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

Chapter: Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements

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Suggested Citation:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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:"Appendix A: Impacts of Commercial Aviation Safety Team Safety Enhancements." 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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The committee reviewed the list of 126 Commercial Aviation Safety Team (CAST) Safety Enhancements (SEs) that have been initiated since 1999. The committee’s aim was to begin understanding the impact of the work of Aviation Safety Information Analysis and Sharing and CAST on safety and the relationship of CAST SEs to the causal factors identified in fatal accidents with multiple (50 or more) fatalities over the past 15 years. This appendix should be viewed as only a preliminary step based on data that are publicly available. OVERVIEW OF SAFETY ENHANCEMENTS The committee observes that not all SE write-ups and plans indicate a specific safety metric(s) the enhancement is intended to improve. The com- mittee reviewed all of the SEs and gleaned from the write-ups and associ- ated plans which safety metric was meant to be improved, as summarized in Figure A-1. Figure A-1 shows that, of the 126 SEs, 58 (46%) addressed controlled flight into terrain (CFIT), loss of control (LOC), midair collisions, or cargo- related accidents. Forty-two CAST SEs (33%) addressed arrival/departure/ surface safety issues. Our analysis shows that in the years 1999–2000, almost all SEs were aimed at reducing CFIT accidents and approach and landing accidents. From 2003 to 2006, the focus shifted to reducing LOC accidents. In 2007, the CAST SEs focused on cargo-related accidents, as well as incidents and accidents involving the wrong runway upon depar- ture. Some attention was shown to unnecessary Traffic Collision Avoidance Appendix A Impacts of Commercial Aviation Safety Team Safety Enhancements 85

86 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 System alerts. In 2013, numerous CAST SEs addressed LOC accidents and 2014 brought focus to runway excursions. The most recent SEs address misalignment with a runway or taxiway. The Federal Aviation Administration (FAA) and CAST members who briefed the committee could not provide a clear picture of the impact on these safety metrics following the implementation of CAST SEs, and it is not clear whether such data are collected or analyzed. It is also not appar- ent from the Skybrary database whether, when, and by whom the CAST SEs were implemented.1 Therefore, in dating the introductions of CAST SEs 1 See https://skybrary.aero/enhancing-safety/cast-safety-enhancements. FIGURE A-1 Safety metrics addressed by CAST safety enhancements. NOTE: # = number of CAST safety enhancements that address that aviation issue. Aviation Issue  #  Accidents and incidents  5  Controlled flight into terrain  17  Cargo‐related accidents  10  Aircraft‐related  1  Approach and landing  5  Arrival/departure deviations  2  Departure  3  Engine‐related  2  Maintenance‐related  6  Loss of control  26  Icing‐related  2  Runway incursions  9  Runway excursions  8  Wiring‐related  1  Communications  1  Pilot errors  1  Overtaken by events  3  Turbulence‐related injuries  1  Weather‐related  1  Pre‐flight/dispatch‐related  1  Wrong runway  12  Midair collisions  5 

APPENDIX A 87 described below we use the date of the implementation plan unless specific target dates for implementation are provided within them. Figure A-2 shows that, overall, of the 126 SEs, nine (7%) led to imple- mentation of new technology on the aircraft. Twenty-three SEs (18%) led to outcomes that were advisory in nature (i.e., Advisory Circulars [ACs], Airworthiness Directives [ADs], Standard Operating Procedures [SOPs], and Bulletins). Thirty-nine CAST SEs (31%) led to new guidance or new or revised procedures. Six (5%) led to a regulatory action such as a new rule or Technical Standard Order (TSO). No action was listed for 25 of the SEs. Fourteen CAST SEs (11%) resulted in plans for which the committee was unable to determine subsequent implementation dates or change in safety performance of the national airspace system as a direct result of implemen- tation of SEs. Correspondence of CAST SEs to Major Fatal Accidents In the remainder of this appendix we list all fatal accidents worldwide with 50 or more fatalities and all airline hull losses in the United States over the past 15 years and identify the correspondence with CAST SEs based on the probable causes of fatal accidents identified in formal accident investigation FIGURE A-2 Types of safety enhancement actions taken. Safety Enhancement Type  #  Advisory (AC, AD, SOP, Bulletin,  InFO, SAFO…)  23  Data analysis  1  Design  5  Guidance/training  28  Maintenance procedure  1  Plan/report/study/CONOPS  14  Policy/procedure  11  Prototype  1  Regulatory (Rule, TSO, Order…)  6  Technology implementation  9  No action  25  Overtaken by events  2  TOTAL  126 

