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Commercial Aviation Safety Team (CAST) Overview Kyle L

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1 Commercial Aviation Safety Team (CAST) Overview Kyle L
Commercial Aviation Safety Team (CAST) Overview Kyle L. Olsen Asian Regional Aviation Safety Team 19 – 20 November 2008 – Bangkok Commercial Aviation Safety Team (CAST) briefing by: Kyle L. Olsen Federal Aviation Administration (FAA) - Retired Aircraft Certification Service Phone: FAX: 1

2 Vision - Mission - Goals
Key aviation stakeholders acting cooperatively to lead the world-wide aviation community to the highest levels of global commercial aviation safety by focusing on the right things. Mission Enable a continuous improvement framework built on monitoring the effectiveness of implemented actions and modifying actions to achieve the goal. Goal Reduce the US commercial aviation fatal accident rate 80% by 2007. And Maintain a continuous reduction in fatality risk in US and International commercial aviation beyond 2007.

3 Commercial Aviation Safety Team (CAST)
CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agenda Industry Government AIA Airbus ALPA APA ATA IFALPA NACA Boeing GE* RAA FSF DOD FAA Aircraft Certification Flight Standards System Safety Air Traffic Operations Research NASA ICAO** EASA / JAA TCC NATCA** NTSB** Commercial Aviation Safety Team (CAST) The strength of CAST lies in its extensive membership, its proactive commitment to safety and its ability to effect change. The CAST has proven effective because it is: a Voluntary partnership of Key stakeholders in the operation of the commercial aviation system Safety leaders from those organizations - able to commit and effect change These organizations have come together voluntarily to improve aviation safety: Aerospace Industries Association (AIA) Department of Defense (DOD) Air Line Pilots Association (ALPA) Federal Aviation Administration (FAA) Allied Pilots Association (APA) National Aeronautics and Space Administration (NASA) Air Transport Association (ATA) International Civil Aviation Organization (ICAO) National Air Carrier Association (NACA) Joint Aviation Authorities (JAA) Pratt and Whitney (P&W) Transport Canada (TCC) Regional Airline Association (RAA) National Air Traffic Controllers Association (NATCA) Flight Safety Foundation (FSF) National Transportation Safety Board (NTSB) (observer) International Air Transport Association (IATA) European Aviation Safety Agency (EASA) Association of Asia Pacific Airlines (AAPA) Air Transport Association of Canada (ATAC) Association of Professional Flight Attendants (APFA) General Electric (GE) Rolls Royce (RR) IATA** AAPA** ATAC** APFA** * Representing P&W and RR ** Observer

COMMERCIAL AVIATION GENERAL AVIATION Controlled Flight Into Terrain CABIN SAFETY Aeronautical Decisionmaking Loss of Control Loss of Control Passenger Interference Uncontained Engine Failures Weather Passenger Seat Belt Use Runway Incursion Controlled Flight Carry-on Baggage Into Terrain Approach and Landing CAST has focused it’s activity on those accident categories that provide the greatest potential for improving the fatal accident rate, as indicated in yellow. These accident categories, have historically and repetitively over time, had the highest numbers of recurring accidents and loss of life. Child Restraint Survivability Weather Runway Incursions Turbulence HUMAN FACTORS IMPROVED DATA IN OPERATIONS & & ANALYSIS MAINTENANCE

5 Joint Implementation Measurement Data Analysis Team (JIMDAT)
Commercial Aviation Safety Team (CAST) CAST Joint Safety Analysis Teams (JSAT) Data analyses Joint Safety Implementation Teams (JSIT) Safety enhancement development Straightforward & rigorous process JSAT – Analyze data Identify problems or precursors Propose interventions against those problems (can be out of the box proposals) JSIT – Develop candidate safety enhancements Assess feasibility of interventions Group promising interventions into package of enhancements Develop Detailed Implementation Plans (DIPs) JIMDAT – Prioritization/Evaluation of Effectiveness Determine overall effectiveness of proposals some much more effective than others Identify synergies Recognize resource requirements Develop into integrated, prioritized package of enhancements to the aviation system for CAST review JIMDAT/JSIT interaction may be iterative to maximize effectiveness of the detailed implementation plans Master safety plan Enhancement effectiveness Future areas of study Joint Implementation Measurement Data Analysis Team (JIMDAT)

6 General Methodology for Calculating the Potential Benefit of a Safety Enhancing Intervention
= ( ) Accident Risk Reduction Effectiveness that an intervention has for reducing the accident rate if incorporated , Portion of world fleet with intervention implemented The mathematical expression for the JIMDAT tool is that fatality risk reduction is some function of the effectiveness that the enhancement has against the threat and the level that the enhancement has been implemented in the subject fleet.

