1. Commercial Aviation Safety Team (CAST) Overview

2. In the U.S., our focus was set by the White House Commission on Aviation Safety, and The National Civil Aviation Review Commission (NCARC)
Reduce Fatal Accident Rate . . .
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 year 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.
Strategic Plan to Improve Safety
Improve Safety Worldwide . . . 2

3. Vision - Mission - Goals
Key aviation stakeholders acting cooperatively to lead the world-wide aviation community to the highest levels of global commercial aviation safety by focusing on the right things.
Mission
Enable a continuous improvement framework built on monitoring the effectiveness of implemented actions and modifying actions to achieve the goal.
Goal
Reduce the US commercial aviation fatal accident rate 80% by 2007
and
Maintain a continuous reduction in fatality risk in US and International commercial aviation beyond 2007.
The vision ,mission, and goals of CAST are as shown on this slide.

4. CAST brings key stakeholders to cooperatively develop & implement a prioritized safety agenda
Industry
Government
AIA
Airbus
ALPA
APA
ATA
IFALPA
NACA
Boeing
GE*
RAA
FSF
DOD
FAA
Aircraft Certification
Flight Standards
System Safety
Air Traffic Operations
Research
NASA
ICAO**
EASA (ECAST)
TCC
NATCA**
NTSB**
Commercial Aviation
Safety Team
(CAST)
The strength of CAST lies in its extensive membership, its proactive commitment to safety and its ability to effect change. The CAST has proven effective because it is a voluntary association of key stakeholders in the operation of the commercial aviation system and the participants are safety leaders from those organizations able to commit and effect change
These organizations have come together voluntarily to improve aviation safety:
Aerospace Industries Association (AIA)
Department of Defense (DOD)
Air Line Pilots Association (ALPA)
Federal Aviation Administration (FAA)
Allied Pilots Association (APA)
National Aeronautics and Space Administration (NASA)
Air Transport Association (ATA)
International Civil Aviation Organization (ICAO)
National Air Carrier Association (NACA)
European Aviation Safety Agency (EASA)
General Electric (GE)-representing all engine manufacturers
Transport Canada (TCC)
Regional Airline Association (RAA)
National Air Traffic Controllers Association (NATCA) (observer)
Flight Safety Foundation (FSF)
National Transportation Safety Board (NTSB) (observer)
International Air Transport Association (IATA) (observer)
Association of Asia Pacific Airlines (AAPA) (observer)
Air Transport Association of Canada (ATAC) (observer)
Association of Professional Flight Attendants (APFA) (observer)
IATA**
AAPA**
ATAC**
APFA**
ACI-NA**
* Representing P&W and RR
** Observer

5. Safety Analysis Process1.
NTSB Accident
Incident Reports 2.
21.3 Reports
ASIAS data
Airclaims data
Historical
Data
Industry
Pareto Plots
JSAT
JSAT 3. 4.
Accident
Threat
Combined
Threat
Causal Analysis
Intervention Strategy
Cause
Cause
Cause
Cause
A summary of the process is highlighted in this chart.
The process relies on data at it’s 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.
JSAT
JSAT 7.
Industry 6.
Safer
Skies
Government
Implementation Strategy
JSIT
AvSP
Measuring Progress to Goal
Coordinated Plan
5.3-23 23

6. CAST Safety Strategy Data Analysis Set Safety Priorities Agree on
Implement Safety Enhancements - U.S.
Set Safety
Priorities
Agree on
problems and interventions
Influence Safety Enhancements - Worldwide
In a nutshell the CAST strategy is to use data to identify accident contributing factors and interventions that will reduce the likelihood of the contributing factors occurrence. Prioritize all of the possible safety improving actions and then implement the improvements in the United States and work with other regions to implement improvements as appropriate.
Achieve consensus on
priorities
Integrate into existing work and distribute

