason, 1997). The answers to the questions why human beings,
apart from their fallible nature, commit errors and violations need to be pursued. The reasons
behind such commitment can be poor design of the system, procedure or equipment causing
ergonomic mismatch (Garland, Wise and Hopkin, 1999), inadequate training and education, lack of
suitable policies, philosophies and guidance, poor communications, and improper supervision and so
Page | 15
on. These reasons are termed latent conditions. Latent conditions can lie dormant within the system
waiting for active failures to be triggered by the operator and interacted with, to cause an
accident or a catastrophe (Reason, 1997)
2.6 PARENT DISCIPLINE TWO: AVIATION SAFETY MANAGEMENT
Since the passage of Airline Deregulation Act in 1978, cost control inairlines in the USA seems
commonplace (Oster, Jr, Strong and Zorn, 1992, Eaton, 2000). This is due to the fact that facilitation
of new entrants, through the introduction of Airline Deregulation Act, has forced airlines to put more
focus on productivity improvements such as seat-kilometer, price competition and competitive
marketing. This phenomenon does not only affect the US air transportation market. It also affects
markets everywhere.
Though deregulation helps consumers enjoy the benefit of low price, a choice of carriers, and a wide
choice of timetable, the safety of the traveling public seems to be in question especially when
corner cutting in maintenance is perceived to be the main cost reduction technique (Oster Jr,
Strong and Zorn, 1992, Sekaran 2003). Nevertheless, this concern can be eased when many
regulatory bodies have laid down stricter regulations and exercised tougher inspection.
As spending on safety increases, the rate of
increase of the degree of safety begins to decrease
when the point of Diminishing Marginal Returns
is reached as illustrated in 2.2.2.
Figure 2.6.1: The Relationship between the Effects of Over-spending and Under- spending on Safety
Figure 2.6.1 shows that the distance between the optimal safety spending line and the bankruptcy
through over-spending line is greater than the distance between the optimal safety spending line
and the bankruptcy through safety under-spending line. This implies that it is difficult for an
organization to reach a bankruptcy state through safety over-spending, and takes a longer time to
Page | 16
reach such a state.

Because increased spending is often monitored, traced and audited; management always
questions any extra spending that does not yield increased productivity in both qualitative and
quantitative terms. On the contrary, reaching bankruptcy through safety under-spending, such
as reducing budgets for accident prevention programs, can be achieved easily because cost
cutting is one of managements usual alternatives to margin creation. This statement is supported
by Reason (1997), who indicates that management often looks into the production more than the
prevention side of the equation.
However, the above example is based on the assumption that standards of safety undertaken
for both cases remain the same. This, therefore, means that for a given cost, a better safety
management program yields better results for accident prevention. The demonstration iterates the
implication of safety on economy.
Flight Operations Production
However, as far as flight operations are concerned, there are two assumptions to be considered here.
The first assumption is that productivity produced by the flight crew in this context refers to
a safety margin that a crew can produce in a flight operation. This is because commercial departments
already assign production in terms of seat-kilometer or ton-kilometer and the number is fixed. Seatkilometer is the number of seats sold for every one kilometer flown. Ton-kilometer is the number of
tons of cargo carried for every one kilometer. Seat-kilometer and ton-kilometer are the units of
production of an airline. How good a crew performs a flight does not directly affect the number of
seats sold and tons of cargo carried. But how well a crew conducts a flight can distinctly make a
difference to safety. Hence the product is the safety margin.
Figure 2.6.2 explains how a flight operations product is created. The flight operations process, as
guided by prescribed procedures, is derived from policies and established philosophy as
mentioned in Section 2.4.2.2 which are in the form of the operations four Ps concept (Orlady
and Orlady, 1999). The customers are the traveling passengers who are viewed as external
customers, and those stakeholders within the organization, such as other departments, are viewed
as internal customers.
In order for a quality product to be produced, according to the International Organization of

Standardization reproduced by NOVO Quality Services, Thailand (15 December 2000, Third
Edition), it is required to identify the product, the process and the customer requirements. A product
is the output of a process which is the collection of activities of using and managing resources in
Page | 17
order to transform inputs into outputs. Inputs are the raw materials before being fed into the
process. Products must be in conformance with customer requirements. Thus, before requirements
are known, a customer must be identified. If customer requirements are met, satisfaction is bound to
occur which results in an increase in revenue.
Figure 2.6.2: Product and Process of Flight Operations at Operation Level

Legend: RAW MAT=Raw materials
Page | 18
Figure 2.6.3: Overall Organization Aviation Process at Organization Level
Analogous to Figure 2.6.2 and looking from a bigger scale, according to Figure 2.6.3, it can be seen
that major components in the aviation process are the collective processes of the marketing,
operations and finance departments. Global conditions and environment, such as wars, world
economy, disease outbreaks, etc. can affect the process outcomes. Other factors that affect the process
outcomes are ethical and social obligations.
Figure 2.6.4 shows conceptually how safety margin, at different phases of flight, relates to crew
performance or ability limits.
Figure 2.6.4: Concept of Safety Margin

