Emerging Hazards in
Commercial Aviation—
Report 2

Ensuring Safety During Transformative Changes

______

Committee on Emerging Trends in
Aviation Safety

Transportation Research Board

Consensus Study Report

Transportation Research Board Special Report 351

Subscriber Categories: Aviation; safety and human factors

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This study was sponsored by the Federal Aviation Administration.

International Standard Book Number-13: 978-0-309-72100-4
International Standard Book Number-10: 0-309-72100-8
Digital Object Identifier: http://doi.org/10.17226/27805

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COMMITTEE ON EMERGING TRENDS IN AVIATION SAFETY

AMY R. PRITCHETT (Chair), The Pennsylvania State University

CODY H. FLEMING, Iowa State University

R. JOHN HANSMAN, JR., Massachusetts Institute of Technology

CHRISTOPHER A. HART, Hart Solutions LLC

MARGARET T. JENNY, MJENNY STRATEGIES, LLC

PAUL MCCARTHY, PEEMAC, LLC

WILLIAM B. ROUSE, Curis Meditor, LLC

NADINE B. SARTER, University of Michigan

ASHOK N. SRIVASTAVA, Intuit

KATHLEEN M. SUTCLIFFE, Johns Hopkins University

ALYSON G. WILSON, North Carolina State University

Study Staff

LIDA BENINSON, Study Director, Consensus and Advisory Studies, Transportation Research Board

STEPHEN GODWIN, Scholar, Consensus and Advisory Studies, Transportation Research Board

THOMAS R. MENZIES, JR., Director, Consensus and Advisory Studies, Transportation Research Board

DYLAN REBSTOCK, Program Officer, Consensus and Advisory Studies, Transportation Research Board

DANIEL TALMAGE, Program Officer, Board on Human-Systems Integration, Division of Behavioral and Social Sciences and Education

CLAUDIA SAULS, Program Coordinator, Consensus and Advisory Studies, Transportation Research Board

TIMOTHY MARFLAK, Program Coordinator, Consensus and Advisory Studies, Transportation Research Board

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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by CHRIS HENDRICKSON

(NAE), Carnegie Mellon University, and CRAIG PHILIP (NAE), Vanderbilt University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

The committee appreciates the support of the Federal Aviation Administration (FAA) staff in providing background information related to the Commercial Aviation Safety Team, the Aviation Safety Information Analysis and Sharing program, and the Annual Safety Culture Survey.

This report was developed under the overall supervision of Thomas R. Menzies, Jr., Director of Consensus and Advisory Studies, Transportation Research Board (TRB). Lida Beninson, Senior Program Officer, TRB, served as the study director. She and Stephen Godwin, Scholar, TRB, assisted the study committee in the preparation of this report. Dylan Rebstock provided support for report development. Daniel Talmage provided liaison with the National Academies of Sciences, Engineering, and Medicine’s Board on Human-Systems Integration. Claudia Sauls and Timothy Marflak of TRB provided support to the committee in arranging meetings.

The committee would like to thank the following individuals for providing input to this study:

The committee would like to acknowledge the work of the consultants from The Aerospace Corporation who have supported the workshops efforts for this report: Kara Cunzeman, Paul Frakes, Sarah Georgin, Catrina Melograna, Jeffrey Parr, and Paula Pool.

Contents

PREFACE

ACRONYMS AND ABBREVIATIONS

EXECUTIVE SUMMARY

1 INTRODUCTION

Reference

2 CURRENT PREDICTIVE PROCESSES FOR AVIATION SAFETY RISK MANAGEMENT RELATIVE TO TRANSFORMATIVE CHANGES IN AVIATION TECHNOLOGIES AND OPERATIONS

Summary: Federal Aviation Administration Processes for Certification

Summary: Air Traffic and General Operating Rules Within the National Airspace System

Relating Current Federal Aviation Administration Processes to Foreseeable Transformative Changes to Technology and Operations