7. 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
Straightforward & rigorous process
JSAT – Analyze data
Identify problems or precursors
Propose interventions against those problems (can be out of the box proposals)
JSIT – Develop candidate safety enhancements
Assess feasibility of interventions
Group promising interventions into package of enhancements
Develop Detailed Implementation Plans (DIPs)
JIMDAT – Prioritization/Evaluation of Effectiveness
Determine overall effectiveness of proposals
some much more effective than others
Identify synergies
Recognize resource requirements
Develop into integrated, prioritized package of enhancements to the aviation system for CAST review
JIMDAT/JSIT interaction may be iterative to maximize effectiveness of the detailed implementation plans
Master safety plan
Enhancement effectiveness
Future areas of study
Joint Implementation Measurement Data Analysis Team (JIMDAT)

8. Joint Safety Analysis Team (JSAT)
Process

9. Typical JSAT Membership
ALPA/APA
FAA (AIR, AFS, ASA, AAI, ATO)
Airbus
EASA
ATA
Transport Canada
NASA
Engine companies – (PW, GE, RR-Allison)
Boeing
RAA
NACA
AIA
NATCA 19

10. 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
Identify
Intervention
Strategies
Evaluate
Intervention
Effectiveness
Technical
Review &
Report
Results
Prioritize
Interventions
5.5-24 24

11. Developed Event Sequence
Facts and data
Pilot - controller voice events
Missed calls
Events that occurred or should have
Time coded each event

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

13. 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

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

15. Intervention Effectiveness
Power
Effectiveness of a specific intervention in reducing the likelihood that a specific accident would have occurred (“Perfect World”)
Confidence
Confidence that this specific intervention will have the desired effect
Future Global Applicability
How well the intervention can be extrapolated to apply to a world-wide fleet in the future

16. Effectiveness Rating Scales
POWER
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
FUTURE GLOBAL APPLICABILITY
This scale is to be used to estimate how well the intervention can be extrapolated to apply to a world-wide fleet in the future.
(for example: how often the situation it addresses occurs in accident scenarios; whether 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

17. JSAT Reports Standard Problem Statements Interventions Prioritized
Recommendations

18. Joint Safety Implementation Teams (JSIT)
Process

19. JSIT Feasibility Scales
Technical
Financial
Operational
Schedule
Regulatory
Sociological

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

21. Joint Implementation Measurement Data Analysis Team (JIMDAT)
Process

22. Develops a Prioritization Methodology (JIMDAT)
Identifies the most effective solutions derived from all accident categories
Considers effectiveness vs. resources
Tests solutions against fatal and hull loss accidents
Creates draft master strategic safety plan
Identifies 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.

23. Resource Cost Vs. Risk Reduction
100%
10000
Risk Reduction
APPROVED PLAN $
9000
Total Cost in $ (Millions)
8000
75%
7000
6000
Risk Eliminated by Safety Enhancements $
50%
Resource Cost ($ Millions)
5000
2007
2020
4000
3000
25%
2000
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.
As you can see there was a definite knee in the resource cost curve. The selected CAST plan provided an estimated 74% risk reduction by 2020 at a cost of about 740 million dollars. To implement all of the CAST possible projects would increase the risk reduction by about 5 percent but require more than 5 billion dollars to implement. $ $
1000 $ 0%
Completed
Completed + Plan (2007 Implementation Level)
Completed + Plan (2020 Implementation Level)
All JSIT Proposed Enhancements (2020 Implementation Level)

24. Cost Savings Dollars/Flt. Cycle
Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents
100
Historical cost of accidents per flight cycle 80
74% Risk reduction
Savings ~ $74/Flight Cycle Or
~ $814 Million Dollars/Year
Dollars/Flt. Cycle 60 40
When we break down costs of our current accident rate, accidents cost us approximately $100 for every flight.
By implementing the 72 carefully selected, data-driven safety enhancements, we will have reduced these costs by $74 per flight.
This adds up to a savings about $814 Million EVERY YEAR into the future. 20
Cost of accident fatalities following implementation of the CAST 2020 levels
2007
2020

25. General Methodology for Calculating the Potential Benefit of a Safety Enhancing Intervention=  ( )
Accident Risk Reduction
Effectiveness
that an intervention has for reducing the accident rate if incorporated ,
Portion of world fleet
with intervention implemented
The mathematical expression for the JIMDAT tool is that fatality risk reduction is some function of the effectiveness that the enhancement has against the threat and the level that the enhancement has been implemented in the subject fleet.

