Transcript CAST - Overview

Commercial Aviation
Safety Team
(CAST)
Overview
Kyle L. Olsen
Asian Regional Aviation Safety Team
19 – 20 November 2008 – Bangkok
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.
CAST brings key stakeholders to cooperatively
develop & implement a prioritized safety agenda
Industry
AIA
Airbus
ALPA
APA
ATA
IFALPA
NACA
Boeing
GE*
RAA
FSF
Commercial Aviation
Safety Team
(CAST)
IATA**
AAPA**
ATAC**
APFA**
* Representing P&W and RR
** Observer
Government
DOD
FAA
•
•
•
•
•
Aircraft Certification
Flight Standards
System Safety
Air Traffic Operations
Research
NASA
ICAO**
EASA / JAA
TCC
NATCA**
NTSB**
Safer Skies
COMMERCIAL AVIATION
GENERAL AVIATION
Aeronautical
Decisionmaking
Loss of Control
Controlled Flight
Into Terrain
CABIN SAFETY
Loss of Control
Uncontained
Engine Failures
Weather
Passenger Interference
Passenger Seat Belt Use
Runway Incursion
Controlled Flight
Into Terrain
Approach and
Landing
Carry-on Baggage
Child Restraint
Survivability
Weather
Runway Incursions
IMPROVED DATA
& ANALYSIS
Turbulence
HUMAN FACTORS
IN OPERATIONS &
MAINTENANCE
Commercial Aviation Safety Team (CAST)
CAST
Joint Safety
Analysis Teams (JSAT)
• Data analyses
Joint Safety
Implementation
Teams (JSIT)
• Safety
enhancement
development
Joint Implementation
Measurement Data
Analysis Team (JIMDAT)
• Master safety plan
• Enhancement
effectiveness
• Future areas of
study
General Methodology for Calculating the
Potential Benefit of a Safety Enhancing
Intervention
Accident
Risk
Reduction
= (
Effectiveness
that an intervention
has for reducing the
accident rate if
incorporated
,
Portion of
world fleet
with intervention
implemented
)
Spreadsheet Example – Historical Airplane Accidents &
Proposed Safety Enhancements
Accident
Date
Class
Location
Aircraft
Type
Description
Accident Description
Portion
of
Accident
Intervention Name
EGPWS
CFIT TRN
Portion of World Fleet w
Eliminated .600
.900
Intervention Effectivene
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
CFIT
1/2/1988
2/8/1988
2/27/1988
3/17/1988
6/12/1988
7/21/1988
10/17/1988
10/19/1988
2/8/1989
2/19/1989
6/7/1989
7/27/1989
8/25/1989
10/21/1989
10/26/1989
2/14/1990
6/2/1990
11/14/1990
12/4/1990
3/5/1991
8/16/1991
1/20/1992
2/15/1992
3/24/1992
6/22/1992
7/31/1992
9/28/1992
11/25/1992
11/26/1992
4/26/1993
IZMIR, TURKEY
737
LUANDA, ANGOLA
707
KYRENIA MTS, CYPRUS727
CUCUTA, COLUMBIA
727
POSADAS, ARGENTINA MD80
LAGOS, NIGERIA
707
ROME, ITALY
707
AHMEDABAD, INDIA
737
SANTA MARIA AZORES 707
KUALA LUMPUR, MALAYS
7I
4A
7
PARAMARIBO, SURINAME
DC8
TRIPOLI, LIBYA
DC10
ANKARA, TURKEY
727
TEGUCIGALPA, HONDURA
727
HUALIEN, TAIWAN
737
BANGALORE, INDIA
A320
UNALAKLEET, ALASKA 737
ZURICH, SWITZERLANDDC9
NAIROBI, KENYA
707
MT LA AGUADA, VENEZU
DE
CL
9A
IMPHAL, INDIA
737
STRASBOURG, FRANCE A320
KANO, NIGERIA
DC8
ATHENS, GREECE
707
CRUZEIRO DO SUL, BRA
7Z
3I
7L
KATMANDU, NEPAL
A310
KATMANDU, NEPAL
A300
KANO, NIGERIA
707
MANAUS, BRAZIL
707
AURANGABAD, INDIA
737
HIT MOUNTAIN ON APPROACH
.657 .950
HIT ANTENNA ON APPROACH
.586 .800
HIT MOUNTAIN ON APPROACH
.657 .950
HIT MOUNTAIN DURING CLIMB
.657 .950
CRASHED ON FINAL APPROACH
.203 .000
CRASHED ON APPROACH
