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By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO Air Navigation Commission Jay Pardee Director, Office of Accident Investigation and Prevention October 6, 2009 Improving Safety through Collaborative Safety Initiatives

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Page 1: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

By:

Date:

Federal AviationAdministration

Commercial Aviation Safety Team (CAST)

Aviation Safety Information Analysis Sharing (ASIAS)

Presented to ICAO Air Navigation Commission

Jay Pardee

Director, Office of Accident Investigation and Prevention

October 6, 2009

Improving Safety through Collaborative Safety Initiatives

Page 2: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Commercial Aviation Safety Team (CAST)

Overview

Commercial Aviation Safety Team (CAST)

Overview

Page 3: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

In the U.S., our focus was set by theIn the U.S., our focus was set by theWhite House Commission on Aviation Safety, and White House Commission on Aviation Safety, and The National Civil Aviation Review Commission The National Civil Aviation Review Commission

(NCARC) (NCARC)

1.1 . . . Reduce Fatal Accident Rate . . .

• . . . Strategic Plan to Improve Safety . . . • . . . Improve Safety Worldwide . . .

Page 4: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Vision - Mission - GoalsVision - Mission - GoalsVision - Mission - GoalsVision - Mission - GoalsVision 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.

Mission Enable a continuous improvement framework built on

monitoring the effectiveness of implemented actions and modifying actions to achieve the goal.

Goal Reduce the US commercial aviation fatal accident rate 80% by

2007. And Maintain a continuous reduction in fatality risk in US and

International commercial aviation beyond 2007.

Page 5: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

* Representing P&W and RR** Observer

AIAAirbusALPAAPAATAIFALPANACABoeingGE*RAAFSF

CAST brings key stakeholders to cooperatively CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agendadevelop & implement a prioritized safety agendaCAST brings key stakeholders to cooperatively CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agendadevelop & implement a prioritized safety agenda

Industry

Commercial Aviation Safety Team

(CAST)

Government

DODFAA

• Aircraft Certification• Flight Standards• System Safety• Air Traffic Operations• Research

NASAICAO**EASA (ECAST)TCCNATCA** NTSB**

IATA**AAPA** ATAC**APFA**ACI-NA**

Page 6: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

• Safety enhancement development

• Master safety plan • Enhancement

effectiveness• Future areas of

study

• Data analyses

CAST

Joint Safety Analysis Teams (JSAT)

Joint Safety Implementation

Teams (JSIT)

Joint Implementation Measurement Data

Analysis Team (JIMDAT)

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

Page 7: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Safety Plan DevelopmentSafety Plan Development

AccidentJSATS

Case studies

AccidentJSITS

Case studies

SafetyEnhancements

IncidentAnalysisProcess

JIMDATReview

EmergingRisk

ChangingRisk

DevelopEnhancements

& Metrics

AviationSystem

Changes

PresentIn MasterFactors

Yes

No

DemographicChanges

IdentifyHazards

IdentifyFactors

DevelopContributing

Factors(new or

emerging

IdentifyHazards

IdentifyFactors

MasterContributing

Factors

11-5-03 CAST-051R

FAST Hazards

CASTPlan

RecommendedPlan

Revision

PerformanceTo PlanReview

Non-PerformanceInformation

Metrics

Page 8: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO
Page 9: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Robust CAST MethodologyRobust CAST Methodology

Detailed event sequence - problem identification from worldwide accidents and incidents

Broad-based teams (45-50 specialists /team)

Over 450 problem statements (contributing factors)

Over 900 interventions proposed

Analyzed for effectiveness and synergy

Page 10: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

CAST Process Led to Integrated CAST Process Led to Integrated Strategic Safety PlanStrategic Safety Plan

CAST Process Led to Integrated CAST Process Led to Integrated Strategic Safety PlanStrategic Safety Plan

Part 121 or equivalent passenger and cargo operations studied

Current CAST plan:

72 Prioritized Safety Enhancements

50 Complete and 22 underway

Projected 74% fatality risk reduction by 2020

Industry and Government implementing plan

Page 11: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Resource Cost Vs. Risk ReductionResource Cost Vs. Risk ReductionResource Cost Vs. Risk ReductionResource Cost Vs. Risk Reduction

