Out Front on Airline Safety: Two Decades of Continuous Evolution
The commercial aviation system in the United States operates at an unprecedented level of safety. During the past 20 years, commercial aviation fatalities in the U.S. have decreased by 95 percent as measured by fatalities per 100 million passengers.
We achieved this safety record because the FAA continually evolved in how it approaches safety oversight – both in detecting risks and in responding to the risks identified. Key to this approach is a longstanding commitment to sharing data through an open and collaborative safety culture to detect risks and address problems before accidents occur.
Our comprehensive, risk-based safety oversight process consists of several key elements: the Commercial Aviation Safety Team; the Aviation Safety Information and Sharing program; voluntary reporting programs; Aviation Safety Infoshare; the FAA’s Safety Assurance System; airline Safety Management Systems; and the FAA’s approach to ensuring compliance..
Commercial Aviation Safety Team (CAST)
The FAA, with the aviation industry, formed CAST in 1997. CAST marked an evolution beyond the traditional approach of examining accident data to a proactive approach that focuses on detecting risk and implementing mitigation strategies before accidents or serious incidents occur. Voluntary reporting programs are an important data source for CAST.
This transition to prognostic safety analysis emphasizes acquiring, sharing, and analyzing safety data from across the aviation community. CAST uses the data to identify emerging and changing risks, and airlines voluntarily implement safety mitigation strategies that CAST develops.
CAST’s work, along with new aircraft, regulations, and other activities, has virtually eliminated the traditional common causes of commercial accidents – controlled flight into terrain, weather, wind shear, and failure to complete checklists. As a result, the fatality risk for commercial aviation in the United States fell 83 percent from 1998 to 2008. CAST aims to reduce the U.S. commercial fatality risk by another 50 percent between 2010 and 2025.
The FAA expects carriers to assess risks, including those identified by CAST and theAviation Safety Information Analysis and Sharing (ASIAS)system, and take appropriate actions. Inspectors follow up with the carriers to ensure their Safety Management System (SMS) processes consider risks that CAST and ASIAS identified. If the carriers have not evaluated these risks, the inspector may program the Safety Assurance System (SAS)to require increased surveillance of the carrier.
Check out this fact sheet for more information on CAST.
Aviation Safety Information Analysis and Sharing (ASIAS)
The ASIAS program, which began about 10 years ago, brings together data and information across government and industry, including voluntarily provided safety data, to detect emerging risks, monitor known risks, and evaluate the effectiveness of mitigations.
ASIAS is an evolving program that continually adds participants and data sources. Current participants include 46 scheduled airlines, 63 corporate/business operators, 10 universities, five manufacturers, and two maintenance, repair, and overhaul organizations. ASIAS safety data comes from operators that account for 99 percent of U.S. air carrier commercial operations.
ASIAS has established metrics that enable CAST to evaluate the effectiveness of safety mitigations. ASIAS also partners with the industry-sponsored Aviation Safety InfoShare meeting, which facilitates the sharing of safety issues and best practices in a protected environment. This partnership enables ASIAS to help identify emerging systemic safety issues early on.
This fact sheet has additional information on ASIAS.
Since CAST’s inception, its members have adopted more than 100 safety enhancements. The last 22 safety enhancements that CAST adopted were based on data that ASIAS provided.
Here’s one example:
Terrain Awareness and Warning Systems (TAWS) alert pilots when they’re flying too close to terrain. It’s one of the technologies that has virtually eliminated the risk of controlled-flight-into-terrain accidents in U.S. commercial passenger operations.
However, through information from voluntary safety programs, ASIAS learned that TAWS sometimes generated alerts that pilots perceived to be incorrect or overly conservative. This was leading pilots to become desensitized to the alerts.
ASIAS pioneered an approach to identify what caused TAWS to alert when the aircraft was not at risk. Based on these factors, CAST developed two safety enhancements to reduce TAWS nuisance alerts, resulting in a drop in reported nuisance alerts.
This is an example of how the FAA and the airline industry, through information sharing, were able to monitor the effectiveness of a safety technology and take steps to address an unforeseen issue with it.
Voluntary Reporting Programs
As noted above, data collection and analysis is key to identifying potential risks before they become major problems. In the late 1990s, the FAA began implementing non-punitive, voluntary reporting programs to help ensure that aviation professionals provide this critical safety information.
Today, we have voluntary reporting programs for pilots, cabin crew members, dispatchers, mechanics, air traffic controllers, FAA airport division employees and others. They have significantly contributed to the nation’s safety record, including improvements to training and operational and maintenance procedures.
Information on these voluntary programs is available in this fact sheet.
