General Aviation Joint Steering Committee Loss of Control Working Groups, Final Report

SE–3 Aeronautical Decision Making SOW ................................................................................16 SE–4 Over Reliance on Automation SOW ................................................................................16 SE–5 and SE–6 Transition Training SOW ................................................................................16 SE–7 Utilization of Type Clubs SOW .......................................................................................16 SE–8 Flight Training After Period of Flight Inactivity SOW .........................................................17 SE–9 Part 135 Safety Culture SOW ........................................................................................17 SE–10 Stabilized Approach and Landing SOW .........................................................................17 SE–12 and SE–13 Weather Technology ..................................................................................17 SE–14 Engine Monitoring Technology SOW .............................................................................17 SE–15 Flight After use of Medications with Sedating Effects SOW ..............................................17 SE–16 and SE–17 Flight with Impairing or Incapacitating Medical Conditions SOW ......................18 SE–21 Risk Based Flight Review SOW ....................................................................................18 SE–22 Flight Data Monitoring SOW ........................................................................................19 SE–23 E–AB/Flight Test SOW ................................................................................................19 SE–24 Single Pilot CRM SOW ................................................................................................19 SE–25, SE–26 and SE–27 Reduce Regulatory Roadblocks (R³) SOW ..........................................19 General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e iii SE–28 Pilot Response to Unexpected Events SOW ...................................................................21 SE–30 Medications List for Pilots SOW ...................................................................................21 SE–31 Test Pilot Utilization and E-AB Proficiency SOW .............................................................21 SE–32 Airman Certification Standards SOW ............................................................................22 SE–33 Safety Culture SOW ...................................................................................................23 SE–34 Outreach SOW ..........................................................................................................23 6.0 Task 6 .........................................................................................................................24 IV. Areas of Focus for Further Study and Technical Studies .........................................................25 Medical Issues and Medications .............................................................................................25 Part 23 Regulatory Reform Aviation Rulemaking Committee .....................................................25 Inclusion of E–LSA in GA Accident Metrics ..............................................................................26 General Aviation Accident Metric ...........................................................................................26 Crashworthiness and Survivability .........................................................................................26 Appendix 1 — LOCWG 1.0 Charter ........................................................................................ A1–1 Appendix 2 — LOCWG 1.0 Participants................................................................................... A2–1 Appendix 3 — LOCWG 1.0 Meetings ...................................................................................... A3–1 Appendix 4 — LOCWG 2.0 Charter ........................................................................................ A4–1 Appendix 5 — LOCWG 2.0 Participants................................................................................... A5–1 Appendix 6 — LOCWG 2.0 Meetings ...................................................................................... A6–1 Appendix 7 — Accident Selection Process ............................................................................... A7–1 Appendix 8 — Accident Set Reviewed by the LOCWG 1.0 ......................................................... A8–1 Appendix 9 — Accident Set Reviewed by the LOCWG 2.0 ......................................................... A9–1 Appendix 10 — Technical Briefings Provided to LOCWG 1.0 .................................................... A10–1 Appendix 11 — Technical Briefings Provided to LOCWG 2.0 .................................................... A11–1 Appendix 12 — GAJSC Approved Safety Enhancements ......................................................... A12–1 Appendix 13 — Standard Problem Statements ...................................................................... A13–1 Appendix 14 — LOCWG 1.0 Prioritized Interventions ............................................................. A14–1 Appendix 15 — LOCWG 2.0 Prioritized Interventions ............................................................. A15–1 Appendix 16 — Intervention Feasibility ................................................................................ A16–1 Appendix 17 — LOCWG 1.0 Bucketed Interventions............................................................... A17–1 Appendix 18 — LOCWG 2.0 Bucketed Interventions............................................................... A18–1 Appendix 19 — LOCWG 1.0 Example of Event Sequence ........................................................ A19–1 Appendix 20 — LOCWG 2.0 Example of Event Sequence ........................................................ A20–1 General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e iv TABLE OF FIGURES Figure 1.1 – GAJSC Process Overview following 2011 Revisions ..................................................... 2 Figure 1.2 – GAJSC Fatal Accident Pareto Calendar Year 2001−2011 .............................................. 