APPROVED PLAN

Completed + Plan (2007

Implementation Level)

Completed + Plan (2020

Implementation Level)

All JSIT Proposed Enhancements

(2020 Implementation

Level)

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Re

so

urc

e C

os

t ($

Mil

lio

ns

)

Risk Reduction

Total Cost in $ (Millions)

2007 2020

0%

25%

50%

75%

100%

Ris

k E

lim

ina

ted

by

Sa

fety

En

ha

nc

em

en

ts

Completed

$$

$$ $$ $$

$$

Page 12: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Do

llars

/Flt

. Cy

cle

Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents

100

80

60

40

20

0

Historical cost of accidents per flight cycle

74% Risk reductionSavings ~ $74/Flight Cycle

Or

~ $814 Million Dollars/Year

Cost of accident fatalities following implementation of the CAST plan @ 2020 levels

2020

Cost SavingsCost SavingsCost SavingsCost Savings

2007

Page 13: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

CAST Safety PlanCAST Safety PlanCAST Safety PlanCAST Safety Plan

51 Completed Safety Enhancements51 Completed Safety Enhancements• Safety Culture Safety Culture

• Maintenance Procedures Maintenance Procedures

• Flight Crew TrainingFlight Crew Training

• Air Traffic Controller TrainingAir Traffic Controller Training

• Uncontained Engine FailuresUncontained Engine Failures

• Terrain avoidance warning system (TAWS)Terrain avoidance warning system (TAWS)

• Standard Operating ProceduresStandard Operating Procedures

• Precision ApproachesPrecision Approaches

• Minimum Safe Altitude Warning (MSAW) SystemsMinimum Safe Altitude Warning (MSAW) Systems

• Proactive Safety Programs (FOQA + ASAP)Proactive Safety Programs (FOQA + ASAP)

Page 14: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

CAST Safety Plan (cont.)CAST Safety Plan (cont.)CAST Safety Plan (cont.)CAST Safety Plan (cont.)

21 Committed Safety Enhancements21 Committed Safety Enhancements• Policies and ProceduresPolicies and Procedures

• Aircraft Design Aircraft Design

• Flight Crew Training (additional aspects)Flight Crew Training (additional aspects)

• Runway Incursion PreventionRunway Incursion Prevention

• Precision Approaches (additional projects)Precision Approaches (additional projects)

• Icing (additional turboprop projects) Icing (additional turboprop projects)

• MidairMidair

• MaintenanceMaintenance

• Runway SafetyRunway Safety

• Safety culture, policies and proceduresSafety culture, policies and procedures

Page 15: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Fatal Accident Rate and Full Airplane Loss EquivalentsRate for Part 121 Operations (5 year moving average)

Fatal Accident Rate and Full Airplane Loss EquivalentsRate for Part 121 Operations (5 year moving average)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.019

91

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Fa

talit

y A

ccid

en

ts o

r F

ull

Lo

ss A

ccid

en

t E

qu

iva

len

ts

pe

r 1

0 M

illio

n D

ep

art

ure

s

5 year moving avg of fatal accidents per 10 million departures

82% Fatality AccidentRate Reduction1996-2007

Page 16: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

International PerspectiveInternational PerspectiveCAST Safety EnhancementsCAST Safety Enhancements

Western-built transport hull loss accidents, by airline domicile, 2001 through 2007

Accidents permillion departures

United Statesand Canada

0.4

Latin Americaand Caribbean

2.1

Europe0.7

China0.3

Middle East2.3

Africa10.0

Asia2.1

Oceania0.0

(ExcludingChina)

C.I.S.1

CAST70 SEs48 complete22 in work74% reduction

RASG-PA

ESSI35 SEs JAA11 SEs EASA62% reduction

ASET

COSCAP CIS

COSCAP NA, SA, SEA40 SEs in work60% reduction

1 Insufficient fleet experience to generate reliable rate.

World1.1

COSCAP GulfCOSCAP BAG

Page 17: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

SummarySummary

• History shows focused action and introduction of History shows focused action and introduction of new capabilities have led to accident risk new capabilities have led to accident risk reductionsreductions

