Commercial Aviation Safety Team (CAST) Process Overview It is our privilege today to provide you with an overview of the joint government and industry safety effort known as CAST, the Commercial Aviation Safety Team. 1

In the U.S., our focus is 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.

We Need to Continuously Improve Aviation Safety 50 45 40 35 30 25 20 15 10 5 The accident rate has been static for a number of years Hull loss accident rate 1965 1975 1985 1995 2005 2015 Year

We Need to Continuously Improve Aviation Safety 50 45 40 35 30 25 20 15 10 5 Airplanes in service 28,550 2019 12,595 1997 Boeing 11,300 Millions of departures However, departures are increasing. Hull loss accident rate 1965 1975 1985 1995 2005 2015 Year

We Need to Continuously Improve Aviation Safety 50 45 40 35 30 25 20 15 10 5 Airplanes in service 28,550 12,595 15,800 Business as usual Boeing 11,300 1997 2000 2019 Hull loss accidents per year Our goal This combination leads to an increasing number of accidents, even though the rate is stable. Our goal is to drive the rate lower. Millions of departures Hull loss accident rate 1965 1975 1985 1995 2005 2015 Year

Regional Perspective Accident Rates Vary by Region of the World Western-built transport hull loss accidents, by airline domicile, 1992 through 2001 C.I.S.1 Europe 0.9 United States and Canada 0.4 JAA - 0.7 Non JAA – 3.0 China 1.1 Middle East 3.4 Asia 2.6 (Excluding China) Africa 12.4 Latin America and Caribbean 3.1 Oceania 0.0 Accidents per million departures World 1.3 1Insufficient fleet experience to generate reliable rate. 3/19/02 REG-053a

Safety Responsibilities Are Shared Air Safety Manufacturers Government Operators Our safety responsibilities are shared. If we are to achieve a higher level of safety we must all work together. No one segment of the industry can accomplish significant safety enhancements alone. Manufacturers Safe airplane design Safety enhancing technology development Flight and maintenance operations, recommendations, documents, training, and support Maintenance planning Safety related analysis Safety initiatives Operators Operations policy and procedures Airplane/pilot publications Approved maintenance program Maintenance, policy, and procedures Maintenance publications Safety program Training Government Aviation law Operations specification Rules and regulations Inspectors policy, procedures, and training Airline policy and procedures requirements Safety, health, environmental law, and regulations Navigation facilities/operations Airport facilities Departure enroute, arrival, approach policy, and procedures Air traffic control services Safe Airplane + Safe Operation + Safe Infrastructure = Safe Air Travel

Safety Analysis Process 1. NTSB Accident Incident Reports 2. 21.3 Reports NASDAC data Airclaims data Historical Data FOQA data Pareto Plots JSAT Industry JSAT A summary of the process is highlighted in this chart. The process relies on data at its foundation. We need to access all available data sources and analyze the data into helpful information for decisionmaking. We look forward to the ability to collect and analyze FOQA data as a potential significant new source of data, and the eventual reality of a GAIN (Global Aviation Information Network). We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type. We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry. The feedback loop is critical to make sure we are achieving the wanted results. Metrics will track our success at reducing the overall accident type as well as implementation of the interventions. 5.3-23 23

Safety Analysis Process 1. NTSB Accident Incident Reports 2. 21.3 Reports NASDAC data Airclaims data Historical Data FOQA data Pareto Plots JSAT Industry JSAT 3. 4. Accident Threat Combined Threat Causal Analysis Intervention Strategy A summary of the process is highlighted in this chart. The process relies on data at its foundation. We need to access all available data sources and analyze the data into helpful information for decisionmaking. We look forward to the ability to collect and analyze FOQA data as a potential significant new source of data, and the eventual reality of a GAIN (Global Aviation Information Network). We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type. We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry. The feedback loop is critical to make sure we are achieving the wanted results. Metrics will track our success at reducing the overall accident type as well as implementation of the interventions. Cause Cause Cause Cause JSAT JSAT 5.3-23 23

Safety Analysis Process 1. NTSB Accident Incident Reports 2. 21.3 Reports NASDAC data Airclaims data Historical Data FOQA data Pareto Plots JSAT Industry JSAT 3. 4. Accident Threat Combined Threat Causal Analysis Intervention Strategy A summary of the process is highlighted in this chart. The process relies on data at its foundation. We need to access all available data sources and analyze the data into helpful information for decisionmaking. We look forward to the ability to collect and analyze FOQA data as a potential significant new source of data, and the eventual reality of a GAIN (Global Aviation Information Network). We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type. We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry. The feedback loop is critical to make sure we are achieving the wanted results. Metrics will track our success at reducing the overall accident type as well as implementation of the interventions. Cause Cause Cause Cause 5. JSAT JSAT 7. Industry 6. Safer Skies Government Implementation Strategy JSIT AvSP Measuring Progress to Goal Coordinated Plan 5.3-23 23

