Commercial Aviation Safety Team (CAST) Plan & Metrics It is our privilege today to update you on the substantial progress that has been made by the joint government and industry safety effort known as CAST, the Commercial Aviation Safety Team. 1

Agenda Historical Background Progress to Date Annual Safety Plan Executive Overview of CAST Progress Historical Background Progress to Date Annual Safety Plan Inclusion of R & D Business model Action Plan Garner support for continued CAST activities We will cover some historical background, to include how the CAST process has evolved into a very effective tool for positive change in the area of aviation safety. We will put some focus on how CAST has prioritized its dauntingly large list of safety recommendations, through a sub-team activity known as the Joint Implementation Measurement and Data Analysis team or “JIMDAT”.

CAST Origin

In the U.S., our focus was set by the White House Commission on Aviation Safety 1.1 Government and industry should establish a national goal to reduce the aviation fatal accident rate by a factor of five within ten years and conduct safety research to support that goal 1.2 The FAA should develop standards for continuous safety improvement, and should target its regulatory resources based on performance against those standards Both government and industry had been long been searching for a reliable way to choose wisely among the many deserving suggested actions to improve various aspects of aviation, thereby reducing risk. The Gore Commission’s challenge to reduce accidents by 80% over the next ten years provided the impetus for even closer collaboration to develop a data-driven process to help us focus our scarce resources on those initiatives with the most potential to reduce the risk of accidents. We were all convinced that the rigor of analyzing reliable data was the surest path to continually improving our performance. 5.3-2 2

The National Civil Aviation Review Commission (NCARC) on Aviation Safety Provided Additional Direction FAA and the aviation industry must develop a strategic plan to improve safety, with specific priorities based on objective, quantitative analysis of safety information and data Government should expand on their programs to improve aviation safety in other parts of the world The NCARC was released in the same time period and gave further impetus to the notion of objective, quantitative analysis as the answer to sorting out which among the many ideas before us should be chosen first as the most promising and productive ways to reduce risk below the already excellent levels we had achieved over the preceding decades. The NCARC also recognized that the global nature of aviation demanded that we needed to contribute to safety improvements worldwide, not just at home. In 1997, the National Civil Aviation Review Committee (NCARC) assessed the state of Commercial Aviation Safety and the safety initiatives of Government and industry in the United States. One of the recommendations received from NCARC suggested that Government and Industry should combine and leverage their individual safety programs and develop an integrated strategic safety plan. 5.3-3 3

In Response Ongoing Industry and FAA Safer Skies Initiatives were Combined into CAST Data-Driven, Consensus-Based, Integrated Strategic Safety Plan Developed In place and fully supported by Government and Industry with Worldwide Recognition - “CAST” The U.S. aviation industry had been simultaneously organizing around this same notion of data-driven decision making, using the same accident data that led FAA to their strategy, so it was logical to combine our efforts into a joint team -- which we named the Commercial Aviation Safety Team. Since large portions of the money to be invested would be by private companies in their own airplanes, this program needed to be voluntary. This turned out not to be a problem, since data-driven analyses would show the benefits of an enhancement, and companies would naturally choose the ones offering the most benefit. I will show you how this process has enabled us to winnow down a list of hundreds of recommendations into a coordinated and integrated Safety Plan that is well on the way to yielding a 73% risk reduction by 2007.

Excluding all security events Both government and industry had known for some time which categories of accidents were happening most often and causing the greatest losses of life and property. If we could substantially mitigate the greatest fatality risks, we should make good progress toward our Gore Commission goal.

