By Nicholas Sabatini

Air travel in our country is incredibly safe. We are living in unprecedented times. This is the safest period in the history of powered flight. The U.S. aviation system is the largest, most complex airspace in the world and it is not a miracle, luck, or happenstance that air travel is so safe. This strong record is the result of the hard work of dedicated safety professionals in the Federal Aviation Administration (FAA) and in industry working together.

This paper will briefly cover how the U.S. aviation community reached this remarkable level of safety, and will address what the FAA is doing to maintain pressure on the accident rate and to continue to improve aviation safety.

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The current air carrier accident rate is zero.

Air travel is so safe in our country that it can be a challenge to meaningfully express just how safe it is to travel by air. The official way we express the level of safety for U.S. commercial air carriers is in fatalities per 100 million persons on board. As I write this in March 2008, the current rate for both fiscal year 2008 (which began Oct. 1, 2007) and for calendar year 2008 is zero.

As for corporate aviation, there has been one fatal accident this fiscal year.       In fact, the broader general aviation (GA) community is also enjoying its safest period. Last year, GA had the fewest fatal accidents and fewest fatalities since World War II. There were 284 fatal GA accidents in 2007, nearly half the number of fatal accidents there were 20 years ago.

Let’s look at how U.S. aviation reached the point where pilots are actually safer on the job than when they are not at work. For the most part, the gains have been achieved from continual improvements in technology that reduce the opportunity for human error — or from improvements that enable us to recover after a serious error. 

Here are a few examples of how technology has improved safety. Pressurized aircraft in the 1940s started flying above most of the weather and terrain, at least en route.  That change alone significantly reduced controlled-flight-into-terrain (CFIT) accidents and loss of control in flight. (CFIT occurs when an airworthy aircraft under the control of the flightcrew is flown unintentionally into terrain, obstacles or water, usually with no prior awareness by the crew.)

The introduction of Very High Frequency Omni-Directional Range (VOR) and the first Instrument Landing Systems in the 1940s and 1950s also drove down the number of CFIT accidents and approach-and-landing accidents.  Radar in the 1950s changed the environment permanently.  VOR/Distance Measuring Equipment (DME) receivers in the 1960s further reduced those types of events. 

            The introduction of jet aircraft is often cited as the single-most significant improvement in airline safety. The jet engine quickly far surpassed the safety and reliability of even the most sophisticated piston engines. In fact, as piston-driven airplanes increased in power, the rate of engine failure often increased. By the early 1950s, top-of-the-line piston engines could run a maximum of only 1,500 hour-time-between-overhauls. With today’s jet engines, we are enjoying greater engine reliability than ever before.

            Before the jet, from 1946 to 1958, for example, U.S. air carriers averaged 4.5 major accidents and 50 fatalities per year from engine-related accidents. In contrast, air carrier jet operators have had just two such fatal accidents in the past 20 years. 

            If we jump forward to more recent developments, such as Traffic Alert and Collision Avoidance System (TCAS) and Terrain Awareness Warning System (TAWS), there are dramatic examples of technology getting us out of trouble. With TCAS, no U.S. air carrier has had a midair collision since 1978. Previously, fatal mid-airs had been a common accident scenario.

            The experience with Ground Proximity Warning Systems (GPWS) and CFIT is more dramatic. Between 1946 and 1955, large passenger aircraft averaged 3.5 fatal CFIT accidents a year, which translated to a fatal CFIT accident about every 15 weeks. Through the mid-1970s, in the United States, we were still averaging two fatal passenger airline accidents per year due to CFIT. The major change in CFIT safety resulted from the Dec. 1, 1974, accident when a Boeing 727 slammed into a hill about 35 miles northwest of Washington’s DullesInternationalAirport. One of the accident’s causal factors was the absence of an alerting system to warn the crew they were dangerously close to terrain. The following year, the FAA required all commercial aircraft with more than 30 seats to operate with a warning system, e.g., GPWS, which sounds an alert whenever an aircraft was flown too close to the surface.

In March 2005, a rule requiring TAWS increased both the level of sophistication and, more importantly, the range of aircraft equipped. All turbine-powered airplanes configured for six or more passenger seats now must be equipped with TAWS, whether they are used in air carrier service (part 121) or in part 91 operations. 

Technology improves our ability to enhance human performance. Just look at the benefits from advanced simulators. It used to be that pilots perished in flight training. Today, with advanced six-axis simulators, pilots can train for a host of non-normal situations, including engine fires and failures, wind shear, hydraulic system failures, wake turbulence, among others. Also, using real data from real flights makes crew resource management training more realistic and much more valuable. Flight simulators are so advanced that pilots can achieve type ratings without touching the real aircraft. Follow all these improvements with major leaps in automation and precision flying throughout the 1990s, as well as the jet revolution reaching corporate aviation, and that brings us to the level of safety we enjoy today.