.203 .000
LANDED SHORT
.203 .000
LANDED SHORT
.586 .800
TERRAIN IMPACT/DESCENT
.657 .950
TERRAIN IMPACT/APPROACH
.657 .950
T E R R A I N I M P A C T / F I N A L A P P R O A C H. 2 0 3 . 0 0 0
T E R R A I N I M P A C T / F I N A L A P P R O A C H. 2 0 3 . 0 0 0
HIT ILS ANT. ON TAKEOFF
.000 .000
TERRAIN IMPACT/APPROACH
.657 .950
TERRAIN IMPACT/DEPARTURE
.657 .950
HIT SHORT (300 FT)
.203 .000
HIT HILL 7 MILES OUT IN FOG
.657 .950
CRASHED 5 MILES SHORT
.634 .900
HIT POWER LINE ON ILS FINAL
.203 .000
HIT MOUNTAIN/APPROACH
.657 .950
A / C H I T H I L L 2 0 M I L E S O U T / A P P.
R6
O5
A7
C H. 9 5 0
IMPACTED GROUND/FINAL
A P P R O A.
C5
H8 6 . 8 0 0
C F I T O U T O F P R O C E D U R E T R N - D A R.
K5 8 6 . 8 0 0
ABANDONED APPROACH-HIT MTN
.657 .950
HIT SHORT,DRK NT,DISTRACTED
.203 .000
CFIT-HIT MTN-MISSED APPROACH .657 .950
C R A S H E D S H O R T D U R I N G A P P R O A C H. 6 5 7 . 9 5 0
L A N D E D S H O R T M I S L E A D I N G L I G H T.
S5 3 8 . 7 0 0
H I T L I G H T S O N T O / R M L G C O L L A P S.
E0 0 0 . 0 0 0
HIT TRUCK AFTER TAKEOFF
.000 .000
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.000
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.226
.000
.000
Example Scatter Chart
2007 Implementation & Resources
25
20
Dollars
In
Millions
15
10
Combined Score
5
Combined SOPs
0
0.0
2.0
4.0
6.0
8.0
10.0
Score
12.0
14.0
16.0
18.0
20.0
CAST Safety Plan
47 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)
CAST Safety Plan (cont.)
23 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
Cargo safety culture, policies and procedures
Runway Safety
CAST
Implementation Status
CAST Safety Plan - October 2, 2008
Late
0%
In Question
0%
On Tgt
33%
70 Safety Enhancements
47 Complete
23 Underway
23
47
Complete
67%
CHANGES from last meeting
2020 Plan Risk Reduction
Estimate 74 %
Complete
On Tgt
Late
In Question
12
2020 CAST SAFETY PLAN – WORKING SEs
(Total Plan – 70 SE; 47 Complete; 23 Underway)
39
ANM
47
ATO
53
ARA
120
ATA
101R1
AIA
121
ATA
125R1
ATA
127R2
AIR
131R
1
ATA
133R1
AIA
134R2
AIA
136
ATA
159R1
ATO
165R3
AFS
169R1
AFS
170R2
AIA
172R1
AFS
175R1
ATA
179R1
AFS-1
180
ATS-1
181R
1
ARP
182R1
ATO-1
183R1
AFS-1
Action
Needed
SE #
LOOSE
C
ON TRACK
COMPLETED
LATE
LATE OP
IN QUESTION
13
CAST
Moving into the Future
Safety Plan Development
Accident
JSITS
Case
studies
Accident
JSATS
Case studies
Incident
Analysis
Process
Master
Contributing
Factors
Emerging
Risk
Safety
Enhancements
Develop
Enhancements
& Metrics
Recommended
Plan
Revision
JIMDAT
Review
Changing
Risk
CAST
Plan
Metrics
Performance
To Plan
Review
Aviation
System
Changes
Identify
Hazards
Identify
Factors
Yes
Present
In Master
Factors
FAST Hazards
Demographic
Changes
NonPerformance
Information
Identify
Hazards
Identify
Factors
No
Develop
Contributing
Factors
(new or
emerging
11-5-03 CAST-051R
Aviation Safety Information Analysis Sharing
ASIAS Activities Summary
to the CAST
7 August 2008
Distribution limited to CAST only
7 August 2008
17
Signed MOUs
Distribution limited to CAST only
7 August 2008
18
Regional Airlines Outreach
Distribution limited to CAST only
7 August 2008
19
ASIAS Architecture:
Where We Are
DNAA
DNFA