• Joint industry and government teams working Joint industry and government teams working together to a common goal can further enhance the together to a common goal can further enhance the safety of our very safe aviation systemsafety of our very safe aviation system

• Full implementation will require a coordinated effort Full implementation will require a coordinated effort between industry and governmentbetween industry and government

• CAST is moving forward to meet the challengeCAST is moving forward to meet the challenge

• ASIAS (Aviation Safety Information Analysis and ASIAS (Aviation Safety Information Analysis and Sharing) initiative is under way help aviation safety Sharing) initiative is under way help aviation safety teams (CAST, IHST, GAJSC) meet the challenge teams (CAST, IHST, GAJSC) meet the challenge

Page 18: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

18Federal AviationAdministration

FAA International Forum

March 24, 2009

• A collaborative Government-Industry initiative on data sharing & analysis to proactively discover safety concerns before accidents or incidents occur, leading to timely mitigation and prevention

What is ASIAS….

Page 19: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

AAIRIRTTRAN RAN AAIRWAYS IRWAYS

AALASKA LASKA AAIRLINES IRLINES

AAMERICAN MERICAN AAIRLINESIRLINES

AAMERICANMERICAN EEAGLE AGLE

AATLANTIC TLANTIC SSOUTHEAST OUTHEAST AAIRLINESIRLINES CCHAUTAUQUAHAUTAUQUA A AIRLINESIRLINES

CCOMAIROMAIR

CCOMMUTOMMUTAAIRIR

CCOMPASS OMPASS AAIRLINES IRLINES

CCONTINENTAL ONTINENTAL AAIRLINESIRLINES

EEXPRESSXPRESSJJETET

FFRONTIERRONTIER AAIRLINESIRLINES

ASIAS AIRLINE PARTNERSASIAS AIRLINE PARTNERS

GGULFSTREAMULFSTREAM

IINTERNATIONAL NTERNATIONAL AAIRLINESIRLINES

JJETETBBLUE LUE AAIRWAYSIRWAYS

DDELTAELTA--NNORTHWEST ORTHWEST AAIRLINESIRLINES

RREPUBLIC EPUBLIC AAIRLINES IRLINES

SSHUTTLE HUTTLE AAMERICAMERICA

SSKYKYWWEST EST AAIRLINESIRLINES

SSOUTHWEST OUTHWEST AAIRLINES IRLINES

SSUN UN CCOUNTRY OUNTRY AAIRLINES IRLINES

UUNITED NITED AAIRLINESIRLINES

UUNITED NITED PPARCEL ARCEL SSERVICEERVICE

USUS AAIRWAYSIRWAYS

Page 20: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Proprietary – Not for Distribution

ASIAS Participants at Major US Airports

20

Page 21: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Proprietary – Not for DistributionASIAS Proprietary – Not for Distribution21

ASIAS ASAP Records in Production

Record counts as of 14 Sept 2009

Page 22: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Proprietary – Not for DistributionASIAS Proprietary – Not for Distribution22

ASIAS FOQA Records in Production

As of Sept 2009, over 5 Million FFD Records available to ASIAS

Page 23: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Data Sources Supporting ASIAS InfoSharing and Analysis

23

Safety Reports

• Aviation Safety Reporting System

• Runway Incursion• Surface Incident• Operational Error / Operational Deviation

• Pilot Deviation• Vehicle or Pedestrian Deviation

• National Transportation Safety Board

• Accident/Incident Data System

• Service Difficulty Reports

De-Identified FOQA Data

De-Identified ASAP Data

• Traffic Management Reroutes and Delays

• Airport Configuration and Operations

• Sector and Route Structure

• Procedures• Surveillance Data for En Route, Terminal and Airport

ATC Information

• Bureau of Transportation Statistics

• Weather / Winds• Manufacturer Data• Avionics Data• Worldwide Accident Data

Other Information

• Flight Operations

•Maintenance

• Dispatch • ATSAP

Page 24: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Document Number Here

