Briefing to COSCAP-SABriefing to COSCAP-SA

South AsiaSouth Asia

Steering CommitteeSteering Committee

Kyle L. OlsenKyle L. OlsenAviation Safety Consultant – FAAAviation Safety Consultant – FAA

26 - 28 January 2010 – Bangkok, Thailand26 - 28 January 2010 – Bangkok, Thailand

Commercial AviationSafety Team

(CAST)

Commercial Aviation Safety Commercial Aviation Safety Team (CAST)Team (CAST)

* Representing P&W and RR** Observer

AIAAirbusALPAAPAATAIFALPANACABoeingGE*RAAFSF

CAST brings key stakeholders to cooperatively CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agendadevelop & implement a prioritized safety agenda

Industry

Commercial Aviation Safety Team

(CAST)

Government

DODFAA

• Aircraft Certification• Flight Standards• System Safety• Air Traffic Operations• Research

NASAICAO**JAA / EASATCCNATCA** NTSB**

IATA**AAPA** ATAC**APFA**

HUMAN FACTORSIN OPERATIONS &

MAINTENANCE

Carry-on Baggage

Child Restraint

Passenger Interference

CABIN SAFETY

IMPROVED DATA & ANALYSIS

GENERAL AVIATION

Loss of Control

Weather

Survivability

Aeronautical Decisionmaking

Controlled Flight

Into Terrain Approach and Landing

COMMERCIAL AVIATION

Controlled Flight Into Terrain

Loss of Control

Weather

Uncontained Engine Failures

Runway IncursionPassenger Seat Belt Use

Runway Incursions

Safer SkiesSafer Skies

Turbulence

• Safety enhancement development

• Master safety plan • Enhancement

effectiveness• Future areas of

study

• Data analyses

CAST

Joint Safety Analysis Teams (JSAT)

Joint Safety Implementation

Teams (JSIT)

Joint Implementation Measurement Data

Analysis Team (JIMDAT)

Commercial Aviation Safety Team (CAST)Commercial Aviation Safety Team (CAST)Commercial Aviation Safety Team (CAST)Commercial Aviation Safety Team (CAST)

5.5-24

JSAT Process

CharterDevelopment

EstablishTeam

SelectData Set

ReviewData

IdentifyInterventionStrategies

AssignStandardProblem

Statements

RecordCharacteristics/

Indicators

DevelopEvent

Sequence

EvaluateIntervention

Effectiveness

PrioritizeInterventions

Technical Review &

ReportResults

IdentifyProblems

(what/why)

GlobalReview of

Characteristics/Indicators

EvaluateProblem Importance

Effectiveness

that an intervention has for reducing the accident rate if incorporated

Portion of world fleet with intervention implemented

( ),Accident Risk Reduction =

General Methodology for Calculating the General Methodology for Calculating the Potential Benefit of a Safety Enhancing Potential Benefit of a Safety Enhancing

InterventionIntervention

General Methodology for Calculating the General Methodology for Calculating the Potential Benefit of a Safety Enhancing Potential Benefit of a Safety Enhancing

InterventionIntervention

Accident Date Location Aircraft Accident Description Portion Intervention Name

Class Type of EGPWS CFIT TRN

Description Accident Portion of World Fleet with Intervention Implemented by (2007)

Eliminated .600 .900

Intervention Effectiveness (%/100)

