International Society of Air Safety Investigators
Good evening. It is truly a pleasure to be here tonight. I give many speeches to people who do a lot for aviation safety. I have to say that tonight’s audience is a group that does much and is deeply committed to safety. Thank you for what you do. The contributions of air safety investigators are clear: Air travel in our country is incredibly safe.
Tonight, I want to talk briefly about how we reached this remarkable level of safety, about what we in aviation must do to maintain pressure on the accident rate, and I’ll touch on the role of air safety investigators in the 21st century.
As FAA’s safety official, I am frequently asked, “What are the major causes of fatal airliner accidents?”
In the U.S. (and the developed world) there are no major causes. Fatal airline accidents are such rare events that there are no longer what qualifies as “common causes.”
Air travel is so safe that we at FAA find it a challenge to meaningfully express the level of safety. The official way we express it is in fatal accidents per 100,000 departures. That rate is now at .022.
But, what does .022 mean to the man on the street?
And, when you drill down, you will find that .022 largely consists of cargo accidents or cases where a ground employee is struck by an aircraft on the ramp or an employee drives a tug into an aircraft.
If we speak only of events that most people have in mind when they think fatal airline accidents, the rate for passenger airlines is on the order of 0.007 per 100,000 departures. If we speak only of passenger jets, the number is about half that level.
How do you explain how safe point-zero-zero four is?
We keep trying. Here’s one way: You must fly every day for 43,000 years to get to an even chance of being killed in an airline accident. Or how about: An accident with fatalities occurs about every 15 to 16 million flights. Or try this: You are about 40 times safer in an airliner than on the safest highway system in the country (the Interstate).
I think you see the challenge. Add to that challenge the news appeal of airline accidents — they are so rare therefore they are big news. Then, add all the reasons why people are nervous about flying and you can begin to understand why people don’t appreciate the magnitude of the achievement that is modern air travel.
I’m beginning to sound like Rodney Dangerfield.
Let’s turn to how we reached the point where pilots are safer on the job than when they are not at work.
For the most part, it’s been continual improvements in technology that reduce the opportunity for human error or that enable us to recover after a serious error.
Here are a few examples. Pressurized aircraft in the 1940s started flying above most of the weather and terrain, at least en route. That change alone significantly reduced CFIT accidents and loss of control in flight.
The introduction of VORs and the first ILSs in the 1940s and 1950s also drove down the number of CFIT accidents and approach-and-landing accidents. Radar in the 1950s changed the environment permanently. VOR/DME receivers in the 1960s further reduced those types of events.
Most agree the jet remains the biggest single long-term improvement in safety. Remember the joke about the four-engine DC-7 being the best three-engine aircraft ever designed?
The introduction of the jet engine dramatically increased engine reliability, for about a 20-fold increase. Within several years of the first jet in the U.S. fleet, reliability increased 50-fold. Now we are approaching 100-fold versus the pinnacle of reciprocating engine technology.
Before the jet, we averaged 3.5 fatal air carrier accidents per year due to engine failure in a rather small system. In contrast, Part 121 jet operators have had just two such fatal accidents in the past 20 years (Sioux City and Pensacola).
If we jump forward to more recent developments, such as TCAS and Terrain Awareness Warning Systems (or TAWS), we find dramatic examples of technology getting us out of trouble. With TCAS, no Part 121 U.S. carrier has had a midair collision since 1978. Previously, fatal mid-airs had been a common accident scenario.
The experience with GPWS and Controlled Flight Into Terrain, or CFIT, is more dramatic. Between 1946 and 1955, large passenger aircraft averaged 3.5 fatal CFIT accidents a year. Think of it: A fatal CFIT accident about every 15 weeks. Through the mid-70s we were still averaging two fatal passenger airline accidents per year due to CFIT.
In contrast, no jet operator has suffered such an event in U.S. airspace since 1974.
A new rule requiring Terrain Alert Warning Systems (TAWS) in March 2005 has increased both the level of sophistication and, more importantly, the range of aircraft equipped. All turbine-powered airplanes configured for six or more passenger seats now must be equipped with TAWS, whether they are used in air carrier service or in Part 91 operations.
Technology improves our ability to enhance human performance. Just look at the benefits from simulator training. With the six-axis simulator, using real data from real flights, we have improved crew resource management training with real-world scenarios. Pilots gain “real” experience flying through and out of wind shear. They learn in a risk-free environment how to handle an engine failure or failed flight controls, and so much more.
Follow all these improvements with major leaps in automation and precision flying throughout the 1990s, plus the jet revolution reaching the regional industry, and we come to the level of safety we enjoy today.
We often hear that accident rates have reached such a low level that we should no longer expect sudden and sustained breakthroughs in future rates.
We are on the threshold of reaching the next level in commercial aviation safety. And here is the keystone to the next series of breakthroughs — safety information.
Achieving a stronger future for aviation safety is all about sharing safety data.
Today, we don’t even know how much safety information is out there, be it with operators, manufacturers, repair stations, suppliers, and more across the aviation community. How much of this safety information do you think FAA can access?
I’d say about 5 percent.
If we’re going to continue to put downward pressure on the accident rate, we need far more information about trends, about precursors, and about what is going on every day in the manufacturing and operating and maintenance environments.
