Presentation on theme: "Commercial Aviation Safety Team (CAST) Plan & Metrics"— Presentation transcript:
2 Commercial Aviation Safety Team (CAST) Plan & Metrics It is our privilege today to update you on the substantial progress that has been made by the joint government and industry safety effort known as CAST, the Commercial Aviation Safety Team.1
3 Agenda Historical Background Progress to Date Annual Safety Plan Executive Overview of CAST ProgressHistorical BackgroundProgress to DateAnnual Safety PlanInclusion of R & DBusiness modelAction PlanGarner support for continued CAST activitiesWe will cover some historical background, to include how the CAST process has evolved into a very effective tool for positive change in the area of aviation safety.We will put some focus on how CAST has prioritized its dauntingly large list of safety recommendations, through a sub-team activity known as the Joint Implementation Measurement and Data Analysis team or “JIMDAT”.
5 In the U.S., our focus was set by the White House Commission on Aviation Safety 1.1 Government and industry should establish a national goal to reduce the aviation fatal accident rate by a factor of five within ten years and conduct safety research to support that goal1.2 The FAA should develop standards for continuous safety improvement, and should target its regulatory resources based on performance against those standardsBoth government and industry had been long been searching for a reliable way to choose wisely among the many deserving suggested actions to improve various aspects of aviation, thereby reducing risk.The Gore Commission’s challenge to reduce accidents by 80% over the next ten years provided the impetus for even closer collaboration to develop a data-driven process to help us focus our scarce resources on those initiatives with the most potential to reduce the risk of accidents.We were all convinced that the rigor of analyzing reliable data was the surest path to continually improving our performance.5.3-22
6 The National Civil Aviation Review Commission (NCARC) on Aviation Safety Provided Additional DirectionFAA and the aviation industry must develop a strategic plan to improve safety, with specific priorities based on objective, quantitative analysis of safety information and dataGovernment should expand on their programs to improve aviation safety in other parts of the worldThe NCARC was released in the same time period and gave further impetus to the notion of objective, quantitative analysis as the answer to sorting out which among the many ideas before us should be chosen first as the most promising and productive ways to reduce risk below the already excellent levels we had achieved over the preceding decades.The NCARC also recognized that the global nature of aviation demanded that we needed to contribute to safety improvements worldwide, not just at home.In 1997, the National Civil Aviation Review Committee (NCARC) assessed the state of Commercial Aviation Safety and the safety initiatives of Government and industry in the United States.One of the recommendations received from NCARC suggested that Government and Industry should combine and leverage their individual safety programs and develop an integrated strategic safety plan.5.3-33
7 In ResponseOngoing Industry and FAA Safer Skies Initiatives were Combined into CASTData-Driven, Consensus-Based, Integrated Strategic Safety Plan DevelopedIn place and fully supported by Government and Industry with Worldwide Recognition - “CAST”The U.S. aviation industry had been simultaneously organizing around this same notion of data-driven decision making, using the same accident data that led FAA to their strategy, so it was logical to combine our efforts into a joint team -- which we named the Commercial Aviation Safety Team.Since large portions of the money to be invested would be by private companies in their own airplanes, this program needed to be voluntary. This turned out not to be a problem, since data-driven analyses would show the benefits of an enhancement, and companies would naturally choose the ones offering the most benefit.I will show you how this process has enabled us to winnow down a list of hundreds of recommendations into a coordinated and integrated Safety Plan that is well on the way to yielding a 73% risk reduction by 2007.
8 Excluding all security events Both government and industry had known for some time which categories of accidents were happening most often and causing the greatest losses of life and property.If we could substantially mitigate the greatest fatality risks, we should make good progress toward our Gore Commission goal.
9 Safer 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 its 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
10 CAST GoalsReduce the U.S. commercial aviation fatal accident rate by 80% by 2007Work together with airlines, JAA, ICAO, IATA, FSF, IFALPA, other international organizations and appropriate regulatory/ government authorities to reduce worldwide commercial aviation fatal accident rateCAST has established very concise goals to guide its activity, based on the Gore Commission & NCARC recommendations:Reduce the U.S. commercial aviation fatal accident rate by 80% by Thus, the predicted 73% reduction in the fatality risk that I will discuss later, puts us within reach of the 80% goal many thought to be impossible.And to work together with international organizations to reduce the worldwide commercial aviation fatal accident rate.
