Accident prevention rests in terabytes of safety data and global cooperation

Sep 30, 2007

As the world fleet multiplies and passenger traffic is counted in billions, one of aviation’s major challenges is to drive down the accident rate. And meeting that goal requires a new method of prevention—harvesting terabytes of data from safety reporting systems—to identify causal precursors and stop the smoking hole in the ground from happening.

“We are living in an era of unprecedented aviation safety, both in the U.S. and around the world,” says the FAA’s Nicholas A. Sabatini, associate administrator for aviation safety. Last year, the U.S. recorded 0.223 total accidents, and 0.018 fatal accidents, per 100,000 departures The International Air Transport Assn. declared 2006 “the safest year ever” for world aviation with 1.0 accidents per 1.5 million departures, and 0.65 fatal accidents for every 1 million departures (see chart).

Those numbers did not happen by chance, says Sabatini. From 1946 to the present, the U.S. fatal accident rate dipped due to interventions put in place.

In this period, the traditional post-accident diagnostic method of prevention was in play: First, the crash occurred; second, an investigative agency found probable cause; third, recommendations, regulations were enacted to prevent recurrence.

“But the method is not one we can continue to use,” says Sabatini. “We are no longer seeing common-cause accidents. What we are seeing is that each has unique circumstances.”

“The future is about [identifying] what could potentially happen, and key to its success is working with industry to resolve the safety issues before us,” Sabatini notes.

Through analyzing data, precursors will be noted and interventions put in place before an incident occurs.

To move from diagnostic to prognostic accident analysis on a world scale, FAA is developing the Aviation Safety Information Analysis and Sharing (ASIAS) program that will be accessible to the global aviation community.

ASIAS will gather safety data from government and industry sources. These include FAA’s air traffic control data, the NTSB accident/incident base, and established non-punitive safety data reporting systems, such as Flight Operational Quality Assurance and Aviation Safety Reporting Systems (see chart). The terabytes of data are de-identified, grouped and studied to pinpoint trends.

How exactly would data translate to saving lives? Sabatini provides an example following the NTSB’s determination of probable cause of the Aug. 27, 2006, crash of Comair Flight 5191 at Lexington (Ky.) Blue Grass Airport.

The flight crew’s failure to use available cues to determine the aircraft’s position led to a takeoff from the wrong runway that ended in a crash that killed 49 of 50 people on board.

Parties to the investigation looked beyond that, says Sabatini, and asked if there was cause for pilot confusion at select airports. The ASIAS office examined 5.4 million records to discover that in a 20-year period there were 117 isolated instances where flight crews reported confusion while operating at certain U.S. airports.

“The data was there,” says Sabatini, who notes the challenge of such a system is “how to determine what event[s] are of concern and require a paradigm to address them.”

And when data indicated a rise in Category A runway incursions (where the greatest chance for collision exists), the FAA in August convened an unprecedented Call to Action with industry decision makers to address the urgent global issue of incursions.

The meeting was a “snapshot of the future” says Sabatini, where industry and government will collaborate in finding solutions when data drive them together.

The Call to Action translated into practical safety measures. Air Wisconsin, for example, initiated a simulator training scenario that begins at the gate and includes taxi out to the runway, rather than at the traditional starting point, the departure end of the runway. The airport community also weighed in on runway markings that required improvement.

If the system is to work, aviation laws will require harmonization, with infrastructure (both regulatory and physical) standardized worldwide. “When it comes to safety, sovereignty has no boundaries,” says Sabatini.

“And as industry globalizes, it has to be far more involved in global issues as well,” says Flight Safety Foundation President/CEO William R. Voss. “You can’t be distracted by your own backyard.”

A strong regulatory capability to build and enforce a safe system is required. “If the regulator doesn’t engage, you are handed an unwinnable fight.” Voss is concerned that some developing states will have a tough time “trying to live up to the safety record of the rest of the world because it is going to be difficult for them to say ‘no’ to [economic] growth. So too, regulators in some new countries cannot keep up oversight responsibility. Fees that are aimed for support of aviation growth aren’t necessarily being directed at infrastructure, but toward the regulatory mechanisms that must be put into place.

“We have to make safety a political issue,” says Voss, “[and apply] a ‘pressure among peers’ of regulators, of states looking out for other states.”

He cites the U.S. and Europe putting pressure on other states to live up to their safety oversight obligations. Voss says he maintains a “pro-activist rather than a pro-blacklist posture. Countries working in a sort of web of enforcement is really the ultimate answer to many regulatory problems.”

Voss points to China’s creative solution to managing growth. Yang Yuan Yuan, minister for civil aviation, has limited the rate of economic growth and is holding safety as the constant, raising pilot training requirements, for example. China’s traffic grew nearly 19.5% in the first half of the year; 4,000 aircraft are anticipated to be flying in 2020 compared with 1,039 now in operation.

The globalization of aviation is increasingly evident. The International Air Transport Assn. Operational Safety Audit program, a requirement for members, is aimed at setting an operations standard. IATA formed a working group to examine the new airline pilot licensing standard (see p. 54) and is offering workshops on implementing the Safety Management System (SMS), a program Voss describes as an “absolutely vital and efficient way of attaining levels of safety.”

