good reasons, the team should have investigated their potential impact as well as the magnitude of biases resulting from failure to locate sampled pilots and other forms of nonresponse. In particular, the collection and analysis of supplemental data during the early phase of the survey would have enabled a reliable assessment of the various biases and may have led, if necessary, to the development of alternative design strategies.

The committee identified deficiencies in the structure and wording of the questions used in the survey. Some of the questions asked pilots for information that they would not have had without a post-flight analysis. Other questions had complex structure or multiple parts or used vague phrases to describe the events that the survey was attempting to measure. In addition, both the AC and the GA questionnaires asked respondents to include events, flight hours, and flight legs in segments of aviation that went beyond even the broadest definition of AC operations and beyond the conventional definition of GA operations. As a result, highly disparate segments of the aviation industry were aggregated into the safety-related event rates that were calculated from the AC and GA surveys. Finally, the inability to link safety-related events to the aircraft type or to the type of operating environment in which the event occurred severely hinders any meaningful analysis of event rates or trends in event rates by aircraft type or by segment of aviation.

The committee did not have access to the original survey data. The redacted data sets have several limitations that further constrain the ability to analyze the data to meet the committee’s objectives. For example, the time of survey response was grouped into years, so estimates of event rates could be computed only by years. This limits the ability to track changes in event rates over shorter timescales, to determine the effects of changes in the aviation system on event rates, and to assess seasonal and similar types of effects. In addition, grouping the exposure data (number of hours and flight legs flown) into categories increases the uncertainty in the estimates of event rates broken down by key characteristics, such as pilot experience and plane type. Issues associated with preserving respondents’ anonymity and confidentiality and with the public release of data have been known in the survey community for some time, and these issues should have been anticipated and addressed at the design stage of the NAOMS project.

The committee’s limited analysis of the redacted data revealed serious problems with data quality: substantial fractions of the reported non-zero counts of events had implausibly large values, and respondents often rounded their answers to convenient numbers. The extent and magnitude of these problems raise serious concerns about the accuracy and reliability of the data. In the committee’s view, some of these problems could have been reduced substantially if more effort had been spent on ensuring data accuracy during the interview and data-entry stages and if respondents had been asked to refer to their logbooks when possible. This would have been especially useful in providing reliable information on the number of hours flown and the number of flights (takeoffs/landings) and in helping to confine the answers to the recall period. The committee does note that many of the biases that are relevant for estimating event rates would be mitigated for trend analysis to the extent that the biases remain relatively constant over time. However, the degree of mitigation might vary substantially across event types.

The committee did not find any evidence that the NAOMS team had developed or documented data analysis plans or conducted preliminary analyses as initial data became available in order to identify early problems and refine the survey methodology. These activities should be part of a well-designed survey, especially a research study to assess the feasibility of survey methodology in aviation safety.

Given the deficiencies identified, and despite some methodological strengths of the NAOMS project, the committee recommends that the publicly available NAOMS data should not be used for generating rates or trends in rates of safety-related events in the National Airspace System. The data could, however, be useful in developing a set of lessons learned from the project.

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