Presentation on theme: "Improving Safety through Collaborative Safety Initiatives"— Presentation transcript:
1 Improving Safety through Collaborative Safety Initiatives Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO Air Navigation CommissionJay PardeeDirector, Office of Accident Investigation and PreventionOctober 6, 20091
3 In the U.S., our focus was set by the White House Commission on Aviation Safety, and The National Civil Aviation Review Commission (NCARC)Reduce Fatal Accident Rate . . .Strategic Plan to Improve SafetyImprove Safety Worldwide . . .Both 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 year 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.2
4 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.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.The vision ,mission, and goals of CAST are as shown on this slide.
5 CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agenda IndustryGovernmentAIAAirbusALPAAPAATAIFALPANACABoeingGE*RAAFSFDODFAAAircraft CertificationFlight StandardsSystem SafetyAir Traffic OperationsResearchNASAICAO**EASA (ECAST)TCCNATCA**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 association of key stakeholders in the operation of the commercial aviation system and the participants are safety 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)European Aviation Safety Agency (EASA)General Electric (GE)-representing all engine manufacturersTransport Canada (TCC)Regional Airline Association (RAA)National Air Traffic Controllers Association (NATCA) (observer)Flight Safety Foundation (FSF)National Transportation Safety Board (NTSB) (observer)International Air Transport Association (IATA) (observer)Association of Asia Pacific Airlines (AAPA) (observer)Air Transport Association of Canada (ATAC) (observer)Association of Professional Flight Attendants (APFA) (observer)IATA**AAPA**ATAC**APFA**ACI-NA*** Representing P&W and RR** Observer
6 Joint 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)
7 Safety Plan Development AccidentJSATSCase studiesAccidentJSITSCase 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.CAST is transitioning to 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 green 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 into the future (orange), 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 European led 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
9 Robust CAST Methodology Detailed event sequence - problem identification from worldwide accidents and incidentsBroad-based teams (45-50 specialists /team)Over 450 problem statements (contributing factors)Over 900 interventions proposedAnalyzed for effectiveness and synergyExtremely robust and disciplined processAmazing array of talent brought to bear to develop CAST planEvidence of commitment of participants to the CAST process
10 CAST Process Led to Integrated Strategic Safety Plan Part 121 or equivalent passenger and cargo operations studiedCurrent CAST plan:72 Prioritized Safety Enhancements50 Complete and 22 underwayProjected 74% fatality risk reduction by 2020Industry and Government implementing planAcknowledge that other enhancements ongoing bring number to over 80%
11 Resource Cost Vs. Risk Reduction 100%10000Risk ReductionAPPROVED PLAN$9000Total Cost in $ (Millions)800075%70006000Risk Eliminated by Safety Enhancements$50%Resource Cost ($ Millions)5000200720204000300025%2000A 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.As you can see there was a definite knee in the resource cost curve. The selected CAST plan provided an estimated 74% risk reduction by 2020 at a cost of about 740 million dollars. To implement all of the CAST possible projects would increase the risk reduction by about 5 percent but require more than 5 billion dollars to implement.$$1000$0%CompletedCompleted + Plan (2007 Implementation Level)Completed + Plan (2020 Implementation Level)All JSIT Proposed Enhancements (2020 Implementation Level)
12 Cost Savings Dollars/Flt. Cycle Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents100Historical cost of accidents per flight cycle8074% Risk reductionSavings ~ $74/Flight CycleOr~ $814 Million Dollars/YearDollars/Flt. Cycle6040When we break down costs of our current accident rate, accidents cost us approximately $100 for every flight.By implementing the 72 carefully selected, data-driven safety enhancements, we will have reduced these costs by $74 per flight.This adds up to a savings about $814 Million EVERY YEAR into the future.20Cost of accident fatalities following implementation of the CAST 2020 levels20072020
13 CAST Safety Plan 51 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 50 completed safety enhancements, this list illustrates the areas, and types of actions, that were covered in the enhancements completed to date. This list clearly indicates how a range of training, operational and design solutions were utilized. CFIT-PAI-Vertical Angles - Increases the use of Precision approach through addition of vertical angles on approach plates to achieve constant angle descent.
