NAM/CAR/SAM Air Traffic Services Quality Assurance Programme Seminar "Quality for Tomorrow Begins Today"

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Global Aviation Information Network (gainweb.org)
Christopher A. Hart
Federal Aviation Administration
Assistant Administrator for System Safety
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Worldwide Airline Fatality Rate
AN INTERNATIONAL COMPARISON
THE LAST 6 YEARS
THE WORLD'S 85 MAJOR AIRLINES BY REGION
FATALITIES PER MILLION PASSENGERS WORLDWIDE
AUSTRALASIA
0.0
18
1.1
UNITED STATES
0.3
0.9
0.9
NORTH AMERICA
0.4
16
(INCLUDES U.S.)
0.84
EUROPE
14
CENTRAL AND
SOUTH AMERICA
1.7
12
No Jet Fatalities in U.S. in 1993
AFRICA
2.6
1994 - 264 Fatalities on U.S.Scheduled Airlines
- 5 year high
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ASIA
3.0
8
6
4
2
0
1950 1960
1970 1980
1990 1994
Per Million Passengers Carried Worldwide
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The Hands-On Front Line Folks
We All Knew About That Problem
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Benefits of FDR Use
Worldwide
FDR Use lt7Years
Total U.S.
FDR Use 7-14 Years
FDR Use gt14 Years
Sources Total U.S.- FAA NASDAC
Other - Skandia Insurance Co. Ltd.
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Norwegian Rail Experience
Total number of reported and analyzed events
Lost Time 37 reduction
Accidents40 reduction
96
97
98
95
Source Pride AS
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Current System Data Flow
Almost all Data is Lost Forever
Currently Only a Minute Portion of Data
is Collected and Analyzed
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Heinrich Pyramid
ACCIDENTS
INCIDENTS
UNREPORTED OCCURRENCES
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Common Characteristics

• Inadvertent
• Could Be A Link
• In An Accident Chain
• Happens Repeatedly

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So Should We...

• Regulate More?
• Punish More?
• Increase Training?
• OR...

Share Information to Fix the System?
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Fix the Person or the System?
Is the Person Clumsy? Or Is the Problem . . .
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Fix the Person or the System?
Is the Person Clumsy? Or Is the Problem . .
. The Step???
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Is This Light Random?
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Accidents Result From a Combination of Events
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Global Aviation Information Network The
Concept
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Others Who Are Interested

• Transportation Department
• Coast Guard (IMISS)
• Highway Administration
• Railroad Administration
• Pipeline Safety
• Critical Infrastructure Assurance Office (CIAO)

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The Health Care Industry
To Err Is Human Building a Better Health Care
System The focus must shift from blaming
individuals for past errors to a focus on
preventing future errors by designing safety into
the system. Institute of Medicine, Committee on
Quality of Health Care in America
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Information The Fuel for Our Engine
Zero Accidents
Information
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Obstacles that Block the Flow of Information
Concerns About

• Public Disclosure
• Job Sanctions/Enforcement
• Criminal Sanctions
• Civil Litigation

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Removing U.S. Obstacles

• FAA Reauthorization, 1996
• - Prohibits public disclosure of voluntarily
  provided aviation safety information
• President Clinton, January 2000
• - Announced Aviation Safety Action Programs
  (ASAP) for voluntary pilot reporting
• FAA NPRM, June 2000
• - Proposes protections for airlines and their
  employees from enforcement actions for regulatory
  violations discovered from voluntary reporting
  programs

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Removing Intl Obstacles

• ICAO 32nd Assembly, 1998- Resolution to improve
  safety through enhanced collection, analysis and
  dissemination of safety information
• ICAO AIG, September 99- Approved
  recommendation to Annex 13 that States should
  establish non-punitive incident reporting
  systems, promote establishment of safety
  information sharing networks, and facilitate free
  exchange of information on potential safety
  deficiencies

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Challenges
Improved Analytical Tools
Legal Issues
As we begin to get over the first hurdle, we must
start working on the second.
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Analytical Tools
Must be able to help analysts

• Identify Potential Problems
• Prioritize Potential Problems
• Develop Solutions
• Evaluate Success

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Information Overload
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Many Have Already Begun The Process
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avings
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Three Domains For GAIN
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Steering Committee

• Airlines
• Northwest Airlines (Chair)
• Air France (Vice Chair)
• British Airways
• Japan Airlines
• Air Transport Association
• Manufacturers
• Airbus Industrie
• The Boeing Company
• Flight Safety Foundation

• Labor
• Air Line Pilots Association
• Intl Association of Machinists Aerospace
  Workers
• National Air Traffic Controllers Association
• General Aviation
• National Business Aviation Association
• Military
• US Navy

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Working Groups

• Working Group A
• Aviation Operator Safety Practices
• Working Group B
• Analytical Methods and Tools
• Working Group C
• Global Information Sharing Prototypes
• Working Group D
• Reducing Impediments

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Fourth GAIN World Conference

• Where Paris, France
• When June 13-15, 2000
• Hosted By

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FAA Administrator Jane Garvey

• GAIN is one of our best hopes for enhancing
  aviation safety in the next century.

GAIN III World Conference November 1998
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Please Visit and Explore...
www.gainweb.org