SMS is a structure of voluntary, non-punitive reporting methods set up within a company to foster safety awareness throughout the organization, from boardroom to maintenance bay. Some regulators have already instituted broad-based safety programs. In 2005, Transport Canada mandated its airlines adopt SMS.

When the worst occurs, it remains the investigative agency’s job to follow the post-accident diagnostic method: Discover the probable cause and issue recommendations.

Finding precursors is not the NTSB’s mission per se, says Chairman Mark Rosenker. He considers the agency very proactive in terms of preventing accidents from recurring through recommendations, and says this plays “a tremendous role in bringing down the rates.”

“The more data available, the better equipped you are to deal with incidents and accidents, and a better understanding of the trends can truly make a difference in recommendations,” Rosenker adds.

The NTSB also is engaged in the new predictive methodology, and is in the initial stages of building a data bank for internal use that will provide “good hard data” on causes of U.S. general aviation accidents and incidents. This sector, while much improved, recorded 6.64 total accidents and 1.32 fatal accidents per 100,000 departures in 2006 (see p. 57). In building safety on a global scale, the highly respected accident investigation body, says Rosenker, can be “a tremendous influence.” It is invited by many developing nations to assist in investigations, provide guidance in building counterpart agencies and aid in the training of investigators and other personnel.

However, the need for pressure among peers again rises. Rosenker says, “More needs to be done [in industry] to target countries where there is a lack of standardization, some lack of regulation, or where a pattern of accidents occurred that could have been prevented—countries who are not compliant with ICAO Annex 13 guidelines to the spirit and letter.”

“You can make a difference in this business. Investigating an accident, finding its cause, preventing it from recurring . . . short of being a doctor, I can’t think of any greater profession dedicated to saving lives.”   from this link


Fatal Crashes of Airplanes Decline 65%

Published: October 1, 2007
WASHINGTON, Sept. 30 — After two infamous crashes in 1996 that together killed 375 people, a White House commission told the airline industry and its regulators to reduce the domestic rate of fatal accidents 80 percent over 10 years. That clock ended Sunday.

They have come close to reaching that goal. Barring a crash before midnight Sunday, the drop in the accident rate will be about 65 percent, to one fatal accident in about 4.5 million departures, from one in nearly 2 million in 1997.

There have been no fatal airliner crashes involving scheduled flights this year in the United States and just one fatal accident: a mechanic who was trying to close the cabin door of a chartered Boeing 737 on the ground in Tunica, Miss., fell to the pavement during a rainstorm.

Around the world, airliners continue to crash. There have been 7 crashes this year that killed more than 20 people each.

Even so, there has been strong progress internationally. William R. Voss, president of the Flight Safety Foundation, recently calculated that if the 1996 accident rate had remained the same in 2006, there would have been 30 major accidents last year. Instead, there were 11.

“This is the golden age of safety, the safest period, in the safest mode, in the history of the world,” said Marion C. Blakey, the administrator of the Federal Aviation Administration, in a speech to an aviation group in Washington on Sept. 11, two days before her five-year term ended.

Some of the improvement may be luck, as there is an element of randomness to crashes. But part of the explanation certainly lies in the payoff from sustained efforts by American and many foreign airlines to identify and eliminate small problems that are common precursors to accidents.

Airlines around the world, even in less-developed nations, have also benefited from equipment improvements, like cockpit instruments that help planes steer clear of mountains when visibility is poor, and jet engines that are so reliable that pilots can go through their entire careers without seeing one fail.

Aviation safety experts have uncovered subtle problems. One oft-cited example is a discovery in the last decade by US Airways (then US Air) that many of its planes approaching Charlotte Douglas International Airport in North Carolina were coming in “high and hot,” too fast and at a steep angle.

As a result, airplanes were conducting “unstabilized approaches,” meaning pilots had to fiddle with flaps, throttle and other controls just before landing.

The US Airways discovery at Charlotte was something new because the airline did not demostrate it after a crash or from pilot reports.

The airline instead tapped into the system that feeds information to one of the “black boxes,” the flight data recorder, and siphoned off a stream of data that went to a removable recording device. Then it analyzed flights by the hundreds and looked for unusual patterns, a technique now common with airlines.

Convinced, the F.A.A. changed the approach procedure there, and the airport installed a system to guide planes at a proper angle.

Nearly all unstabilized approaches end with a safe landing, but a study by Mr. Voss’s organization found that such approaches were a factor in two-thirds of 76 accidents and serious incidents worldwide during landing attempts from 1984 to 1997. So one focus of the last 10 years has been to look for air traffic procedures that could cause problems.

The Air Line Pilots Association cited another problem that is now being resolved. The airlines pooled their data — an action that was itself an innovation — on operations at Reno, Nev., and found that the cockpit system that warns of imminent flight into a mountain often sounded a false alarm.

Aviation experts say that if safety alarms sound falsely too often, they become like the homeowner’s smoke alarm that is set off by an egg frying in the kitchen — people start ignoring it. As at Charlotte with the “high and hot” approaches, this was a known glitch in the system that had not caused any crashes, but that might someday contribute to one.