3 Figure 3.1 – Example Prioritization Sorting .................................................................................10 Figure 4.1 – SE Effectiveness Score ...........................................................................................12 Figure 4.2 – SE Accident “Count” Against 30 Randomly Selected LOC Accidents ..............................12 Cover Photo Courtesy of the Aircraft Owners and Pilots Association (AOPA) General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 1 I. GAJSC Loss of Control Working Group Background The General Aviation Joint Steering Committee (GAJSC) was reestablished in January 2011 after several years of being dormant. It originally was created in the mid-1990s to parallel the Commercial Aviation Safety Team (CAST) under the Safer Skies initiative. The GAJSC had many successes through the mid-2000s, including the Federal Aviation Administration’s (FAA) annual General Aviation and Air Taxi Activity Survey, which provided the FAA and industry with credible data on flight hours, from which meaningful accident rates could be computed. However, industry and FAA involvement subsided and the committee was inactive by 2010. The impetus for reforming the GAJSC came from the Secretary of Transportation and the Future of Aviation Advisory Committee (FAAC). In its final report, the FAAC Safety Subcommittee identified the need to refocus joint FAA/industry work1 on proactive and cooperative safety analysis to reduce the fatal accident rate in general aviation. The FAAC Safety Subcommittee also determined it was necessary to emphasize the FAA’s strategic plan, also referred to as the “Flight Plan”. The GAJSC sought to avoid previous problems by adopting a structured, strategic process and making its work data driven (see figure 1.1 for the revised GAJSC process). This ensures analytical credibility and would allow the FAA and industry to plan for implementation activities. The GAJSC noted it was essential to keep any ongoing projects from the previous incarnations of the committee and therefore directed the Safety Analysis Team (SAT) to inventory ongoing activities. In the spring of 2011, the GAJSC also tasked the SAT to conduct a review of GA accidents and determine the priorities for joint FAA/Industry analysis of risks leading to fatal GA accidents. 1 FAAC, Safety Recommendation, #3 “Voluntary Safety Data” and #5 “Identification of Safety Priorities.” General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 2 Figure 1.1 – GAJSC Process Overview following 2011 Revisions The GA fatal accident rate is one of the metrics the FAA’s Aviation Safety organization monitors. While the FAA established a GA safety metric under the Safer Skies initiative based on the number of annual fatal accidents that occurred2, industry and the FAA jointly transitioned to a rate based metric in 2007. The FAA and industry agreed to base the new metric on the three safest years in GA (2006−2008)3 and plan for an annual improvement of a one percent reduction in the fatal accident rate. Meeting this reduction would result in a fatal accident rate of no greater than one fatal accident per 100,000 hours flown by 2018. It should be noted that the three year baseline did not include hours flown by two-place ultralight – now certificated Experimental Light-Sport Aircraft. The SAT decided to focus on fatal accidents in Title 14 Code of Federal Regulations (14 CFR) part 91 GA operations, on demand 14 CFR part 135 operations, and 14 CFR part 137 aerial application operations. While FAA safety efforts in air carrier operations have moved from analysis of fatal accident data to more proactive work analyzing incidents and non-fatal accidents, the SAT determined such preventative work was not appropriate because of the number of fatal accidents in GA. Instead, it recommended the FAA and the GA industry undertake root cause analysis of fatal GA accidents, an undertaking not conducted since the early 2000s. The FAA developed an overview of the 2001−2010 fatal GA accidents. It determined 40.2 percent of fatal accidents, or 1,259, were identified as “Loss of Control” (LOC) according to 2 The FAA and industry jointly established a safety metric in the mid-1990s based on the number of fatal accidents in 1 year. At that time, industry and the FAA were reluctant to establish a rate based metric because of limitations in the exposure data from GA. Through joint work under the GAJSC General Aviation Data Improvement Team, the exposure data (hours flown) was improved and currently has an accuracy of approximately 1.6 percent Standard Error, which was deemed acceptable for transitioning to a rate based metric and goal for GA safety for 2007–2018. 3 The 3 years with the fewest fatal accidents since World War II were 2006–2008. Converted to a rate, these years experienced 1.12 fatal accidents per 100,000 hours flown. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 3 the CAST−International Civil Aviation Organization (ICAO) Common Taxonomy.4 The GAJSC, being data driven, decided to focus on LOC, the highest risk area. It also plans to conduct future work in other accident areas. Figure 1.2 – GAJSC Fatal Accident Pareto Calendar Year 2001−2011 The GAJSC decided to focus the first LOC working group on accidents which occurred during the “approach and landing” phase of flight because of its applicability to the three main GA aircraft certifications: experimental amateur built, certified piston engine airplanes and turbine airplanes. At its April, 26, 2011, meeting, the GAJSC approved the charter and formation of the first LOC working group (see appendix 1) to examine approach and landing accidents (see appendix 8). Its membership consisted of appropriate government and industry subject matter experts (SME) to support the project over nine months. At its October 3, 2012, meeting, the GAJSC approved the subsequent charter and formation of the second LOC working group (see appendix 4) to examine the remaining en-route and departure accidents (see appendix 9). Its membership consisted of SMEs that would support the project over 12 months. Organization The first Loss of Control Working group (LOCWG 1.0) focused on approach and landing accidents, held its first meeting in September, 2011, at the headquarters of the Aircraft Electronics Association (AEA). It was scheduled to begin work in August 2011, but the FAA’s temporary funding problems prevented a number of key LOCWG 1.0 members from participating. The LOCWG 1.0 was co-chaired by the Experimental Aircraft Association (EAA) and FAA Flight Standards (AFS−850), with technical support and process guidance provided by the FAA’s Office of Accident Prevention and Analysis (AVP). 4 The CAST-ICAO Common Taxonomy Team (CICTT) was formed in the late 1990s to standardize accident analysis taxonomy in aviation. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 4 The LOCWG 1.0 had three sub teams based on the accident selection subsets of experimental amateur-built, certified piston engine airplanes, and turbine engine powered airplanes. Appendix 3 contains a list of the seven meetings of the LOCWG 1.0, including its hosts. All participating organizations in GAJSC were offered an opportunity to nominate technical experts based on the expertise identified in the LOCWG 1.0 charter. The final membership of the LOCWG 1.0 is included in appendix 2. The second Loss of Control Working group (LOCWG 2.0), focused on en-route and departure LOC accidents, and held its first meeting in September 2012 at the headquarters of the Aircraft Electronics Association (AEA). The LOCWG 2.0 was co-chaired by the Aircraft Owners and Pilots Association (AOPA) and the FAA Flight Standards (AFS-850). Appendix 6 contains a list of the seven meetings of the LOCWG 2.0, including its hosts. The final membership of the LOCWG 2.0 is included in appendix 5. II. Scope of This Report This report is organized according to the following tasks contained in the LOCWGs charters: 1. Conduct an in depth analysis and review of the Loss of Control accidents provided by the SAT. The SAT established a statistically acceptable process to reduce the 1,259 accidents that occurred during 2001–2010 into a data set that can be practically reviewed by the working groups within the timeframe. 