A European Safety Strategy Initiative (ESSI)

1. European Commercial Aviation Safety Team (ECAST)Future Aviation Safety Team (FAST)Generic Presentation – “Draft”March 2007 A European Safety Strategy Initiative (ESSI)

2. PURPOSE • Explanation • JSSI/ESSI/ECAST context • What is FAST? • What it’s not… • Present “FAST Method” • Provide overview of process & results

3. EXPLANATION • HISTORY - JSSI TERMS OF REFERENCE • FOCUS AREAS • HAZARD IDENTIFICATION • RISK MANAGEMENT MODEL • FAST CHARTER • ESSI/ECAST IS SUCESSOR OF JSSI • SUMMARY OF FAST PRODUCTS • PROBLEM APPOACH • FUTURE AREAS OF CHANGE • WHAT THE FAST IS AND IS NOT…

4. HISTORY – JSSI Terms of Reference • Reduce the annual number of accidents and fatalities in each JAA member state and its operators irrespective of the growth in air traffic • Focused safety agenda with deliverables • Partnership + cooperation + communication + implementation • Structured complementary approaches, leading for: • Historic FAA/CAST • Prognostic JAA/JSSI Reference JAA website http://www.jaa.nl/jssi/profile.html

5. FOCUS AREAS • JSSI • Design Related • Future Aviation Safety • Occupant Safety & Survivability

6. HAZARD IDENTIFICATION Retrospective (Historic & Diagnostic) Predictive (Prognostic - FAST) • Historic & current operational data exist • Expertise and experience exist • Current analysis tools can: • Identify hazards • Define their causal factors • Establish frequencies (risk) • Provide learning • Establishes the baseline • Provides validation for predictive risk assessment techniques • No operational data exist, but conclusions can be drawn from current & future trends • No experts or experience exist but domain experts know “what keeps them up at night” • Qualitative hazard identification: • Predict likely hazards • Identify possible causal factors • Quantitative risk assessment adds: • Refinement of probable causal factors & estimate of frequencies • Bases for focused studies using computational & human-in-the-loop simulations

7. RISK MANAGEMENT MODEL SUGGESTED BY FAST PROGNOSTIC “FUTURES” FEEDBACK LOOP Prediction & Refined Causal Analyses HISTORIC FEEDBACK LOOP RAPID RESPONSE DIAGNOSTIC FEEDBACK LOOP Systematic measurement, hazard qualification & quantification and/or scenario-specific Monte Carlo simulations Strategic Use Predict domains & severity Determine contributing factors & severity Evaluate frequency & severity Tactical Use Future Hazard Analysis Historic & Causal Analysis Statistical & Causal Analysis Identify Trends Identify Events Identify Patterns Convert to Information Convert to Information Convert to Information Codify, classify, & merge Gather, codify, classify, & merge Monitor, codify, classify, & merge FUTURE CHANGES Heterogeneous ACCIDENT DATA Heterogeneous INCIDENT & OPERATIONAL DATA INTERVENTION&INNOVATION - Design - Operations - Investment - etc.

8. FAST Charter Vision • Identify possible future hazards to the safety of aviation in order to prevent those hazards from appearing within the future aviation system. Mission • Enable individuals or organizations and in particular the ESSI/ECAST, to evaluate proposed changes to the aviation system, identify hazards that may be created by such changes and by interaction effects, and subsequently develop mitigating actions. Goal • To prevent aviation accidents by eliminating or mitigating future hazards.

9. ESSI by EASA has succeededto JSSI by JAA • During the JAA – EASA transition, EASA has begun to build up the European Strategic Safety Initiative (ESSI) in 2005 • ESSI foundation meeting took place on April 27 2006 and the JSSI-ESSI handover was performed on June 28 2006

10. The 3 ESSI Pillars • 3 pillars • Commercial Aviation (ECAST) • Working with CAST • Partnership • Rotorcraft (EHEST) • Working in IHST • Partnership • General Aviation (EGAST) • Safety Committee • Promotion • Consistent approach to safety risk management

11. ESSI / ECAST Construction • 27 April 2006 • Foundation group: Bring the parties together • 13 July 2006 • Making a charter • 12 October 2006 • Agree foundation documents • 13 & 14 December 2006 • Establishing a work programme • FAST reconducted as a Working Group of ECAST • 2007 • Full schedule of activities

12. Where FAST fits in ESSI Open and Closed Forums COORDINATION GROUP ECAST COMMERCIAL AVIATION SAFETY TEAM EHEST HELICOPTER SAFETY TEAM EGEST GENERAL AVIATIONSAFETY TEAM FAST Other WORKING GROUPS WORKING GROUPS WORKING GROUPS