14 CAST Safety Plan (cont.) 21 Committed Safety EnhancementsPolicies and ProceduresAircraft DesignFlight Crew Training (additional aspects)Runway Incursion PreventionPrecision Approaches (additional projects)Icing (additional turboprop projects)MidairMaintenanceRunway SafetySafety culture, policies and proceduresStudy 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.
15 Fatal Accident Rate and Full Airplane Loss Equivalents Rate for Part 121 Operations (5 year moving average)9.08.05 year moving avg of fatal accidents per 10 million departures7.06.05.0Fatality Accidents or Full Loss Accident Equivalentsper 10 Million Departures4.03.082% Fatality AccidentRate ReductionSince we are past the original period, the question you might ask is – Did CAST reach its 2007 goal?? This chart illustrates the five year rolling average of the fatal accident rate in U. S. Part 121 operations (red line) and the fatality risk (blue line). This clearly shows that the CAST activity, coupled with other ongoing safety activities by government and industry, have resulted in an 82 percent reduction in the fatal accident rate in the ten years ending in 2007.2.01.00.019911992199319941995199619971998199920002001200220032004200520062007
16 International Perspective CAST Safety Enhancements Western-built transport hull loss accidents, by airline domicile, 2001 through 2007COSCAP CISC.I.S.1Europe0.7ESSI35 SEs JAA11 SEs EASA62% reductionCOSCAP NA, SA, SEA40 SEs in work60% reductionUnited Statesand Canada0.4China0.3CAST70 SEs48 complete22 in work74% reductionMiddle East2.3Asia2.1(ExcludingChina)COSCAP BAGAfrica10.0COSCAP GulfLatin Americaand Caribbean2.1Oceania0.0ASETRASG-PAWorld1.1Accidents permillion departures1 Insufficient fleet experience to generate reliable rate.
17 SummaryHistory shows focused action and introduction of new capabilities have led to accident risk reductionsJoint industry and government teams working together to a common goal can further enhance the safety of our very safe aviation systemFull implementation will require a coordinated effort between industry and governmentCAST is moving forward to meet the challengeASIAS (Aviation Safety Information Analysis and Sharing) initiative is under way help aviation safety teams (CAST, IHST, GAJSC) meet the challenge
18 What is ASIAS….A collaborative Government-Industry initiative on data sharing & analysis to proactively discover safety concerns before accidents or incidents occur, leading to timely mitigation and prevention18
29 Safety Enhancement 184 – Minimum Vectoring Altitude Reevaluation Reevaluate minimum vectoring altitudes (MVAs) at prioritized sites identified in the CAST TAWS study to reduce the number of terrain awareness warning system (TAWS) alerts.ASIAS has developed a tool to identify MVA’s that should be reviewed.The CAST mitigation team is coordinating the evaluation of this tool within the FAA.2929
31 Safety Enhancement 185 – TAWS and RNAV Visual or Other Procedures This enhancement provides better separation from terrain by providing RNAV Visual or other procedures that mitigate known TAWS and terrain issues.jetBlue has agreed to be the lead carrier in developing a RNAV visual flight procedure for OAKMultiple airports identified in the TAWS study have implemented, or are developing, visual and/or instrument flight proceduresABQ:RWY 26 RVFP in placeRWY 26 RNP waiting for completion of sight surveyLAS:RWY 19 RVFP (USAirways & NetJets)SAN:RWY 27 RNP SAR having issues with survey & environmentalGuam:Continental talking about RVFP (no formal application)3131
32 OAK Traffic – RNAV Capable Aircraft RNAV equipped per AC ADME/DME/IRU and/or GPS sensor inputNOTE: Explain adequate equipage levels and weather suitability for procedure during this slide.32
33 Proposed: RNAV VISUAL Approach to OAK RWY 11 33
34 Safety Enhancement 120 – TAWS Improved Functionality Current production models, new type design airplanes, and existing aircraft, where appropriate, will include GPS equipment to allow incorporation of certain TAWS enhancements.CAST is developing a cost benefit analysis to help promote this initiative3434
36 EGPWS Mode-2 Pull Ups w/218 or Higher (about 20X Less Frequent) 36
