are we safe enough? - streaming.nbaa.orgstreaming.nbaa.org/ebace/slides2007/safety_matthews.pdf ·...

Are We Safe Enough?Are We Safe Enough?Are We Safe Enough?by

Stuart MatthewsFormer President and CEOFlight Safety Foundation

EBACESafety Workshop

Geneva, Switzerland 23rd May 2007

byStuart Matthews

Former President and CEOFlight Safety Foundation

EBACESafety Workshop

Geneva, Switzerland 23rd May 2007

Flying is very safe but, are we safe enough?

Flying is very safe but, are we safe enough?

NO!

We can never be safe enough.

But, we have to balance the risk

NO!

We can never be safe enough.

But, we have to balance the risk

An Important QuestionAn Important QuestionAn Important Question

Hu

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ate

in lo

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per

mill

ion

de

part

ure

s 5.64

2.16 1.47 1.29 0.890 . 0 0

2 . 0 0

4 . 0 0

6 . 0 0

8 . 0 0

10 . 0 0

60's 70's 80's 90's 2000's

Source: Boeing, AvSoft

Western Built Commercial Jets (>60,000 lbs)

Accident rates 1960 thru 2005Accident rates 1960 thru 2005

Flying Has Become Much SaferFlying Has Become Much SaferFlying Has Become Much Safer

Just How Safe is Flying?Just How Safe is Flying?Just How Safe is Flying?

Rates1947 9 million pax 1 : 15,000

600 fatalities2002 – 6 2,500 million pax 1 : 5,000,000

500 fatalities + 333

1996 16 million flights 1 : 12,3001,300 fatalities

2006 25 million flights 1 : 33,600

745 fatalities + 2.70

Rates1947 9 million pax 1 : 15,000

600 fatalities2002 – 6 2,500 million pax 1 : 5,000,000

500 fatalities + 333

1996 16 million flights 1 : 12,3001,300 fatalities

2006 25 million flights 1 : 33,600

745 fatalities + 2.70

Commercial Aviation FactCommercial Aviation FactCommercial Aviation Fact

Worldwide :-- 25 million airline flights per year- about 15 fatal accidents- accident rate about 0.6 per million flights

In the U.S.A. :-- 12 million airline flights per year- typically about 3 fatal accidents- accident rate about 0.22 per million flights



Aviation is probably the safest mode of mass transportation


In only in Europe or North Americait would be twice as long

In only in Europe or North Americait would be twice as long

The Risk of Commercial FlyingThe Risk of Commercial FlyingThe Risk of Commercial Flying

Statistics0.60 accidents per million airplane flights

= 1 accident per 1.7 million flights

Statistics0.60 accidents per million airplane flights

= 1 accident per 1.7 million flights

If you take a flight every single day it will be over 4,500 years before

you are involved in an airplane accident

If you take a flight every single day it will be over 4,500 years before

you are involved in an airplane accident

Flying is very safeFlying is very safe

Flying does have risks buthow does it compare

with other risks?

Flying does have risks butFlying does have risks buthow does it compare how does it compare

with other risks?with other risks?

Commercial FlyingCommercial FlyingCommercial Flying

As many people are killed on our roads

every day

as die in commercial aviation accidents

every year

43,000 people die on roads in USA

As many people are killed on our roads

every day

as die in commercial aviation accidents

every year

43,000 people die on roads in USA

The Awful TruthThe Awful TruthThe Awful Truth

Another Awful TruthAnother Awful TruthAnother Awful Truth

In the USAover 90,000 people die every year

as a result of medical mistakes

In the USAover 90,000 people die every year

as a result of medical mistakes

That’s 250 every day!That’s 250 every day!

What Has Made Aviation So Safe?

What Has Made Aviation What Has Made Aviation So Safe?So Safe?

Airbus A 330 Cockpit

Constellation cockpitConstellation cockpit

This is true for both commercial and corporate

airplanes

This is true for both commercial and corporate

airplanes

New Generation Aircraft are SaferNew Generation Aircraft are SaferNew Generation Aircraft are Safer

c

6868

TrainingTrainingTraining

Use of flight simulatorsUse of flight simulators

Head Up Display (HUD)Head Up Display (HUD)

TAWSTAWSEFBEFB

TCASTCAS

Technological ImprovementsTechnological ImprovementsTechnological Improvements

If Flying is Safe EnoughDo We Need To Improve It?

If Flying is Safe EnoughDo We Need To Improve It?

• Flying today is incredibly safe, but it is safe because of all the defenses

• We must not relax our defenses or safety will deteriorate.

• We must strive not only to keep it safe but also to make it even safer.

• Flying today is incredibly safe, but it is safe because of all the defenses

• We must not relax our defenses or safety will deteriorate.

