commercial aviation safety team (cast) process overview commercial aviation safety team (cast)...

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

Process OverviewProcess Overview

In the U.S., our focus is set by theIn the U.S., our focus is set by theWhite House Commission on Aviation White House Commission on Aviation

SafetySafety

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 The National Civil Aviation Review Commission (NCARC) Commission (NCARC)

on Aviation Safety Provided Additional Directionon 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

In ResponseIn Response Ongoing Industry and FAA Safer

Skies Initiatives were Combined into CAST

Data-Driven, Consensus-Based, Integrated Strategic Safety Plan Developed

In place and fully supported by Government and Industry with Worldwide Recognition - “CAST”

We Need to Continuously ImproveWe Need to Continuously ImproveAviation SafetyAviation Safety

1965 1975 1985 1995 2005 2015

Year

50

45

40

35

30

25

20

15

10

5

0

Hull loss accident rate


1965 1975 1985 1995 2005 2015

Year

50

45

40

35

30

25

20

15

10

5

0


Millions of departures

Airplanes in service28,550

2019

12,595

1997

Boeing 11,300


1965 1975 1985 1995 2005 2015

Year

50

45

40

35

30

25

20

15

10

5

0

Hull loss accidentsper year


Airplanes in service28,550

2019

Millions of departures

Business as usual

Our goal

15,800

2000

Boeing 11,300

1997

12,595

Regional PerspectiveRegional PerspectiveAccident Rates Vary by Region of the WorldAccident Rates Vary by Region of the World

Regional PerspectiveRegional PerspectiveAccident Rates Vary by Region of the WorldAccident Rates Vary by Region of the World

Western-built transport hull loss accidents, by airline domicile, 1992 through 2001

Accidents permillion departures

1Insufficient fleet experience to generate reliable rate.

United Statesand Canada

0.4

Latin Americaand Caribbean

3.1

Europe0.9

China1.1

Middle East3.4

Africa12.4

Asia2.6

World1.3

Oceania0.0

(ExcludingChina)

JAA - 0.7Non JAA – 3.0

C.I.S.1

3/19/02 REG-053a

Safety Responsibilities Are Shared

Air Safety

Manufacturers Government

Operators

Safe Airplane + Safe Operation + Safe Infrastructure = Safe Air Travel

NTSB AccidentIncident Reports

21.3 Reports

Airclaims data

Turbofans Installed on part 25 Aircraft

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5.3-23


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3.4.


Industry

FOQA data

JSAT

JSAT JSAT

Intervention Strategy

5.3-23

Approve TrainingProposal

5 8.25d

1/2/96 1/12/96

Select Accident/IncidentSets

1 15d

10/30/95 11/17/95

Review Accident/IncidentReports

2 5d

10/30/95 11/3/95

Analyze Accident/IncidentReports

3 5d

11/6/95 11/10/95

Develop PrioritizedIntervention Strategies

7 2h

1/10/96 1/10/96

Prepare Draft Report

6 3d

1/2/96 1/4/96

Revise Report

4 5d

11/13/95 11/17/95

Prepare FinalReport

8 1h

1/11/96 1/11/96

Approve FinalReport

9 1h

1/11/96 1/11/96

Select InterventionStrategies

10 1d

1/11/96 1/12/96


21.3 Reports

Airclaims data

Implementation Strategy JSIT


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FOQA data

JSAT

JSAT JSAT


6.7.

Coordinated Plan

Measuring Progress to Goal

Industry

Government

SaferSkies

AvSP

5.3-23

Historical Part 121 Fatality Risk (1987-2000)

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Excluding all security events

HUMAN FACTORSIN OPERATIONS &

MAINTENANCE

Carry-on Baggage

Child Restraint

Passenger Interference

CABIN SAFETY

IMPROVED DATA & ANALYSIS

GENERAL AVIATION

Loss of Control

Weather

Survivability

Aeronautical Decisionmaking

Controlled Flight

Into Terrain Approach and Landing

COMMERCIAL AVIATION

Controlled Flight Into Terrain

Loss of Control

Weather

Uncontained Engine Failures

Runway IncursionPassenger Seat Belt Use

Runway Incursions

Safer SkiesSafer Skies

Turbulence

Industry

Commercial Aviation Commercial Aviation Safety TeamSafety Team

(CAST)(CAST)

Government

*Representing GE and RR

DODFAA

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

NASAICAOJAATCCNATCA

AIAAirbusALPAAPAATANACABoeingP&W*RAAFSFIATAAAPAATACAPFA

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

CAST GoalsCAST Goals

Reduce the U.S. commercial aviation fatal accident rate by 80% by 2007

Work together with airlines, JAA, ICAO, IATA, FSF, IFALPA, other international organizations and appropriate regulatory/ government authorities to reduce worldwide commercial aviation fatal accident rate

• Safety enhancement development

• Master safety plan • Enhancement

effectiveness• Future areas of study

CASTCAST• Data analysis

Joint Safety Joint Safety Analysis Teams (JSAT)Analysis Teams (JSAT)

Joint Safety Joint Safety Implementation Implementation

Teams (JSIT)Teams (JSIT)

Joint Implementation Joint Implementation Measurement Data Measurement Data

Analysis Team (JIMDAT)Analysis Team (JIMDAT)


CASTCASTA Three-Stage ProcessA Three-Stage Process

Influence Safety Enhancements -

Worldwide

DataAnalysis

Set SafetyPriorities

Achieve consensus on

priorities Integrate into existing work and distribute

Implement Safety Enhancements -

U.S.