CFIT 1/2/1988 IZMIR, TURKEY 737 HIT MOUNTAIN ON APPROACH .657 .950 .226CFIT 2/8/1988 LUANDA, ANGOLA 707 HIT ANTENNA ON APPROACH .586 .800 .226CFIT 2/27/1988 KYRENIA MTS, CYPRUS 727 HIT MOUNTAIN ON APPROACH .657 .950 .226CFIT 3/17/1988 CUCUTA, COLUMBIA 727 HIT MOUNTAIN DURING CLIMB .657 .950 .226CFIT 6/12/1988 POSADAS, ARGENTINA MD80 CRASHED ON FINAL APPROACH .203 .000 .226CFIT 7/21/1988 LAGOS, NIGERIA 707 CRASHED ON APPROACH .203 .000 .226CFIT 10/17/1988 ROME, ITALY 707 LANDED SHORT .203 .000 .226CFIT 10/19/1988 AHMEDABAD, INDIA 737 LANDED SHORT .586 .800 .226CFIT 2/8/1989 SANTA MARIA AZORES 707 TERRAIN IMPACT/DESCENT .657 .950 .226CFIT 2/19/1989 KUALA LUMPUR, MALAYSIA747 TERRAIN IMPACT/APPROACH .657 .950 .226CFIT 6/7/1989 PARAMARIBO, SURINAMEDC8 TERRAIN IMPACT/FINAL APPROACH.203 .000 .226CFIT 7/27/1989 TRIPOLI, LIBYA DC10 TERRAIN IMPACT/FINAL APPROACH.203 .000 .226CFIT 8/25/1989 ANKARA, TURKEY 727 HIT ILS ANT. ON TAKEOFF .000 .000 .000CFIT 10/21/1989 TEGUCIGALPA, HONDURA727 TERRAIN IMPACT/APPROACH .657 .950 .226CFIT 10/26/1989 HUALIEN, TAIWAN 737 TERRAIN IMPACT/DEPARTURE .657 .950 .226CFIT 2/14/1990 BANGALORE, INDIA A320 HIT SHORT (300 FT) .203 .000 .226CFIT 6/2/1990 UNALAKLEET, ALASKA 737 HIT HILL 7 MILES OUT IN FOG .657 .950 .226CFIT 11/14/1990 ZURICH, SWITZERLAND DC9 CRASHED 5 MILES SHORT .634 .900 .226CFIT 12/4/1990 NAIROBI, KENYA 707 HIT POWER LINE ON ILS FINAL .203 .000 .226CFIT 3/5/1991 MT LA AGUADA, VENEZUELADC9 HIT MOUNTAIN/APPROACH .657 .950 .226CFIT 8/16/1991 IMPHAL, INDIA 737 A/C HIT HILL 20 MILES OUT/APPROACH.657 .950 .226CFIT 1/20/1992 STRASBOURG, FRANCE A320 IMPACTED GROUND/FINAL APPROACH.586 .800 .226CFIT 2/15/1992 KANO, NIGERIA DC8 CFIT OUT OF PROCEDURE TRN-DARK.586 .800 .226CFIT 3/24/1992 ATHENS, GREECE 707 ABANDONED APPROACH-HIT MTN .657 .950 .226CFIT 6/22/1992 CRUZEIRO DO SUL, BRAZIL737 HIT SHORT,DRK NT,DISTRACTED .203 .000 .226CFIT 7/31/1992 KATMANDU, NEPAL A310 CFIT-HIT MTN-MISSED APPROACH .657 .950 .226CFIT 9/28/1992 KATMANDU, NEPAL A300 CRASHED SHORT DURING APPROACH.657 .950 .226CFIT 11/25/1992 KANO, NIGERIA 707 LANDED SHORT MISLEADING LIGHTS.538 .700 .226CFIT 11/26/1992 MANAUS, BRAZIL 707 HIT LIGHTS ON TO/RMLG COLLAPSE.000 .000 .000CFIT 4/26/1993 AURANGABAD, INDIA 737 HIT TRUCK AFTER TAKEOFF .000 .000 .000

Spreadsheet Example – Historical Airplane Accidents & Proposed Safety Enhancements

Spreadsheet Example – Historical Airplane Accidents & Proposed Safety Enhancements

0

5

10

15

20

25

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0

Score

Combined Score

Combined SOPs

Example Scatter ChartExample Scatter Chart

DollarsIn

Millions

2007 Implementation & Resources

CAST Safety PlanCAST Safety Plan52 Completed Safety Enhancements52 Completed Safety EnhancementsSafety Culture Safety Culture

Maintenance Procedures Maintenance Procedures

Flight Crew TrainingFlight Crew Training

Air Traffic Controller TrainingAir Traffic Controller Training

Uncontained Engine FailuresUncontained Engine Failures

Terrain avoidance warning system (TAWS)Terrain avoidance warning system (TAWS)

Standard Operating ProceduresStandard Operating Procedures

Precision ApproachesPrecision Approaches

Minimum Safe Altitude Warning (MSAW) SystemsMinimum Safe Altitude Warning (MSAW) Systems

Proactive Safety Programs (FOQA + ASAP)Proactive Safety Programs (FOQA + ASAP)

CAST Safety Plan (cont.)CAST Safety Plan (cont.)