11 Commercial Aviation Safety Team (CAST) IndustryGovernmentAIAAirbusALPAAPAATANACABoeingP&W*RAAFSFIATAAAPAATACAPFADODFAAAircraft CertificationFlight StandardsSystem SafetyAir Traffic OperationsResearchNASAICAOJAATCCNATCACommercial AviationSafety Team(CAST)CAST is comprised of Industry and Government organizations that represent all aspects of the commercial aviation community and therefore have the ability to effect change.These organizations have come together voluntarily to improve aviation safety.The strength of CAST lies in its extensive membership, its proactive commitment to safety and its ability to effect change.*Representing GE and RR
12 Joint Implementation Measurement Data Analysis Team (JIMDAT) Commercial Aviation Safety Team (CAST)CASTJoint SafetyAnalysis Teams (JSAT)Data analysesJoint SafetyImplementationTeams (JSIT)Safety enhancement developmentThe CAST process is straightforward: Analyze causes of past accidents, identify enhancements that could have prevented them, implement the most promising enhancements, measure results, and repeat the process.CAST accomplishes that work through a series of teams. Joint Safety Analysis Teams, or “JSATs”, study accidents and incidents in a selected flight category such as CFIT, identifying precursors to problems and interventions to reduce or eliminate these precursors.Joint Safety Implementation Teams, or “JSITs”, conduct feasibility assessments of these interventions and design “Safety Enhancements” and “Detailed Implementation Plans” (DIPs) to deploy these safety solutions.Finally, a Joint Implementation Measurement Data Analysis Team, or “JIMDAT”, evaluates these safety solutions across all flight categories and provides prioritized recommendations to CAST for implementation. We’ll look a little further into the JIMDAT prioritization activity later in the presentation.Master safety planEnhancement effectivenessFuture areas of studyJoint Implementation Measurement Data Analysis Team (JIMDAT)
13 CAST A Three-Stage Process DataAnalysisImplement Safety Enhancements - U.S.Set SafetyPrioritiesAgree onproblems and interventionsInfluence Safety Enhancements - WorldwideAchieve consensus onprioritiesIntegrate into existing work and distribute
14 Additional Safer Skies Activities Although the primary purpose of our briefing focuses on CAST, there are other Safer Skies focus areas:General Aviation Joint Steering Committee (JSC)Cabin Safety
15 Integrated Strategic Safety Plan Data-Driven, Consensus-Based, Integrated Strategic Safety Plan Developed46 Prioritized Safety Enhancements8 R&D Projects and 2 Studies46 safety enhancements optimized to include those actions with the best effectiveness vs. resource relationships - 22 complete/24 committed and underwayInitially combines short-term “liveware”-based enhancements with transition to design change enhancements long termProjected 73% Risk Reduction by 2007 (75% by 2020)Foundation for U.S-supported continuous improvements in worldwide aviation safetyUsing the JIMDAT approach, CAST has developed a strategic safety plan as recommended by the NCARC. The plan contains 46 safety enhancements (of which 22 have already been completed). The number of completed items is fluid as CAST approves on-going initiatives. The items in the plan have the potential for a 73% reduction in fatality risk by 2007.The plan is a combination of short-term actions, such as training or Standard Operating Procedures, and longer range design-based solutions.
17 Completed Safety Enhancements Terrain avoidance warning system (TAWS)CFIT Standard Operating ProceduresPrecision approach implementation (PAI) Vertical Angles – Increase constant angle approachesMinimum Safe Altitude Warning (MSAW) SystemsProactive Safety Programs (FOQA + ASAP)CFIT Crew Resource Management (CRM) trainingCFIT Prevention trainingAir Traffic Controller CFIT trainingPAI-VGSI at runway endsPAI-DME at airportsRI SOPsGround Operations (General Aviation)Tow tug operatorsATCAlthough time does not permit my discussing each of the following 22 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 -- and though CFIT is still happening, it is on airplanes not yet upgraded with these enhancements.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.
