Transcript Rewriting Safety’s Future

Rewriting
Safety’s Future
F-117
“... 90 per cent of the total
accidents that have occurred
are directly traceable to the
lack of knowledge of or failure
to realize dangerous positions
of the airplane operations,
whether of speed, angle, or
direction.”
Aero and Hydro, Vol 5, Nov 2,
1912, 80-81, "Aviation
Instruments: Construction
and Use, I. Altitude"
E. R. Armstrong
Wright Flyer
F-22
If you do not have the
technical expertise to
engineer, build, or fly
the aircraft then what I
have to say next does
not matter.
Bleriot
Why do we care?
The Motivation:
In a five year span from
September 1989 to
September 1994 my airline
experienced five major
airline accidents resulting
from:
B-737
A Rejected Take-off:
20 September 1989; 737400; La Guardia Airport,
New York:
The crew of flight 5050 rejected
takeoff due to rudder trim problems.
The aircraft overran the runway and
was partially submerged in water.
Two of the 55 passengers were
killed.
Controller Error:
1 February 1991; 737-300;
Los Angeles, CA:
Flight 1493 was cleared to land on
a runway which also had a
Metroliner III on the runway
awaiting takeoff. The aircraft
collided and burst into flames.
Two of the six crew members and
20 of the 83 passengers on the jet
were killed. All 10 passengers and
2 crew members on the Metro III
were killed.
F-28
Deicing: 22 March 1992;
F28-4000; New York, NY:
On flight 405 the aircraft crashed
just after takeoff in snowy
conditions due to icing on the
aircraft's wings. Three of the four
crew members and 24 of the 47
passengers were killed.
DC-9
Wind Shear: 2 July 1994; DC931; Charlotte, NC:
On Flight 1016 the aircraft encountered
heavy rain and wind shear during
approach at about 3.5 miles (5.6 km)
from the runway. The crew executed a
go around for another landing attempt,
but the aircraft could not overcome the
wind shear. All five crew members
survived, but 37 of the 52 passengers
were killed.
Rudder Upset:
8 September 1994; 737-300;
near Pittsburgh, PA:
On flight 427 the aircraft lost control
at about 6,000 feet (1830 meters)
during approach. All five crew
members and 127 passengers were
killed.
Individually these
accidents were not in
and of themselves
directly related to
operations and could
have occurred at any
airline.
The Microscope on the
Problem
Airline Mergers
 In
the past 25 years 23% of all 121 air
carrier fatalities have occurred during
merger integration
 The
catalyst of Change
The Microscope on the
Problem
Mirror Image
 Unfamiliarity
 Inadvertent
with a Task
Selective Compliance
A Dangerous
Mindset
The Microscope on the
Problem
Altitude Excursions
Runway Incursions
P-51
The Approach and Results
Operation Restore Confidence
Life Preservers
 Pointing Fingers
 Altitude Awareness

Altitude
ASAP
deviations - 10 per month
(Aviation Safety Action
Partnership)
F- 4
F-4
The Approach and
Results
CRM (Crew Resource Management)
Viable
By
Program
Pilots for Pilots
The Approach and
Results
ECAP (Enhanced Crew Awareness
Program)
Error Management Model
(based on the Volant Model)
The Approach and
Results
ECAP (Enhanced Crew Awareness
Program)
Foundation of our training and
operating practice
CONDITIONS THAT INCREASE
HUMAN ERROR PROBABILITY



Unfamiliarity with the task = 17X
Time pressure = 11X
Poor human-machine interface = 8X
SR-71
INADEQUATE FLIGHT CREW
MONITORING
ASRS (Aviation Safety Reporting
System) Study – 1997
Monitoring Errors
 78%
 76%
resulted in altitude deviations
identified in the study, were initiated
when the aircraft was in some "vertical"
phase of flight
NTSB's Special Study
 “Crew
Caused" air carrier accidents
 84%
involved flight crew failure to
adequately monitor the aircraft
flight path
ASAP (Aviation Safety Action
Program) reports
Remember 1912
“... 90 per cent of the total
accidents that have occurred are
directly traceable to the lack of
knowledge of or failure to realize
dangerous positions of the
airplane operations, whether of
speed, angle, or direction.”
ADHERENCE TO PROCEDURES
Boeing's "Accident Prevention
Strategies" study 1996-2005
 Hull
Loss Accidents Worldwide cites Flight
Crews as being the primary cause by 55%
Procedures and Standardization
incorporated in our ECAP program
Operate “in the green"
Conclusions
Data Streams Report the Airline’s
Progress
 ASAP
(Aviation Safety Action
Program)
 FOQA (Flight Operation Quality
Assurance)
 SOA (Special Operations Area)
Focus
Familiarizing ourselves with the
tasks at hand
 Increasing our crew monitoring
and cross checking skills
 Adherence to policies and
procedures

No Accidents Since Those Tragic
Years
Has Weathered The Storms of
•
•
•
9-11
bankruptcies
another merger
The ECAP Procedures continue to
evolve as they have proven to be
the best tools for Rewriting our
Safety’s Future.
Airbus 330
Rewriting our Safety’s Future
Excerpts from this piece have been reprinted from US Airway's
Safety On Line 2005 article on "Merger Related Accidents", US
Airway’s 1990 Altitude Awareness Program data files, US
Airway’s 1991 CRM Program data files, US Airway’s 2007/2008
Flight Training and Standards article on “Challenge to Change
History” by Capt. Lori Cline, ECAP White Paper by Capt. Robert
Sumwalt, ASRS's: "What ASRS Data Tell About Inadequate
Flight Crew Monitoring," Boeing's Study on "Accident
Prevention Strategies," FAA documents, NTSB reports, ALPA
records, and Aero and Hydro – Nov. 1912