# Presentation: 041075

## TurbulenceJSAT BriefingRod BogueNASA Dryden Flight Research Center

- TurbulenceJSAT BriefingRod BogueNASA Dryden Flight Research Center

## In the U.S. our focus is set by theWhite House Commission on Aviation Safety

- In the U.S. our focus is set by theWhite 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 goal.**
**1.2****	****The FAA should develop standards for continuous safety improvement, and should target its regulatory resources  based on performance against those standards**

- 5.3-2

## The National Civil Aviation Review Commission (NCARC) on Aviation Safety Provided Additional Direction

- The National Civil Aviation Review Commission (NCARC) *on Aviation Safety Provided Additional Direction*

**FAA and the aviation industry must develop a strategic plan to improve safety, with specific priorities based on objective, quantitative analysis of safety information and data.**** **
**Government should expand on their programs to improve aviation safety in other parts of the world.**

- 5.3-3

## Why worry about accidents?Gore Commission Recommendation 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 goal.

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- Why worry about accidents?*Gore Commission Recommendation 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 goal.*

- 1965

- 1975

- 1985

- 1995

- 2005

- 2015

**Year**

**Hull loss accidents****per year**

**Hull loss accident rate**

**Airplanes in service**

**12,595**

**25,598**

**1997**

**2016**

**Millions of departures**

**Our goal**

- Jet Transports 60,000 lbs. or greater

- 5.3-4

**Notes:**
When you combine the data – accident rate, regional variation, and traffic growth, you can predict the future number of hull losses.
This assumes no significant change in accident rate or traffic growth.  Both assumptions may be invalid.
The number of airplanes in service will more than double by the year 2015, going from about 11,000 airplanes today to over 23,000 in 2015. 
On a worldwide basis, the data suggest nearly a hull loss accident per week by the year 2015.
We have suggested that to improve the overall accident rate, the improvement areas are lessons learned, regulations, airplanes, flight operations, maintenance, air traffic management, and infrastructure.

## Hull Loss Accident Rates by World Regionsby Accident Site

- Hull Loss Accident Rates by World Regionsby Accident Site

- Western-Built Transports, 1988 through 1997

**United States**
**and Canada**
**0.5**

**Latin America**
**and Caribbean**
**4.7**

**Europe**
**0.8**

**China**
**2.7**

**Middle East**
**1.9**

**Africa**
**9.5**

**Asia**
**2.3**

**World**
**1.4**

**Oceania**
**0.5**

**Accidents per**
**million departures**

**(Excluding**
**China)**

**JAA - 0.6**
**NonJAA - 1.2**

**C.I.S.***

***Insufficient fleet experience to generate reliable rate.**

**Notes:**
In addition to working in the U.S., we need to initiate this type of effort worldwide, especially in light of regional differences in accident rates.
The hull loss accident rates by region are derived from historical data and represent hull losses in the region regardless of country of registry.  This data shows the significance of regional differences.
While safety can and should be improved everywhere, significant improvement in some world regions will have a large impact on the number of hull loss accidents and average accident rate.
Regional information needs to be considered when looking for incremental safety enhancements.
It must be noted that even in regions with a higher accident rate, many airlines exist with safety records among the best in the world.
The low accident rates in some regions illustrate that safety can be improved if we can determine the proper means of transferring lessons learned from one region or airline to another.

## Potential for Totally New Airplane Designs

- to Affect Safety is Very Small

**25000**

**20000**

**15000**

**10000**

**5000**

**0**

**2005**

**2010**

**2015**

**Number of**
**airplanes at **
**years end**

**Total Airplanes Produced**
**After 1998**

**2000**

**Out of Production Models**
**(as of 1998)**

**Retained Fleet**

**New Designs**

**1998**

**2007**

**Notes:**
Many ideas for enhancing safety focus on technology improvements to airplanes.  While such improvements are important, it should be noted that their impact will not be significant unless they can be implemented on the existing airplane fleet.
  A large portion of the airplanes that will be operating in 2007 have already been built, and most of the rest have already been designed.  
The data shows that there are significant factors outside of the airplane design itself that influence the worldwide accident rate.  
The other areas to be considered are lessons learned (or communication of knowledge and learning), regulations and regulatory oversight, flight operations and maintenance, air traffic management and infrastructure.