Performance-Based Standards

Changes to General Operating and Flight Rules

References

3 INTEGRATED SAFETY MANAGEMENT ACROSS THE LIFECYCLE AND ACROSS ORGANIZATIONS

Review of Current Processes for Safety Assurance

Opportunities and Challenges for Data Collection Supporting Safety Assurance with Transformative Changes to Technology and Operations

Opportunities and Challenges for Data Analysis Methods Supporting Safety Assurance with Transformative Changes to Technology and Operations

Opportunities and Challenges for Change Management and Continuous Improvement in Safety Assurance with Transformative Changes to Technology and Operations

References

4 SAFETY CULTURE

Status of the Office of Aviation Safety’s Safety Culture Assessment

Regulatory Safety Culture

Maturing Safety Culture Across the Industry

References

5 INTEGRATED SAFETY MANAGEMENT ACROSS THE LIFECYCLE AND ACROSS ORGANIZATIONS

References

6 CONCLUSIONS

The Overarching Finding: New Concerns Always Emerge

Gaps in the State of the Art on Aviation Safety Management

APPENDIXES

A CASE STUDY HIGHLIGHTING THE MANY CONSIDERATIONS IN DEFINING AND IMPLEMENTING GENERAL FLIGHT AND OPERATING RULES

B PUBLIC WORKSHOP AND MEETING AGENDAS

C STUDY COMMITTEE BIOGRAPHICAL INFORMATION

Boxes, Figures, and Tables

BOXES

1-1 Statement of Task

2-1 Aircraft Safety-Critical Functions

4-1 Hypothesized Dimensions of Regulator Safety Culture

A-1 Regulations Governing Visual Reference Criteria by Which Pilots May Continue an Instrument Landing Approach Below Decision Altitude/Decision Height

A-2 Exact Phraseology for an Air Traffic Control Clearance to Conduct an Instrument Approach

FIGURES

2-1 Layers of defense in current air traffic safety, and the assumptions they are built on

4-1 Safety culture maturity ladder

4-2 Framework for sociotechnical risk

A-1 Representative instrument approach plate in the Aeronautical Information Manual

A-2 Segments of an approach procedure

TABLES

1-1 Safety Management Components and Elements

4-1 Safety Culture Organizational Traits

4-2 Principles and Attributes of Regulator Safety Culture

Preface

I write this preface from the 2024 Experimental Aircraft Association Air Venture gathering in Oshkosh, Wisconsin, a great annual event in aviation. I am struck here by the dichotomy it captures—the value of historical experience (as the old guard shares with the new all their insights on the classic technologies underlying so much of present-day aviation) juxtaposed with the spirit of innovation (shown by all the new things being demonstrated overhead as I type).

This report is written within this tension between the security of the known and the potential for innovation. In the closing chapter of our first report (NASEM, 2022), our committee identified several major potential sources of stress on commercial aviation safety, presenting both challenges and opportunities. These include new technologies, new business models, and new entrants who are not steeped in the same knowledge and culture underlying aviation safety.

Our focus in this report is on transformative changes to technology and operations, which we define as those representing such a step-change that current methods for assessing and managing safety cannot be simply tweaked or extrapolated. We stepped back to examine how and where safety of transformative changes can and needs to be addressed, using the existing safety management principles recommended by the International Civil Aviation Organization as a framework. This framework includes (1) the safety-risk management inherent to designing, evaluating, certifying, and approving new technologies and operations; (2) the safety assurance process of continually monitoring operations for any possible safety

concern; and (3) the aspects of organizational structure and culture that can drive an organization’s ability to support safety in all its aspects.

To learn from the community, we held two workshops that engaged representatives of the Federal Aviation Administration (FAA), those proposing transformative changes to technology and operations, and the aviation safety community. The agendas of these workshops appear in Appendix B. We continued our efforts by engaging with current and former representatives of FAA and experts in safety culture.

Finally, we are grateful for the comments of independent peer reviewers and their perspectives and improvements to the report, whose names were unknown to the committee during the review process.

Amy R. Pritchett, Chair
Committee on Emerging Trends in Aviation Safety

REFERENCE

Acronyms and Abbreviations

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¹ LOSA is referred to as “Line Operation Safety Assessment” in some documents by the Federal Aviation Administration.

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