Enhanced
Data
Management
Tools
ASDE-X
National
Offload
Program
MITRE CRS Data
FAA ASIAS Data
ASDE-X Airports
ATL-BDL-CLT-FLL-HOU
IAD-LAX-MCO-MKE-ORD
PVD-SDF-SEA-STL
Expanded
Analytical
Tools
Data Fusion
20
New Airlines
Distribution limited to CAST only
7 August 2008
20
5. Wx
6. Traffic Procedures
3. Radar
Tracks
1. FOQA TAWS Alerts
4. Terrain
database
Distribution limited to CAST only
2. MVA
7 August 2008
21
Study of
Remaining Risks
Joint Implementation Data Analysis Team (JIMDAT)
Remaining Risk
• Cargo
• Icing
• Midair
• Maintenance
SE-165 Midair
TCAS Policies and Procedures
• Prevent midair collisions by requiring
flightcrews to follow TCAS Resolution
Advisories (RA’s), establish procedures for
TCAS range setting and requiring that
TCAS-capable simulators and flighttraining devices are used for training
TCAS responses and Maneuvers.
• SEA AC 018 issued 25 June 2008.
SE-164 Midair
TCAS Installation
• Worldwide installation of TCAS in all
aircraft of 33,000 pounds or greater max
takeoff weight.
• ICAO requirement for aircraft of 6,700kg
• TCAS required in Asia – SE-164 is
complete
SE-121 Cargo
Standard Operating Procedures
• Reduce cargo-related accidents and
incidents by publishing and enforcing
clear, concise and accurate standard
operating procedures (SOP), and training
the rationale behind those procedures
• Cathay Pacific and AAPA to provide
briefing.
• CAST activity to be complete April 2010
SE-125 Cargo
Hazardous Materials - HazMat
• Reduce hazmat related accidents and
incidents develop and implement by
regulators, manufacturers (of packaging
material) and shipping companies a multitier system to identify and safely process
undeclared hazardous material.
• CAST to provide information after
completion in December 2010
SE-129 Regulation & Policy
Compliance, Enforcement and Restricted
Operations
• Regulators should improve their legal
processes for compliance, enforcement
and operational restrictions.
• FAA Order 2150.3B now contains
timeliness goals for completion of an
investigation, preparation of the
enforcement report and the processing of
legal actions.
SE-129 Regulation & Policy
Compliance, Enforcement and Restricted
Operations - continued
• Also, FAA Order 2150.3B now contains
policies and procedures for the grant of
immunity from FAA enforcement to
persons who provide information about
violations to the regulations.
SE-131 Cargo
Safety Culture
• Reduce cargo-related accidents and
incidents by encouraging a culture that
enhances operational safety. Safety
culture can be enhanced by a safety
management system (SMS).
• To be covered by SMS
• CAST activity complete October 2011
SE-136 Icing
Training – Engine Surge Recovery
• To prevent accidents resulting from an
engine surge caused by ice ingestion,
airlines should provide adequate training
for flight crews to ensure appropriate
responses.
• CAST activity complete April 2009
SE-127 Cargo
Fire Containment
• To reduce the occurrence of accidents and
incidents from cargo fires, improved cargo
containers should be developed to contain
(or suppress) fires originating in shipped
cargo
• Not applicable for implementation by
ARAST.