Safer Skies HUMAN FACTORS IMPROVED DATA IN OPERATIONS & & ANALYSIS COMMERCIAL AVIATION GENERAL AVIATION Controlled Flight Into Terrain CABIN SAFETY Aeronautical Decisionmaking Loss of Control Loss of Control Passenger Interference Uncontained Engine Failures Weather Passenger Seat Belt Use Runway Incursion Controlled Flight Carry-on Baggage Into Terrain Approach and Landing CAST has focused its activity on those accident categories that provide the greatest potential for improving the fatal accident rate, as indicated in yellow. These accident categories, have historically and repetitively over time, had the highest numbers of recurring accidents and loss of life. Child Restraint Survivability Weather Runway Incursions Turbulence HUMAN FACTORS IMPROVED DATA IN OPERATIONS & & ANALYSIS MAINTENANCE

CAST Goals Reduce the U.S. commercial aviation fatal accident rate by 80% by 2007 Work together with airlines, JAA, ICAO, IATA, FSF, IFALPA, other international organizations and appropriate regulatory/ government authorities to reduce worldwide commercial aviation fatal accident rate CAST has established very concise goals to guide its activity, based on the Gore Commission & NCARC recommendations: Reduce the U.S. commercial aviation fatal accident rate by 80% by 2007. Thus, the predicted 73% reduction in the fatality risk that I will discuss later, puts us within reach of the 80% goal many thought to be impossible. And to work together with international organizations to reduce the worldwide commercial aviation fatal accident rate.

Commercial Aviation Safety Team (CAST) Industry Government AIA Airbus ALPA APA ATA NACA Boeing P&W* RAA FSF IATA AAPA ATAC APFA DOD FAA Aircraft Certification Flight Standards System Safety Air Traffic Operations Research NASA ICAO JAA TCC NATCA Commercial Aviation Safety Team (CAST) CAST is comprised of Industry and Government organizations that represent all aspects of the commercial aviation community and therefore have the ability to effect change. These organizations have come together voluntarily to improve aviation safety. The strength of CAST lies in its extensive membership, its proactive commitment to safety and its ability to effect change. *Representing GE and RR

Joint Implementation Measurement Data Analysis Team (JIMDAT) Commercial Aviation Safety Team (CAST) CAST Joint Safety Analysis Teams (JSAT) Data analyses Joint Safety Implementation Teams (JSIT) Safety enhancement development The CAST process is straightforward: Analyze causes of past accidents, identify enhancements that could have prevented them, implement the most promising enhancements, measure results, and repeat the process. CAST accomplishes that work through a series of teams. Joint Safety Analysis Teams, or “JSATs”, study accidents and incidents in a selected flight category such as CFIT, identifying precursors to problems and interventions to reduce or eliminate these precursors. Joint Safety Implementation Teams, or “JSITs”, conduct feasibility assessments of these interventions and design “Safety Enhancements” and “Detailed Implementation Plans” (DIPs) to deploy these safety solutions. Finally, a Joint Implementation Measurement Data Analysis Team, or “JIMDAT”, evaluates these safety solutions across all flight categories and provides prioritized recommendations to CAST for implementation. We’ll look a little further into the JIMDAT prioritization activity later in the presentation. Master safety plan Enhancement effectiveness Future areas of study Joint Implementation Measurement Data Analysis Team (JIMDAT)

CAST A Three-Stage Process Data Analysis Implement Safety Enhancements - U.S. Set Safety Priorities Agree on problems and interventions Influence Safety Enhancements - Worldwide Achieve consensus on priorities Integrate into existing work and distribute

Additional Safer Skies Activities Although the primary purpose of our briefing focuses on CAST, there are other Safer Skies focus areas: General Aviation Joint Steering Committee (JSC) Cabin Safety

Integrated Strategic Safety Plan Data-Driven, Consensus-Based, Integrated Strategic Safety Plan Developed 46 Prioritized Safety Enhancements 8 R&D Projects and 2 Studies 46 safety enhancements optimized to include those actions with the best effectiveness vs. resource relationships - 22 complete/24 committed and underway Initially combines short-term “liveware”-based enhancements with transition to design change enhancements long term Projected 73% Risk Reduction by 2007 (75% by 2020) Foundation for U.S-supported continuous improvements in worldwide aviation safety Using the JIMDAT approach, CAST has developed a strategic safety plan as recommended by the NCARC. The plan contains 46 safety enhancements (of which 22 have already been completed). The number of completed items is fluid as CAST approves on-going initiatives. The items in the plan have the potential for a 73% reduction in fatality risk by 2007. The plan is a combination of short-term actions, such as training or Standard Operating Procedures, and longer range design-based solutions.