Source: Adapted from Thom, (1994, p. 96) and Turner, (1995, p. 98).
The second assumption is that the safety margin, in this case, is limited to that created by the flight
crew alone. There are other factors that can also affect the safety margin of a flight. Those factors
are, for example, failure of equipment, flight environment, air traffic controllers ability, ground
crew errors, other aircraft or vehicle involved, and others.
Page | 19
Since accident investigation results show that the flight crew accounts for approximately 70
per cent of all airplane accident (Boeing Statistical Summary of Commercial Jet Airplane
Accident, 2000, Garland, Wise and Hopkin, 1999, Orlady and Orlady, 1999, James and
Sumwalt III, 2000), only crew-induced factors are considered. From the pilot performance
measurement perspective, other factors which are beyond crews control are assumed to be constant.
The statement above indicates that, in order to conduct a safe and efficient flight, effective safety
management needs to be undertaken.
Flight safety management, in fact, started as early as 1903, when the Wright brothers moved on with
flying one step at a time philosophy when they thought it was safe to do so (McAllister, 2001).
Management involves planning, organizing, staffing, leading, coordinating and controlling
(Koontz, ODonnell and Weihrich, 1980). A good application of management techniques brings
about a systematic approach to aviation problem solving.
Today, aviation technology has improved so much that the rate of accidents caused by
mechanical failure is miniscule (Young, 1987). Excluding failure caused by sabotage, the remaining
proportion is the human element. Since most of the windows of opportunity for mechanical failure
are closed, the remaining windows that are left open for an accident to occur are those for human
failure. According to the book written by Orlady and Orlady (1999) titled: Human Factors for Multicrew Operation, the researcher concludes that the underlying reasons, on the part ofthe crew, for these
phenomena are:
1) Failure to follow appropriate procedure
2) Inadequate consideration of culture
3) Inadequate training
4) Improper supervision
5) Inadequate communication
6) Human fallible nature of committing errors (reduced by proper
procedure design), and
7) Ergonomic mismatch
Ignoring the need for improvement of those underlying reasons is likely to cause the same
accident rate to remain unaltered. The number of accidents per year will increase because of the
growth of the aviation industry paralleling the growth of world population and globalization.
Airfares are comparatively cheaper because of fierce price competition as a result of deregulation,
Page | 20
improvement in technology, and more effective management methods in reducing production and
operating costs, etc.
Aviation accidents always hit the front page of the media because a great number of deaths
are usually involved due to the fact that airplanes are always operated in a high-energy
environment such as high-kinetic (speed) and high-potential (altitude) energy conditions.
The
politicians, the regulators, the media and the traveling public demand that safety be improved
because the number of annual fatalities will look frightening if the accident rate is to remain in the
status quo.
Aviation accidents are a human problem. In order to understand the aviation accident rate further,
this report will review the literature on Management Practice (MP), Human Resource Development
(HRD), pilot Performance Measurement (PM), and Reporting System (RS), because these areas
have significant impact on aviation safety (Focus Group Interviews).
2.6.1 Management Practice
The 1931 Heinrichs established principles of industrial safety number four states that there are
four motives for the occurrence of unsafe acts; they are improper attitude, physical unsuitability, lack
of knowledge or skill, and improper environment (Petersen, 1975, pp. 15-16).
Improper Attitude
Petersen (1975) and Reason (1997) show that attitude plays an important part in an accident
occurrence. Reason (1997) indicates that attitudes of the operator are also influenced by corporate
culture. Corporate culture has direct influence on safe flight operations because it has great
effect on an individuals response to rules, regulations, policies, procedures and practice of the
organization (Orlady and Orlady, 1999).
Therefore safety culture enhances the quality of operations where safety is considered productivity
(as mentioned in Section 2.4) which is the case of flight operations. Management of an airline is in
the best position to create a better safety culture through safety attitude and appropriate value system
creation among its employees throughout all level of activities.
Attitude can be modified through proper training and education (Garland, Wise and Hopkin, 1999).
Management practices and proper training can help enhance this safe attitude.
Physical Unsuitability
Petersen (1975) did not elaborate on this issue. Physical condition in this case can mean two
things relevant to safety. First is the physique of the worker or the operator. For example, length
Page | 21 of the arms and legs has significant effect on manipulation of the machine especially an aircraft.
Ergonomics has thus become a vital part of the design (Garland, Wise and Hopkin, 1999).
Second is the physical condition of the operator: Is the operator in a physically and mentally suitable
condition to perform the tasks? This topic is strongly stressed in the aviation safety field today. As a
result, a stringent medical examination is required for pilots, especially those who are over 40 years
of age (ICAOs Annex One to the Convention of International Civil Aviation, 1990). Since 1920,
pilots have been required by US air regulations to undergo periodic physical examination (Orlady
and Orlady, 1999). Many regulators also draft regulations with regard to maximum duty time and
required rest time of the flight crew (Flight International, 18-24 March 2003, p.13).
Lack of Knowledge or Skill
According to Davenport and Prusak (1998), knowledge is a mixture of formed experience,
values, contextual information and expert insight. This knowledge provides a platform for
evaluating and incorporating new experience and information. This is a matter of training, education
and drilling, both in the cognitive and psychomotor areas.
Lack of knowledge can bring about a breach of defense mentioned in Section 2.3.7, which is the
last line of accident prevention or aversion as mentioned by Reason (1997). Drilling with
exercises of different scenarios in flight simulators can enhance key skills needed for day-today operations, such as maneuvering of an aircraft, etc. Flight simulators are excellent tools in
enhancing crew competency in which worst-case scenarios can be created. It is impossible to do so,
on a real aircraft.
Improper Environment
Environment in this context does not mean ecological environment. It represents the working
environment in which a flight operation occurs (ICAO Accident Prevention Manual, Doc. 9422AN/923, First edition, 1984). A good example is the operation of an aircraft in a hostile
environment, which can be bad weather or dangerously high terrain, or the two in combination,
and so on. Pilots cannot control this kind of environment, but through proper HRD and
training programs, it can safely and effectively be overcome. Improper environment can also mean
the group dynamics caused by the captains leadership style. If the captain is too authoritative, the
environment in the cockpit can be tensed.
These four motivations, responsible for the occurrence of unsafe acts in flight operations can be
reduced, if not totally eliminated, by proper implementation of human resource training and
development and a good management practice.
Page | 22
From statements mentioned earlier, management has the greatest influence on organization safety.
The following example demonstrates this case well. The management of Unocal Thailand, Ltd.,
an energy company in Thailand, through a committee and various working groups, has set up
Good Operations Health, Environment and Safety (GO-HES),a review and action plan in which
three major policies are explicitly articulated (Unocal Thailand, Ltd., GO-HES Review and Action
Plan Handbook, 2002).
The three major policies are compliance policy, environmental care policy and safety and loss
prevention policy:
The Compliance Policy
The organization is committed to compliance with all legal and regulatory requirements that apply to
the operation of the organization.
The Environmental Care Policy
The organization is committed to conducting its operations in compliance with local and international
environmental care requirements. This is to best preserve global natural conditions.
The Safety and Loss Prevention Policy
The organization is committed to its policy to support the philosophy that safety and loss
prevention must be thoroughly integrated in all organization activities.
2.6.2 Human Resource Development
Thomson and Mabey (1994) have quoted from Garavan, (1991), the definition of Human Resource
Development, in the book titled: Developing Human Resources, as: The strategic management of
training, development and of management/professional education interventions, so as to achieve
the objectives of the organization while at the same time ensuring the full utilization of the
knowledge in detail and skill of individual employees (Thomson and Mabey, 1994, p.20). From this
definition, the word HRD will, in this context, include all kinds of training as well as the development
of human resources.
One of the purposes of HRD is to enhance motivation and commitment of the operators to a safe
operation. One theory of motivation is Maslows hierarchy of needs. Maslow implies that to survive
a human being is motivated to acquire basic physiological needs of food, shelter, medication,
clothing, etc. Once the basic level is satisfied, the individual moves on to satisfy higher levels of
needs, as shown in Figure 2.6.5.
Page | 23
Figure 2.6.5: Maslows Hierarchy of Needs

Source: Adapted from Thomson and Mabey, 1994, pp. 143-144, Orlady and Orlady,1999, p. 184.
However, Alderfer, according to Thomson and Mabey (1994), argues that people might have desire
for all levels of needs at the same time. The process does not have to follow the hierarchical order
prescribed by Maslow. McClelland, according to Thomson and Mabey (1994), reinforces that the
existence of one of the needs may not preclude other needs.
Table 2.6.1: A Comparison of Needs Theory

Source: Adapted from Thomson and Mabey, 1994, p.144
If all the three needs, namely needs of existence, needs of relatedness and needs of growth are
present, a person is likely to be strongly motivated (Thomson and Mabey, 1994).
However, commitment, which is more than motivation, is related to extra effortan individual exerts
into the tasks based on the degree of loyalty and responsibility, of that individual. Expectancy theory
or path-goal theory of motivation explains the relation between effort and outcomes as
demonstrated in figure 2.6.6. From expectancy theory, Thomson and Mabey (1994) conclude that
Page | 24
human behavior is governed by peoples expectations about the relationship between their
behavior and the achievement of desired outcomes. Since motivation is a function of behavior
and behavior is a function of belief and attitude (Myers, 1994) that can be modified through HRD,
HRD can support motivation for safe behavior (Orlady and Orlady, 1999). A safe behavior is the
behavior that results in minimum risk in operations for a given condition.
Figure 2.6.6: The Link between Effort, Performance and Outcomes

Source: Thomson and Mabey, 1994, p.63.
Thomson and Mabey (1994) conclude that the driving forces for a positive culture towards
HRD are:
(i) The appointment of a training champion especially among senior management,
(ii) Systems for analysis and delivery of training activities,
(iii) Line managers positive attitudes toward training supported by managements relieved constraint
on budgetary and time costs of releasing staff,
(iv) Internal requirements for health and safety training governed by regulatory bodies or demanded
by formal groups such as a labor union
If a senior manager is appointed and behaves as a training champion, employees are more
likely to be motivated to willingly take part in HRD. Management is also in a position to support
creation of systems for analysis, timetable and delivery of training activities. In order to support a
positive culture towards HRD,management needs to relax on HRD budget constraints and prepare for
costs of nonproductive periods. Requirements for health and aviation safety training set by
aformal group such as a labor union can also support a positive culture towards HRD. It is obvious
Page | 25
that a good management practice can greatly influence HRD.

Some hindrances to HRD often faced by BIMAN.
(a) Finance: Financial factors and figures control decisions so that the short-term result seems
to override longer-term consideration of HRD. Management considering putting long-term HRD
priority before short-term financial gain can overcome this.
(b) Culture: Hofstede and Hofstede, (2005) imply that corporate culture, influenced by Eastern
national culture possessing great power distance, does not support the development of human
resources. This is because the culture-bound bosses do not like to feel that their subordinates
are more knowledgeable. Cultural effects must be made known.
(c) Motivation: There is a lack of incentives for employees and employers to make HRD one of
the top priorities. Relief on tax for employers who provide effective HRD programs and allowance
for out-of-office period for HRD training can, for example, be considered as an incentive for
employers and employees since meals and lodging are paid for.
(d) Economy: For economic reasons, wide use of contracted labor does not demand on HRD
budget (caused by a why should we train other peoples staff attitude). Contracting outside
labor must be carefully considered.
Proper management practice and effective communication can overcome such hindrances.
Thomson and Mabey (1994) point out that HRD can be used as a tool to pursue quality: A good
HRD program can mold behavior concurrent with the desired, effective, preplanned pattern that
promotes safety. They also note that a well-designed HRD program can also create a learning climate
and support self-development.
2.6.3 Performance Measurement

Curt Lewis and Tom Chidester state in extracted American Airlines (AA) Flight Safety which is
published in THAI Flight Safety Information, July 2002 edition, that the human factor is the most
Page | 26
vital component of the aviation system. Humans make decisions guided by their judgments, which
eventually lead to actions (THAI Flight Safety Information, July 2002, pp. 15-17).
Flying is a constant process of decision making. Pilots constantly make decisions both in normal and
emergency situations because the flight environment is dynamic and changing all the time. In flight
operations, decision making is often done instantaneously. When accidents occur, the judgment of
pilots always comes into the central interest of investigation and controversy. The quality of decisions
depends on time and quality of information available since information affects judgment and
behavior (Kouri, 1999). When pilots are confronted with a situation requiring immediate actions,
they decide quickly and most of the time, accurately, if information received is complete, correct and
concise.
Performance measurement is the collective measurement of pilots' achievements which stem from
decision making and other elements of piloting skill.
2.6.3.1 The Importance of Information for Decision Making
Gary Klien (1989) indicates in THAI Flight Safety Information, July, 2002 that pilots do not usually
generate and evaluate alternative actions because of limited time available. Most of the actions
are correct and effective because pilots are highly trained to apply predefined solutions (THAI
Flight Safety Information, July 2002, pp. 15-17). In order to make a quality decision in a limited time
available, accurate and adequate information is needed. Time and information are therefore very
important elements of decision making. Quality information is the information that is correct,
complete, and relevant and obtained in a timely fashion.
To ensure safe flying, pilots are required to use quality information that they sense through those
sensors such as vision, audio, kinesthesia, smell and taste, in order to make correct decision and take
actions (Green et al. 1991).
Flying is a constant process of decision-making, and decision-making depends on information, the
need for information hunt or information search thus integrates into key tasks needed for pilots
to perform flight operations safely. Many pilots actions in the flight decks, such as poor checklist
management, etc., can affect good information search process, which in turn affects quality of
information and consequently decision-making.
2.6.4 Reporting Systems (RS)

