Transcript Commercial Aviation Safety Team (CAST)

Commercial Aviation
Safety Team (CAST)
Overview
In the U.S., our focus was set by the
White 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 . . .
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
Government
Industry
AIA
Airbus
ALPA
APA
ATA
IFALPA
NACA
Boeing
GE*
RAA
FSF
Commercial Aviation
Safety Team
(CAST)
IATA**
AAPA**
ATAC**
APFA**
ACI-NA**
* Representing P&W and RR
** Observer
DOD
FAA
•
•
•
•
•
Aircraft Certification
Flight Standards
System Safety
Air Traffic Operations
Research
NASA
ICAO**
EASA (ECAST)
TCC
NATCA**
NTSB**
Safety Analysis Process
Turbofans Installed on part 25 Aircraft
NTSB Accident
Incident Reports
25
2.
21.3 Reports
ASIAS data
Airclaims data
Historical
Data
20
Level 4
15
Level 3
10
5
3.
4.
Intervention Strategy
Selectove
Appr
Pr oposal
Set
s
AccidTr
entain
/ in
Ig
ncident
Review
Repor t s
Accident / I ncident
Analyze
Repor t s
8. 25d
15d
2
5d
3
1/ 2/30/
10/
9695
1/ 12/
11/
17/96
95
10/ 30/ 95
11/ 3/ 95
11/ 6/ 95
Develop
I nt er vent ion
Pr ior it ized
St r at egies
Pr epar e
Dr af t
Repor t
Revise
11/ 10/ 95
Repor t
2h
6
3d
4
5d
1/ 10/ 96
1/ 2/ 96
1/ 4/ 96
11/ 13/ 95
11/ 17/ 95
Final
Repor t
Cowl separation
Multi-related
Unknown
Threat
Combined
Threat
Causal Analysis
Cause
Cause
JSAT
5d
1/ 10/ 96
Final
Engine separation
Accident
Accident / I ncident
7
Pr epar e
Crew error
JSAT
JSAT
5
1
Case rupture
Pareto Plots
Cause Cause
5.
Multi - unrelated
Fuel
contam./exhaustion
Reverser
Multi - common other
Fire (e.g., under
cowl)
Uncontained - blades
Malfunction + crew
error
JSAT
Multi - common - env.
0
Uncontained disk/spacers
Industry
CAAM Level 3 and 4 Events
1.
Repor t
Appr ove
8
1h
9
1h
Select
I nt er vent ion
St r at egies
10
1d
1/ 11/ 96
1/ 11/ 96
1/ 11/ 96
1/ 11/ 96
1/ 11/ 96
1/ 12/ 96
6.
Safer
Skies
Industry
7.
Government
Implementation Strategy
JSIT
AvSP
Measuring Progress to Goal
Coordinated Plan
5.3-23
CAST
Safety Strategy
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
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
Joint Safety Analysis
Team (JSAT)
Process
Typical JSAT Membership
• ALPA/APA
• FAA (AIR, AFS, ASA,
•
•
•
•
AAI, ATO)
Airbus
EASA
ATA
Transport Canada
• NASA
• Engine companies –
•
•
•
•
•
(PW, GE, RR-Allison)
Boeing
RAA
NACA
AIA
NATCA
JSAT Process
Charter
Development
Evaluate
Problem
Importance
Global
Review of
Characteristics/
Indicators
Assign
Standard
Problem
Statements
Identify
Intervention
Strategies
Establish
Team
Identify
Problems
(what/why)
Evaluate
Intervention
Effectiveness
Select
Data Set
Develop
Event
Sequence
Prioritize
Interventions
Review
Data
Record
Characteristics/
Indicators
Technical
Review &
Report
Results
5.5-24
Developed Event Sequence
• Facts and data
• Pilot - controller voice events
• Missed calls
• Events that occurred or should have
• Time coded each event
#
1015
Time
21:53:28
1016
1017
1018
1019
21:53:28
21:53:32
21:53:33
Event
ATC issued ATIS information Sierra: Ceiling
100’ overcast, 1/2 mile visibility and fog
F/O call 200’ above minimums
F/O calls ATC to report Marker Inbound
F/O call out 100’ above minimums
F/O fails to call out “runway not in sight” at the
minimums for the Decision Height
Develop Problem Statements
• Problem statements
–
–
–
–
What went wrong
Deficiency definition
Potential reason
Something which happened or didn’t happen
# Time
Event/Data Point
8:53:00 Aircraft took off
from Taipei Intl
1
Airport
10:45:00 F/O
briefed CAPT
2
on approach into
10:49:00 Capt gave very
basic guidance to
the F/O on aircraft
control during
approach and
landing.