26. Spreadsheet Example – Historical Airplane Accidents & Proposed Safety Enhancements
This is an example of the spreadsheet as it was used by the JIMDAT.
Across the top of the sheet are listed all of the safety enhancements that we evaluated. The left hand column is a listing of the threats that are to be evaluated. In the case of CAST it was initially the accidents that had occurred in the U.S. Part 121 fleet from 1988 through For the worldwide accident data set it was all of the fatal and hull loss accidents that had occurred in operations, equivalent to U.S. Part 121, throughout the world.
The pale green columns are the effectiveness scores assigned to each of the enhancements. The blue column is the mathematical determination of the probability that the particular accident would have occurred if all of the enhancements had been in place.
The yellow columns contain additional information about the particular accident.

27. Basics of the Selection Spreadsheet
Effectiveness
Each safety enhancements is evaluated against each undesired condition in the set to determine how effective the enhancement would be at eliminating these conditions if the enhancement were put in place.
Implementation
Implementation level is based on the portion of the affected population with the enhancement incorporated or predicted to be incorporated by a future date.
Severity Weighting
To account for differences in severity or significance of the undesired conditions, a weighting value can be entered so that the relative risk of the undesired conditions is realized.
The spreadsheet tool we have developed is very easy to use. For CAST, each enhancement was evaluated for its effectiveness against each of the accidents in the data base. This effectiveness score was basically the probability that the accident would have been eliminated had the enhancement been in place.
For any given point in time the implementation level for the proposed enhancement was estimated. Implementation level was shown in tenths with 1.0 being fully implemented. In the case of CAST two points in time were evaluated – 2007 and 2020.
To truly evaluate risk the probability of occurrence must be multiplied by the severity of the event. In the CAST case we chose the severity weighting value to be the percentage of people aboard an accident airplane who perished. Thus, CAST based its plan upon minimizing the risk of fatalities and not on fatal accident rate.

28. Severity Weighting Overview
To account for differences in fatality risk associated with each accident in the data set, a severity value was applied. In this assessment, the severity value represented the portion of people onboard that perished in the given accident.
Example: Comparison of two fatal accidents
757 CFIT accident, 98% perished. Weighting factor is .98
747 Turbulence accident, .6% perished. Weighting factor is .006
Hypothetically assume an assessment showed that the chance of these accident occurring would have been reduced by proposed safety enhancements by 50%.
The associated portion of fatality risk eliminated can be determined using the severity weighting factor as follows:
757 CFIT.98 x .5 = .49
747 Turbulence, .006 x .5 = .003
Each event in the data set evaluated received a severity score. For the CAST evaluation that score was the percentage of persons aboard the airplane who perished.
The CAST data is based on equivalent fatalities which modifies the actual fatality data to account for serious injuries. In accordance with FAA standards 17 serious injuries is equated to one fatality. Thus the fatality numbers you will see on the CAST spreadsheet will sometimes be higher than the actual reported number of fatalities.

29. Analysis Tool Output
The spreadsheet output can be set up to show the effect that an individual safety enhancement, or group of safety enhancements have on reducing exposure to the undesired condition.
Fatality
Risk
Reduction
This chart illustrates the effect of the “belts and suspenders” effect. The chart shows the risk reduction achieved by three different safety enhancements – SE1, SE2 and SE3. The three bars on the left of the graph represent the risk reduction that would occur if each of those enhancements were put in place individually with no other enhancements in place.
The bar labeled SE1 and SE2 shows that the risk reduction of implementing SE1 and SE2 is not quite as large as the sum of the individual scores for the two enhancements. This would indicate that a few of the contributing factors that were addressed by SE1 were also addressed by SE2.
The bar labeled SE1 and SE3 is higher than either the SE1 bar or the SE3 bar but not nearly as high as the two individual bars if added together. This illustrates that even though SE3 is more powerful individually than SE2, when combined with SE1 the overall effect is not as good because SE3 acts on many of the same contributing factors as SE1.
If resources were available to implement only two of the three enhancements we would elect to implement SE1 and SE2 because the overall risk reduction in the fleet would be the greatest.
SE1
SE2
SE3
SE1 &
SE1 &
SE2
SE3

