Speech

61st International Air Safety Seminar

It’s a privilege to be here with so many people who have done so much for aviation safety around the world. I want to thank each of you for your commitment and your professionalism. Good morning! Or, since we are in Hawaii, perhaps I should say, “Aloha.” Aloha means “hello.” It also means “goodbye.”

In preparing for this trip, I learned some other Hawaiian words. I’m sure you saw the “wiki wiki” buses at the airport. “Wiki” means quick. Another Hawaiian word — “ohana” — means “family.” Ohana is an appropriate word to use at the 61^st International Air Safety Seminar.

You here today represent a host of disciplines. You have a range of experience. You are from different organizations. And, while you come from dozens of countries, we all want the same thing:  The continuous improvement of global aviation safety.

We are “ohana.” We are a family of passionate safety professionals. And, we all know — and these international seminars are testimony:  The best things we do in aviation, we do together.

The “founding father” of the Flight Safety Foundation — Jerry Lederer — had eight people at his first safety seminar. Sixty years later, look around, we number in the hundreds. We come together across borders, because we know that in aviation safety there are no boundaries.

When Jerry started the Flight Safety Foundation in 1947, U.S. air carriers averaged a major accident every 16 days. The rate:  1,400 fatalities per 100 million persons flown. Today, that rate is down to an average of 2.5 fatalities per 100 million persons flown. On a global scale the overall rate is quite a bit higher, but this higher rate is driven by several regions that continue to have high accident rates.

Yet, the safety record in many regions of the world — as well as the U.S. performance of 2.5 fatalities per 100 million persons flown — is a remarkable achievement. And, that is what I want to talk about today:  This remarkable achievement and what we can — what we must — do to build upon this achievement and keep improving aviation safety.

Even with this remarkable record, a series of events this past year put the Federal Aviation Administration — its safety oversight as well as the relationships between regulator and       regulated — under the spotlight.

The public scrutiny began in the spring with congressional hearings on possible lapses in FAA’s safety oversight. In addition to the hearings, there were investigations and our own internal reviews. In May, Secretary of Transportation Mary Peters named a blue-ribbon panel to review FAA’s approach to safety oversight. Ambassador Ed Stimpson chaired that Independent Review Team. Ed, thank you for your leadership.

The Independent Review Team’s report, titled “Managing Risks in Civil Aviation,” was a thorough and a thoughtful review of the role — and the challenges — of being a regulator. The group devoted a lot of time in a short period to talk with employees and experts across FAA and across industry. Their conclusion:  Working together has produced remarkable results.

As the team said in the report’s summary:  “We are phenomenally impressed with what this agency has achieved, in collaboration with the aviation industry, in driving accident rates down to extraordinarily low levels.”

The great thing about a review panel, such as the Independent Review Team, is that the members really understand the subject matter:  The aviation safety business. And, with that understanding they use their experience and their expertise to focus on the tough issues. One area Ambassador Stimpson’s team addressed is voluntary disclosure of safety information. The future of voluntary disclosure programs was threatened by the misuse of the program by a few from FAA and Southwest Airlines.

Yet, the Independent Review Team’s report provided an unqualified endorsement of these voluntary programs. Let me quote: “We re-affirm the value of the FAA’s voluntary disclosure programs as vital to continuing improvement. Such programs are more vital to the FAA, in our view, than to other regulatory agencies, given the essentially preventive nature of the residual risk-control task, and the resulting importance of learning about and learning from precursor events.” The Team offered recommendations on how to improve voluntary disclosure programs.

They also had ideas to improve how we handle Airworthiness Directives (ADs), including a progress-toward-compliance review of AD implementation.

One tough area the team tackled is the conflict that can arise within individual offices when employees take different approaches to oversight or have diverse regulatory approaches, or ideologies. As the report pointed out, these ideologies can range from strict enforcement to total cooperation. The team concentrated on how the FAA can address these potential disagreements and offered suggestions on training and on internal review mechanisms.

This discussion of organizational culture underscores the importance of self- reflection. As we at FAA work to manage risks in civil aviation as the regulator we must take a two-pronged approach.

First, we must manage risk from the “inside out.” We must take a hard look at ourselves — at how we are organized, at our processes, at our internal measures and accountability. At the same time, we must also focus outward on the entities and individuals that we regulate.

Professor James Reason has discussed the importance of an “inside-out” approach. In his book — Managing the Risks of Organizational Accidents — Reason says you must manage risks from inside because an organization, such as the FAA, could unwittingly contribute to an unsafe condition or unsafe practices.

There’s lot of research about how organizations — including regulators — can contribute to unsafe conditions. In the book — The Logic of Failure — the author Dietrich Dorner examines a number of scenarios that had unintended consequences. Perhaps the most dramatic example:  The Chernobyl atomic plant explosion, which was due to human error. It involved a team of experts breaking safety rules. These experts reinforced each other’s inflated sense of competence.

Organizational risk is not new in aviation. It has always been there. Organizational risk was present in Kitty Hawk with the Wright brothers and their machinist Charlie Taylor. It was present in the 1940s when we had accidents every 16 days. Yet, organizational risk was largely undetected because it was over-shadowed by greater risks — such as engine failure, controlled flight into terrain, loss of control, and approach and landing accidents.

Now that we have fundamentally addressed those common causes, the organizational risks are greater. They are taller due to the flatness of the surrounding terrain.

I am pleased the Independent Review Team highlighted organizational risk. It is essential that FAA be introspective and hold ourselves to the same high standards that we hold industry.

