improving general aviation safety and fostering industry growth

IMPROVING GENERAL AVIATION SAFETY

AND FOSTERING INDUSTRY GROWTH

Presented to:

By:

Date:

Federal AviationAdministrationGA Accident

Statistics and Future Mitigation Work

Meeting Safety Challenges through Pilot Training Reform

SAFE Pilot Training Reform Symposium

Corey StephensOffice of Accident Investigation and Prevention

May 4th, 2011

Federal AviationAdministration 4GA Accident Statistics and Future Mitigation Work

May 4th, 2011

GA MetricsFY not CY, but can be convertedN-registered aircraft only• Overall GA Fatal Accidents per 100,000 hrs

– Everything not 121 or commuter• Alaska Fatal and Serious Injury Accidents per

100,000 hrs– Everything not 121, includes commuter

• Experimental Aircraft Fatal Accidents– Interim until we can establish a rate-based metric and

goal


May 4th, 2011

AVS FY10 Safety PerformanceGA Fatal Accident Rate

(Fatal Accidents/100,000 Hours)

1.221.19

1.16

1.121.11

1.08 1.07 1.06 1.05 1.04 1.02 1.01 1.00

1.101.16 1.13

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.30

1.40

Apr

200

6

Apr

200

7

Apr

200

8

FY09

FY10

FY11

FY12

FY13

FY14

FY15

FY16

FY17

FY18

3-Yr Baseline (May 06 - Apr 08)NTE Target - 10% Reduction by FY18Actual Rate

3-Year Baseline

Fata

l Acc

iden

t Rat

e

Current Flight Plan TargetsConverted to Rates


May 4th, 2011

AVS FY11 Safety Performance GA Fatal Accident Rate

(Fatal Accidents/100,000 Hours)

1.061.13 1.081.051.021.001.001.00

1.091.081.081.04

0.940.950.95

1.01

1.091.08

0.94

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.30

1.40

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Fata

l Acc

iden

t Rat

e

NTE Rate Actual Rate *

* Based on Projected Hours

Currently Equates to 252 Fatal Accidents


May 4th, 2011

AVS FY11 Safety Performance Alaska Fatal/Serious Injury Accident Rate

(FSI Accidents/100,000 Hours)

2.57

1.992.021.90

3.042.63

1.84

2.02

2.39

2.152.141.85

0.000.00 0.000.00 0.00 0.00 0.000.000.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

5.50

Oct* Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

FSI A

ccid

ent R

ate

NTE Rate

Actual End of Month Rate * (Assumes noadditional FSIs in the current month)

* Based on Projected Hours


May 4th, 2011

General Aviation Fatal Accidents 2001-2010 by Top 10 CICTT Occurrence Category

0

200

400

600

800

1000

1200

1400

LOSS

OF

CON

TRO

L - I

NFL

IGHT

(LO

C-I)

CON

TRO

LLED

FLI

GHT

INTO

OR

TOW

ARD

TERR

AIN

(CFI

T)

SYST

EM/C

OM

PON

ENT

FAIL

URE

OR

MAL

FUN

CTIO

N(P

OW

ERPL

ANT)

(SCF

-PP)

LOW

ALT

ITU

DE O

PERA

TIO

NS

(LAL

T)

OTH

ER (O

THR)

UN

KNO

WN

OR

UN

DETE

RMIN

ED (U

NK)

FUEL

REL

ATED

(FU

EL)

SYST

EM/C

OM

PON

ENT

FAIL

URE

OR

MAL

FUN

CTIO

N(N

ON

-PO

WER

PLAN

T) (S

CF-N

P)

AIRP

ROX/

ACAS

ALE

RT/L

OSS

OF

SEPA

RATI

ON

/NEA

RM

IDAI

R CO

LLIS

ION

S/M

IDAI

R CO

LLIS

ION

S (M

AC)

WIN

DSHE

AR O

R TH

UN

DERS

TORM

(WST

RW)

RECIPROCATING NON-HOMEBUILTTURBINEHOMEBUILT

Note: Homebuilt category incorporates all homebuilt aircraft and is not limited to experimental and LSA.