18 Completed Safety Enhancements (cont’d) Safety CultureIndustry will include essential safety information in the appropriate airline manuals (i.e., training programs)FAA inspectors will utilize the Aircraft Flight Manual (AFM) databaseCEO and Director of Safety (DOS) more visibleMaintenance ProceduresFAA published guidance on:Servicing landing strutsSurveillance of maintenance subcontractorsMinimum Equipment List (MEL) (covers recurring maintenance events)Air Carriers’ Directors of Safety completed internal surveys to verify guidance was being followedALAR Flight crew trainingUncontained Engine FailuresFAA issued Airworthiness Directives requiring the Inspection of High-Energy Rotating PartsWe’ve tackled ALAR, the other tallest bar on the Pareto chart, with Safety Culture through leadership emphasis, better manuals, and better training.This includes ensuring essential flight safety info (such as holding speeds in icing conditions) is incorporated in the flight manuals in a timely fashionWe have established an AFM database for inspectors that will enable POIs to ensure that flight crews and operators have the most timely essential flight info in their manuals.We’ve emphasized better maintenance guidance and procedures on aircraft structure and engines.And for UEF (uncontained engine failures), we issued AD’s that ensure engine high-energy rotating parts are inspected using a best business practice-based method when they are exposed in the shop.
19 Committed Plan Elements Policies and ProceduresIndustry will develop/implement Risk Management toolsIndustry will develop a process to inform personnel/flight crew of critical safety informationIndustry will develop a process to enhance flight crew proficiencyFAA/Industry will develop standard operating procedures for loss of control related accidentsAircraft DesignFAA will issue guidance on Continuing AirworthinessFAA will issue guidance on Critical System MaintenanceFAA will amend guidance to include recommendations surrounding autoflight designs for new type designsManufacturers will implement Flight Deck Equipment Upgrades for new type designs (i.e. interactive checklists)FAA/JAA will amend guidance to include recommendations regarding Displays and Alerting Systems for new designsManufacturers agree to install Vertical Situation Displays in new aircraftFAA/JAA will issue amended icing certification criteria for criteria for new airplane designs not equipped with evaporative systemsManufacturers agree to install Flight Envelope Protection in new type designsBeyond those areas completed, we are committed to better Risk Assessment and Management.We compile and assess guidance materials related to risk assessment and risk management tools to prioritize safety-related decisions for operational issues regarding service bulletins, aircraft accident/incident analysis, flight-critical safety information, and recurring intermittent failures related to dispatch. We utilize risk management tools to prioritize safety-related decisions for operational issues.In the area of airplane design, FAA has added focus to Critical System Maintenance. and to the identification of flight-critical system components to ensure that maintenance procedures do not degrade the original intended level of safety.The Flight Envelope Protection Safety Enhancement involves active or passive flight envelope protection systems in all new aircraft designs to reduce reliance on training.
20 Committed Plan Elements (cont.) Runway IncursionsEnhanced airport surveillance equipmentStandard operating procedures (SOPs)Ground operations (121/135)Vehicle operatorsClearance readback requirementsTrainingPilotsATCEnhanced Tower Controller TrainingCRMRunway incursion prevention is getting a lot of attention for controllers and ramp operators through:Enhanced surveillance equipment.Develop and implement technology tools, including data link, that will provide and/or enhance airport surface situational awareness to air traffic controllers. Examples of these technology tools include, but are not limited to, Airport Movement Area Safety System (AMASS), Airport Surface Detection Equipment (ASDE-X), Automated Dependent Surveillance – Broadcast (ADS-B), Next Generation Air-Ground Communications System (NEXCOM), Surface Movement Advisor (SMA), and Airport Target Identification System (ATIDS).Standard Operating procedures.FAR Part 121 operators and Part 135 operators establish, document, train to, and follow standard operating procedures (SOPs) for ground operations. The implementation of Standard Operating Procedures for surface operations is one of the most powerful near-term interventions in mitigating the risk of runway incursions. This plan builds upon the recent Advisory Circular , "Flight Crew Procedures During Taxi Operations", to develop templates of SOPs for use by air carriers, general aviation pilots.Training for vehicle operatorsThe development and use of recommended “best practices”, for ground operations for use by mechanics and others who tow or otherwise move aircraft within the airport movement area, will improve aviation safety by reducing the frequency and severity of runway incursions.