7 Spreadsheet Example – Historical Airplane Accidents & Proposed Safety Enhancements
This is an example of the spreadsheet as it was used by the JIMDAT. Across the top of the sheet are listed all of the safety enhancements that we evaluated. The left hand column is a listing of the threats that are to be evaluated. In the case of CAST it was initially the accidents that had occurred in the U.S. Part 121 fleet from 1988 through For the worldwide accident data set it was all of the fatal and hull loss accidents that had occurred in operations, equivalent to U.S. Part 121, throughout the world. The pale green columns are the effectiveness scores assigned to each of the enhancements. The blue column is the mathematical determination of the probability that the particular accident would have occurred if all of the enhancements had been in place. The yellow columns contain additional information about the particular accident.

8 2007 Implementation & Resources
Example Scatter Chart 2007 Implementation & Resources 25 20 Dollars In Millions 15 10 An example of a typical “scatter plot”. Takes the effectiveness score of the preceding spreadsheet and adds the resource values to implement. Shows the relationships between safety effectiveness and resources for sample safety enhancements. Such scatter plots were used to provide an initial picture of the relative strengths of various safety enhancements based on effectiveness and resources. Enables us to select those safety enhancements that are optimally balanced in terms of effectiveness versus resources. Combined Score 5 Combined SOPs 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 Score

9 CAST Safety Plan 47 Completed Safety Enhancements Safety Culture
Maintenance Procedures Flight Crew Training Air Traffic Controller Training Uncontained Engine Failures Terrain avoidance warning system (TAWS) Standard Operating Procedures Precision Approaches Minimum Safe Altitude Warning (MSAW) Systems Proactive Safety Programs (FOQA + ASAP) Although time does not permit my discussing each of the following 40 completed safety enhancements, I have provided comments on a few of them in my published notes to indicate, for those of you who wish to read further, how a range of training, operational and design solutions are utilized. As you can see from this chart, we’ve made heavy emphasis on preventing CFIT, approach and landing, loss of control, runway safety, -- & though these types of accidents and serious incidents are still happening, the risk has been significantly reduced. CFIT-PAI-Vertical Angles - Increases the use of Precision approach through addition of vertical angles on approach plates to achieve constant angle descent. CFIT-MSAW – All U.S. ATC minimum safe altitude warning radars have been site checked to ensure no obstructions exist and all ATC personnel have been trained on timely MSAW alerts to flight crews. CFIT Prevention Training - All U.S. carriers have incorporated CFIT prevention training in their curriculums. CFIT ATC Training – All ATC personnel have rec’d CFIT prevention training to eliminate CFIT hazards such as “slam dunk” approaches.

10 CAST Safety Plan (cont.)
23 Committed Safety Enhancements Policies and Procedures Aircraft Design Flight Crew Training (additional aspects) Runway Incursion Prevention Precision Approaches (additional projects) Icing (additional turboprop projects) Midair Maintenance Cargo safety culture, policies and procedures Runway Safety Study of midair, maintenance, cargo and additional icing related accidents and serious incidents resulted in a number of new Safety Enhancements. The new Safety Enhancements are currently being implemented.

11 CAST Implementation Status

12 23 47 70 Safety Enhancements 47 Complete 23 Underway
CHANGES from last meeting 2020 Plan Risk Reduction Estimate 74 %

(Total Plan – 70 SE; 47 Complete; 23 Underway) 39 ANM 47 ATO 53 ARA 120 ATA 101R1 AIA 121 ATA 125R1 ATA 127R2 AIR 131R1 ATA 133R1 AIA 134R2 AIA 136 ATA 159R1 ATO 165R3 AFS 169R1 AFS 170R2 AIA 172R1 AFS 175R1 ATA 179R1 AFS-1 180 ATS-1 181R1 ARP 182R1 ATO-1 183R1 AFS-1 Action Needed SE # LOOSEC ON TRACK COMPLETED LATE LATE OP IN QUESTION

14 Rate per million departures
Cooperative efforts are bringing accident rate down Hull Loss Accident Rate Worldwide Commercial Jets (>60,000 lbs, non-CIS) Through 31 December 2002 2.00 5 year running average 1.60 FSF CFIT/ALAR Industry effort starts CAST/JSSI/ COSCAPs begin PAAST begins 1.20 Rate per million departures 0.80 We are beginning to see the results of team efforts on a worldwide basis. This chart shows the hull loss accident rate in losses per million departures and the 5 year running average of that rate. As you can see, the 5 year average shows a definite and encouraging downward trend So, there is still work to be done. Our success in improving safety has made it more challenging to identify actions that will bring even more effective and affordable safety improvements 0.40 0.00 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