## All Parts of Industry Must Work Together

**Each accident may involve many issues**
**The degree of involvement varies with accident type and region of the world**
**Data analysis will be used to determine actions**

**Operator**

**Flight**
**Crew**

**Airplane**

**Air Traffic**
**Control/**
**Airport**

**Maintenance**

**Weather**

**Other**

**Notes:**
There are opportunities for preventing accidents in all segments of the air transport system.  We do not have an understanding of which segments offer the opportunities for greatest leverage.
Only by analyzing accident/incident data and applying judgment about future trends can we determine the most effective actions.
Understanding the variety of causal factors and circumstances involved in many different accidents can help determine which actions are likely to be most effective and feasible. What caused a particular accident is less important for this type of analysis than what could have prevented it.
Even if an accident type is well understood, the issues involved and prevention strategies are varied.  There are many ways to intervene to prevent accidents. 
We need to focus our resources on the prevention strategies that deliver the most safety benefit.
Our analysis plan needs to address all types of fatal and hull loss accidents.
We need to work together.
We need to understand the data.

## Safety Responsibilities Are SharedSafe Airplane + Safe Operation + Safe Infrastructure = Safe Air Travel

- Safety Responsibilities Are SharedSafe Airplane + Safe Operation + Safe Infrastructure = Safe Air Travel

- * Including Air Traffic Service providers

**Notes:**
The commercial air transportation system has achieved a high level of safety: for the 10 year period from 1988 through 1997 there were approximately 149 million departures and 213 hull loss accidents.
Aviation system safety responsibilities are shared among government, operators, and manufacturers, creating a safe aviation system in those countries and regions where there is a balance among the three elements of the system.  The actions of manufacturers, operators, and government working together in the U.S.  has resulted in 2 million safe flights for every accident. 
This excellent safety record is due to many factors:  Industry and government in some countries and regions have made large investments in regulatory oversight, airplanes, airports, navigation aids, and air traffic control equipment.  Large investments have also been made in training the people that design, operate, and maintain the airplane, and provide the air traffic control, and regulatory oversight.  These countries and regions have the lower accident rates. We need to look at how to economically implement these same improvements worldwide.
Accident history provides us with a source of information on where to focus efforts for incremental improvements in the level of safety.  Incident information is another important source of information.
The search for incremental improvements should consider all elements of the system – airplanes, operations, and government as well as the level of risk reduction provided.

## Commercial Aviation Safety Team (CAST)

**Commercial Aviation Safety Team (CAST)**

## CAST Mission

**Provide government and industry leadership to develop and focus implementation of an integrated, **_**data driven**_** strategy to improve commercial aviation safety.**

- Taken from Commercial Aviation Safety Team (CAST) Master Plan, dated 10/9/98

- 5.3-12

## CAST Vision

_**Achieve**_** the **_**highest levels**_** of safety in the domestic and international commercial aviation system **_**by**_** **_**focusing on the right things prioritized to result in the greatest improvement in commercial aviation safety**_**.**

- CAST Goal

**Reduce the commercial aviation fatal accident rate by 2007.**

- Taken from Commercial Aviation Safety Team (CAST) Master Plan, dated 10/9/98

- 5.3-13

## Working Together

*Commercial Aviation Safety Team*

**Industry**

**Commercial Aviation **
**Safety Team**
**(CAST)**

**Government**

**Boeing**
**P&W***
**RAA**
**FSF**
**IATA**

***Representing GE and RR**

**DOD**
**FAA**
**Aircraft Certification**
**Flight Standards**
**System Safety**
**Air Traffic Operations**
**Research**

**AIA**
**Airbus**
**ALPA**
**APA**
**ATA**

**NASA**
**ICAO**
**JAA**

**FAA and the aviation industry must develop a strategic plan to improve safety, with specific priorities based on objective, quantitative analysis of safety information and data.  *****NCARC recommendation dated 12/97.***

- 5.3-11

**Notes:**
JSAT
Accident/incident analyses
Problem statements
Intervention/effectiveness
JSIT
Intervention feasibility
Intervention projects/plans
Intervention implementation

## A FOCUSED AGENDA

**Carry-on Baggage**

**Child Restraint**

**Passenger Interference**

**CABIN SAFETY**

**GENERAL AVIATION**

**Loss of Control**

**Weather**

**Survivability**

**Pilot Decisionmaking**

**Approach and Landing**

**COMMERCIAL AVIATION**

**Controlled Flight**
** ****Into Terrain**

**Loss of Control**

**Turbulence**

**Uncontained **
**Engine Failures**

**Runway Incursion**

**Passenger Seat Belt Use**

**Runway Incursions**

**Notes:**
  THIS SAFETY AGENDA FOCUSES ON THREE MAJOR SAFETY AREAS  --  COMMERCIAL AVIATION, GENERAL AVIATION & CABIN SAFETY.

  THESE FOCUS AREAS WERE IDENTIFIED THROUGH A COLLABORATION WITH THE AVIATION COMMUNITY.  