Safety Analysis Process 1. NTSB Accident Incident Reports 2. 21.3 Reports NASDAC data Airclaims data Historical Data FOQA data Pareto Plots JSAT Industry JSAT 3. 4. Accident Threat Combined Threat Causal Analysis Intervention Strategy A summary of the process is highlighted in this chart. The process relies on data at its foundation. We need to access all available data sources and analyze the data into helpful information for decisionmaking. We look forward to the ability to collect and analyze FOQA data as a potential significant new source of data, and the eventual reality of a GAIN (Global Aviation Information Network). We have developed a process all can agree upon for analyzing data to identify key safety focus areas and understanding what happens across accident types to develop the most effective interventions aimed at reducing the occurance of that accident type. We will take action on the critical few interventions yielding the most safety benefit and are feasible to implement through the JSIT process and coordinated plans among government and industry. The feedback loop is critical to make sure we are achieving the wanted results. Metrics will track our success at reducing the overall accident type as well as implementation of the interventions. Cause Cause Cause Cause 5. JSAT JSAT 7. Industry 6. Safer Skies Government Implementation Strategy JSIT AvSP Measuring Progress to Goal Coordinated Plan 5.3-23 23

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

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

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.

CAST Commercial Aviation Safety Team (CAST) Joint Safety Analysis Teams (JSAT) Data analysis Joint Safety Implementation Teams (JSIT) Safety enhancement development CAST accomplishes its work through Joint Safety Analysis Teams, or “JSATs”, which study accidents and incidents in a selected flight category, identifying precursors to problems and “Safety Enhancements” to reduce or eliminate these precursors. Joint safety Implementation teams, or JSITs”, conduct feasibility assessments of these potential Safety Enhancements and design detailed implementation plans (DIPs) to deploy these safety solutions. Finally, a Joint safety Measurement and 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

Joint Safety Analysis Team (JSAT) Process

Typical JSAT Membership ALPA/APA FAA (AIR, AFS, ASY, AAI) Airbus JAA ATA Transport Canada NASA Engine companies – (PW, GE, RR-Allison) Boeing RAA Air Traffic Services NATCA 19

JSAT Process Charter Development Establish Team Select Data Set Review Data Evaluate Problem Importance Assign Standard Problem Statements Identify Problems (what/why) Develop Event Sequence Record Characteristics/ Indicators The first JSAT was chartered to develop a detailed process to analyze accident and incident data. The process developed includes an analysis of selected accidents/incidents, identification of problems encountered, and development of safety intervention strategies and assessments of effectiveness and feasibility. This process is currently being finalized. Additionally the team will review the results of prior studies and validate its own findings by comparison to the findings and recommendations of these studies. Results of the JSAT studies will be reported to the CAST. This process will help the industry to achieve a more intervention- oriented analysis approach. The JAA’s Joint Safety Strategy Initiative (JSSI) plans to use the same process as CAST and the JSATs and is participating directly on JSAT teams. This is an example of analysis to identify problems and interventions which is necessary to ensure our actions are data driven and will be effective. Both the CAST and JSSI efforts will be presented in detail in later papers. Global Review of Characteristics/ Indicators Technical Review & Report Results Identify Intervention Strategies Evaluate Intervention Effectiveness Prioritize Interventions 5.5-24 24

Developed Event Sequence Facts and data pilot - controller voice events missed calls events that occurred or should have Time coded each event

Develop Problem Statements What went wrong Deficiency definition Potential reason Something which happened or didn’t happen

Sample Standard Problem Statements 10 FLIGHTCREW – Failure of flight crew to follow established procedures (SOP) 39 AIRCRAFT EQUIPMENT – DESIGN NOT ERROR TOLERANT System design does not provide adequate redundancy to counteract errors or alerting of the effects of errors. 44 FLIGHTCREW – Flight crew failure to recognize and correct unstable approach. 100 REGULATORS – INSUFFICIENT AIR CARRIER OVERSIGHT . Insufficient regulatory oversight of air carrier operations including management and training practices.