24 FAA International Forum March 24, 2009 24Federal Aviation

Administration

ASIAS is Governed by Formal Principles

Non-punitive reportingData used solely for

advancement of safety

Airline data is de-identifiedAnalyses approved by an ASIAS Executive Board

Page 25: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Studies Completed or Underway

25

Terrain Awareness Warning

Airline Stability Metric

TCAS Resolution Advisories

AirlineBenchmarks

TCAS Resolution Advisories

Runway SafetyTerrain Awareness Warning

Unstable Approaches

Directed Studies

Approach and Landing

Controlled Flight Into Terrain

Mid-Air Collision

Icing

Cargo

Maintenance

Loss of Control

CAST Metrics:

Known Risk Monitoring

Safety Enhancement Assessment

Analysis In ProgressAnalysis

Completed

Page 26: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Analytical ProductsAnalytical Products

Terrain Awareness Warning System (TAWS)Traffic Collision Advisory System (TCAS)Wrong Runway Departures (WR)Metrics

Page 27: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Data Fusion Provides Valuable Insights

Terrain Source: National Elevation Data

WeatherSource: FAA & NOAA

Traffic TracksSource: FAA National Offload

Program

Minimum Vectoring Altitudes

Source: Air Traffic Control

Airport & Airspace Procedures

Source: Air Traffic Control

Safety Event FocusSource: Digital Flight Data,

Safety Reports

Page 28: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Bay Area Traffic Flows – SE Plan

Page 29: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

2929

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.

Page 30: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Page 31: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

3131

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 OAK– Multiple airports identified in the TAWS study have implemented,

or are developing, visual and/or instrument flight procedures• ABQ:

– RWY 26 RVFP in place– RWY 26 RNP waiting for completion of sight survey

• LAS:– RWY 19 RVFP (USAirways & NetJets)

• SAN:– RWY 27 RNP SAR having issues with survey & environmental

• Guam:– Continental talking about RVFP (no formal application)

Page 32: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

OAK Traffic – RNAV Capable

Aircraft RNAV equipped per AC 90-100A DME/DME/IRU and/or GPS sensor input

Page 33: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

33

Proposed: RNAV VISUAL Approach to OAK RWY 11

Page 34: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

3434

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 initiative

Page 35: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

35

EGPWS Mode-2 Pull Ups – Pre 218

Page 36: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

36

EGPWS Mode-2 Pull Ups w/218 or Higher(about 20X Less Frequent)

Page 37: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

37

Analytical ProductsAnalytical Products

Terrain Awareness Warning System (TAWS)Traffic Collision Advisory System (TCAS)Wrong Runway Departures (WR)Metrics

Page 38: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Proprietary – Not for DistributionASIAS Proprietary – Not for Distribution

Data Sources and Analysis

FOQA Assess NAS-wide and airport-specific TCAS RA landscape. Provide Trend Information. Investigate pilot response to advisories.

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.)

TOPA Mode-S downlink provides information similar to FOQA, and is enhanced with surveillance radar data.

Text Reports Help get the story behind the numbers at selected airports.

38

(National Offload Program radar surveillance data)

(TCAS Operational Performance Assessment)

(ASAP, ASRS, OE)

Page 39: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

39

ASIAS Directed Study on TCAS RAs: Location from FOQA Data

39

Over a three-year period, Southern California, Northern California, and Denver accumulated the greatest concentrations of TCAS RA events. *

Page 40: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Proprietary – Not for DistributionASIAS Proprietary – Not for Distribution

Common Themes Observed at Study Airports: VFR and IFR Traffic Interaction

GA aircraft under tower control interacting with structured* IFR traffic at a nearby airport

Example: 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 enforcement

Structured VFR flow near structured IFR traffic Example: VFR helicopter route crossing under EWR arrivalsExample: GA traffic crossing under JFK arrivals

*Arrival /departure route or an approach

40

500-ft separation is maintained in most cases, but it is not sufficient to prevent TCAS RAs

Page 41: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

ASIAS Proprietary – Not for DistributionASIAS Proprietary – Not for Distribution

Common Themes Observed at Study Airports: IFR Traffic Interacting with Other IFR Traffic