CAST Safety Plan

Completed Safety Enhancements Terrain avoidance warning system (TAWS) CFIT Standard Operating Procedures Precision approach implementation (PAI) Vertical Angles – Increase constant angle approaches Minimum Safe Altitude Warning (MSAW) Systems Proactive Safety Programs (FOQA + ASAP) CFIT Crew Resource Management (CRM) training CFIT Prevention training Air Traffic Controller CFIT training PAI-VGSI at runway ends PAI-DME at airports RI SOPs Ground Operations (General Aviation) Tow tug operators ATC Although time does not permit my discussing each of the following 22 completed safety enhancements, I have provided comments on a few of them in my published notes to indicate, for those of you who wish to read further, how a range of training, operational and design solutions are utilized. As you can see from this chart, we’ve made heavy emphasis on preventing CFIT -- and though CFIT is still happening, it is on airplanes not yet upgraded with these enhancements. CFIT-PAI-Vertical Angles - Increases the use of Precision approach through addition of vertical angles on approach plates to achieve constant angle descent. CFIT-MSAW – All U.S. ATC minimum safe altitude warning radars have been site checked to ensure no obstructions exist and all ATC personnel have been trained on timely MSAW alerts to flight crews. CFIT Prevention Training - All U.S. carriers have incorporated CFIT prevention training in their curriculums. CFIT ATC Training – All ATC personnel have rec’d CFIT prevention training to eliminate CFIT hazards such as “slam dunk” approaches.

Completed Safety Enhancements (cont’d) Safety Culture Industry will include essential safety information in the appropriate airline manuals (i.e., training programs) FAA inspectors will utilize the Aircraft Flight Manual (AFM) database CEO and Director of Safety (DOS) more visible Maintenance Procedures FAA published guidance on: Servicing landing struts Surveillance of maintenance subcontractors Minimum Equipment List (MEL) (covers recurring maintenance events) Air Carriers’ Directors of Safety completed internal surveys to verify guidance was being followed ALAR Flight crew training Uncontained Engine Failures FAA issued Airworthiness Directives requiring the Inspection of High-Energy Rotating Parts We’ve tackled ALAR, the other tallest bar on the Pareto chart, with Safety Culture through leadership emphasis, better manuals, and better training. This includes ensuring essential flight safety info (such as holding speeds in icing conditions) is incorporated in the flight manuals in a timely fashion We have established an AFM database for inspectors that will enable POIs to ensure that flight crews and operators have the most timely essential flight info in their manuals. We’ve emphasized better maintenance guidance and procedures on aircraft structure and engines. And for UEF (uncontained engine failures), we issued AD’s that ensure engine high-energy rotating parts are inspected using a best business practice-based method when they are exposed in the shop.

Committed Plan Elements Policies and Procedures Industry will develop/implement Risk Management tools Industry will develop a process to inform personnel/flight crew of critical safety information Industry will develop a process to enhance flight crew proficiency FAA/Industry will develop standard operating procedures for loss of control related accidents Aircraft Design FAA will issue guidance on Continuing Airworthiness FAA will issue guidance on Critical System Maintenance FAA will amend guidance to include recommendations surrounding autoflight designs for new type designs Manufacturers will implement Flight Deck Equipment Upgrades for new type designs (i.e. interactive checklists) FAA/JAA will amend guidance to include recommendations regarding Displays and Alerting Systems for new designs Manufacturers agree to install Vertical Situation Displays in new aircraft FAA/JAA will issue amended icing certification criteria for criteria for new airplane designs not equipped with evaporative systems Manufacturers agree to install Flight Envelope Protection in new type designs Beyond those areas completed, we are committed to better Risk Assessment and Management. We compile and assess guidance materials related to risk assessment and risk management tools to prioritize safety-related decisions for operational issues regarding service bulletins, aircraft accident/incident analysis, flight-critical safety information, and recurring intermittent failures related to dispatch. We utilize risk management tools to prioritize safety-related decisions for operational issues. In the area of airplane design, FAA has added focus to Critical System Maintenance. and to the identification of flight-critical system components to ensure that maintenance procedures do not degrade the original intended level of safety. The Flight Envelope Protection Safety Enhancement involves active or passive flight envelope protection systems in all new aircraft designs to reduce reliance on training.

