Improving the Continued Airworthiness of Civil Aircraft

A Strategy For the FAA's Aircraft Certification Service

Committee on Aircraft Certification Safety Management

Aeronautics and Space Engineering Board

Commission on Engineering and Technical Systems

National Research Council

NATIONAL ACADEMY PRESS
Washington, D.C.
1998



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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service Improving the Continued Airworthiness of Civil Aircraft A Strategy For the FAA's Aircraft Certification Service Committee on Aircraft Certification Safety Management Aeronautics and Space Engineering Board Commission on Engineering and Technical Systems National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1998

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the panel responsible for the report were chosen for their special competencies and with regard for appropriate balance. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and interim vice chairman, respectively, of the National Research Council. This study was supported by the Federal Aviation Administration under contract No. DTFA03-96-C-00041. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for the project. International Standard Book Number: 0-309-06185-7 Available for sale from: National Academy Press Box 285 2101 Constitution Ave., N.W. Washington, DC 20055 800-624-6242 202-334-3313 (in the Washington Metropolitan Area) http://www.nap.edu Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service COMMITTEE ON AIRCRAFT CERTIFICATION SAFETY MANAGEMENT JAMES G. O'CONNOR (chair), Pratt & Whitney (retired), Coventry, Connecticut M. CRAIG BEARD, Federal Aviation Administration (retired), Delaplane,Virginia EUGENE E. COVERT, Massachusetts Institute of Technology, Cambridge THEODORE E. DUMONT, Sikorsky Aircraft (retired), Milford, Connecticut FRANK C. FICKEISEN, The Boeing Company (retired), Bellevue, Washington CLYDE KIZER, Airbus Service Company, Herndon, Virginia DEAN J. LENNARD, General Electric Aircraft Engines (retired), Cincinnati, Ohio STEVEN R. LUND, Boeing Commercial Airplane Group, Douglas Products Division, Long Beach, California C. JULIAN MAY, Delta Airlines (retired), Kennesaw, Georgia WILLIAM H. SCHULTZ, General Aviation Manufacturers Association, Washington, D .C. NOZER D. SINGPURWALLA, George Washington University, Washington, D.C. COLIN TORKINGTON, Air Navigation Commission of the International Civil Aviation Organization, Montreal, Canada ASEB Liaison WILLIAM HOOVER, U.S. Air Force (retired), Williamsburg, Virginia Staff ALAN ANGLEMAN, Study Director GEORGE LEVIN, Director, Aeronautics and Space Engineering Board MARY MESZAROS, Senior Project Assistant TED MORRISON, Senior Project Assistant

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service AERONAUTICS AND SPACE ENGINEERING BOARD WILLIAM W. HOOVER chair, U.S. Air Force (retired), Williamsburg, Virginia A. DWIGHT ABBOTT, Aerospace Corporation, Los Angeles, California RUZENA BAJSCY, NAE, IOM, University of Pennsylvania, Philadelphia AARON COHEN, NAE, Texas A&M University, College Station RAYMOND S. COLLADAY, Lockheed Martin Astronautics, Denver, Colorado DONALD C. FRASER, NAE, Boston University, Boston, Massachusetts JOSEPH FULLER, JR., Futron Corporation, Bethesda, Maryland ROBERT C. GOETZ, Lockheed Martin Skunk Works, Palmdale, California RICHARD GOLASZEWSKI, GRA Inc., Jenkintown, Pennsylvania JAMES M. GUYETTE, Rolls-Royce North American, Reston, Virginia FREDERICK HAUCK, AXA Space, Bethesda, Maryland BENJAMIN HUBERMAN, Huberman Consulting Group, Washington, D.C. JOHN K. LAUBER, Airbus Service Company, Miami Springs, Florida DAVA J. NEWMAN, Massachusetts Institute of Technology, Cambridge JAMES G. O'CONNOR, NAE, Pratt & Whitney (retired), Coventry, Connecticut GEORGE SPRINGER, NAE, Stanford University, Stanford, California KATHRYN C. THORNTON, University of Virginia, Charlottesville DIANNE S. WILEY, Northrop Grumman, Pico Rivera, California RAY A. WILLIAMSON, George Washington University, Washington, D.C. Staff GEORGE LEVIN, Director