As mentioned earlier, a good decision-making relies on quality information and time available. In
order for good decision-making to be made, it is important that quality information be
Page | 27
effectively transferred to decision-makers. A good reporting system is an effective means of

transferring information. Orlady and Orlady (1997) emphasize the importance of information
transferring system, especially the no punitive incident reporting system.
A good reporting system does not only provide incident reporting, it includes all kinds of reports
that have impacts on decisions that support flight safety. A reporting system involves means of
transferring quality information, formatting the report contents so that they can be easily interpreted.
As mentioned earlier, a good decision-making relies on quality information and time available. In
order for good decision-making to be made, it is important that quality information be
effectively transferred to decision-makers. A good reporting system is an effective means of
transferring information. Orlady and Orlady (1997) emphasize the importance of information
transferring system, especially the no punitive incident reporting system.
A good reporting system does not only provide incident reporting, it includes all kinds of reports
that have impacts on decisions that support flight safety. A reporting system involves means
of transferring quality information, formatting the report contents so that they can be easily
interpreted.
In order to encourage reporting as a whole by individuals concerned, reports must be nonpunitive. Most incidents result in undestroyed aircraft and uninjured crew. But the risk that the
incidents induce has been great. Sometimes sheer luck stops the development of accidents. Many
of such incidents have gone by without reports. With references from the literature, the researcher
concludes that what prevent such reporting are fears.
According to the late Bobbie R. Allens statement mentioned in Orlady and Orladys (1999)
Human Factors in Multi-Crew Flight Operations, p.397, those fears are: fear of litigation, fear
of regulation, and fear of punitive action. The researcher deems it necessary to add two fears to it,
especially when Eastern cultures are concerned, that fear is the fear of losing face apart from fear of
financial liability as mentioned b Orlady and Orlady (1999). Limited skills in language can also
prevent an individual from reporting.
Data obtained from the reports enables management to facilitatetraining needs and setting of required
standards of performance relevant to safety enhancement. As far as non-punitive reporting is
concerned, management should provide immunity to individuals who make such reports by creating
statements and behaviors that guarantee immunity of the reporters. With this management practice,
reports of incidents will be well encouraged. The following section, aviation safety in THAI,
demonstrates how the THAI organization is structured. It also describes the authorities and
responsibilities of functions within THAI that are directly concerned with aviation safety.
Page | 28
These
four
processes afore-mentioned namely: management
practice, human resource
development, performance measurement, and reporting system should bear some linkages so
that a loop is formed. This loop formation facilitates feedback between processes. A loop formation
of feedbacks or transfer of information creates a Continual Improvement (CI) system.
2.7 A review of major accident categories and risk areas
2.7.1 Controlled flight into terrain (CFIT)

Controlled flight into terrain (CFIT) describes an unintentional collision with terrain during the
normal operation of an aircraft. By definition, the aircraft will be airworthy and the pilot will be in
control of the aircraft, but unaware of the impending disaster. This commonly occurs in areas of high
terrain and poor visibility.
The International Civil Aviation Organization (ICAO) measured a reduction in CFIT-related fatalities
of almost 40%, from 1,818 fatalities in the period 1997-2001 to 1,143 fatalities in the period 20022006.Historically, CFIT has been a major concern for many international organizations.
Boeing statistics of worldwide commercial jet accidents from 1997-2006, attribute 20 fatal accidents
and 1,655 onboard fatalities to this type of accident. In 2007, CFIT accounted for 5% of global
accidents. 80% of these accidents were fatal, and all resulted in a hull loss.
International Civil Aviation Organization (ICAO) data notes that the CFIT accident category has
shown the greatest decrease in the number of fatalities in recent years.There were 1,143 fatalities
because of CFIT accidents in commercial aviation from
2002-2006. This was a reduction of nearly 40% from the previous five-year time period of 19972001, in which there were 1,818 CFIT-related fatalities.
Although the number and threat of CFIT accidents has been greatly reduced through the
implementation of Terrain Awareness and Warning System (TAWS) equipment, safety activity
continues in this area. ICAO has expressed concern over the risks posed by a complacent attitude
towards this readily available and proven technology.
Failure to link TAWS to global navigation satellite systems, or to promptly update the software and
databases this equipment rely on, can lead to false, delayed, or even no warnings being given, thereby
giving flight crews a false sense of confidence in these systems. Furthermore ICAO-quoted industry
sources state that 62% of false warnings arise from database errors, 16% from flight management
Page | 29
system errors and13% from altitude errors, most of which can be prevented by employing simple
updates.
2.7.2 Approach and landing accidents
The characteristics of approach and landing accidents were examined and found to result from factors
such as high-energy approaches (where an aircraft is too high, too fast, or both) and decisions by crew
not to initiate missed approaches. Studies showed that cargo, ferry and positioning flights are more
likely to be involved in an approach or landing accident than passenger flights. In addition,
commercial aircraft flying non-precision approaches were found to be more likely to be involved in
an approach and landing accident than commercial aircraft flying precision approaches.
The FSFs Approach and Landing Accident Reduction Task Force has studied numerous approach
and landing accidents and serious incidents. Major findings of their studies point to a general lack of
risk assessment. Case studies revealed that 83% of flight crews did not conduct go-around or missed
approaches when necessary, 30% of accidents and serious incidents were fast or high on approach,
42% involved press-on-its, where crews continued the approach and landing despite cues indicating
that a go-around or a missed approach was appropriate.
From their studies on approach and landing accidents, the FSF have additionally concluded that:
The approach and landing accident rate for cargo, ferry and positioning flights is eight times
higher than the rate for passenger flights;
Commercial aircraft flying a non-precision approach has an accident risk five times greater
compared to those flying a precision approach;
The approach and landing phase of flight, only accounts for approximately 4% of the average
flight time, yet 45% of hull losses.
2.7.3 Loss of control in-flight
ICAO data for the period 2002-2006 indicated that loss of control in-flight claimed more lives than
any other accident category. Other organizations concluded that this type of occurrence still presents
a high risk, with a high proportion of these accidents resulting in fatalities and hull losses.
Loss of control in-flight can be defined as the loss of aircraft control during an airbornephase of flight.
The European
Aviation Safety Agency (EASA) worldwide fatal accident statistics from 1997-2006 show that loss
of control in-flight was the top accident category in terms of the number of fatal accidents1. The
average rate of fatal accidents to aircraft registered in EASA member states2 involving loss of control
in-flight was stable from 2000-2006, at approximately 0.27 accidents per million flights.
Page | 30
ICAO data indicate that loss of control in-flight claimed the most number of lives in commercial
aviation from 2002-2006 compared to other types of accidents. ICAO attributes 1,391 fatalities to
loss of control in-flight from 2002-2006. Lives lost due to accidents from loss of control in-flight in
the period 2002-2006 have decreased compared to the period 1997-2001.
The Commercial Aviation Safety Team (CAST) have identified loss of control in-flight as the
accident category that globally still has the highest proportion of risk (from hull loss/ fatal/ security
accidents) to be reduced.
The International Air Transport Associations (IATA) 2007 safety report, attribute 13% of accidents
in 2007 to loss of control in-flight. All these accidents led to hull losses, and 85% were fatal. IATA
believes the major risk factors in a loss of control event are environmental, such as meteorological or
birds and foreign objects; aircraft malfunctions; and maintenance events.
2.7.4 Fire (Post-Impact and In-Flight)
Post-impact fire can be described as fire or smoke in or on the aircraft, resulting froman impact.
EASA worldwide fatal accident statistics from 1997-2006 show post-impact fire to be the third
highest accident category in terms of the number of fatalities2. Directly following an impact, fire and/
or smoke inhalation represent a significant hazard to the survival of aircraft occupants. Research
conducted for Transport Canada, suggests that rapid fire progression is by far the most significant
reason for the majority of nonimpact-injured passengers failing to evacuate the aircraft. Almost all
are attributable to fuel fed fires.In-flight fire can be described as fire or smoke in or on the aircraft
during flight, whichis not the result of an impact.
In-flight fire is a significant accident category, which is often overlooked in international published
statistics, compared to other categories such as controlled flight into terrain, loss of control in-flight
or even post impact fires. Historical data shows in-flight fires to have been within the four highest
accident categories in terms of the number of fatalities. Fatal accident data on worldwide commercial
jet aircraft from 1997-2006 attributes 110 on board fatalities to in-flight fires in this time period; this
more recent data puts in-flight fire events within the top 10 CAST/ ICAO accident categories.
It is estimated that more than 1,000 in-flight smoke events occur annually resulting in over 350
unscheduled or precautionary landings. Most in-flight fires are in unprotected areas. Boeing
conducted a study on in-flight smoke, fumes, fire and overheating events in pressurized areas on
Boeing aircraft between November 1992 and June 2000. The analysis found that 64% of the smoke
events had an electrical source.
Page | 31
A study conducted for the US Federal Aviation Administration (FAA), of 101 survivable airliner
accidents where fatalities or aircraft destruction occurred, found approximately 70% involved a fire.
The US National Transportation Safety Board (NTSB) has been involved in the investigation of fuel
tank explosions for several years, and has long been an advocate of the use of fuel tank inverting
technologies. To eliminate flammable fuel/ air vapors in fuel tanks on transport category aircraft is
listed on the NTSBs 2008 most wanted list of aviation safety improvements. 13 worldwide
accidents to transport category aircraft were identified during the period 1966-1995 that may have
involved a fuel tank explosion.
2.7.5 Runway excursions
Runway excursions occur during either take-off or landing, and involve an aircraft either overrunning
the end of the runway or veering off to one side of the runway. Studies showed that runway excursions
were the most common type of accident in 2007. Approximately a third of commercial jet accidents
in the period 1995-2007 involved a runway excursion.
Runway excursions include overruns and veer-offs, in which an aircraft goes off the end or side of
the runway respectively. Runway excursions are the most common type of runway safety accident,
representing approximately 80% of fatal runway accidents and 75% of fatalities. The International
Federation of Air Line Pilots Associations (IFALPA) believes that runway excursions are among the
most serious threats to aviation safety. IFALPA state that over the last 20 years, runway excursions
occurred at an average rate of approximately 4 per month. IATA data shows that 48% of accidents in
2007 occurred during the landing phase.
The majority of these accidents involved a runway excursion, making runway excursion the single
largest accident category of 2007. There were 26 runway excursion accidents in 2007, an accident
rate of 0.73 accidents per million sectors flown for all aircraft types.
FSF analysis has shown that there were 379 runway excursion accidents involving all (western and
eastern built) commercial turbojet and turboprop aircraft from 1995-2007. This equates to 28.5% of
total world accidents. Approximately one in three commercial jet accidents are an excursion; the
excursion accident rate for turboprops is one in four. Turboprops have a higher risk of veer-offs,
whereas jets have a higher risk of overruns. From 1991-2002, 25.1% of business jet accidents were
excursions.
There was found to be a factor of three reductions in the landing overrun accident rate over the 35year period 1970-2004. The decrease in the accident rate can most likely be attributed to
advancements in braking devices, improvements in understanding of runway friction issues, and
safety awareness campaigns.
Page | 32
2.7.6 Runway incursions