Agree onproblems and interventions

Joint Safety Analysis Joint Safety Analysis Team (JSAT)Team (JSAT)

ProcessProcess

Typical JSAT Membership Typical JSAT Membership

ALPA/APA FAA (AIR, AFS, ASY,

AAI) Airbus JAA ATA Transport Canada

NASA Engine companies –

(PW, GE, RR-Allison) Boeing RAA Air Traffic Services NATCA

5.5-24

JSAT Process

CharterDevelopment

EstablishTeam

SelectData Set

ReviewData

IdentifyInterventionStrategies

AssignStandardProblem

Statements

Record Characteristics/

Indicators

DevelopEvent

Sequence

EvaluateIntervention

Effectiveness

PrioritizeInterventions

Technical Review &

ReportResults

IdentifyProblems

(what/why)

GlobalReview of

Characteristics/Indicators

EvaluateProblem Importance

Developed Event SequenceDeveloped Event Sequence

• Facts and data– pilot - controller voice events– missed calls– events that occurred or should have

• Time coded each event# Time Event

1015 21:53:28 ATC issued ATIS information Sierra: Ceiling100’ overcast, 1/2 mile visibility and fog

1016 21:53:28 F/O call 200’ above minimums1017 21:53:32 F/O calls ATC to report Marker Inbound1018 21:53:33 F/O call out 100’ above minimums1019 F/O fails to call out “runway not in sight” at the

minimums for the Decision Height

Develop Problem StatementsDevelop Problem Statements• Problem statements

– What went wrong– Deficiency definition– Potential reason– Something which happened or didn’t happen

# Time Event/Data PointProblem (What)

Contributing Factors (Why)

1

8:53:00 Aircraft took off from Taipei Intl Airport

210:45:00 F/O briefed CAPT

on approach into

3

10:49:00 Capt gave very basic guidance to the F/O on aircraft control during approach and landing.

F/O was inexperienced; his actions were not commensurate with 1034 hours in type.

It is not normal practice at China Airlines for Capt and F/O to rotate takeoffs and landings. The FO is required to fly aircraft "in t/o and landing phases at least 3 times every 3 months" (3-28) (airline culture)

Sample Standard Problem StatementsSample Standard Problem Statements

10 FLIGHTCREW – Failure of flight crew to follow established procedures (SOP)

39 AIRCRAFT EQUIPMENT – DESIGN NOT ERROR TOLERANT System design does not provide adequate redundancy to counteract errors or alerting of the effects of errors.

44 FLIGHTCREW – Flight crew failure to recognize and correct unstable approach.

100 REGULATORS – INSUFFICIENT AIR CARRIER OVERSIGHT . Insufficient regulatory oversight of air carrier operations

including management and training practices.

Scoring - Problem ImportanceScoring - Problem Importance

POWER – P1– Importance of the problem or contributing

factor in the cause of the accident

FUTURE GLOBAL APPLICABILITY

– Frequency of the problem or contributing factor (to this accident type) in future operations on a worldwide basis

RATING SCALES – Problem Statements

POWER – P1

This scale is to be used to judge the importance of a specific specific problem or contributing factor in the cause of the accident.

Little Importance

Slightly important

Moderately important

Quite important

Highly important

No importance

Completely important

0 1 2 3 4 5 6

FUTURE GLOBAL APPLICABILITY

This scale is to be used to estimate the frequency of the problem or contributing factor in future operations on a worldwide basis (for example: how often the situation occurs in accident scenarios; its impact is on present and future operations (equippage, traffic, regulatory differences); and whether it is applicable across airlines/airplanes/regions.

Hardly any applicable

Slightly applicable

Moderately applicable

Quite applicable

Highly applicable

0 1 2 3 4 5 6

Not at all applicable

Completely applicable

Identify Intervention StrategiesIdentify Intervention Strategies

• Intervention strategies– Suggested solutions– Things to do to prevent or mitigate the problem– Etc.# Time Event/Data Point

Problem (What)

Contributing Factors (Why)

Standard Problem Statement

P1 A

1

8:53:00 Aircraft took off from Taipei Intl Airport

210:45:00 F/O briefed CAPT

on approach into

3

10:49:00 Capt gave very basic guidance to the F/O on aircraft control during approach and landing.

F/O was inexperienced; his actions were not commensurate with 1034 hours in type.