2. Review and determine the applicability of other work done in the area of LOC. This work includes the Flight Safety Foundation’s Approach and Landing Accident Reduction (ALAR) tool kit. 3. The working groups will develop and prioritize safety intervention strategies that will reduce the potential for LOC accidents. In addition to documenting its analysis results and recommended intervention strategies, the working group will also document its assumptions regarding the analysis. 4. The working groups will present the prospective interventions to the GAJSC for review and approval. The report will include the analysis and rationale for how the intervention strategies were dispensed. 5. Following the GAJSC’s approval of the interventions, the working group will develop a detailed implementation plan (DIP) for each intervention. Each DIP will contain—  Prioritized implementation strategies,  Parties responsible for action,  Major implementation milestones,  Metrics to monitor progress in meeting these milestones, and  Metrics for tracking success of the interventions. The working group will present each DIP to the GAJSC for review and approval. Using the experience gained through the first working group, LOCWG 2.0 decided the DIPs were both difficult to create and cumbersome to track the responsible association General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 5 and tasks. Instead of creating and presenting DIPs, the second working group created comprehensive Safety Enhancements (SEs) for consideration – clearly stating expected timeline, responsible parties, and tasks. 6. The working groups provided feedback to the GAJSC about what worked and what did not work with respect to this process to help assist with future working groups. Additionally, the report includes recommendations for areas of further investigation are included at the end of the report (section IV). The appendices contain detailed information about the analysis and processes used by the LOCWG in formulating the safety enhancements (SE). III. Taskings 1.0 Task 1 The working group conducted an in depth analysis and review of the LOC accidents provided by the SAT. The SAT established a statistically acceptable process to reduce the LOC accidents that occurred during 2001 through 2010 into a data set that can be practically reviewed by the working group within the timeframe provided. The number of GA accidents from 2001 to 2010 made a detailed review of all fatal accident, including all LOC accidents, prohibitive from a time and resource perspective. To address the issue of data volume, the SAT asked the GAJSC participants from the Center for Excellence in General Aviation Research (CGAR) to develop a method to select representative accidents to be used by the LOCWG in their analysis. For LOCWG 1.0, the GAJSC members from CGAR randomly selected 60 accidents for turbine, certified piston airplanes, and experimental amateur built aircraft respectively. From the 60 randomly selected accidents given to each sub group, the first 30 well documented accidents from the lists were analyzed in detail. The detailed process for accident selection is included in appendix 7. For LOCWG 2.0, members of CGAR randomly selected a total of 120 LOC accidents, irrespective of certification basis. The 120 randomly selected accidents were subsequently reduced to the first 90 well documented accidents. Differing from the first working group, LOCWG 2.0 utilized two sub teams to analyze 90 selected accidents. It was determined through the previous working group that causal factors were not specific to aircraft certification, eliminating the need to segment the accidents and subject matter experts. The National Transportation Safety Board (NTSB) assisted by compiling the accident dockets containing additional information about the accident sequence and pilot data, including post mortem information from the medical examination, to facilitate the root cause analysis. 2.0 Task 2 The working group reviewed and determined the level of applicability of other work done in the area of LOC and approach and landing accidents. This work includes the Flight Safety Foundations Approach and Landing Accident Reduction (ALAR) tool kit. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 6 The working groups took advantage of the expertise of its individual members and invited SMEs. The SMEs provided briefings about angle of attack indicators, electronic recovery control system, upset recovery training, and the use of prescription and over the counter drugs. A list of these briefings is included in appendix 10 and 11. The LOCWG considered the solutions on existing work conducted in the area of LOC offered during the briefings. When applicable to the risks identified in this study, the LOCWG incorporated these fixes into the final recommendations. 3.0 Task 3 The working group developed and prioritized safety intervention strategies that will reduce the potential for LOC accidents occurring in the future. In addition to documenting its analysis results and recommended intervention strategies, the working group also documented its assumptions regarding the analysis. 3.1 Methodology Sub teams of the LOCWG membership, three in LOCWG 1.0 and two in LOCWG 2.0 were assigned a set of accident reports to analyze. Each sub team utilized an event sequence spreadsheet (see appendixes 19 and 20). Each spreadsheet included the events necessary to provide context for understanding the nature of the accident sequence. The sub teams then evaluated the events to determine if they represented a “problem” involving hardware/software failure or human execution errors, decisions, or procedural noncompliance. If the sub team members considered an event was considered contributory to the accident, they developed a statement describing why it contributed to the accident. They identified the specific nature of the problem associated with an event in the sequence along with the factors that could have precipitated the problem. These contributing factors were then restated in more general terms as standard problem statements (SPS) to make them relevant beyond the specific accident. The list of SPS continues past each working group, making them available to subsequent working groups. The sub teams rated the standard problem statements as described below. They developed potential interventions to address each standard problem statements. Appendix 16 contains a list of potential interventions, and appendix 13 lists the standard problem statements the LOCWGs used, along with their respective frequencies. 