1. 1 2013 – The Year in Review

2. The Fleets - 2013 Type Western Built Eastern Built Total Turbojets 22,113 1,007 23,120 Turboprops 4,797 1,001 5,898 Business Jets 18,072 Source: Ascend - A Flight Global Advisory Service

3. Accident Classifications Aircraft * Type: Turbojets, Turboprops, Piston, Helicopters * Size: Weight, number of seats * Use: Passenger, cargo, business, government * Western built or Eastern built How Measured * Per hours flown * Per departures * Per number of aircraft Classification * Hull Loss Accident * Total Loss Accident * Economic Loss Accident * Substantial Damage Accident * Fatal Accident * Major Accident

5. Accident Classifications Aircraft * Type: Turbojets, Turboprops, Piston, Helicopters * Size: Weight, number of seats * Use: Commercial, business, government * Western built or Eastern built How Measured * Per hours flown * Per departures * Per number of aircraft Classification * Hull Loss Accident * Total Loss Accident * Economic Loss Accident * Substantial Damage Accident * Fatal Accident * Major Accident

6. Accident Classifications Major Accident: An accident in which any of three conditions is met: 1. Aircraft destroyed, or 2. Multiple fatalities to occupants, or 3. One fatality and aircraft substantially damaged

7. Major Accidents Commercial Jets 1 January 2012 to 31 December 2012 CFIT LOC Excursion DateOperatorAircraftLocationPhaseFatal 20 AprilBhoja AirlinesB-737Islamabad, PakistanApproach127 9 MaySukhoiSU-100 Mount Salak,Indonesia Enroute45 2 JuneAllied AirB-727Accra, GhanaLanding0 3 JuneDana AirMD-83Lagos, NigeriaApproach153 30 NovAero ServiceIL-76Brazzaville, Congo Go Around 7 25 DecAir BaganF-100 Heho, MyanmarLanding 1 29 DecRed Wings AirlinesTU-204 Moscow, RussiaLanding 5 Source: Ascend - A Flight Global Advisory Service

8. Major Accidents Commercial Jets 1 January 2013 to 28 October 2013 CFIT LOC Excursion DateOperatorAircraftLocationPhaseFatal 29 JanuarySCAT AirCRJ-200Almaty, KazakhstanApproach21 13 AprilLion AirB-737 Bali, Indonesia Approach0 29 AprilNational AirlinesB-747Bagram, AfghanistanTakeoff7 6 JulyAsiana AirlinesB-777San Francisco, USALanding3 14 AugustUPSA-300Birmingham, AL, USA Approach 2 Source: Ascend - A Flight Global Advisory Service

9. Commercial Jet Major Accidents 2000 through 2012 20 15 10 5 200102030405060708091011 13 19 13 16 11 17 19 17 19 14 12 Eastern Built 7

10. Major Accidents Business Jets 1 January 2013 to 28 October 2013 DateOperatorAircraftLocationPhaseFatal 20 FebruaryThe Vein GuysPremier IThomson, GA, USALanding5 4 March Global Jet Luxembourg Premier IAnnemasse, FranceTakeoff2 17 March 7700 Enterprises Premier I South Bend, IA, USA Approach2 5 MayPrivateLear 60 Valencia, Venezuela Approach2 29 September CREW MMCLLCCessna CJ2 Santa Monia, CA, USA Landing4 18 OctoberDufrense, IncCitation IDerby, Kansas, USAClimb2 Source: Ascend - A Flight Global Advisory Service

11. Business Jet Major Accidents 2000 through 2012 20 15 10 5 200102030405060708091011 14 8 8 15 9 1211 7 8 10.5 7 12 13

12. Business Jet Major Accident Rate 2000 through 2012 (Accidents per 1,000 Aircraft) 1.0.75.50.25 200506070809101112 4 Year Average:.52 8 Year Average:.67

13. Major Accidents Commercial Turboprops (> 14 seats) 1 January 2013 to 28 October 2013 CFIT DateOperatorAircraftLocationPhaseFatal 23 JanurayKenn Borek AirDHC-6 Terra Nova Bay, Antarctia Enroute3 13 February South AirlinesAN-24Donetsk, UkraineApproach5 4 MarchCAAFokker 50Goma, DRCApproach7 8 MarchACE Air CargoBeech 1900 Anchorage, Alaska, USA Approach2 7 AprilSahel Air ServiceBeech 1900 San Tome and Principe Approach1 17 AprilLao AirDHC-6 Vientiane-Wattay, Laos Takeoff0 16 MayNepal AirlinesDHC-6Jomson, NepalLanding0 16 May Flying Dragon Aviation Y-12Shenyang, ChinaClimb0 1 JuneSita AirDO-228Simikot, NepalLanding0 10 JuneMerpati AirlinesMA-60Kupang, IndonesiaLanding0 13 JuneSkyBahamasSAAB 340 Marsh Harbor, Bahamas Landing0 29 JuneBatair CargoEMB-110 Francistown, Botswana Approach2 9 SeptCorpFliteDO-228Vina Del Mar, ChileApproach2 3 October Associated Aviation EMB-120Lagos, NigeriaTakeoff13 10 OctoberMASwingsDHC-6Kudat, MalaysiaLanding2 16 OctoberLao AirlinesATR-72Pakse, LaosApproach49 Source: Ascend - A Flight Global Advisory Service

14. Major Accidents Commercial Turboprops (> 14 seats) 1 January 2013 to 28 October 2013 (cont.) CFIT DateOperatorAircraftLocationPhaseFatal 19 OctoberAir NiuginiATR-42 Madang, Papua New Guinea Takeoff0 Source: Ascend - A Flight Global Advisory Service