Scoring - Problem Importance POWER – P1 Importance of the problem or contributing factor in the cause of the accident FUTURE GLOBAL APPLICABILITY Frequency of the problem or contributing factor (to this accident type) in future operations on a worldwide basis

RATING SCALES – Problem Statements POWER – P1 This scale is to be used to judge the importance of a specific specific problem or contributing factor in the cause of the accident. 1 2 3 4 5 6 No importance Little Importance Slightly important Moderately important Quite important Highly important Completely important FUTURE GLOBAL APPLICABILITY This scale is to be used to estimate the frequency of the problem or contributing factor in future operations on a worldwide basis (for example: how often the situation occurs in accident scenarios; its impact is on present and future operations (equippage, traffic, regulatory differences); and whether it is applicable across airlines/airplanes/regions. 1 2 3 4 5 6 Not at all applicable Hardly any applicable Slightly applicable Moderately applicable Quite applicable Highly applicable Completely applicable 1

Identify Intervention Strategies Suggested solutions Things to do to prevent or mitigate the problem Etc.

Scoring - Intervention Effectiveness POWER – P2 Ability of the intervention to mitigate the problem or contributing factor (in a “Perfect World”) CONFIDENCE Confidence that the intervention will have the desired effect

RATING SCALES – Interventions POWER – P2 This scale is to be used to judge the effectiveness of a specific intervention in reducing the likelihood that a specific accident would have occurred had the intervention been in place and operating as intended. (“perfect world”) 1 2 3 4 5 6 Not at all effective Hardly any effect Slightly effective Moderately effective Quite effective Highly effective Completely effective CONFIDENCE This scale is to be used to define the level of confidence that you have that this specific intervention will have the desired effect. 1 2 3 4 5 6 Not at all confident Hardly any confidence Slightly confident Moderately confident Quite confident Highly confident Completely confident 1

JSAT Reports Standard Problem Statements Interventions Prioritized Recommendations

CAST Commercial Aviation Safety Team (CAST) Joint Safety Analysis Teams (JSAT) Data analysis Joint Safety Implementation Teams (JSIT) Safety enhancement development Joint safety Implementation teams, or JSITs”, conduct feasibility assessments of these potential Safety Enhancements and design detailed implementation plans (DIPs) to deploy these safety solutions. Master safety plan Enhancement effectiveness Future areas of study Joint Implementation Measurement Data Analysis Team (JIMDAT)

JSIT Feasibility Scales Technical Financial Operational Schedule Regulatory Sociological

JSIT Safety Enhancements Develop Safety Enhancements from Interventions Collect detailed resource information Prepare Detailed Implementation Plans (DIP’s)

CAST Commercial Aviation Safety Team (CAST) Joint Safety Analysis Teams (JSAT) Data analysis Joint Safety Implementation Teams (JSIT) Safety enhancement development Finally, a Joint Implementation Measurement and 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)

Joint Implementation Measurement Data Analysis Team (JIMDAT) Process

Developed a Prioritization Methodology (JIMDAT) Identified the most effective solutions derived from all accident categories Considered effectiveness vs. resources Tested solutions against all fatal and hull loss accidents, U.S. domestic Part 121 Operations, 1987-2001 Created draft Master strategic safety plan Identified areas for future study/mitigation CAST developed a JIMDAT process which looks at solutions across multiple accident categories, considers solution effectiveness and resources and evaluated the ability of each solution to eliminate or mitigate prior U.S. fatal or hull loss accidents, had they been in place at the time. Using these results a master strategic safety plan was developed which also indicated areas where further risk reduction was needed.

JIMDAT Process Provides consistent estimates of the accident prevention potential of safety enhancements Accounts for the benefit of a single intervention or a combined group of interventions Addresses overlap with other interventions/technologies Preserves analysis criteria and results The CAST JIMDAT process provides a means to achieve consistent estimates of solution safety potential, can account for individual or grouped solutions, as well as overlapping solutions, preserves in a documented form the criteria and results of the analysis.

Using JIMDAT for CAST Plan Development Risk reduction is primary measure Identified effectiveness and associated resource requirements for each enhancement Used for initial differentiation (2007 and 2020) The JIMDAT focused on risk reduction as a primary parameter, considered safety effectiveness and resources required for each solution and used plots of effectiveness versus resources, or scatter plots, for initial identification of high priority safety solutions.

Integrated Strategic Safety Plan Contains 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 Foundation for U.S.-driven continuous improvements in worldwide aviation safety Using the JIMDAT approach CAST have 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 completed items to date, have the potential for a 73% reduction in fatality risk (excluding security events). The plan is a combination of short term actions, such as training or Standard Operating Procedures, and longer range design based solutions.