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Past technological breakthroughs continue to contribute to safety.

Our great safety record has come from a “forensics” or after-the-fact approach to making enhancements. We lose one. We investigate. We learn what happened. Then, we correct the most recent accident. This was the case with mid-air collisions and TCAS, with CFIT accidents and TAWS, with wind-shear accidents and ground-based Doppler radar, among others. Technology brought considerable benefits, which continue to contribute to today’s remarkable safety record.

Even with all the progress, we will continue to investigate accidents when they occur. There is still more to learn, and, with the great complexity, there is always the chance that a change intended to enhance safety could have an unintended and serious consequence.

The good news is that fatal accidents are rarer and increasingly one-of-a-kind. The aviation community with its intense focus on improving safety has largely picked the “low-hanging fruit” and addressed the common causes of accidents. This is why we often hear that air carrier and corporate aviation accident rates have reached such a low level that we should no longer expect sudden and sustained breakthroughs in future rates. 

We are on the threshold of reaching the next level in aviation safety.

We are on the threshold of reaching the next level in aviation safety. Here is the keystone to the next series of breakthroughs — using safety information and practicing risk management through safety management.

In the near future, the FAA, along with the entities it oversees, whether they are airlines, corporate aviation departments, manufacturers, or repair stations, among others, will increasingly use safety data to make decisions. More importantly, with the greater availability of safety information and sophisticated data analysis tools, the FAA will be able to detect safety trends, assess risks, and prioritize mitigations. Furthermore, we will continually measure performance and when we do make a change, we will assess its effect on performance.

In short, our goal is a standardized, higher quality systems approach to safety regulation and oversight. This goal is essential, especially given industry’s rapid growth powered by rising demand. The FAA forecasts annual U.S. airline passenger volume will grow from 765 million passengers in 2007 to 1 billion passengers by 2016. In addition, we project continuing strong growth in business aviation demand driven by a growing U.S. and world economy, as well as by a growing fleet of very light jets (VLJs).

In addition to growing demand, we are today witnessing more change than ever before in the 105-year history of powered flight. For one, we are seeing dramatically different business models, which include greater outsourcing. Components of new aircraft, such as the Boeing 787, with as much as 50 percent of its primary structure made of composite materials, are being produced by a host of international suppliers. Furthermore, new aircraft types, including VLJs and unmanned aircraft, are entering the National Airspace System at record rates.

To take preemptive action, we must share critical safety data.

This is exactly what we are doing.

Let me offer a real-world example of how we have used the analysis of safety data to make a big difference in safety. After the accident in August 2006 when an airplane took off from the wrong runway at Lexington, Kentucky’s BlueGrassAirport, the FAA’s newly formed Aviation Safety Analytical Services staff reviewed 5.4 million incident records from a number of databases.

This examination uncovered 116 occurrences of wrong runway departures involving commercial air carriers over the previous 20 years. These results led us to look further. In a Wrong Runway Study, we found that certain airports had common elements/physical characteristics that could lead to confusion. For example, runway thresholds that terminate in a large apron area can cause confusion. Other common elements that can contribute to crewmember confusion include a short distance between the airport terminal and the runway, a complex airport design, and the use of a runway as a taxiway.

We used this data and these findings to bring together the aviation community at the FAA’s August 2007 Call to Action on Runway Safety. After seeing the findings and recognizing the safety implications, various elements of the community stepped up to make voluntary — not Government-mandated — safety improvements.

That is just one example of the power of data — analyzing it and sharing it. The power of data is why the FAA and the aviation community initiated a safety analysis and data sharing collaboration to proactively analyze broad and extensive data to advance aviation safety. This initiative, known as Aviation Safety Information Analysis and Sharing (ASIAS), leverages internal FAA datasets, airline safety data, publicly available data, manufacturers’ data, as well as other data. 

ASIAS participants bring together a range of data sources and talents and include the FAA’s Office of Aviation Safety Analytical Services, the National Aeronautics and Space Administration, The MITRE Corporation (MITRE), manufacturers, and major airlines who provide data from their Aviation Safety Action Programs, or ASAP, and Flight Operational Quality Assurance, or FOQA, programs. 

ASAP encourages employees to voluntarily report critical safety information.  Airlines have ASAP agreements with flightcrews, maintenance and dispatch personnel, and as well as with flight attendants. Also, repair stations have them with their employees. Today, there are 166 ASAP agreements in place for pilots, mechanics, dispatchers, and flight attendants distributed over 69 airlines as well as with five repair stations.