3.2 “Standard Problem Statement” Rating System Ratings The sub teams used the following rating factors to prioritize the interventions: power (P); confidence (C); and applicability (A). They determined the overall effectiveness (OE) using the scores assigned to “P,” “C,” and “A.” Power indicates how important a problem was to an accident and the degree to which an intervention could have resolved the problem and broken the chain of events. There was confusion in previous CAST Joint Safety Analysis Teams (JSAT) about the practical meaning of power. In practice, “P” sometimes was scored to indicate the relative power of General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 7 the targeted problem in the accident; at other times it indicated the power of an intervention to resolve a specific problem and thereby break the chain of events. As a result, “P” often failed to integrate the two concepts and instead scored one side of the concept to the exclusion of the other. Recognizing this confusion, the process changed following the Approach and Landing JSAT. The two factors within outlined above were partitioned into “P1” and “P2” so each could be rated separately. P1 indicates the importance of the problem or contributing factor as a causal link in the accident. P2 indicates the ability of the rated intervention to mitigate the problem or contributing factor. The 0−6 rating scales used to evaluate P1 and P2 were similar to those used for previous ratings. The two scores were combined arithmetically to produce a single power rating. This explicitly addressed the past confusion and yielded a single power score conceptually equivalent to the power rating used by previous CAST Joint Safety Analysis Teams (JSATs). The LOCWG incorporated the change into revised process guidelines. In sum, P1 focuses on the problem or contributing factor, while P2 focuses on the intervention. Confidence indicates how strongly the respective sub team believed everyone and everything would perform as expected if the interventions were implemented. The confidence factor assesses the real world, in which interventions are seldom perfect or 100 percent effective. Applicability indicates how frequently the problems being addressed by the specific intervention recur. Applicability provides a bridge from the specifics of the accident to future operations. Overall Effectiveness To support prioritization of the proposed interventions, the sub teams ranked each intervention by its overall effectiveness. To do this, it was necessary to reduce the P/C/A ratings to a single value that roughly approximated Overall Effectiveness (OE). The intent was for the OE score to provide the first sort of the interventions. The following algorithm is used to convert P/C/A to OE: OE = P x C/6 x A/6 = P x C x A/36 Appendixes 13 and 14 list the interventions ranked by OE. 3.3 Bucketed Interventions The LOCWG 1.0 three subgroups proposed 204 individual interventions. They “bucketed” or grouped the interventions according to common themes or concentration areas such as training, policy, technology, medical, and miscellaneous (for the list of bucketed interventions, see appendix 17). This resulted in a manageable number of 98 interventions that were divided between two groups responsible for assessing the feasibility of each intervention. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 8 LOCWG 2.0 two subgroups proposed 187 new individual interventions (see appendix 18). These new interventions were bucketed using the same methodology from the first working group. This resulted in a manageable number of 97 new interventions in which feasibility was assessed. 3.4 Assigning Feasibility The feasibility assessment was accomplished by assigning a numerical value to each intervention for each of the following six elements: 1. Technical, 2. Financial, 3. Operational, 4. Schedule, 5. Regulatory, and 6. Sociological. Feasibility values of 1, 2, or 3 were assigned to each feasibility element and are described as follows: Technical feasibility is the ability of the project to take advantage of the current state of technology in pursuing further development. 3—Off−the−shelf technology, no development required. 2—Some development required, not currently in public use. 1—Major technology development effort required. Financial feasibility should consider the total cost of the implementation, including the planning process. Financial feasibility also involves the capability of the participating organizations (FAA, manufacturers, and air carriers and operators) to provide the appropriate funding needed to implement the project. 3—Less than $100 million to implement. 2—Between $100 million and $250 million to implement. 1—Greater than $250 million to implement. Operational feasibility involves the practicality of the project within the context of the operating environment including areas such as the National Airspace System, ground operations, maintenance, and inspection. It also considers which organizations within the aviation system are affected and the degree of the impact. 3—Minimal change to entities within the operating environment. 2—Modest change to operating environment. 1—Major change to operating environment. Schedule feasibility addresses whether the project can contribute to achieving the goal in a selected timeframe. It must consider implementation schedule by project. 3—Less than 2 years to full implementation. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 9 2—Full implementation in 2−5 years. 1—Longer than 5 years to full implementation. Regulatory feasibility should be evaluated against current rules and certification process. A long approval process could be a deterrent. 3—No policy change. 2—Guidance change only (orders, handbooks, policy). 1—Rule change. Sociological feasibility requires an evaluation of the project goals’ compatibility with the prevailing goals of the political system. Worthy projects may face heavy opposition because of political factors. 3—Positive push from political system. 2—Neutral. 1—Negative. Once the working groups completed all the feasibility evaluations, they collated their numbers and added the value for each feasibility element and the average value for that project into the spreadsheet. To build consensus and ensure the values were defendable, the LOCWG reviewed the numerical assessments for each feasibility element after the working groups entered all the values. 3.5 Generate Color coded Spreadsheets The initial step in generating color coded spreadsheets was to numerically sort the interventions by the overall effectiveness and feasibility ratings. This sorting identified clusters in the data where colors can be assigned. The LOCWGs set break points for effectiveness and feasibility wherever naturally occurring breaks appeared between clusters of ratings. These breakpoints will be different for future working groups. With the Overall Effectiveness and Average Feasibility columns populated, the spreadsheet was ready for use with an Excel feature called “Conditioning.” This is a method of applying criteria to a set of numerical values and highlighting these in color. The condition format can be applied to the whole spreadsheet or a section, and the specific criteria may vary depending upon where the natural breakpoints occur in the ratings. Colors for the LOCWG were assigned as follows: Overall Effectiveness Feasibility Red 0 to 2 0 to 2 Yellow 2 to 3 2 to 2.6 Green 3 to 5 2.6 to 3 Assigning red, yellow, and green colors permitted the working group to present interventions in instructive visual displays. For example, interventions with effectiveness “greens” could be clustered; or they could be clustered together with feasibility “greens.” The combination of numerical sorting and color conditioning is a very powerful tool. The visually coded General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 10 numerical values give a strong sense of priority and order, and they help to visually segregate the data. 3.6 Prioritize Interventions The LOCWGs’ next step was to determine the product of the overall effectiveness rating and the feasibility rating. The LOCWG multiplied OE, the already determined overall effectiveness value, by F, the feasibility value determined by the subgroups, to generate a rating used to determine priorities of interventions. This resultant product, OE x F, was captured in the spreadsheet and shown in a separate column. The interventions should be sorted based on this product value to aid in their prioritization. This sort portrayed how the color codes for effectiveness and feasibility compare (green green, green yellow, etc.). Figure 3.1 is an example from the LOCWG 1.0. Figure 3.1 – Example Prioritization Sorting Based upon the resulting sort of OE x F, a cutoff value for OE x F was determined to identify the interventions most effective at reducing accident rates. The cutoff value for OE x F will vary between working groups. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 11 For each intervention contained in this OE x F “product value set,” the associated intervention buckets were identified. These bucket areas and their remaining interventions were determined to be the high priority project areas. A new spreadsheet was generated based upon a resorting of the data by intervention bucket and the product (OE x F). This provided the teams with a visual representation of the high priority project areas, their associated interventions, and the color coded relationships for all of the interventions within each specific project area. 3.7 Establish Safety Enhancements (SEs) The high priority project areas were reassigned to the sub teams. The first task of the sub teams was to organize the interventions in their respective buckets into Safety Enhancements (SEs). An SE is a plan containing one or more intervention strategy to prevent or mitigate a problem associated with the cause of an accident. The teams identified the agencies, organizations, or associations potentially affected by the outputs or actions of their specific SE. One or more individuals from each of these agencies and organizations were identified and their assistance solicited to act as working group members during the SE drafting and planning phase. It is important to note that the team may require the assistance of the GAJSC in identifying individuals of various agencies and organizations and obtaining approval for participation of the working group members. Common contributing factors from the first working group were evidenced through the analysis of the second working group. 19 interventions that were above the LOCWG 2.0 cut off line were interventions used in developing LOCWG 1.0 Safety Enhancements. Due to the fact that the interventions were already being enacted as part of an existing approved SE, no further action was warranted but strengthened the prior analysis and need for action. 4.0 Task 4 The working group presented the prospective interventions identified for implementation to the GAJSC for review and approval. The analysis and rationale for how all the intervention strategies were dispensed was included in the report. 4.1 Developed SEs The LOCWG 1.0 developed 28 SEs, which were presented to the SAT in May 2012. The SAT undertook an effectiveness assessment of the 28 SEs against 30 randomly selected LOC accidents. The scores developed during this assessment were used as an additional tool for the GAJSC’s decision making process on which SEs would be assigned resources for implementation as part of the FAA Industry General Aviation Safety Plan. The LOCWG 2.0 developed nine new SEs, which were assessed by the SAT using the same process and methodology as the first working group’s SEs. 4.2 Accident Analysis Methodology Compared to CAST Unlike the process used by CAST, because of the large number of accidents, the SAT did not score the SE effectiveness against all LOC approach and landing accident or the full set of fatal accidents between 2001 and 2011. As a result, the effectiveness scores and analysis are General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 12 intended to be a decision tool as opposed to a comprehensive analysis of the aggregate effectiveness. 4.3 Rating the Effectiveness of the SEs The SAT assessed the effectiveness of each SE in mitigating the randomly selected accidents on a scale of 0.0 through 1.0. The effectiveness was scored which resulted in an effectiveness rating as shown in Figure 4.1 for LOCWG 1.0. Additionally, Figure 4.2 shows the number of times (that is, “counts”) each SE was identified as having any effectiveness in mitigating the contributing risks found in each of one of the randomly selected accidents. Figure 4.1 – SE Effectiveness Score Figure 4.2 – SE Accident “Count” Against 30 Randomly Selected LOC Accidents General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 13 4.4 GAJSC Presented the Effectiveness Ratings of the SAT At the GAJSC meetings, the SAT and working groups presented the effectiveness analysis for approval consideration. 4.5 GAJSC Approved List of SEs The GAJSC approved 29 individual SEs with the Lead Organization for Overall Output Coordination (LOOC). Appendix 12 contains the approved SEs. LOCWG 2.0 presented new outputs for SE-5, Transition Training and SE-25, New Safety Technologies, and SE-15, Flight after use of Medications with Sedating Effects. 5.0 Task 5 Following the GAJSC’s approval of the interventions, the LOCWG 1.0 developed a detailed implementation plan (DIP) for each intervention. LOCWG 2.0 chose not to create DIPs due to the difficulty in creating and tracking the plans that contained multiple SEs. 5.1 Scope of this Section This section contains the statement of work (SOW) for each recommended SE’s DIP and the methodology used in developing the SOWs and DIPs. The entire DIP for each SE is located in appendix 12. 5.2 Methodology – Development of DIPs The DIPs contain the following elements: SOW, SE Description, Score, Total Resource Requirements, Outputs (with Resources, Lead Organization for Output Completion (LOOC), Timelines, and Actions), Relationship to Current Aviation Initiatives, and Performance Goals and Indicators. A description of the elements follows. 1. The SOW should, using brief, clear, and unambiguous text, include a description of the project’s objective, a brief statement of the approach, and the outcome(s). 2. The LOCWG 1.0 was responsible for the identification of the LOOPC, the roles and responsibilities of which include—  Overseeing completion of necessary outputs (critical path elements, progress against the plan),  Conducting program status checks at predetermined implementation process milestones to verify performance against plan and completion of tasks,  Ensuring detailed plans are in place to achieve the project outputs,  Identifying and communicating resource needs to GAJSC, and  Reporting to the SAT the progress against the plan and the completion of tasks. 3. The SE description is a brief synopsis of the activity to prevent or mitigate a problem associated with the cause of an accident. 4. The SAT determined the score and prioritizes based on the relative ranking of SEs for potential risk reduction. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 14 5. Resource requirements apply to organizational effect and financial or material requirements to complete the output. The LOCWG 1.0 also was responsible for identifying the LOOC, the roles and responsibilities of which include—  Developing and implementing plan to accomplish that output,  Identifying and communicating resource needs to the Lead Organization for Overall SE Completion,  Reporting to the LOOPC the progress against the plan and the completion of tasks, and  Ensuring plans for output accomplishments contain an adequate number of milestones for program status checks and recovery actions before program end date. 6. Outputs are defined as the products and services produced and delivered or implemented in support of the stated SE. 7. Relationship to current aviation community initiatives are ongoing programs directly related to a specific output. 