federal aviation administration presented to: the national academy of sciences by: daniel i. cheney,...

Federal AviationAdministration

Presented to: The National Academy of Sciences

By: Daniel I. Cheney, Manager, Safety Programs

Federal Aviation Administration

Federal AviationAdministrationLessons Learned

From Aviation Accidents

Creation of a Web-Based Knowledge System

2 2Federal AviationAdministrationFederal AviationAdministration

National Academy of Sciences

Washington, D.C.; April 18-19, 2011

Background

During the 1990’s and early 2000’s, several major airplane accidents occurred which exposed errors in:

– Airplane design

– Airline operations

– Maintenance programs

and the processes linking them




These accidents included:

– Trans World Airways Flight 800– Swissair Flight 111– American Eagle Flight 4184 – Alaska Airlines Flight 261




TWA Flight 800

747 crash off the coast of Long Island, NY– Center fuel tank exploded in flight

• Flawed assumptions regarding fuel tank components




Swissair Flight 111

MD-11 crash off the coast of Nova Scotia

– Electrical Arc resulted in cabin insulation material that burned aggressively

• Flawed assumptions regarding burn characteristics




Alaska Flight 261

MD-80 crash off the coast of California

– Loss of control resulting from failure of horizontal stabilizer trim jackscrew

• Inadequate lubrication




American Eagle Flight 4184

ATR 72 crash near Roselawn, Indiana

– Ice contaminated wing surface and loss of airplane control

• Ice built up on unexpected areas of wing




Costly lessons from these and many other major accidents were being lost by the passage of time




Accident Awareness

• The FAA identified lack of accident knowledge as key factor in several major accidents

• Awareness of specific accidents not widespread throughout aviation community




“Those who cannot remember the past are condemned to repeat it.”

George SantayanaProfessor of Philosophy

Harvard UniversityThe Life of Reason, Volume I

1905

Nearly all large transport accidents are enormous human tragedies.

• A second tragedy is to not learn from them.




No Aviation-wide accident LL resource was available

• Fear of negative publicity

• Lengthy investigation/resolution

• Continual workforce turnover

• IT tools only recently available




FAA Initiative

• The FAA has now developed a web based “Lessons Learned from Transport Airplane Accidents” library– Threat based– Search/sort capability




Purpose of Accident Library

• Stop and reverse the loss of costly lessons• Maintain and improve the safety of an already

very safe international aviation system




Summary

• A web-based Accident Library is now available to enhance the safety of an already very safe international aviation system

– Currently available at: http://accidents-ll.faa.gov/– 57 accident modules; more added each year




The Lessons Learned web site will now be demonstrated @ accidents-ll.faa.gov/

federal aviation administration presented to: the national academy of sciences by: daniel i. cheney,...

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