Sharpening Our Focus All safety enhancements are valuable Some safety enhancements are more effective than others across the various accident categories Implementation reality demands better prioritization While all 84 safety enhancements are valuable, some are more effective than others across more than one accident category. This is where it is important to maximize the safety benefit versus the resources required when making final selections about which safety enhancements to deploy.

Output Evaluation Spreadsheet Example This an example of a of a portion of the output spreadsheet. It shows U.S. Fatal and Hull loss accidents, 1987-2001 listed vertically on the left, the 84 possible safety enhancements horizontally along the top, and the performance of each solution is then rated, had it been in place, against all of the accidents in the dataset.

2007 Implementation & Resources Example Scatter Chart 2007 Implementation & Resources 25 20 Dollars In Millions 15 10 An example of a typical “scatter plot”. Takes the effectiveness score of the preceding spreadsheet and adds the resource values to implement. Shows the relationships between safety effectiveness and resources for sample safety enhancements. Such scatter plots were used to provide an initial picture of the relative strengths of various safety enhancements based on effectiveness and resources. Enables us to select those safety enhancements that are optimally balanced in terms of effectiveness versus resources. Combined Score 5 Combined SOPs 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 Score

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

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

Joint Implementation Measurement Team (JIMT) Process

Reporting Standards Progressing on plan Plan developed but not progressing - may not make plan or no plan exists Late or critically off plan On plan but effected by late or critically off plan Output in plan completed Status of non-aligned carriers (color same as above) 5-30-00 CAST-3-05

TAWS (Potential US Accident Rate Reduction ~5%) 12/31/99 3/31/00 3/31/01 3/31/03 3/31/04 3/31/05 AFS-200 ACE-100 ATA (1.) FAA FAA AIR Retrofit program complete - all Part 121 aircraft have TAWS TAWS Final Rule All aircraft manufactured for use under Part 121 delivered with TAWS TAWS TSO TAWS AC OPS guidance TAWS Part 23 AC released AFS-200 (1.) AIR TAWS HBAT OPS guidance TAWS AFM requirement for newly manufactured airplanes ANM-100 Part 25 TAWS AC released Issues 1. 3/31/02 ops guidance not asked for no problems reported, moved to 3/31/03

Precision-Like Approaches (Potential US Accident Rate Reduction ~7%) 6/30/00 7/31/00 9/30/00 12/31/00 4/30/01 (2.) (2.) Crew procedures for stabilized approach Update pilot and ATIS information Plan to include angles AFS-400 Revise FAA order 8260.48 ATA Carriers Implement training ATA (11) (4) (24,27) (11) (23) (6) (3) Plan for public use (5) AVN AFS-400 Plan for 3d NAV procedures Plan for implementation of multiple "minima" ICAO SARPs S&GAS AFS-400 (17) (28a) (9,24, 27) AFS-200 FAA Standards for new training and procedures (20) (11,21,6,20) AFS-400 POIs policies to authorize GPS procedures as RNAV (19) Plan for education of inspectors, Check airmen & examiners (7) AFS-200 Plan for VGSI @ each runway end (7) (11) AFS-400 Update RNP policy & criteria (21) (22,25a) (8) (24) Plan for operational approval of VNAV & RNAV AFS-400 AFS-400 RNP procedures operational processes (11,15,16,20,24,25A,26,27,29) Issue AC 120-29A (24,25a) (1.) AFS-200 (9) (22) (27) (3.) Plan to install DME’s Transition to RNAV/RNP AVN (24,27) (12) (25a) Issues 1. AC 120-29A in final coordination (9) 2. Non-Alliance To Report (11) & (6) 3. Needs AC 120-29A

Global Aviation Safety

Global Aviation Safety Programs ICAO IFALPA IATA FSF Concept Working together Common Strategy for Accident Prevention Data Analysis Data Driven Plan FAA JSSI CAST SARAST SEARAST Etc. We believe the concept of industry and government working together on common data driven accident prevention strategies will be highly effective and are recommending use of a similar concept throughout the world. The JAA Safety Strategy Initiative (JSSI) is an example of a similar program. To that end, we want to share the information and data, the analysis methods, and information on the adopted interventions from the U.S. efforts. Intervention strategies may need to differ depending upon the different operating environments. We want to encourage you to take advantage of this opportunity to work together to improve safety PAAST Opportunities

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.

