HistoryofAviationSafetyManagement.pptxHistory of Aviation Safety Management
First Aircraft Fatality
Sept 17th, 1908
Military demonstration of the Wright Flyer by Orville Wright
Lt. Thomas Selfridge was a passenger
Orville had put on longer props (4 inches longer in diameter) – this was a test flight
End of right prop separated, struck upper wire leading to the rudder, causing rudder to fall over
Lt. Selfridge was killed; Orville seriously injured
Octave Chanute wrote the first “accident report”
Shorter props were re-installed
Army bought plane in 1909
First Report
Obviously reactive
Enduring ideas
Crowd control (everyone kept away)
Preserving the evidence
Evaluating any “clues” in the evidence
Talking to witnesses and survivors
Identification of a “probable cause”
Early Days
No US government regulation of aviation until 1926
Air Commerce Act of 1926
Among other things, “to provide safety through a system of regulation…”
Also granted authority to the Secretary of Air Commerce to, “investigate, record, and make public the cause of accidents in civil air navigation”
Civil Aeronautics Act – 1938 (amended 1940)
Established:
Civil Aeronautics Board – The CAB’s Bureau of Aviation was responsible for aircraft accident investigation
Civil Aeronautics Administration – Responsible for the development and enforcement of aviation regulations (including safety)
Other legislative developments
1958 – Federal Aviation Act
Gave the Federal Aviation Agency the responsibility for promoting the industry, making the rules, and enforcing the rules
1966 – Department of Transportation
In addition to FAA (Renamed the Federal Aviation Administration) the National Transportation Safety Board (NTSB) was formed. The NTSB became fully independent in 1975, and is the entity responsible for the conduct of all transportation accidents
Regardless of the organization responsible, “safety” to this point was improved upon by investigating aircraft accidents and incidents, and then making changes to whatever problem was found
TWA Flight 514
In 1974, TWA 514 crashed on an approach to Dulles Airport (had originally been scheduled to land at National, but had to divert due to high winds)
Received a clearance for a VOR/DME approach at Dulles 44 miles from the airport, descended below minimums, and crashed into terrain
Issues:
1) FAA (ATC) knew there was confusion regarding their terminology
2) Problem with giving an approach clearance when aircraft was on an unpublished route without clearly defined minimum altitudes
3) Inadequate depictions of altitude restrictions on the profile view of the approach chart
TWA Flight 514
Saddest point – A United Airlines flight, about 6 weeks before, had the same issue, caught it in time, and had submitted a report to the United company safety awareness program, resulting in other United pilots becoming aware of the issue
Of course, there was no mechanism for TWA pilots to become aware of this information
Aviation Safety Reporting System (ASRS)
NTSB recommended the FAA set up an industry-wide reporting program
Interestingly enough, this was already in the works, BUT
After years of adversarial dealings with the FAA, pilots were very skeptical of submitting any report that could be used against them in a certificate action
In 1976, the FAA entered into a Memorandum of Understanding with NASA, making NASA the clearinghouse for collecting, de-identifying, analyzing, and reporting in aggregate data fed into the Aviation Safety Reporting System
This was the first attempt at a proactive approach to safety in the aviation industry
This has been somewhat effective, but really had more impact on general aviation than air carriers, especially for the first 20-25 years
1995 Aviation Safety Summit
Due to a number of accidents in the preceding year, the FAA called a meeting with representatives from all aspects of industry
A total of 540 issues were identified by these attendees, over a two day period
The FAA developed an Aviation Safety Action Plan based on the outcomes of the meeting
Many new initiatives arose from the Summit, especially voluntary safety programs at air carriers
AQP, ASAP, FOQA, IEP, LOSA
The common thread was a move toward proactive programs
A Broader Look:
The technical era — beginning of flight throught the late 1960s. Safety issues were initially related to technical factors and technological failures. By the 1950s, technology improvements led to a gradual decline in the frequency of accidents, and safety processes were broadened to encompass regulatory compliance and oversight.
The human factors era — early 1970s until the mid-1990s. Aviation became safer from a technical standpoint, and the focus of safety moved to include human factors issues. However, human performance continued to be cited as a recurring factor in accidents. The human factors approach focused on the individual, without considering the operational and organizational context. In the early 1990s that it was acknowledged that individuals operate in a complex environment, which includes a number of factors that affect behavior.
A Broader View
The organizational era — mid-1990s to present. Safety starts to be looked at from a system perspective, encompassing organizational factors as well as human and technical factors. The impact of organizational culture and policies on the effectiveness of safety begins to be examined.
Traditional data collection and analysis efforts (data collected through investigation of accidents and serious incidents) begins to be supplemented by a proactive approach to safety. This is based on routine collection and analysis of data using proactive as well as reactive methodologies to monitor known safety risks and detect emerging safety issues.
2006 – Real SMS beginnings…
ICAO began requiring member states' operators to develop and implement SMS for greater safety
Australia and Canada immediately jumped on board and implemented rapidly
While the FAA did some pilot programs with Part 139 Airports and published an initial AC on the topic of SMS between 2010-2015…
…it took US until 2015 for the FAA to pass 14 CFR Part 5, which required air carriers to have an SMS in place by 2018.
We’ll come back to the regulatory development later on
For now, we’re going to stop and learn a little bit more about the “behavioral” versus “organizational” error, and review the James Reason Swiss Cheese Model
Behavioral errors (active failures)
Human failures (often called active failures) at the operational level which breach the system’s inherent safety defenses
“Pilot error”, “controller error”, “maintenance error”, etc.
Often the last step in the error chain, and if you don’t look carefully at an accident sequence, the fault could seem to lie with the individual
Examples…
Organizational Errors (Latent Errors)
This is error-causing conditions that exist in the aviation system well before an accident is experienced. Initially, these conditions are not seen as harmful. These conditions are generally created by people far removed in time and space from the event.
Latent conditions may include lack of safety culture; poor equipment or procedural design; conflicting organizational goals; defective organizational systems or management decisions.
Aviation accidents are almost always part of an “error chain”
Typically, 4-7 “errors” lead to an accident
A more robust way of thinking of this is James Reason’s Swiss Cheese Model
James Reason’s Swiss Cheese Model
An easy (non-aviation) example
