Commercial Aviation Safety Team CAST Aviation Safety Information Analysis Sharing ASIAS Presented to

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

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In the U.S., our focus was set by theWhite House
Commission on Aviation Safety, and The National
Civil Aviation Review Commission (NCARC)
1.1 . . . Reduce Fatal Accident Rate . . .

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

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Vision - Mission - Goals

• Vision
• 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.

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CAST brings key stakeholders to cooperatively
develop implement a prioritized safety agenda
Industry
Government
AIA Airbus ALPA APA ATA IFALPA NACA Boeing GE RAA
FSF

• DOD
• FAA
• Aircraft Certification
• Flight Standards
• System Safety
• Air Traffic Operations
• Research
• NASA
• ICAO
• EASA (ECAST)
• TCC
• NATCA
• NTSB

Commercial Aviation Safety Team (CAST)
IATA AAPA ATAC APFA ACI-NA
Representing PW and RR Observer
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Commercial Aviation Safety Team (CAST)
CAST
Joint Safety Analysis Teams (JSAT)

• Data analyses

• Safety enhancement development

Joint Safety Implementation Teams (JSIT)

• Master safety plan
• Enhancement effectiveness
• Future areas of study

Joint Implementation Measurement Data Analysis
Team (JIMDAT)
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Safety Plan Development
Accident JSITS Case studies
Accident JSATS Case studies
Safety Enhancements
Recommended Plan Revision
Emerging Risk
Develop Enhancements Metrics
Incident Analysis Process
Master Contributing Factors
JIMDAT Review
CAST Plan
Changing Risk
Metrics
Performance To Plan Review
Non- Performance Information
Aviation System Changes
Identify Hazards
Identify Factors
Yes
Present In Master Factors
Develop Contributing Factors (new or emerging
No
FAST Hazards
Demographic Changes
Identify Hazards
Identify Factors
11-5-03 CAST-051R
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(No Transcript)
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Robust 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

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CAST Process Led to Integrated Strategic 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

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Resource Cost Vs. Risk Reduction
10000
100
APPROVED PLAN
Risk Reduction
9000

Total Cost in (Millions)
8000
75
7000
6000

Risk Eliminated by Safety Enhancements
50
5000
Resource Cost ( Millions)
2007
2020
4000
3000
25
2000

1000


0
0
All JSIT Proposed Enhancements (2020
Implementation Level)
Completed
Completed Plan (2020 Implementation Level)
Completed Plan (2007 Implementation Level)
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Cost Savings
Part 121 Aviation Industry Cost Due to Fatal/Hull
Loss Accidents
100
Historical cost of accidents per flight cycle
80
Savings 74/Flight Cycle Or 814 Million
Dollars/Year
74 Risk reduction
Dollars/Flt. Cycle
60
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Cost of accident fatalities following
implementation of the CAST plan _at_ 2020 levels
20
0
2020
2007
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CAST Safety Plan

• 51 Completed Safety Enhancements
• Safety Culture
• Maintenance Procedures
• Flight Crew Training
• Air Traffic Controller Training
• Uncontained Engine Failures
• Terrain avoidance warning system (TAWS)
• Standard Operating Procedures
• Precision Approaches
• Minimum Safe Altitude Warning (MSAW) Systems
• Proactive Safety Programs (FOQA ASAP)

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CAST Safety Plan (cont.)

• 21 Committed Safety Enhancements
• Policies and Procedures
• Aircraft Design
• Flight Crew Training (additional aspects)
• Runway Incursion Prevention
• Precision Approaches (additional projects)
• Icing (additional turboprop projects)
• Midair
• Maintenance
• Runway Safety
• Safety culture, policies and procedures

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Fatal Accident Rate and Full Airplane Loss
Equivalents Rate for Part 121 Operations (5 year
moving average)
9.0
8.0
5 year moving avg of fatal accidents per 10
million departures
7.0
6.0
5.0
Fatality Accidents or Full Loss Accident
Equivalents
per 10 Million Departures
4.0
3.0
82 Fatality Accident Rate Reduction 1996-2007
2.0
1.0
0.0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
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International PerspectiveCAST Safety Enhancements
Western-built transport hull loss accidents, by
airline domicile, 2001 through 2007
COSCAP CIS
C.I.S.1
Europe 0.7
ESSI 35 SEs JAA 11 SEs EASA 62 reduction
COSCAP NA, SA, SEA 40 SEs in work 60 reduction
China 0.3
United States and Canada 0.4
CAST 70 SEs 48 complete 22 in work 74
reduction
Middle East 2.3
Asia 2.1
(Excluding China)
COSCAP BAG
COSCAP Gulf
Africa 10.0
Latin America and Caribbean 2.1
Oceania 0.0
ASET
RASG-PA
World 1.1
Accidents per million departures
1 Insufficient fleet experience to generate
reliable rate.
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Summary

• History shows focused action and introduction of
  new capabilities have led to accident risk
  reductions
• Joint industry and government teams working
  together to a common goal can further enhance the
  safety of our very safe aviation system
• Full implementation will require a coordinated
  effort between industry and government
• CAST is moving forward to meet the challenge
• ASIAS (Aviation Safety Information Analysis and
  Sharing) initiative is under way help aviation
  safety teams (CAST, IHST, GAJSC) meet the
  challenge

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What is ASIAS.