– (FEDEX can provide additional information if there is interest.)
CAST
Sharing with the World
Cost Savings
Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents
100
Dollars/Flt. Cyc
80
Historical cost of
accidents per flight
cycle
Savings ~ $56/Flight Cycle
Or
~ $620 Million Dollars/Year
60
40
20
Cost of accident fatalities
following implementation of the
CAST plan @ 2007 levels
0
2002
2007
CAST Links to International
Safety Activities
•
ICAO
–
•
ESSI: European
Strategic Safety Initiative
Central and South
America
–
PAAST: Pan American
Aviation Safety Team
Africa
–
•
Europe
–
•
COSCAP (Cooperative
Development of
Operational Safety and
Continuing
Airworthiness)
•
Asia/Pacific
–
•
African Safety
Enhancement Team
(ASET)
Association of Asia
Pacific Airlines
North America
–
NAFTA: North American
Free Trade Association
• Others
Regional Perspective
Accident Rates Vary by Region of the World
Western-built transport hull loss accidents, by airline domicile, 1998 through 2007
United States
and Canada
CAST
0.4
70 SEs
47 complete
23 in work
74% reduction
ESSI
35 SEs JAA
11 SEs EASA
62% reduction
Europe
0.7
C.I.S.1
COSCAP CIS
China
0.3
Middle East
2.3
COSCAP
BAG
Latin America
PAAST
and Caribbean
CFIT and ALAR
2.1
Africa
10.0
(Excluding
China)
Oceania
0.0
ASET
Accidents per
million departures
Insufficient fleet experience to generate reliable rate.
Asia
2.1
COSCAP Gulf
World
1.1
1
COSCAP NA, SA, SEA
40 SEs in work
60% reduction
CAST Approach to Safety:
A Three Stage Process
Data
Analysis
Implement Safety
Enhancements U.S.
Set Safety
Priorities
Agree on
problems and
interventions
Achieve consensus on
priorities
Influence Safety
Enhancements Worldwide
Integrate into existing
work and distribute
Conclusions
•
CAST brings together all the key players
– Air Carriers
– Manufacturers
– Employee Groups
– Government
•
Predicted 74% risk reduction by 2020
•
CAST is committed to worldwide participation
•
History shows focused action and introduction of
new capabilities have led to large accident rate
reductions
Thank you
Backup Slides
CAST
sharing with
COSCAP’s in Asia
Distribution limited to CAST only
7 August 2008
49
CAST and GASR
 CAST supports the Global Aviation Safety
Roadmap (GASR) as an international strategic
plan to promote aviation safety programs,
which is complementary to the
implementation of appropriate tactical
solutions contained in the CAST Safety Plan
COSCAP History
 COSCAP-South East Asia has been working
on safety issues for the last seven years.
 South East Asia Regional Aviation Safety
Team (SEARAST):
 reviews safety recommendations,
 develops interventions,
 tracks implementation.
 Focused primarily on improving safety by
reducing accident risk.
Global Aviation Safety
Roadmap (GASR)
 Proactive approach to aviation safety
 Help coordinate and guide safety policies
 12 Focus Areas established
 4 Focused on States (government)
 1 Joint regional responsibilities
 8 Focused on industry (operators)
 The Focus Areas are high level
 Accident risk reduction not defined or identified
 Best Practices identified for each Focus Area
12 Global Safety Initiatives
 The strategic action plan, ‘Implementation
the Global Aviation Safety Roadmap’ defines:
 Focus Areas.
 Objective of each Focus Area.
 Best Practices for each Focus Area.
 Metrics for each Best Practices.
Metrics
 In many instances the metrics link with:
 ICAO USOAP audit results used when related to States.
 IATA ISOA audit results used when related to industry.
 ICAO Annexes, SARPS, Documents, etc.
 Prior Roadmap Workshops have developed an
implementation tool.
