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Suggested Citation:"1 Introduction." 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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Page 5
Page 6
Suggested Citation:"1 Introduction." 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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Page 6
Page 7
Suggested Citation:"1 Introduction." 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.
×
Page 7
Page 8
Suggested Citation:"1 Introduction." 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.
×
Page 8
Page 9
Suggested Citation:"1 Introduction." 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.
×
Page 9
Page 10
Suggested Citation:"1 Introduction." 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.
×
Page 10
Page 11
Suggested Citation:"1 Introduction." 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.
×
Page 11
Page 12
Suggested Citation:"1 Introduction." 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.
×
Page 12

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5 In response to a request from Congress in Section 132 of the Aircraft Certification, Safety, and Accountability Act of 2020 (the Act), a committee operating under the auspices of the Transportation Research Board of the National Academies of Sciences, Engineering, and Medicine was formed to “identify, categorize, and analyze emerging safety trends in air transporta- tion.” This report is the first of six reports over a 10-year period. The request from Congress was made in the aftermath of two fatal accidents involving Boeing 737 Max 8 aircraft—the Thai Lion Flight 610 crash into the Java Sea shortly after take-off in 2018 and the Ethiopian Air Flight 302 accident shortly after taking off from Addis Ababa Bole Interna- tional Airport in 2019. A total of 346 passengers and crew members died. These tragic events prompted Congress to ask whether sufficient efforts are in place to avert future accidents and resulted in the chartering of this com- mittee to examine how emerging trends in aviation safety are, and should be, identified and managed by the commercial aviation sector in the United States in consultation with international aviation organizations. New methods for identifying emerging trends are necessary since acci- dents in the United States have fortunately become too rare to serve as indicators. The probability of a fatal airline accident has declined more than 40-fold over the past 60 years (see Figure 1-1). Over the past two decades, there have been 8 years in which no fatal commercial aviation acci dents occurred in North America (see Figure 1-1). U.S. air carriers have transported more than 7.8 billion people in U.S. passenger operations since 1 Introduction

6 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 FIGURE 1-1 Annual commercial aviation fatal accident rates, 1959–2020. SOURCE: The Boeing Company, 2021. 2010.1 The worldwide decline in fatal accidents is all the more remarkable given that more than 30 million aircraft departures occurred in 2019, the peak year of air travel before the COVID-19 pandemic of 2020 sharply reduced air travel worldwide. Thus, as elaborated further below, the com- mercial aviation industry also needs to analyze for potential hazards that are emerging or, due to emerging stressors on aviation, may reduce protec- tion against hazards. Safety enhancements in commercial aviation responsible for the down- ward trend in the accident rate have resulted from myriad successful efforts 1 Bureau of Transportation Statistics for January 1, 2010, through August 31, 2019. See https://transtats.bts.gov/TRAFFIC.

INTRODUCTION 7 to manage safety by air carriers, manufacturers, suppliers, air traffic man- agement, and regulators. These enhancements have created multiple pro- tections through “front-line” defenses such as careful choices in criteria for pilot selection and training, guidance for appropriate use of standard operating procedures, and widespread adoption of systems for detecting and resolving hazardous states such as flight toward terrain. Other layers of defense have also been created at organizational levels, including airlines’ development of safety management systems (SMSs) and corresponding on- going data monitoring of flight data for precursors (i.e., Flight Operational Quality Assurance) and of related processes such as the efficacy of pilot training (Advanced Qualification Programs) At the broadest level, collab- orative national and international efforts are encouraging broad sharing and analysis of data both to look at focused areas of concern and to moni- tor current operations for identified precursors. However, lapses in any part of the system for managing safety can create vulnerabilities. The congressional staff who briefed the committee noted that this project was initiated as a result of concern that the specific failures that led to the 737 Max 8 accidents warrant examination of the aviation system more broadly to clarify the extent to which the myriad efforts currently in place are able to identify and address the full range of potential emerging safety trends. INTERPRETATION OF THE STATEMENT OF TASK The text of Section 132 of the Act and the Statement of Task (see Box 1-1) refers to “emerging safety trends in air transportation.” Con gressional staff who briefed the committee at its first meeting corroborated the commit- tee’s understanding that its mission would focus on commercial aviation (primarily scheduled flights with paying passengers or freight). Regarding terminology, the committee relies on a definition of “emerging” that refers to something “becoming apparent or prominent.” Thus, the committee interprets emerging trends in safety to include both new hazards emerging via proposals for new technologies or operations, as well as current con- cerns that may be becoming prominent. For example, a current concern is with the assumption that pilots can consistently monitor complex, highly automated systems and then have the knowledge and currency in manual flight skills to intervene should the automation malfunction or encounter flight conditions outside its operating envelope. The committee’s key concern is how such emerging trends can, and should be, monitored for and analyzed for the purpose of managing any hazards they reveal. This report reviews how safety-critical systems such as commercial aviation manage safety. It characterizes the many potential data sources, processes for monitoring for safety concerns and identifying

