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Christopher A. Hart

G lobal A viation I nformation N etwork (gainweb.org). Christopher A. Hart. Federal Aviation Administration. Assistant Administrator for System Safety. Worldwide Airline Fatality Rate*. AN INTERNATIONAL COMPARISON. THE LAST 6 YEARS. THE WORLD'S 85 MAJOR AIRLINES BY REGION.

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Christopher A. Hart

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  1. Global Aviation Information Network (gainweb.org) Christopher A. Hart Federal Aviation Administration Assistant Administrator for System Safety

  2. Worldwide Airline Fatality Rate* AN INTERNATIONAL COMPARISON THE LAST 6 YEARS THE WORLD'S 85 MAJOR AIRLINES BY REGION FATALITIES PER MILLION PASSENGERS WORLDWIDE AUSTRALASIA 0.0 1.1 18 UNITED STATES 0.3 0.9 0.9 NORTH AMERICA 0.4 16 (INCLUDES U.S.) 0.84 EUROPE 14 CENTRAL AND SOUTH AMERICA 1.7 12 No Jet Fatalities in U.S. in 1993 AFRICA 2.6 1994 - 264 Fatalities on U.S.Scheduled Airlines - 5 year high 10 ASIA 3.0 8 6 4 2 0 1950 1960 1970 1980 1990 1994 * Per Million Passengers Carried Worldwide

  3. The Hands-On “Front Line” Folks: “We All Knew About That Problem”

  4. Benefits of FDR Use Worldwide FDR Use <7Years Total U.S. FDR Use 7-14 Years FDR Use >14 Years Sources: Total U.S.- FAA NASDAC Other - Skandia Insurance Co. Ltd.

  5. Synergi implemented Number of reported and analyzed near-misses Norwegian Rail Experience Total number of reported and analyzed events Lost Time: 37 % reduction Accidents:40 % reduction ‘95 ‘96 ‘97 ‘98 Source: Pride AS

  6. Current System Data Flow Almost all Data is Lost Forever Currently Only a Minute Portion of Data is Collected and Analyzed

  7. Heinrich Pyramid ACCIDENTS INCIDENTS UNREPORTED OCCURRENCES

  8. Common Characteristics • Inadvertent • Could Be A Link • In An Accident Chain • Happens Repeatedly

  9. So Should We... • Regulate More? • Punish More? • Increase Training? • OR... Share Information to Fix the System?

  10. Fix the Person or the System? Is the Person Clumsy? Or Is the Problem . . .

  11. Fix the Person or the System? Is the Person Clumsy? Or Is the Problem . . . The Step???

  12. Is This Light Random?

  13. Accidents Result From a Combination of Events

  14. Global Aviation Information Network: The Concept

  15. Others Who Are Interested • Transportation Department • Coast Guard (IMISS) • Highway Administration • Railroad Administration • Pipeline Safety • Critical Infrastructure Assurance Office (CIAO)

  16. The Health Care Industry To Err Is Human: Building a Better Health Care System “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” Institute of Medicine, Committee on Quality of Health Care in America

  17. Information: The Fuel for Our Engine Zero Accidents Information

  18. Obstacles that Block the Flow of Information Concerns About • Public Disclosure • Job Sanctions/Enforcement • Criminal Sanctions • Civil Litigation

  19. Removing U.S. Obstacles • •FAA Reauthorization, 1996 • - Prohibits public disclosure of voluntarily provided aviation safety information • President Clinton, January 2000 • - Announced Aviation Safety Action Programs (ASAP) for voluntary pilot reporting • • FAA NPRM, June 2000 • - Proposesprotections for airlines and their employees from enforcement actions for regulatory violations discovered from voluntary reporting programs

  20. Removing Int’l Obstacles • ICAO 32nd Assembly, 1998- Resolution to improve safety through enhanced collection, analysis and dissemination of safety information • ICAO AIG, September ‘99-Approved recommendation to Annex 13 that States should establish non-punitive incident reporting systems, promote establishment of safety information sharing networks, and facilitate free exchange of information on potential safety deficiencies

  21. Challenges Improved Analytical Tools Legal Issues As we begin to get over the first hurdle, we must start working on the second.

  22. Analytical Tools Must be able to help analysts: • Identify Potential Problems • Prioritize Potential Problems • Develop Solutions • Evaluate Success

  23. Information Overload

  24. Many Have Already Begun The Process

  25. $avings

  26. Flight Deck ATC Maintenance Three Domains For GAIN

  27. Steering Committee • Airlines • Northwest Airlines (Chair) • Air France (Vice Chair) • British Airways • Japan Airlines • Air Transport Association • Manufacturers • Airbus Industrie • The Boeing Company • Flight Safety Foundation • Labor • Air Line Pilots Association • Int’l Association of Machinists & Aerospace Workers • National Air Traffic Controllers Association • General Aviation • National Business Aviation Association • Military • US Navy

  28. Working Groups • Working Group A • Aviation Operator Safety Practices • Working Group B • Analytical Methods and Tools • Working Group C • Global Information Sharing Prototypes • Working Group D • Reducing Impediments

  29. Where: Paris, France When: June 13-15, 2000 Hosted By: Fourth GAIN World Conference

  30. “GAIN is one of our best hopes for enhancing aviation safety in the next century.” FAA Administrator Jane Garvey: GAIN III World Conference November 1998

  31. Please Visit and Explore... www.gainweb.org

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