Runway incursions are the incorrect presence of an aircraft, vehicle or person on a runway.The use
of a runway by definition involves aircraft coming into much closer proximity to one another than
during normal flight. Hence, the risk of two aircraft colliding prompts many organizations to consider
as a priority, reducing the number of runway incursions. One study concluded that increasing the
amount of air traffic at an airport disproportionately increases the risk of runway incursions.
In-flight fires do not have the high rate of fatalities that the accident categories described above
experience. Nevertheless, they contribute to a number of cabin smoke events and to numerous
diversions. This type of accident can include occurrences as diverse as fuel tank explosions, fires
from high energy density batteries (such as laptop batteries), or other electronic equipment.
The ICAO definition of a runway incursion is: any occurrence at an aerodrome involving the
incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for
the landing and take-off of aircraft.
There were no accidents involving a runway incursion in 2007. However, many incidents were
reported worldwide.
A runway incursion was a significant contributing factor to the most severe accident in aviation
history (in terms of the number of onboard fatalities). Over 560 lives were claimed when two Boeing
747s collided at Los Rodeos Airport, Tenerife in 1977.
The US Federal Aviation Administrations analysis of runway incursions from 2003-2006, found that
pilot deviation, operational errors/deviations and vehicle/pedestrian deviations accounted for 54%,
29% and 17% of runway incursions respectively.
A Transport Canada study on runway incursions concluded that a 20% increase in traffic volume at
an aerodrome causes a 140% increase in runway incursion potential.
The study also found that:
As traffic volumes increase, runway incursion potential increases more rapidly when capacityenhancing procedures, such as simultaneous intersecting runway operations and intersection
departures, are in effect than when they are not in effect; and
If traffic volume remains unchanged, the potential for runway incursions will increase when
capacity-enhancing procedures are implemented.
The Transport Canada study cited traffic volume, capacity-enhancing procedures, airport layouts,
Page | 33 complexity and human performance as contributing factors to the increase in runway incursions.
2.7.7 Other Significant Accident Categories

Although mid-air collision accidents are rare in public transport operations, when they do occur the
number of fatalities involved are very high. Mid-air collisions and near collisions, are listed as the
fifth highest accident category in terms of number of fatalities in worldwide commercial jet fatal
accident data from 1997-2006. IATA list mid-air collision as a top safety issue, citing contributing
factors such as level busts and ATC-pilot communication as issues needing to be actively reduced.
Almost 20% of accidents in 2007 related to ground damage. 26% of these resulted in hull losses. The
FSF estimate that globally there are 27,000 ramp accidents and incidents, and 243,000 injuries every
year. Ground accidents and incidents are thought to cost the airline industry US$4.2 billion annually.
Fatal accident data on worldwide commercial jet aircraft from 1997-2006 attributes 546 on board
fatalities to System/ Component Failure or Malfunction Non-Power plant, making it the third
highest accident category in terms of the number of fatalities.
The rate of accidents related to aircraft systems/components/engine failures per million departures to
European registered public transport operations was stable from 2002 to 2006 resulting from a stable
number of fatal accidents in this category. The ESSI Commercial Aviation Safety Team considers
Safety Management Systems and Ground Handling as their priority areas of intended action.
Page | 34
Chapter-
Analysis on safety performance of Biman Bangladesh

Airlines.
3.0 Safety performance of Biman Bangladesh Airlines

Biman Bangladesh Airlines has successfully passed its ICAO IASA (International Aviation Safety
Assessment) audit, a universal safety program that monitors adherence to international aviation safety
Page | 35
standards.
The airline is working on obtaining the approval of the US TSA (Transport Security Administration)
for their screening and secondary screening processes for international passengers, and continues
work with the Bangladesh Civil Aviation Authority to secure a Category One rating in the FAA's
International Aviation Safety Assessment Program. The latter is a prerequisite for any airline that
wants to introduce new services to the USA.
Flight Safety Department plays a pivotal role in ensuring and maintaining safety standards of Biman
Bangladesh Airlines Ltd. Their data driven safety approach relies on data from various sources and
looks past to take lesson for future plan. They received data through Air Safety Report (ASR) form,
Crew de-briefing, Mandatory Occurrence Report (MOR), Confidential Report, Adverse Training
Record, Inspection and Surveillance, Safety audit, Investigation into accident-incident and liaison
with external agency. Raw data are sorted, organized and analyzed and reports are prepared.
If it is within the purview of Chief of Flight Safety, then she/ he takes necessary action in accordance
with the report otherwise issues are brought to the Safety Review Board chaired by Managing
Director and CEO. Safety Review Board comprising of following senior executives meets once in
every three months to review the safety issues and to take necessary actions.
Figure 3.0.1: Flight risk Analysis Program
Man behind the machine is responsible for 85% of worldwide accident-incident. Their relentless
effort to develop human resources helps improve their safety. Training courses like Crew Resource
Management (CRM), Safety Equipment and Emergency Procedure (SEEP), Aviation Security,
Dangerous Goods Regulations (DGR) and Fire Training are organized routinely by Flight Safety
Page | 36
Department. CRM cell has been formed to develop CRM course. To ensure quality training, an
Instructor Selection Committee headed by DFO has been constituted.
It is evident that their crew and operational staffs play a major role in their data driven safety
approach. They always try to reach customers to get their input. Confidential Safety Reporting box
are mounted in different location of Biman to ease reporting, safety website (www.flysafebg.com)
has been developed for electronic reporting and we always try to acknowledge your report and if
possible let you know the action taken against a report.
Flight Data Monitoring (FDM) system is an important tool to capture performance of an aircraft and
crew. They are working to equip the aircraft with FDM and hope to get important data from the FDM
in near future.
Capability to harness lesson from mistakes is necessary to avoid recurrence of past. Investigation
findings of previous accident-incident are used for educational purposes. Its safety circular, news
bulletin, awareness program and training courses reflect its learning from the past mistakes. The CRM
Cell is working to make CRM course contextual to Biman.
Losses can be minimized by preparedness for the worst possible situation. Responsibility of each
individual is spelled out in our Emergency Response Plan (ERP) and detailed action plan is depicted.
Passengers will get answer to questions Who-What-Where-When-How during an emergency from
our ERP. They could not be relieved confining ERP in Flight Safety Manual, as such large ERP
boards have been prepared and mounted in different installation of Biman to conversant all concern
with ERP and to be used as checklist during emergency. Fire Fighting and Fire Rescue Teams have
been formed for all Biman establishments to act if fire emergency happened. Emergency Drill for
Cabin Crew and Cockpit Crew are conducted regularly as an integral part of mandatory SEEP (Safety
Equipment and Emergency Procedure) course.
Safety cannot be achieved without passengers participation. Passengers should translate its plan into
reality through their skill and knowledge, help the Biman to know the scenario and take decision by
reporting, and correct us providing feedback. It has teamed up with passengers to transform Biman
into safest possible airlines.
Extracting useful information, isolating accident precursor, determining critical control point,
maintaining confidentiality, preserving data for future reference and readying for easy data retrieval
are as challenging as collecting data. They have developed their very own database application "FSBiman Data Bank v1.5.0" that makes it effective, efficient and secured.
Page | 37
3.1 Accidents and incidents by Biman Bangladesh Airlines Ltd.