Aviation Safety Infoshare
Along with CAST and ASIAS, the FAA also participates in Infoshare. This is a semi-annual, industry-sponsored and FAA-facilitated event for domestic, international and corporate operators, labor organizations, trade associations, government organizations and major manufacturers. Infoshare started two decades ago with a handful of operators and now includes more than 800 aviation safety professionals.
The forum enables participants to share information about safety issues and concerns, best practices for data analysis, successful mitigation strategies, and the results of their studies of proactive safety programs, including Aviation Safety Action Program (ASAP) and Flight Operations Quality Assurance (FOQA).
InfoShare’s success is based on longstanding collaborative partnerships and is made possible through voluntary safety programs; trust between management, labor and the regulator; confidential protections for the data reporting systems; and a non-punitive reporting environment.
CAST and ASIAS use the information from InfoShare to better understand the factors that contribute to systemic safety issues in the National Airspace System.
Safety Assurance System
The Safety Assurance System (SAS) is the FAA’s comprehensive, data-driven system that provides a standardized and methodical approach to verify that all airlines comply with their mandate to operate to the highest possible safety levels.
SAS is a sophisticated, interactive computer system that draws safety data from numerous and varied sources. It helps alert FAA safety inspectors to areas of an airline's operation on which they should focus their oversight. It also allows inspectors to tailor their oversight plans to each airline’s unique operation and to any issues the data identifies.
SAS contains data on every aspect of an airline's operation, including organizational management, flight operations, crew training, maintenance, dispatch and more. Inspectors can program up to 38 separate risk indicators into the system, ranging from previous safety oversight findings to incidents the carrier recently experienced.
The data in the system is continually updated with information that inspectors find during inspections and that the airline provides, and from more than two dozen additional sources. These sources include voluntary reporting programsthat allow airline personnel to report safety information without fear of punishment, as well as information from the National Transportation Safety Board and from numerous FAA safety, accident/incident, enforcement, quality control, aircraft and pilot databases.
By constantly analyzing large volumes of diverse data, the system provides FAA inspectors with a real-time, comprehensive and highly accurate depiction of a carrier's operations–and whether anything needs to be done to address a particular risk factor.
Here is an example of how SAS works:
An airline voluntarily reports that its pilots have accidentally flown without authorization into restricted airspace. In addition to addressing the immediate issue with the airline, the FAA inspector would program the SAS to require additional assessments of the airline’s flight operations training program.
Safety Management Systems
A Safety Management System (SMS) is a set of policies and processes that enables airlines to identify potential hazards in their operations, assess the risks from those hazards, implement measures to address those risks, and ensure those measures are effective. In 2015, the FAA required all scheduled U.S. airlines to have accepted SMS in place by March 2018. All 70 airlines met that deadline.
The SMS requirement is a significant evolution in how our safety oversight system works. With SMS, the FAA now expects airlines to play a more proactive safety role by identifying potential risks in their operation and presenting the FAA with plans for addressing them. SMS does not replace FAA oversight; rather, it adds another layer of redundancy to the safety system.
An airline’s SMS must cover all aspects of its operation, including dispatch, flight operations, maintenance and training. The SMS has four components: a safety policy that defines the methods, processes and organizational structure needed to meet its safety goals; a risk-management strategy that determines the need for, and adequacy of, new or revised measures to address risks; a safety assurance element that continually evaluates the effectiveness of those measures; and actions to promote safety such as training and communication.
The FAA’s SMS regulation also requires airlines to identify a specific executive who is accountable for safety, and enable employees to confidentially report safety concerns and propose solutions or improvements.
Through the SMS regulation, the FAA requires airlines to develop processes to perform safety risk analyses when they make changes to their operations including adding new aircraft or routes or beginning new types of service; investigate internal reports that the carrier has failed to comply with regulations; and develop processes to analyze the safety data they acquire.
Airlines design their own SMS to match the size, complexity and business model of their operations. FAA safety inspectors then use the Safety Assurance System to determine whether the carrier’s proposed SMS is properly designed to identify hazards and effectively address the associated risks. FAA inspectors also use the SAS to determine whether the airline’s SMS is achieving the intended safety results.
Here are two examples of how SMS works.
Example One: An airline flies in areas that experience frigid winter conditions. As a result, the carrier’s organizational processes include its de-icing operation. The airline’s first step in integrating its de-icing operation into its SMS is to inventory every aspect of this operation at every airport it serves. The airline looks at everything from how employees are trained to the tools they use to where the de-icing fluid is purchased. It evaluates the risk of improper de-icing, and determines the risk is high. So it puts extensive processes in place that, among other things, ensure employees get recurrent training in proper de-icing procedures, specify what procedures must be followed in specific icing conditions, and require periodic inspections of the vendors that supply the de-icing chemicals. The airline also sets up processes to analyze how often mistakes are made in the de-icing program so that corrective actions can be quickly identified and implemented. It also sets up a process to evaluate the effectiveness of those corrective actions.
