federal aviation administration presented to: the national academy of sciences by: daniel i. cheney,...
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Federal AviationAdministration
Presented to: The National Academy of Sciences
By: Daniel I. Cheney, Manager, Safety Programs
Federal Aviation Administration
Federal AviationAdministrationLessons Learned
From Aviation Accidents
Creation of a Web-Based Knowledge System
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National Academy of Sciences
Washington, D.C.; April 18-19, 2011
Background
During the 1990’s and early 2000’s, several major airplane accidents occurred which exposed errors in:
– Airplane design
– Airline operations
– Maintenance programs
and the processes linking them
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National Academy of Sciences
Washington, D.C.; April 18-19, 2011
These accidents included:
– Trans World Airways Flight 800– Swissair Flight 111– American Eagle Flight 4184 – Alaska Airlines Flight 261
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Washington, D.C.; April 18-19, 2011
TWA Flight 800
747 crash off the coast of Long Island, NY– Center fuel tank exploded in flight
• Flawed assumptions regarding fuel tank components
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National Academy of Sciences
Washington, D.C.; April 18-19, 2011
Swissair Flight 111
MD-11 crash off the coast of Nova Scotia
– Electrical Arc resulted in cabin insulation material that burned aggressively
• Flawed assumptions regarding burn characteristics
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Washington, D.C.; April 18-19, 2011
Alaska Flight 261
MD-80 crash off the coast of California
– Loss of control resulting from failure of horizontal stabilizer trim jackscrew
• Inadequate lubrication
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American Eagle Flight 4184
ATR 72 crash near Roselawn, Indiana
– Ice contaminated wing surface and loss of airplane control
• Ice built up on unexpected areas of wing
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National Academy of Sciences
Washington, D.C.; April 18-19, 2011
Costly lessons from these and many other major accidents were being lost by the passage of time
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National Academy of Sciences
Washington, D.C.; April 18-19, 2011
Accident Awareness
• The FAA identified lack of accident knowledge as key factor in several major accidents
• Awareness of specific accidents not widespread throughout aviation community
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National Academy of Sciences
Washington, D.C.; April 18-19, 2011
“Those who cannot remember the past are condemned to repeat it.”
George SantayanaProfessor of Philosophy
Harvard UniversityThe Life of Reason, Volume I
1905
Nearly all large transport accidents are enormous human tragedies.
• A second tragedy is to not learn from them.
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Washington, D.C.; April 18-19, 2011
No Aviation-wide accident LL resource was available
• Fear of negative publicity
• Lengthy investigation/resolution
• Continual workforce turnover
• IT tools only recently available
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FAA Initiative
• The FAA has now developed a web based “Lessons Learned from Transport Airplane Accidents” library– Threat based– Search/sort capability
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Washington, D.C.; April 18-19, 2011
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
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Summary
• A web-based Accident Library is now available to enhance the safety of an already very safe international aviation system
– Currently available at: http://accidents-ll.faa.gov/– 57 accident modules; more added each year
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The Lessons Learned web site will now be demonstrated @ accidents-ll.faa.gov/