date
type
registration
operator
fat.
location
12MAR2007
Airbus A310-325
S2-ADE
Biman
Bangladesh
Dubai Airport
01-JUL2005
DC-10-30ER
S2-ADN
Biman
Bangladesh
Chittagong-Sylhet
08-OCT2004
Fokker F-28
Fellowship 4000
S2-ACH
Biman
Bangladesh
Sylhet-Osmani
International Airport
22-APR2003
Fokker F-28
Fellowship 4000
S2-ACV
Biman
Bangladesh
Dhaka
22-DEC1997
Fokker F-28
Fellowship 4000
S2-ACJ
Biman
Bangladesh
Sylhet
04-APR1996
British Aerospace
ATP
Biman
Bangladesh
Barisal Airport
05-AUG1984
Fokker F-27
Friendship 600
S2-ABJ
Biman
Bangladesh
49
near Dhaka
03-APR1980
Boeing 707-373C
S2-ABQ
Biman
Bangladesh
Singapore-Paya
Lebar Airport
18-NOV1979
Fokker F-27
Friendship 200
S2-ABG
Biman
Bangladesh
near Savar Bazar
25-JUL1979
Fokker F-27
Friendship
Biman
Bangladesh
Calcutta
10-FEB1972
Douglas DC-3
Biman
Bangladesh
near Dhaka
Source: Aviation Safety Network

Last updated: 20 April 2014
11 occurrences in the ASN safety database, showing occurrence 1 11
3.2 Reasons of previous accidents and incidents

Coming into operations since Jan 1972, Biman has witnessed around 11 incidents or accidents. Lets
take a tour with their bad points:
Page | 38 On 10 February 1972: Only more than a month since their establishment, Biman had to experience
the first accident. During a testing flight, the Douglas DC-3 crashed near Dhaka capital, resulted in
the death of five crewmembers. It was a training flight.
On 18 November 1979: A flight-training plane, named Fokker F27 had to land and was written off
in a field near Savar Bazar because the engines caught fire and cut out following a stall test at 8,000
feet (2,400 m). Forced landed in a field following the flameout of both engines.
On 3 April 1980: Named "City of Bayezed Bostami", A Boeing 707 lost power following takeoff
from Paya Lebar Airport, reaching an altitude of some 100 feet (30 m) and sinking back to the runway
with the landing gear retracted. The aircraft, that was due to operate an international scheduled
SingaporeDhaka passenger service, skidded for about 2,000 feet (610 m) before it came to rest. All
four engines had apparently flamed out, although it was also deemed possible that the takeoff was
aborted too late. The aircraft was written off.
On 4 August 1984: A Fokker F-27 from Chittagong to Dhaka, crashed near Dhaka, killing all 49
people on board. Captain Kaniz Fatema Roksana, the airline's first female pilot, made two attempts
to land in reduced visibility but could not find the runway. On the third attempt the Fokker F27
crashed in swamps 1,640 feet (500 m) short of the runway, after several missed approaches amid
inclement weather.
On 22 December 1997: Flight BG609 from Dhaka to Sylhet made a belly landing on paddy fields 2
Km short of Osmani International Airport in heavy fog. Seventeen of the eighty-nine people on board
were injured. The Fokker F28 was written off.
On 8 October 2004: Flight BG601 from Dhaka to Sylhet landed far down the 9,000 feet (2,700 m)
runway at Osmani International Airport in heavy rain and overshot the end by 150 feet (46 m), coming
to rest in a ditch 15 feet (4.6 m) deep. The aircraft was heavily damaged and the plane was written
off. All 79 passengers (including a number of VIPs from the Bangladesh government) escaped with
minor injuries. The captain Shahana Begum broke his arm.
On 1 July 2005: The aircraft that was operating an international scheduled DubaiChittagong
Dhaka passenger service as Flight 48 when it ran off the runway immediately after touchdown at
Shah Amanat International Airport amid inclement weather; following the collapse of the starboard
main undercarriage, the right-hand side engine got separated from the wing and caught fire as the
aircraft sank into the mud. Some passengers got injuries while the aircraft was evacuated, but all of
the occupants managed to escape from it safely. An enquiry found no failures with the aircraft and
put the blame for the accident on the incompetence of the pilot, who was fired.
Page | 39
On 26 September 2005: 5,500 staff and 150 pilots at Biman went on strike, shutting down the largest
international airport in Bangladesh, when the president of the Bangladesh Airlines Pilots Association
was served a retirement notice. The strike, lasting nine hours, stranded more than 1,000 passengers
at Hazrat Shahjalal International Airport, which is also maintained by Biman.
On 12 March 2007: Flight BG006 from London via Dubai to Dhaka was crippled while accelerating
down the runway of Dubai International Airport, as the nose gear of the Airbus A310300 collapsed.
The aircraft came to rest at the end of the runway and was evacuated, but closed the only active
runway and forced the airport to close for eight hours while authorities inspected the runway. There
were 236 people on board; only fourteen people suffered minor injuries and the aircraft was written
off.
Viewing flight safety as the single most important element of aviation, in recent years Biman has
invested so much on training crews as well as improve aircrafts conditions. We keep a bright hope
that the airline will perform a good safety record from now on.
3.3 A brief comparison between Biman Bangladesh Airlines and the safest airlines based on
safety rating criteria
Biman Bangladesh Airlines is certified as safe to fly in Europe by the European Aviation Safety
Agency. It also successfully passed the IATA Operational Safety Audit and since then, the airline has
resumed flights to some of its previous destinations in Asia and Europe. On the other hand, it is not
considered among the safest airlines. It has 4stars in Airline Ratings, 2013.
The safety rating for each airline is based on a comprehensive analysis utilizing information from the
world's aviation governing body and leading association along with governments and crash data. Each
airline has the potential to earn seven stars. The criteria are assessed here in the context of Biman
Bangladesh Airlines:
Is the airline IOSA certified?
If yes two stars are awarded; if not, no star is given. Bangladesh Biman has successfully passed the
IATA Operational Safety Audit and got 2stars here.
The IATA* Operational Safety Audit (IOSA) certification audit is an internationally recognised and
accepted evaluation system designed to assess the operational management and control systems of an
airline. IOSA uses internationally recognized audit principles and is designed to conduct audits in a
standardized and consistent manner. Airlines are reevaluated every two years. Registering for IOSA
certification and auditing is not mandatory therefore an airline that does not have IOSA certification
may have either failed the IOSA audit or alternatively chosen not to participate. *IATA (International
Page | 40
Air Transport Association)