37 Analytical Products Terrain Awareness Warning System (TAWS) Traffic Collision Advisory System (TCAS)Wrong Runway Departures (WR)Metrics
38 Data Sources and Analysis NOP Run simulations that will encompass all carriers and traffic to better estimate RA rates and degree of risk. Perform domestic / foreign comparisons. (Provides intruder information.)(National Offload Program radar surveillance data)FOQA Assess NAS-wide and airport-specific TCAS RA landscape. Provide Trend Information. Investigate pilot response to advisories.(TCAS Operational Performance Assessment)TOPAMode-S downlink provides information similar to FOQA, and is enhanced with surveillance radar data.Four primary data sourcesAll are valuable, but all have limitations…NOP -- Surprisingly difficult to get high fidelity data. Only got one month of data for each target airport. Data must be run through simulator to estimate RAsFOQA – Highly detailed for single aircraft, but de-identification makes it impossible to see the context and see the intrude -- Includes only the five ASIAS airlines with data in the FOQA systemTOPA – A new data source available at only a few airports. Big advantage is that it has radar (for intruder info) and “hears” actual RasText Reports – Difficult to use quantitatively because of self-report bias.Text ReportsHelp get the story behind the numbers at selected airports.(ASAP, ASRS, OE)3838
39 ASIAS Directed Study on TCAS RAs: Location from FOQA Data Over a three-year period, Southern California, Northern California, and Denver accumulated the greatest concentrations of TCAS RA events. *3939
40 Common Themes Observed at Study Airports: VFR and IFR Traffic Interaction GA aircraft under tower control interacting with structured* IFR traffic at a nearby airportExample: BUR arrival and departure interaction with VNY“Loitering” VFR traffic interacting with structured IFR traffic to/from nearby airportExample: Philadelphia downtown VFR traffic interaction with PHL arrivalsTypes of traffic observed in data: radio / TV traffic reporting airplanes and helicopters, aerial photography, law enforcementStructured VFR flow near structured IFR trafficExample: VFR helicopter route crossing under EWR arrivalsExample: GA traffic crossing under JFK arrivals*Arrival /departure route or an approachLooking across the airports, a number of common themes emerged.This slide shows the VFR vs IFR themes (next slide is IFR vs. IFR)TCAS will often sound an RA at 600’ vertical separation, but 500’ is “legal” but you’ll still get an RA500-ft separation is maintained in most cases, but it is not sufficient to prevent TCAS RAs4040
41 Common Themes Observed at Study Airports: IFR Traffic Interacting with Other IFR Traffic Visual approaches to parallel runwaysClose spacingExample: SFO 28R/L with 750’ centerline spacingHigh altitude with increased TCAS sensitivityExample: DEN 16R/L with 2500’ centerline spacingArrival / departure interaction triggered by closure rateExample: TEB west departures with EWR 22 arrivalsExample: DEN west departures with arrivals on both north and south flowsThis slide shows the IFR vs IFR themes seen across airportsParallel runways at SFO and DEN were big --Keep in mind some airlines at SFO shift to TA-onlyTCAS sensitivity decreases as altitude decreases ( to prevent unwanted RAs)Baro Pressure is used to determine altitude until radar altimeter kicks in. DEN parallels may be experiencing “over sensitivity” before radar altimeters kick in.Because TCAS can’t take INTENT into consideration, a departure climbing to and an arrival descending to could set off an RAThese procedures are in accordance with , but they do not provide sufficient separation to prevent TCAS RAs4141
42 Analytical Products Terrain Awareness Warning System (TAWS) Traffic Collision Advisory System (TCAS)MetricsWrong Runway Departures (WR)
43 Mapping Problem Statements to FOQA Metrics The mapping of Problem Statements to actual metrics that can be measured in FOQA data is a complex task. It is not a one-to-one relationship, and in many cases problem statements map to multiple metrics and individual metrics map to multiple problem statements.4343