Committed Plan Elements (cont.) Runway Incursions Enhanced airport surveillance equipment Standard operating procedures (SOPs) Ground operations (121/135) Vehicle operators Clearance readback requirements Training Pilots ATC Enhanced Tower Controller Training CRM Runway incursion prevention is getting a lot of attention for controllers and ramp operators through: Enhanced surveillance equipment. Develop and implement technology tools, including data link, that will provide and/or enhance airport surface situational awareness to air traffic controllers. Examples of these technology tools include, but are not limited to, Airport Movement Area Safety System (AMASS), Airport Surface Detection Equipment (ASDE-X), Automated Dependent Surveillance – Broadcast (ADS-B), Next Generation Air-Ground Communications System (NEXCOM), Surface Movement Advisor (SMA), and Airport Target Identification System (ATIDS). Standard Operating procedures. FAR Part 121 operators and Part 135 operators establish, document, train to, and follow standard operating procedures (SOPs) for ground operations. The implementation of Standard Operating Procedures for surface operations is one of the most powerful near-term interventions in mitigating the risk of runway incursions. This plan builds upon the recent Advisory Circular 120-74, "Flight Crew Procedures During Taxi Operations", to develop templates of SOPs for use by air carriers, general aviation pilots. Training for vehicle operators The development and use of recommended “best practices”, for ground operations for use by mechanics and others who tow or otherwise move aircraft within the airport movement area, will improve aviation safety by reducing the frequency and severity of runway incursions.

Committed Plan Elements (cont.) Flight Crew Training Advanced Maneuvers Training will be provided by all operators Industry will incorporate a human factors-related training guide into training programs and SOPs Precision approach implementation (PAI) FAA and Industry will develop: Recommended procedures, displays and training that will enable pilots of commercial aircraft to fly a stabilized vertical path to the runway for all instrument approaches Criteria and guidance for reduced landing minima Laterally and vertical guided approach paths to runway ends not served by Instrument Landing System (ILS) Flight Crew Training. Many operators have already implemented Advanced Maneuvers Training (AMT) to prevent and recover from hazardous flight conditions outside of the normal flight envelope, such as inflight upsets, stalls, ground proximity and wind shear escape maneuvers. The philosophy is that this training will be accomplished via ground and simulator instruction within the normal flight envelope, with emphasis on recognition, prevention and recovery techniques Movement toward PAI is steady and positive. The various systems and procedures under development will enhance capability and improve safety.

CAST R&D Plan CFIT – Synthetic Vision Systems Develop capabilities that permit flight crews to operate in a day VMC-like environment, regardless of visibility CFIT – FOQA & ASAP Develop low cost analytical tools (including decision making) and methods that both large and small operators can apply to FOQA and ASAP information CFIT – Datalink Develop datalink capabilities and systems for automatic digital transmission I’d like to mention the 10 R&D Projects and Studies that are on the CAST R&D plan. CFIT – Synthetic Vision Systems Develop capabilities that permit flight crews to operate in a day VMC-like environment, regardless of visibility. Terrain and obstacle alerting. Geospatial databases. Weather display. Traffic display and alerting. Flight path information. Energy state awareness information CFIT – FOQA & ASAP Develop low cost analytical tools (including decision making) and methods that both large and small operators can apply to FOQA and ASAP information. develop a capability to measure effectiveness of CAST Safety Enhancements. CFIT – Datalink Develop datalink capabilities and systems for automatic digital transmission; ATC instructions/information between the ground controller and the aircraft. Weather information. Air traffic information. Status of aircraft systems. Other safety information.