13. Main FAST Input: Top Emerging and Future risks C O O R D I N A T I O N C O M M U N I C A T I O N 1. Assess and Prioritise Accident Risks and Causal factors in Europe (yearly revised) ECAST Process 2. Identify and Review Safety Programmes 3. Define Safety Performance Metrics 4. Define Safety Enhancement Objectives 5. Institute Safety Programmes 6. Make Recommendations for Safety Enhancements 7. Perform Costs Benefits Analysis 8. Develop Action Plans 9. Implement Action Plans and Monitor Implementation 10. Monitor Action Plans Efficacy to Achieve Safety Objectives Mid Term Programme Review - 2012

14. FAST Summary of Results • A structured methodology incorporated into a formal handbook. • A prioritized list of Areas of Change [AoC]. • Two applications/tests of the methodology: • Recommendations resulting from the study of the AOC “Increasing Crew Reliance on Cockpit Automation”, e.g. related to the Air Ground Space System [AGS] • Results from the study of future hazards generated by the concept of operations for 2011developed by EUROCONTROL. • A FAST website

15. discovers informs intervention prevents discovers Diagnostic informs intervention prevents discovers informs intervention prevents more accidents PROBLEM APPROACH Has it caused an accident? Intervention Processes Discovery Processes Does it exist yet? Is it known? 0 0 0 Prognostic e.g. Emergent, FAST, etc. PrognosticDesign of new Aviation System components or practices 0 0 1 1 0 0 Diagnostice.g. ASAP, COSP, ISDSR, LOSA, FOQA, ISDSR, ASRS, SRB. ECCAIRS, ODA etc. 1 0 1 1 1 0 Historice.g. Accident Investigation Historic 1 1 1 1 = yes, 0 = no e.g. Regulation, Product Improvement, CAST, ECAST, company safety (e.g. SRP) processes, FSF/ALAR tool kit, Human factors tool kit etc.

16. FUTURE AREAS OF CHANGE AoC aphase out of Gen I transports AoC b AoC c Introduction of UAV’s AoC d Spectrum and Magnitude of Areas of Change Affecting the Future Aviation System AoC e AoC f AoC g AoC h AoC i AoC j AoC k advent of very-light jets AoC l t NOW 2010 2015 2020 Past

17. IMPORTANCE OF IDENTIFYINGAREAS OF CHANGE… • The future is not necessarily a direct extrapolation of the past. • Present and near-term safety interventions that are intended to prevent future accidents caused by previously known hazards may not be enough to prevent new types of accidents from happening in the future. A mid-1990’s study by a major manufacturer looked at accidents in which airplane systems were involved in an accident or where they could have prevented the event and did not. It was found that in approximately 70% of the accidents involving airplane systems, the original design assumptions were inadequate for the situation existing at the time of the accident due to changes in… - the aviation system - airplane operational usage - personnel demographics - evolving infrastructure or other considerations.

18. CHANGING NATURE OF ACCIDENTS “Technological innovations are changing both aircraft and the airspace in which they operate.Cumulatively, these technological changes aim to increase reliability throughout the aviation system and vastly improve safety in the skies. These changes include systems designed to move aircraft more efficiently in the air and on the ground, methods for providing pilots and ground controllers with better information about traffic and weather conditions, and improvements in aircraft components and design. “The growth in aircraft system complexity is exponential in many areas, with the most significant trend being the inter-connectedness of systems.Current-generation aircraft operate as highly integrated systems with extensive cross-linking. As system complexity grows, so does the concern about hidden design flaws or possible equipment defects. “Accidents involving complex systems and events present investigators with new and different failure modes that multiply the number of potential scenarios they must consider.The historically common causes of accidents are occurring less frequently, leaving more challenging accidents to diagnose.” * * - Safety in the Skies Personnel and Parties in NTSB Aviation Accident Investigations-Master Volume, Chapter Three: Emerging Aviation Trends: Potential Impact on Aircraft Accident Investigations, By: Liam P. Sarsfield, William Stanley, Cynthia C. Lebow, Emile Ettedgui, Garth Henning, published in 2000

19. Areas of Change: Some Principles • Changes must be understood as broadly as possible. • To bring consistency and coherence to the process, Areas of Change are grouped by categories. • The diagram on the next sheet illustrates the eleven broad categories of Areas of Change affecting aviation identified by the FAST