88 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 reports. Although CAST is a North American, largely U.S., enterprise, the International Civil Aviation Organization has issued similar guidance on many of the CAST SEs. This list of major fatal accidents does not include the Thai Lion and Ethiopian Air crashes of Boeing 737 Max 8 aircraft in 2018 and 2019, nor the China Eastern flight 5735 of April 2022 for which a formal accident investigation report has not yet been issued. The italicized text in the accident descriptions below are direct quotes from formal accident investigation reports. Several CAST SEs are referenced multiple times on topics such as CFIT standard operating procedures, crew resource management training, advanced maneuver training, effective upset prevention training, and human factors and automation. The inference we draw is that for several of its SEs, CAST anticipated important causal factors leading to fatal accidents which continue to this day. Most of the CAST SEs were introduced before the accidents listed below, but, as noted above, we lack information about when and which airlines around the world adopted them. Pakistan International Airlines (PIA) 8303, A320, 5-22-20, Attempted gear up landing, go around, subsequent dual engine failure.2 • CAST SE011 (Crew Resource Management [CRM] training, Imple- mentation Plan of September 1999), SE026 (Standard Operating Procedures, Implementation Plan of February 2003), and SE031 (Advanced Maneuver Training, Implementation Plan of February 2003) There is a preliminary report which clearly indicates significant crew deviation from acceptable operating practices throughout the flight. The investigating agency seeks additional information including the following: (f) Critical analysis of monitoring of performance of the pilots by PIA for stabilized approaches, use of Flight Deck Management analysis tools, CRM training mechanism, and supervision of simulator ses- sions etc. and related regulatory oversight by the Directorate of Flight Standards (DFS) of Civil Aviation Authority (CAA), will be undertaken and shall require detailed visits of relevant departments of PIA and CAA. (g) Assessment of Safety Management System of PIA and State Safety Programme (SSP) of CAA for the safety oversight of operators, and evaluation of the Safety and Quality Management System (SQMS) for the safety oversight of the Directorate of Operations of CAA, 2 See https://caapakistan.com.pk/Upload/SIBReports/AAIB-431.pdf.

APPENDIX A 89 will be undertaken by the Aircraft Accident Investigation Board (AAIB). Flydubai 981, B737-800 3-19-16, Loss of control on go around.3 • CAST SE002 (Standard Operating Procedures, Implementation Plan of August 1999), SE026 (Standard Operating Procedures, Implementation Plan of February 2003) The fatal air accident to the Boeing 737-8KN A6-FDN aircraft occurred during the second go around, due to an incorrect aircraft configuration and crew piloting, the subsequent loss of Pilot in Command’s (PIC’s) situa- tional awareness in nighttime in Instrument Meteorological Conditions. This resulted in a loss of control of the aircraft and its impact with the ground. The accident is classified as Loss of Control In-Flight (LOC-I) occurrence. Some factors listed include: • the loss of the PIC’s leadership in the crew after the initiation of go-around and his “confusion” that led to the impossibility of the on-time transition of the flight mental mode from “approach with landing” into “go-around”; • the crew’s uncoordinated actions during the second go-around: on the low weight aircraft the crew was performing the standard go- around procedure; and • the absence of the criteria of the psychological incapacitation in the airline OM, which prevented the F/O from the in-time recognition of the situation and undertaking more decisive actions. Air Asia Indonesia 8501, A320 12-28-14, Instrument failure, loss of control.4 • CAST SE 019 (Maintenance Procedures, Implementation Plan of September 2000); SE031 (Advanced Maneuver Training, Imple- mentation Plan of February 2003), and SE170 (Monitoring of Service History, Implementation Plan of April 2008) The crew received a non-serious rudder control warning that had been a historical problem with this aircraft. The captain elected to reset com- puters by recycling circuit breakers that were not to be reset in flight. His action placed the aircraft in a lower mode of control and induced a large 3 See http://www.mak-iac.org/upload/iblock/3d1/report_a6-fdn_eng.pdf. 4 See https://bea.aero/uploads/tx_elydbrapports/Final_Report_PK-AXC-reduite.pdf.