20 Committed Safety Enhancements20 Committed Safety EnhancementsPolicies and ProceduresPolicies and Procedures

Aircraft Design Aircraft Design

Flight Crew Training (additional aspects)Flight Crew Training (additional aspects)

Runway SafetyRunway Safety

Precision ApproachesPrecision Approaches

Icing (additional turboprop projects) Icing (additional turboprop projects)

MidairMidair

MaintenanceMaintenance

Cargo safety culture, policies and proceduresCargo safety culture, policies and procedures

12

72 Safety Enhancements

52 Complete – 72%

20 Underway – 28%

2020 Plan Risk Reduction Estimate

74 %

72%

22%

6%

Safety Enhancements

13ECAST #4-099 December 2009

13

2020 CAST SAFETY PLAN – 72 SE; 51 Complete; 21 Underway

115.1

215.0

3.5

41.1

5.4

67.9

77.9

87.9

9.8

1016.4

113.4

125.3

13.8

145.7

159.2

16.7

170

181.5

190.1

203.6

211.5

237.4

24R22.4

256.0

262.3

278.8

285.0

291.9

30R10.7

3112.2

320

34R10

390

400

461.6

471.2

491.5

502.6

532.7

520

510

551.7

590

601.5

780

84.8

851.2

COMPLETE ON TRACK IN QUESTION LATE

JIMDAT Score/2007 implementation level

1200

14

SE-184 TAWS:

Minimum Vectoring Altitude Re-evaluation (ATO)

The purpose of this Safety enhancement is to reduce or eliminate the number of TAWS alerts by adjusting MVAs where needed. To help determine which MVAs need to be adjusted, an analytical capability will be developed that can identify, by geographical area, the minimum MVA. Sector design and airspace limitations will also be considered in the reevaluation as appropriate.

OP1

Develop an analytical capability

to facilitate the study of MVAs

8/31/2010 8/31/2011

ASA

8/6/2009

COMPLETED

OP2

Accomplish a study of MVAs at prioritized sites

OP3

Implement the MVA changes identified

by the MVA evaluation

ATOATO

DIP

CAST approved 8/6/2009.

15

SE-185 TAWS:

TAWS and RNAV Visual or other procedures (AFS-400)

The purpose of this enhancement is to reduce terrain alerts and to provide better separation from terrain by providing RNAV Visual or other procedures that mitigate known TAWS and terrain issues.

OP1

Develop criteria and tools to

evaluate procedures

02/28/2010 02/28/2011 02/28/2010

ATO

8/31/2010

OP2

Prioritize locations and investigate

potential for mitigation

OP3

Develop RNAV Visual procedures where appropriate

OP4

Develop plan for other mitigation

procedures

AFS-470JIMDAT ATO

DIP

CAST approved 8/6/2009.

COSCAP- South AsiaCOSCAP- South Asia

• 45 CAST Safety Enhancements have 45 CAST Safety Enhancements have been accepted and are being been accepted and are being implemented. implemented. (19SCM-DP2-Att-3)(19SCM-DP2-Att-3)

• 8 Advisory Bulletins issued8 Advisory Bulletins issued

• 17 Advisory Circulars issued17 Advisory Circulars issued

• Guidance materialGuidance material

• TrainingTraining

• Web site: www.coscapsa.orgWeb site: www.coscapsa.org

ICAO Global Aviation Safety ICAO Global Aviation Safety Plan – Roadmap Plan – Roadmap

Global Aviation Safety PlanGlobal Aviation Safety Plan

n Proactive approach to aviation safety

n 12 Focus Areas established– 4 Focused on States (government)– 1 Joint regional responsibilities– 7 Focused on industry (operators)

n The Focus Areas are high level– Accident risk reduction not defined or

identified

Global Aviation Safety PlanGlobal Aviation Safety Plann Global Safety Initiative 1 (GSI-1)

