Rewriting Rewriting Safety’s FutureSafety’s Future

F-117

““... ... 90 per cent90 per cent of the total of the total accidents that have occurred accidents that have occurred are directly traceable to the are directly traceable to the lack of knowledge of or failure lack of knowledge of or failure to realize dangerous positions to realize dangerous positions of the airplane operations, of the airplane operations, whether of speed, angle, or whether of speed, angle, or direction.”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: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: A Rejected Take-off: 20 September 1989; 737-20 September 1989; 737-400; La Guardia Airport, 400; La Guardia Airport, New York: 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-9DC-9

Wind Shear: 2 July 1994; DC9-31; Charlotte, NC:

On Flight 1016 the aircraft encountered On Flight 1016 the aircraft encountered heavy rain and wind shear during heavy rain and wind shear during approach at about 3.5 miles (5.6 km) approach at about 3.5 miles (5.6 km) from the runway. The crew executed a from the runway. The crew executed a go around for another landing attempt, go around for another landing attempt, but the aircraft could not overcome the but the aircraft could not overcome the wind shear. All five crew members wind shear. All five crew members survived, but 37 of the 52 passengers survived, but 37 of the 52 passengers were killed.were killed.

Rudder Upset:Rudder Upset: 8 September 1994; 737-300; 8 September 1994; 737-300; near Pittsburgh, PA: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 with a Task

Inadvertent Selective ComplianceA Dangerous MindsetA Dangerous Mindset

The Microscope on the Problem

Altitude Excursions

Runway Incursions

P-51

The Approach and Results

Operation Restore ConfidenceOperation Restore Confidence Life Preservers Pointing Fingers Altitude Awareness

Altitude deviations - 10 per month ASAP (Aviation Safety Action

Partnership)

F-4F- 4

The Approach and The Approach and ResultsResults

CRMCRM (Crew Resource Management)(Crew Resource Management)

Viable Program

By Pilots for Pilots

The Approach and The Approach and ResultsResults

ECAP (Enhanced Crew Awareness Program)

Error Management Model (based on the Volant Model)

The Approach and Results

ECAP (Enhanced Crew Awareness (Enhanced Crew Awareness Program) 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% resulted in altitude deviations 78% resulted in altitude deviations

76% identified in the study, were initiated 76% identified in the study, were initiated when the aircraft was in some "vertical" when the aircraft was in some "vertical" phase of flightphase 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 1912Remember 1912

““... ... 90 per cent90 per cent of the total of the total accidents that have occurred are accidents that have occurred are directly traceable to the lack of directly traceable to the lack of knowledge of or failure to realize knowledge of or failure to realize dangerous positions of the dangerous positions of the airplane operations, whether of airplane operations, whether of speed, angle, or direction.”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 Data Streams Report the Airline’s ProgressProgress ASAP (Aviation Safety Action ASAP (Aviation Safety Action

Program)Program) FOQA (Flight Operation Quality FOQA (Flight Operation Quality

Assurance)Assurance) SOA (Special Operations Area)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 AccidentsNo Accidents Since Those Tragic Since Those Tragic YearsYears

Has Weathered The StormsHas Weathered The Storms ofof • 9-119-11• bankruptciesbankruptcies• another mergeranother merger

The ECAP Procedures continue to evolve as they have proven to be the best tools for Rewriting our Safety’s Future.

Airbus 330Airbus 330

Rewriting ourRewriting our Safety’s FutureSafety’s Future

Excerpts from this piece have been reprinted from US Airway's Excerpts from this piece have been reprinted from US Airway's Safety On Line 2005 article on "Merger Related Accidents", US Safety On Line 2005 article on "Merger Related Accidents", US Airway’s 1990 Altitude Awareness Program data files, US Airway’s 1990 Altitude Awareness Program data files, US Airway’s 1991 CRM Program data files, US Airway’s 2007/2008 Airway’s 1991 CRM Program data files, US Airway’s 2007/2008 Flight Training and Standards article on “Challenge to Change Flight Training and Standards article on “Challenge to Change History” by Capt. Lori Cline, ECAP White Paper by Capt. Robert History” by Capt. Lori Cline, ECAP White Paper by Capt. Robert Sumwalt, ASRS's: "What ASRS Data Tell About Inadequate Sumwalt, ASRS's: "What ASRS Data Tell About Inadequate Flight Crew Monitoring," Boeing's Study on "Accident Flight Crew Monitoring," Boeing's Study on "Accident Prevention Strategies," FAA documents, NTSB reports, ALPA Prevention Strategies," FAA documents, NTSB reports, ALPA records, and Aero and Hydro – Nov. 1912records, and Aero and Hydro – Nov. 1912