8 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 BOX 1-1 Statement of Task In response to a request from Congress, this project will “identify, categorize, and analyze emerging safety trends in air transportation.” The committee will review data and analyses of all relevant sources of information, such as operational data being used by the Federal Aviation Administration (FAA) and the air trans- port industry to monitor for potential safety concerns; government and industry voluntary aviation safety reporting systems; FAA’s annual safety culture assess- ment; and other sources the committee deems appropriate, including National Transportation Safety Board accident investigations; FAA investigations of acci- dents and incidents; air carrier incidents and safety indicators; and international investigations of accidents and incidents, including information from foreign authorities and the International Civil Aviation Organization. The committee will assess whether these available sources of information are being analyzed in ways that can help identify emerging safety risks as the aviation system evolves and whether other information should be collected and analyzed for this purpose, such as data on accident precursors. The committee may engage in its own empirical analyses of databases. The project will focus primarily on commercial air transportation sector, but will also include other current and prospective users of the National Airspace System that could pose risks to commercial aviation. The committee will 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 informa- tion throughout the agency and with the public. The project will produce an initial report in mid-2022, biennial reports through 2030, and a final report in 2031. It is expected that the committee’s first report will include a high-level assessment of the efficacy of domestic public and private sources of data and information for identifying and assessing emerging risks and advise on data gaps that need filling. The first report is also expected to include the approach the committee intends to pursue in subsequent biennial reports to assess the robustness of domestic and international data sources and processes for analyzing them for the purpose of identifying emerging risks to commercial air transportation. In addition to documenting its study findings in each report, the committee may offer advice to Congress, FAA, industry, and others on options for improving means for identifying, monitoring, understand- ing, and addressing emerging aviation safety risks, including supplementing, improving, and harmonizing existing databases, reporting systems, and analysis methods. potential hazards, and methods for incorporating these insights in use in ongoing safety management. Congressional staff urged the committee to consider a broad range of topics reflecting many potential emerging safety trends. These included such examples as the rigor of the certification process, including delegation of

INTRODUCTION 9 authority for some aspects of analysis to the applicant; whether subsequent updates to certification requirements via airworthiness directives should be reviewed to highlight gaps in certification processes; the role of the pilot in highly automated aircraft; introduction of advanced materials into air- craft design whose properties are not as well characterized as traditional materials; manufacturing quality control; outputs from SMSs and how they are utilized to manage risk; and the adequacy of precursor data for assess- ing all types of hazards. The committee understood these examples as not limiting its consideration but instead indicating a broad scope for its inqui- ries into data sources and methods for monitoring, analysis, and addressing the full range of potential safety issues covering design, manufacturing, operations, and regulatory oversight. The overall goal is clear: to avoid accidents through assiduous monitoring and analysis of data and feeding insights gleaned from these efforts back into operations, design, and other processes in ways that can manage hazards as they emerge. The committee’s scope includes advising the Federal Aviation Admin- istration (FAA) on the newly required annual safety culture assessment of the FAA Aviation Safety (AVS) office. AVS is responsible for the certifica- tion and continued airworthiness of aircraft and the certification of pilots, mechanics, and others in safety-related positions, and for the approval of all aspects of civil flight operations, including airline operations (e.g., safety management processes, processes for training personnel including pilots, and maintenance processes) and airspace and air traffic operations, including the approval of arrival and approach procedures. As part of sec- tion 132, Congress mandated that FAA establish and undertake an annual assessment of AVS safety culture due to concerns raised by its employees about the management and conduct of the 737 Max 8 certification process. In the first year of this project, the committee conducted a high-level assessment of data and methods for identifying and monitoring emerg- ing trends in this first report. Throughout the several months since its formation, the committee sought and received briefings on the principal government–industry collaborative effort to monitor trends and the myriad government and proprietary data it draws on. It also received briefings from FAA and others on major national sources of accident precursor data, processes in place to analyze them for emerging trends, and an overview of comparable aviation safety trend monitoring efforts in the European Union. Part of the committee’s task is to advise on “options for improving means for identifying, monitoring, understanding, and addressing emerging aviation safety risks, including supplementing, improving, and harmonizing existing databases, reporting systems, and analysis methods.” As the committee goes about its future work, it intends to identify any areas where data do not exist or are inadequate; opportunities to improve existing data bases and re- porting systems; potential improvement in analysis methods currently being