CAST R&D Plan (cont’d) CFIT Precision-Like Approach Conduct research necessary to determine human factors guidelines for design of instrument procedures ALAR - Health & Usage Monitoring Systems (HUMS) Conduct research and develop technology for detection, prediction and/or annunciation of impending equipment failures ALAR – Human Factors Conduct research into correcting and eliminating the underlying reasons/causes for procedural noncompliance. CFIT Precision-Like Approach Conduct research necessary to determine human factors guidelines for design of instrument procedures. Determine the minimum number of approach charts to runway end with multiple minima, (suitable for xLS, RNP, LNAV/VNAV, and LNAV minima). As part of this plan, conduct a research project to address issues of charting, content, etc. Develop guidelines for non ILS-like approaches. Develop guidelines for approaches using synthetic vision. ALAR - Health & Usage Monitoring Systems (HUMS) Conduct research and develop technology for: Detection, prediction and/or annunciation of impending equipment failures. Detection and annunciation of inappropriate settings that may affect safe flight. Real time decision making support for maintenance and operations. Smart alerting systems that provide real time assistance to flight crews with on board system failures and include diagnostics, prioritization schemes and elimination of nuisance alerts ALAR – Human Factors Conduct research into: Correcting and elimination the underlying reasons/causes for procedural noncompliance. The phenomenon of flight crew overload. Preventing plan continuation errors. To develop an effective tactical decision making model for flight crews. Developing human performance models.

CAST R&D Plan (cont’d) LOC – Icing For aircraft that incorporate non-evaporative ice protection systems, develop systems that sense the presence of ice accretion on the aircraft, automatically activate and manage the ice protection systems, and provide the pilot with feedback including the effect on measured aircraft performance, stability, and control LOC - Envelope Protection -Existing Airplanes Complete study and determine feasibility of modifying existing aircraft to include angle-of-attack / low speed protection (e.g., stick pushers/nudgers, column force ramps/gradients, automatic elevator/stabilizer inputs); thrust asymmetry compensation; and bank angle protection using hard or soft limits LOC – Icing For aircraft that incorporate non-evaporative ice protection systems, develop systems that sense the presence of ice accretion on the aircraft, automatically activate and manage the ice protection systems, and provide the pilot with feedback including the effect on measured aircraft performance, stability, and control. provides annunciation that alerts the crew to respond appropriately to the icing hazard. ground and aircraft based means of detection of meteorological icing onditions define the effects of all ice accretions, with particular emphasis on the roll effect due to ice contaminated wings understand the effects of super-cooled large droplets (sld) LOC – Basic Airplane Design - Mode Confusion Complete survey using information from instructors and check airmen relating to mode confusion during training and line operations, and supply a model specific issues summary report to CAST, manufacturers, and aviation human factors working groups to enable design and training changes to reduce the potential for mode confusion.

CAST R&D Plan (cont’d) RI - ATC Procedures -Review Capacity Enhancement Program - LAHSO) Complete review of capacity enhancement programs to determine if they are contributory to runway incursions RI - RI Visual Aids Enhancement and Automation Technology - Airports - Runway occupancy signal Develop, evaluate and install a visual signal to indicate runway occupancy to flight crews on final approach to that runway RI - ATC Procedures -Review Capacity Enhancement Program (Original Name - LAHSO) Complete review of capacity enhancement programs to determine if they are contributory to runway incursions. LAHSO procedures “Reduced Separation on Final” procedures RI - RI Visual Aids Enhancement and Automation Technology Develop, evaluate and install a visual signal to indicate runway occupancy to flight crews on final approach to that runway.