Is the airline on the European Union (EU) Blacklist?
If no a full star is awarded; if yes then no star is given. Biman Bangladesh Airlines is certified as safe
to fly in Europe by the European Aviation Safety Agency and got a full star here.
A list of airlines banned from flying into European airspace due to safety concerns arising from
alleged poor aircraft maintenance and/or regulatory oversight. Airlines banned by the EU may have
a flawless safety record however the potential risk towards passenger safety is deemed by the EU as
too high and a ban is put in place.
Has the airline maintained a fatality free record for the past 10 years?
If yes the airline are awarded a full star; if not then no star is given. Here, Biman Bangladesh got a
full star.
A fatality is deemed as the death of crew and/or passengers whilst on board the aircraft due to an
accident. If deaths occurred through acts of terrorism or hijackings they have not been included. If an
airline suffered a fatal accident through no fault of their own such as a runway incursion on the active
runway (an incident where an unauthorized aircraft, vehicle or person is on a runway) this has also
not been included.
Is the airline FAA endorsed?
If yes a full star is awarded; if not, no star is given.
Bangladesh Biman Airlines is not FAA endorsed yet. Here, no star is given to Biman Bangladesh
airlines. In the United States, the Federal Aviation Authority (FAA) has a list that bans countries (not
airlines) from flying into American Airspace. The ban arises from a deemed inability to adhere to
international aviation standards for aircraft operations and maintenance. According to the FAA Web
site, those that do not meet these international standards cannot initiate new service and are restricted
to current levels of any existing service to the United States while corrective actions are underway."
An airline or airlines from a prohibited country may have a flawless safety record. However the
potential risk to safety is deemed too high by the FAA to allow operations in American airspace.
Does the country of airline origin meet all 8 ICAO safety parameters?
If yes TWO stars are awarded to the airline. If 5 to 7 of the criteria are met one star is awarded. If the
country only meets up to four criteria no star is given. The International Civil Aviation Organization
Page | 41 (ICAO) was created to promote the safe and orderly development of international civil aviation
throughout the world. It sets standards and regulations necessary for aviation safety, security,
efficiency and regularity, as well as for aviation environmental protection. The 8 ICAO audit
parameters that pertain to safety are; Legislation, Organizations, Licensing, Operations,
Airworthiness, Accident Investigation, Air Navigation Service and Aerodromes.
100
50
30
54
66
82
73
35
55
Figure 3.3.1: Effective Implementation in Bangladesh, Safety Audit Information (ICAO, June 2012).
Here, Biman Bangladesh has met only 4 parameters. Therefore, no star is given. It has to do well in
Legislation, Accident Investigation, Air Navigation Service and Aerodromes.
Has the airline's fleet been grounded by the country's governing aviation safety authority due
to safety concerns?
If yes, an additional star will be taken off the total for five years from the time of grounding. No star
is given for Biman Bangladesh Airlines in this criterion.
Does the airline operate only Russian built aircraft?
If yes, an additional star will be taken off the total. Here, no star is taken off from Biman Bangladesh
Airlines.
Page | 42
Chapter-
Methodology.
4.0 Methodology
This chapter explains the procedures and techniques that were used in the study. A theoretical
perspective on the research process is provided. The manner in which the theory was applied in order
Page | 43
to conduct the research component of the study, is also discussed. Detail is provided on the data
collection methods, sampling process.
Cooper and Schindler (2001:16) explain that good research follows the standards of a scientific
method. This implies that:
the purpose of the research is clearly defined;
the research procedures are clearly detailed;
the research design is thoroughly planned;
high ethical standards are applied in planning, conducting and analysing research;
limitations of the research are revealed;
research findings are presented unambiguously;
Parasuraman & Grewal (2004:42) identify two types of data, namely primary data and secondary
data. Secondary data refers to information that has already been collected and is readily available
from other sources, while primary data are collected for specific research needs.
Berg (2007:268) states that primary data are the sources involving the oral or written testimony of
eyewitnesses, whereas secondary sources involve the oral or written testimony of people not
immediately present at the time of a given event. These sources are documents written or objects
created by others that relate to a specific research question or area of research interest.
Both primary and secondary data sources were used in this study. Secondary sources were used to
form the theoretical foundation of the study and to define and structurethe methods used as well as
processes followed to conduct primary research.
4.1 Steps in the Research Methodology
According to Parasuraman et al. (2004:34), it is convenient and helpful to divide the research process
into a series of chronological steps, although in reality the steps are interrelated. Given the approaches
of various authors and the nature and purpose of this study, the following research steps were used
ensuring that the methodology is clear, concise and appropriate:
Define the research problem and purpose.
Define the research objectives.
Develop the research design.
Determine the research method.
Design data collection procedures.
Select the sampling procedure.

4.2 Research Objectives
Page | 44
Cooper and Schindler (2001:95) state that the research objectives flow naturally from the research
purpose. It is the planning and determining of specific, concrete and achievable goals.
The research objectives of this report were explained in Section 1.3 of Chapter 1. For convenience,
the research objectives are stated below:
The primary research objective was to determine consumer perceptions about the safety issues of
BIMAN.
The following secondary research objectives were identified, namely:
To determine how BIMAN can enhance aviation safety.
To assess whether differences existed between customers expectation and BIMANs
performance.
4.3 Methods Available For Business Research
4.3.1 Exploratory Research

Exploratory research is an initial research that is there to help, as well as confirm, an original
concept, and to discover new ideas about a problem and its potential solution. Exploratory
research helps develop concepts more clearly, and facilitate priority and better research design. It also
helps save time and money. It is usually used as a method to examine new models of the problem.
Exploratory research includes focus group meetings and interviews, pilot studies, observations
and even case-study
approaches (Zikmund,
2000). Exploratory research also includes elite
interviews of expert opinions.

Cooper and Emory (1995) mention that the objective of exploratory study may be accomplished
employing several data collection approaches. Although exploratory study relies heavily on a
qualitative approach, both qualitative and quantitative techniques may be applied to this type of
research. Cooper and Emory (1995) go on to say that qualitative exploratory study may include
the following means of data collection:
Page | 45
In-depth interviews
Participant observations
Films, photographs, and videotape
Projective techniques and psychological testing
Case studies
Street ethnography
Elite interviews
Document analysis
Proxemics and kinesics (Cooper and Emory, 1995, pp. 118-119).
4.3.2 Descriptive Research
Descriptive research is a study that is designed to help describe characteristics of a group of

population or a phenomenon (Zikmund, 2000). Descriptive study tries to find the answers to the
questions of who, what, when, where, and how. It does not try to answer the question why (Cooper
and Emory, 1995, Zikmund, 2000).
It is different from exploratory research in that the descriptive research is rooted on some
understanding beforehand of the nature of the problem. It does not give an explanation (Cooper and
Emory, 1995, Zikmund, 2000). Salkind (2000) indicates that descriptive research, apart from
providing a broad picture of a phenomenon one might be interested in exploring, can also serve
as a basis for other types of study.
4.3.3 Causal/Experimental Research
Causal research is the research that attempts to determine cause-and-effect relationships between
variables: causal research attempts to say that when one thing happens other things will also occur
(Zikmund, 2000). The three types of approaches to the research may be suitable for different
research problems. One might be suitable for one type of problem and not suitable for another.
However, in some types of problem, the combination of any or all types of approach may be used
effectively to yield valid results.
4.4 Research Design
According to Cooper and Schindler (2001:134), research design constitutes the blueprint for the
collection, measurement and analysis of data. Research design is the plan and structure of
investigation to obtain answers to the research questions.
There is consensus in research literature (Cooper & Schindler, 2001:134; Berg, 2007:24;Collis &
Hussey, 2003:10) regarding research design:
The design is an activity and a time-based plan.
The design is based on the research question or idea.
The design guides the selection of sources and types of information.
The design is a framework for specifying the relationships among the variables
studied in the research.
Page | 46
The design outlines procedures for every research activity.
Different categories to which research is classified were identified. Parasuraman et al. (2004:44)
reason that research is viewed as either exploratory or formal. These dimensions of the research
design are investigated in the next section. Table 4.3.1 lists the main types of researches and the basis
of classification.
Figure 4.3.1: Research Design
Figure 4.3.1 shows sequential linking between Research Questions, Research Design and
Conclusions. Maxwell defines research design as a series of tasks in conducting a study
(Maxwell, 1996).
4.5 The Research Method: The Selection of Data Sources
According to Proctor (2003:69), information helps an organization to solve its marketing problems
and to make marketing decisions. A distinction is made between information and data. Data
comprises unorganized news, facts and figures about any kind of topic. Information is a body of facts
that is organized around a specific topic or subject. It comprises facts organized and presented to help
solve a problem or develop a plan.
Both primary and secondary data sources were used for this research. Secondary data from existing
sources was presented by means of an extensive literature review (Chapters 2 while primary data was
collected by means of a questionnaire and focus group interviews. In this study, respondents were
selected by means of a convenience sample as this was an exploratory study. Figure 4.5.1 illustrates
the sequence of the data collected in this study.
Page | 47
Figure 4.5.1: The sequence of data collection
4.6 Data Collection Methods