21 Committed Plan Elements (cont.) Flight Crew TrainingAdvanced Maneuvers Training will be provided by all operatorsIndustry will incorporate a human factors-related training guide into training programs and SOPsPrecision approach implementation (PAI)FAA and Industry will develop:Recommended procedures, displays and training that will enable pilots of commercial aircraft to fly a stabilized vertical path to the runway for all instrument approachesCriteria and guidance for reduced landing minimaLaterally and vertical guided approach paths to runway ends not served by Instrument Landing System (ILS)Flight Crew Training.Many operators have already implemented Advanced Maneuvers Training (AMT) to prevent and recover from hazardous flight conditions outside of the normal flight envelope, such as inflight upsets, stalls, ground proximity and wind shear escape maneuvers. The philosophy is that this training will be accomplished via ground and simulator instruction within the normal flight envelope, with emphasis on recognition, prevention and recovery techniquesMovement toward PAI is steady and positive. The various systems and procedures under development will enhance capability and improve safety.
22 CAST R&D Plan CFIT – Synthetic Vision Systems Develop capabilities that permit flight crews to operate in a day VMC-like environment, regardless of visibilityCFIT – FOQA & ASAPDevelop low cost analytical tools (including decision making) and methods that both large and small operators can apply to FOQA and ASAP informationCFIT – DatalinkDevelop datalink capabilities and systems for automatic digital transmissionI’d like to mention the 10 R&D Projects and Studies that are on the CAST R&D plan.CFIT – Synthetic Vision SystemsDevelop capabilities that permit flight crews to operate in a day VMC-like environment, regardless of visibility.Terrain and obstacle alerting.Geospatial databases.Weather display.Traffic display and alerting.Flight path information.Energy state awareness informationCFIT – FOQA & ASAPDevelop low cost analytical tools (including decision making) and methods that both large and small operators can apply to FOQA and ASAP information.develop a capability to measure effectiveness of CAST Safety Enhancements.CFIT – DatalinkDevelop datalink capabilities and systems for automatic digital transmission;ATC instructions/information between the ground controller and the aircraft.Weather information.Air traffic information.Status of aircraft systems.Other safety information.
23 CAST R&D Plan (cont’d) CFIT Precision-Like Approach Conduct research necessary to determine human factors guidelines for design of instrument proceduresALAR - Health & Usage Monitoring Systems (HUMS)Conduct research and develop technology for detection, prediction and/or annunciation of impending equipment failuresALAR – Human FactorsConduct research into correcting and eliminating the underlying reasons/causes for procedural noncompliance.CFIT Precision-Like ApproachConduct research necessary to determine human factors guidelines for design of instrument procedures.Determine the minimum number of approach charts to runway end with multiple minima, (suitable for xLS, RNP, LNAV/VNAV, and LNAV minima). As part of this plan, conduct a research project to address issues of charting, content, etc.Develop guidelines for non ILS-like approaches.Develop guidelines for approaches using synthetic vision.ALAR - Health & Usage Monitoring Systems (HUMS)Conduct research and develop technology for:Detection, prediction and/or annunciation of impending equipment failures.Detection and annunciation of inappropriate settings that may affect safe flight.Real time decision making support for maintenance and operations.Smart alerting systems that provide real time assistance to flight crews with on board system failures and include diagnostics, prioritization schemes and elimination of nuisance alertsALAR – Human FactorsConduct research into:Correcting and elimination the underlying reasons/causes for procedural noncompliance.The phenomenon of flight crew overload.Preventing plan continuation errors.To develop an effective tactical decision making model for flight crews.Developing human performance models.