The solution in Reno, which is still being developed, is better guidance for pilots to follow flight paths precisely and stay farther away from mountains in the area.

In other places, improvements have been as simple as better signs on taxiways to prevent planes from moving into the path of other aircraft.

“It’s not one thing. It’s a series of small things,” said John Cox, who was an Air Line Pilots Association safety representative for 20 years. Many of those small things were minor problems observed in everyday operations, he said, then counted, scrutinized and eliminated before they caused an accident.

Newer planes are also safer. All American airliners, for example, now have “enhanced ground proximity warning systems.” These systems use the Global Positioning System to compare the plane’s position against a database of mountains and buildings, and warn of impending collision.

Analyzing data from safe flights is a reversal of the historic practice, which is to go out and “kick the tin” after a plane crash, looking for clues. Analyzing safe flights is almost all that is left, experts say, as the accident rate falls and there is less tin to kick.

“The sample is so small, you won’t have effective data sampling,” said Hank Krakowski, a United Airlines executive who served as co-chairman of the Commercial Aviation Safety Team. That team is an outgrowth of the White House commission, and it comprises airlines, aircraft builders and pilot unions. (In October, Mr. Krakowski is to become the F.A.A.’s chief operating officer.)

Some unions have complained about trends like maintenance outsourcing, in which an airline pays another airline or an outside shop to do crucial safety work, and some government auditors have echoed the concern.

But there have been no fatal crashes in which maintenance error was a cause since January 2003, when a US Airways Express flight, a Beechcraft 1900, went out of control on takeoff because of an improperly rigged tail. Statistically, the era of outsourcing appears to be safer than when airlines did most of the work themselves, although that does not suggest a cause-and-effect relationship.

The decade-long push to reduce the accident rate began with a “safety summit” in 1996, after the T.W.A. Flight 800 disaster off Long Island and the ValuJet crash in the Everglades of Florida. The summit was convened by the secretary of transportation at the time, Federico F. Pena, who declared a goal of zero accidents.

In 1997, a national commission on aviation safety and security, led by Vice President Al Gore and known as the Gore Commission, concluded that a more realistic goal would be to cut the rate of fatal accidents by 80 percent. Because crashes are sporadic, the goal was stated as the average of the most recent three years.

Despite the safety improvements since then, not all the trends are positive. Airports have lately recorded a disturbing number of what they call “proximity events,” in which a plane lands on a runway already occupied by another because someone made a wrong turn or a controller made an error.

On July 11, for example, a United plane in Fort Lauderdale, Fla., took a wrong turn onto a runway where a Delta Air Lines plane was supposed to land; the two came within 100 feet, according to the F.A.A.

“Probably the biggest threat of all, today, many, many people agree, is not so much a midair collision as a runway incursion incident,” said Richard Healing, an aviation safety expert and former member of the National Transportation Safety Board.

The F.A.A. has a radar system at many airports to warn tower controllers of conflicts on the airport surface, but the system can be confused by puddles on the pavement, which the radar sometimes misinterprets as airplanes. And it warns only the controllers, not the pilots directly.

The F.A.A. is improving the ability to track airplanes on the ground by gradually installing a system that uses a combination of radar and other means, including one that uses multiple antennas to listen for radio beacons on the plane and, by triangulation, calculate its position.

But the safety board argues that even if the new system works as designed, it is still inadequate because several seconds will elapse from the time the system sounds an alarm to when the controller sees it and issues instructions to pilots.

The F.A.A. is experimenting at Dallas-Fort Worth with “runway status lights,” embedded in the pavement, that flash at pilots when a runway is occupied.

As the number of flights increases, the rate of crashes has to decline or the absolute number of crashes will rise. And as airports get busier, the risk of a crash on the ground increases.

Adding to the problem is that airliners are getting smaller, and a new class of “very light jets,” seating four to eight people, is entering service. Some of those may be flown by a single pilot who is not a professional, but they will fly at the same altitudes as airliners.

The F.A.A. is facing challenges as it handles ever more traffic. It wants a new air traffic system that can squeeze planes closer together. It wants more reliance on user fees instead of taxes on passenger tickets, cargo and fuel.

But Congress has not agreed. It has approved only a temporary extension of current taxes. And although the F.A.A. administrator’s five-year term has expired, the White House has not named a candidate it will try to get through the Democratic Senate.

The aviation system continues to evolve, with new runways, new terminals and new towers.

In mid-September, the F.A.A. opened a new tower at Washington Dulles International Airport. It will handle 25 million to 26 million passengers this year, but the airport’s managers estimate that traffic will double by 2025. The number of runways will go to five from three, and midfield concourses will double to four.

The new tower replaces the signature Eero Saarinen model of the early ’60s, which is perched next to the sweeping roof line of the terminal. It can house up to a dozen working controllers comfortably; the old one was a squeeze for nine.

At 25 stories tall, it lets controllers see even small jets between the terminals. The older, shorter tower required them to strain to see some planes taxiing between terminals.

“With the regional jets, we’d see the top of the tail through the air-conditioners,” said David Bridson, a controller.

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