It is not normal practice at China Airlines for Capt and F/O to rotate takeoffs and landings. The FO is required to fly aircraft "in t/o and landing phases at least 3 times every 3 months" (3-28) (airline culture)

20 AIRLINE OPERATIONS - LACK OF TRAINING (FLIGHTCREW)

3 5

414 Airline operations – training failed to adequately develop FIRST OFFICER piloting skills. (SPS-20)

4 3

Scoring - Intervention Scoring - Intervention EffectivenessEffectiveness

POWER – P2– Ability of the intervention to mitigate the

problem or contributing factor (in a “Perfect World”)

CONFIDENCE – Confidence that the intervention will have the

desired effect

RATING SCALES – Interventions

POWER – P2

This scale is to be used to judge the effectiveness of a specific intervention in reducing the likelihood that a specific accident would have occurred had the intervention been in place and operating as intended. (“perfect world”)

Hardly any effect

Slightly effective

Moderately effective

Quite effective

Highly effective

Not at all effective

Completely effective

0 1 2 3 4 5 6

This scale is to be used to define the level of confidence that you have that this specific intervention will have the desired effect.

Hardly any confidence

Slightly confident

Moderately confident

Quite confident

Highly confident

0 1 2 3 4 5 6

Not at all confident

Completely confident

CONFIDENCE

JSAT ReportsJSAT Reports

Standard Problem Statements Interventions PrioritizedRecommendations

JSIT Feasibility ScalesJSIT Feasibility Scales

Technical Financial Operational Schedule Regulatory Sociological

JSIT Safety EnhancementsJSIT Safety Enhancements

Develop Safety Enhancements from Interventions

Collect detailed resource informationPrepare Detailed Implementation

Plans (DIP’s)


Analysis Team Analysis Team (JIMDAT)(JIMDAT)

ProcessProcess

Developed a Prioritization Developed a Prioritization Methodology (JIMDAT)Methodology (JIMDAT)

Identified the most effective solutions derived from all accident categories

Considered effectiveness vs. resources Tested solutions against all fatal and hull loss

accidents, U.S. domestic Part 121 Operations, 1987-2001

Created draft Master strategic safety plan Identified areas for future study/mitigation

JIMDAT ProcessJIMDAT Process

Provides consistent estimates of the accident prevention potential of safety enhancements

– Accounts for the benefit of a single intervention or a combined group of interventions

– Addresses overlap with other interventions/technologies

– Preserves analysis criteria and results

Using JIMDAT for CAST Plan Using JIMDAT for CAST Plan DevelopmentDevelopment

Risk reduction is primary measure

Identified effectiveness and associated resource requirements for each enhancement

Used for initial differentiation (2007 and 2020)

Integrated Strategic Safety PlanIntegrated Strategic Safety Plan

• Contains 46 safety enhancements optimized to include those actions with the best effectiveness vs. resource relationships

• 22 complete/24 committed and underway• Initially combines short-term “liveware”-based

enhancements with transition to design change enhancements long term

• Projected 73% risk reduction by 2007• Foundation for U.S.-driven continuous

improvements in worldwide aviation safety

Sharpening Our FocusSharpening Our Focus

All safety enhancements are valuableSome safety enhancements are more

effective than others across the various accident categories

Implementation reality demands better prioritization

Output Evaluation Spreadsheet ExampleOutput Evaluation Spreadsheet Example

1

23

45

6

789

101112131415161718192021

22232425262728293031

32333435363738394041

H I J K L M AE AF AG AH AI AJ AK1 2 3 4 5

Revised Date Airline Location Aircraft Accident Description Portion Safety Enhancement NameSafety Enhancement NameSafety Enhancement NameClass Type of 1. CFIT TAWS- one project2. CFIT SOPs – one project3. CFIT PAI-Vertical angles (PAI 1-7, 11)4. CFIT PAI-VGSI at runway ends (PAI 8)5. CFIT PAI-DME at airports (PAI 2)Def Accident Portion of World Fleet with Safety Enhancement Implemented by (2007)

8/9/01 Eliminated 1.000 .800 1.000 .200 .000JIMDAT Safety Enhancement Effectiveness (%/100)

1 CFIT 951220 American Cali B757 CFIT at 9000; peak at 9190. Night VOR/DME approach from MIA; 2 hrs late. PIC concerned to get cabin crew on ground to meet AAL rules on cabin crew rest (for next day return flight). Cali in long no-so valley; high terrain west & east. Cleared to Cali VOR; readback "cleared direct," entered "direct;" way points go off display. Later cleared to interim Tulua VOR; unsure of location. Fumble with charts & Tulua ID -- already past Tulua. Aircraft began turning back to Tulua; PIC overrode. Then ATC offers direct approach from north (was 01; now 19). Rushed to get down. Put in single-letter ID for ROSO, but Colombia has 2 navaids with single-letter "R." Per ICAO, software defaults to "R" with more traffic (well north at Romeo VOR--Bogota); had to punch in all 4 let ters for ROSO. Again A/C began turning back. Crew very confused. FO (driving): "where are we?" PIC says go So/SoE -- east of valley, 13 miles off course & below terrain. Now more confused; reading DME to ROMEO, not ROSO. Step down early, configured to land.997 .850 .350 .000 .000 .000