May 4th, 2011

How to Act on this Information

We have identified types of accidents

Now we determine why the accidents are occurring


May 4th, 2011

GA Joint Steering Committee

• Evolve GA JSC to a CAST like Model– Voluntary commitments– Consensus decision-making– Data driven risk management– Implementation-focused

• The GA JSC is a means to… Focus Limited Government/Industry

Resources on Data Driven Risks and Solutions


May 4th, 2011

• Identify future areas of study/risk• Charter safety studies• Provide guidance and direction• Draw data from various areas• Develop a prioritized Safety Plan • Develop metrics to measure

effectiveness of safety solutions

• Data analyses• Safety enhancement / mitigation

development

• Strategic guidance • Management/Approval of Safety Plan• Provide direction• Membership Outreach• Provides linkage to ASIAS

Steering CommitteeCo-Chairs: Bruce Landsberg (ASI) Tony Fazio (FAA/AVP)Government - FAA (AFS, AIR, ATO & ARP) - NASA (Research)

- NWSIndustry - AOPA, EAA, GAMA, NATA,

NBAA, LAMA, Insurance

Safety Analysis Team (SAT)Co-chairs: Corey Stephens (FAA) Jens Hennig (GAMA)Members: FAA, NTSB, AOPA, EAA, FSF, CGAR, FAST, NAFI, LAMA, Insurance, SAFE, etc.

Working Groups (WGs)(To include SMEs from various general

aviation segments, depending on study)

General Aviation Joint Steering Committee (GAJSC)


May 4th, 2011

What is the CAST model?• Work began in 1997 after two significant

accidents in 1996 (TWA 800 & ValueJet 592)• CAST focus was set by:

– White House Commission on Aviation Safety– The National Civil Aviation Review

Commission (NCARC) • Opportunity for industry and government to

focus resources on one primary aviation safety initiative


May 4th, 2011

GA JSC Working Group Process• WGs to be formed based on risk (example:

LOC)

• Broad-based teams (30-40 specialists /team)

• Teams can be divided by aircraft or operation type (example: turbine, reciprocating and homebuilt reciprocating/turbine)

• Detailed event sequence - problem identification from US accidents and incidents


May 4th, 2011

GA JSC Working Group Process• WGs to develop mitigations based on

problems found and build Detailed Implementations Plans (DIPs)• DIPs will describe each mitigation and

explain steps to implementation• Groups are identified for leadership and

metrics are developed• DIPs then go to the SAT for

resource/benefit evaluation


May 4th, 2011

• SAT identifies the most effective solutions derived from all accident categories

– Considers effectiveness vs. resources

– Tests solutions against fatal accidents

• Creates draft master strategic safety plan

• Plan is submitted to GA JSC for approval

GA JSC SAT Process


May 4th, 2011

• Once plan is approved, industry and government begin implementation

• SAT will track implementation schedules and levels (are mitigations on time and at levels we were expecting)

• SAT will work to track effectiveness of the mitigations in place

• SAT will identify and recommend areas for future study/mitigation

GA JSC SAT Process


May 4th, 2011

Summary: GA JSC, SAT & WGs Moving Forward• 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

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

• The GA JSC is moving forward to meet the challenge

Avemco Insurance Company

A subsidiary of HCC Insurance Holdings, Inc.

Risk Mismanagement as the Root Cause of Most Fatal Accidents

presented by: Jim Lauerman, President

Our Unique Perspective

• All the losses• Direct Insurer• Established Relationship

Personal Background

• Then• Now

Friday Meetings

Real Costs

• Human• Financial• Public Relations

– New Rules– Unintended

Consequences

Why Aren’t We Solving the Problem?

• Regulations?• Technology?• Training?

“It’s not so much what pilots know that gets them in trouble –”

• But What They Care About

The Culture of General Aviation

• More Ethical than Technical• Matters of the Heart, not Just the Head

– We Pilots Aren’t Good at This• A More Professional Attitude

– Accepting that there is risk– Being “grown ups”

• Accepting Responsibility for Managing the Risks

Avemco Insurance Company

A subsidiary of HCC Insurance Holdings, Inc.

Questions?877 359 [email protected]

411 Aviation Way, Suite 100, Frederick, Maryland 21701

28

WHAT WE CAN LEARN FROM PROFESSIONAL ETHICS

Bill Rhodes, Ph.D.Aerworthy Consulting, LLC

29

Acknowledgments

• Portions of the research underlying this presentation were conducted under a Cooperative Research and Development Agreement with the Department of Philosophy, USAF Academy

• Avemco is AERI’s charter sponsor

30

Who is this guy?

• Former USAFA prof• Professional identity formation• Author in applied ethics• Private pilot/AC owner• AERI lead investigator

31

What I’ll Suggest

• Hardware/software innovation• Improved technical skills, new rules etc.• …Address some pilot-induced mishaps• Professional ethics will address all• …And it’s not all that hard to do

32

Ethics: Why?

