1. Commercial Aviation Safety Team (CAST) Overview Kyle L
Commercial Aviation Safety Team (CAST) Overview Kyle L. Olsen Asian Regional Aviation Safety Team 19 – 20 November 2008 – Bangkok
Commercial Aviation Safety Team (CAST) briefing by:
Kyle L. Olsen
Federal Aviation Administration (FAA) - Retired
Aircraft Certification Service
Phone:
FAX: 1

2. 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.

3. Commercial Aviation Safety Team (CAST)
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 / JAA
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 partnership of
Key stakeholders in the operation of the commercial aviation system
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) Joint Aviation Authorities (JAA)
Pratt and Whitney (P&W) Transport Canada (TCC)
Regional Airline Association (RAA) National Air Traffic Controllers Association (NATCA)
Flight Safety Foundation (FSF) National Transportation Safety Board (NTSB) (observer)
International Air Transport Association (IATA) European Aviation Safety Agency (EASA)
Association of Asia Pacific Airlines (AAPA)
Air Transport Association of Canada (ATAC)
Association of Professional Flight Attendants (APFA)
General Electric (GE)
Rolls Royce (RR)
IATA**
AAPA**
ATAC**
APFA**
* Representing P&W and RR
** Observer

4. 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 it’s 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

5. 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)

6. 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.

7. 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.

8. 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

9. CAST Safety Plan 47 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 40 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, approach and landing, loss of control, runway safety, -- & though these types of accidents and serious incidents are still happening, the risk has been significantly reduced.
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.

10. CAST Safety Plan (cont.)
23 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
Cargo safety culture, policies and procedures
Runway Safety
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.

11. CAST Implementation Status

12. 23 47 70 Safety Enhancements 47 Complete 23 Underway
CHANGES from last meeting
2020 Plan Risk Reduction Estimate 74 %

13. 2020 CAST SAFETY PLAN – WORKING SEs
(Total Plan – 70 SE; 47 Complete; 23 Underway) 39
ANM 47
ATO 53
ARA
120
ATA
101R1
AIA
121
ATA
125R1
ATA
127R2
AIR
131R1
ATA
133R1
AIA
134R2
AIA
136
ATA
159R1
ATO
165R3
AFS
169R1
AFS
170R2
AIA
172R1
AFS
175R1
ATA
179R1
AFS-1
180
ATS-1
181R1
ARP
182R1
ATO-1
183R1
AFS-1
Action
Needed
SE #
LOOSEC
ON TRACK
COMPLETED
LATE
LATE OP
IN QUESTION

14. Rate per million departures
Cooperative efforts are bringing accident rate down
Hull Loss Accident Rate
Worldwide Commercial Jets (>60,000 lbs, non-CIS) Through 31 December 2002
2.00
5 year running average
1.60
FSF
CFIT/ALAR
Industry effort
starts
CAST/JSSI/
COSCAPs
begin
PAAST
begins
1.20
Rate per million departures
0.80
We are beginning to see the results of team efforts on a worldwide basis.
This chart shows the hull loss accident rate in losses per million departures and the 5 year running average of that rate.
As you can see, the 5 year average shows a definite and encouraging downward trend
So, there is still work to be done. Our success in improving safety has made it more challenging to identify actions that will bring even more effective and affordable safety improvements
0.40
0.00
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002

15. CAST Moving into the Future

16. Safety Plan Development
Accident
JSITS
Case studies
Accident
JSATS
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
Identify
Hazards
Identify
Factors
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. 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.
Yes
Present
In Master
Factors
Develop
Contributing
Factors
(new or emerging
FAST Hazards No
Demographic
Changes
Identify
Hazards
Identify
Factors
CAST-051R

17. ASIAS Activities Summary to the CAST
Aviation Safety Information Analysis Sharing
ASIAS Activities Summary to the CAST
7 August 2008

18. Signed MOUs

19. Regional Airlines Outreach

20. ASIAS Architecture: Where We Are
ASDE-X Airports
ATL-BDL-CLT-FLL-HOU
IAD-LAX-MCO-MKE-ORD
PVD-SDF-SEA-STL
FAA ASIAS Data
Enhanced Data Management Tools
Expanded Analytical Tools
DNAA DNFA
ASDE-X
MITRE CRS Data
National Offload Program
Data Fusion
New Airlines

21. 6. Traffic Procedures
5. Wx
3. Radar Tracks
1. FOQA TAWS Alerts
4. Terrain database
This is an example of data that has been gathered for a CAST study concerning TAWS alerts in selected locations.
Red dots – FOQA TAWS alerts used to identify areas of interest (source: airlines)
Cylinders – Minimum Vectoring Altitude (source: ATC) Why they received TAWS alerts
Terrain Map – National Elevation Data. What the MVA was protecting
Red lines – Radar Traffic Tracks (source: FAA National Offload Program) Actual tracks thru MVA
We also looked at weather patterns at the time of the alerts and airport & airspace procedures for this airport arrival route.
2. MVA