2 CFIT 890208 Independent Air Azores B707 Day CFIT at 1800 MSL on descent to refuel enroute Italy-Dominancan Rep; chartered by Italian travel agent. VFR but Mt. Pico Alto covered in cloud. Reported passing thru FL200 on way to 4000. Cleared to 3000. Communication stepped on; FO readback "cleared 2 ,000." Controller missed error due partly to FO's "poor communications technique." S.O. commented "3000" but made no more effort to query FO's response & awareness. Crew then failed to do approach brief & skipped several SOPs. FA was in cockpit for some ti ome time during all this; crew & FA in small talk & chatter. Found "lack of professionalism" & "remarkable lack of clear-sightedness & attention." Approaching 2000, GPWS warning for 7 seconds; crew made no comment on this (CVR) & made no effort to re.933 .850 .350 .000 .000 .0003 CFIT 891028 Aloha Island Air Malawi Bay DHC-6 CFIT; nav error; hit rising terrain; thought he was going north of it.928 .850 .000 .000 .000 .0004 CFIT 931201 NoWest Air Link Hibbing BAe-31 CFIT. Hit trees & crashed into low hill on night ILS backcourse approach 3.25 miles short. No distress call & no sign of problems. Cloud base at 350; freezing drizzle; 1 mile vis. PIC's record "raised questions about his airmanship & behavior" in crew coor behavior" in crew coordination (intimidated FOs); carrier took no action. PIC purposely delayed start of descent, then needed fast descent rate to reach FAF & MDH. PIC actions distracted crew; lost altitude awareness; went thru mandat.964 .550 .350 .000 .000 .0005 CFIT 880119 Trans Colorado Bayfield, Co SA-227 FO went below MDA; hit terrain at 7180 MSL on VOR/DME approach; 15 knot tailwind throughout. High rate of descent & unstable approach. PIC used cocaine before flight; affected ability to monitor approach. Both pilots had several serious driving violations ach; 15 knot tailwind throughout. High rate of descent & un.976 .850 .350 .000 .000 .0006 CFIT 920103 Cumutair/USAir X Gabriels, NY BE1900 CFIT. Cleared to intersection 17 miles out, but never stabilized on either LOC or glideslope; crossed LOC several times & above & below glideslope several times. Then into rapid descent (1200-2000 FPM 2 miles outside OM with full flaps, spoilers, etc. Hit e & below glideslope several times. Then into rapid descent (1200-2000 FPM 2 miles outside OM with full flaps, spoilers, etc. .989 .850 .350 .000 .000 .0007 CFIT 890219 Flying Tiger Malaysia B747 CFIT into steep terrain on non-precision approach .970 .850 .350 .000 .000 .0008 CFIT 870413 Buffalo KCI B707 CFIT into ground 3 miles short on ILS final to 01 in night fog & 0.5-mile vis. Vectored to intercept ILS at 2400 MSL & cleared for approach. Reported at OM but already descended to 1700. FO called out altitudes in 100-foot increments down to DH (1211), but ements down to DH (1211), but never mentioned being low at OM or that runway was not in sight at DH (it was not). Controller warned crew they were low & advised immediate climb to 2,400. No response (had some time). Hit shortly.890 .350 .000 .000 .000 .0009 CFIT 920608 GP Express Ft McClellan Al BE99 CFIT. GP had just begun flying in So Eastern US (well established in upper Midwest). First flight for either pilot in this region & first flight together. Daylight, but fog & cloud cover. Got disoriented around Anniston. Got clearance for ILS approach, the ton. Got clearance for ILS approach, then flew north instead of south (thought they were south of airport). Mistakenly picked up backcourse approach & descended too early & at high speed. Were flying away from ILS in.925 .850 .350 .000 .000 .35010 LOC GND 890920 USAir LGA B737 Bad wx in East; crew from pool with limited experience in their roles in 737. Rudder improperly trimmed on t/o; FO had t/o; PIC took over to abort; couldnt stop; into Bay. Crew pairing & communication before t/o & in emergency.889 .000 .550 .000 .000 .00011 LOC GND 990601 American Little Rock MD-80 Landed hot in severe windshear & t-storm. Got wx all the way on downwind & base leg. Wind then reported gusting to 48 knots; kept coming. CVR shows crew noting they would touchdown just as front crossed runway—they were right! Wind then gusting to 78 & sh eg. Wind then reported gusting to 48 knots; kept coming. CVR shows crew noting th.508 .000 .000 .000 .000 .00012 LOC GND 950428 Millon Guatemala DC-8 Cargo charter for Lineas Aereas Mayas; Landed long & hot in IMC wet runway 19--5400' remaining at 135 knots & flaps at 50 degrees; skid marks last 1800. Guatemala City infamous for hydroplaning. Overran, hit approach lights, thru fence, down 50-foot inclin long & hot in IMC wet runway 19--5400' remaini.904 .000 .350 .350 .350 .35013 LOC TO 870816 Northwest Romulus DC-9 Crashed on t/o. Not configured properly (no flaps & slats). Rotated & plowed into nearby highway. One onboard survivor..523 .000 .350 .000 .000 .00014 LOC TO 961022 Millon Air Ecuador B707 At or above max gross weight & #2 engine not performing properly before t/o roll. On lift-off, as gear raised, uncontained failure in #3; debris damaged #4. Crashed into affluent neighborhood several miles from airport. Low-time PIC (owner's son-in-law)..080 .000 .000 .000 .000 .00015 LOC TO 871115 Continental DEN DC-9 Sat on runway 27 minutes after deicing in snow; t/o seemed normal, but over rotated; rolled right & crashed; failed to de-ice & rapid rotation in ice contamination.499 .000 .000 .000 .000 .00016 LOC TO 920322 USAir LGA FK-28 Freezing rain/snow. Crashed & burned on t/o. De-iced twice; pushback 35 minutes after second de-ice, exceeded Type-1 fluid holdover limit of 11 minutes. FO called VR 11 knots early & PIC rotated 5 knots early. Stalled, slid into river; part submerged. USAi USAir had