As the regulator, we require the organizations we regulate to operate with a Safety Management System and to have a safety culture. We are imposing the same high standards on our organization. FAA’s Aviation Safety organization — with nearly 7,000 personnel and many more designees who act on behalf of the Administrator — is moving to a Safety Management System. We developed an SMS doctrine in concert with industry. And, we are moving ahead with an implementation plan for an integrated system safety approach across our organization.

SMS is built on a foundation of a Quality Management System, which we implemented through ISO 9001 standards. Our organization achieved ISO registration two years ago. We quickly learned that maintaining our ISO registration is just as challenging as achieving it.

QMS addresses processes. It addresses standardization and consistency as well as continuous improvement. We must add the SMS element to assure we practice risk management. Yet, both QMS and SMS are processes that are executed by humans. What is crucial is that these processes exist in a safety culture.

Getting the culture right is as important — perhaps more important — than the systems you use. This is what is most important about managing from the inside out.

What about the second prong — the regulator’s essential external focus? What can we do to manage risk more effectively across civil aviation?

At an air carrier accident rate of 2.5 fatalities per 100 million persons flown, some might think the accident rate has reached such a low level that we should no longer expect sudden and sustained breakthroughs in future rates.

I disagree.

The aviation community is on the threshold of reaching the next level in aviation safety.

How is this possible?

We can do it — together — by managing risk far more effectively. And, we will do this through gathering and sharing key safety data, through sophisticated data analysis to identify precursors and detect emerging risks, and through prioritizing and measuring mitigations.

Today, with FAA’s Aviation Safety Information Analysis and Sharing initiative — or ASIAS — we are gathering crucial safety information from a number of data sources. With sophisticated analysis tools, we are detecting trends, identifying precursors, and assessing risks.

Here’s a real-world example of how data analysis and sharing can make a big safety difference. In the August 2006 accident at Lexington, Kentucky, an airplane took off from the wrong runway. Forty-nine people perished. After that accident, our data experts reviewed 5.4 million records from a number of databases.

In a search of twenty years of data, we found 116 instances where flight crews attempted a wrong runway departure. In some cases, the crew corrected themselves. In other cases, air traffic controllers corrected the crew. And, some did indeed take off from the wrong runway.

One hundred and sixteen instances:  That was a “red flag” to dig deeper. In a Wrong Runway Study, we found that certain airports had common factors that could be confusing to pilots. For example, runway thresholds that end in a large apron area can be confusing. Other elements that can contribute to crewmember misunderstanding include a short distance between the airport terminal and the runway, or a complex airport design, or the use of a runway as a taxiway. Or, it was all of the above.

We used these findings to bring the aviation community together last year for a “Call to Action” on Runway Safety. After seeing the findings, members of the community stepped up and made voluntary — not Government-mandated — safety improvements.

Furthermore, the ASIAS team is pushing the science of advanced data analysis and fostering the development of cutting-edge data analysis tools. For example, last year several airlines reported that their FOQA data showed that they were getting warnings from their Terrain Awareness Warning Systems, or TAWS, at several airports with adjacent mountainous terrain in a sector of Oakland, California, airspace.

That was one data point:  Several airlines receiving TAWS alerts in the same area. Our analysts reviewed multiple data sources to get a clearer and fuller picture of the problem. They analyzed Minimum Vectoring Altitudes, or MVAs. They plotted the TAWS alert locations in relationship to these MVAs to reveal a relationship. Next, they overlaid radar track data from arriving flights. Then they overlaid the terrain database combining — or fusing — it with the MVA and TAWS data.

With all of this, they were able to “see” a causal relationship that could not be seen from any one data source. The experts call what they did “fusion.”

The single data point — the five TAWS alerts — is just that:  A single piece of information. But, fusing the data sources — including the MVAs, radar track data, and more — provided a larger picture and a more complete understanding of the issues.

From those five TAWS alerts in Oakland airspace, thanks to data gathering, sharing, and analysis, we are making flying safer — in the way we design MVAs, in how we vector traffic, in the design of TAWs software, and more.

With ASIAS, we are making a game-changing move from forensics to pre-emption.

The greater amount of data, coupled with advanced analysis, will help us find emerging threats and identify precursors that could be buried in “terabytes” of safety data. This gives us an advantage we’ve never had:  The ability to act ahead of time to prevent accidents and to manage risk.

Yet, how does this preventive work — this cooperative work — fit in with the role of the regulator? Is it our place?

You bet it is. It would be irresponsible and reckless to wait for the next accident to make additional safety enhancements. As safety professionals, we must use every tool — especially the best tools — available to manage risk.

It is entirely fitting that as the regulator, the FAA lead and foster new ways to improve safety and that we create the infrastructure that can be used across the aviation community. That is the role of the regulator in the 21^st century.

There will inevitably be times when there is ambiguity about the important problems and how to fix them. That is what is so important about data. There’s a reason we are still quoting Alan Mulally long after he left Boeing to head the Ford Motor Company. He’s the one who said, “The data will set you free.”

Yes, it will. It is facts and reasoned analysis that will enable us to manage risk more effectively. For example, the wrong runway analysis led us directly to the airports and to the issues that were causing the problems.

Flight Safety Foundation founder Jerry Lederer issued his own call to action when he said, “Risks are ever-present, must be identified, analyzed, evaluated, and controlled.”

He was right, then. And, in today’s interconnected world — with growing demand and greater complexity — Jerry’s words are more important than ever.

We must manage risk. And, we must do it together.

Here’s to managing risk and to the world’s leading safety professionals, who are gathered here this week.

Here’s to “Ohana.”  

Thank you for everything you do for aviation safety.      

Aloha.