3
Problem
(What)
Contributing
Factors
(Why)
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 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
Identify Intervention Strategies
• Intervention strategies
– Suggested solutions
– Things to do to prevent or mitigate the problem
– Etc.
# Time
Event/Data Point
8:53:00 Aircraft took off
from Taipei Intl
10:45:00 Airport
F/O briefed CAPT
2
on approach into
10:49:00 Capt gave very
basic guidance to
the F/O on aircraft
control during
approach and
landing.
Problem
(What)
Contributing
Factors
(Why)
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)
Standard Problem
Statement
A
P1
1
3
20 AIRLINE
OPERATIONS - LACK
OF TRAINING
(FLIGHTCREW)
3
5
414 Airline operations – 4
training failed to
adequately develop
FIRST OFFICER
piloting skills. (SPS-20)
3
Intervention Effectiveness
•
Power
–
•
Confidence
–
•
Effectiveness of a specific intervention in reducing the
likelihood that a specific accident would have occurred
(“Perfect World”)
Confidence that this specific intervention will have the
desired effect
Future Global Applicability
–
How well the intervention can be extrapolated to apply
to a world-wide fleet in the future
Effectiveness Rating Scales
POWER
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”)
0
Not at all
effective
1
2
3
4
5
6
Hardly any
effect
Slightly
effective
Moderately
effective
Quite
effective
Highly
effective
Completely
effective
CONFIDENCE
This scale is to be used to define the level of confidence that you have that this specific intervention will have the desired effect.
0
Not at all
confident
1
Hardly any
confidence
2
Slightly
confident
3
Moderately
confident
4
Quite
confident
5
6
Highly
confident
Completely
confident
FUTURE GLOBAL APPLICABILITY
This scale is to be used to estimate how well the intervention can be extrapolated to apply to a world-wide fleet in the future.
(for example: how often the situation it addresses occurs in accident scenarios; whether its impact is on present and future
operations (equippage, traffic, regulatory differences); and whether it is applicable across airlines/airplanes/regions.
0
Not at all
applicable
1
Hardly any
applicable
2
Slightly
applicable
3
Moderately
applicable
4
Quite
applicable
5
Highly
applicable
6
Completely
applicable
JSAT Reports
•
Standard Problem Statements
•
Interventions Prioritized
•
Recommendations
Joint Safety
Implementation Teams
(JSIT)
Process
JSIT Feasibility Scales
•
•
•
•
•
•
Technical
Financial
Operational
Schedule
Regulatory
Sociological
JSIT Safety Enhancements
•
Develop Safety Enhancements from
Interventions
•
•
Collect detailed resource information
Prepare Detailed Implementation Plans
(DIP’s)
Joint Implementation
Measurement Data
Analysis Team (JIMDAT)
Process
Develops a Prioritization Methodology
(JIMDAT)
•
Identifies the most effective solutions
derived from all accident categories
•
Considers effectiveness vs. resources
•
Tests solutions against fatal and hull loss
accidents
•
Creates draft master strategic safety plan
•
Identifies areas for future study/mitigation
Resource Cost Vs. Risk Reduction
10000
Risk Reduction
$
APPROVED PLAN
9000
Total Cost in
$ (Millions)
8000
75%
7000
6000
$
50%
2007
2020
5000
4000
3000
25%
2000
0%
$
$
$
1000
0
Resource Cost ($ Millions)
Risk Eliminated by Safety Enhancements
100%
Cost Savings
Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents
100
Historical cost of accidents
per flight cycle
Dollars/Flt. Cycle
80
Savings ~ $74/Flight Cycle
Or
~ $814 Million Dollars/Year
60
40
Cost of accident fatalities
following implementation of the
CAST plan @ 2020 levels
20
0
2007
2020
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
Intervention Name
EGPWS
CFIT TRN
Accident Portion of World Fleet
Eliminated .600
.900
Intervention Effectiven
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, MALAYSIA
747
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, VENEZUELA
DC9
IMPHAL, INDIA
737
STRASBOURG, FRANCE A320
KANO, NIGERIA
DC8
ATHENS, GREECE
707
CRUZEIRO DO SUL, BRAZIL
737
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
TERRAIN IMPACT/FINAL APPROACH.203 .000
TERRAIN IMPACT/FINAL APPROACH.203 .000
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 HIT HILL 20 MILES OUT/APPROACH
.657 .950
IMPACTED GROUND/FINAL
APPROACH
.586 .800
CFIT OUT OF PROCEDURE TRN-DARK
.586 .800
ABANDONED APPROACH-HIT MTN
.657 .950
HIT SHORT,DRK NT,DISTRACTED
.203 .000
CFIT-HIT MTN-MISSED APPROACH .657 .950
CRASHED SHORT DURING APPROACH.657 .950
LANDED SHORT MISLEADING LIGHTS
.538 .700
HIT LIGHTS ON TO/RMLG COLLAPSE
.000 .000
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
Basics of the Selection Spreadsheet
• Effectiveness
Each safety enhancements is evaluated against each undesired
condition in the set to determine how effective the enhancement would be
at eliminating these conditions if the enhancement were put in place.