Cooper and Schindler (2001:135) explain that data collection methods can be classified into a
monitoring process and a communication process. The former includes studies in which the
researcher inspects the activities of a subject or the nature of some material without attempting to
elicit responses from anyone. For the purposes of this study, a communication process was followed.
According to Berg (2007:97), the notion of accurate communication of ideas implies that researchers
have a clear idea about the type of information they want to access and about the purpose of the
research. Questionnaires and focus groups are effective methods of collecting information,
particularly when investigators are interested in understanding the perceptions of participants or
learning how participants come to attach certain meanings to phenomena or events.
4.6.1 Primary data collection method: Focus Groups
A focus group interview is an unstructured interview with a small group of people (Zikmund,
2000). It is used to confirm original concepts and seek new ideas and insights. In this study, focus
group interviews were conducted twice within a time span of about one month. The reason for
performing the focus group interviews twice was to make sure that the I did not miss any
potential useful information.
Three top level employees were in the focus group. The first focus group interview meeting was held
in February. The purposes of the meeting were to envisage general concepts to develop guidelines for
the study, to draw a flowchart of activities that had an impact on aviation safety, to formulate
questionnaire.
4.6.2 Primary data collection method: Questionnaires
Page | 48 I wanted to ensure by means of the focus groups that the questions produced for the questionnaire
would set out to collect the information needed to meet the research objectives. The questionnaire
was pre-tested to establish if relevant perceptions would be gathered from the convenience sample
and whether the questions were interpreted correctly.
The pre-tested questionnaire derived meaningful data, therefore, I decided to use questionnaires as
the research instrument to obtain data. 20 MCQ questions were put to the respondents to collect and
analyze the respondents perceptions. The respondents were requested to mark their responses in the
questionnaire in order to gain meaningful and relevant perceptions.
4.6.3 Primary data collection method: Unstructured Observation
I observed top-level executives and lower level employees for actual data collection. And I tried to
note down anything I felt relevant and then sorted them out later on.
4.6.4 Secondary Data collection method
Secondary data are second hand information. They are not collected from the source as the primary
data. In other words, secondary data are those which have already been collected. So they may be
relatively less accurate than the primary data. Secondary data are generally used when the time of
enquiry is short and the accuracy of the enquiry can be compromised to some extent. Secondary data
can be collected from a number of sources which can broadly be classified into two categories.
Published sources
Unpublished sources
Published Sources:
Mostly secondary data are collected from published sources. Some important sources of published
data are the following.
1. Published reports of ICAO.
2. Statistical abstracts, census reports and other reports published by different ministries of the
Government.
3. Official publications of the BIMAN and Ministry of Civil Aviation.
4. Reports and Publications of aviation industry, financial institutions etc.

5. Journals, Magazines and periodicals.
7. Reports submitted by Economists, Research.
Page | 49
8. Published works of research institutions.

Unpublished Sources:
Statistical data can also be collected from various unpublished sources. The important unpublished
source of the study from which secondary data can be collected are:
1. The records maintained by BIMAN. They may not like to publish the information considering them
as business secret.
2. Records and statistics maintained by Aviation ministry
Secondary data are already collected information. They might have been collected for some specific
purposes. So they must be used with caution. It is generally very different to verify such information
to find out inconsistencies, errors, omissions etc.
Therefore scrutiny of secondary data is essential. Because the data might be inaccurate, unsuitable or
inadequate. Thus it is very risky to use statistics collected by other people unless they have been
thoroughly edited and found reliable, adequate and suitable for the purpose.
Page | 50
Chapter-
Data Analysis.
5.0 Data Analysis
5.1 Sampling
Page | 51
The logic of using a sample of subjects is to make inferences about some larger population from a
smaller sample. Parasuruman (2004:356) asserts that sampling is the selection of a fraction of the
total number of units of interest for the ultimate purpose of being able to draw general conclusions
about the entire body of units.
Cooper and Schindler (2001:163) define sampling as the method used to select some of the elements
in the population. By doing so, conclusions can be drawn about the entire population.
According to Cooper and Schindler (2001:167), there are several decisions to be made in securing a
sample. These decisions essentially pertain to the relevance of the population and the parameters of
interest, the sample type and the sample size. For the purpose of this research, the focus groups were
selected to answer open-ended questions and respondents selected to fill out MCQ questionnaire.
5.1.1 The Population
Parasuruman (2004:256) defines population as consisting of the entire body of units of interest to
decision-makers in a situation. Proctor (2003:102) elaborates on this definition of the population as
the total group to be studied. It is the grand total of what is being measured.
The composition of the respondents interviewed met research objectives. The aim was to collect
relevant perceptions.
5.1.2 Sample size
Convenience sampling was used to obtain information from the focus groups and the questionnaire.
The reasons for using and advantage of convenience sampling are that it lowers cost (Parasuruman,
2004:356). Cooper and Schindler (2001:163) broaden this view by identifying four reasons for
sampling, namely lower cost, greater accuracy of results, greater speed of data collection and
availability of population elements.
One focus group was conducted as well as 75 questionnaires were administered. The questionnaire
was pre-tested. The sample size of 75 was deemed sufficient. The perceptions recorded initially by
the focus groups were used to compare whether the perceptions gathered through the questionnaires
were of similar nature.
5.2 Questionnaire for Respondents

This questionnaire was given to 75 respondents in the Dhaka Sales Office (DSO), Mothijheel. Some
were filled up by me and the others by respondents. The core objective of the survey was to get
Page | 52
perceptions of BIMANS customer about its safety measures.

The Questionnaire
Aviation Safety Management Survey
1. Name:
2. Gender:
3.
4.
5.
6.
7.
8.
9.
Male
Female
Occupation:
Private company
State owned company
Business
NGO
Immigrant
Age group:
18-30
31-42
43-54
55 and above
How often do you travel by Biman Bangladesh Airlines in a year?
Once
Twice
Three times
More than three times
Have you ever been involved in an aircraft accident?
Yes
No
How much you know about aviation safety?
Very Good
Good
Poor
Which is the most threatening safety hazard to you?
Structural faults
Misleading information
Bird strike
Pilot caused problems
How much you know about aviation safety activities of Biman Bangladesh Airlines?
Very Good
Page | 53
Good
Poor
10. Do the Biman Bangladesh Airlines satisfy you with the security checks?
Much satisfied
Satisfied
Dissatisfied
11. Do you think that the safety briefing contains adequate information?
Adequate
Inadequate
Needs to add more information
12. How would you describe the safety of flights between Biman Bangladesh Airlines
compared with similar flights in other airlines?
Definitely more safe
Probably more safe
About the same level of safety
Probably less safe
Definitely less safe
Can't say
13. If you were to board a flight today in Biman Bangladesh Airlines, how confident would
you be about arriving safely at your destination?
Very confident
Reasonably confident
Somewhat concerned
Very concerned
Can't say
14. How would you describe the safety of flights today compared to 12 months ago?
Much more safe
Somewhat more safe
About the same level of safety
Somewhat less safe
Much less safe
Can't say
15. Thinking about Governments supervision of the safety of major airlines such as Biman
Bangladesh Airlines, which of the following statements is closest to your views?
Should supervise a lot more closely
Should supervise a little more closely
No change needed in current level of supervision
Should give a little more freedom to manage their own safety
Should give a lot more freedom to manage their own safety
Can't say
End
5.3 Analysis of survey Results by Questions

Gender
GENDER
Page | 54
Male
Female
25%
75%
Figure 5.3.1: Percentage of male and female among respondents.
Occupation
Occupation
Occupation
0%
20%
40%
60%
80%
Occupation
70
Immigrant
State Owned
20
Business
10
Immigrant
State Owned
Business
Figure 5.3.2: Occupation of Respondents
100%
Age group
AGE GROUP
18-30
Page | 55
31-42
43-54
60
Age
0%
10%
20%
30%
25
40%
50%
60%
70%
15
80%
90%
100%
Figure 5.3.3: Percentage of age group of Respondents

5) How often do you travel by Biman Bangladesh Airlines in a year?
Almost 70% of the immigrant respondents travel by BIMAN once in two years. Rest of the passengers
Usually travel one time per year.
6) Have you ever been involved in an aircraft accident?
This news is very hopeful that almost every passengers did not involve in aircraft accident.
7) How much you know about aviation safety?
Most of the respondents travelled in more than two types of different airlines. Therefore, passengers
are much aware about aviation safety. Some respondents shown that they have little knowledge about
it.
8) Which is the most threatening safety hazard to you?
Page | 56
Unconsciousn
ess of Pilot
30%
Infrastructura
l Problem.
40%
Misleading
Information
30%
Figure 5.3.4: Most Threatening safety hazards

9) How much you know about aviation safety activities of Biman Bangladesh Airlines?
It is matter of concern that the immigrant respondents are unaware about the safety activities of
BIMAN. Rest of the respondents opined that they know very little about it.
10) Do the Biman Bangladesh Airlines satisfy you with the security checks?
Average respondents are somewhat satisfied in this issue. But a very good number of passengers
expressed dissatisfaction about the security checks.
11) How would you describe the safety of flights between Biman Bangladesh Airlines compared
with similar flights in other airlines?
Same level safety
Less safety
35%
65%
Figure 5.3.5: Comparison between BIMAN and other airlines.
Although passengers are dissatisfied with the service quality but major part of the respondents think
BIMAN ensures as same level safety as other international airlines.
12) Thinking about Governments supervision of the safety of major airlines such as Biman
Page | 57
Bangladesh Airlines, which of the following statements is closest to your views?