• We must strive not only to keep it safe but also to make it even safer.

YES!YES!

BUT HOW?BUT HOW?

What Are the Main Problems?What Are the Main Problems?What Are the Main Problems?

Commercial aviationCommercial aviationCommercial aviation

Accident RecordAccident RecordAccident RecordCommercial Aircraft

Year 2004 2005 2006 Total

Accidents 13 16 11 40

Fatalities 283 788 745 1816

ALA 4 10 6 20

CFIT 0 5 1 6

LOC 1 3 3 7

Commercial Aircraft

Year 2004 2005 2006 Total


Fatalities 283 788 745 1816

ALA 4 10 6 20

CFIT 0 5 1 6

LOC 1 3 3 7

Accident RecordAccident RecordAccident RecordCommercial Aircraft

Year 2004 2005 2006 Total


Fatalities 283 788 745 1816

ALA 4 10 6 20 (50%)

CFIT 0 5 1 6 (15%)

LOC 1 3 3 7

Commercial Aircraft

Year 2004 2005 2006 Total


Fatalities 283 788 745 1816

ALA 4 10 6 20 (50%)

CFIT 0 5 1 6 (15%)

LOC 1 3 3 7

What Are the Main Problems?What Are the Main Problems?What Are the Main Problems?

Corporate aviationCorporate aviationCorporate aviation

Total FatalTotal Fatal

ALA 97 36ALA 97 36

CFIT 40 26CFIT 40 26

Accidents 195 54Accidents 195 54

Accident RecordAccident RecordAccident RecordBusiness Jet Aircraft 1991 - 2000

Total FatalTotal Fatal

ALA 97 (50%) 36 (66%)ALA 97 (50%) 36 (66%)

CFIT 40 (21 %) 26 (48%)CFIT 40 (21 %) 26 (48%)

Accidents 195 54Accidents 195 54

Accident RecordAccident RecordAccident RecordBusiness Jet Aircraft 1991 - 2000

Accident Phases of Flight1991 - 2002

Accident Phases of FlightAccident Phases of Flight1991 1991 -- 20022002

0 20 40 60 80 100

Ground

Takeoff

Climb

Cruise

Descent

Approach

Landing

Go-Around

Non-FatalFatal

0 10 20 30 40 50 60

Runway Excursion

CFIT

Undershoot

Loss of Control

Hard Landing

Gear-Up

Other

Non-FatalFatal

Types of Approach and Landing Accidents

1991 – 2002

Types of Types of Approach and Landing AccidentsApproach and Landing Accidents

1991 1991 –– 20022002

Reducing Approach and Landing Accidents

Reducing Approach and Reducing Approach and Landing Accidents Landing Accidents

Aviation’s biggest challenge

FSF’s ALAR Toolkit can help!

Aviation’s biggest challenge

FSF’s ALAR Toolkit can help!

Human Factors AreAnother Problem

Human Factors AreHuman Factors AreAnother ProblemAnother Problem

Human error contributes to over 85% of all accidents.

People make inadvertent mistakes!

Not just in aviation.Any accident; any time; anywhere

Human error contributes to over 85% of all accidents.

People make inadvertent mistakes!

Not just in aviation.Any accident; any time; anywhere

Human FactorsHuman FactorsHuman Factors

Inadvertent human error is quite normal behaviourInadvertent human error is quite normal behaviour

• Flight crews• Ground crew• ATC• Designers• Manufacturers• Regulators• You • Me

• Flight crews• Ground crew• ATC• Designers• Manufacturers• Regulators• You • Me

Everyone makes inadvertentmistakes

Everyone makes inadvertentmistakes

Who makes mistakes?Who makes mistakes?Human FactorsHuman FactorsHuman Factors

Dealing With Human ErrorDealing With Human ErrorDealing With Human Error

Dutch Aerospace Laboratory Study

Dutch Aerospace Laboratory Dutch Aerospace Laboratory StudyStudy

Factors in aircraft accidents 1970-1997Factors in aircraft accidents 1970-1997

5%5%

11%11%

12%12%

15%15%

35%35%

42%42%

69%69%

ATCATC

MaintenanceMaintenance

AerodromeAerodrome

PowerplantPowerplant

EnvironmentEnvironment

AircraftAircraft

CrewCrew

ALAR Causal FactorsALAR Causal FactorsALAR Causal Factors

0102030405060708090

100

Lack

of

posi

tion

awar

enes

s

Lack

of

posi

tion

awar

enes

s

Failu

re C

RM

-cr

oss

chec

k

Failu

re C

RM

-cr

oss

chec

k

Proc

edur

aler

rors

Proc

edur

aler

rors

Poor

judg

emen

t/ai

rman

ship

Poor

judg

emen

t/ai

rman

ship

Occ

urr

ence

s%

Occ

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ence

s%

Flig

ht h

andl

ing

Flig

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andl

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The Human Factor The Human Factor The Human Factor

