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Lessons Learned From Aviation Accidents

Lessons Learned From Aviation Accidents. Creation of a Web-Based Knowledge System. Background. During the 1990’s and early 2000’s, several major airplane accidents occurred which exposed errors in: Airplane design Airline operations Maintenance programs and the processes linking them.

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Lessons Learned From Aviation Accidents

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  1. Lessons Learned From Aviation Accidents Creation of a Web-Based Knowledge System

  2. Background During the 1990’s and early 2000’s, several major airplane accidents occurred which exposed errors in: • Airplane design • Airline operations • Maintenance programs and the processes linking them

  3. These accidents included: • Trans World Airways Flight 800 • Swissair Flight 111 • American Eagle Flight 4184 • Alaska Airlines Flight 261

  4. TWA Flight 800 747 crash off the coast of Long Island, NY • Center fuel tank exploded in flight • Flawed assumptions regarding fuel tank components

  5. Swissair Flight 111 MD-11 crash off the coast of Nova Scotia • Electrical Arc resulted in cabin insulation material that burned aggressively • Flawed assumptions regarding burn characteristics

  6. Alaska Flight 261 MD-80 crash off the coast of California • Loss of control resulting from failure of horizontal stabilizer trim jackscrew • Inadequate lubrication

  7. American Eagle Flight 4184 ATR 72 crash near Roselawn, Indiana • Ice contaminated wing surface and loss of airplane control • Ice built up on unexpected areas of wing

  8. Costly lessons from these and many other major accidents were being lost by the passage of time

  9. Accident Awareness • The FAA identified lack of accident knowledge as key factor in several major accidents • Awareness of specific accidents not widespread throughout aviation community

  10. “Those who cannot remember the past are condemned to repeat it.” George Santayana Professor of Philosophy Harvard University The Life of Reason, Volume I 1905 Nearly all large transport accidents are enormous human tragedies. • A second tragedy is to not learn from them.

  11. No Aviation-wide accident LL resource was available • Fear of negative publicity • Lengthy investigation/resolution • Continual workforce turnover • IT tools only recently available

  12. FAA Initiative • The FAA has now developed a web based “Lessons Learned from Transport Airplane Accidents” library • Threat based • Search/sort capability

  13. Purpose of Accident Library • Stop and reverse the loss of costly lessons • Maintain and improve the safety of an already very safe international aviation system

  14. Summary • A web-based Accident Library is now available to enhance the safety of an already very safe international aviation system • Currently available at: http://accidents-ll.faa.gov/ • 57 accident modules; more added each year

  15. The Lessons Learned web site will now be demonstrated @ accidents-ll.faa.gov/

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