Resource Cost vs. Risk Reduction APPROVED PLAN Completed + Plan (2007 Implementation Level) Completed + Plan (2020 Implementation Level) All JSIT Proposed Enhancements (2020 Implementation Level) 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 Resource Cost ($ Millions) Risk Reduction Total Cost in $ (Millions) 2007 2020 0% 25% 50% 75% 100% Risk Eliminated by Safety Enhancements Completed A graphical representation of resource application versus risk reduction, which also depicts the CAST JIMDAT prioritized selection criteria for the draft strategic plan. In the example plot, it can be seen how the CAST plan items for 2007 and 2020 were selected using benefits versus resources and the rationale for not selecting all the solutions. This represents the “sweet spot” in terms of prioritizing safety enhancements. The blue bars go well above 70% and approach 80% when we take credit for the effects that completed enhancements are bringing, as some of them are exceeding their projected success levels. The tool developed by CAST to determine the priorities of various enhancements will be described in detail in Paul Russell’s presentation on Thursday afternoon. The CD contains not only the results of our analysis of the worldwide accident data from 1988-2001 but a “generic” spreadsheet with use instructions that can be tested in your own operating environment.

Safety Plan Benefits Prediction of a 73% risk reduction that also results in approximately $620 million annual savings to the industry Current accident cost per flight is approximately $76 cycle Implementation of the 46 selected safety enhancements reduces this cost by $56 per flight cycle Safety is morally required and is also good for business The ultimate benefit of reducing fatality risk is the savings achieved in loss of life prevented, but money savings are also important. By implementing the 46 carefully selected, data-driven safety enhancements, we should reach a predicted 73% reduction in fatality risk by 2007, which will produce approximately $620M cost avoidance (savings) every year for the industry. This dramatically demonstrates that Safety is good for business! NOTE – cost and risk reduction figures are specific to US operations; similar analysis can be performed for international operations. .

Cost Savings Dollars/Flt. Cyc Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents 100 Historical cost of accidents per flight cycle 80 Savings ~ $56/Flight Cycle Or ~ $620 Million Dollars/Year Dollars/Flt. Cyc 60 73% Risk reduction 40 When we break down costs of our current accident rate, accidents cost us $76 for every flight. By implementing the 46 carefully selected, data-driven safety enhancements, we will have reduced these costs by $56 per flight. This adds up to a savings about $620 Million EVERY YEAR into the future. 20 Cost of accident fatalities following implementation of the CAST plan @ 2007 levels 2002 2007

U.S. Hull Loss & Fatal Accidents Portion of Total Fatality Risk Mitigated by the CAST Plan (2007 Implementation Values) 100% Risk Eliminated 90% Risk Remaining 80% 70% CAST 1987-2000 Fatal/Hull Loss Database – Security events excluded 60% Portion of Risk 50% 40% 30% The potential fatality risk mitigation value of the CAST plan by 2007 is 73% with security events excluded. This value increases to 79% when the beneficial effects of other ongoing safety initiatives developed outside of CAST by industry and government are considered. Utilizing the JIMDAT process and applying the results to identify risk eliminated for the dataset evaluated also provides insight into areas of remaining unmitigated risk which are guiding future CAST study areas. As a result of this analysis CAST has formed a Joint Safety Analysis Team to investigate and provide interventions for four areas of the unmitigated risk. They are icing (particularly ground deicing), maintenance error, midair collisions and cargo handling/loading. The team is expected to recommend safety enhancements in these areas by the fall of 2004. 20% 10% 0% Total CFIT LOC Flt Midair Evac LOC GND Crew Inc Eng-UCEF Sys-Comp Turbulence Fire/Explosion Runway Collision

Risk Eliminated Risk Remaining All Regions Combined Worldwide Hull Loss & Fatal World Wide Accidents Portion of Fatality Risk Mitigated If CAST Plan is Adopted Worldwide (2007 Implementation Values) 100% Risk Eliminated 90% Risk Remaining 80% 70% 60% Portion of Risk 50% 40% 30% The Joint Implementation Data Analysis Team (JIMDAT) of the CAST has analyzed the worldwide fatal accidents (1988-2001) to determine what risk would be eliminated if the 46 elements of the CAST Safety Plan were implemented worldwide. It would appear that the CAST enhancements have broad applicability to the global aviation system. 20% 10% 0% RI Total CFIT ICE RE LOC-I Midair FUEL ARC USOS ADRM SCF-PP SCF-NP FIRE-NI WSTRW OTHER-BIRD Accident Classes Defined by CAST/ICAO Common Taxonomy

The CAST Process is Flexible It may be used to analyze: Suggestions from outside industry Regulatory initiatives Accident lessons learned Incident data Other The CAST JIMDAT process can also be used to provide an assessment of the safety potential associated with suggestions or ideas from outside sources and enable CAST to evaluate their merit against the CAST dataset.

