National Academies Press: OpenBook
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes. Washington, DC: The National Academies Press. doi: 10.17226/26673.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Committee on Emerging Trends in Aviation Safety Transportation Research Board Emerging Hazards in Commercial Aviation— Report 1 Initial Assessment of Safety Data and Analysis Processes Consensus Study Report

Transportation Research Board Special Report 344 Subscriber Categories: Aviation; safety and human factors Transportation Research Board publications are available by ordering individual publications directly from the TRB Business Office, through the Internet at www.TRB.org or nationalacademies.org/trb, or by annual subscription through organizational or individual affiliation with TRB. Affiliates and library subscribers are eligible for substantial discounts. For further information, contact the Transportation Research Board Business Office, 500 Fifth Street, NW, Washington, DC 20001 (telephone 202-334-3213; fax 202-334-2519; or e-mail TRBsales@nas.edu). Copyright 2022 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved. Printed in the United States of America. This publication was reviewed by a group other than the authors according to the procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the National Academy of Medicine. This study was sponsored by the Federal Aviation Administration. International Standard Book Number-13: 978-0-309-69228-1 International Standard Book Number-10: 0-309-69228-8 Digital Object Identifier: http://doi.org/10.17226/26673 Library of Congress Control Number: 2022946405

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. The Transportation Research Board is one of seven major programs of the National Academies of Sciences, Engineering, and Medicine. The mission of the Transportation Research Board is to provide leadership in transportation improvements and innovation through trusted, timely, impartial, and evidence- based information exchange, research, and advice regarding all modes of transportation. The Board’s varied activities annually engage about 8,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state departments of transportation, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individuals interested in the development of transportation. Learn more about the Transportation Research Board at www.trb.org.

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

v COMMITTEE ON EMERGING TRENDS IN AVIATION SAFETY AMY RUTH PRITCHETT (Chair), The Pennsylvania State University CODY FLEMING, Iowa State University ROBERT J. HANSMAN, JR., Massachusetts Institute of Technology CHRISTOPHER A. HART, Hart Solutions LLP MARGARET T. JENNY, MJENNY STRATEGIES, LLC PAUL McCARTHY, PEEMAC, LLC NADINE B. SARTER, University of Michigan ASHOK N. SRIVASTAVA, Intuit KATHLEEN M. SUTCLIFFE, Johns Hopkins University ALYSON WILSON, North Carolina State University Study Staff LIDA BENINSON, Study Director, Consensus and Advisory Studies, Transportation Research Board STEPHEN GODWIN, Scholar, Consensus and Advisory Studies, Transportation Research Board THOMAS R. MENZIES, JR., Director, Consensus and Advisory Studies, Transportation Research Board ARUL MOZHI, Senior Program Officer, Aeronautics and Space Engineering Board, Division on Engineering and Physical Sciences DANIEL TALMAGE, Program Officer, Board on Human-Systems Integration, Division of Behavioral and Social Sciences and Education CLAUDIA SAULS, Program Coordinator, Consensus and Advisory Studies, Transportation Research Board MICHAEL COVINGTON, Program Assistant, Consensus and Advisory Studies, Transportation Research Board

vii This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: CARLTON CAVES, University of New Mexico KEVIN CONNOR, Conner Innovation Engineering, LLC MARGARET GILLIGAN, Gilligan Group, Inc. DAVE HOFMAN, University of North Carolina at Chapel Hill JAMES KLINECT, Line Operation Safety Audit (LOSA) Collaborative NANCY LEVESON, Massachusetts Institute of Technology EMILIE ROTH, Roth Cognitive Engineering HASSAN SHAHIDI, Flight Safety Foundation DUSAN ZRNIC, National Oceanic and Atmospheric Administration Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by CHRIS HENDRICKSON (NAE), Carnegie Mellon University, and CRAIG PHILIP (NAE), Vanderbilt Reviewers

viii REVIEWERS University. They were responsible for making certain that an indepen- dent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the author ing committee and the National Academies.