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service Foreword The National Research Council (NRC) was asked to conduct an independent assessment of the safety management process used by the Aircraft Certification Service of the Federal Aviation Administration (FAA) to define how the current process might be improved. The Committee on Aircraft Certification Safety Management, comprised of individuals chosen for their diverse perspectives and technical expertise in accordance with established procedures of the NRC, undertook the assigned study. The Committee was comprised of six members with industry expertise in large aircraft manufacturing and operations (engines, airframes, avionics, maintenance, and safety disciplines), two members with related experience (rotary wing and general aviation aircraft), and four members outside industry altogether (International Civil Aviation Organization, the FAA, and academia). The committee was asked to review common causes of accidents and incidents involving civil aircraft and determine which causes might be related to the certification process with an emphasis on continued airworthiness. The focus of the study was on how an already small frequency of accidents, made smaller still by a necessary connection with the certification process, might be made even smaller in the next decade. The committee had to consider quantifiable, qualitative, and latent risks and, based on risk assessment methodologies used by manufacturers, determine how the small risk of accidents could be further reduced. Defining a top-level aircraft certification safety management process that could reduce near-term accident risks entailed taking into account expected changes in both the aircraft fleet and certification. The committee was also asked to consider how their recommended safety management process might be applied to civil transport aircraft and other types of aircraft, to identify implementation barriers, and to define a strategy for assessing the effects of the recommended approach. A complex study like this one, which investigates near-term safety improvements in just one of many processes that could affect aircraft safety, requires that committee members be in possession of the relevant facts and prior experience to make informed judgments. The inclusion of such committee members, especially those with industrial experience, was deemed essential for the credibility of the results among manufacturing and operational constituencies, as well as the FAA. In addition, it was also necessary to ensure that the committee maintain a balance with a number of outside members, so that the results would be unbiased. Public credibility on matters of safety depends on this balance. We believe we have struck a careful balance in the composition of this expert committee. Moreover, this report was carefully reviewed and critiqued, according to standard NRC procedures, by independent and knowledgeable experts from diverse perspectives. The responsibility for the final report rests entirely with the authoring committee and the institution. The consensus recommendations in this report outline improvements to the certification process that could effect possible near-term improvements to a system that is already quite safe. The recommendations call for a deeper partnership between the FAA and the manufacturing industry and operational community. Based on data now in the possession of industry, the partnership would facilitate the analysis of these data under a process for which the FAA would have oversight responsibility. We commend this report to serious consideration by the FAA and industry. We believe the report makes a major contribution to the enhancement of aviation safety. WILLIAM WULF, President National Academy of Engineering

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service Preface Every day, the United States air transportation system provides safe and efficient service to millions of travelers, and it is the common goal of U.S. airlines, aircraft manufacturers, and the federal government to make air travel even safer. Accomplishing this goal, even as the number of passengers and total miles flown increases each year, will require cooperation among many different organizations. The Aircraft Certification Service of the Federal Aviation Administration (FAA) oversees aspects of civil aviation safety related to the design and manufacture of aircraft and aircraft systems, equipment, and parts. This includes assessing accidents, incidents, and other unexpected events to determine when certification standards for new and existing aircraft should be modified to maintain expected levels of continued airworthiness. As one element of the overall effort to improve aviation safety, the FAA requested that the National Research Council conduct an independent assessment of the safety management processes used by the Aircraft Certification Service. In response, the National Research Council established the Committee on Aircraft Certification Safety Management to conduct the study, the results of which are published in this report. As described herein, the committee verified that the current aircraft certification system contributes to the low rate of accidents in this country, as evidenced by the small fraction of accidents caused by aircraft system malfunctions. Even so, the current approach to aircraft certification and continued airworthiness can be improved. A new approach could be established that accounts for—and takes advantage of—changes in the aircraft industry since the current system was established. By becoming more performance-based, the Aircraft Certification Service could leverage existing resources to carry out its stated missions and priorities more effectively and help the FAA meet its extremely challenging safety goals. Industry should fully participate in the safety management process in partnership with the FAA. Safety monitoring and preventive measures should be based on reliable data and modem analysis techniques, tools, and logic. Barriers to implementation of a new, more effective safety management process are mostly bureaucratic and legalistic and will be difficult to overcome in a timely fashion. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the National Research Council in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: Brace Aubin, Air Canada (retired) Robert Blouin, National Business Aircraft Association Anthony Broderick, Federal Aviation Administration (retired) Robert Davis, The Boeing Company John Lauber, Airbus Service Company Robert G. Loewy, Georgia Institute of Technology Duncan Luce, University of California-Irvine Stuart Matthews, Flight Safety Foundation Kenneth Rosen, Sikorsky Aircraft Corporation Harvey Schadler, General Electric Corporate Research and Development Center (retired) Gareth Thomas, University of California-Berkeley While the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the National Research Council. The committee also wishes to thank everyone else who supported this study, especially those who took the time to participate in committee meetings (see Appendix c). JAMES G. O'CONNOR, Pratt & Whitney (Retired) Chairman, Committee on Aircraft Certification Safety Management