JAA Joint Safety Strategy Initiative (JSSI) Process

JSSI Top Level Methodology - CAST Issue (ex. CFIT) Verify Validity Yes CAST Implementation Plan Data Verification of Validity of Results Required ? No Data No Data Yes Others Analyzing Focus Area? Develop Action Plan Recommend-ation Choose Focus Area Yes Do We Participate? Yes Interventions & Problems defined by others ? Yes Determine European Feasibility Yes Intervention Under JAA Purview? Yes 1 No No Yes No Other Considerations No Define Problem Statements, Interventions, Effectiveness Create Analysis Team Recommend Action to Appropriate Organization JSSI STG Approval ? Data Data Yes Develop Detailed Plan Monitor Results Execute Plan 2-1-00 JSSI-004

JSSI Top Level Methodology - JSSI Issue (ex. Design Related) Verify Validity Yes CAST Implementation Plan Data Verification of Validity of Results Required ? No Data No Data Yes Others Analyzing Focus Area? Develop Action Plan Recommend-ation Choose Focus Area Yes Do We Participate? Yes Interventions & Problems defined by others ? Yes Determine European Feasibility Yes Intervention Under JAA Purview? Yes 1 No No Yes No Other Considerations No Define Problem Statements, Interventions, Effectiveness Create Analysis Team Recommend Action to Appropriate Organization JSSI STG Approval ? Data Data Yes Develop Detailed Plan Monitor Results Execute Plan 2-1-00 JSSI-003

Pan American Aviation Safety Team (PAAST)

Pan American Aviation Safety Team - PAAST Covers all of America south of the U.S. Well developed and organized Three Co-Chairs Al Castan, IATA - Miami Capt “Rocky” Marco Rocha, TAM Airlines - Brazil Capt Luis Garcia, IFALPA - Mexico Active Action Teams / Volunteers Active ICAO participation

PAAST PAAST Integration and Consolidation of safety efforts Airline Management FSF IATA IFALPA Airline Safety Departments PAAST AITAL IFATCA Pilots & Controllers AIRBUS BOEING EMBRAER ICAO States and Regulators IBAC CAST (US), JSSI (Europe) & Other Regional Teams

CAST Links with ICAO

Working with ICAO CAST - ICAO Common Taxonomy Team ICAO Safety Indicators Study Group COSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness) South Asia Regional Aviation Safety Team South East Asia Regional Aviation Safety Team Flight Safety Foundation CFIT/ALAR Action Group (CAAG) CAST and the FAA is working with ICAO on a number of programs to improve aviation safety world wide. The following are just a few examples: CAST - ICAO Common Taxonomy Team Agreement on Accident Category definitions and Phase of Flight definitions Common definitions will help us to agree on the problems and work together on the solutions. ICAO Safety Indicators Study Group First meeting April 2002 The identification of Safety Indicators will help all of the member States of ICAO focus on the critical problems and most effective safety enhancements. ICAO to sponsor annual meeting to agree on accident category (CFIT, approach and landing, etc) for pervious years accidents The categorization of the accidents over the last ten years will also be completed in the Fall of 2002. COSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness Under ICAO Technical Co-operation Programme)   COSCAP-South Asia South Asia Regional Aviation Safety Team (SARAST) COSCAP-South East Asia South East Asia Regional Aviation Safety Team (SEARAST) CAST and the FAA are providing CAST information and help in developing Safety Enhancements for the two ICAO sponsored COSCAP programs in Asia. Flight Safety Foundation CFIT/ALAR ACTION GROUP (CAAG) ICAO, CAST and the FAA are active participants in the CAAG ICAO has purchased 10,000 copies of the Flight Safety Foundation Tool Kit to be distributed world wide FAA has plans to provide each Ops inspector, FSDO, ACO, regional and HQ offices copies of the Tool Kit

Summary

Safety Analysis Process 1. NTSB Accident Incident Reports 2. 21.3 Reports NASDAC data Airclaims data Historical Data FOQA data Pareto Plots JSAT Industry JSAT 3. 4. Accident Threat Combined Threat Causal Analysis Intervention Strategy Cause Cause Cause Cause 5. JSAT JSAT 7. Industry 6. Safer Skies Government Implementation Strategy JSIT AvSP Measuring Progress to Goal Coordinated Plan 5.3-23 23

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

Our Challenge: Stay Focused Work together internationally Coordinate strategy Target our resources Focus on prevention Communicate industry and government safety processes and initiatives Share results The present and future success of CAST is based on these principles: Working together internationally to leverage our success. Maintaining a coordinated strategy and targeting our resources carefully on prevention. Continuing to communicate CAST safety initiatives and sharing safety results globally.

CAST Process Data-Driven Industry/Regulatory Collaboration 1