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IMPROVING GENERAL AVIATION SAFETY AND FOSTERING INDUSTRY GROWTH . GA Accident Statistics and Future Mitigation Work. Meeting Safety Challenges through Pilot Training Reform. SAFE Pilot Training Reform Symposium. Corey Stephens Office of Accident Investigation and Prevention. - PowerPoint PPT Presentation
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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
Federal AviationAdministration 5GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 6GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 7GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 8GA Accident Statistics and Future Mitigation Work
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.
Federal AviationAdministration 9GA Accident Statistics and Future Mitigation Work
May 4th, 2011
How to Act on this Information
We have identified types of accidents
Now we determine why the accidents are occurring
Federal AviationAdministration 10GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 11GA Accident Statistics and Future Mitigation Work
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)
Federal AviationAdministration 12GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 13GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 14GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 15GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 16GA Accident Statistics and Future Mitigation Work
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
Federal AviationAdministration 17GA Accident Statistics and Future Mitigation Work
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
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
eo Aviation Lightning Ranch Group
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…..
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,
2011
Lima Rom
eo Aviation Lightning Ranch Group
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?
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,
2011
HOW CAN IT BE TAUGHT? LEARNED? MEASURED?
Lima Rom
eo Aviation Lightning Ranch Group
•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
eo Aviation Lightning Ranch Group
•Critical Decision Making SeminarsCase Studies
•FITS Syllabi (CSIP, CPPP) SBT•Full Motion SIM ScenariosSimulation
•Quantify and QualifyEvaluation
P
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,
2011
Lima Rom
eo Aviation Lightning Ranch Group
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
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,
2011
Lima Rom
eo Aviation Lightning Ranch Group
•Critical Decision Making SeminarsCase Studies
•Cirrus Standardized Instructor ProgramSBT•Full Motion SIM ScenariosSimulation
•Quantify and QualifyEvaluation
PSAFE Pilot Training Reform SSymposium
Carol R. Jensen, PhD May 4, 2011
Lima Rom
eo Aviation Lightning Ranch Group
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,
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
eo Aviation Lightning Ranch Group
•Critical Decision Making SeminarsCase Studies
•Cirrus Standardized Instructor ProgramSBT•Full Motion SIM ScenariosSimulation
•Quantify and QualifyEvaluation PSAFE Pilot Training Reform SSymposium
Carol R. Jensen, PhD May 4, 2011
Lima Rom
eo Aviation Lightning Ranch Group
Case Studies
SBT
Simulation
EvaluationSAFE Pilot Training Reform SSymposium
Carol R. Jensen, PhD May 4, 2011
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
eo Aviation Lightning Ranch Group
USING TEACHINGHIGHER ORDER PILOT SKILLS
TO REDUCE FATAL ACCIDENT RISKS
1.CASE STUDY METHODOLOGY2.SIMULATORS & SIMULATION3.INSTITUTIONALIZE UTILIZATION
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4,
2011
BREAK