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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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Improving general aviation safety and fostering industry growth

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 Occurrence Category

We have identified types of accidents

Now we determine why the accidents are occurring


Ga joint steering committee
GA Joint Steering Committee Occurrence Category

  • 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


Improving general aviation safety and fostering industry growth

General Aviation Joint Steering Committee (GAJSC) Occurrence Category

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? Occurrence Category

  • 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 Occurrence Category

  • 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 Occurrence Category

  • 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 Occurrence Category

  • 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 Occurrence Category

  • 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, Occurrence CategorySAT & 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


Risk mis management as the root cause of most fatal accidents

Risk Occurrence CategoryMismanagement as the Root Cause of Most Fatal Accidents

presented by: Jim Lauerman, President


Our unique perspective
Our Unique Perspective Occurrence Category

  • All the losses

  • Direct Insurer

  • Established Relationship


Personal background
Personal Background Occurrence Category

  • Then

  • Now

Friday Meetings


Real costs
Real Costs Occurrence Category

  • Human

  • Financial

  • Public Relations

    • New Rules

    • Unintended

      Consequences


Why aren t we solving the problem
Why Aren’t We Solving the Problem? Occurrence Category

  • Regulations?

  • Technology?

  • Training?


It s not so much what pilots know that gets them in trouble
“It’s not so much what pilots Occurrence Categoryknow that gets them in trouble –”

  • But What They Care About


The culture of general aviation
The Culture of General Aviation Occurrence Category

  • 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? Occurrence Category877 359 2836avemco@ave.com

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 Occurrence Category

Bill Rhodes, Ph.D.

Aerworthy Consulting, LLC


Acknowledgments
Acknowledgments Occurrence Category

  • 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? Occurrence Category

  • 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 Occurrence Category

  • 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? Occurrence Category

  • 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??? Occurrence Category

  • 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 Occurrence Category

  • 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??? Occurrence Category

  • 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 Occurrence Category

  • 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 Occurrence Category

  • 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 Occurrence Category

  • 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 Occurrence Category

  • 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


Aerworthy consulting llc may 2011 brhodes@aerworthy com 719 229 7369

Aerworthy Consulting, LLC. Occurrence Category

May, 2011

brhodes@aerworthy.com

(719) 229-7369


Improving general aviation safety and fostering industry growth

IT Occurrence Category’S TIME TO CREATE A CULTURAL SEA-CHANGE IN GENERAL AVIATION


There has been virtually no change
There has been Occurrence Categoryvirtually 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 Occurrence Category

  • We are going to keep on getting what we’ve been getting

    • Even if we do it better


What we have been getting
What we have been getting Occurrence Category

  • Is unacceptable


Solutions to problems
Solutions to problems Occurrence Category

  • Are not obvious until after they are solved


3 counter intuitive solutions
3 Counter-intuitive solutions Occurrence Category

  • Ban low airspeed “phobia”

  • Ban the “big lie”

  • Ban “safety”


Ban low airspeed phobia
Ban low airspeed phobia Occurrence Category

  • 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 Occurrence Category

  • Stall/spin accidents come from flying too slow


Let s consider
Let’s consider Occurrence Category

  • 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 Occurrence Category

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 Occurrence Categoryincrease 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 Occurrence Category

Their students will stall

  • Therefore they have them fly too fast


The result is
The result is Occurrence Category

  • Huge patterns

  • Steeper banks

  • More load factor


Ban the big lie
Ban the “big lie” Occurrence Category

It will

  • Increase sales

  • Strengthen the industry—

    • Accidents are bad for the industry


The big lie
The BIG LIE Occurrence Category

  • “The most dangerous part of the flight is the trip to the airport”


The truth
The truth Occurrence Category

  • It is irresponsible and intellectually dishonest to characterize aviation as an entirely safe activity


We want pilots to feel
We want pilots to feel Occurrence Category

  • Safe

  • Comfortable


We tell pilots
We tell pilots Occurrence Category

  • Flying is “safe”


85 of accidents
85% of accidents Occurrence Category

  • Are caused by pilots


Pilots
Pilots Occurrence Category

  • Grossly underestimate risk


Vfr in bad weather
VFR in bad weather Occurrence Category

  • 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 Occurrence Category

  • We must be honest in everything we do


Ban safety
Ban Occurrence Category“safety”

  • It is not a useful word in general aviation


We use the word safety
We use the word Occurrence Category“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” Occurrence Category

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 Occurrence Category“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 Occurrence Categorysaying instead is

  • Identify and

  • Manage

    • The risks of your flight


We can still say have a safe trip
We can still say Occurrence Category“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 Occurrence Category

  • 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 Occurrence Category

  • Ban low airspeed “phobia”

  • Ban the “big lie”

  • Ban “safety”


Improving general aviation safety and fostering industry growth

USING HIGHER ORDER PILOT SKILLS Occurrence Category

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


Improving general aviation safety and fostering industry growth

Aircraft Accident Brief Occurrence CategoryCrash 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


Improving general aviation safety and fostering industry growth

HOW Occurrence CategoryCAN 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


Improving general aviation safety and fostering industry growth

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


Improving general aviation safety and fostering industry growth

P Carol R. Jensen, PhD May 4, 2011

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


Improving general aviation safety and fostering industry growth

CASE STUDIES Carol R. Jensen, PhD May 4, 2011

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


Improving general aviation safety and fostering industry growth

P Carol R. Jensen, PhD May 4, 2011

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


Improving general aviation safety and fostering industry growth

SIM “SCENARIOS” Carol R. Jensen, PhD May 4, 2011

--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


Improving general aviation safety and fostering industry growth

P Carol R. Jensen, PhD May 4, 2011

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


Improving general aviation safety and fostering industry growth

OBSTACLES Carol R. Jensen, PhD May 4, 2011 & 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


Improving general aviation safety and fostering industry growth

USING Carol R. Jensen, PhD May 4, 2011  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


Improving general aviation safety and fostering industry growth

BREAK Carol R. Jensen, PhD May 4, 2011