• Implementation
Implementation level is based on the portion of the affected population
with the enhancement incorporated or predicted to be incorporated by a
future date.
• Severity Weighting
To account for differences in severity or significance of the undesired
conditions, a weighting value can be entered so that the relative risk of
the undesired conditions is realized.
Severity Weighting Overview
• To account for differences in fatality risk associated with each accident in the
data set, a severity value was applied. In this assessment, the severity value
represented the portion of people onboard that perished in the given accident.
• Example: Comparison of two fatal accidents
757 CFIT accident, 98% perished. Weighting factor is .98
747 Turbulence accident, .6% perished. Weighting factor is .006
• Hypothetically assume an assessment showed that the chance of these
accident occurring would have been reduced by proposed safety
enhancements by 50%.
• The associated portion of fatality risk eliminated can be determined
using the severity weighting factor as follows:
757 CFIT.98 x .5 = .49
747 Turbulence, .006 x .5 = .003
Analysis Tool Output
• The spreadsheet output can be set up to show the
effect that an individual safety enhancement, or
group of safety enhancements have on reducing
exposure to the undesired condition.
Fatality
Risk
Reduction
SE1
SE2
SE3
SE1 &
SE2
SE1 &
SE3
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
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
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
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
CAST Safety Plan
50 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.)
22 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
Fatal Accident Rate and Full Airplane Loss Equivalents
Rate for Part 121 Operations (5-Year Rolling Average)
Fatality Accidents or Full Loss Accident Equivalents
per 10 Million Departures
9.0
8.0
5 year moving avg of fatal accidents
per 10 million departures
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
82% Fatality Accident
Rate Reduction
1996-2007
International Perspective
CAST Safety Enhancements
Europe
United States
and Canada
CAST
72 SEs
50 complete
22 in work
ECAST
35 SEs JAA
11 SEs EASA
C.I.S.1
JAA
Non JAA
COSCAP CIS
Specific CIS Projects
Middle East
COSCAP GS
COSCAP BAG
Africa
COSCAP CEMEC
Latin America
and Caribbean
RASG-PA
COSCAP UEMOA
China
Asia
(Excluding
China)
COSCAP NA, SA, SEA
40 SEs in work
Oceania
CAST Phase 2
Transition to Decision Making
Based on Analysis of Incident and
System Safety Performance Data
Aviation Safety Information
Analysis Sharing (ASIAS)
The Aviation Safety Information Analysis
and Sharing (ASIAS) System Was Created
in Order To:
•
•
•
Develop tools to make data analysis more efficient
•
Develop automated information integration
capabilities centered on aviation safety risk topics
•
Transfer technologies and key data sources into
National Archives
Identify and access key data sources
Discover potential aviation safety risks using the
key data sources
ASIAS Enables Various Types of
Proactive Safety Analyses
Known Risk Monitoring
Vulnerability Discovery
Benchmarking Operations
Safety Enhancement
Assessments
Directed Studies
ASIAS Has Access to Multiple Data
Sources
Airline
Data
FAA
Other
Sources
• Digital Flight Data
• Voluntary Pilot Safety Reports
• Surveillance Data
• Traffic Management Reroutes & Delays
• Airport Configuration and Operations
• Sector and Route Structure
• Procedures
•Safety Reports
• Bureau of Transportation Statistics
• Aviation Safety Reporting System
• Weather / Winds
• Manufacturer data
• Worldwide Accident Data
ASIAS is Governed by Formal
Principles
Data used solely for
advancement of safety
Non-punitive reporting
Airline data is de-identified
Analyses approved by an
ASIAS Executive Board
Airlines Participating in ASIAS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
AirTran Airways Inc
Alaska Airlines
American Airlines
American Eagle
Atlantic Southeast Airlines
Chautauqua Airlines
Compass
Continental
Delta Airlines
Express Jet
Frontier Airlines
Gulfstream Intl
Jet Blue
Northwest
Republic Airlines
Shuttle America
SkyWest
Southwest
United
UPS
US Airways
• 21 ASIAS airlines with
signed Memoranda of
Understanding (MOUs)
(as of July 7, 2009)
• 75% of 2008 operations
Participating Airlines
21 airlines participating in ASIAS
representing 75% of 2008 operations
(as of July 7, 2009)
size of
circle:
240,000
ops
44
Benefits of ASIAS
With ASIAS, the aviation community will be able to . . .