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   7     Objectives   7     Study Process and Approach   8     Organization of This Report   9     References   9 2   ROLE OF THE AIRCRAFT CERTIFICATION SERVICE (AIR)   10     History and Statutory Authority   10     Organization of the Aircraft Certification Service (AIR)   13     Specific Regulatory Actions   15     Related Activities   20     References   21 3   CAUSES OF INCIDENTS AND ACCIDENTS   22     Introduction   22     Primary Causes   24     Causes of Jet Transport Accidents   25     Causes of Jet Transport Incidents   27     Summary   27     References   28 4   RECOMMENDED SAFETY MANAGEMENT PROCESS   29     Overview   29     Data Collection   31     Database Management   32     Risk Analysis   33     Risk Management/Action   36     Monitoring Effectiveness   37     Approved Design Organizations   38     References   39 5   HUMAN FACTORS   40     Introduction   40     Relationships between Human Factors, Environmental Factors, and Equipment Factors in Accidents and Incidents   40     Current Initiatives to Reduce Accidents and Incidents Associated with Human Error   41     Improving the Effectiveness of the FAA's Human Factors Projects   42     References   43

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service 6   BARRIERS   44     External Pressures and Influences   44     Coordination and Communications   45     Legal Issues   46     Rulemaking Process   47     Economic Impact   48 7   SMALL AIRPLANES AND ROTORCRAFT   50     Introduction   50     Safety and Safety Management Processes   51     Additional Small Airplane Concerns   52     Additional Rotorcraft Concerns   53     References   54     APPENDICES         A LIST OF FINDINGS AND RECOMMENDATIONS   57     B BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS   60     C PARTICIPANTS IN COMMITTEE MEETINGS   63     D DATA REQUIREMENTS   65     E PROBABILITY AND RELIABILITY ANALYSIS   69     F SAMPLE LEGISLATIVE AMENDMENT FOR APPROVED DESIGN ORGANIZATIONS   73     ACRONYMS   74

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Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA's Aircraft Certification Service Tables and Figures TABLE 3-1   Causes of Aircraft Incidents   27 FIGURES ES-1   Primary cause factors for hull loss accidents involving large U.S.-registered commercial jet airplanes   2 ES-2   The recommended process for aircraft certification safety management,   3 2-1   Current aircraft certification and safety management process   13 2-2   Partial organizational diagram of the FAA and AIR   14 3-1   Worldwide hull loss accident rates, 1959 through 1996   23 3-2   "Spinning disk" view of accident and incident events   24 3-3   Primary cause factors for hull loss accidents involving large commercial jet airplanes worldwide   25 3-4   Primary cause factors for U.S. hull loss accidents involving large commercial jet airplanes   25 3-5   Airplane system cause factors for hull loss accidents involving large commercial jet airplanes worldwide, 1959 through 1996   26 3-6   Airplane-related cause factors in worldwide incidents involving large commercial jet aircraft produced by a particular manufacturer (about 25 percent of the worldwide commercial jet fleet), 1987 through 1996,   27 4-1   The recommended process for aircraft certification safety management   30 4-2   A perspective on safety risk management   34 5-1   Elements for consideration in safety evaluations   41 5-2   Current initiatives to reduce human error contributions to accidents/incidents   42 E-1   Series system   70 E-2   Parallel system   70 E-3   Series-parallel system   70 E-4   Two-out-of-three system   70 E-5   Fault tree diagram of dual-engine failure   71

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