90 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 bank angle. The first officer (FO) was unable to control the roll and induced a large pitch angle which led to a stall which was not recovered. In general, the safety actions covered several improvement plans for the flight operation relating to upset training, Safety Management System (SMS) and CRM. Moreover, the operator had also provided several safety improvements for the maintenance aspects related to repetitive problems. Air Algerie 5017, MD83 7-24-14, Loss of engine thrust in icing leading to a stall.5 • CAST SE030 (Human Factors and Automation, Implementation Plan of May 2006) The airplane speed, piloted by the autothrottle, decreased due to the ob- struction of the pressure sensors located on the engine nose cones, probably caused by ice crystals. The autopilot then gradually increased the angle of at- tack to maintain altitude until the airplane stalled. The stall was not recovered. • The crew’s late reaction to the decrease in speed and to the erroneous Engine Pressure Ratio values, possibly linked to the work load asso ciated with avoiding the convective zone and communication difficulties with air traffic control. • The crew’s lack of reaction to the appearance of buffet, the stick- shaker, and the stall warning. • The lack of appropriate inputs on the flight controls to recover from a stall situation. The absence of a usable Cockpit Voice Recorder recording limited the possibility of analyzing the crew’s behavior during the flight. Specifically, it was not possible to study CRM aspects or to evaluate the possible contribu- tion of the employment context and the experience of the crew members. Tartarstan 363, B737-500 11-17-13, Loss of control on go around.6 • CAST SE011 (CRM Training, Implementation Plan of September 1999), SE131 (Safety Culture, Implementation Plan of October 2007), SE196 (Effective Upset Prevention and Recovery Train- ing, Implementation Actions 2014–2016), SE199 (Enhanced CRM Training, Implementation Actions 2017–2019) 5 See https://bea.aero/uploads/tx_elydbrapports/ec-v140724.en.pdf. 6 See https://mak-iac.org/upload/iblock/459/report_vq-bbn_eng.pdf.

APPENDIX A 91 The go around followed a poorly flown instrument approach. There were no malfunctions with the aircraft (although one investigator disagreed with this, there was no physical evidence). As the crew was formed of two “weak” pilots who had underwent training with deviations from applicable requirements, there was a sig- nificant safety risk that did not comply with the basic risk management principles and was evidence of inoperative SMS in the airline. The FO, distracted by communication with the ATC, was not crosschecking the PIC’s actions and failed to perform any of the SOP requirements. Taking into consideration the quickly changing situation as well as the PIC’s lack of pertinent skills and his actual low qualification, he was not able to apply the required recovery techniques. The level of flight operations organization in the airline was low, which resulted in the failure to eliminate deficiencies in navigation equipment usage, airmanship, and CRM. Air India Express 812, B737-800 5-22-10, Unstabilized approach, long touchdown and attempted go around resulting in overshoot due to captain ignoring multiple warnings from FO.7 • CAST SE002 (Standard Operating Procedures, Implementation Plan of August 1999); SE011 (CRM Training, Implementation Plan of September 1999), SE031 (Advanced Maneuver Training, Implemen- tation Plan of February 2003) The FO had correctly identified that the aircraft was in an “unstabilized approach.” He had also asked the captain to “GO AROUND” three times. During training, endeavor should also be made on inculcating a common company culture amongst the crew. Aspects of CRM … [as required by the Director General of Civil Aviation via Operations Circular no. 2] … should be covered in ground training. Afriqiyah 771, A330 5-12-10, Loss of flight path control on go around.8 • CAST SE011 (Standard Operating Procedures, Implementation Plan of September 1999); CAST SE011 (CRM Training, Implemen- tation Plan of September 1999) 7 See https://web.archive.org/web/20120227044218/http://dgca.nic.in/accident/reports/VT- AXV.pdf. 8 See https://web.archive.org/web/20130903094253/http://caa.ly/finalReport/FINAL_5A- ONG-1.pdf.

92 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 The Crew’s CRM was limited during approach, further weakened at go around. The accident resulted from: • The lack of a common action plan during the approach and a final approach continued below the Minimum Descent Altitude, without ground reference acquired • The inappropriate application of flight control inputs during a go around and on the activation of Terrain Avoidance and Warning System (TAWS) warnings • The lack of monitoring and controlling the flight path AFRIQIYAH airways should make a regular follow up and control on pilot performance emphasizing on Crew CRM (make use of LOSA). Spanair 5022, MD82 8-20-08, Attempted no flap takeoff.9 • CAST SE227 (Air Carrier Procedures for Takeoff Configuration, Implementation Actions 2017–2020) The flaps and slats were not extended. The configuration warning sys- tem did not activate. The aircraft was unable to sustain flight. The crew lost control of the airplane as a consequence of entering a stall immediately after takeoff due to an improper airplane configuration. Atlas Air 3591, B767F 2-23-19, Inadvertent selection of Go Around mode on approach with subsequent loss of control.10 • CAST safety enhancements not applicable. Despite the presence of the go-around mode indications on the flight mode annunciator and other cues that indicated that the airplane had transitioned to an automated flight path that differed from what the crew had been expecting, neither the FO nor the captain were aware that the airplane’s automated flight mode had changed. The FO likely experienced a pitch-up somatogravic illusion as the air- plane accelerated due to the inadvertent activation of the go-around mode, which prompted him to push forward on the elevator control column. The captain’s failure to command a positive transfer of control of the airplane 9 See http://www.fomento.es/NR/rdonlyres/EC47A855-B098-409E-B4C8-9A6DD0D0969F/ 107087/2008_032_A_ENG.pdf. 10 See https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2002.pdf.