• Identify Systemic Risks
• Establish safety baselines of current operations
• Identify known and newly emerging system
vulnerabilities
• Monitor safety trends
• Evaluate Identified Risks
• Estimate their probabilities
• Assess their severities
• Uncover event precursors
• Diagnose event causation
• Formulate Interventions
• Assess the probable effects of safety enhancements
through simulation studies
• Monitor Intervention Effects
• Assess the effectiveness of interventions (SEs) in
accordance with metrics established by the CAST
ASIAS Studies In Progress or
Completed
Runway Safety
Directed Studies
Terrain Awareness Warning System Study
TCAS Resolution Advisories
CAST
Known Risk and
Safety Enhancement
Effectiveness
Monitoring
Risk of Landing Runway Overrun
Approach and Landing Accident Risks
Controlled Flight Into Terrain (CFIT)
Terrain Awareness Warning System Alerts
Airline
Benchmarks
Unstabilized Approaches
TCAS Resolution Advisories
Prioritization Issues/Considerations
• There is a need for CAST to prioritize its desired
tasks so that MITRE resources and CAST
Subject Matter Expert (SME) support can be
managed effectively
• Use of MITRE resources and associated CAST
SME support needs to be looked at in total and
each task given a priority
47
CAST Use of Data
Status: currently ongoing:
Potential safety concerns are being
Developed & prioritized by JIMDAT.
CAST will request AEB to allocate
MITRE resources to build query tools
and provide query results
Study items from outside
requests
Processed data
Data (ASIAS
and any
other data)
Data Queries
& Data
Processing
Threshold
Filter
Attention
Items
(Disseminate information
to CAST when above a
TBD threshold)
Contributing
Factors
Understood?
No
Meet Study
Guidelines?
Yes
Prioritize CAST
Study Items
(Risk/Resources)
Yes
No
CAST may direct that
additional metrics or trend
monitoring be developed
(May require AEB approval)
CAST may direct that
additional metrics or trend
monitoring be developed
(May require AEB approval)
No
Perform study on
selected item
(May require AEB
approval – data &
MITRE resources)
Is risk level
sufficient for
mitigating
action?
Yes
Develop SE Metrics per
CAST direction
(May require AEB approval)
Initiate CAST
SE Development
48
Status: currently ongoing:
Potential safety concerns are being
developed & prioritized by JIMDAT.
CAST will request AEB to allocate
MITRE resources to build query
tools and provide query results
ASIAS Data
Data Queries
& Data Processing
Based on issue priority, CAST will
request resources (AEB/MITRE,
SMEs) for tool development, data
queries, data processing.
CAST Issue C
80
70
A
Number of Events
60
B
C
Potential
Study
Item
50
Threshold
40
30
20
10
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
CAST Precursors and Issues
1970
0
Year
Thresholds, exceedences, and
abnormalities will be unique to each
issue and have yet to be established
49
Safety Study Decision Guidelines
1. AIRPLANE ACCIDENT SAFETY
YES
NO
Supporting
data
A. The condition of interest was likely a significant contributing factor in a Part 121 or equivalent
catastrophic event (including relevant events on other classes of operations).
B. The condition of interest is considered to have a significant adverse influence on the effectiveness or
implementation of an approved safety enhancement that was not considered in the SEs original
assessment
C.
1.
1.1)
The condition of interest is considered to be a significant contributing factor to the occurrence
of a catastrophic accident in the future and:
there is an expectation of at least one catastrophic accident within the next 20 years.
OR
1.2)
the probability* of one or more catastrophic accidents is greater than 4x 10-6/flt cyc.
*Average per-cycle probability as applicable.
2. PERSONAL SAFETY
The condition could result in serious injury or death to crew or passengers, and cannot be shown to be
less probable than 1E-5/flight cycle (TBD).
3. OTHER
An event/condition that any CAST member considers to be a condition of study provided rationale is
presented and those resources needed for the study are approved by the affected CAST members.
50
Study Prioritization
(Fleet Risk)
Yrs to 1 or more expected accidents
30
Risk Level Appropriate for Monitoring
25
1 accident in 20 yrs
20
Risk Level Appropriate for Study
15
RR SEs Risk Levels
10
5
Fatality Accident Expectation @ Current Accident Rate
0
1%
10%
Fatality Risk - (Severity)
100%
51
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
• CAST has detailed plans in place to address known
problems
• CAST is refining incident analysis and operational
data mining to uncover problems before they result
in accidents
52
http://www.cast-safety.org/