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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
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
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
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
Tables and Figures
TABLE
3-1 |
Causes of Aircraft Incidents |
FIGURES
ES-1 |
Primary cause factors for hull loss accidents involving large U.S.-registered commercial jet airplanes |
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ES-2 |
The recommended process for aircraft certification safety management, |
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2-1 |
Current aircraft certification and safety management process |
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2-2 |
Partial organizational diagram of the FAA and AIR |
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3-1 |
Worldwide hull loss accident rates, 1959 through 1996 |
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3-2 |
"Spinning disk" view of accident and incident events |
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3-3 |
Primary cause factors for hull loss accidents involving large commercial jet airplanes worldwide |
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3-4 |
Primary cause factors for U.S. hull loss accidents involving large commercial jet airplanes |
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3-5 |
Airplane system cause factors for hull loss accidents involving large commercial jet airplanes worldwide, 1959 through 1996 |
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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, |
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4-1 |
The recommended process for aircraft certification safety management |
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4-2 |
A perspective on safety risk management |
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5-1 |
Elements for consideration in safety evaluations |
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5-2 |
Current initiatives to reduce human error contributions to accidents/incidents |
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E-1 |
Series system |
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E-2 |
Parallel system |
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E-3 |
Series-parallel system |
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E-4 |
Two-out-of-three system |
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E-5 |
Fault tree diagram of dual-engine failure |