Lessons Learned From Aviation Accidents Creation of a

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Lessons Learned From Aviation Accidents Creation of a Web-Based Knowledge System Presented to: The

Lessons Learned From Aviation Accidents Creation of a Web-Based Knowledge System Presented to: The National Academy of Sciences By: Daniel I. Cheney, Manager, Safety Programs Federal Aviation Administration

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

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 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 2 2

These accidents included: – Trans World Airways Flight 800 – Swissair Flight 111 –

These accidents included: – Trans World Airways Flight 800 – Swissair Flight 111 – American Eagle Flight 4184 – Alaska Airlines Flight 261 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 3 3

TWA Flight 800 747 crash off the coast of Long Island, NY – Center

TWA Flight 800 747 crash off the coast of Long Island, NY – Center fuel tank exploded in flight • Flawed assumptions regarding fuel tank components National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 4 4

Swissair Flight 111 MD-11 crash off the coast of Nova Scotia – Electrical Arc

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 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 5 5

Alaska Flight 261 MD-80 crash off the coast of California – Loss of control

Alaska Flight 261 MD-80 crash off the coast of California – Loss of control resulting from failure of horizontal stabilizer trim jackscrew • Inadequate lubrication National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 6 6

American Eagle Flight 4184 ATR 72 crash near Roselawn, Indiana – Ice contaminated wing

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 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 7 7

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

Costly lessons from these and many other major accidents were being lost by the passage of time National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 8 8

Accident Awareness • The FAA identified lack of accident knowledge as key factor in

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 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 9 9

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

“Those who cannot remember the past are condemned to repeat it. ” George Santayana Professor of Philosophy Harvard University The Life of Reason, Volume I 1905 Nearly all large transport accidents are enormous human tragedies. • A second tragedy is to not learn from them. National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 10 10

No Aviation-wide accident LL resource was available • • Fear of negative publicity Lengthy

No Aviation-wide accident LL resource was available • • Fear of negative publicity Lengthy investigation/resolution Continual workforce turnover IT tools only recently available National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 11 11

FAA Initiative • The FAA has now developed a web based “Lessons Learned from

FAA Initiative • The FAA has now developed a web based “Lessons Learned from Transport Airplane Accidents” library – Threat based – Search/sort capability National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 12 12

Purpose of Accident Library • Stop and reverse the loss of costly lessons •

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 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 13 13

Summary • A web-based Accident Library is now available to enhance the safety of

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 National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 14 14

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

The Lessons Learned web site will now be demonstrated @ accidents- ll. faa. gov/ National Academy of Sciences Washington, D. C. ; April 18 -19, 2011 Federal Aviation Administration 15 15

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