Example Two: An airline aborts its takeoff because the aircraft’s tail strikes the runway as the plane is about to leave the ground. The airline’s SMS requires it to look at what could have caused the tail strike, and it determines the event likely was due to an uneven distribution of passengers. Upon identifying this risk, the airline proactively takes steps to improve its passenger distribution process. The airline’s first step is to map out all the activities involved in the passenger-loading process and in calculating weight and balance, and looking at every factor that could lead to a mistake. Once it identifies where mistakes have occurred, the airline will make changes or apply controls to reduce the chance that this mistake will occur again. This includes developing new processes for flight attendants to ensure an even passenger distribution, and to ensure flight attendants have done this before informing the pilots that the cabin is ready for departure. The carrier revises its flight attendant manual o incorporate a checklist that requires flight attendants to perform a visual inspection and passenger count to confirm passengers are evenly distributed throughout the cabin. The airline also shares this new process data with the FAA. The FAA inspectors who oversee the airline then program their Safety Assurance System to require additional assessments to evaluate the effectiveness of the airline’s new process for configuring passenger distribution and for calculating weight and balance.
The key to continuous improvements in airline safety is to create a sustainable culture of safety through an open and transparent exchange of information and data between the FAA and the aviation community. The FAA began this process in the 1990s by establishing a framework for airlines and others to share safety data in a non-punitive setting, through voluntary programs such as the Aviation Safety Action Program (ASAP) and the Voluntary Disclosure Reporting Program (VDRP).
The success of these voluntary safety programs has demonstrated that in today’s highly complex operating environment, a collaborative compliance approach is the most effective way to achieve the FAA’s core goal: to quickly find and fix safety issues before they can cause an accident or incident. By adopting this approach, the FAA is able to obtain actionable information to identify emerging risks, employ the most appropriate measures to address those risks, and monitor the situation to ensure the measures continue to be effective.
The FAA’s approach mirrors the open and transparent information-sharing approach that the International Civil Aviation Organization (ICAO) expects its member countries to implement.
It emphasizes a shared commitment to safety–that all stakeholders are responsible for, and accountable for, ensuring the safest possible aviation system. At the same time, it recognizes that people make inadvertent mistakes and that those mistakes can provide valuable data and information to help mitigate future problems and prevent accidents. Accordingly, it encourages information sharing about safety issues by enabling operators to do so without the fear of being punished
Therefore, in cases where a deviation results from factors such as flawed procedures, simple mistakes or a lack of understanding, the FAA uses tools like training or documented improvements to procedures to ensure compliance.
However, when the FAA encounters intentional reckless behavior, flagrant violations, or refusal to cooperate in corrective action, it uses the tool of legal enforcement action to gain compliance. If an air carrier is unwilling or unable to comply with laws and regulations, the agency can – and does – revoke the company’s ability to operate.
This approach distinguishes between the goal–compliance with the regulations–and the many tools the agency can use to achieve compliance. By emphasizing the goal of compliance, the FAA has improved communication with operators and fostered the kind of open, transparent, and robust safety culture we need to collectively assure aviation safety.
Here are two real-world examples of how our compliance approach has worked to improve safety:
Example One: In 2017, a commercial airline crew inadvertently landed on a taxiway instead of a runway at an airport that did not have a control tower. The crew voluntarily reported the incident to the FAA through the Aviation Safety Action Program. Because the crew was comfortable with the safety culture and this approach to compliance, during the FAA investigation they freely discussed what happened and provided invaluable insight about why it happened: the only lights they saw were taxiway lights, because a flooded electrical box had extinguished the runway lights. This open, first-hand reporting allowed the quick mitigation of a hazard that could have similarly confused other flight crews.
Example Two: Because of the increased openness and transparency fostered by the FAA’s compliance approach, a major air carrier has allowed FAA inspectors to have unfettered access to dozens of its proprietary, real-time event-reporting databases. The immediate information inspectors get from the live databases enables them to quickly adjust their surveillance to any areas of the carrier’s operation where there is an indication of increased risk. Access to real-time data also tells inspectors whether their surveillance activities and actions are effective. The carrier provided this access knowing that doing so could potentially alert FAA inspectors to a regulatory violation. This type of openness is possible because the FAA’s compliance approach encourages operators to share information without the fear of being punished for inadvertent violations.