22. Study of Remaining Risks
Joint Implementation Data Analysis Team (JIMDAT)

23. Remaining Risk
Cargo
Icing
Midair
Maintenance

24. SE-165 Midair TCAS Policies and Procedures
Prevent midair collisions by requiring flightcrews to follow TCAS Resolution Advisories (RA’s), establish procedures for TCAS range setting and requiring that TCAS-capable simulators and flight-training devices are used for training TCAS responses and Maneuvers.
SEA AC 018 issued 25 June 2008.

25. SE-164 Midair TCAS Installation
Worldwide installation of TCAS in all aircraft of 33,000 pounds or greater max takeoff weight.
ICAO requirement for aircraft of 6,700kg
TCAS required in Asia – SE-164 is complete

26. SE-121 Cargo Standard Operating Procedures
Reduce cargo-related accidents and incidents by publishing and enforcing clear, concise and accurate standard operating procedures (SOP), and training the rationale behind those procedures
Cathay Pacific and AAPA to provide briefing.
CAST activity to be complete April 2010

27. SE-125 Cargo Hazardous Materials - HazMat
Reduce hazmat related accidents and incidents develop and implement by regulators, manufacturers (of packaging material) and shipping companies a multi-tier system to identify and safely process undeclared hazardous material.
CAST to provide information after completion in December 2010

28. SE-129 Regulation & Policy Compliance, Enforcement and Restricted Operations
Regulators should improve their legal processes for compliance, enforcement and operational restrictions.
FAA Order B now contains timeliness goals for completion of an investigation, preparation of the enforcement report and the processing of legal actions.

29. SE-129 Regulation & Policy Compliance, Enforcement and Restricted Operations - continued
Also, FAA Order B now contains policies and procedures for the grant of immunity from FAA enforcement to persons who provide information about violations to the regulations.

30. SE-130 Cargo Regulation & Policy - Oversight
Regulators should develop/enhance and implement a system that ensures appropriate inspector coverage for all airlines, sub-contracting, and leasing operations and assign highly-experienced inspectors to operators that require the most oversight
Not applicable for implementation by ARAST.

31. SE-131 Cargo Safety Culture
Reduce cargo-related accidents and incidents by encouraging a culture that enhances operational safety. Safety culture can be enhanced by a safety management system (SMS).
To be covered by SMS
CAST activity complete October 2011

32. SE-136 Icing Training – Engine Surge Recovery
To prevent accidents resulting from an engine surge caused by ice ingestion, airlines should provide adequate training for flight crews to ensure appropriate responses.
CAST activity complete April 2009

33. SE-163 Midair See-and Avoid
Prevent midair collisions by improving see-and-avoid capability.
Future Implementation

34. SE-159 Midair Airspace Design
Prevent midair collisions by designing B/C/D airspace to be more easily identifiable, improving the usability of VFR charts and ensuring adequate and timely coordination of airspace design changes to users.
Not applicable for implementation by ARAST.

35. To General Aviation SE-162 Midair
Prevent midair collisions by facilitating aircraft separation for users of advanced navigation systems not receiving ATC separation services.
Not applicable for implementation by ARAST.
To General Aviation

36. SE-127 Cargo Fire Containment
To reduce the occurrence of accidents and incidents from cargo fires, improved cargo containers should be developed to contain (or suppress) fires originating in shipped cargo
Not applicable for implementation by ARAST.
(FEDEX can provide additional information if there is interest.)

37. SE-133 – Icing Turboprop Aircraft Ice Detection Systems
To prevent accidents caused by in-flight icing, for turboprop aircraft with non-evaporative ice protection systems and non-powered flight controls, install systems that automatically detect ice, measure the rate of ice accretion and warn the crew.
Not applicable for implementation by ARAST.

38. SE-134 Icing Aircraft Design - Avionics
Avionic manufacturers and aircraft manufacturers should develop and install smart pitch guidance systems on all aircraft not presently equipped to prevent over rotation in conjunction with a low energy state or aerodynamic degradation due to the presence of ice.
Not applicable for implementation by ARAST.

39. SE-101 Aircraft Design Advanced Circuit Protection
Develop and install advanced circuit protection / arc fault breaker technology
Not applicable for implementation by ARAST.