20. FAST AREAS OF CHANGE CATEGORIES CountCategory 29 Aircraft 11 Maintenance, Repairs, Overhaul 19 Operations 21 Crew 7 Passenger 10 Organization 12 Authority 22 Air Navigation System 7 Airport 35 Environment 5 Space Operations ___ 179 Total Areas of Change as of 24 February 2006 AIRCRAFT SPACE OPERATIONS MAINTENANCE, REPAIRS, OVERHAUL ENVIRONMENT GLOBAL AVIATION SYSTEM OPERATIONS AIRPORT CREW AIR NAVIGATION SYSTEM PASSENGER AUTHORITY ORGANIZATION The FAST continuously solicits submission of new, candidate AoC’s via the process shown in Backup Charts. Submissions should be made to Rudi den Hertog, Chief Engineer, Fokker Services, FAST Co-chair, rudi.denhertog@stork.com

21. What is an Area of Change • The Global Aviation System (GAS) is in fact a "system of systems." • Examples of "systems" include • airplanes, • air traffic control systems, • company processes, and • regulatory systems. • The future GAS will be fundamentally different than what exists today because changes affecting the GAS will continuously occur as the system evolves into the future. • The ongoing process of change including both evolutionary and sudden, disruptive events or paradigm shifts must be considered for effective safety risk management.

22. Distributed multi agent system • Free routing/free flight • New airspace classification • 4-D dimensional trajectories Air Ground Space System • Civil aerospace challenges • Increased aerospace capacity • Better respect of the environment (“sustainable growth” approach) • improved safety • 2020 situation • Integrated Air Ground Space System • Operates during all phases of flight • Communicates through data link

23. Importance • It is important that aviation practitioners who are designing future systems have foreknowledge of potential future hazards. • A change to any one system could affect other systems. Interactions of future changes to several systems could likewise affect the whole. • These changes could have adverse impacts on the safety of the Global Aviation System. • The goal of "discovering" future hazards is to eliminate, avoid or mitigate hazards in the future that may arise as a result of the changes. This will reduce the risk of future incidents and accidents.

24. WHAT’S FAST? • OBJECTIVES • WHAT’S SO SPECIAL? • WHAT FAST IS AND WHAT NOT • COMPOSITION • CORE TEAM

25. OBJECTIVES of the FAST method Studying potential future changes in the Aerospace System in order to : • Identify relevant Areas of Change [AoC] either within or external to the aviation system • Identify Hazards, both inherent to the AoC as well as those arising from interaction with other AoC’s • Develop recommendations to eliminate hazards or mitigate their effects, such as: • Tools to analyze and mitigate the hazards including studies and simulations to quantify the risks of identified hazards • Providing probable hazard information to influence entities that shape the future

26. DISTINCTIVE CHARACTERISTICS • Concept of considering a comprehensive set of “Areas of Change” affecting aviation safety • Using a broad representation of domain experts representing diverse affected organizations within an Expert Team hazard-discovery setting looking for direct and indirect hazards • Direct- as well as Indirect hazard(s) identification, with indirect hazards resulting from interaction among AoC’s within a novel future operational scenario - identifies hazard catalysts not ammenable to computational modeling • Maintaining and providing to the aviation community an up-to-date repository of AoC’s, possible aviation futures, Technology Watch Items & hazards. • Offering a Future Hazard Analysis method that can be used universally by any organization • Having a FAST Core Team ready to assist Customers using its Future Hazard Analysis method

27. What the FAST is and is not… The FAST process is a systematic approach to identification of: • Wide range of changes affecting aviation safety (AoC’s) • Systemic vulnerabilities and hazards within highly integrated systems • Boundary aspects not only within aviation but external to it that may be the catalysts for future hazards including common cause factors and interactions The FAST process is not a risk assessment method - that is, it doesn’t estimate relative frequency of hazards. The FAST generally does not recommend or develop safety interventions - FAST can feed Risk Assessment and Risk Management processes in which safety interventions are developed and implemented, and action efficacy is monitored. These are best left to the customers.