8. Performance Goals and Indicators for SEs are defined as the target levels of performance expressed as a tangible, measurable objective against which actual performance can be compared within specified time frames, including goals as quantitative standards, values, or rates. Performance goals may be applied to processes, outputs, and outcomes. They can be characterized as the expected benefit of the projects in accidents prevented. Performance indicators are measures applied to a process, output, or SE to ascertain the extent to which performance goals are met. This will be characterized as the methodology to measure the effectiveness of the intervention. The LOCWG's minimum requirement for DIPs is that they contain strategies for implementing the interventions in the selected projects that are above the selected OE x F cutoff value. Whenever possible, the lower ranked interventions should be included in the detailed plans unless the inclusion would result in activities requiring excessive resources or time to implement. 5.3 Methodology – LOCWG 2.0 Revised Safety Enhancements Due to the difficulty in creating and tracking a DIP which contained several SEs and multiple organizations responsible for coordination and tracking, the LOCWG 2.0 made the decision to eliminate the DIPs and focus on Safety Enhancements. To further aid in the tracking and communicating its intent, the working group revised the SE template to contain the following. 1. Summary: Clearly lays out the Lead Organization for Overall Output Coordination (LOOC) and lists the outputs contained in the SE. This is then followed by the estimated cost for SE completion, the completion goal – expressed in months or years after SE approval, and the date of SE approval. 2. Statement of Work: In order to make the intent more clear, this section was expanded to include specifics of what the SE is trying to fix. Additionally, the SE now included the intervention that generated the SE – providing justification reasoning. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 15 3. Outputs: Outputs are listed in order with completion goal and LOOC clearly stated. 4. Actions: The list of specific actions is presented chronologically. 5. Additional resources: Provided to assist LOOC in accomplishing SE. 6. Relationship to Current Aviation Community Initiatives: Ongoing programs that are directly related to the output. 7. Implementation Order: Gantt chart developed to clearly show the order of output implementation, relationship to other outputs, SE approval date, and associated timelines. 5.4 Safety Enhancements SE–1 Angle of Attack Systems—New and Current Production SOW To reduce the risk of inadvertent stall/departure resulting in LOC accidents, the GA community should install and use AOA based systems for better awareness of stall margin. AOA systems are not in wide use in GA. The GA community should embrace to the fullest extent the stall margin awareness benefits of these systems. To help the GA community understand the safety benefits of AOA systems, a public education campaign should be developed by industry and the FAA. GA aircraft manufacturers should work to develop cost effective AOA installations for new and existing designs currently in production. Owners and operators of GA aircraft should be encouraged to have AOA systems installed in their aircraft. The DIP on this subject originally targeted the simple, low cost AOA systems currently available for GA airplanes. During development, it became obvious that other, more complex approaches offer safety benefits for airspeed/energy state awareness. For example, concepts such as fast/slow cues and pitch limits are examples of AOA based information that should be explored for use in the GA community. SE–2 Angle of Attack Systems—Existing GA Fleet SOW To reduce the risk of inadvertent stall/departure resulting in LOC accidents, the GA community should install and use AOA based systems for better awareness of stall margin. AOA systems are not in wide use in GA. The GA community should embrace to the fullest extent the stall margin awareness benefits of these systems. To help the GA community understand the safety benefits of AOA systems, a public education campaign should be developed by industry and the FAA. GA aircraft manufacturers should work to develop cost effective AOA installations and retrofit systems for the existing GA airplane fleet. Owners and operators of GA aircraft should be encouraged to install AOA systems in their aircraft. The DIP on this subject originally targeted the simple, low cost AOA systems currently available for GA airplanes. During development, it became obvious that other, more complex approaches offer safety benefits for airspeed/energy state awareness. For example, concepts such as fast/slow cues and pitch limits are examples of AOA based information that should be explored for use in the GA community. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 16 SE–3 Aeronautical Decision Making SOW To reduce the risk of loss of control accidents, the GA community should develop and implement a flight safety program focusing on aeronautical decision making (ADM). The initiative should focus on ADM in preflight planning; professional decision making; flight risk assessment tools (FRAT); and stabilized approaches, missed approaches, and go arounds. SE–4 Over Reliance on Automation SOW Purpose: To reduce the risk of LOC accidents by improving certain aspects of flight training related to over reliance on automated flight systems. Over reliance on automated flight systems has resulted in LOC accidents. The FAA and industry should encourage training that requires pilots to demonstrate proficiency in manual flying in the event of automation malfunction. As the lead organization, the FAA will promote existing publications that properly address the need for manual flying skills in the event of automation malfunction or failure. SE–5 and SE–6 Transition Training SOW Transition training is not uniformly applied leading to accidents resulting from unfamiliarity with airframe and/or equipment. To reduce the risk of loss of control accidents, the GAJSC recommends the development of Web based tools that will aid in all aspects of transition to unfamiliar aircraft across GA, to include ADM (see ADM Detailed Implementation Plan), to identify the risk of inadequate training when operating unfamiliar equipment. The FAA and industry should update existing documentation relating to transition training. The FAA and industry should conduct an outreach campaign on the need for transition training including ADM when flying an airplane that is unfamiliar to the pilot. The FAA and industry should work with type clubs and associations to incorporate best practices from advisory material and promote use and training in those communities. The FAA in conjunction with industry organizations, type clubs, and kit manufacturers/makers of experimental amateur built aircraft will reach out to pilots of these aircraft to encourage education on operationally specific requirements. The FAA should amend current policy5 that restricts type specific training in rented, kit, or experimental amateur built aircraft to allow proper transition training and reduce accidents. SE–7 Utilization of Type Clubs SOW Type Clubs are groups of owners and operators centered around particular aircraft. To reduce LOC accidents, GAJSC will leverage type clubs to develop and disseminate critical safety related information. The owners/operators of type clubs are most familiar with operating characteristics and procedures specific to particular aircraft and are in an excellent position to develop, communicate, and promote safety mitigation strategies that target loss of control accidents. 