Canadian Aviation Safety Seminar (CASS 2003)

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Slide 1

Global Aviation Information
Network (gainweb.org)

Christopher A. Hart
Federal Aviation Administration
Assistant Administrator for System Safety

Slide 2

Outline

• Goal: Develop Tools and Processes for Aviation Community to Make Data-Driven Decisions Using Data Beyond Accidents or Incidents
  • Data-Driven Decisions for Safety Management System
• Challenges and Solutions
• Participants
• Significant Immediate Savings
• Applicable to Many Industries – Other Transportation Modes, Health Care, National Security, Others

Slide 3

The Hands-On
“Front Line” Folks:

“We All Knew About
That Problem”

Slide 4

Benefits of Routine FDR Use

Slide 5

Norwegian Rail Experience

 

Slide 6

Current System Data Flow

 

Slide 7

Heinrich Pyramid

 

Slide 8

National Civil Aviation
Review Commission:*

“The aviation community must look deeper than accidents and incidents to identify latent and emerging problems and fix them before a mishap occurs.”

Avoiding Aviation Gridlock & Reducing the Accident Rate, Dec. 1997, p. III-20

* Chair: Hon. Norman Y. Mineta, now Secretary, U.S. Department of Transportation

Slide 9

Common Characteristics

• Inadvertent
• Could Be A Link In An Accident Chain
• Happens Repeatedly

Slide 10

So Should We...

• Regulate More?
• Punish More?
• Increase Training?

OR...
Share
Information to
Fix the System?

Slide 11

Fix the Person or the System?

Is the Person Clumsy?

Or Is the Problem . . .

The Step???

Slide 12

GAIN is:

• A network – NOT A BIG CENTRAL DATABASE
• Privately owned and operated
• An international cooperative effort
• Voluntary

Slide 13

Former FAA Administrator Jane Garvey:

“GAIN is one of our best hopes for enhancing aviation safety in the next century.”

GAIN III World Conference
November 1998

Slide 14

Information: The Fuel for Our Engine

 

Slide 15

Concerns That Discourage
Collection and Analysis

• Public Disclosure
• Job Sanctions and/or Enforcement
• Criminal Sanctions
• Civil Litigation

Slide 16

Addressing Legal Concerns

• Public Disclosure
  • Addressing Legal Concerns
  • 1996 FAA Reauthorization
  • Part 193
  • Prohibits Public Disclosure of Voluntarily Provided Aviation Safety Information
• Enforcement
  • Some Began Collecting and Analyzing Information Without Protection From Enforcement
  • FAA FOQA Policy Statement, 1998
  • FOQA Rule, 2001, A Foundation for GAIN

Slide 17

Shifting the Paradigm

How It Is Now . . . You are highly trained and If you did as trained, you would not make mistakes Humans make mistakes so You weren’t careful enough so You should be PUNISHED!

How It Should Be . . . You are human and Humans make mistakes so Let’s also explore why the system allowed, or failed to accommodate, your mistake and Let’s IMPROVE THE SYSTEM!

Slide 18

Legal Concerns (con’t)

• Criminal:
  • Watching Developments Carefully
• Civil Litigation:
  • Evolving From
    
    Concern About Collecting and Analyzing
    
    To
    
    Concern About Not Collecting and Analyzing

Slide 19

International Responses

• ICAO 32nd Assembly, 1998
• Resolution to improve safety through enhanced collection, analysis, and dissemination of safety information
  
  
• ICAO AIG, 1999
• Approved recommendation to Annex 13 that States should establish non-punitive incident reporting systems, promote establishment of safety information sharing networks, and facilitate free exchange of information on potential safety deficiencies

Slide 20

Challenges

Slide 21

Is This Light Random?

 

Slide 22

Accidents Result From a Combination of Events

 

Slide 23

Information Overload

 

Slide 24

GAIN Provides:

Tools and Processes to Help Aviation Community Members Use Their Data Better

Slide 25

Increasing Acceptance

• Domestic
  • FAA Administrator as Luncheon Speaker, GAIN III, 1998
  • FAA/AVR-1 as Luncheon Speaker, GAIN V, 2000
  • Use of Operator’s Flight Safety Handbook (including by AFS)
  • ATA Endorsement, 2002
    
    
• International
  • Participation of ICAO, Governments in GST
  • ICAO Journal, Aviation Safety Letter to States, 2002
  • IATA Participation in Steering Committee
  • Translation of Operator’s Flight Safety Handbook into Japanese, Spanish, and other languages
  • Asia-Pacific Regional Conference sponsored by JCAB, Tokyo, 2002

Slide 26

Industry Taking Charge

First Two GAIN Conferences:

• Sponsored by FAA, UK CAA, Royal Aeronautical Society (UK)

Industry Has Taken the Lead:

• Conference Hosts – Airbus Industrie (twice), Delta Airlines, Air France, United Airlines
• GAIN Steering Committee – Led by Industry
• Working Groups – Mostly Industry

Slide 27

GAIN Organization

Slide 28

Steering Committee

• Airlines
  • jetBlue (Chair)
  • Alaska Airlines
  • American Airlines
  • Middle East Airlines
  • Japan Airlines
  • Air Transport Association
  • Int’l Air Transport Association
  • Regional Airline Association
• Manufacturers
  • Airbus
  • Boeing

• Labor
  • Air Line Pilots Association
  • Int’l Association of Machinists & Aerospace Workers
  • National Air Traffic Controllers Association
• General Aviation
  • National Business Aviation Association
  • Helicopter Association Int’l
• U.S. Military
• Flight Safety Foundation

Slide 29

Working Groups

• Working Group A
  • Aviation Operator Safety Practices
• Working Group B
  • Analytical Methods and Tools
• Working Group C
  • Global Information Sharing Prototypes
• Government Support Team (GST)
  • Several Countries, JAA, European Commission, ICAO
• Working Group E
  • Flight Ops/ATC Ops Safety Information Sharing

Slide 30

GST Members

• Australia
• Canada
• France
• Italy
• Japan
• New Zealand
• United Kingdom
• United States
• European Commission
• International Civil Aviation Organization
• Joint Aviation Authorities
• The Nordic Group (rep. by Sweden)

 

Slide 31

Products Developing

• Operator’s Flight Safety Handbook (WG A)
• Cabin Safety Compendium (WG A)
• Guide to Methods and Tools for Airline Flight Safety Analysis (WG B)
• Two prototype systems for near-real time sharing of airline safety events (WG C), four initial airlines
• List of legal impediments to collecting and sharing safety information, and initial list of solutions to those impediments (GST)
• Thousands distributed and downloaded from the Internet (www.gainweb.org)

Slide 32

Many Have Already Begun The Process

Slide 33

Three Domains For GAIN

 

Slide 34

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Others Who Are Interested

Transportation Department

• Coast Guard, MARAD (IMISS)
• Highway Administration
• Railroad Administration
• Pipeline Safety

Slide 36

Others (con’t)

• Critical Infrastructure Assurance Office (CIAO)
• Nuclear Power
• Chemical Manufacturing
• Public Utilities
• Firefighters
• Health Care Industry

Slide 37

The Health Care Industry

To Err Is Human:
Building a Better Health Care System

“The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.”

Institute of Medicine, Committee on Quality of Health Care in America, 1999

Slide 38

Developing Data Mining Tools:

Defense – $35 Million

CIA – $27 Million

Healthcare – $??

Others?

Slide 39

The Future:

Role of GAIN
In
Security???

Slide 40

Want To Get Involved?

Next GAIN World Conference:
Rome, June 18-19, 2003
Sponsored by

www.gainweb.org