28. COMPOSITION • MEMBERS from DGAC, CAA-UK, CAA-NL, ENAC, EASA, Civil Aircraft Inspection Board of Poland, ASD, EC/Joint Research Centre, EUROCONTROL, ERA/EASYJET, IFALPA/SAS Norway, IAPA, IFA, Air Transport Association of Canada, NASA Airbus, Boeing, Bombardier, Fokker, Rockwell Collins • CORE TEAM is driving force, meeting approximately quarterly

29. FAST METHOD • DEFINITIONS • CUSTOMERS • STAKEHOLDERS • EXPERT TEAMS • TECHNOLOGY WATCH ITEMS • PROCESS FLOWS

30. DEFINITIONS: • CUSTOMERS are organizations that have authority to either recommend or implement changes to the Global Aviation System • STAKEHOLDERS are organizations that may be impacted by an envisioned change to the Global Aviation System EXPERT TEAM • Drawn from Customer & Stakeholder organizations • Selected by FAST and Customer collaboratively based on the envisioned future being considered • Must have specific expertise associated with the future being evaluated • No experience with FAST method required initiate changes affected by changes

31. DEFINITIONS, cont. • TECHNOLOGY WATCH ITEMS • A repository of tell-tale advances in technology and other relevant factors that may indicate which possible aviation future is unfolding and thereby signal if postulated direct hazards and/or indirect hazards (interaction hazards) are coming about. • To be revisited after significant events (incidents & accidents) and be part of risk assessment plans. • Maintained for the benefit of the worldwide aviation community similar to the CAST Problem Statements.

32. FAST Methodology / Process 2. Define Scope of Expert Team Hazard- Identification Study Enhance and/or Modify Planned Changes Customer/ Stakeholder Responsibility 3. Assemble an Expert Team Advocate the FAST Philosophy FAST Core Team Responsibility Maintain Futures & Watch Items Maintain Areas of Change Repository Commission Expert Teams Guide FAST Facilitators 10. Inform FAST & Customers Regarding results Enhance the FAST Method 4. Understand Customer Requirements and Future of Interest 6. Identify Areas of Change Pertinent to Future of Interest 7. Enrich Hazards by Evaluating Interactions with Areas of Change 9. Formulate Recommendations & Identify Watch Items Expert Team Responsibility 5. (optional) Identify Intrinsic Hazards Within Future of Interest 8. (optional) Identify Mitigations & Effects of Areas of Change on Mitigations 1. Responsible Party Proposes Change(s) to Global Aviation System; recognizes need for systematic prediction of hazard(s) associated with changes and need to design potential hazards out of system or avoid or mitigate hazard(s)

33. OVERVIEW of PROCESS & RESULTS Work progressed in phases: • Phase I (Oct/99-Sep/00): Established methodology, identified 157 changes affecting the aviation system. • Phase II (Nov/00-July/01): Prioritised Areas of Change • Phase III (Oct/01-Jan/04): Analysed highest priority Area of Change: Increasing Reliance on Flight Deck Automation • Phase IV (Feb 05-Mar06) : Re-check/update AoC list, develop Process Handbook/Generic Presentation/Public Website, • Phase V (Mar 06-July 06: ConOps 2011 analysis [ANS-1].

34. OVERVIEW OF RESULTS • TOP 4 AREAS OF CHANGE • SYNTHESIS FROM TOP 20 AoC • PHASE III OUTPUT • ConOps 2011 [ANS-1] ANALYSIS

35. TOP 4 AREAS OF CHANGE PRIORITISED & CATEGORIZED FROM CURRENT LIST OF 179 • Increasing Crew Reliance on Flight Deck Automation (Aircraft) • Emergence of New Concepts for Airspace Management (Air Navigation System) • Introduction of New Technologies with Unforeseen Human Factors Aspects (Crew) • Proliferation of Heterogeneous Aircraft with Widely-varying Equipment and Capabilities (Aircraft)

36. SYNTHESIS FROM TOP 20 AREAS OF CHANGE • Introduction of new air, ground, and satellite-based automated systems • Increased heterogeneity of: aircraft types & flight capabilities, equipage & software, airspace utilization approaches, and development directions & timelines for airborne, ground, and space-based aviation support systems • Increase in absolute numbers of aviation operations and corresponding reduction in safety margins as a result of: increased demand, decreased separation and more frequent operation in or near adverse weather conditions • Ensuring adequate maintenance of air- and ground-based systems in an environment of increased outsourcing of work, increased complexity of hardware, firmware & software, and a shortage of qualified maintenance personnel Common threads as they appeared within the 2001 top 20 AoC synthesis.