no "specific exterior inspection for ice contamination of F-28" in freezing precip, despite history of F-28 & wing icing. FAA a causal factors for inadequate icing standards on F-28 hard wing. Led to new icing standards on hard wings (F28/DC-.817 .000 .350 .000 .000 .00017 LOC TO 900505 Aerial Transit Guatemala DC-6 On t/o, reported engine problems & tried to return; crashed into residential neighborhood (shanty town below end of runway.000 .000 .000 .000 .000 .00018 LOC TO 880831 Delta DFW B727 Flaps & slats not configured for t/o. Rotated & as gear came up, "began to roll violently," struck ILS at end of 18L, & came to rest 3200 feet pasr runway end, broke into 3 sections in field & pond; 1 section consumed by post-crash fire.782 .000 .000 .000 .000 .00019 LOC TO 880219 AvAir-AmEagle Cary, NC SA-227 45 degree descending turn into reservoir after night t/o in low ceiling. Trimmed for level flight; stall warning light on, but stall warning switch off. F/O flying; PIC had complained about feeling ill. PIC had history of poor performance. NTSB cited compa voir after night t/o in low ceiling..893 .000 .350 .000 .000 .00020 LOC TO 970807 Fine Air MIA DC-8 Stall on t/o; out of C/G. Aircraft changed out; required new loading plan. Security did not get documentation about new A/C; required loaders to follow original load plan. Ran into trouble so loaders didn't even follow that plan. Rotated & went "extreme no an. Security did not get documentation about new A/C; required loaders .719 .000 .550 .000 .000 .00021 LOC TO 20000216 Emery Rancho Cordova, Ca DC-8-71 Arrived late; 58-minute turn-around in SAC. T/O 22L & rotated at mid-runway. Banked left after liftoff & remained very low. Began to porpoise & crashed in auto junk yard. Post-crash fireball fed by fuel in cars.Cargo loading?.953 .000 .000 .000 .000 .00022 LOC TO 950627 Salair Dominican R CV-440 Reported "problems" on t/o; into ocean .000 .000 .000 .000 .000 .00023 LOC TO 910217 Emery CLE DC-9 Landed after 40 minutes in icing, then sat in snow for 35-minute turn at CLE; never inspected for ice. Stalled on t/o; crashed & burned. Neither pilot trained in wing contamination. FAA a causal factor as it was "aware for several years of this DC-9 (& 10) for ice. Stalled on t/o; crashed & burned. Neither pilot trained in wing contamination. FAA .780 .000 .000 .000 .000 .00024 LOC TO 890318 Evergreen Saginaw, Tex DC-9 Cargo door not properly closed for t/o; tried to return but lost control & crashed..959 .000 .000 .000 .000 .00025 LOC Flt 20000131 Alaska Point Mugu, Ca MD-83 At 1620, enroute Puerto Vallarta-SFO. Runaway elevator at altitude; jackscrew. Enroute Puerto-Vallarta-SFO. Had trouble up the Mexican coast but tried to get to SFO (ALA base). Passed LAX then tried to return; lost control; hit inverted. Destroyed. All 5 .948 .000 .000 .000 .000 .00026 LOC Flt 941031 Simmons-AmEg Roselawn ATR-42 Icing in 45-minute hold pattern for ORD. Ice built-up behind boots; lost control on descent. Controversial case with French over pilot behavior & performance (NTSB laid it on aircraft & Italian/French failure to advise of similar accident in 1983 in Italy) c.999 .000 .350 .000 .000 .00027 LOC Flt 970109 Comair NW A Lnk Monroe, Mi EMB-120 Vector for approach to DTW from CVG. Other pilots reported icing. On descent slowed to 145 to turn; banked 30 degrees; into icing stall. Certification had put icing stall speed at 150. Later, but before accident, Embraer issued letter advising 160, but did grees; into icing stall. Certification had put icing stall speed at 150. Later, but before accident, Embraer iss1.000 .000 .350 .000 .000 .00028 LOC Flt 910405 Atlantic So East Brunswick, Ga EMB-120 Left prop below flight idle; uncorrectable; quill spleen.958 .000 .000 .000 .000 .00029 LOC Flt 910911 Britt/Cont Exp Eagle Lake, Tx EMB-120 Maintenance left out 46 screws on stabilizer .940 .000 .000 .000 .000 .00030 LOC Flt 950821 Atlantic So East Carrolton, Ga EMB-120 Enroute 45 minutes out ATL-Gulfport; 1 blade of Ham Standard prop broke off. Emergency vector to West Ga Regional, but into field 5 miles short; destroyed by impact & post-crash fire. Led to emergency AD to inspect Ham Standard props. .850 .000 .000 .000 .000 .00031 LOC ALA 940908 USAir PIT B737 Lost control on approach; rudder hardover? .875 .000 .000 .000 .000 .00032 LOC ALA 940702 USAir Charlotte DC-9 F/O on full ILS final. Heavy rain & low vis. Descended thru 200 AGL 0.6 miles out & tried go-around. Retracted flaps from 40 to 15 & into right turn to avoid wx over runway. Climbed to 350 AGL, then "severe sink rate." Went max power, but continued sink; h it power lines & trees 0.5 miles out & 0.2 miles right in 5-d right bank & 5-d nose-up. Broke up & caught fire. Daylight, but heavy t-storm & gusts. ATC gave windshear alert on approach from LLWAS 2000 feet from runway, but pilot may not have heard. NASA s 0.2 miles right in 5-d right bank & 5-d.619 .000 .000 .000 .000 .00033 LOC ALA 871123 Ryan Homer, Ak BE1900 Landed short; heavily iced; 600 lbs over max; CG 11 inches past aft..154 .000 .000 .000 .000 .00034 LOC ALA 941213 Flagship/AmEg Raliegh-D BAe-31 One engine failed on ILS approach. Crew did not recognize low-power engine failure. Light came on but crew explained it away as "momentary negative torque" when prop speed levers went to 100%. Continued to discuss & responded too late. Crashed 4 miles shor en.991 .000 .350 .000 .000 .00035 LOC ALA 910710 L'Express Birmingham, Al BE99 Last flight at end of duty tour. Despite receiving several accurate & timely wx advisories, flew into known severe t-storms to try to land via ILS approach. Hit severe windshear & lost control. Into & took out several homes; .759 .000 .550 .000 .000 .000