We know the problem is

Human Error

We know the problem is

Human Error

The challenge is how to

deal with it

The challenge is how to

deal with it

Through Education and Awareness:

- CRM

- TEM

- Fatigue/Alertness Management

- Risk Management

- Decision Making

- Lessons Learned from Accidents

Through Education and Awareness:

- CRM

- TEM

- Fatigue/Alertness Management

- Risk Management

- Decision Making

- Lessons Learned from Accidents

Dealing With Human FactorsDealing With Human FactorsDealing With Human Factors

Through Technology:

- FOQA

- EMAS

- TCAS

- MSAW

- TAWS

Through Technology:

- FOQA

- EMAS

- TCAS

- MSAW

- TAWS


Through Other Tools:

- SOPs

- Culture Surveys

- A “Just Culture”

Through Other Tools:

- SOPs

- Culture Surveys

- A “Just Culture”


Elimination of Human ErrorElimination of Human ErrorElimination of Human Error

Unlikely.

But further reductions are possibleand necessary

Unlikely.

But further reductions are possibleand necessary

but it can never be low enoughbut it can never be low enoughbut it can never be low enough

We can and must make flying even safer !

We can and must We can and must make flying even safer !make flying even safer !

Flying Is A Very Low RiskFlying Is A Very Low Risk

Committed to the continuous improvement of aviation safety since 1947

Committed to the continuous improvement Committed to the continuous improvement of aviation safety since 1947of aviation safety since 1947

Flight Safety FoundationFlight Safety FoundationFlight Safety Foundation

Things You Should KnowThings You Should KnowThings You Should Know

Some facts FSF has learned that might be useful

to you

Some facts FSF has learned that might be useful

to you

RunwayRunway

Precision Approach

Precision Approach

Step-d

own Approach

Step-d

own Approach

A constant angle precision approach:Five times less risk than anon-precision approach

A constant angle precision approach:Five times less risk than anon-precision approach

6464


Approaching to landApproaching to land


• High terrain is not a prerequisite for CFIT• High terrain is not a prerequisite for CFIT

CFITCFIT

0

20

40

60

80

100

Acc

iden

ts %

Acc

iden

ts %

Approach and Landing AccidentsApproach and Landing Accidents


Nogo-around

Nogo-around

Go-aroundGo-around

If the approach is not right,make a go-around!

If the approach is not right,make a go-around!

Flying pilot adherence to procedureFlying pilot adherence to procedureOther operational proceduralOther operational procedural

considerationsconsiderationsNonNon--flying pilot adherence toflying pilot adherence to

procedureprocedureEmbedded piloting skillsEmbedded piloting skills

Design improvementDesign improvementCaptain or instructor pilot exerciseCaptain or instructor pilot exercise

of authorityof authorityMaintenance or inspection actionMaintenance or inspection action

Approach path stabilityApproach path stabilityATC system performanceATC system performanceFirst officerFirst officer’’s crosss cross--checkcheck

performance as nonperformance as non--flying pilotflying pilot

GoGo--around decisionaround decision

Runway hazards eliminatedRunway hazards eliminated

Percentage of AccidentsPercentage of Accidents20201010 3030 4040Primary FactorPrimary Factor 5050 6060

Each bar represents the percentage of hull-loss accidents that contained at least one instance of the listed prevention strategy.

138 Accidents 5,686 Fatalities

HullHull--loss Accidents (1982loss Accidents (1982--1991)1991)

Accident Causal FactorsAccident Causal FactorsThings You Should KnowThings You Should KnowThings You Should Know

Adhere strictly to SOPsAdhere strictly to SOPs

Surface contamination equivalent to one grain of salt per square centimetercan reduce lift coefficient by more than

30 per cent

Surface contamination equivalent to one grain of salt per square centimetercan reduce lift coefficient by more than

30 per cent

Ground IcingGround Icing


Accident rate is 8 times higher than for passenger operations

Accident rate is 8 times higher than for passenger operations


Freight and repositioning flightsFreight and repositioning flights

Flight Safety FoundationFlight Safety FoundationFlight Safety Foundation

What is it? What is it? What is it?

• Independent• Non political• Not-for-profit• International

• Independent• Non political• Not-for-profit• International

Founded in 1947,FSF’s sole interest is the continuous

improvement of aviation safety

What is the Flight Safety Foundation ?

What is the Flight Safety What is the Flight Safety Foundation ?Foundation ?