Visual approaches to parallel runways– Close spacingExample: SFO 28R/L with 750’ centerline spacing– High altitude with increased TCAS sensitivity

Example: DEN 16R/L with 2500’ centerline spacing Arrival / departure interaction triggered by closure rate

Example: TEB west departures with EWR 22 arrivalsExample: DEN west departures with arrivals on both north and south flows

41

These procedures are in accordance with 7110.65, but they do not provide sufficient separation to

prevent TCAS RAs

Page 42: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

42

Analytical ProductsAnalytical Products

Terrain Awareness Warning System (TAWS)Traffic Collision Advisory System (TCAS)Metrics Wrong Runway Departures (WR)

Page 43: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Click to edit Master title style

ASIAS Proprietary – Not for Distribution

Mapping Problem Statements to FOQA Metrics

43

Unique FOQA Data used to Assess PSsUnstable Approach (HAT Method)Go-AroundBelow Desired Glide Path on ApproachVFE (Flap Airspeed Limit) ExceedenceFast Approach (CAS -VREF)Airspeed Low Relative to Stall SpeedRisk of Tail Strike during LandingSlow Approach (CAS-VREF)Low Power on ApproachAbove Desired Glide Path on ApproachHard Landing (Vertical Speed Method)Final Flap Position not Valid for LandingLate Final Flap ExtensionGPWS: Too Low GearLate Gear ExtensionLow-Level WindshearHigh Rate of Descent for this HeightHigh Rate of Descent on Final ApproachNot Aligned with Runway (Localizer Deviation)GPWS: Too Low FlapGPWS: Too Low TerrainGround Spoilers Armed LateGPWS: Sink Rate (Pull Up)GPWS: Terrain (Pull Up)GPWS: Glide SlopeNot currently measurable in FOQA

Accident Category Unique Problem Statements (PS)48. Lack of stabil ized approach criteria, mandatory go-around policy

19. Lack of basic piloting performance

44. Flightcrew failure to correct unstabil ized approach

47. Flightcrew failure to maintain system status awareness

42. Flightcrew failure to address combination of critical factors

22. Pilot Not Flying (PNF) failed to perform duties

45. Flightcrew failure to recognize impact of degraded systems

14. Equipment/Warning system failure

21. Flightcrew disregard of or failure to recognize cues to terminate current course of action or maneuver

11. Failure of flightcrew to correctly identify aircraft height

12. Failure of flightcrew to correctly identify aircraft position over the ground

34. Failure of captain to exercise command authority

10. Failure of flightcrew to follow established procedures (SOPs)

17. Failure of the airl ine/operator to provide standard operating procedures (SOPs)

23. Flightcrew intentional disregard of and failure to respond to flight deck warnings

Approach & Landing Accident Reduction

(ALAR)

Controlled Flight Into Terrain (CFIT)

Approach & Landing Accident Reduction

(ALAR); and Controlled Flight Into

Terrain (CFIT)

Page 44: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Click to edit Master title style

ASIAS Proprietary – Not for Distribution

1

1

Unstable approaches are measured using the Height Above Touchdown (HAT) method, which captures the HAT on the

first approach when the aircraft is 100% stable

Accident Spotlight

Air Carrier: Cayman Airways Aircraft Type: B737-300 Location: 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 angle

1

1. Stable on Glideslope2. Stable on Localizer3. Stable [CAS-Vapp]4. Stable [CAS-Vref]5. Stable Ground Speed6. Stable Rate of Descent (ROD)7. Stable Thrust

8. Landing Flaps Set9. Gear Down10. Stable in Pitch11. Stable in Roll12. Stable in Yaw13. Ground Spoilers Armed14. Speed Brakes Retracted

Metric Category

Level

Metric Category

Level

Safety Enhancement

Level

Safety Enhancement

Level

Problem Statement

Level

Problem Statement

Level

MetricLevel

MetricLevel

Example Metrics for Approach and Landing Accident Risks

44

Page 45: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Click to edit Master title style

ASIAS Proprietary – Not for Distribution

0

10

20

30

40

50

60

70

80

90

0 ≤ HAT < 500 500 ≤ HAT < 1000 HAT ≥ 1000

Perc

ent o

f Tot

al F

light

s

Height Above Touchdown (ft)