ix The committee appreciates the support of the Federal Aviation Adminis- tration (FAA) and The MITRE Corporation (MITRE) staff in providing background information related to the Commercial Aviation Safety Team, the Aviation Safety Information Analysis and Sharing program, and the Annual Safety Culture Survey. This report was developed under the overall supervision of Thomas R. Menzies, Jr., Director of Consensus and Advisory Studies, Transportation Research Board (TRB). Lida Beninson, Senior Program Officer, TRB, served as the study director. She and Stephen Godwin, Scholar, TRB, assisted the study committee in the preparation of this report. Arul Mozhi and Daniel Talmadge provided liaison with the National Academies of Sciences, Engineer ing, and Medicine’s Aeronautics and Space Engineering Board and Board on Human-Systems Integration, respectively. Claudia Sauls and Michael Covington of TRB provided support to the committee in arrang- ing meetings. The committee would like to thank the following individuals for pro- viding input to this study: KATHY ABBOTT, FAA BARBARA ADAMS, FAA JODI BAKER, FAA DON CARTER, Southwest Airlines ANDY CEBULA, Airlines for America ERIC CHANG, MITRE (former) HEATHER DANNER, FAA Acknowledgments

x ACKNOWLEDGMENTS DAVID HEMPE, FAA BECKY HOOEY, NASA STEVE JANGELIS, Air Line Pilots Association (ALPA) JAMES KLINECT, Line Operation Safety Audit (LOSA) Collaborative ANDREW LE BOVIDGE, National Air Traffic Controllers Association TERRY McVENES, RTCA MARK MILLAM, Flight Safety Foundation SHWETA MULCARE, MITRE EUGENE MWENDWA, MITRE WARREN RANDOLPH, FAA MIKE SCHILZ, ALPA JEFFERY SCHROEDER, FAA JOSEPH SEDOR, National Transportation Safety Board DAVID SILVER, Aerospace Industries Association VIVEK SOOD, FAA GREG TENNILLE, MITRE DAI WHITTINGHAM, UK Flight Safety Committee

xi Contents PREFACE xv ACRONYMS AND ABBREVIATIONS xvii EXECUTIVE SUMMARY 1 1 INTRODUCTION 5 Interpretation of the Statement of Task, 7 2 MANAGING SAFETY IN COMPLEX SYSTEMS 13 Key Safety Management Principles, 14 Organizational Safety Controls, 18 System Accidents, 19 Precursors, 21 Aviation Socio-Technical System Safety Controls, 23 Scope of Precursor Monitoring and Analysis, 24 Summary and Assessment, 29 References, 31 3 SAFETY CULTURE AND ITS ASSESSMENT 33 Safety Culture, 34 AVS Safety Culture Assessment to Date, 36 Methods for Assessing Safety Culture, 40 Conclusions, 44 References, 45

xii CONTENTS 4 DATA SOURCES AND ANALYSIS PROCESSES FOR IDENTIFYING EMERGING TRENDS 47 Data Types and Sources, 48 Analysis Processes, 58 Summary, 71 References, 74 5 POTENTIAL EMERGING AVIATION SAFETY HAZARDS AND FUTURE IDENTIFICATION 77 Potential Sources of New Emerging Trends in Aviation Safety, 77 Future Committee Activities and Reports, 81 Scanning for Emerging Aviation Safety Trends, 82 References, 83 APPENDIXES A Impacts of Commercial Aviation Safety Team Safety Enhancements 85 B Public Meeting Agendas 97 C Study Committee Biographical Information 103

BOXES 1-1 Statement of Task, 8 3-1 Excerpts from Shepardson (2020), Reuters, 34 3-2 Five Practices for Developing “Mindfulness,” 38 FIGURES 1-1 Annual commercial aviation fatal accident rates, 1959–2020, 6 2-1 Precursor role in risk identification and mitigation, 21 2-2 Control in a socio-technical system, 24 A-1 Safety metrics addressed by CAST safety enhancements, 86 A-2 Types of safety enhancement actions taken, 87 TABLES 2-1 Illustrative Generic Accident Precursor Measures, 26 3-1 Traits of a Positive Safety Culture, 35 3-2 Methods for Assessing Safety Culture, 42 4-1 Examples of Precursor Data Sources, 62 Boxes, Figures, and Tables xiii

