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IMPROVING GENERAL AVIATION SAFETY AND FOSTERING INDUSTRY GROWTH . GA Accident Statistics and Future Mitigation Work. Meeting Safety Challenges through Pilot Training Reform. SAFE Pilot Training Reform Symposium. Corey Stephens Office of Accident Investigation and Prevention.

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slide1

IMPROVING

GENERAL AVIATION SAFETY

AND

FOSTERING INDUSTRY GROWTH

ga accident statistics and future mitigation work

GA Accident Statistics and Future Mitigation Work

Meeting Safety Challenges through Pilot Training Reform

SAFE Pilot Training Reform Symposium

Corey StephensOffice of Accident Investigation and Prevention

May 4th, 2011

ga metrics
GA Metrics

FY not CY, but can be converted

N-registered aircraft only

  • Overall GA Fatal Accidents per 100,000 hrs
    • Everything not 121 or commuter
  • Alaska Fatal and Serious Injury Accidents per 100,000 hrs
    • Everything not 121, includes commuter
  • Experimental Aircraft Fatal Accidents
    • Interim until we can establish a rate-based metric and goal
general aviation fatal accidents 2001 2010 by top 10 cictt occurrence category
General Aviation Fatal Accidents 2001-2010 by Top 10 CICTT Occurrence Category

Note: Homebuilt category incorporates all homebuilt aircraft and is not limited to experimental and LSA.

how to act on this information
How to Act on this Information

We have identified types of accidents

Now we determine why the accidents are occurring

ga joint steering committee
GA Joint Steering Committee
  • Evolve GA JSC to a CAST like Model
    • Voluntary commitments
    • Consensus decision-making
    • Data driven risk management
    • Implementation-focused
  • The GA JSC is a means to…

Focus Limited Government/Industry Resources on Data Driven Risks and Solutions

slide11

General Aviation Joint Steering Committee (GAJSC)

Steering Committee

Co-Chairs: Bruce Landsberg (ASI)

Tony Fazio (FAA/AVP)

Government - FAA (AFS, AIR, ATO & ARP)

- NASA (Research)

- NWS

Industry - AOPA, EAA, GAMA, NATA, NBAA, LAMA, Insurance

  • Strategic guidance
  • Management/Approval of Safety Plan
  • Provide direction
  • Membership Outreach
  • Provides linkage to ASIAS
  • Identify future areas of study/risk
  • Charter safety studies
  • Provide guidance and direction
  • Draw data from various areas
  • Develop a prioritized Safety Plan
  • Develop metrics to measure effectiveness of safety solutions

Safety Analysis Team (SAT)

Co-chairs: Corey Stephens (FAA)

Jens Hennig(GAMA)

Members: FAA, NTSB, AOPA, EAA, FSF, CGAR,

FAST, NAFI, LAMA, Insurance, SAFE, etc.

Working Groups (WGs)

(To include SMEs from various general aviation segments, depending on study)

  • Data analyses
  • Safety enhancement / mitigation development
what is the cast model
What is the CAST model?
  • Work began in 1997 after two significant accidents in 1996 (TWA 800 & ValueJet 592)
  • CAST focus was set by:
    • White House Commission on Aviation Safety
    • The National Civil Aviation Review Commission (NCARC)
  • Opportunity for industry and government to focus resources on one primary aviation safety initiative
ga jsc working group process
GA JSC Working Group Process
  • WGs to be formed based on risk (example: LOC)
  • Broad-based teams (30-40 specialists /team)
  • Teams can be divided by aircraft or operation type (example: turbine, reciprocating and homebuilt reciprocating/turbine)
  • Detailed event sequence - problem identification from US accidents and incidents
ga jsc working group process1
GA JSC Working Group Process
  • WGs to develop mitigations based on problems found and build Detailed Implementations Plans (DIPs)
    • DIPs will describe each mitigation and explain steps to implementation
    • Groups are identified for leadership and metrics are developed
    • DIPs then go to the SAT for resource/benefit evaluation
ga jsc sat process
GA JSC SAT Process
  • SAT identifies the most effective solutions derived from all accident categories
    • Considers effectiveness vs. resources
    • Tests solutions against fatal accidents
  • Creates draft master strategic safety plan
  • Plan is submitted to GA JSC for approval
ga jsc sat process1
GA JSC SAT Process
  • Once plan is approved, industry and government begin implementation
  • SAT will track implementation schedules and levels (are mitigations on time and at levels we were expecting)
  • SAT will work to track effectiveness of the mitigations in place
  • SAT will identify and recommend areas for future study/mitigation
summary ga jsc sat wgs moving forward
Summary: GA JSC, SAT & WGs Moving Forward
  • 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
  • Full implementation will require a coordinated effort between industry and government
  • The GA JSC is moving forward to meet the challenge
our unique perspective
Our Unique Perspective
  • All the losses
  • Direct Insurer
  • Established Relationship
personal background
Personal Background
  • Then
  • Now