Safety Metrics Purpose: Measure to determine if program is resulting in desired risk reduction. Identify issues needing more detailed analysis if desired result is not occurring Assumption: Measurement of accident rate is not effective means of identifying program success Concentrate on using reporting systems currently in existence (ex: FOQA, Partnership programs, SDR, NAOMS, etc.) Direct link is through the problem statements identified by data analysis Identify events that reflect the problem Identify available method for measuring the event frequency Establish event baseline Identify trend The use of fatal accident rate as a metric to determine the effectiveness of our enhancements is not satisfactory. It is an "after the fact" measure and does not allow CAST to adapt its plan to address enhancements that may not be turning out to be as effective as thought. By developing a metric system as outlined here, we will be able to identify plan weaknesses before they effect the accident rate and take steps to correct those weaknesses. Our metric process is designed to use currently-available reporting systems for routine evaluation of our plan and identification of improvements.

Safety Metrics Examples Safety Enhancement Indicator 1. Terrain Avoidance Warning System (TAWS) Reduction in MSAW alerts Reduction in valid GPWS alerts (CFIT) 4. CFIT PAI-Vertical Angles (7-11,18) Percentage of operators who have adopted constant angle approaches Continuous reduction in selected metrics 21. ALAR Flight Deck Equipment Upgrades – New Type Designs (1-3) Reduction in number of inadvertent descents below decision height 23. ALAR Flight Crew Training – one project Continuous reduction in the number of busted approach gates Continuous reduction in altitude busts 27. LOC Policies and Procedures – Risk Assessments and Management – one project Percentage of operators/manufacturers with risk assessment/management processes in place Continuous reduction in the number of operations with recurring intermittent failures in flight critical systems Percentage of operators with a process to include safety information in manuals The Measurement of accident rate alone is neither a complete nor timely measure for tracking program progress. It is an "after the fact" measure and does not allow CAST to adapt its plan to address enhancements that may not be turning out to be as effective as thought. By developing a metric system that concentrates on using reporting systems currently in existence to identify precursors (ex: FOQA, Partnership programs, SDR, NAOMS, etc.), we will be able to identify plan weaknesses before they affect the accident rate and take steps to correct those weaknesses. These are example indicators that are linked to problems identified in the original case studies. The rate of occurrences of these problems link to measuring the interventions. We are working with all segments of government and industry in the US to acquire the information needed to continuously measure the effectiveness of our enhancements. For example, every Federal Aviation Administration (FAA) operations, maintenance and avionics inspector has been briefed on the contents of the CAST plan, the voluntary nature of CAST and specific information we would like the inspectors to gather from their carriers. Additionally, we are working with the Advisory Rulemaking Committees (ARC) on FOQA and ASAP to identify metrics that might be available from these data sources. We are also working with NASA in the development of data from sources such as the Aviation Safety Reporting System (ASRS) and the National Aviation Operations Monitoring Service (NAOMS).

CAST Links to International Safety Activities Asia/Pacific ICAO COSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness) NARAST, SARAST, SEARAST Association of Asia Pacific Airlines Europe JSSI: JAA Safety Strategy Initiative Central / South America PAAST: Pan American Aviation Safety Team East Africa African Airlines Safety Council, AFRASCO West Africa ASECNA (Agence pour la Securite de la Navigation Aerienne en Afrique et a Madagascar) Flight Safety Foundation CAAG (CFIT & Approach and Landing Action Group) ICAO Global Aviation Safety Plan (GASP) CAST, in focusing on its second goal of reducing the worldwide accident rate, has shared safety information with and supported the efforts of several international safety activities. These activities will continue and hopefully expand.

