Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes (2022)

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1 Executive Summary At the request of Congress, the National Academies of Sciences, Engineer- ing, and Medicine has initiated a series of reports that this project will produce. Over a 10-year period, the project aims to review and advise on data and methods for identifying emerging hazards1 in the evolving U.S. commercial air transportation system. This is the first of six reports and reviews the public and private data systems and methods that are currently being used by the commercial aviation industry and the Federal Aviation Administration (FAA) to detect emerging hazards. There has been a significant and sustained reduction in airline accidents in the United States over the past two decades. The challenge and opportu- nity now is in getting ahead of accidents by monitoring and characterizing known or hypothesized hazards and discovering new hazards when, or ideally before, they become apparent in operations. This will require new methods for analyzing data, and potentially new data sources. In addition to monitoring for physical events and acute performance breakdowns, as has been done traditionally, the safety culture of aviation organizations needs to be examined. Experience shows that complex systems are at risk of failing when organizations dedicated to managing hazards become com- placent and overconfident. 1 The term “hazard” is defined in the International Civil Aviation Organization Safety Man- agement Manual (Doc 9859) as “a condition or object with the potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function.” See https://www.icao.int/SAM/Documents/2017-SSP-BOL/ CICTT%20Hazard%20Taxonomy.pdf.

2 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 Chapter 2 of this report develops a conceptual framework describing how safety is monitored in complex systems such as aviation, in which accidents often involve multiple failures and dysfunctional interactions. This framework starts by recognizing that systematic processes must be employed to identify, characterize, and handle hazards. Even once identified, some hazards cannot be eliminated, and instead must be protected against using multiple layers of defense. Thus, the framework focuses on taking proactive measures to detect potential hazards warranting investigation, characteriza- tion, and research into proper mitigations. It includes organizational factors and feedback loops between the various hazards and mitigation strategies in an effort to fully understand the many potential contributors and counter- measures to hazards. These elements include the “front line” (i.e., the per- sonnel designing, manufacturing, maintaining, and operating the aircraft), as well as management decisions and processes and the overall safety culture of the organizations involved. Identification of precursors should also account for the time dimension over which they emerge. Some analyses are suited to managing safety in the immediate time frame (operations); others are suited to the more intermediate or future time frames (incorporating design and system evolution). Chapter 3 reviews how safety cultures influence the behavior of orga- nizations and how these cultures can be assessed. Next, Chapter 4 starts by reviewing the primary data types and sources analyzed to monitor hazards. Processes for analyzing these data are then characterized using the framework introduced earlier, noting that these processes must often accommodate both pragmatic and conceptual difficulties with sharing and integrating data of different types and data considered proprietary and sen- sitive by different organizations. Some processes, such as the monitoring of exceedances and lagging in- dicators such as incident reports, are occurring through broad, system-wide voluntary collaborations. The most notable example involves the activities of the Commercial Aviation Safety Team (CAST) and the Aviation Safety Information Analysis and Sharing (ASIAS) initiative, whose members and contributors span most of the U.S. aviation industry. CAST and ASIAS are mainly focused on monitoring known hazards and assessing the efficacy of mitigations to the hazards, termed “safety enhancements,” as they are implemented. The CAST/ASIAS collaboration has an invaluable role in im- mediate safety management, but it may not be the best forum for applica- tion of tools and methods for analyses of hazards that are not yet known or not prevalent in current day operations. Thus, Chapter 4 also discusses two further categories of analysis pro- cesses that are typically better suited to the intermediate and future time frames. First, where hazards have been identified, increasingly sophisticated “big data” methods can be brought to bear to better characterize them and

EXECUTIVE SUMMARY 3 to use this characterization to make better use of data. The committee was briefed on several studies applying these types of methods. Second, a more ambitious task focuses on identifying new, trending hazards—or those that will emerge in the future with proposed changes in aviation. Based on the information received so far, the committee is not aware of future time- frame efforts seeking to discover new hazards that are not already identi- fied beyond research attempting to develop methods for them. Such studies could include discovery efforts seeking to identify hitherto-unidentified anomalous patterns of behavior in the aviation system visible only as “weak signals.” They may also be suited to hypothesis-driven investigation of the impact of likely stressors on the aviation industry or proposed changes to technology, traffic density and distribution, and procedures and policies that may warrant a structured exploration by subject-matter experts and predictive modeling. In support of this open area of identifying new, trending phenomena, and based on several briefings from FAA, aviation organizations, and ex- perts in the United States and abroad, the committee has developed a tenta- tive list of potential emerging hazards, presented in Chapter 5. The focus is on identifying systemic stressors on aviation safety potentially arising from increasing pressure on current safety controls or by undermining the assumptions on which they are based. These include safety management in increas ingly complex systems, new entrants in aviation, new business models, and the introduction of new technologies. In future reports the committee will assess to what extent these examples, and others the com- mittee may identify, can be detected, monitored, and mitigated by safety management processes already in place, and by adding new processes. The committee does not offer recommendations in this report, but future reports may include recommendations based on further research and committee activities. In the next phase of the study, committee members will use a strategic foresight strategy known as horizon scanning to identify emerging trends in aviation safety through facilitated workshop activities with broad input from diverse stakeholders. While this activity may identify previ- ously unidentified or overlooked hazards in commercial aviation through hypothesis-driven approaches and envisioning multiple prospective futures, its primary aim will be to demonstrate a method that can be broadly applied to identify such emerging trends in aviation safety. Finally, an additional element of the committee’s task is to “draw on the results of FAA’s annual internal safety culture assessments and also advise the agency on data and approaches for assessing safety culture to ensure that FAA is identifying emerging risks to commercial aviation and sharing that information throughout the agency and with the public.” This task refers specifically to the annual safety culture assessment that Congress

4 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 required the FAA Aviation Safety office to conduct following the two acci- dents involving Boeing 737 Max 8 aircraft in Indonesia and Ethiopia. FAA progress on this front is briefly described in Chapter 3, but the first safety culture survey will not be finished until later this year. Hence, we plan to report more completely on this subject in the next report.