Friday Meetings

real costs
Real Costs
  • Human
  • Financial
  • Public Relations
    • New Rules
    • Unintended

Consequences

why aren t we solving the problem
Why Aren’t We Solving the Problem?
  • Regulations?
  • Technology?
  • Training?
it s not so much what pilots know that gets them in trouble
“It’s not so much what pilots know that gets them in trouble –”
  • But What They Care About
the culture of general aviation
The Culture of General Aviation
  • More Ethical than Technical
  • Matters of the Heart, not Just the Head
    • We Pilots Aren’t Good at This
  • A More Professional Attitude
    • Accepting that there is risk
    • Being “grown ups”
      • Accepting Responsibility for Managing the Risks
questions 877 359 2836 avemco @ ave com

Questions?877 359 [email protected]

411 Aviation Way, Suite 100, Frederick, Maryland 21701

what we can learn from professional ethics bill rhodes ph d aerworthy consulting llc
WHAT WE CAN LEARN FROM PROFESSIONAL ETHICS

Bill Rhodes, Ph.D.

Aerworthy Consulting, LLC

acknowledgments
Acknowledgments
  • Portions of the research underlying this presentation were conducted under a Cooperative Research and Development Agreement with the Department of Philosophy, USAF Academy
  • Avemco is AERI’s charter sponsor
who is this guy
Who is this guy?
  • Former USAFA prof
  • Professional identity formation
  • Author in applied ethics
  • Private pilot/AC owner
  • AERI lead investigator
what i ll suggest
What I’ll Suggest
  • Hardware/software innovation
  • Improved technical skills, new rules etc.
  • …Address some pilot-induced mishaps
  • Professional ethics will address all
  • …And it’s not all that hard to do
ethics why
Ethics: Why?
  • Mishap pilots
    • Pass the tests (know the rules)
    • But not the most relevant tests
    • Are products of a “perfect design”
  • Notice subcultures of aviators
    • Where would you like your kid to learn airmanship
    • Why?
ethics
Ethics???
  • I AM NOT SUGGESTING
    • Additional regulation
    • Invasion of privacy
    • “Compliance” with a list of constraints
  • I AM SUGGESTING
    • Humble regard for aviation and the stakes
    • Determining selves to be trustworthy Airmen
    • Fostering the same in our community
professional ethics
Professional ethics
  • Do’s and Don’ts can only get us so far
  • Education in addition to instruction: limit
  • Professional identity formation
  • Professionally-minded don’t need to be told

Judgment: figure out what’s best

Self-mastery: do it (short run)

Self-determination: habitually (long run)

professionalism
Professionalism???
  • I AM NOT SUGGESTING
    • A matter of jurisdiction
    • Or a matter of being paid
  • I AM SUGGESTING
    • Committing to functional identity—who pilot is
    • Able to reach goals reliably—what pilot does
    • Worthy of trust—OTG and OK
developing professionals
DEVELOPING PROFESSIONALS
  • Self-Mastery (short term)
  • …in today’s context

Who pilot is

(dispositions)

What pilot does

Outcome

(OTG and OK

Plus?)

  • Self-determination (long term)
  • …in cultural context
where to begin
Where to begin
  • Forthright confrontation of problem
  • The culture (enemy is us)
  • Messages
    • What is admired
    • What is disdained—even mocked
  • Social norms are powerful
  • But what messages should be sent?
aviation insiders know
Aviation Insiders Know
  • What sort of pilot is scary?
  • What sort of pilot do you trust?
  • SME interviews: Insurance underwriters, investigators, CFI’s, and examiners convergent
  • Draft concepts are compiled
  • One example: professional detachment
professionalism at home
Professionalism at home
  • Quality matters
    • Make no apologies for education and devotion
    • Admit that current cultural values
    • …may differ from professional imperatives
    • And select the professional imperatives
  • Reform demands seeing past “our way” to what works
there has been virtually no change
There has been virtually no change
  • In the general aviation accident rate for the last 20 years
if we keep on doing what we have been doing
If we keep on doing what we have been doing
  • We are going to keep on getting what we’ve been getting
    • Even if we do it better
solutions to problems
Solutions to problems
  • Are not obvious until after they are solved
3 counter intuitive solutions
3 Counter-intuitive solutions
  • Ban low airspeed “phobia”
  • Ban the “big lie”
  • Ban “safety”
ban low airspeed phobia
Ban low airspeed phobia
  • One-third of all fatalities come from stalls/spins while maneuvering
  • So therefore we should tell pilots to slow down when maneuvering
most people think
Most people think
  • Stall/spin accidents come from flying too slow
let s consider
Let’s consider
  • That they may be caused by flying too fast
an imminent stall caused by flying too slow
An imminent stall caused by flying too slow

Is easy to recognize

  • The controls get mushy
  • The air noise decreases
  • The airplane buffets well in advance
a stall caused by an increase in load factor
A stall caused by an increase in load factor

Gives much less warning

  • The controls aren’t mushy
  • The air noise is still at the usual level
  • The buffet gives little if any warning
flight instructors are afraid
Flight instructors are afraid