I have found consensus on the issue of govt. supervision of the safety issues. Majority think that govt.
supervision is prerequisite for BIMAN to increase market share by developing safety policy. Govt.
shout contribute money so that BIMAN can be emerged as a global standard airlines.
Page | 58
Chapter-
Findings.
6.0 Findings
The core belief behind BIMANs safety program is that Safety is not an isolated event rather it is an
outcome of concerted acts. Its safety program should emphasizes on senior management
Page | 59
commitment, integration of all tiers of employees in the safety program, non-punitive reporting
system, promoting a culture of upholding safety, dissemination of information and data-driven safety
approach:
Senior management commitment
Senior Management must be fully committed to ensure safety and meet statutory requirements.
Integration
The integration of all tiers of employees in the safety program the junior- most employee up to the
senior-most should be dedicated to & responsible for upholding safety.
A non-punitive reporting system
Non-punitive reporting system needs to be ensured so that safety reports are for improving safety not
to punish anybody.
Promoting a culture of upholding safety
BIMAN relentlessly should put its effort to instill safety beliefs in our culture.
Dissemination of information
Safety findings should not be protected in the name of confidentiality. Information will be
disseminated to all personnel in a variety of ways to educate and raise awareness.
A data-driven safety approach
Flight data should be routinely analyzed in order to devise & ensure safety measures.
Safety cannot be achieved by establishing a modern office, enacting some rules and expecting that
everyone will abide by it. Awareness, responsibility, cultural integration and a healthy attitude
towards safety are major factors to make this system successful. Statistics show that most of the
Accidents-Incidents that have happened in aviation history are due to the non-compliance of Standard
Operating Procedure (SOP).
There is Inspection and Surveillance to ensure compliance with SOP, but it is neither possible nor
feasible to be omnipresent. Therefore BIMAN should give special emphasis on voluntary reporting
system in addition to the Mandatory Occurrence Report (MOR), the Air Safety Report and the Crew
Debriefing.
Page | 60
To enhance aviation safety it is necessary to implement the Flight Data Monitoring (FDM) system as
an important tool to ensure overall safety and to enhance the standard of the airline operation.
To identify the hazard, analyze the risk factor and to implement the appropriate measures to mitigate
or control the risk leading to an accident or incident, a safety management system (SMS)is mandatory
for an Airline. By following ICAO Doc 9859, to meet the requirements of CAAB for implementation
of SMS, we are working on a CAAB approved timeline.
I am sure that you will all agree that although in the end we may successfully put together all the tools
for a complete safety management system, in reality it will never be truly effective unless we are able
to accept it culturally.
Chapter 7
Conclusion
The Biman Bangladesh Airlines Ltd is the only national flag carrier airline in Bangladesh. It is first
Page | 61 Airline Company which is providing low price air services to the people of our country. It is
the symbol of our sovereignty. It is providing services in very low coat. To grip their leadership in t
the airline industry they should target on developing safety management strategy.
The report reflects that by branding its safety programs to the potential and existing customers it can
increase customer satisfaction. Integration of all level of employees is needed to provide safest
aviation service to the customers.
BIMAN is a state owned organization, so govt. needs to focus on this issue. The Ministry of Civil
Aviation should regulate the safety program in a regular basis.
Many survey respondents expressed concern over inadequate resources to carry out their desired
safety program. Adequate workforce and some of the basic tools are often lacking. Routine tasks take
too much of their time. Other functions occupy time that could beneficially be used for analysis if
more automated tools were available. Most Flight Safety Managers (FSM) indicated that the
implementation of safety recommendations is adequate, but some noted that the follow-up could be
improved.
The available tools are both an asset and a liability. Having the basic data sources (air safety reports
and flight data analysis) is a significant advantage. On the other hand, the poor capabilities of the
tools that are used to work with these data often result in the FSMs spending too much time on data
entry and manual routines. Better tools would liberate time for more useful activities, as well as
support more effective management of the information reporting process.
There are a lot of common problems affecting most FSMs, such as lack of compatibility of tools and
data standards, and resource problems. Similarly, many reported positive factors are simply
investments in good facilities and personnel. There are also virtually free positive factors, which
could be included in a list of best practices. When survey respondents were asked how to improve
flight safety management, their answers cover better tools, improved internal processes and changes
in the organizational culture.
The stereotypic image of an FSM drawn by these results is a person who is trying to manage safety
without a clear set of detailed objectives and priorities and with limited guidance about how to do the
work. He has inadequate resources and is losing a lot of valuable time in less-productive routine
activities. He has to concentrate on short-term actions, and does not have enough time for longerPage | 62
term activities and higher-level analysis. FSMs who are equipped with a set of good state-of-the-art
tools and some manpower can do their job quite well, even if they still suffer from lost time and
limited resources, and often have to concentrate on short-term issues. Less common, FSMs with good
tools and ample resources have the possibility to also undertake longer-term activities and work more
proactively.
There is a need for effective automated tools that could help get the routine jobs done and allow more
resources for analysis.
Appendices
Appendix-1:
Department of Civil Aviation, Bangladesh
Page | 63
Figure 1: Safety Model of BIMAN

Appendix-2
Figure 2: Flight Operations Practice Model
Appendix-3
Page | 64
BIMAN
Figure3: Flight Safety Model

Appendix-4
Figure 4: Pilot Performance Model
References
Biman Bangladesh Airlines Limited, Annual Report, 2010.
Biman Market Research Department, System Performance, 2010.
Hasan R.(2007), Biman turns public limited company, Dhaka, The Daily Star
Page | 65
Hasan R. (2007), Biman at height of flight disarray, Dhaka, The Daily Star
Hasan R.(2007), Biman offers its staffs voluntary retirement, Dhaka, The Daily Star
Rodwell Julie F. (2009), Essential in Aviation Management: A Guide for Aviation Service Businesses
(6thEdition), New York, Houghton Mifflin Company, ISBN-078-72-976-23
http://www.biman-airlines.com
http://www.airlineroutemaps.com
http://www.planespotters.net/Airline/Biman-Bangladesh-Airlines.
http://www.ti-bangladesh.org/research/EX_Summary_Biman_Eng.pdf
Beaty, D 1995, The Naked Pilot: The Human Factor in Aircraft Accidents, AirlifePublishing Ltd.,
Shrewsbury, England.
Boeing Statistical Summary of Commercial Jet Airplane Accident 2000, p.20, Airplane Safety
Engineering, Boeing Commercial Airplane Group, U.S.A.
Campbell, RD & Bagshaw, M (eds) 1991, Human Performance and Limitations in Aviation,BSP
Professional Books, Oxford, England.
Chase, RB & Aquilano, NJ (eds) 1995, Production and Operations Management: Manufacturing and
Services, Richard D. Irwin, Inc., Illinois, U.S.A.
Churchill, Jr, GA 1995, Marketing Research: Methodological Foundations, 6 th edition., The Dryden
Press, U.S.A.
Cooper, DR & Emory, WC (eds) 1995, Business Research Methods, 5th ed., Richard
D. Irwin, Inc., Illinois, U.S.A., pp. 118-119, p.149.
Sankaran, S, Dick, B, Passfield, R & Swepson, P (eds), 2001,Effective Change Management Using
Action Learning and Action Research, Southern Cross University Press, Australia.
Sekaran, U 2003, Research Methods for Business, 4th ed., John Wiley & Sons, Inc., U.S.A.

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A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Page | 1 Mr. Ruhual Amin

Subject: Submission of Internship Report.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Declaration of the Student

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

1.1 Origin of the report

2.6.3.1 The Importance of Information for

2.6.4 Reporting Systems (RS)

3.2 Reasons of previous accidents and

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

3.3 A brief comparison between Biman

5.1.2 Sample size

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Background of the Study.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

identified, quantified and prioritized for detailed treatment.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

To get an overview of Biman Bangladesh Airlines.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Review of Related Literature.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

2.0 Review of Related Literature

from mechanical or organizational failures, environmental conditions and human error.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

2.2 Economic Issues

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Risk vs. Safety concept.

Figure 2.2.1: Risk-Safety Spectrum

Figure 2.2.2: Safety Cost Model

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

2.3 Social issues

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

facilitates warnings including terrain closure much earlier.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

they became the subject of

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

One of typical problems is the

inherent man-machine interface difficulty (Garland, Wise and Hopkin, 1999).

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

reach such a state.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

In order for a quality product to be produced, according to the International Organization of

Figure 2.6.2: Product and Process of Flight Operations at Operation Level

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Figure 2.6.3: Overall Organization Aviation Process at Organization Level

Figure 2.6.4: Concept of Safety Margin

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Figure 2.6.5: Maslows Hierarchy of Needs

Table 2.6.1: A Comparison of Needs Theory

A critical evaluation of aviation safety: A study on Biman Bangladesh Airlines Ltd.

Figure 2.6.6: The Link between Effort, Performance and Outcomes