Presentation on theme: "Commercial Aviation Safety Team (CAST) Overview Kyle L"— Presentation transcript:
1Commercial 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 – BangkokCommercial Aviation Safety Team (CAST) briefing by:Kyle L. OlsenFederal Aviation Administration (FAA) - RetiredAircraft Certification ServicePhone:FAX:1
2Vision - 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.MissionEnable a continuous improvement framework built on monitoring the effectiveness of implemented actions and modifying actions to achieve the goal.GoalReduce the US commercial aviation fatal accident rate 80% by 2007.AndMaintain a continuous reduction in fatality risk in US and International commercial aviation beyond 2007.
3Commercial Aviation Safety Team (CAST) CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agendaIndustryGovernmentAIAAirbusALPAAPAATAIFALPANACABoeingGE*RAAFSFDODFAAAircraft CertificationFlight StandardsSystem SafetyAir Traffic OperationsResearchNASAICAO**EASA / JAATCCNATCA**NTSB**Commercial AviationSafety 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 ofKey stakeholders in the operation of the commercial aviation systemSafety leaders from those organizations - able to commit and effect changeThese 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
4Safer Skies HUMAN FACTORS IMPROVED DATA IN OPERATIONS & & ANALYSIS COMMERCIAL AVIATIONGENERAL AVIATIONControlled FlightInto TerrainCABIN SAFETYAeronauticalDecisionmakingLoss of ControlLoss of ControlPassenger InterferenceUncontainedEngine FailuresWeatherPassenger Seat Belt UseRunway IncursionControlled FlightCarry-on BaggageInto TerrainApproach andLandingCAST 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 RestraintSurvivabilityWeatherRunway IncursionsTurbulenceHUMAN FACTORSIMPROVED DATAIN OPERATIONS && ANALYSISMAINTENANCE
5Joint Implementation Measurement Data Analysis Team (JIMDAT) Commercial Aviation Safety Team (CAST)CASTJoint SafetyAnalysis Teams (JSAT)Data analysesJoint SafetyImplementationTeams (JSIT)Safety enhancement developmentStraightforward & rigorous processJSAT – Analyze dataIdentify problems or precursorsPropose interventions against those problems (can be out of the box proposals)JSIT – Develop candidate safety enhancementsAssess feasibility of interventionsGroup promising interventions into package of enhancementsDevelop Detailed Implementation Plans (DIPs)JIMDAT – Prioritization/Evaluation of EffectivenessDetermine overall effectiveness of proposalssome much more effective than othersIdentify synergiesRecognize resource requirementsDevelop into integrated, prioritized package of enhancements to the aviation system for CAST reviewJIMDAT/JSIT interaction may be iterative to maximize effectiveness of the detailed implementation plansMaster safety planEnhancement effectivenessFuture areas of studyJoint Implementation Measurement Data Analysis Team (JIMDAT)
6General Methodology for Calculating the Potential Benefit of a Safety Enhancing Intervention =()Accident Risk ReductionEffectivenessthat an intervention has for reducing the accident rate if incorporated,Portion of world fleetwith intervention implementedThe 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.
7Spreadsheet 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.
82007 Implementation & Resources Example Scatter Chart2007 Implementation & Resources2520DollarsInMillions1510An 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 Score5Combined SOPs0.02.04.06.08.010.012.014.016.018.020.0Score
9CAST Safety Plan 47 Completed Safety Enhancements Safety Culture Maintenance ProceduresFlight Crew TrainingAir Traffic Controller TrainingUncontained Engine FailuresTerrain avoidance warning system (TAWS)Standard Operating ProceduresPrecision ApproachesMinimum Safe Altitude Warning (MSAW) SystemsProactive 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.
10CAST Safety Plan (cont.) 23 Committed Safety EnhancementsPolicies and ProceduresAircraft DesignFlight Crew Training (additional aspects)Runway Incursion PreventionPrecision Approaches (additional projects)Icing (additional turboprop projects)MidairMaintenanceCargo safety culture, policies and proceduresRunway SafetyStudy 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.
1223 47 70 Safety Enhancements 47 Complete 23 Underway CHANGES from last meeting2020 Plan Risk Reduction Estimate 74 %
132020 CAST SAFETY PLAN – WORKING SEs (Total Plan – 70 SE; 47 Complete; 23 Underway)39ANM47ATO53ARA120ATA101R1AIA121ATA125R1ATA127R2AIR131R1ATA133R1AIA134R2AIA136ATA159R1ATO165R3AFS169R1AFS170R2AIA172R1AFS175R1ATA179R1AFS-1180ATS-1181R1ARP182R1ATO-1183R1AFS-1ActionNeededSE #LOOSECON TRACKCOMPLETEDLATELATE OPIN QUESTION
14Rate per million departures Cooperative efforts are bringing accident rate downHull Loss Accident RateWorldwide Commercial Jets (>60,000 lbs, non-CIS) Through 31 December 20022.005 year running average1.60FSFCFIT/ALARIndustry effortstartsCAST/JSSI/COSCAPsbeginPAASTbegins1.20Rate per million departures0.80We 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 trendSo, 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 improvements0.400.0019921993199419951996199719981999200020012002
16Safety Plan Development AccidentJSITSCase studiesAccidentJSATSCase studiesSafetyEnhancementsRecommendedPlanRevisionEmergingRiskMasterContributingFactorsIncidentAnalysisProcessDevelopEnhancements& MetricsJIMDATReviewCASTPlanChangingRiskMetricsPerformanceTo PlanReviewNon-PerformanceInformationAviationSystemChangesIdentifyHazardsIdentifyFactorsWe 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.YesPresentIn MasterFactorsDevelopContributingFactors(new or emergingFAST HazardsNoDemographicChangesIdentifyHazardsIdentifyFactorsCAST-051R
17ASIAS Activities Summary to the CAST Aviation Safety Information Analysis SharingASIAS Activities Summary to the CAST7 August 2008
20ASIAS Architecture: Where We Are ASDE-X AirportsATL-BDL-CLT-FLL-HOUIAD-LAX-MCO-MKE-ORDPVD-SDF-SEA-STLFAA ASIAS DataEnhanced Data Management ToolsExpanded Analytical ToolsDNAA DNFAASDE-XMITRE CRS DataNational Offload ProgramData FusionNew Airlines
216. Traffic Procedures5. Wx3. Radar Tracks1. FOQA TAWS Alerts4. Terrain databaseThis 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 alertsTerrain Map – National Elevation Data. What the MVA was protectingRed lines – Radar Traffic Tracks (source: FAA National Offload Program) Actual tracks thru MVAWe also looked at weather patterns at the time of the alerts and airport & airspace procedures for this airport arrival route.2. MVA
22Study of Remaining Risks Joint Implementation Data Analysis Team (JIMDAT)
24SE-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.