Their students will stall

  • Therefore they have them fly too fast
the result is
The result is
  • Huge patterns
  • Steeper banks
  • More load factor
ban the big lie
Ban the “big lie”

It will

  • Increase sales
  • Strengthen the industry—
    • Accidents are bad for the industry
the big lie
The BIG LIE
  • “The most dangerous part of the flight is the trip to the airport”
the truth
The truth
  • It is irresponsible and intellectually dishonest to characterize aviation as an entirely safe activity
we want pilots to feel
We want pilots to feel
  • Safe
  • Comfortable
we tell pilots
We tell pilots
  • Flying is “safe”
85 of accidents
85% of accidents
  • Are caused by pilots
pilots
Pilots
  • Grossly underestimate risk
vfr in bad weather
VFR in bad weather
  • Low time pilots are more comfortable with it than high time pilots
  • Non-IFR pilots are more comfortable with it than IFR-rated pilots
aviation centers around the element of trust
Aviation centers around the element of trust
  • We must be honest in everything we do
ban safety
Ban “safety”
  • It is not a useful word in general aviation
we use the word safety
We use the word “safety”

Without meaning what we say

  • “Safety is the number one priority”
  • ‘We will not compromise with safety”
  • “We will only accept one level of safety”
we use safe and safety
We use “safe” and “safety”

As an expression of goodwill

  • “Have a safe trip”
  • It is a social courtesy like saying
    • “Have a good day”
the word safety
The word “safety”
  • Is not specific enough to be helpful
  • Gives me no guidance on what I should do
what we should be saying instead is
What we should be saying instead is
  • Identify and
  • Manage
    • The risks of your flight
we can still say have a safe trip
We can still say “Have a safe trip”
  • We just need to recognize that it is lousy professional advice
  • Instead it is merely a statement of goodwill
use scenario based training to create pilots who
Use scenario-based training to create pilots who
  • Are good risk managers, and
  • Truly ready to be pilot-in command
  • Become safe, capable pilots, and
  • Long-term members of the aviation community
3 counter intuitive solutions1
3 Counter-intuitive solutions
  • Ban low airspeed “phobia”
  • Ban the “big lie”
  • Ban “safety”
slide75

USING HIGHER ORDER PILOT SKILLS

TO REDUCE FATAL ACCIDENT RISKS

HOW TO TEACH (OR AFFECT)

HIGHER ORDER THINKING TO REDUCE RISK

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide76

Aircraft Accident BriefCrash During Turn ManeuverCirrus SR-20, N929CD Manhattan, New York CityOctober 11, 2006

CAN IT BE TAUGHT?

“Contrary to popular opinion, good judgment can be taught.” …“The effectiveness of [ADM training] has been validated in six independent studies ….

The differences were statistically significant and ranged from about 10 to 50 percent fewer judgment errors.”

… plea to the aviation community and/or aviation researchers is to work diligently to

look for new and effective ways to teach better judgment and decision making…..

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide77

HOWCAN IT BE TAUGHT?

LEARNED? MEASURED?

Experience (“License to Learn”)

Scenario Based Training

Hangar Flying  What is learned? Can it be formalized?

Simulation  Realistic Flying Scenarios

Evaluation  How To Quantify and Qualify?

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide78
SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011
slide79

P

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide80

CASE STUDIES

NTSB PROBABLE CAUSE

The pilots\' inadequate planning, judgment, and airmanship in the performance of a 180º turn maneuver inside of a limited turning space.

VS

THE CASE STUDY

*Low time pilot— had CFI come along

*Expected CFI to “protect him?”

*Expected CFI to know “how to make this flight?”

*CFI “new” to aircraft

*CFI from CA, “new” to airspace?

*CFI “pressured” (to impress?) by famous client?

*Lack of attention to the wind?

*Two Pilot Distraction?

*Fear of busting Class B airspace?

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide81

P

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide82

SIM “SCENARIOS”

--utilizing NTSB reports

INSTRUMENT PROCEDURES

STUDENT/VFR PILOTS 

ENGINE FAILURE SHORTLY AFTER TAKEOFF

MANEUVERING ACCIDENTS

eg. Cory Lidle flight

VFR  IMC

--utilizing NTSB scenarios

--eg. JFK Jr. flight

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide83

P

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide84

OBSTACLES & CHALLENGES

CAN ALL FLIGHT EDUCATORS TEACH IT?

WILL ALL FLIGHT EDUCATORS TEACH IT?

VALUE PROPOSITION– CFI ? PILOT?

BUILDING FLIGHT TIME VS…..

INCENTIVES?

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

slide85

USING  TEACHING

HIGHER ORDER PILOT SKILLS

TO REDUCE FATAL ACCIDENT RISKS

1.CASE STUDY METHODOLOGY

2.SIMULATORS & SIMULATION

3.INSTITUTIONALIZE UTILIZATION

SAFE Pilot Training Reform SSymposium Carol R. Jensen, PhD May 4, 2011

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