15 CAST Moving into the Future

16 Safety Plan Development
Accident JSITS Case studies Accident JSATS Case studies Safety Enhancements Recommended Plan Revision Emerging Risk Master Contributing Factors Incident Analysis Process Develop Enhancements & Metrics JIMDAT Review CAST Plan Changing Risk Metrics Performance To Plan Review Non- Performance Information Aviation System Changes Identify Hazards Identify Factors We have completed the historical study of CFIT, Loss of Control, Approach and Landing, Runway Incursion and Turbulence accidents and hull losses which have occurred in U.S. FAR 121 operations over the time frame of 1987 to Additionally we have completed an assessment of accidents and hull losses world wide over that same timeframe. The yellow boxes, ‘Accident JSAT’s’, ‘Accident JSIT’s’, etc. depict this historical study of accidents from which CAST has identified safety solutions to proactively apply and prevent/mitigate recurrence. But what is the future direction of CAST? Where do we go next to look at future risks? CAST is developing an incident analysis process that will allow us to become more proactive in accident prevention by identifying changing and emerging risks. This is shown by the purple boxes, ‘Incident Analysis Process’, ‘Emerging Risk’, ‘Changing Risk’, etc. Safety enhancements from this activity will be rolled into the CAST plan, related metrics will be developed and any newly identified contributing factors will be added to the Master Contributing Factor list. Also to reach further yet into the future (as shown in green), CAST will examine and identify hazards that may result from ‘Aviation System Changes’ and ‘Demographic Changes.” Much of this work has been done by CAST’s sister organization, the JAA Future Aviation Safety Team (FAST), which is developing future hazards based on their study of future areas of changes. CAST will incorporate the results from the FAST analysis into the CAST plan; safety enhancements and related metrics will be developed and the newly identified contributing factors will be added to the Master Contributing Factor list. Yes Present In Master Factors Develop Contributing Factors (new or emerging FAST Hazards No Demographic Changes Identify Hazards Identify Factors CAST-051R

17 ASIAS Activities Summary to the CAST
Aviation Safety Information Analysis Sharing ASIAS Activities Summary to the CAST 7 August 2008

18 Signed MOUs

19 Regional Airlines Outreach

20 ASIAS Architecture: Where We Are
ASDE-X Airports ATL-BDL-CLT-FLL-HOU IAD-LAX-MCO-MKE-ORD PVD-SDF-SEA-STL FAA ASIAS Data Enhanced Data Management Tools Expanded Analytical Tools DNAA DNFA ASDE-X MITRE CRS Data National Offload Program Data Fusion New Airlines

21 6. Traffic Procedures 5. Wx 3. Radar Tracks 1. FOQA TAWS Alerts 4. Terrain database This is an example of data that has been gathered for a CAST study concerning TAWS alerts in selected locations. Red dots – FOQA TAWS alerts used to identify areas of interest (source: airlines) Cylinders – Minimum Vectoring Altitude (source: ATC) Why they received TAWS alerts Terrain Map – National Elevation Data. What the MVA was protecting Red lines – Radar Traffic Tracks (source: FAA National Offload Program) Actual tracks thru MVA We also looked at weather patterns at the time of the alerts and airport & airspace procedures for this airport arrival route. 2. MVA

22 Study of Remaining Risks
Joint Implementation Data Analysis Team (JIMDAT)

23 Remaining Risk Cargo Icing Midair Maintenance

24 SE-165 Midair TCAS Policies and Procedures
Prevent midair collisions by requiring flightcrews to follow TCAS Resolution Advisories (RA’s), establish procedures for TCAS range setting and requiring that TCAS-capable simulators and flight-training devices are used for training TCAS responses and Maneuvers. SEA AC 018 issued 25 June 2008.