Commercial aviation safety in the United States, as documented in Chapter 1, has improved more than 40-fold over the past several decades. Expectations for aviation safety are such that two fatal accidents abroad in 2018 and 2019 involving U.S.-manufactured aircraft caused Congress to ask the National Academies of Sciences, Engineering, and Medicine to review existing data and processes for identifying anomalies before they can potentially turn into future accidents. (The congressional request, task statement, and nature of the project are described in Chapter 1.) To carry out this project, the National Academies formed a committee of experts operating under the auspices of the Transportation Research Board and chaired by Amy Pritchett, Department Head of Aerospace Engi- neering, Penn State College of Engineering. The members of the committee have expertise in a wide range of areas including aviation safety, aerospace/ aeronautical engineering, aviation operations, human factors, statistics, data science, and high-reliability organizations. The committee members bring the perspectives of academia as well as those of experts in aviation safety regulation, commercial aviation piloting, and aviation standards, and current experts in big data analysis and safety culture in aviation and other sectors. The committee held several open meetings during which time it was briefed by aviation industry experts, Federal Aviation Administra- tion officials, and experts in aviation safety data and methods in the United States and Europe. These briefings addressed the state of the art in mining available data to identify emerging hazards and mitigation of those of con- cern. The committee is deeply appreciative of the time and effort made by the many individuals listed in the acknowledgments. This report, the first Preface xv

xvi PREFACE of six reports over a 10-year period, provides the committee’s initial review of the major processes for detecting emerging trends in aviation safety in place in the United States and its plans for the next report. Amy Ruth Pritchett, Chair Committee on Emerging Trends in Aviation Safety

AAIB Aircraft Accident Investigation Board ACARS Aircraft Communications, Addressing and Reporting System ACSAA Aircraft Certification, Safety, and Accountability Act AFDS autopilot flight director system AI artificial intelligence AIDS Aircraft Integrated Data System AQP Advanced Qualification Program ARIA Aviation Risk Identification and Assessment ASAP Aviation Safety Action Program ASIAS Aviation Safety Information Analysis and Sharing ASRS Aviation Safety Reporting System ATC air traffic control ATSAP Air Traffic Safety Action Program (a VSRP for ATC) AVS Aviation Safety office of FAA CAA Civil Aviation Authority CAP corrective action plan CASS Continuing Analysis and Surveillance System CAST Commercial Aviation Safety Team CFIT controlled flight into terrain CNS communications, navigation, and surveillance CRM Crew Resource Management EPR Engine Pressure Ratio Acronyms and Abbreviations xvii

xviii ACRONYMS AND ABBREVIATIONS FAA Federal Aviation Administration FDM Flight Deck Management FMS Flight Management System FO First Officer FOQA Flight Operational Quality Assurance FRMS Fatigue Risk Management System IAEA International Atomic Energy Agency ICAO International Civil Aviation Organization IMC Instrument Meteorological Conditions LOC loss of control LOSA Line Operations Safety Audit1 MDA Minimum Descent Altitude MEDA Maintenance Error Decision Aid M-LOSA Maintenance LOSA MOPS Minimum Operational Performance Standards MOR Mandatory Occurrence Report NAS National Airspace System NASA National Aeronautics and Space Administration NMAC near-midair collision NRC Nuclear Regulatory Commission NSF National Science Foundation NTSB National Transportation Safety Board OEM original equipment manufacturer PIA Pakistan International Airlines PIC Pilot in Command QA quality assurance R-LOSA Ramp Operations LOSA RTCA Radio Technical Commission for Aviation (a standards body now known by its acronym) SA safety assurance SE Safety Enhancement 1 LOSA is referred to as “Line Operation Safety Assessment” in some documents by the Federal Aviation Administration.

ACRONYMS AND ABBREVIATIONS xix SME subject-matter expert SMS safety management system SOP standard operating procedure SOT Statement of Task STAMP System-Theoretic Accident Model and Processes TAWS Terrain Avoidance and Warning System TCAS Traffic Collision Avoidance System TCWS Takeoff Configuration Warning System TEM Threat and Error Management UAS unmanned aviation system USDOT U.S. Department of Transportation VSRP Voluntary Safety Reporting Program

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Commercial aviation safety in the United States has improved more than 40-fold over the last several decades, according to industry statistics. The biggest risks include managing safety in the face of climate change, increasingly complex systems, changing workforce needs, and new players, business models, and technologies.

TRB Special Report 344: Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes is the first of a series of six reports that will be issued from TRB and the National Academies of Sciences, Engineering, and Medicine over the next 10 years on commercial aviation safety trends in the U.S.

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