Resource 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

Safety Plan BenefitsSafety Plan Benefits

Prediction of a 73% risk reduction that also results in approximately $620 million annual savings to the industry– Current accident cost per flight is approximately $76

cycle– Implementation of the 46 selected safety

enhancements reduces this cost by $56 per flight cycle

Safety is morally required and is also good for business

Do

llars

/Flt

. Cy

c

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

100

80

60

40

20

0

Historical cost of accidents per flight cycle

73% Risk reduction

Savings ~ $56/Flight Cycle

Or

~ $620 Million Dollars/Year

Cost of accident fatalities following implementation of the CAST plan @ 2007 levels

2002 2007

Cost SavingsCost Savings

U.S. Hull Loss & Fatal AccidentsPortion of Total Fatality Risk Mitigated by the CAST Plan

(2007 Implementation Values)

0%10%20%30%40%50%60%70%80%90%

100%

Tota

l

LOC

Flt

CFI

TFi

re/E

xplo

sion

Run

way

Col

lisio

n

LOC

GN

D

Mid

air

Cre

w In

c

Eng

-UC

EF

Sys

-Com

p

Turb

ulen

ce

Eva

c

Po

rtio

n o

f R

isk

Risk EliminatedRisk Remaining

CAST 1987-2000 Fatal/Hull Loss Database – Security events excluded

All Regions Combined Worldwide Hull Loss & Fatal World Wide AccidentsPortion of Fatality Risk Mitigated If CAST Plan is Adopted Worldwide

(2007 Implementation Values)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%To

tal

CFI

T

LOC

-I

SC

F-P

P

SC

F-N

P

ICE

Mid

air

FIR

E-N

I

FUE

L RI

AR

C

RE

US

OS

WS

TRW

AD

RM

OTH

ER

-BIR

D

Po

rtio

n o

f R

isk

Risk EliminatedRisk Remaining

Accident Classes Defined by CAST/ICAO Common Taxonomy

CASTCASTA Three-Stage ProcessA Three-Stage Process

Influence Safety Enhancements -

Worldwide

DataAnalysis

Set SafetyPriorities

Achieve consensus on

priorities Integrate into existing work and distribute

Implement Safety Enhancements -

U.S.