25 SE-164 Midair TCAS Installation
Worldwide installation of TCAS in all aircraft of 33,000 pounds or greater max takeoff weight. ICAO requirement for aircraft of 6,700kg TCAS required in Asia – SE-164 is complete

26 SE-121 Cargo Standard Operating Procedures
Reduce cargo-related accidents and incidents by publishing and enforcing clear, concise and accurate standard operating procedures (SOP), and training the rationale behind those procedures Cathay Pacific and AAPA to provide briefing. CAST activity to be complete April 2010

27 SE-125 Cargo Hazardous Materials - HazMat
Reduce hazmat related accidents and incidents develop and implement by regulators, manufacturers (of packaging material) and shipping companies a multi-tier system to identify and safely process undeclared hazardous material. CAST to provide information after completion in December 2010

28 SE-129 Regulation & Policy Compliance, Enforcement and Restricted Operations
Regulators should improve their legal processes for compliance, enforcement and operational restrictions. FAA Order B now contains timeliness goals for completion of an investigation, preparation of the enforcement report and the processing of legal actions.

29 SE-129 Regulation & Policy Compliance, Enforcement and Restricted Operations - continued
Also, FAA Order B now contains policies and procedures for the grant of immunity from FAA enforcement to persons who provide information about violations to the regulations.

30 SE-130 Cargo Regulation & Policy - Oversight
Regulators should develop/enhance and implement a system that ensures appropriate inspector coverage for all airlines, sub-contracting, and leasing operations and assign highly-experienced inspectors to operators that require the most oversight Not applicable for implementation by ARAST.

31 SE-131 Cargo Safety Culture
Reduce cargo-related accidents and incidents by encouraging a culture that enhances operational safety. Safety culture can be enhanced by a safety management system (SMS). To be covered by SMS CAST activity complete October 2011

32 SE-136 Icing Training – Engine Surge Recovery
To prevent accidents resulting from an engine surge caused by ice ingestion, airlines should provide adequate training for flight crews to ensure appropriate responses. CAST activity complete April 2009

33 SE-163 Midair See-and Avoid
Prevent midair collisions by improving see-and-avoid capability. Future Implementation

34 SE-159 Midair Airspace Design
Prevent midair collisions by designing B/C/D airspace to be more easily identifiable, improving the usability of VFR charts and ensuring adequate and timely coordination of airspace design changes to users. Not applicable for implementation by ARAST.

35 To General Aviation SE-162 Midair
Prevent midair collisions by facilitating aircraft separation for users of advanced navigation systems not receiving ATC separation services. Not applicable for implementation by ARAST. To General Aviation

36 SE-127 Cargo Fire Containment
To reduce the occurrence of accidents and incidents from cargo fires, improved cargo containers should be developed to contain (or suppress) fires originating in shipped cargo Not applicable for implementation by ARAST. (FEDEX can provide additional information if there is interest.)

37 SE-133 – Icing Turboprop Aircraft Ice Detection Systems
To prevent accidents caused by in-flight icing, for turboprop aircraft with non-evaporative ice protection systems and non-powered flight controls, install systems that automatically detect ice, measure the rate of ice accretion and warn the crew. Not applicable for implementation by ARAST.

38 SE-134 Icing Aircraft Design - Avionics
Avionic manufacturers and aircraft manufacturers should develop and install smart pitch guidance systems on all aircraft not presently equipped to prevent over rotation in conjunction with a low energy state or aerodynamic degradation due to the presence of ice. Not applicable for implementation by ARAST.

39 SE-101 Aircraft Design Advanced Circuit Protection
Develop and install advanced circuit protection / arc fault breaker technology Not applicable for implementation by ARAST.

40 CAST Sharing with the World

41 Cost Savings Dollars/Flt. Cyc
Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents 100 Historical cost of accidents per flight cycle 80 Savings ~ $56/Flight Cycle Or ~ $620 Million Dollars/Year Dollars/Flt. Cyc 60 73% Risk reduction 40 When we break down costs of our current accident rate, accidents cost us $76 for every flight. By implementing the 46 carefully selected, data-driven safety enhancements, we will have reduced these costs by $56 per flight. This adds up to a savings about $620 Million EVERY YEAR into the future. 20 Cost of accident fatalities following implementation of the CAST 2007 levels 2002 2007

42 CAST Links to International Safety Activities
ICAO COSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness) Europe ESSI: European Strategic Safety Initiative Central and South America PAAST: Pan American Aviation Safety Team Africa African Safety Enhancement Team (ASET) Asia/Pacific Association of Asia Pacific Airlines North America NAFTA: North American Free Trade Association Others