We must get better about getting the right information. Our great safety record has come from a “forensics” and “diagnostics” approach to making enhancements. You know this better than anyone. We lose one. You investigate. We learn what happened. We make corrections.
Now, with no “common causes” we need to move more and more to a “prognostic” or predictive approach. We need more data points. We need analytical expertise to discern trends and identify precursors.
And we need to share what we learn.
As you know, we’re already gathering information to help identify trends and precursors. We have a demonstration project with the airlines on gathering and sharing data from Aviation Safety Action Programs, or ASAP, and from Flight Operational Quality Assurance, or FOQA, programs.
ASAP encourages airline employees to voluntarily report critical safety information. Today, 51 carriers have 106 programs covering pilots, mechanics, flight attendants, and dispatchers.
While ASAP deals with the human element, FOQA collects and analyzes digital flight data generated during normal operations. FOQA data is unique because it provides objective information not available through other methods. It’s this routine data that can give us insight into the total flight operations environment. Today, 15 U.S. airlines have FAA-approved FOQA programs.
We’ve seen a host of benefits from ASAP and FOQA information, including changes in training as well as enhanced operational and maintenance procedures.
How many of you know about the work of the Commercial Aviation Safety Team?
CAST, which includes representatives from government, industry, and employee groups, is co-chaired by Hank Krakowski, Vice President, Corporate Safety, United Airlines, and Peggy Gilligan, FAA Deputy Associate Administrator for Aviation Safety. The purpose: Develop an integrated data-driven strategy to reduce the U.S. commercial aviation fatality risk.
CAST has been highly successful. How? Because of its disciplined and focused approach to analyzing accidents and incidents, identifying precursors, and developing targeted implementation strategies. Furthermore, after the strategies are implemented, CAST monitors and measures their effectiveness and identifies future areas of study.
Thanks to CAST, we’re on target to reduce the fatality risk in commercial air travel by 73 percent by 2007. That’s the power of using data to drive decisions.
At the same time, FAA has been working with NASA to get our arms around the many aviation safety data sources. We want to bring them together and leverage the power of combined databases to help reveal the rare and infrequent emerging threats and hazards. We want to push the science of advanced data analysis tools that will enable “vulnerability discovery”, reveal precursors to accidents, and permit us to proactively take steps to mitigate risks before loss of life.
This is how we will achieve the next level of breakthrough safety technology that will lead the way to orders-of-magnitude reduction in fatality risk, sharing safety information in a more powerful way than ever before and desperately needed to keep pace with the planned increases in transportation system capacity.
Earlier this year, we established an Aviation Safety Analytical Unit headed by Jay Pardee. Jay headed our Engine and Propeller Directorate. In his new role, Jay and his team will pick up the analytical work that Jay did for CAST as well as work with NASA on Aviation Safety Information Analysis and Sharing systems (ASIAS).
In addition, the new unit will support Jay’s work as the FAA Aviation Safety lead for the Joint Planning and Development Office (JPDO) Safety Integrated Product Team, or IPT. The Safety IPT is committed to implementing a Safety Management System within JPDO and its member governmental agencies and customers.
A Safety Management System will set the standards for safety culture and safety risk management. Its foundation will be based on aviation safety information analysis and sharing.
Another assignment for the analytical unit is, quite simply, looking ahead. Often we get so caught up responding to today’s issues that we don’t make the time to look ahead and see what’s coming, what it is we will need to address. With growing demand, introduction of new aircraft, globalization and more, we must keep our eye firmly focused on the horizon.
We also know that risk will always be higher than zero. U.S. airlines have more than 30,000 daily flights. This will likely surpass 40,000 daily flights in the not-too-distant future. In a system of this size and complexity, fatal accidents will not go away.
I applaud the work ISASI is doing to look ahead. You recognize that the role of Air Safety Investigators is changing. You know that we are no longer domestic, or international, or even global. We are now in space. Increasingly, machines and technology will be different. The medical issues will be different. The human factors issues will be more complex. In addition, business models are changing, as is the infrastructure of the entire National Aviation System.
What skills do we need in future air safety investigators?
Keith McGuire put it plainly at ISASI 2005. Top of the list — and this won’t change — is “logical thought process.”
McGuire also listed strong interpersonal skills, psychological and physical preparedness, and a person who is continually learning. A person who is continually learning — that is especially important with the rate of change we’re experiencing. Would you have imagined just several years ago the activity we’re seeing today with Very Light Jets, Light Sport Aircraft, unmanned aircraft, and commercial space?
A few weeks ago we lost one of aviation’s greats — Scott Crossfield.
As a boy, Crossfield watched Boeing’s test pilot Eddie Allen fly and he took the advice he got seriously: “Be an engineer. Help build the airplanes. Then fly them and find out what you did wrong.”
Fly them and find out what you did wrong. We will not always have that luxury; we need to use every tool, every skill, and every resource that we can bring to bear to enhance safety.
Those tools, skills, and resources include accident investigators, yes, to look back, and leveraging information and analysis to look forward to anticipate, to prepare, and prevent.
That’s how all of us in aviation will improve safety and save lives. It does not get any more rewarding than that.
That’s what you as professional air safety investigators do and you do it extremely well.