• Mishap pilots– Pass the tests (know the rules)– But not the most relevant tests– Are products of a “perfect design”

• Notice subcultures of aviators– Where would you like your kid to learn

airmanship– Why?

33

Ethics???

• I AM NOT SUGGESTING– Additional regulation– Invasion of privacy– “Compliance” with a list of constraints

• I AM SUGGESTING– Humble regard for aviation and the stakes– Determining selves to be trustworthy Airmen– Fostering the same in our community

34

Professional ethics

• Do’s and Don’ts can only get us so far• Education in addition to instruction: limit• Professional identity formation• Professionally-minded don’t need to be told

Judgment: figure out what’s bestSelf-mastery: do it (short run)Self-determination: habitually (long run)

35

Professionalism???

• I AM NOT SUGGESTING– A matter of jurisdiction– Or a matter of being paid

• I AM SUGGESTING– Committing to functional identity—who pilot is– Able to reach goals reliably—what pilot does– Worthy of trust—OTG and OK

36

DEVELOPING PROFESSIONALS

• Self-Mastery (short term)• …in today’s context

Who pilot is(dispositions) What pilot does

Outcome(OTG and OK

Plus?)

• Self-determination (long term)•…in cultural context

37

Where to begin

• Forthright confrontation of problem• The culture (enemy is us)• Messages

– What is admired– What is disdained—even mocked

• Social norms are powerful• But what messages should be sent?

38

Aviation Insiders Know

• What sort of pilot is scary?• What sort of pilot do you trust?• SME interviews: Insurance underwriters,

investigators, CFI’s, and examiners convergent

• Draft concepts are compiled• One example: professional detachment

39

Professionalism at home• Quality matters

– Make no apologies for education and devotion– Admit that current cultural values– …may differ from professional imperatives– And select the professional imperatives

• Reform demands seeing past “our way” to what works

40

Aerworthy Consulting, LLC. May, 2011

[email protected](719) 229-7369

IT’S TIME TO CREATE A CULTURAL SEA-CHANGE

IN GENERAL AVIATION

There has been virtually no change

• In the general aviation accident rate for the last 20 years

If we keep on doing what we have been doing

• We are going to keep on getting what we’ve been getting–Even if we do it better

What we have been getting• Is unacceptable

Solutions to problems• Are not obvious until after

they are solved

3 Counter-intuitive solutions• Ban low airspeed “phobia”• Ban the “big lie”• Ban “safety”

Ban low airspeed phobia

• One-third of all fatalities come from stalls/spins while maneuvering

• So therefore we should tell pilots to slow down when maneuvering

Most people think• Stall/spin accidents come from flying

too slow

Let’s consider• That they may be caused by flying too

fast

An imminent stall caused by flying too slow

Is easy to recognize • The controls get mushy• The air noise decreases• The airplane buffets well in advance

A stall caused by an increase in load factor

Gives much less warning • The controls aren’t mushy• The air noise is still at the usual level• The buffet gives little if any warning

Flight instructors are afraidTheir students will stall• Therefore they have them fly too fast

The result is• Huge patterns • Steeper banks• More load factor

0

500

1000

1500

2000

2500

65 80 95 110

Radius of Turn versus Speed

Radiusof Turnin feet

Ban the “big lie”It will• Increase sales• Strengthen the industry—

–Accidents are bad for the industry

The BIG LIE• “The most dangerous part of the flight

is the trip to the airport”

The truth• It is irresponsible and intellectually

dishonest to characterize aviation as an entirely safe activity

We want pilots to feel• Safe• Comfortable

We tell pilots• Flying is “safe”

85% of accidents• Are caused by pilots

Pilots• Grossly underestimate risk

VFR in bad weather• Low time pilots are more comfortable

with it than high time pilots

• Non-IFR pilots are more comfortable with it than IFR-rated pilots

Aviation centers around the element of trust

• We must be honest in everything we do

Ban “safety”• It is not a useful word in general

aviation

We use the word “safety”Without meaning what we say• “Safety is the number one priority”• ‘We will not compromise

with safety”• “We will only accept

one level of safety”

We use “safe” and “safety”As an expression of goodwill• “Have a safe trip”• It is a social courtesy like saying

–“Have a good day”

The word “safety”

• Is not specific enough to be helpful• Gives me no guidance on what I should

do

What we should be saying instead is

• Identify and • Manage

–The risks of your flight

We can still say “Have a safe trip”