Agree onproblems and interventions

Joint Implementation Joint Implementation Measurement Team Measurement Team

(JIMT)(JIMT)

ProcessProcess

Reporting Standards

Progressing on plan

Plan developed but not progressing - may not make plan or no plan exists

Late or critically off plan

On plan but effected by late or critically off plan

Output in plan completed

Status of non-aligned carriers (color same as above)

5-30-00 CAST-3-05

12/31/99 3/31/00 3/31/01 3/31/03

Retrofit program

complete - all Part 121

aircraft have TAWS

3/31/04

TAWSTAWS(Potential US Accident Rate Reduction ~5%)(Potential US Accident Rate Reduction ~5%)

TAWS TSO

Issues

TAWS Part 23 AC

released

3/31/05

ATA

TAWSFinalRule

AFS-200

ACE-100

TAWS AC OPS

guidance

AFS-200

TAWS HBAT OPS guidance

FAA

All aircraft manufactured for use under

Part 121 delivered

with TAWS

AIRFAA

TAWS AFM requirement

for newly manufactured

airplanes

AIR

Part 25TAWS ACreleased

ANM-100

1. 3/31/02 ops guidance not asked for no problems reported, moved to 3/31/03

(1.)

(1.)

CarriersImplement

training

6/30/00 7/31/00 9/30/00 4/30/0112/31/00

Precision-Like ApproachesPrecision-Like Approaches(Potential US Accident Rate Reduction ~7%)(Potential US Accident Rate Reduction ~7%)

AFS-200

Revise FAA order 8260.48

Plan to include angles

Plan for public use

(5)

Issue AC120-29A

Plan for VGSI @ each runway

end

FAA Standards for new training and procedures

Update pilot and ATIS

information

1. AC 120-29A in final coordination (9)2. Non-Alliance To Report (11) & (6)3. Needs AC 120-29A

Issues

(6)

Transition to RNAV/RNP

(25a)

(23)

POIs policies to authorize GPS procedures as RNAV (19)

Update RNP policy & criteria

RNP procedures operational processes

Plan for 3d NAV procedures

(17)

(24)

(27)

ICAO SARPs S&GAS

(28a)

(4)

(7)

(8)

(9)

(3)

Plan to install DME’s

(12)

AFS-400

AVN

ATAAFS-400

AFS-400

AVN

ATA

AFS-400

AFS-400

AFS-200

(11,15,16,20,24,25A,26,27,29)

(11)

(11,21,6,20)

(24,27)

(9,24,27)

(11)

(22)

AFS-400

AFS-400

(20)

Plan forimplementation

of multiple"minima"

Plan foroperational approval of

VNAV & RNAV

Plan foreducation of inspectors,

Check airmen & examiners

(21)

AFS-200(7)

(24,25a)

(24,27)

(22,25a)

(2.)

(11)

Crew procedures for stabilized

approach

(2.)

(1.)(3.)

Global Aviation Safety Global Aviation Safety

ICAOIFALPAIATAFSF

Global Aviation Safety Programs

JSSI

ConceptConcept• Working togetherWorking together• Common Strategy for Common Strategy for

Accident PreventionAccident Prevention• Data Analysis Data Analysis • Data Driven PlanData Driven Plan

FAA

CAST

SARASTSEARAST

Etc.

Opportunities

PAAST

CAST Links to International Safety ActivitiesCAST Links to International Safety Activities

Asia/Pacific– ICAO COSCAP

(Cooperative Development of Operational Safety and Continuing Airworthiness)

– NARAST, SARAST, SEARAST

– Association of Asia Pacific Airlines

Europe– JSSI: JAA Safety

Strategy Initiative Central / South America

– PAAST: Pan American Aviation Safety Team

East Africa– African Airlines Safety

Council, AFRASCO West Africa

– ASECNA (Agence pour la Securite de la Navigation Aerienne en Afrique et a Madagascar)

Flight Safety Foundation– CAAG (CFIT & Approach

and Landing Action Group) ICAO

– Global Aviation Safety Plan (GASP)

JAA JAA Joint Safety Strategy Joint Safety Strategy

Initiative Initiative (JSSI) (JSSI)

ProcessProcess

Verify Validity

JSSI Top Level Methodology - CAST Issue (ex. CFIT)

2-1-00 JSSI-004

Data

Choose Focus Area

OtherConsiderations

Do We Participate?

Others Analyzing

Focus Area?

Interventions & Problems defined by

others?

Verification of Validity of

Results Required

?

Data

Yes

YesYes

No

No

Yes

No

Create Analysis

Team

Define Problem

Statements, Interventions, Effectiveness

DetermineEuropean Feasibility

Yes

Data

Intervention Under JAA Purview?

Yes

No

YesDevelop

Action Plan Recommend-

ation

Data

Monitor Results

Execute Plan

Develop Detailed

Plan

JSSI STG

Approval?

No

1

Yes

Recommend Action to

Appropriate Organization

Yes

CAST Implementation

Plan

Data

No

Verify Validity

JSSI Top Level Methodology - JSSI Issue (ex. Design Related)

2-1-00 JSSI-003

Data

Choose Focus Area

OtherConsiderations

Do We Participate?

Others Analyzing

Focus Area?

Interventions & Problems defined by

others?

Verification of Validity of

Results Required

?

Data

Yes

YesYes

No

No

Yes

No

Create Analysis

Team

Define Problem

Statements, Interventions, Effectiveness

DetermineEuropean Feasibility

Yes

Data

Intervention Under JAA Purview?

Yes

No

YesDevelop

Action Plan Recommend-

ation

Data

Monitor Results

Execute Plan

Develop Detailed

Plan

JSSI STG

Approval?