40. CAST Sharing with the World

41. 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 2007 levels
2002
2007

42. CAST Links to International Safety Activities
ICAO
COSCAP (Cooperative Development of Operational Safety and Continuing Airworthiness)
Europe
ESSI: European Strategic Safety Initiative
Central and South America
PAAST: Pan American Aviation Safety Team
Africa
African Safety Enhancement Team (ASET)
Asia/Pacific
Association of Asia Pacific Airlines
North America
NAFTA: North American Free Trade Association
Others

43. Regional Perspective Accident Rates Vary by Region of the World
Western-built transport hull loss accidents, by airline domicile, 1998 through 2007
COSCAP CIS
C.I.S.1
Europe
0.7
ESSI
35 SEs JAA
11 SEs EASA
62% reduction
COSCAP NA, SA, SEA
40 SEs in work
60% reduction
United States
and Canada
0.4
China
0.3
CAST
70 SEs
47 complete
23 in work
74% reduction
Middle East
2.3
Asia
2.1
(Excluding
China)
COSCAP BAG
Africa
10.0
COSCAP Gulf
Latin America
and Caribbean
2.1
Oceania
0.0
ASET
PAAST
CFIT and ALAR
Regional cooperative safety activities (ICAO and local regulators work together – COSCAPs) by region.
This chart shows two things.
Accident rates by region of the world
Regional cooperative safety activities (ICAO and local regulators working together – COSCAPs) by region.
The number of CAST Safety Enhancements adopted by the Asian COSCAPs and the European JSSI (Joint Safety Strategy Initiative) are also depicted.
COSCAP = cooperative Development of Operational Safety and Continuing Airworthiness Programme
World
1.1
Accidents per
million departures
1 Insufficient fleet experience to generate reliable rate.

44. CAST Approach to Safety: 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

45. Conclusions CAST brings together all the key players
– Air Carriers – Manufacturers
– Employee Groups – Government
Predicted 74% risk reduction by 2020
CAST is committed to worldwide participation
History shows focused action and introduction of new capabilities have led to large accident rate reductions
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 47 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.

46. Thank you

47. Backup Slides

49. CAST sharing with COSCAP’s in Asia

51. CAST and GASR
CAST supports the Global Aviation Safety Roadmap (GASR) as an international strategic plan to promote aviation safety programs, which is complementary to the implementation of appropriate tactical solutions contained in the CAST Safety Plan

52. COSCAP History
COSCAP-South East Asia has been working on safety issues for the last seven years.
South East Asia Regional Aviation Safety Team (SEARAST):
reviews safety recommendations,
develops interventions,
tracks implementation.
Focused primarily on improving safety by reducing accident risk.

53. Global Aviation Safety Roadmap (GASR)
Proactive approach to aviation safety
Help coordinate and guide safety policies
12 Focus Areas established
4 Focused on States (government)
1 Joint regional responsibilities
8 Focused on industry (operators)
The Focus Areas are high level
Accident risk reduction not defined or identified
Best Practices identified for each Focus Area

54. 12 Global Safety Initiatives
The strategic action plan, ‘Implementation the Global Aviation Safety Roadmap’ defines:
Focus Areas.
Objective of each Focus Area.
Best Practices for each Focus Area.
Metrics for each Best Practices.

55. Metrics In many instances the metrics link with:
ICAO USOAP audit results used when related to States.
IATA ISOA audit results used when related to industry.
ICAO Annexes, SARPS, Documents, etc.
Prior Roadmap Workshops have developed an implementation tool.

56. Example from Focus Area 1, International Standards
Best Practices, Metrics and Implementation

57. Example from Focus Area 9, Inconsistent Adoption of Industry Best Practices
Best Practices, Metrics and Implementation

58. Example from Focus Area 5, Inconsistent Coordination of Regional Programs
Best Practices, Metrics and Implementation

59. Evaluation
Prior to a GASR Workshop, the Programme Coordinator working with the SEARAST should evaluate the Focus Areas, Objectives and Metrics to identify possible duplication and gaps within the Region.

60. Benefits of an Evaluation
Help maintain perspective between:
Current Safety Team activity,
USOAP audit results and actions,
IOSA audit results and actions, and
GASR Focus Areas
Help to focus on priorities reducing risk
Identify and avoid duplication
Ongoing activity and efforts
Teams

61. Possible Duplication USOAP Programme, DP3
SEARAST recommendations, actions and implementation, DP5
Safety Management Systems (SMS), DP6
Incident and Accident Investigation
Creation of an additional safety team

62. In South East Asia
Programme Coordinator and Safety Team (SEARAST) to evaluate GASR Best Practices, Metrics and Implementation Level to identify gaps and areas of duplication.
Programme Coordinator:
Report results of review to Steering Committee.
Recommend future action.
Approve the revised Terms of Reference.