– Inconsistent Implementation of International Standards

n Global Safety Initiative 2 (GSI-2)– Inconsistent Regulatory Oversight

n Global Safety Initiative 3 (GSI-3)– Impediments to Reporting of Errors and

Incidentsn Global Safety Initiative 4 (GSI-4)

– Ineffective Incident and Accident Investigations

Global Aviation Safety PlanGlobal Aviation Safety Plan

n The strategic action plan, ‘Roadmap’ defines for each initiative:– Focus Areas.– Objective for each Focus Area.– Best Practices for each Focus Area.– Metrics for each Best Practices.

GASR Best Practice exampleGASR Best Practice exampleGSI - 3GSI - 3

Table 3a –Best Practices Metrics Implementation

BP 3a-1 – The State has a legislative framework that protects safety data.  The State legislation must include provisions which protect privacy, prevent self incrimination and properly apportion criminal liability for actions. Without these basic features, full disclosure of safety related information will be extremely difficult.

a. ICAO Annex 13 Attachment E b. USOAP AIG 6.505

□ Complete  □ Somewhat  □ Little/None  □ Not Applicable  Analysis:

GASR Best Practice exampleGASR Best Practice exampleGSI - 4GSI - 4

Table 4a –Best Practices Metrics Implementation

BP 4a-3 – States have access to trained accident investigators.  a. States have access to a set of trained accident investigators, either internal investigators or from a regional or international/global source.  b. As applicable, procedures have been established for delegation of accident investigations to other States or regional bodies.

ICAO Doc 9756 Part I    USOAP AIG 6.033; AIG 6.109 ; AIG 6.113

□ Complete  □ Somewhat  □ Little/None  □ Not Applicable  Analysis:

COSCAP Asian Regional Aviation COSCAP Asian Regional Aviation Safety Team - June 2009Safety Team - June 2009

Safety Sub-Team – November 2009Safety Sub-Team – November 2009

n Reviewed Best Practice, GSI-1 to -5– Actions proposed

– (19SCM-DP2-Att-2)

n Additional Actions related to GSI-3 & -4:– AIG / Reporting sub-team meet Nov 2009– Develop model AIG rules – Develop model manuals– Continued analysis of GSI-3 and GSI-4

– (19SCM-DP2-Att-5)

SummarySummary

Regional PerspectiveRegional PerspectiveAccident Rates Vary by Region of the WorldAccident Rates Vary by Region of the WorldWestern-built transport hull loss accidents, by airline domicile, 1998 through 2007

Accidents permillion departures

United Statesand Canada

0.4

Latin Americaand Caribbean

2.1

Europe0.7

China0.3

Middle East2.3

Africa10.0

Asia2.1

Oceania0.0

(ExcludingChina)

C.I.S.1

1 Insufficient fleet experience to generate reliable rate.

World1.1

Regional PerspectiveRegional PerspectiveAccident Rates Vary by Region of the WorldAccident Rates Vary by Region of the WorldWestern-built transport hull loss accidents, by airline domicile, 1998 through 2007

Accidents permillion departures

United Statesand Canada

0.4

Latin Americaand Caribbean

2.1

Europe0.7

China0.3

Middle East2.3

Africa10.0

Asia2.1

Oceania0.0

(ExcludingChina)

C.I.S.1

CAST72 Ses52 complete20 in work74% reduction

PAASTCFIT and ALAR

ESSI35 SEs JAA11 SEs EASA62% reduction

ASET

COSCAP CIS

COSCAP NA, SA, SEA45 SEs in work60% reduction

1 Insufficient fleet experience to generate reliable rate.

World1.1

COSCAP GulfCOSCAP BAG

SADC

SummarySummary History shows focused action and has

led to accident risk reductions.

Joint industry and government teams working together can further enhance the safety of our very safe aviation system.

Full implementation will require a coordinated effort between industry and government.

Thank youThank you

http://www.cast-safety.org/http://www.cast-safety.org/