37. PHASE III OUTPUT Analysis of highest priority AoC: Increasing Crew Reliance on Flight Deck Automation: • Identification/prioritisation of hazards • Development and prioritisation of recommendations addressing most important hazards • Introduction of Technology Watch Items • Present the methodology used and lessons-learned

38. Eurocontrol’s FAST – ConOps Workshops • ConOps is the Eurocontrol Concept of Operation for 2011 • FAST was tasked to identify future hazards in ConOps • Two workshops held (6-9 June and 17-20 July 2006) with European and US experts

39. Air Traffic Flow & Capacity Management Airspace Organisation & Management Airspace User Operations Information Management& Services Airport Operations Separation Assurance Synchronisation Air Traffic Control CONOPS 2011 - CONTENT • Concept of Operations 2011 • Description of the ATM System in 2011 - the Main Changes • The ATM Components, OI’s and System Enablers • The ATM Operational Model • The Key Enablers – SWIM, the Network Operations Plan and Collaborative Decision Making • The Principles of the Layered Planning Process • High-Level System Capabilities • Business Impact Statements • Annexes • The Actors – Roles and Responsibilities • Operational Scenarios and Use cases

40. FAST – ConOps Evaluation: From EUROCONTROL final comments • Lessons learned • Very useful exercise • Hazards identified may allow improving ConOps • Pass results to SESAR, maybe a FAST customer • FAST methodology requires further development • Subsequent development • FAST Handbook upgraded • Clarification of AoC use for: • Hazard Identification / Enrichment • Mitigations • Link to classical Risk Assessment Methods • Transferable methodology

41. FAST Website http://fast.jrc.it/ Under development http://fast.jrc.ec.europa.eu/ Final URL

42. An essential element of a safety strategy • Future hazards can not be entirely extrapolated from the past • There is a need to address future changes and hazards in safety today • FAST offers a method of worldwide interest

43. THANK YOU FOR YOUR ATTENTION For FAST Output Status see http://fast.jrc.it

44. BACKUP CHARTS

45. Acronyms • ADREP ICAO Accident/Incident Data Reporting System • AoC Area of Change developed by FAST • AGS Air Ground Space System • ANSP Air Navigation Service Provider • ATC Air Traffic Control • AWOS Automatic Weather Observation System • CAST Commercial Aviation Safety Team (North America) • CICTT CAST/ICAO Common Taxonomy Team • ConOps In FAST context: Eurocontrol’s Concept of Operations for 2011 • ConOps General: air traffic providers concept of operations • ESSI European Safety Strategy Initiative • ECAST European Commercial Aviation Safety Team (EuroCAST) • ECCAIRS European Co-ordination Centre for Aviation Incident Reporting Systems

46. Acronyms - continued • FAST Future Aviation Safety Team • GTG Gate-to-Gate • ICAO International Civil Aviation Organization • JAA Joint Aviation Authorities (Europe) • JSSI JAA Safety Strategy Initiative • JSAT Joint Safety Analysis Team (CAST) • JSIT Joint Safety Implementation Team (CAST) • JPDO Joint Planning and Development Office (part of NGATS in USA) • NGATS Next Generation Air Transportation System (USA) • SESAR Single European Sky ATM Research Programme • TCAS Traffic Collision Avoidance System • TAWS Terrain Avoidance Warning System

47. FAST Contribution to CAST Safety Plan Introducing and integrating the Prospective component of safety Accident Analysis JSATS “Historic” Accident JSIT’s Safety Enhancements CAST Plan CASTPlan Revision Master Contributing Factors Safety Metrics JIMDAT Process Incident Analysis Process “Historic” Emerging Risk Remaining Risk JSA/IT Enhancements Operational Data Analysis (NASA ISDSR) “Diagnostic” Changing Risk Aviation System Changes Yes Develop Contributing Factors (new or emerging) Predictive Analysis (FAST & FST) “Prognostic” No Present In Master Factors? Identify Causal Factors External Changes Identify Future Hazards B. Smith; 2/7/06

48. Area of Change (AoC) Submission Process Continuous Call For New Aoc’s Refine Wording & Add Descriptive Comments Candidate AoC External Group or Individual FAST Core Team Comparison with Existing AoC List Review for FAST Consistency New? Okay? yes no no yes Evaluate for Potential to Enrich Existing AoC’s Concatenate to Existing AoC List

50. Examples of global Air Ground Space system Technology Watch ItemsTheme I • Development of system using Artificial Intelligence (e.g. neural nets, fuzzy logic). • Development of “intelligent” aircraft (with systems of smart sensors, microprocessors and adaptive control that monitor operator performance, environment and automatically avoid hazardous situations) • Emergence of computational capabilities and monitoring systems that could replace conventional air traffic control functions • Development of “intelligent” vehicles (e.g. smart cars) as cross fertilisation may affect aviation • Collaborative decision making (CDM); Computer Support to Cooperative Work (CSCW) • eSafety of road and air transport and eHealth, Multimodal Interfaces, Semantic-based knowledge systems, technology-enhanced learning