  UNDERLYING ALL THESE AREAS IS A  RECOGNITION OF THE IMPORTANCE OF IMPROVED DATA AND ANALYSIS, AND HUMAN FACTORS ISSUES. 

## JSAT Organizational Relationships

## Safety Analysis Process

- NTSB Accident
- Incident Reports

- 21.3 Reports

- Airclaims data

- Historical
- Data

- Pareto Plots
- CAST

- NASDAC data

**1.**

**2.**

**Safety Analysis Process**

- Industry

- FOQA data

-   CAST

- 5.3-23

**Notes:**
A summary of the process is highlighted in this chart.  
The process relies on data at it’s foundation.  We need to access all available data sources and analyze the data into helpful information for decisionmaking.  We look forward to the ability to collect and analyze FOQA data as a potential significant  new source of data, and the eventual reality of a GAIN (Global Aviation Information Network).
We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type.  
We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry.
The feedback loop is critical to make sure we are achieving the wanted results.  Metrics will track our success at reducing the overall accident type as well as implementation of the interventions.

## Safety Analysis Process

- NTSB Accident
- Incident Reports

- 21.3 Reports

- Airclaims data

- Historical
- Data

- Pareto Plots
- CAST

- NASDAC data

- Causal Analysis

- Combined
- Threat

- Threat

- Cause

- Cause

- Cause

- Cause

- Accident

**1.**

**2.**

**3.**

**4.**

**Safety Analysis Process**

- Industry

- FOQA data

-  CAST

- JSAT

- JSAT

- Intervention Strategy

- 5.3-23

**Notes:**
A summary of the process is highlighted in this chart.  
The process relies on data at it’s foundation.  We need to access all available data sources and analyze the data into helpful information for decisionmaking.  We look forward to the ability to collect and analyze FOQA data as a potential significant  new source of data, and the eventual reality of a GAIN (Global Aviation Information Network).
We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type.  
We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry.
The feedback loop is critical to make sure we are achieving the wanted results.  Metrics will track our success at reducing the overall accident type as well as implementation of the interventions.

## Safety Analysis Process

- NTSB Accident
- Incident Reports

- 21.3 Reports

- Airclaims data

- Historical
- Data

- Pareto Plots
- CAST

- NASDAC data

- Causal Analysis

- Combined
- Threat

- Threat

- Cause

- Cause

- Cause

- Cause

- Accident

**1.**

**2.**

**3.**

**4.**

**Safety Analysis Process**

- Industry

- FOQA data

-   CAST

- JSAT

- JSAT

- Intervention Strategy

- 5.3-23

**Notes:**
A summary of the process is highlighted in this chart.  
The process relies on data at it’s foundation.  We need to access all available data sources and analyze the data into helpful information for decisionmaking.  We look forward to the ability to collect and analyze FOQA data as a potential significant  new source of data, and the eventual reality of a GAIN (Global Aviation Information Network).
We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type.  
We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry.
The feedback loop is critical to make sure we are achieving the wanted results.  Metrics will track our success at reducing the overall accident type as well as implementation of the interventions.

## CAST Process Summary

**Government & Industry Partnership**
**Integrated Focused Strategy**
**Data-Driven**
**Optimized for Safety Benefits**
**Reviews of Results to Adjust Focus**

##  JSAT Progress Status

**Select highest **
**leverage **
**areas of**
**interest**

-  JSAT Progress Status
- in the CAST Process

**CAST**

**JSAT**

**Initiate/**
**approve **
**JSAT**

***Agree on problems and interventions***

***Achieve consensus on priorities***

***Integrate into existing work and distribute***

**CAST**

**Conduct**
**JSAT**
**analysis**

**Review/approve**
**JSAT**
**report**

**CAST**

**CAST**

**Initiate/ approve**
**JSIT**

**CAST**

**JSIT**

**CAST**

**CAST**

**Data Analysis**

**Set Safety Priorities**

**Implement Safety Enhancements**

**Initial**
**project**
**selection**

**JSIT**

**JSIT**

**Adjustments as**
**necessary**

**Conduct**
**JSIT Analysis**

**ID Immediate Action(s)**

**Prepare initial**
**project proposals**

**JSIT**

**Immediate**
**Action**
**approval**

**Immediate Action**
**specific plans**

**Final Immediate**
**Action approval**

**Execute &**
**Monitor  progress**

**JSIT /**
**CAST**

**Immediate Action**
**initial approval**

*4/20/99*

**3/99**

**8/99**

**6/00**

**9/00**

## JSAT Status

- Accident Data Set Defined
- Event Sequences Developed
- Standard Problem Statements Defined
- Draft Interventions Developed
- Report to CAST 8/30/00