Percent of Unstable Approaches by HAT & Last Event Type

Gear

Flaps

Thrust

ROD

Ground Speed

CAS-Vref

CAS-Vapp

Localizer

Glideslope

83.1%

15.8%

1.1%

Initial Results: Unstable Approach Metric

45

Page 46: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Click to edit Master title style

ASIAS Proprietary – Not for Distribution

Initial Results: Unstable Approach Metric

0

20

40

60

80

100

120

140

160

1st Qtr (2006)

2nd Qtr (2006)

3rd Qtr (2006)

4th Qtr (2006)

1st Qtr (2007)

2nd Qtr (2007)

3rd Qtr (2007)

4th Qtr (2007)

1st Qtr (2008)

2nd Qtr (2008)

3rd Qtr (2008)

4th Qtr (2008)

1st Qtr (2009)

2nd Qtr (2009)

3rd Qtr (2009)

Even

ts p

er 1

0,00

0 Fl

ight

s

Unstable Approach (HAT Method) Events - Below 500 Feet HAT

No Go Around Go Around

46

Page 47: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

Analytical Analytical ProductsProductsAnalytical Analytical ProductsProducts

Terrain Awareness Warning System (TAWS)Traffic Collision Advisory System (TCAS)Metrics Wrong Runway Departures (WR)

Page 48: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

48

Lexington Blue Grass (LEX) 2006

• Aircraft was cleared for departure on Runway 22 but departed on Runway 26– Comair flight 5191 crashed

approximately ½ mile from the end of runway 26

• Similar non-fatal events have occurred prior to this event– Cleared for 22 but lined up on 26 (1993)

– Poor visual cues and lighting also cited in other taxing related events by air crews

• Similar non-fatal events have occurred after this event

Page 49: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

49

Findings – Part 121 OperationsWrong Runway Departures By Data Source

NOTE: ASRS database with certain exceptions captures ~ 18% of reports received by NASA on monthly basis0

10

20

30

40

50

60

70

80

90

ASRS

PDS

NTSB (I)

AIDS (I)

PTRS

NTSB (A)

84

32

1

Page 50: By: Date: Federal Aviation Administration Commercial Aviation Safety Team (CAST) Aviation Safety Information Analysis Sharing (ASIAS) Presented to ICAO

50

Findings – Part 121 Operations

Air Carrier Reported Wrong Runway Events (1981-2006)

Cleveland

Houston

Salt Lake CityMiami

ChicagoLexington

NOTE: ASRS database captures only 18% of all reports received by NASA on monthly basis0

5

10

15

20

25

30

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Part 121 Contributing Factors

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JIMDAT Mitigation Assessment

Risk Eliminated

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0

1

2

3

4

5

6

Findings – Part 135 OperationsWrong Runway Events (1981-2006)

NOTE: ASRS database with certain exceptions captures ~ 18% of reports received by NASA on monthly basis

Cleveland

Houston

Los Angeles

RichmondSyracuse Anchorage

PART 121

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Part 139 (Class 1) Airport Review

355 Airports

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International CollaborationInternational Collaboration

• Sharing of CAST safety products worldwide – Sharing of CAST safety products worldwide – COSCAP, GASR, etcCOSCAP, GASR, etc

• CAST ICAO Common TaxonomyCAST ICAO Common Taxonomy• ECCAIRs – common taxonomy, developing data ECCAIRs – common taxonomy, developing data

sharing proposalssharing proposals• TCAS RA mitigation study – including TCAS RA mitigation study – including

EurocontrolEurocontrol• Desire increased connectivity with ICAO ISDCAS Desire increased connectivity with ICAO ISDCAS

(Integrated Safety Data Collection and Analysis (Integrated Safety Data Collection and Analysis System) System)

• IATA GSIC – Evaluating sharing top level safety IATA GSIC – Evaluating sharing top level safety hazardshazards

• Partnered with E-CASTPartnered with E-CAST

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http://www.cast-safety.org/http://www.cast-safety.org/http://www.cast-safety.org/http://www.cast-safety.org/

QUESTIONS?