30. Example Scatter Chart 2007 Implementation & Resources25 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

31. Safety Plan Development
Accident
JSATS
Case studies
Accident
JSITS
Case studies
Safety
Enhancements
Recommended
Plan
Revision
Emerging
Risk
Master
Contributing
Factors
Incident
Analysis
Process
Develop
Enhancements
& Metrics
JIMDAT
Review
CAST
Plan
Changing
Risk
Metrics
Performance
To Plan
Review
Non-
Performance
Information
Aviation
System
Changes
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 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.
CAST is transitioning to 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 green 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 into the future (orange), 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 European led 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.
Identify
Hazards
Identify
Factors
Yes
Present
In Master
Factors
Develop
Contributing
Factors
(new or emerging
FAST Hazards No
Demographic
Changes
Identify
Hazards
Identify
Factors

32. Robust CAST Methodology
Detailed event sequence - problem identification from worldwide accidents and incidents
Broad-based teams (45-50 specialists /team)
Over 450 problem statements (contributing factors)
Over 900 interventions proposed
Analyzed for effectiveness and synergy
Extremely robust and disciplined process
Amazing array of talent brought to bear to develop CAST plan
Evidence of commitment of participants to the CAST process

33. CAST Process Led to Integrated Strategic Safety Plan
Part 121 or equivalent passenger and cargo operations studied
Current CAST plan:
72 Prioritized Safety Enhancements
50 Complete and 22 underway
Projected 74% fatality risk reduction by 2020
Industry and Government implementing plan
Acknowledge that other enhancements ongoing bring number to over 80%

34. CAST Safety Plan 50 Completed Safety Enhancements Safety Culture
Maintenance Procedures
Flight Crew Training
Air Traffic Controller Training
Uncontained Engine Failures
Terrain avoidance warning system (TAWS)
Standard Operating Procedures
Precision Approaches
Minimum Safe Altitude Warning (MSAW) Systems
Proactive Safety Programs (FOQA + ASAP)
Although time does not permit my discussing each of the following 50 completed safety enhancements, this list illustrates the areas, and types of actions, that were covered in the enhancements completed to date. This list clearly indicates how a range of training, operational and design solutions were utilized. CFIT-PAI-Vertical Angles - Increases the use of Precision approach through addition of vertical angles on approach plates to achieve constant angle descent.

35. CAST Safety Plan (cont.)
22 Committed Safety Enhancements
Policies and Procedures
Aircraft Design
Flight Crew Training (additional aspects)
Runway Incursion Prevention
Precision Approaches (additional projects)
Icing (additional turboprop projects)
Midair
Maintenance
Runway Safety
Safety culture, policies and procedures
Study of midair, maintenance, cargo and additional icing related accidents and serious incidents resulted in a number of new Safety Enhancements. The new Safety Enhancements are currently being implemented.

36. Fatal Accident Rate and Full Airplane Loss Equivalents
Rate for Part 121 Operations (5-Year Rolling Average)
9.0
8.0
5 year moving avg of fatal accidents per 10 million departures
7.0
6.0
5.0
Fatality Accidents or Full Loss Accident Equivalents
per 10 Million Departures
4.0
3.0
82% Fatality Accident
Rate Reduction
Since we are now past the original period, the question you might ask is – Did CAST reach its 2007 goal?? This chart illustrates the five year rolling average of the fatal accident rate in U. S. Part 121 operations (red line) and the fatality risk (blue line). This clearly shows that the CAST activity, coupled with other ongoing safety activities by government and industry, have resulted in an 82 percent reduction in the fatal accident rate in the ten years ending in 2007.
2.0
1.0
0.0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007

