Federal Aviation Administration Presented to: The National Academy of Sciences By: Daniel I. Cheney, Manager, Safety Programs Federal Aviation Administration Federal Aviation Administration Lessons Learned From Aviation Accidents Creation of a Web-Based Knowledge System

2 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, 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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, These accidents included: –Trans World Airways Flight 800 –Swissair Flight 111 –American Eagle Flight 4184 –Alaska Airlines Flight 261

4 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, TWA Flight crash off the coast of Long Island, NY –Center fuel tank exploded in flight Flawed assumptions regarding fuel tank components

5 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, 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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, 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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, 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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, Costly lessons from these and many other major accidents were being lost by the passage of time

9 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, 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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, “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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, No Aviation-wide accident LL resource was available Fear of negative publicity Lengthy investigation/resolution Continual workforce turnover IT tools only recently available

12 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, FAA Initiative The FAA has now developed a web based “Lessons Learned from Transport Airplane Accidents” library –Threat based –Search/sort capability

13 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, 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 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, Summary A web-based Accident Library is now available to enhance the safety of an already very safe international aviation system –Currently available at: –57 accident modules; more added each year

15 Federal Aviation Administration Federal Aviation Administration National Academy of Sciences Washington, D.C.; April 18-19, The Lessons Learned web site will now be accidents- ll.faa.gov/ accidents- ll.faa.gov/