No

1

Yes

Recommend Action to

Appropriate Organization

Yes

CAST Implementation

Plan

Data

No

Pan American Aviation Pan American Aviation Safety Team Safety Team

(PAAST) (PAAST)

Pan American Aviation Safety Team - Pan American Aviation Safety Team - PAAST PAAST

Covers all of America south of the U.S. Well developed and organized Three Co-Chairs

– Al Castan, IATA - Miami– Capt “Rocky” Marco Rocha, TAM Airlines - Brazil– Capt Luis Garcia, IFALPA - Mexico

Active Action Teams / Volunteers Active ICAO participation

PAAST

ICAO

FSF IATA

AITAL

IFALPA

AIRBUS BOEING

EMBRAER

Airline Management

Airline Safety Departments

States and Regulators

IFATCA

CAST (US), JSSI (Europe) & Other Regional Teams

IBAC

PAAST Pilots &Controllers

Integration and Consolidation of safety efforts

PAAST

CAST CAST Links with ICAO Links with ICAO

Working with ICAOWorking with ICAO

CAST - ICAO Common Taxonomy Team ICAO Safety Indicators Study GroupCOSCAP (Cooperative Development of

Operational Safety and Continuing Airworthiness)

– South Asia Regional Aviation Safety Team – South East Asia Regional Aviation Safety

TeamFlight Safety Foundation CFIT/ALAR

Action Group (CAAG)

SummarySummary

Approve TrainingProposal

5 8.25d

1/2/96 1/12/96

Select Accident/IncidentSets

1 15d

10/30/95 11/17/95

Review Accident/IncidentReports

2 5d

10/30/95 11/3/95

Analyze Accident/IncidentReports

3 5d

11/6/95 11/10/95

Develop PrioritizedIntervention Strategies

7 2h

1/10/96 1/10/96

Prepare Draft Report

6 3d

1/2/96 1/4/96

Revise Report

4 5d

11/13/95 11/17/95

Prepare FinalReport

8 1h

1/11/96 1/11/96

Approve FinalReport

9 1h

1/11/96 1/11/96

Select InterventionStrategies

10 1d

1/11/96 1/12/96


21.3 Reports

Airclaims data

Implementation Strategy JSIT


0

5

10

15

20

25

Un

cont

ain

ed

-d

isk

/spa

cers

Mul

ti -

com

mon

- en

v.

Ma

lfunc

tio

n +

cre

wer

ror

Un

cont

ain

ed

- bl

ade

s

Fire

(e.

g.,

un

der

co

wl)

Rev

erse

r

Mu

lti -

com

mo

n -

oth

er

Fue

lco

nta

m./

exh

aus

tion

Mu

lti -

unr

ela

ted

Cas

e ru

ptur

e

Cre

w e

rror

En

gin

e se

para

tion

Un

know

n

Mu

lti-r

ela

ted

Cow

l se

par

atio

n

CA

AM

Lev

el 3

an

d 4

Ev

ents

Level 4

Level 3

HistoricalData

Pareto PlotsJSAT

NASDAC data

Causal Analysis

CombinedThreat

Threat


Accident

1.

2.

3.4.

5.


Industry

FOQA data

JSAT

JSAT JSAT


6.7.

Coordinated Plan

Measuring Progress to Goal

Industry

Government

SaferSkies

AvSP

5.3-23

Future VisionFuture Vision

Execute the CAST-approved Safety Plan

Measure Plan effectiveness and modify Plan based on metrics and results

Continue the development of a proactive incident-based risk mitigation methodology

Improve the CAST process

Expand CAST influence on worldwide safety programs

Integrate safety program with R & D initiatives

Catalog the many on-going safety initiatives that dilute limited resources and identify opportunities for program integration and efficiency improvements

Safety Plan DevelopmentSafety Plan Development

AccidentJSAT’s

AccidentJSIT’s

SafetyEnhancements

CASTPlan

IncidentAnalysisProcess

Metrics JIMDATProcess

EmergingRisk

ChangingRisk

SafetyEnhancements

AviationSystem

ChangesPresent

In MasterFactors

Yes

No

DemographicChanges

IdentifyHazards

IdentifyFactors

DevelopContributing

Factors(new or

emerging)

SafetyEnhancements

IdentifyHazards

IdentifyFactors

MasterContributing

Factors

6-11-03 CAST-051

CAST Plan Rev.

FAST Hazards

Metrics

Metrics

Our Challenge: Stay FocusedOur Challenge: Stay Focused

Work together internationallyCoordinate strategyTarget our resourcesFocus on preventionCommunicate industry and government

safety processes and initiativesShare results

CAST ProcessCAST ProcessData-DrivenData-Driven

Industry/Regulatory Industry/Regulatory CollaborationCollaboration

commercial aviation safety team (cast) process overview commercial aviation safety team (cast)...

Documents

safety responsibilities

aviation industry

conduct safety research

hull loss accident rate

continuous safety improvement

ntsb accident incident

safe air travel slide

cast goals