37. International Perspective CAST Safety Enhancements
Europe
C.I.S.1
ECAST
35 SEs JAA
11 SEs EASA
COSCAP CIS
Specific CIS Projects
United States
and Canada
JAA
Non JAA
CAST
72 SEs
50 complete
22 in work
China
Middle East
Asia
COSCAP BAG
COSCAP GS
(Excluding
China)
Africa
COSCAP NA, SA, SEA
40 SEs in work
COSCAP CEMEC
Latin America
and Caribbean
Oceania
COSCAP UEMOA
Regional cooperative safety activities (ICAO and local regulators work together – COSCAPs) by region.
This chart shows some regional cooperative safety activities (ICAO and local regulators working together – COSCAPs) that are supported by representatives from the CAST.
The number of CAST Safety Enhancements adopted by the Asian COSCAPs and the European CAST (ECAST) are also depicted.
COSCAP = cooperative Development of Operational Safety and Continuing Airworthiness Programme
RASG-PA

38. CAST Phase 2 Transition to Decision Making Based on Analysis of Incident and System Safety Performance Data Aviation Safety Information Analysis Sharing (ASIAS)

39. The Aviation Safety Information Analysis and Sharing (ASIAS) System Was Created in Order To:
Develop tools to make data analysis more efficient
Identify and access key data sources
Discover potential aviation safety risks using the key data sources
Develop automated information integration capabilities centered on aviation safety risk topics
Transfer technologies and key data sources into National Archives

40. ASIAS Enables Various Types of Proactive Safety Analyses
Known Risk Monitoring
Vulnerability Discovery
Benchmarking Operations
Safety Enhancement Assessments
Directed Studies 40

41. ASIAS Has Access to Multiple Data Sources
Airline
Data
Digital Flight Data
Voluntary Pilot Safety Reports
Surveillance Data
Traffic Management Reroutes & Delays
Airport Configuration and Operations
Sector and Route Structure
Procedures
Safety Reports
FAA
Other Sources
Bureau of Transportation Statistics
Aviation Safety Reporting System
Weather / Winds
Manufacturer data
Worldwide Accident Data 41

42. ASIAS is Governed by Formal Principles
Data used solely for advancement of safety
Non-punitive reporting
Airline data is de-identified
Analyses approved by an ASIAS Executive Board 42 42

43. Airlines Participating in ASIAS1.
AirTran Airways Inc 2.
Alaska Airlines 3.
American Airlines 4.
American Eagle 5.
Atlantic Southeast Airlines 6.
Chautauqua Airlines 7.
Compass 8.
Continental 9.
Delta Airlines
10.
Express Jet
11.
Frontier Airlines
12.
Gulfstream Intl
13.
Jet Blue
14.
Northwest
15.
Republic Airlines
16.
Shuttle America
17.
SkyWest
18.
Southwest
19.
United
20.
UPS
21.
US Airways
21 ASIAS airlines with signed Memoranda of Understanding (MOUs) (as of July 7, 2009)
75% of 2008 operations
James to provide maps with same formatting for small multiple comparison
Missing airlines based on if ASAP program and largest percent operations
FAA in discussion to establish international participation – will enable more complete coverage 43

44. Participating Airlines
21 airlines participating in ASIAS representing 75% of 2008 operations (as of July 7, 2009)
James to provide maps with same formatting for small multiple comparison
Missing airlines based on if ASAP program and largest percent operations
FAA in discussion to establish international participation – will enable more complete coverage
size of circle:
240,000 ops 44 44

45. Benefits of ASIAS
With ASIAS, the aviation community will be able to . . .
Identify Systemic Risks
Establish safety baselines of current operations
Identify known and newly emerging system vulnerabilities
Monitor safety trends
Evaluate Identified Risks
Estimate their probabilities
Assess their severities
Uncover event precursors
Diagnose event causation
Formulate Interventions
Assess the probable effects of safety enhancements through simulation studies
Monitor Intervention Effects
Assess the effectiveness of interventions (SEs) in accordance with metrics established by the CAST

46. ASIAS Studies In Progress or Completed
Directed Studies
Runway Safety
Terrain Awareness Warning System Study
TCAS Resolution Advisories
CAST Known Risk and Safety Enhancement Effectiveness Monitoring
Risk of Landing Runway Overrun
Approach and Landing Accident Risks
Controlled Flight Into Terrain (CFIT)
Airline Benchmarks
Terrain Awareness Warning System Alerts
Unstabilized Approaches
TCAS Resolution Advisories 46