43 Regional Perspective Accident Rates Vary by Region of the World
Western-built transport hull loss accidents, by airline domicile, 1998 through 2007 COSCAP CIS C.I.S.1 Europe 0.7 ESSI 35 SEs JAA 11 SEs EASA 62% reduction COSCAP NA, SA, SEA 40 SEs in work 60% reduction United States and Canada 0.4 China 0.3 CAST 70 SEs 47 complete 23 in work 74% reduction Middle East 2.3 Asia 2.1 (Excluding China) COSCAP BAG Africa 10.0 COSCAP Gulf Latin America and Caribbean 2.1 Oceania 0.0 ASET PAAST CFIT and ALAR Regional cooperative safety activities (ICAO and local regulators work together – COSCAPs) by region. This chart shows two things. Accident rates by region of the world Regional cooperative safety activities (ICAO and local regulators working together – COSCAPs) by region. The number of CAST Safety Enhancements adopted by the Asian COSCAPs and the European JSSI (Joint Safety Strategy Initiative) are also depicted. COSCAP = cooperative Development of Operational Safety and Continuing Airworthiness Programme World 1.1 Accidents per million departures 1 Insufficient fleet experience to generate reliable rate.

44 CAST Approach to Safety: A Three Stage Process
Data Analysis Implement Safety Enhancements - U.S. Set Safety Priorities Agree on problems and interventions Influence Safety Enhancements - Worldwide Achieve consensus on priorities Integrate into existing work and distribute

45 Conclusions CAST brings together all the key players
– Air Carriers – Manufacturers – Employee Groups – Government Predicted 74% risk reduction by 2020 CAST is committed to worldwide participation History shows focused action and introduction of new capabilities have led to large accident rate reductions In conclusion: CAST has an effective data-driven process that has become the model for Industry/Government consensus building on safety CAST brings together all the key players The 47 Safety Enhancements on the CAST Plan result in the prediction of a 73% risk reduction in the number of fatalities due to commercial aviation accidents Industry is voluntarily implementing CAST recommendations CAST has nearly completed its work of identifying accident prevention programs based on analysis of historic data and has started the development of processes that will proactively use incident, and other, data to identify emerging and changing risks. Through these processes we believe that we can move forward to accident PREVENTION by intervening to reduce risk before an accident can occur.

46 Thank you

47 Backup Slides


49 CAST sharing with COSCAP’s in Asia


51 CAST and GASR CAST supports the Global Aviation Safety Roadmap (GASR) as an international strategic plan to promote aviation safety programs, which is complementary to the implementation of appropriate tactical solutions contained in the CAST Safety Plan

52 COSCAP History COSCAP-South East Asia has been working on safety issues for the last seven years. South East Asia Regional Aviation Safety Team (SEARAST): reviews safety recommendations, develops interventions, tracks implementation. Focused primarily on improving safety by reducing accident risk.

53 Global Aviation Safety Roadmap (GASR)
Proactive approach to aviation safety Help coordinate and guide safety policies 12 Focus Areas established 4 Focused on States (government) 1 Joint regional responsibilities 8 Focused on industry (operators) The Focus Areas are high level Accident risk reduction not defined or identified Best Practices identified for each Focus Area

54 12 Global Safety Initiatives
The strategic action plan, ‘Implementation the Global Aviation Safety Roadmap’ defines: Focus Areas. Objective of each Focus Area. Best Practices for each Focus Area. Metrics for each Best Practices.

55 Metrics In many instances the metrics link with:
ICAO USOAP audit results used when related to States. IATA ISOA audit results used when related to industry. ICAO Annexes, SARPS, Documents, etc. Prior Roadmap Workshops have developed an implementation tool.

56 Example from Focus Area 1, International Standards
Best Practices, Metrics and Implementation

57 Example from Focus Area 9, Inconsistent Adoption of Industry Best Practices
Best Practices, Metrics and Implementation

58 Example from Focus Area 5, Inconsistent Coordination of Regional Programs
Best Practices, Metrics and Implementation

59 Evaluation Prior to a GASR Workshop, the Programme Coordinator working with the SEARAST should evaluate the Focus Areas, Objectives and Metrics to identify possible duplication and gaps within the Region.

60 Benefits of an Evaluation
Help maintain perspective between: Current Safety Team activity, USOAP audit results and actions, IOSA audit results and actions, and GASR Focus Areas Help to focus on priorities reducing risk Identify and avoid duplication Ongoing activity and efforts Teams

61 Possible Duplication USOAP Programme, DP3
SEARAST recommendations, actions and implementation, DP5 Safety Management Systems (SMS), DP6 Incident and Accident Investigation Creation of an additional safety team

62 In South East Asia Programme Coordinator and Safety Team (SEARAST) to evaluate GASR Best Practices, Metrics and Implementation Level to identify gaps and areas of duplication. Programme Coordinator: Report results of review to Steering Committee. Recommend future action. Approve the revised Terms of Reference.

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