Rewriting Safety’s Future

1. Rewriting Safety’s Future

2. F-117

3. “... 90 per cent of the total accidents that have occurred are directly traceable to the lack of knowledge of or failure to realize dangerous positions of the airplane operations, whether of speed, angle, or direction.”

4. Aero and Hydro, Vol 5, Nov 2, 1912, 80-81, "Aviation Instruments: Construction and Use, I. Altitude" E. R. Armstrong

5. Wright Flyer

6. F-22

7. If you do not have the technical expertise to engineer, build, or fly the aircraft then what I have to say next does not matter.

8. Bleriot

9. Why do we care?

10. The Motivation: In a five year span from September 1989 to September 1994 my airline experienced five major airline accidents resulting from:

11. B-737

12. A Rejected Take-off: 20 September 1989; 737-400; La Guardia Airport, New York: The crew of flight 5050 rejected takeoff due to rudder trim problems. The aircraft overran the runway and was partially submerged in water. Two of the 55 passengers were killed.

13. Controller Error:1 February 1991; 737-300;Los Angeles, CA:

14. Flight 1493 was cleared to land on a runway which also had a Metroliner III on the runway awaiting takeoff. The aircraft collided and burst into flames. Two of the six crew members and 20 of the 83 passengers on the jet were killed. All 10 passengers and 2 crew members on the Metro III were killed.

15. F-28

16. Deicing: 22 March 1992; F28-4000; New York, NY: On flight 405 the aircraft crashed just after takeoff in snowy conditions due to icing on the aircraft's wings. Three of the four crew members and 24 of the 47 passengers were killed.

17. DC-9

18. Wind Shear: 2 July 1994; DC9-31; Charlotte, NC: On Flight 1016 the aircraft encountered heavy rain and wind shear during approach at about 3.5 miles (5.6 km) from the runway. The crew executed a go around for another landing attempt, but the aircraft could not overcome the wind shear. All five crew members survived, but 37 of the 52 passengers were killed.

19. Rudder Upset:8 September 1994; 737-300; near Pittsburgh, PA: On flight 427 the aircraft lost control at about 6,000 feet (1830 meters) during approach. All five crew members and 127 passengers were killed.

20. Individually these accidents were not in and of themselves directly related to operations and could have occurred at any airline.

21. The Microscope on the Problem Airline Mergers • In the past 25 years 23% of all 121 air carrier fatalities have occurred during merger integration • The catalyst of Change

22. The Microscope on the Problem Mirror Image • Unfamiliarity with a Task • Inadvertent Selective Compliance • A Dangerous Mindset

23. The Microscope on the Problem Altitude Excursions Runway Incursions

24. P-51

25. The Approach and Results Operation Restore Confidence • Life Preservers • Pointing Fingers • Altitude Awareness • Altitude deviations - 10 per month • ASAP(Aviation Safety Action Partnership)

26. F- 4 F-4

27. The Approach and Results CRM(Crew Resource Management) • Viable Program • By Pilots for Pilots

28. The Approach and Results ECAP(Enhanced Crew Awareness Program) Error Management Model(based on the Volant Model)

30. The Approach and Results ECAP(Enhanced Crew Awareness Program) Foundationof our training and operating practice

31. CONDITIONS THAT INCREASE HUMAN ERROR PROBABILITY • Unfamiliarity with the task = 17X • Time pressure = 11X • Poor human-machine interface = 8X

32. SR-71

33. INADEQUATE FLIGHT CREW MONITORING ASRS (Aviation Safety Reporting System) Study – 1997 Monitoring Errors • 78% resulted in altitude deviations • 76% identified in the study, were initiated when the aircraft was in some "vertical" phase of flight

34. NTSB's Special Study • “Crew Caused" air carrier accidents • 84% involved flight crew failure to adequately monitor the aircraft flight path ASAP(Aviation Safety Action Program) reports

36. Remember 1912 “... 90 per cent of the total accidents that have occurred are directly traceable to the lack of knowledge of or failure to realize dangerous positions of the airplane operations, whether of speed, angle, or direction.”

37. ADHERENCE TO PROCEDURES Boeing's "Accident Prevention Strategies" study 1996-2005 • Hull Loss Accidents Worldwide cites Flight Crews as being the primary cause by 55% Procedures and Standardization incorporated in our ECAP program Operate “in the green"

39. Conclusions Data Streams Report the Airline’s Progress • ASAP (Aviation Safety Action Program) • FOQA (Flight Operation Quality Assurance) • SOA (Special Operations Area)

40. Focus • Familiarizing ourselves with the tasks at hand • Increasing our crew monitoring and cross checking skills • Adherence to policies and procedures

41. No AccidentsSince Those Tragic Years Has Weathered The Stormsof • 9-11 • bankruptcies • another merger The ECAP Procedures continue to evolve as they have proven to be the best tools for Rewriting ourSafety’s Future.

42. Airbus 330

43. Rewriting ourSafety’s Future Excerpts from this piece have been reprinted from US Airway's Safety On Line 2005 article on "Merger Related Accidents", US Airway’s 1990 Altitude Awareness Program data files, US Airway’s 1991 CRM Program data files, US Airway’s 2007/2008 Flight Training and Standards article on “Challenge to Change History” by Capt. Lori Cline, ECAP White Paper by Capt. Robert Sumwalt, ASRS's: "What ASRS Data Tell About Inadequate Flight Crew Monitoring," Boeing's Study on "Accident Prevention Strategies," FAA documents, NTSB reports, ALPA records, and Aero and Hydro – Nov. 1912