24 CAST R&D Plan (cont’d) LOC – Icing For aircraft that incorporate non-evaporative ice protection systems, develop systems that sense the presence of ice accretion on the aircraft, automatically activate and manage the ice protection systems, and provide the pilot with feedback including the effect on measured aircraft performance, stability, and controlLOC - Envelope Protection -Existing AirplanesComplete study and determine feasibility of modifying existing aircraft to include angle-of-attack / low speed protection (e.g., stick pushers/nudgers, column force ramps/gradients, automatic elevator/stabilizer inputs); thrust asymmetry compensation; and bank angle protection using hard or soft limitsLOC – IcingFor aircraft that incorporate non-evaporative ice protection systems, develop systems that sense the presence of ice accretion on the aircraft, automatically activate and manage the ice protection systems, and provide the pilot with feedback including the effect on measured aircraft performance, stability, and control.provides annunciation that alerts the crew to respond appropriately to the icing hazard.ground and aircraft based means of detection of meteorological icing onditionsdefine the effects of all ice accretions, with particular emphasis on the roll effect due to ice contaminated wingsunderstand the effects of super-cooled large droplets (sld)LOC – Basic Airplane Design - Mode ConfusionComplete survey using information from instructors and check airmen relating to mode confusion during training and line operations, and supply a model specific issues summary report to CAST, manufacturers, and aviation human factors working groups to enable design and training changes to reduce the potential for mode confusion.
25 CAST R&D Plan (cont’d)RI - ATC Procedures -Review Capacity Enhancement Program - LAHSO)Complete review of capacity enhancement programs to determine if they are contributory to runway incursionsRI - RI Visual Aids Enhancement and Automation Technology - Airports - Runway occupancy signalDevelop, evaluate and install a visual signal to indicate runway occupancy to flight crews on final approach to that runwayRI - ATC Procedures -Review Capacity Enhancement Program (Original Name - LAHSO)Complete review of capacity enhancement programs to determine if they are contributory to runway incursions.LAHSO procedures“Reduced Separation on Final” proceduresRI - RI Visual Aids Enhancement and Automation TechnologyDevelop, evaluate and install a visual signal to indicate runway occupancy to flight crews on final approach to that runway.
26 Resource Cost vs. Risk Reduction APPROVED PLANCompleted + Plan (2007 Implementation Level)Completed + Plan (2020 Implementation Level)All JSIT Proposed Enhancements (2020 Implementation Level)10002000300040005000600070008000900010000Resource Cost ($ Millions)Risk ReductionTotal Cost in $ (Millions)200720200%25%50%75%100%Risk Eliminated by Safety EnhancementsCompletedA graphical representation of resource application versus risk reduction, which also depicts the CAST JIMDAT prioritized selection criteria for the draft strategic plan.In the example plot, it can be seen how the CAST plan items for 2007 and 2020 were selected using benefits versus resources and the rationale for not selecting all the solutions.This represents the “sweet spot” in terms of prioritizing safety enhancements. The blue bars go well above 70% and approach 80% when we take credit for the effects that completed enhancements are bringing, as some of them are exceeding their projected success levels.The tool developed by CAST to determine the priorities of various enhancements will be described in detail in Paul Russell’s presentation on Thursday afternoon. The CD contains not only the results of our analysis of the worldwide accident data from but a “generic” spreadsheet with use instructions that can be tested in your own operating environment.
27 Safety Plan BenefitsPrediction of a 73% risk reduction that also results in approximately $620 million annual savings to the industryCurrent accident cost per flight is approximately $76 cycleImplementation of the 46 selected safety enhancements reduces this cost by $56 per flight cycleSafety is morally required and is also good forbusinessThe ultimate benefit of reducing fatality risk is the savings achieved in loss of life prevented, but money savings are also important. By implementing the 46 carefully selected, data-driven safety enhancements, we should reach a predicted 73% reduction in fatality risk by 2007, which will produce approximately $620M cost avoidance (savings) every year for the industry.This dramatically demonstrates that Safety is good for business!NOTE – cost and risk reduction figures are specific to US operations; similar analysis can be performed for international operations..