Future Vision Execute the CAST-approved Safety Plan Measure Plan effectiveness and modify Plan based on metrics and results Continue the development of a proactive incident-based risk mitigation methodology Improve the CAST process Expand CAST influence on worldwide safety programs Integrate safety program with R & D initiatives Catalog the many on-going safety initiatives that dilute limited resources and identify opportunities for program integration and efficiency improvements In the future, we will continue to diligently execute and refine our data-driven safety plan each year. We will measure our progress rigorously so we can build a better plan each year and thus continually improve the CAST process. We will transition to a proactive incident-based risk methodology. We look forward to sharing our results with others, so we can expand the positive influence of the CAST process worldwide. And we will integrate the knowledge we gain from this data-driven approach with initiatives to help our Research and Development community focus their efforts on those technologies that promise the most potential benefit. We are examining ways to ensure that safety resources are being used in the most effective manner.

Safety Plan Development CAST Plan Rev. Accident JSAT’s Accident JSIT’s Safety Enhancements CAST Plan Master Contributing Factors JIMDAT Process Metrics Emerging Risk Metrics Incident Analysis Process Safety Enhancements Changing Risk We have completed the historical study of CFIT, Loss of Control, Approach and Landing, Runway Incursion and Turbulence accidents and hull losses which have occurred in U.S. FAR 121 operations over the time frame of 1987 to 2001. Additionally we have completed an assessment of accidents and hull losses world wide over that same timeframe. The yellow boxes, ‘Accident JSAT’s’, ‘Accident JSIT’s’, etc. depict this historical study of accidents from which CAST has identified safety solutions to proactively apply and prevent/mitigate recurrence. But what is the future direction of CAST? Where do we go next to look at future risks? CAST is developing an incident analysis process that will allow us to become more proactive in accident prevention by identifying changing and emerging risks. This is shown by the purple boxes, ‘Incident Analysis Process’, ‘Emerging Risk’, ‘Changing Risk’, etc. Safety enhancements from this activity will be rolled into the CAST plan, related metrics will be developed and any newly identified contributing factors will be added to the Master Contributing Factor list. Also to reach further yet into the future (as shown in green), CAST will examine and identify hazards that may result from ‘Aviation System Changes’ and ‘Demographic Changes.” Much of this work has been done by CAST’s sister organization, the JAA Future Aviation Safety Team (FAST), which is developing future hazards based on their study of future areas of changes. CAST will incorporate the results from the FAST analysis into the CAST plan; safety enhancements and related metrics will be developed and the newly identified contributing factors will be added to the Master Contributing Factor list. Metrics Aviation System Changes Identify Hazards Identify Factors Yes Present In Master Factors Develop Contributing Factors (new or emerging) Safety Enhancements FAST Hazards No Demographic Changes Identify Hazards Identify Factors 6-11-03 CAST-051

Conclusions CAST has an effective data-driven process CAST has become the model for US Industry/Government consensus building on safety CAST brings together all the key players – Air Carriers – Manufacturers – Employee Groups – Government Predicted 73% risk reduction by 2007 Industry is voluntarily implementing CAST recommendations CAST is committed to worldwide participation CAST is moving to develop proactive processes to identify changing and emerging risks In conclusion: CAST has an effective data-driven process that has become the model for Industry/Government consensus building on safety CAST brings together all the key players The 46 Safety Enhancements on the CAST Plan result in the prediction of a 73% risk reduction in the number of fatalities due to commercial aviation accidents Industry is voluntarily implementing CAST recommendations CAST has nearly completed its work of identifying accident prevention programs based on analysis of historic data and has started the development of processes that will proactively use incident, and other, data to identify emerging and changing risks. Through these processes we believe that we can move forward to accident PREVENTION by intervening to reduce risk before an accident can occur.