15. Commercial Turboprop Major Accidents 2000 through 2012 20010203040506070809 5 10 15 20 25 30 35 40 22 31 33 31 39 24 29 21 10 20 11 25.9 (12 years) 21.4 (5 years) 23 12 21 20 17 Eastern Built

17. Approach and Landing Major Accidents Commercial Jets 1 January 2013 through 28 October 2013 DateOperatorAircraftLocationPhaseFatal 29 JanuarySCAT AirCRJ-200Almaty, KazakhstanApproach21 13 AprilLion AirB-737 Bali, Indonesia Approach0 6 JulyAsiana AirlinesB-777San Francisco, USALanding2 14 AugustUPSA-300Birmingham, AL, USA Approach 2

18. Controlled Flight into Terrain Major Accidents Commercial Jets 1 January 2013 to 28 October 2013 DateOperatorAircraftLocationPhaseFatal 29 JanuarySCAT AirCRJ-200Almaty, KazakhstanApproach21 13 AprilLion AirB-737 Bali, Indonesia Approach0 6 JulyAsiana AirlinesB-777San Francisco, USALanding3 14 AugustUPSA-300Birmingham, AL, USA Approach 2 Sources: Honeywell (Don Bateman), Ascend

19. 5 Year Running Average Over the last 7 years, 26 of 88 turboprop major accidents has been a CFIT– that’s 30%, or almost 1 of every 3 !

20. Aircraft Upset Major Accidents Commercial Jets 1 January 2013 through 28 October 2013 DateOperatorAircraftLocationPhaseFatal 29 AprilNational AirlinesB-747 Bagram, Afghanistan Takeoff7

21. Aircraft Upset Major Accidents Commercial Jets 1999 through 2012 Number of Accidents 4 6

22. 22 Being Predictive In A Reactive World

23. Being Predictive Can we be predictive ? Will it be successful in reducing risk ?

24. Safety Basics Safety = Risk Management * Eliminate risk * Reduce risk * Acknowledge risk

25. Managing Risk

27. Risk Management Risk = Probability X Severity Everything in life has risk Manage Risk by modifying P or S

28. The Key to Risk Management # 1 Identify Hazards

29. Being Efficient Want to reduce risk in the highest risk areas e.g. Prevent 1 accident in 10 years: good Prevent 10 accidents in 1 year: better

30. Fatalities by CAST/ICAO Common Taxonomy Team (CICTT) Aviation Occurrence Categories Fatal Accidents – Worldwide Commercial Jet Fleet – 2003 Through 2012

31. Reactive: Tending to react, characterized by reaction Proactive: Preparing for, intervening in, or controlling an expected occurrence or situation Predictive: Inference regarding a future event based on probability

32. The Spectrum of Safety Reactive Predictive Fly-crash-fix-fly Identify hazards as they appear in accidents Study past accidents and incidents to identify hazards and reduce risk Proactive Utilize data from incidents and normal operations to identify trends and reduce risk before an accident happens Single Accident Data----------Consolidated Accident/Incident Data ------Accident/Incident/Operational Data Data Availability/Utilization

33. Predicting We can easily predict 90% of next year’s accidents - There will be 1 or 2 upset aircraft - > 50% will be approach and landing - Half of those will be runway excursions - There will be at least 2 Jet and 4 Turboprop CFIT accidents

34. “Black swan” events Predicting - TWA-800 - QF-32 - BA-038

35. Being Predictive Can we be predictive ?

38. Being Predictive Can we be predictive ? YES

39. Fatalities by CAST/ICAO Common Taxonomy Team (CICTT) Aviation Occurrence Categories Fatal Accidents – Worldwide Commercial Jet Fleet – 2003 Through 2012

40. Safety Fatality Data - Circa 1992 Collision with terrain Approach and landing ATC systems Maintenance Loss of control Postcrash survival Inflight fire/smoke Engine failures Airport ground control Nonconfiguration takeoffs Windshear Deicing/anti-icing Rejected takeoff 300025002000150010005000

41. Can detect trends and future hazards Trending * Systems * Locations * Procedures

42. ASAP and FOQA Analysis of OAK Arrivals Receiving TAWS Alerts

43. TCAS Hotspot Snap Shot

44. Being Predictive Will it be successful in reducing risk ?

45. Predictive Challenge - Being able to get the support of the decision makers

46. Keys to Predictive Success 2. Decision maker support 1. Data to make the risk management case

47. A Change of Paradigm Outcome Based Event Based Keys to Predictive Success

48. The Spectrum of Safety Reactive Predictive Fly-crash-fix-fly Identify hazards as they appear in accidents Study past accidents and incidents to identify hazards and reduce risk Proactive Utilize data from incidents and normal operations to identify trends and reduce risk before an accident happens Single Accident Data----------Consolidated Accident/Incident Data ------Accident/Incident/Operational Data Data Availability/Utilization Negative Outcome Negative Outcome(s) Events

49. Challenges to being successful in predicting Data Technology to utilize data Support of a reactive system TBA X X

51. Major Accident Rate Western-Built Commercial Jets 1999 – 2012 Accident rate per million departures Source: Ascend

52. Aviation Safety 2013  Commercial jets on pace for another great year  Business jets having a better than average year  Turboprops are having an average year  CFIT in both commercial jets and in commercial turboprops has returned as the leading killer  We now have the capability to be predictive in our safety efforts – but is the system ready to take advantage of this capability ?

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