Flight Safety Foundation’s Goal

Flight Safety FoundationFlight Safety Foundation’’s s GoalGoal

To Make Flying Safer by Reducing the Risk of an

Accident


Accident

Over 1000 Members in 150 CountriesOver 1000 Members in 150 CountriesOver 1000 Members in 150 Countries

Current MembershipCurrent MembershipCurrent Membership

• Airlines (incl. all IATA)• Airframe and engine

manufacturers• Equipment suppliers• Corporate operators• Insurance companies• Helicopter operators

• Airlines (incl. all IATA)• Airframe and engine

manufacturers• Equipment suppliers• Corporate operators• Insurance companies• Helicopter operators

• Military organizations• Regulatory authorities• Air service providers• Airports• Fixed-base operators• Research institutions• Academia

• Military organizations• Regulatory authorities• Air service providers• Airports• Fixed-base operators• Research institutions• Academia

Funded by the aviation industryFunded by the aviation industry

FSF Internet WebsiteFSF Internet WebsiteFSF Internet Website

www.flightsafety.orgwww.flightsafety.org 2424

• More than 17,000 pages

• More than 17,000 pages

• Contains all FSF publications and reports issued inthe last 17 years

• Contains all FSF publications and reports issued inthe last 17 years

• Links to many otheraviation sites

•• Links to many otherLinks to many otheraviation sitesaviation sites

0.00

0.40

0.80

1.20

1.60

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

5 year running average

Major Accident Rate(per million departures)

Source: Ascend

Major Accident RateContinues to ImproveMajor Accident RateMajor Accident Rate

Continues to ImproveContinues to Improve

Acc

iden

t ra

te p

er m

illio

n d

epar

ture

s**

Acc

iden

t ra

te p

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illio

n d

epar

ture

s**

Western-Built Commercial Jets

Flight Safety Foundation’s Goal

Flight Safety FoundationFlight Safety Foundation’’s s GoalGoal


Accident


Accident

Russia (CIS)Russia (CIS)

JapanJapan

TaiwanTaiwan

West AfricaWest Africa

AustraliaAustralia

South Eastern EuropeSouth Eastern Europe

FSFFSF

Independent, but modeled after FSFIndependent, but modeled after FSF

FSF Worldwide ChaptersFSF Worldwide ChaptersFSF Worldwide Chapters

IcelandIceland

North AfricaNorth Africa

• IATA• ERA• ATA• NBAA• IFALPA• ISASI

• IATA• ERA• ATA• NBAA• IFALPA• ISASI

• ICAO• ANAE• SAE• RAeS• IFA• AOPA

• ICAO• ANAE• SAE• RAeS• IFA• AOPA

• and many others• and many others

• ACI• AAAE• ATCA• AAPA• NATA• NLR

• ACI• AAAE• ATCA• AAPA• NATA• NLR

• Worldwide accident investigation community• International regulatory authorities

• Worldwide accident investigation community• International regulatory authorities

• ECAC• CANSO• EAA• UKFSC• IFSC• AIAA

• ECAC• CANSO• EAA• UKFSC• IFSC• AIAA

Cooperative EffortsCooperative EffortsCooperative EffortsFSF has built liaisons and works with many aviation

industry and professional organizations:FSF has built liaisons and works with many aviation

industry and professional organizations:

Air Transport Is Very Safe

Air Transport Is Very Air Transport Is Very SafeSafe

Worldwide Commercial Jet Fleet Accident RateWorldwide Commercial Jet Fleet Accident RateWorldwide Commercial Jet Fleet Accident Rate

0202 04049898 0000

Ten year rolling rateTen year rolling rate

Western-Built Commercial Jets

Accident RecordAccident RecordAccident RecordBusiness Jet Aircraft

Year 2004 2005 2006 Total


Fatalities 19 23 19 61

ALA 4 8 9 21 (66%)

CFIT 3 1 2 6 (19%)

LOC 0 3 0 3

Business Jet Aircraft

Year 2004 2005 2006 Total


Fatalities 19 23 19 61

ALA 4 8 9 21 (66%)

CFIT 3 1 2 6 (19%)

LOC 0 3 0 3

Just How Safe is Flying?Just How Safe is Flying?Just How Safe is Flying?

Annual rates

1947 9 million pax 600 fatalities

2002 – 6 2,500 million pax 500 fatalities

1996 16 million flights 1,300 fatalities

2006 25 million flights 745 fatalities

Annual rates

1947 9 million pax 600 fatalities

2002 – 6 2,500 million pax 500 fatalities

1996 16 million flights 1,300 fatalities

2006 25 million flights 745 fatalities

Commercial Aviation FactCommercial Aviation FactCommercial Aviation Fact







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