44 Example Metrics for Approach and Landing Accident Risks Metric Category LevelSafety Enhancement LevelProblem Statement LevelMetricLevel1Accident SpotlightAir Carrier: Cayman AirwaysAircraft Type: BLocation: Grand Cayman, Cayman Is.Synopsis:Night; VMC; Experienced crew; Visual approach; Light rain; Tailwind; 7,021 ft. runway; Thrust reversers inoperative; Speedbrakes not armed or deployed; Fast approach; 3.5° descent angle1Unstable approaches are measured using the Height Above Touchdown (HAT) method, which captures the HAT on the first approach when the aircraft is 100% stableThe same approach was followed to analyze each Problem Statement. This is an excerpt from the MindMap with an Accident Spotlight. The accidents provide specific crash-related metrics that can then be analyzed using FOQA events and measurements.This slide connects Safety Enhancement #23 to Problem Statements 10, 17, and 48 to Did not Fly Stable Approach and Did not Manually Deploy Speedbrakes. The Accident Spotlight summarizes the description that would be found on the MindMap by clicking the “paperclips” marked with red 1s.Stable on GlideslopeStable on LocalizerStable [CAS-Vapp]Stable [CAS-Vref]Stable Ground SpeedStable Rate of Descent (ROD)Stable ThrustLanding Flaps SetGear DownStable in PitchStable in RollStable in YawGround Spoilers ArmedSpeed Brakes Retracted4444
45 Initial Results: Unstable Approach Metric 83.1%15.8%1.1%This slide, reading from right to left, shows that 83.1% of flights were stable by 1,000 feet HAT % of flights became stable between 1,000 feet and 500 feet above touchdown. 1.1% of flights remained unstable below 500 feet above touchdown.The histogram segments, the colors, show which stable approach event became stable last. The tallest bar shows that gear, flaps, thrust, airspeed, on-localizer and on-glideslope were most often last above 1,000 feet. Between 1000 and 500 feet on descent, speed and glideslope are not prominent.The most frequently occurring events in the 1.1% column includes: Low Thrust, Glideslope, Localizer, and Flaps events.And the most frequently occurring of those events is Low Thrust (approximately 0.5% of flights)4545
46 Initial Results: Unstable Approach Metric The previous slide trends Unstable Approach (HAT Method). This one trends Unstable Approach (HAT Method) AND Go-Around.4646
47 Analytical Products Terrain Awareness Warning System (TAWS) Traffic Collision Advisory System (TCAS)MetricsWrong Runway Departures (WR)
48 Lexington Blue Grass (LEX) 2006 Aircraft was cleared for departure on Runway 22 but departed on Runway 26Comair flight 5191 crashed approximately ½ mile from the end of runway 26Similar non-fatal events have occurred prior to this eventCleared for 22 but lined up on 26 (1993)Poor visual cues and lighting also cited in other taxing related events by air crewsSimilar non-fatal events have occurred after this event
49 Findings – Part 121 Operations Wrong Runway Departures By Data SourceNOTE: ASRS database with certain exceptions captures ~ 18% of reports received by NASA on monthly basis102030405060708090ASRSPDSNTSB (I)AIDS (I)PTRSNTSB (A)84321
50 Findings – Part 121 Operations Air Carrier Reported Wrong Runway Events ( )ClevelandHoustonSalt Lake CityMiamiChicagoLexingtonNOTE: ASRS database captures only 18% of all reports received by NASA on monthly basis51015202530
53 Findings – Part 135 Operations Wrong Runway Events ( )ClevelandHoustonLexington51015202530HoustonPART 121ClevelandLos AngelesRichmondSyracuseAnchorageNOTE: ASRS database with certain exceptions captures ~ 18% of reports received by NASA on monthly basis
55 International Collaboration Sharing of CAST safety products worldwide – COSCAP, GASR, etcCAST ICAO Common TaxonomyECCAIRs – common taxonomy, developing data sharing proposalsTCAS RA mitigation study – including EurocontrolDesire increased connectivity with ICAO ISDCAS (Integrated Safety Data Collection and Analysis System)IATA GSIC – Evaluating sharing top level safety hazardsPartnered with E-CAST
56 QUESTIONS? http://www.cast-safety.org/ To meet the recommendations of the recommendations of the White House Commission on Aviation Safety and the National Civil Aviation Review Commission the Existing Industry Safety Strategy Team (ISST) and the Federal Aviation Administration Safety Action Team (SAT) were combined, and augmented, to create the Commercial Aviation safety Team (CAST) in 1998.