1. Presented to: By: Date: Federal Aviation Administration Lessons Learned From Aviation Accidents World Aviation Training Conference Daniel I. Cheney, Manager, Safety Programs Federal Aviation Administration April 27-29, 2010; Orlando, Florida Creation of a Web-Based Knowledge System

2. Lessons Learned From Aviation Accidents 2 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Agenda Background Plans Summary The Accident Library

3. Lessons Learned From Aviation Accidents 3 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Background During the 1990’s and early 2000’s, several large transport accidents occurred which prompted examination of the consistency of: –The design programs –The operational programs –The maintenance programs and the organizational interfaces connecting these programs

4. Lessons Learned From Aviation Accidents 4 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 The Organizational “Life Cycle”

5. Lessons Learned From Aviation Accidents 5 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Background Organizational Interface related accidents included: –Trans World Airways Flight 800 –Swissair Flight 111 –American Eagle Flight 4184 –Alaska Airlines Flight 261

6. Lessons Learned From Aviation Accidents 6 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 At the NTSB accident hearing in 2000, the FAA committed to undertake a detailed review of its certification and operational processes –In March 2002, the Certification Process Study (CPS) was issued Alaska Airlines 261 -The catalyst for an internal review of safety processes

7. Lessons Learned From Aviation Accidents 7 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Web accessible at: http://www.aia-aerospace.org/issues/subject/faa/faa_cert_study.pdf http://www.aia-aerospace.org/issues/subject/faa/faa_cert_study.pdf Study co-chaired by FAA and industry, supported by experts from several major companies and organizations Commercial Airplane Certification Process Study

8. Lessons Learned From Aviation Accidents 8 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 CPS report, Finding # 8 stated: “Adequate processes do not exist … within the commercial aviation industry…to ensure that the lessons learned from specific experience … are captured…and made available to the aviation industry…” Mistakes can be linked to failure to apply past lessons

9. Lessons Learned From Aviation Accidents 9 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 “Those who cannot remember the past are condemned to repeat it.” George Santayana Professor of Philosophy Harvard University The Life of Reason, Volume I 1905 Nearly all large transport accidents are enormous human tragedies. A second tragedy is to not learn from them.

10. Lessons Learned From Aviation Accidents 10 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Current Situation Lessons from major accidents are not being consistently captured, retained, or applied –Reliance of “On the Job Training” (OJT) –Intended to be captured by requirements, specifications –“That’s an old accident. Why do I need to know anything about that?” –“Not my job”

11. Lessons Learned From Aviation Accidents 11 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Barriers to Creating an Accident Lessons Knowledge System Fear of litigation, negative publicity Lengthy Investigation/Resolution Continual workforce turnover IT tools only recently available

12. Lessons Learned From Aviation Accidents 12 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Current Initiative In response, the FAA has developed a web based “Lessons Learned from Large Transport Airplane Accidents” library –Structured; threat based –Comprehensive search/sort capability –Can be integrated with other safety systems

13. Lessons Learned From Aviation Accidents 13 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Purpose of Accident Library Stop and reverse the loss of costly lessons Maintain and improve the safety of an already very safe international aviation system –Training modules are possible using library content

14. Lessons Learned From Aviation Accidents 14 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Library Content What the Library IS : –An orderly assemblage of available accident information –Investigation AND resolution content

15. Lessons Learned From Aviation Accidents 15 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Library Content What the Library is NOT: –Re-investigation of any accident –Assessment of fault or blame –A collection of all accidents; only those with high lesson value

16. Lessons Learned From Aviation Accidents 16 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Accident Life Cycle Investigation Process Resolution Process The Accident Initial corrective actions Regulations & policies (from previous incidents) Investigation Corrective actions Research & Development Proposed rules change Proposed policy change Changed regulations & policies Lessons Learned Identified Airplane certified Operations begin In-service Incidents Reports & Recommendations

17. Lessons Learned From Aviation Accidents 17 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Background Often accidents require several factors in order for the accident to happen –All the factors “line up” on a given flight

18. Lessons Learned From Aviation Accidents 18 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Background Rarely do today’s accidents occur for causes never experienced before –Most accidents involve circumstances similar, if not identical to previous accidents or incidents

19. Lessons Learned From Aviation Accidents 19 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Background Timely and appropriate accident precursor recognition can aid in accident prevention –Those involved in the safety delivery process are now able to gain knowledge of accident causes

20. Lessons Learned From Aviation Accidents 20 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Background Strategic removal of one of the key factors can break the accident chain before all the factors “line up” –Effective intervention begins with knowledge –Training of these factors is now possible

21. Lessons Learned From Aviation Accidents 21 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Plans 200720082009 10 accidents30 accidents50 accidents + Accidents Library Total Content PrototypeLibrary ReleaseOngoing

22. Lessons Learned From Aviation Accidents 22 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Summary A web-based Accident Library is now available to enhance the safety of an already very safe aviation system –Currently available at: http://accidents-ll.faa.gov/

23. Lessons Learned From Aviation Accidents 23 Federal Aviation Administration World Aviation Training Conference, Orlando, Florida; April 27-29, 2010 Demo of the LL Library We will now review the Lessons Learned web site accident library by connecting with the internet on: –http://accidents-ll.faa.gov