25SE-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 6,700kgTCAS required in Asia – SE-164 is complete
26SE-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 proceduresCathay Pacific and AAPA to provide briefing.CAST activity to be complete April 2010
27SE-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
28SE-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.
29SE-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.
30SE-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 oversightNot applicable for implementation by ARAST.
31SE-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 SMSCAST activity complete October 2011
32SE-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
34SE-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.
35To 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
36SE-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 cargoNot applicable for implementation by ARAST.(FEDEX can provide additional information if there is interest.)
37SE-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.
38SE-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.
39SE-101 Aircraft Design Advanced Circuit Protection Develop and install advanced circuit protection / arc fault breaker technologyNot applicable for implementation by ARAST.
41Cost Savings Dollars/Flt. Cyc Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents100Historical cost of accidents per flight cycle80Savings ~ $56/Flight CycleOr~ $620 Million Dollars/YearDollars/Flt. Cyc6073% Risk reduction40When 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.20Cost of accident fatalities following implementation of the CAST 2007 levels20022007
42CAST Links to International Safety Activities ICAOCOSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness)EuropeESSI: European Strategic Safety InitiativeCentral and South AmericaPAAST: Pan American Aviation Safety TeamAfricaAfrican Safety Enhancement Team (ASET)Asia/PacificAssociation of Asia Pacific AirlinesNorth AmericaNAFTA: North American Free Trade AssociationOthers
43Regional Perspective Accident Rates Vary by Region of the World Western-built transport hull loss accidents, by airline domicile, 1998 through 2007COSCAP CISC.I.S.1Europe0.7ESSI35 SEs JAA11 SEs EASA62% reductionCOSCAP NA, SA, SEA40 SEs in work60% reductionUnited Statesand Canada0.4China0.3CAST70 SEs47 complete23 in work74% reductionMiddle East2.3Asia2.1(ExcludingChina)COSCAP BAGAfrica10.0COSCAP GulfLatin Americaand Caribbean2.1Oceania0.0ASETPAASTCFIT and ALARRegional cooperative safety activities (ICAO and local regulators work together – COSCAPs) by region.This chart shows two things.Accident rates by region of the worldRegional 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 ProgrammeWorld1.1Accidents permillion departures1 Insufficient fleet experience to generate reliable rate.
44CAST Approach to Safety: A Three Stage Process DataAnalysisImplement Safety Enhancements - U.S.Set SafetyPrioritiesAgree onproblems and interventionsInfluence Safety Enhancements - WorldwideAchieve consensus onprioritiesIntegrate into existing work and distribute
45Conclusions CAST brings together all the key players – Air Carriers – Manufacturers– Employee Groups – GovernmentPredicted 74% risk reduction by 2020CAST is committed to worldwide participationHistory shows focused action and introduction of new capabilities have led to large accident rate reductionsIn conclusion:CAST has an effective data-driven process that has become the model for Industry/Government consensus building on safetyCAST brings together all the key playersThe 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 accidentsIndustry is voluntarily implementing CAST recommendationsCAST 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.
51CAST and GASRCAST 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
52COSCAP HistoryCOSCAP-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.
53Global Aviation Safety Roadmap (GASR) Proactive approach to aviation safetyHelp coordinate and guide safety policies12 Focus Areas established4 Focused on States (government)1 Joint regional responsibilities8 Focused on industry (operators)The Focus Areas are high levelAccident risk reduction not defined or identifiedBest Practices identified for each Focus Area
5412 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.
55Metrics 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.
56Example from Focus Area 1, International Standards Best Practices, Metrics and Implementation
57Example from Focus Area 9, Inconsistent Adoption of Industry Best Practices Best Practices, Metrics and Implementation
58Example from Focus Area 5, Inconsistent Coordination of Regional Programs Best Practices, Metrics and Implementation
59EvaluationPrior 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.
60Benefits of an Evaluation Help maintain perspective between:Current Safety Team activity,USOAP audit results and actions,IOSA audit results and actions, andGASR Focus AreasHelp to focus on priorities reducing riskIdentify and avoid duplicationOngoing activity and effortsTeams
61Possible Duplication USOAP Programme, DP3 SEARAST recommendations, actions and implementation, DP5Safety Management Systems (SMS), DP6Incident and Accident InvestigationCreation of an additional safety team
62In South East AsiaProgramme 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.