Example from Focus Area 1, International Standards
Best Practices, Metrics and Implementation
Table 1a –Best Practices
BP 1a-2 – States takes all necessary action to ensure
compliance with SARPs and industry best practice.
Metrics
Implementation
a. The State enacts enabling legislation which facilitates a.
the creation and modification of a regulatory scheme
giving SARPs the force of law.
USOAP LEG 1.001; LEG 1.005;
LEG 1.009; ORG 2.009
□ Complete
b. State processes include an evaluation of their own
compliance with SARPs.
USOAP OPS 4.003; 4.005;
AGA 8.003
b.
□ Somewhat
□ Little/None
□ Not Applicable
c. State implements USOAP recommendations.
c.
ICAO Doc. 9735, Chapter 6
d. State secures necessary financial, human and
technical resources to develop, update and implement
regulations meant to enforce SARPS and to implement
industry best practices. Resources are drawn as
necessary from national, regional and international
sources.
d.
USOAP ORG 2.051; ORG 2.053
Analysis:
e.
Percentage of assistance
activities that can be linked to
best practices or focus area Results of assistance activities
are assessed against metrics and
other available benchmarks
f.
Difference are notified to ICAO
–Significant differences are
listed in the State’s AIP –
USOAP LEG 1.025
e. ICAO assistance activities are aligned with the
Global Aviation Safety Plan (GASP) and the Global
Aviation Safety Roadmap.
f. State publishes notice of non compliance to all
affected entities and notifies ICAO in accordance with
Article 38 of the Convention until such time as the
SARP is complied with.
Example from Focus Area 9, Inconsistent Adoption
of Industry Best Practices
Best Practices, Metrics and Implementation
Table 9a –Best Practices
Metrics
BP 9a-1 – The organization creates and maintains an
organizational structure that facilitates adoption of
industry Best Practice within the organization.
Implementation
□ Complete
□ Somewhat
a. The organization designates a specific
individual within the organization or within
each operating unit with responsibility for
researching and disseminating existing best
practice for that unit’s activities. That
individual is able to recommend specific points
for adoption and has follow up responsibilities
to ensure implementation of safely critical
items.
a.
IOSA ORG 1.3.3; 1.4.2;
1.7.7; 2.2.3
b. The organization adopts “Just Culture”
principles to ensure that implementation of best
practices are appropriate to the individual
organization. These principles encourage an
open dialog across all levels of the management
structure to optimize information flow both u
and down the chain.
b.
IOSA ORG 1.2.3; 1.5.1;
2,1,1; 3,2,6
c. The organization vests in line managers the
ability to take action to implement safety best
practices.
c.
IOSA ORG 3.2.4; 3.1.1
d. Best Practice is independent of any cultural
issues. Where cultural issues are presented,
steps are taken to resolve them consistent with
international best practice.
d.
IOSA ORG 1.1.1; 1.5.1
□ Little/None
□ Not Applicable
Analysis:
Example from Focus Area 5, Inconsistent
Coordination of Regional Programs
Best Practices, Metrics and Implementation
Table 5b –Best Practices
Metrics
BP 5b-1 – Regional safety groups use qualitative and
quantitative risk assessment techniques to determine
levels of risk.
a. Risk assessments and development and prioritization
of safety enhancements to address those risks
developed by national and regional groups such as
CAST, ESSI, and COSCAPs North Asia (NA), South
Asia (SA), and Southeast Asia (SEA) are shared
worldwide.
Implementation
□ Complete
□ Somewhat
a.
Risk assessment
techniques are adopted
by regional safety groups
worldwide.
□ Little/None
□ Not Applicable
Analysis:
Benefits of an Evaluation
 Help maintain perspective between:
 Current Safety Team activity,
 USOAP audit results and actions,
 IOSA audit results and actions, and
 GASR Focus Areas
 Help to focus on priorities reducing risk
 Identify and avoid duplication
 Ongoing activity and efforts
 Teams
Possible Duplication
 USOAP Programme, DP3
 SEARAST recommendations, actions and
implementation, DP5
 Safety Management Systems (SMS), DP6
 Incident and Accident Investigation
 Creation of an additional safety team