Currently, reports from flightcrews are included in ASIAS. Future plans include the addition of deidentified reports from maintenance and dispatch personnel, and flight attendants, as well as from FAA air traffic controllers and manufacturer employees.   

While ASAP deals with the human element, FOQA collects and analyzes digital flight data generated during normal operations.  FOQA data is unique because it provides objective information not available through other methods.  It is this routine data that can give us insight into the total flight operations environment. In the years since air carriers instituted ASAP and FOQA programs, they have been able to achieve a host of benefits from their individual programs, including changes in training as well as enhanced operational and maintenance procedures. Combining the programs through ASIAS and making the findings available across the aviation community, not just on an operator-by-operator basis, will unleash the power of information to bring even greater and broader safety benefits.

The airline safety data is safeguarded by MITRE in a deidentified manner to foster broad participation and engagement. The public data sources include the National Transportation Safety Board, Aviation Safety Reporting System, National Weather Service, and Bureau of Transportation Statistics.

The goal of ASIAS is fusing, or bringing together, the data and then, as we did with the wrong runway analysis, leveraging the power of data analysis to help reveal the rare and infrequent emerging threats and hazards. Without a proven problem, it is a challenge to know which data points are simply that — data points — and which ones are important and could be a precursor to an accident. This is why the ASIAS team is focusing on pushing the science of advanced data analysis tools that will enable “vulnerability discovery” and reveal precursors to accidents that will enable us to proactively take steps to mitigate risks before loss of life.

Combining information from different data sources may provide insight into an underlying problem that would not have been possible by analyzing individual sources of safety information. For example, multiple types of data can be "fused," such as textual safety reports, digital aircraft FOQA data, and radar flight-track information to create hybrid databases that can be used to examine the interaction of aircraft terrain warning alerts and minimum vectoring altitudes. In the future, these “hybrid databases” can themselves be combined with other data sources to provide still more ways to detect and understand risks.

But there is more to achieving the next level of safety than gathering and analyzing safety information. Gathering and analyzing — as well as sharing critical safety information — is important, but what is essential is doing this in a system context and operating within a Safety Management System (SMS). 

Simply stated … an SMS enables an organization to identify and manage risk. And that is what we in the aviation safety community do… every time an aircraft takes off… flies (and defies gravity)… and lands safely, we have successfully managed risk. 

Safety data is the lifeblood of SMS.

Many organizations have long practiced system safety, but here is the

difference between system safety and SMS. With system safety, we address hazards that we know about, while an SMS puts in a structured approach embedded within a safety culture and uses data analysis to anticipate potential hazards, make prioritized changes, and then measure the effectiveness of the changes.

Operating under an SMS will enable the FAA to respond to changing industry business models and growth, as well as the challenging Federal budget environment, by allocating resources efficiently and effectively based on data-based risk analysis and assessment. This will ensure we focus our finite resources on the highest priority (or highest risk) hazards. In addition, SMS will help us find, understand, prioritize, and fix problems early — when it is less costly in both lives and dollars.

In addition, SMS will bring us into standardized, measurable, and repeatable safety alignment with our international and national partners. Of equal, or greater, importance, we must work smarter to manage risks from inside the FAA. As Professor James Reason points out in Managing the Risks of Organizational Accidents,an organization, such as the FAA’s Aviation Safety organization, could unwittingly contribute to, or even cause, an unsafe condition.

The FAA’s Aviation Safety organization is well on its way to adopting an SMS. Adopting a Quality Management System (QMS) and achieving International Organization for Standardization (ISO) 9001 registration in 2006 was a critical first step. In fact, Aviation Safety was the first Federal organization to achieve certification to the ISO 9001:2000 quality management standard as a single corporate management system.

When effectively combined, the SMS and QMS ensure safe and quality products. Stated simply:  SMS needs a QMS because SMS requires documented, repeatable processes. The QMS provides the strong foundation upon which an SMS is built.

The aviation community, in particular corporate aviation, has set the bar very high. SMS will be the key in enabling organizations across the aviation community to reach the next level of safety.

One of the all-time classic books for people who love flying and aviation is Ernest Gann’s Fate is the Hunter. Gann writes about flying in the early days when there was a greater degree of risk.  It was far greater — the book is dedicated by name to hundreds of pilots who perished in aviation’s early days.

Ernest Gann said fate was the hunter. Aviation safety at the beginning of the 21^st century is not about fate. Today, aviation safety is about dedicated professionals… staying focused… gathering, analyzing, and sharing information… and working together to manage the risks. 

If we continue to do this, we will meet that great challenge, which is to reach the next level of aviation safety and make air travel even safer for tomorrow’s air travelers.