APPENDIX A 93 as soon as he attempted to intervene on the controls enabled the FO to continue to force the airplane into a steepening dive. UPS 1354, A300F 8-14-13, CFIT on a non-precision approach. Fatigue was considered a factor.11 • CAST SE002 (Standard Operating Procedures, Implementation Plan, Implementation Plan of August of 1999) The flight crew did not monitor the descent rate and continued to fly the airplane with a vertical descent rate of 1,500 ft per minute below 1,000 ft above ground level, which was contrary to standard operating procedures, resulting in an unstabilized approach that should have necessitated a go- around. The flight crew did not sufficiently monitor the airplane’s altitude during the approach and subsequently allowed the airplane to descend below the minimum altitude without having the runway environment in sight. The captain’s poor performance during the accident flight was consis- tent with past performance deficiencies in flying non precision approaches noted during training; the errors that the captain made were likely the result of confusion over why the profile did not engage, his belief that the airplane was too high, and his lack of compliance with standard operating proce- dures. The FO poorly managed her off-duty time by not acquiring sufficient sleep, and she did not call in fatigued; she was fatigued due to acute sleep loss and circadian factors, which, when combined with the time compres- sion and the change in approach modes, likely resulted in the multiple errors she made during the flight. Colgan Air 3407, Bombardier Q400, 2-12-09, Unrecovered stall during approach icing conditions resulting in a CFIT.12 • CAST SE010 (Proactive Safety Programs, Implementation Plan of August 1999), SE011 (CRM Training, Implementation Plan of Sep- tember 1999), SE196 (Effective Upset Prevention Training, Imple- mentation Actions 2014–2016), SE199 (Enhanced CRM Training, Implementation Actions 2017–2019) The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall. The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the FO’s tasks at the time 11 See https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1402.pdf. 12 See https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdf.

94 EMERGING HAZARDS IN COMMERCIAL AVIATION—REPORT 1 the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management. The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the FO’s fail- ure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance. The captain had not established a good foundation of attitude instru- ment flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed. The viability of flight operational quality assurance programs depends on the confidentiality of the data, which would currently not be guaranteed if operators were required to implement these programs and were required to share the data with the Federal Aviation Administration. Asiana 214, B777-200 7-6-2013, Short landing following an unstable vi- sual approach due to insufficient power.13 • CAST SE002 (Standard Operating Procedures, Implementation Plan of August 1999), SE011 (CRM Training, Implementation Plan of September 1999), SE030 (Human Factors and Automation, Imple- mentation Plan of May 2006) The flight crew’s mismanagement of the airplane’s vertical profile dur- ing the initial approach led to a period of increased workload that reduced the pilot monitoring’s awareness of the pilot flying’s actions around the time of the unintended deactivation of automatic airspeed control. About 200 ft., one or more flight crewmembers became aware of the low airspeed and low path conditions, but the flight crew did not initiate a go-around until the airplane was below 100 ft., at which point the airplane did not have the performance capability to accomplish a go-around. Nonstandard communication and coordination between the pilot flying and the pilot monitoring when making selections on the mode control panel to control the autopilot flight director system (AFDS) and autothrottle (A/T) likely resulted, at least in part, from role confusion and subsequently degraded their awareness of the AFDS and A/T modes. By encouraging flight crews to manually fly the airplane before the last 1,000 ft. of the approach, Asiana Airlines would improve its pilots’ abilities 13 See https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1401.pdf.

APPENDIX A 95 to cope with maneuvering changes commonly experienced at major airports and would allow them to be more proficient in establishing stabilized ap- proaches under demanding conditions; in this accident, the pilot flying may have better used pitch trim, recognized that the airspeed was decaying, and taken the appropriate corrective action of adding power.

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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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