10 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 employed; consideration of sources of emerging trends including potential changes both in technology and certification procedures and in stressors on aviation safety, and feedback of information generated by these processes back into improved designs, operating procedures, and safety management. The specific items of the committee’s Statement of Task (SOT) are listed below, each of which is followed by a description of where the reader can find these items addressed in this report as well as plans for their coverage in future reports. 1. In response to a request from Congress, this project will “identify, categorize, and analyze emerging safety trends in air transporta- tion.” The committee will review data and analyses of all relevant sources of information, such as a. operational data being used by the Federal Aviation Admin- istration (FAA) and the air transport industry to monitor for potential safety concerns; b. government and industry voluntary aviation safety reporting systems; c. FAA’s annual safety culture assessment; and d. other sources the committee deems appropriate, including National Transportation Safety Board accident investigations; FAA investigations of accidents and incidents; air carrier incidents and safety indicators; and international investigations of acci- dents and incidents, including information from foreign authori- ties and the International Civil Aviation Organization. The committee will assess whether these available sources of informa- tion are being analyzed in ways that can help identify emerging safety risks as the aviation system evolves and whether other information should be col- lected and analyzed for this purpose, such as data on accident precursors. The committee may engage in its own empirical analyses of databases. For this first report, the committee chose to focus on reviewing the ex- isting precursor data and methods for identifying emerging hazards. It also reviews and provides an initial assessment of the principal U.S. effort for identifying emerging hazards. These topics are covered in Chapter 4. The committee expects to build on its initial assessment of methods and data in future reports. Chapter 5 offers a very preliminary list of potential emerg- ing trends that the committee plans to investigate further and potentially expand on in future reports. Specifically, items 1.a, 1.b, and 1.d of the SOT are addressed in Chap- ter 4. Regarding item 1.c, the first FAA annual assessment of its safety

INTRODUCTION 11 culture was not complete in time for this report and will be covered in the second report. The committee’s initial assessment of “whether these available sources of information are being analyzed in ways that can help identify emerging safety risks” is provided at the end of Chapter 4. 2. The project will focus primarily on the commercial air transporta- tion sector, but will also include other current and prospective users of the National Airspace System that could pose risks to commer- cial aviation. New types of carriers and equipment that may pose new hazards to commercial air transportation are introduced in Chapter 5 and will be explored in future reports. 3. The committee will 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. The committee was briefed by AVS on its plans to survey its staff and will address this item more fully in its next report after the first AVS safety culture assessment is complete. The committee provides initial guidance on safety culture assessment in Chapter 3. 4. The project will produce an initial report in mid-2022, biennial reports through 2030, and a final report in 2031. This first report was initiated in mid-2021 and released in mid-2022. Biennial reports will be prepared in 2024, 2026, 2028, and 2030. A final annual report will be prepared in 2031. Topics identified for the second report are described in Chapters 3 and 5 and the committee may address others as it continues to gather information. The committee will require additional information gathering and deliberation before it will be in a position to decide on the topics for the third and following reports. It ex- pects to draw from the list of topics described above that were suggested by congressional staff in making this decision. 5. It is expected that the committee’s first report will include a high- level assessment of the efficacy of domestic public and private sources of data and information for identifying and assessing emerging risks and advise on data gaps that need filling.

12 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 As noted above, this report provides a high-level assessment of the principal U.S. effort for identifying emerging hazards. The identification of data gaps begins in Chapters 2 and 4 and is expected to be a continuing activity of the committee. 6. The first report is also expected to include the approach the com- mittee intends to pursue in subsequent biennial reports to assess the robustness of domestic and international data sources and pro- cesses for analyzing them for the purpose of identifying emerging risks to commercial air transportation. The process the committee intends to follow in exploring its very pre- liminary list of emerging hazards, as described in Chapter 5, may identify topics for future reports. The committee expects that future reports will cover elements of SOT items 1 and 3 as they are identified. 7. In addition to documenting its study findings in each report, the committee may offer advice to Congress, FAA, industry, and others on options for improving means for identifying, monitoring, under- standing, and addressing emerging aviation safety risks, including supplementing, improving, and harmonizing existing databases, reporting systems, and analysis methods. In the first year of this project the committee developed a framework for categorizing precursors in Chapter 2 that it will build on in future re- ports. The first year also provided an opportunity for an initial survey of ex- isting data and methods. The committee does not believe that it has delved deeply enough into these topics at this stage to offer recommendations.

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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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