47. Prioritization Issues/Considerations
There is a need for CAST to prioritize its desired tasks so that MITRE resources and CAST Subject Matter Expert (SME) support can be managed effectively
Use of MITRE resources and associated CAST SME support needs to be looked at in total and each task given a priority

48. CAST Use of Data Status: currently ongoing:
Potential safety concerns are being
Developed & prioritized by JIMDAT.
CAST will request AEB to allocate
MITRE resources to build query tools
and provide query results
CAST Use of Data
Study items from outside
requests
Contributing
Factors
Understood?
Meet Study
Guidelines?
Data (ASIAS
and any
other data)
Data Queries
& Data
Processing
Processed data
Prioritize CAST
Study Items
(Risk/Resources)
Threshold
Filter
Attention
Items No
Yes
(Disseminate information
to CAST when above a
TBD threshold)
Yes No
Perform study on
selected item
(May require AEB
approval – data &
MITRE resources)
CAST may direct that
additional metrics or trend
monitoring be developed
(May require AEB approval)
Is risk level
sufficient for
mitigating
action?
CAST may direct that
additional metrics or trend
monitoring be developed
(May require AEB approval) No
Yes
Initiate CAST
SE Development
Develop SE Metrics per
CAST direction
(May require AEB approval)

49. CAST Precursors and Issues
ASIAS Data
Data Queries
& Data Processing
Based on issue priority, CAST will request resources (AEB/MITRE, SMEs) for tool development, data queries, data processing.
Potential
Study
Item
Threshold A B C
CAST Precursors and Issues
Thresholds, exceedences, and abnormalities will be unique to each issue and have yet to be established

50. Safety Study Decision Guidelines
1. AIRPLANE ACCIDENT SAFETY
YES NO
Supporting
data
A. The condition of interest was likely a significant contributing factor in a Part 121 or equivalent catastrophic event (including relevant events on other classes of operations).
B. The condition of interest is considered to have a significant adverse influence on the effectiveness or implementation of an approved safety enhancement that was not considered in the SEs original assessment C.
The condition of interest is considered to be a significant contributing factor to the occurrence of a catastrophic accident in the future and:
1.1) there is an expectation of at least one catastrophic accident within the next 20 years. OR
1.2) the probability* of one or more catastrophic accidents is greater than 4x 10-6/flt cyc.
*Average per-cycle probability as applicable.
2. PERSONAL SAFETY
The condition could result in serious injury or death to crew or passengers, and cannot be shown to be less probable than 1E-5/flight cycle (TBD).
3. OTHER
An event/condition that any CAST member considers to be a condition of study provided rationale is presented and those resources needed for the study are approved by the affected CAST members.

51. Risk Level Appropriate for Monitoring
1 accident in 20 yrs
Risk Level Appropriate for Study
RR SEs Risk Levels
Upper limit established by current rare accident occurrence rate
The data process flow chart is intended to be used to facilitate CAST’s transition into incident analysis
Data tools & Data Processing
Studies
Mitigating action
JIMDAT is developing prioritization guidance for data tasks involving CAST and MITRE ASIAS
Prioritization method will consider risk/resource/estimation of outcome viability
Guidelines for potential study items have been drafted and are ready to be used by CAST. Study item prioritization concepts have been defined and the details are in work
As the potential for risk reduction becomes small, an agreed upon criteria is needed to enable CAST decision making respective to the development and incorporation of SEs
It is envisioned that economic benefits other than safety benefit will have to be considered in the future
JIMDAT is developing economic models to include operational benefits of SEs. This will better enable full benefit of SEs to be estimated
Risk Level – Rapid Response
Fatality Accident Current Accident Rate

52. Summary
History shows focused action and introduction of new capabilities have led to accident risk reductions
Joint industry and government teams working together to a common goal can further enhance the safety of our very safe aviation system
CAST has detailed plans in place to address known problems
CAST is refining incident analysis and operational data mining to uncover problems before they result in accidents

53. To meet the recommendations of the recommendations of the White House Commission on Aviation Safety and the National Civil Aviation Review Commission the Existing Industry Safety Strategy Team (ISST) and the Federal Aviation Administration Safety Action Team (SAT) were combined, and augmented, to create the Commercial Aviation safety Team (CAST) in 1998.