28 Cost 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
29 U.S. Hull Loss & Fatal Accidents Portion of Total Fatality Risk Mitigated by the CAST Plan(2007 Implementation Values)100%Risk Eliminated90%Risk Remaining80%70%CAST Fatal/Hull Loss Database –Security events excluded60%Portion of Risk50%40%30%The potential fatality risk mitigation value of the CAST plan by 2007 is 73% with security events excluded.This value increases to 79% when the beneficial effects of other ongoing safety initiatives developed outside of CAST by industry and government are considered.Utilizing the JIMDAT process and applying the results to identify risk eliminated for the dataset evaluated also provides insight into areas of remaining unmitigated risk which are guiding future CAST study areas.As a result of this analysis CAST has formed a Joint Safety Analysis Team to investigate and provide interventions for four areas of the unmitigated risk. They are icing (particularly ground deicing), maintenance error, midair collisions and cargo handling/loading. The team is expected to recommend safety enhancements in these areas by the fall of 2004.20%10%0%TotalCFITLOC FltMidairEvacLOC GNDCrew IncEng-UCEFSys-CompTurbulenceFire/ExplosionRunway Collision
30 Risk Eliminated Risk Remaining All Regions Combined Worldwide Hull Loss & Fatal World Wide AccidentsPortion of Fatality Risk Mitigated If CAST Plan is Adopted Worldwide(2007 Implementation Values)100%Risk Eliminated90%Risk Remaining80%70%60%Portion of Risk50%40%30%The Joint Implementation Data Analysis Team (JIMDAT) of the CAST has analyzed the worldwide fatal accidents ( ) to determine what risk would be eliminated if the 46 elements of the CAST Safety Plan were implemented worldwide. It would appear that the CAST enhancements have broad applicability to the global aviation system.20%10%0%RITotalCFITICERELOC-IMidairFUELARCUSOSADRMSCF-PPSCF-NPFIRE-NIWSTRWOTHER-BIRDAccident Classes Defined by CAST/ICAO Common Taxonomy
31 The CAST Process is Flexible It may be used to analyze:Suggestions from outside industryRegulatory initiativesAccident lessons learnedIncident dataOtherThe CAST JIMDAT process can also be used to provide an assessment of the safety potential associated with suggestions or ideas from outside sources and enable CAST to evaluate their merit against the CAST dataset.
32 Safety MetricsPurpose: Measure to determine if program is resulting in desired risk reduction. Identify issues needing more detailed analysis if desired result is not occurringAssumption: Measurement of accident rate is not effective means of identifying program successConcentrate on using reporting systems currently in existence (ex: FOQA, Partnership programs, SDR, NAOMS, etc.)Direct link is through the problem statements identified by data analysisIdentify events that reflect the problemIdentify available method for measuring the event frequencyEstablish event baselineIdentify trendThe use of fatal accident rate as a metric to determine the effectiveness of our enhancements is not satisfactory. It is an "after the fact" measure and does not allow CAST to adapt its plan to address enhancements that may not be turning out to be as effective as thought. By developing a metric system as outlined here, we will be able to identify plan weaknesses before they effect the accident rate and take steps to correct those weaknesses. Our metric process is designed to use currently-available reporting systems for routine evaluation of our plan and identification of improvements.