• We just need to recognize that it is lousy professional advice

• Instead it is merely a statement of goodwill

Use scenario-based training to create pilots who

• Are good risk managers, and• Truly ready to be pilot-in command• Become safe, capable pilots, and• Long-term members of the aviation

community

3 Counter-intuitive solutions• Ban low airspeed “phobia”• Ban the “big lie”• Ban “safety”

Lima Rom

eo Aviation Lightning Ranch Group

USING HIGHER ORDER PILOT SKILLS TO REDUCE FATAL ACCIDENT RISKS

HOW TO TEACH (OR AFFECT) HIGHER ORDER THINKING TO REDUCE RISK

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,

2011

Lima Rom


CAN IT BE TAUGHT?

Aircraft Accident BriefCrash During Turn ManeuverCirrus SR-20, N929CD Manhattan, New York CityOctober 11, 2006

“Contrary to popular opinion, good judgment can be taught.” …“The effectiveness of [ADM training] has been validated in six independent studies …. The differences were statistically significant and ranged from about 10 to 50 percent fewer judgment errors.”

… plea to the aviation community and/or aviation researchers is to work diligently to look for new and effective ways to teach better judgment and decision making…..


2011

http://www.ntsb.gov/default.htm

http://www.ntsb.gov/Publictn/publictn.htm

http://www.ntsb.gov/Publictn/publictn.htm

Lima Rom


Experience (“License to Learn”)

Scenario Based Training

Hangar Flying What is learned? Can it be formalized?

Simulation Realistic Flying Scenarios

Evaluation How To Quantify and Qualify?


2011

HOW CAN IT BE TAUGHT? LEARNED? MEASURED?

Lima Rom


•Critical Decision Making SeminarsHangar Flying

•FITS Syllabi (CSIP, CPPP) SBT•Full Motion SIM ScenariosSimulation

•Quantify and QualifyEvaluationSAFE Pilot Training Reform SSymposium

Carol R. Jensen, PhD May 4, 2011

Lima Rom


•Critical Decision Making SeminarsCase Studies

•FITS Syllabi (CSIP, CPPP) SBT•Full Motion SIM ScenariosSimulation

•Quantify and QualifyEvaluation

P


2011

Lima Rom


NTSB PROBABLE CAUSE

VS

THE CASE STUDY

The pilots' inadequate planning, judgment, and airmanship in the performance of a 180º turn maneuver inside of a limited turning space.

*Low time pilot— had CFI come along*Expected CFI to “protect him?”*Expected CFI to know “how to make this flight?”

*CFI “new” to aircraft*CFI from CA, “new” to airspace?*CFI “pressured” (to impress?) by famous client?

*Lack of attention to the wind?*Two Pilot Distraction?*Fear of busting Class B airspace?

CASE STUDIES


2011

Lima Rom



•Cirrus Standardized Instructor ProgramSBT•Full Motion SIM ScenariosSimulation

•Quantify and QualifyEvaluation

PSAFE Pilot Training Reform SSymposium


Lima Rom



2011

STUDENT/VFR PILOTS ENGINE FAILURE SHORTLY AFTER TAKEOFFMANEUVERING ACCIDENTS

eg. Cory Lidle flightVFR IMC --utilizing NTSB scenarios --eg. JFK Jr. flight

SIM “SCENARIOS” --utilizing NTSB reports

INSTRUMENT PROCEDURES

Lima Rom



•Cirrus Standardized Instructor ProgramSBT•Full Motion SIM ScenariosSimulation

•Quantify and QualifyEvaluation PSAFE Pilot Training Reform SSymposium


Lima Rom


Case Studies

SBT

Simulation

EvaluationSAFE Pilot Training Reform SSymposium


OBSTACLES & CHALLENGES

CAN ALL FLIGHT EDUCATORS TEACH IT?

WILL ALL FLIGHT EDUCATORS TEACH IT?

VALUE PROPOSITION– CFI ? PILOT?

BUILDING FLIGHT TIME VS…..

INCENTIVES?

Lima Rom


USING TEACHINGHIGHER ORDER PILOT SKILLS

TO REDUCE FATAL ACCIDENT RISKS

1.CASE STUDY METHODOLOGY2.SIMULATORS & SIMULATION3.INSTITUTIONALIZE UTILIZATION


2011

improving general aviation safety and fostering industry growth

Documents

future mitigation workmay

ga metricsfy

accident categories

us accidents

significant accidents

types of accidents

general aviation safety

approvalga jsc