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

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ASIAS AIRLINE PARTNERS
AIRTRAN AIRWAYS ALASKA AIRLINES AMERICAN
AIRLINES AMERICAN EAGLE ATLANTIC SOUTHEAST
AIRLINES CHAUTAUQUA AIRLINES COMAIR COMMUTAIR CO
MPASS AIRLINES CONTINENTAL AIRLINES EXPRESSJET FR
ONTIER AIRLINES
GULFSTREAM INTERNATIONAL AIRLINES JETBLUE
AIRWAYS DELTA-NORTHWEST AIRLINES REPUBLIC
AIRLINES SHUTTLE AMERICA SKYWEST
AIRLINES SOUTHWEST AIRLINES SUN COUNTRY AIRLINES
UNITED AIRLINES UNITED PARCEL SERVICE US AIRWAYS
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ASIAS Participants at Major US Airports
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ASIAS ASAP Records in Production
Record counts as of 14 Sept 2009
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ASIAS FOQA Records in Production
As of Sept 2009, over 5 Million FFD Records
available to ASIAS
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Data Sources Supporting ASIAS InfoSharing and
Analysis
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

• Flight Operations
• Maintenance
• Dispatch
• ATSAP

• 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

Safety Reports

• Bureau of Transportation Statistics
• Weather / Winds
• Manufacturer Data
• Avionics Data
• Worldwide Accident Data

Other Information
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ASIAS is Governed by Formal Principles
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ASIAS Studies Completed or Underway
Directed Studies
Analysis In Progress
Analysis Completed
Terrain Awareness Warning
AirlineBenchmarks
Airline Stability Metric
TCAS Resolution Advisories
Approach and Landing
CAST Metrics Known Risk Monitoring Safety
Enhancement Assessment
Controlled Flight Into Terrain
Loss of Control
Mid-Air Collision
Icing
Cargo
Maintenance
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Analytical Products
Terrain Awareness Warning System (TAWS) Traffic
Collision Advisory System (TCAS) Wrong Runway
Departures (WR) Metrics
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Data Fusion Provides Valuable Insights
Weather Source FAA NOAA
Terrain Source National Elevation Data
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Bay Area Traffic Flows SE Plan
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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 MVAs that
  should be reviewed.
• The CAST mitigation team is coordinating the
  evaluation of this tool within the FAA.

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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)

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OAK Traffic RNAV Capable

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

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Proposed RNAV VISUAL Approach to OAK RWY 11
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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

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EGPWS Mode-2 Pull Ups Pre 218
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EGPWS Mode-2 Pull Ups w/218 or Higher(about 20X
Less Frequent)
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Analytical Products
Terrain Awareness Warning System (TAWS) Traffic
Collision Advisory System (TCAS) Wrong Runway
Departures (WR) Metrics
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Data Sources and Analysis
NOP Run simulations that will encompass all
carriers and traffic to better estimate RA rates
and degree of risk. Perform domestic / foreign
comparisons. (Provides intruder information.)
(National Offload Program radar surveillance data)
FOQA Assess NAS-wide and airport-specific TCAS
RA landscape. Provide Trend Information.
Investigate pilot response to advisories.
(TCAS Operational Performance Assessment)
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.
(ASAP, ASRS, OE)
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ASIAS Directed Study on TCAS RAs Location from
FOQA Data
Over a three-year period, Southern California,
Northern California, and Denver accumulated the
greatest concentrations of TCAS RA events.
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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 airport
• Example Philadelphia downtown VFR traffic
  interaction with PHL arrivals
• Types 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
  arrivals
• Example GA traffic crossing under JFK arrivals
• Arrival /departure route or an approach

500-ft separation is maintained in most cases,
but it is not sufficient to prevent TCAS RAs
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Common Themes Observed at Study Airports IFR
Traffic Interacting with Other IFR Traffic

• Visual approaches to parallel runways
• Close spacing
• Example 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
  arrivals
• Example DEN west departures with arrivals on
  both north and south flows

These procedures are in accordance with 7110.65,
but they do not provide sufficient separation to
prevent TCAS RAs
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Analytical Products
Terrain Awareness Warning System (TAWS) Traffic
Collision Advisory System (TCAS) Metrics Wrong
Runway Departures (WR)
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Mapping Problem Statements to FOQA Metrics
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Example Metrics for Approach and Landing Accident
Risks
Metric Category Level
Safety Enhancement Level
Problem Statement Level
Metric Level
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
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Initial Results Unstable Approach Metric
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Initial Results Unstable Approach Metric
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Analytical Products
Terrain Awareness Warning System (TAWS) Traffic
Collision Advisory System (TCAS) Metrics Wrong
Runway Departures (WR)
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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

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Findings Part 121 Operations
Wrong Runway Departures By Data Source
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Findings Part 121 Operations
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Part 121 Contributing Factors
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JIMDAT Mitigation Assessment
Risk Eliminated
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Findings Part 135 Operations
Wrong Runway Events (1981-2006)
Houston
PART 121
Cleveland
Los Angeles
Richmond
Syracuse
Anchorage
NOTE ASRS database with certain exceptions
captures 18 of reports received by NASA on
monthly basis
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Part 139 (Class 1) Airport Review
355 Airports
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International Collaboration

• Sharing of CAST safety products worldwide
  COSCAP, GASR, etc
• CAST ICAO Common Taxonomy
• ECCAIRs common taxonomy, developing data
  sharing proposals
• TCAS RA mitigation study including Eurocontrol
• Desire increased connectivity with ICAO ISDCAS
  (Integrated Safety Data Collection and Analysis
  System)
• IATA GSIC Evaluating sharing top level safety
  hazards
• Partnered with E-CAST

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http//www.cast-safety.org/
QUESTIONS?