33 Safety Metrics Examples Safety EnhancementIndicator1. Terrain Avoidance Warning System (TAWS)Reduction in MSAW alertsReduction in valid GPWS alerts (CFIT)4. CFIT PAI-Vertical Angles (7-11,18)Percentage of operators who have adopted constant angle approachesContinuous reduction in selected metrics21. ALAR Flight Deck Equipment Upgrades – New Type Designs (1-3)Reduction in number of inadvertent descents below decision height23. ALAR Flight Crew Training – one projectContinuous reduction in the number of busted approach gatesContinuous reduction in altitude busts27. LOC Policies and Procedures – Risk Assessments and Management – one projectPercentage of operators/manufacturers with risk assessment/management processes in placeContinuous reduction in the number of operations with recurring intermittent failures in flight critical systemsPercentage of operators with a process to include safety information in manualsThe Measurement of accident rate alone is neither a complete nor timely measure for tracking program progress. It is an "after the fact" measure and does not allow CAST to adapt its plan to address enhancements that may not be turning out to be as effective as thought. By developing a metric system that concentrates on using reporting systems currently in existence to identify precursors (ex: FOQA, Partnership programs, SDR, NAOMS, etc.), we will be able to identify plan weaknesses before they affect the accident rate and take steps to correct those weaknesses.These are example indicators that are linked to problems identified in the original case studies.The rate of occurrences of these problems link to measuring the interventions.We are working with all segments of government and industry in the US to acquire the information needed to continuously measure the effectiveness of our enhancements. For example, every Federal Aviation Administration (FAA) operations, maintenance and avionics inspector has been briefed on the contents of the CAST plan, the voluntary nature of CAST and specific information we would like the inspectors to gather from their carriers. Additionally, we are working with the Advisory Rulemaking Committees (ARC) on FOQA and ASAP to identify metrics that might be available from these data sources. We are also working with NASA in the development of data from sources such as the Aviation Safety Reporting System (ASRS) and the National Aviation Operations Monitoring Service (NAOMS).
34 CAST Links to International Safety Activities Asia/PacificICAO COSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness)NARAST, SARAST, SEARASTAssociation of Asia Pacific AirlinesEuropeJSSI: JAA Safety Strategy InitiativeCentral / South AmericaPAAST: Pan American Aviation Safety TeamEast AfricaAfrican Airlines Safety Council, AFRASCOWest AfricaASECNA (Agence pour la Securite de la Navigation Aerienne en Afrique et a Madagascar)Flight Safety FoundationCAAG (CFIT & Approach and Landing Action Group)ICAOGlobal Aviation Safety Plan (GASP)CAST, in focusing on its second goal of reducing the worldwide accident rate, has shared safety information with and supported the efforts of several international safety activities. These activities will continue and hopefully expand.
35 Future Vision Execute the CAST-approved Safety Plan Measure Plan effectiveness and modify Plan based on metrics and resultsContinue the development of a proactive incident-based risk mitigation methodologyImprove the CAST processExpand CAST influence on worldwide safety programsIntegrate safety program with R & D initiativesCatalog the many on-going safety initiatives that dilute limited resources and identify opportunities for program integration and efficiency improvementsIn the future, we will continue to diligently execute and refine our data-driven safety plan each year.We will measure our progress rigorously so we can build a better plan each year and thus continually improve the CAST process.We will transition to a proactive incident-based risk methodology.We look forward to sharing our results with others, so we can expand the positive influence of the CAST process worldwide.And we will integrate the knowledge we gain from this data-driven approach with initiatives to help our Research and Development community focus their efforts on those technologies that promise the most potential benefit.We are examining ways to ensure that safety resources are being used in the most effective manner.
36 Safety Plan Development CAST Plan Rev.AccidentJSAT’sAccidentJSIT’sSafetyEnhancementsCASTPlanMasterContributingFactorsJIMDATProcessMetricsEmergingRiskMetricsIncidentAnalysisProcessSafetyEnhancementsChangingRiskWe 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.MetricsAviationSystemChangesIdentifyHazardsIdentifyFactorsYesPresentIn MasterFactorsDevelopContributingFactors(new or emerging)SafetyEnhancementsFAST HazardsNoDemographicChangesIdentifyHazardsIdentifyFactorsCAST-051
37 Conclusions CAST has an effective data-driven process CAST has become the model for US Industry/Government consensus building on safetyCAST brings together all the key players– Air Carriers – Manufacturers– Employee Groups – GovernmentPredicted 73% risk reduction by 2007Industry is voluntarily implementing CAST recommendationsCAST is committed to worldwide participationCAST is moving to develop proactive processes to identify changing and emerging risksIn 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 46 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.