5 FAA Order 8900.1 CHG 155 Volume 3, Chapter 11 – Use of Aircraft Issued Experimental Airworthiness Certificates in Flight Instruction for Compensation or Hire. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 17 Accordingly, the GAJSC will leverage type club owners/operators’ knowledge and experience. Large fleet aircraft operators, such as large flight schools, are also very familiar with the operating characteristics and procedures specific to particular aircraft. The GAJSC also will leverage these organizations for safety strategies that target loss of control accidents. SE–8 Flight Training After Period of Flight Inactivity SOW Purpose: To reduce the risk of LOC accidents by improving certain aspects of flight training related to the return to flying after periods of flight inactivity. Flight inactivity has resulted in LOC accidents. In partnership with industry organizations, the FAA should lead the promotion and dissemination of information on the adverse effects of flight inactivity. SE–9 Part 135 Safety Culture SOW To reduce LOC accidents, the GA community should advocate that part 135 operators conduct mixed operational missions under safety criteria similar to those governing commercial flights to increase safety margins and promote professionalism. SE–10 Stabilized Approach and Landing SOW The FAA and industry will review the adequacy of the existing guidance and advisory material (including Practical Test Standards (PTS) on stabilized approaches and go arounds. Guidance and advisory material will be updated to include emphasis on stabilized approaches throughout various scenarios: wind, balked landings, and go arounds. SE–12 and SE–13 Weather Technology To reduce the risk of accidents due to weather related factors, pilots should rely upon accurate real time weather reporting. While ground based weather reporting systems (such as the Automated Weather Observing System or Automated Surface Observing Systems) have proliferated, remote installation of weather cameras can help provide additional and real time weather information to pilots. Further, there are current weather reporting technologies available about which some pilots may not be aware. SE–14 Engine Monitoring Technology SOW To reduce the risk of loss of control accidents due to engine failure related factors, the FAA and industry will review the current technological capabilities available for engine trend monitoring, engine health analysis, fuel management, and fuel indicator systems. Based on the existing available capabilities, the FAA will update guidance to promote their use. The FAA and industry will develop an educational outreach program to expand the installation and use of these systems. SE–15 Flight After use of Medications with Sedating Effects SOW To reduce the risk of pilot impairment or incapacitation resulting in loss of control accidents, the GA community should implement programs to reduce the likelihood of the use of over General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 18 the counter and prescription sedating medications that adversely affect the pilot’s ability to safely operate aircraft. Tools to improve pilot knowledge about the safe use of sedating medications are available to airmen, but knowledge and use of these tools is not widespread in GA. Additionally, these tools may not meet the needs of the GA community. The GA community should strive, to the fullest extent possible, to improve pilot knowledge and prevent the use of sedating medications that adversely affect flight safety. To help the GA community understand the safety benefits of informed use of medications, industry groups, academia, the FAA, insurance providers, and the medical community should develop educational tools, online reference materials, and surveys (both pre and post implementation) to reduce the risk of pilots inadvertently flying under the influence of over the counter or prescription medications that might adversely affect their ability to safely operate aircraft. SE–16 and SE–17 Flight with Impairing or Incapacitating Medical Conditions SOW To reduce the risk of medical conditions known to the pilot causing in flight impairment or incapacitation resulting in loss of control accidents, the GA community should implement programs to reduce the likelihood of airmen failing to disclose known medical conditions and/or flying with known medical conditions that could adversely affect their ability to safely operate aircraft. Barriers to open/honest communication between airmen and Aviation Medical Examiners (AME) have resulted in airmen failing to disclose possibly impairing medical conditions and subsequently flying with conditions that have contributed to in flight impairment and or incapacitation. The FAA Office of Aerospace Medicine (AAM) and the Aerospace Medical Association in conjunction with the Aircraft Owners and Pilots Association (AOPA) should develop methods or techniques and perform a study (or studies) that will help determine then mitigate barriers to an open and honest communication between pilots and their AMEs and develop methods to improve professionalism of pilots and their ability to conduct accurate medical self-assessment before each flight. SE–21 Risk Based Flight Review SOW To reduce LOC accidents due to reoccurring causal factors, the GAJSC will yearly, provide to the training and instructor community, a report of issues and risks found by the risk based working groups (such as LOCWG). These issues and risks can be used to develop a risk based flight review special emphasis initiative. Once a pilot has been certificated, the only opportunity to evaluate skill levels and emphasize areas of special concern is during the pilot’s biannual flight review. The GAJSC will work with the flight training and instructor community to get this information to certificated flight instructors (CFI) to have the areas of special concern included in all flight reviews. The program would have the flight training and instructor community provide feedback on the results and provide recommendations back to the GAJSC. The GAJSC will also provide the areas of concern to flight schools and include them in the program. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 19 SE–22 Flight Data Monitoring SOW To reduce the risk of loss of control accidents by using Flight Data Monitoring (FDM) as a source of data support in overall industry wide safety initiatives. GA FDM allows the GA community to use the benefits previously afforded to 14 CFR part 23 aircraft in approved Flight Operational Quality Assurance (FOQA) programs. The growing emphasis on formalized safety initiatives in GA has increased the need for diverse data collection methodologies from diverse sources to provide feedback. The use of FDM had not been widely accepted in GA at the time of this analysis. The GA community should strive to encourage the acceptance and expansion of FDM programs to increase the amount of data collected. To exploit these opportunities, the FAA and industry should develop a GA community campaign. GA aircraft manufacturers should work to develop cost effective FDM installations for new type designs and existing type designs currently in production. GA aircraft owners and operators should be encouraged to install FDM systems in their aircraft. SE–23 E–AB/Flight Test SOW To reduce the risk of loss of control accidents, the FAA and industry should develop a best practice guide for how to flight test an experimental amateur built (E–AB) aircraft following a modification. Additionally, testing for center of gravity (CG) limits, including lateral, should be added to Advisory Circular (AC) 90–89A, Amateur Built Aircraft and Ultralight Flight Testing Handbook. The FAA and industry will develop an educational outreach program to expand the awareness and use of AC 90–89A. SE–24 Single Pilot CRM SOW Crew Resource Management (CRM) has been embraced by the air carrier industry as a necessary initiative that has helped mitigate aircraft accidents caused by human error. Even though traditional CRM focused on multicrewed environments, several elements (such as communications, teamwork, decision making, and situational awareness) can be applied to single pilot operations. There have been some single pilot CRM initiatives undertaken by the FAA and industry to develop learning materials directed at single pilot operators, but a more concerted and formalized industry wide effort should be undertaken. If single pilot operators learn and practice CRM skills targeted directly to them, many of the safety related benefits realized in the air carrier community should transfer to the GA community. SE–25, SE–26 and SE–27 Reduce Regulatory Roadblocks (R³) SOW GA is going through a technical revolution that started in the mid 1990’s and is accelerating today. At the same time the United States has a fleet of over 200,000 GA airplanes and over 100,000 instrument flight rules (IFR) capable GA airplanes, the majority of which are still equipped with 1960’s to 1980’s vintage instruments and avionics. Taking advantage of the rapidly expanding technical revolution is an important component of reducing GA accidents. Data from the FAA AVP shows that the United States saw over a 60 percent drop in fatal controlled flight into terrain (CFIT) accidents from 2001 to 2010. CFIT accidents are General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 20 predominantly instrument meteorological conditions (IMC) related and frequently the accident is on approach. Providing pilots with information like Global Positioning System (GPS) position on a moving map, real time weather, terrain awareness, and traffic awareness has made a significant reduction in pilot workload. In addition, the proliferation of precision GPS approaches that replaced non-precision approaches has helped the pilot during IMC operations. Contrasting these technologies with the 1960s vintage panel so typical of the GA fleet, makes it clear a dramatic decrease in CFIT accidents is possible. The decrease in CFIT accidents is due, in large part, to new technology. In the 1990s, the FAA Small Airplane Directorate (ACE–100) applied a risk management approach to avionics certification by putting the appropriate level of certification on the product. It was this FAA initiative along with several industry/National Aeronautics and Space Administration (NASA) initiatives that brought about the glass cockpits that are in virtually every new part 23 airplane. However, new airplanes, even after 10 years, make up only between 5 and 10 percent of the GA fleet. These airplanes could not have lowered the accident rate this dramatically. The FAA must recognize that the bulk of the safety enhancing technology that lowered the accident rate was in the form of handheld equipment not installed in the airplane. The FAA must also recognize that the vast majority of pilot/owners of the 200,000+ fleet of GA airplanes votes on safety equipment with their money and purchase decisions. The cost to purchase an FAA approved device6, installed in the instrument panel costs 5–10 times more than the same technology in handheld form. Based on purchase history, the pilot/owner community has apparently determined that the safety benefits of FAA approved devices are not worth the cost difference. CFIT accident scenarios are easily addressed with new awareness technology, but this is not completely the case for LOC accidents. The technology to address LOC accidents can, in some cases, be designed as a portable device; but more typically, technologies that can address LOC accidents must be installed on the airplane. This is the main reason that cost keeps this technology out of small airplanes. Two good examples are a simple AOA indicator and an autopilot. The AOA indicator provides pilots with an awareness (visual and audio) of their margin above stall. The system accounts for all conditions such as weight and acceleration by design, whereas using stall speed does not. AOA system installations should be easy because they are not required equipment and do not interface with any existing equipment. The cost to put an existing AOA system on a certified airplane is almost 10 times higher than putting it on a homebuilt. The other example is an autopilot. An AOPA Air Safety Institute report points out that LOC accidents at night and in IMC would drop by 50 percent simply by installing autopilots in the more than 100,000 IFR capable GA airplanes. Homebuilders can install an autopilot for as little as $2,500. However, for most light airplanes that cost would be between $10,000 and $15,000 with the airplane value around $20,000 to $100,000. That is simply too large a fraction of the airplane’s value to justify the expense. The AOA system and the autopilot are not required equipment in all but a few high end part 23 airplanes. The only requirement that should be placed on these devices is that their failure 6 FAA approved avionics would include added costs from the certification process, including technical standard orders, supplemental type certificates, and installation approvals. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 21 would not cause a safety problem for the pilot. Clearly the FAA is on the right track, but must find ways to help reduce the cost to about half of what it costs today to install safety enhancing technology. Given that an installation may have minimal risk but offer substantial safety benefit, the FAA needs to apply a risk management approach to address the current situation in which the FAA is actually an obstacle to getting safety enhancing technology into the GA fleet. The FAA will need to identify the right level of certification. This will entail moving away from a single level of safety and performance. The shift should incorporate a continuum of certification rigor to match the continuum of safety expectations. If done properly the GA fleet can reap the potential benefit of reward with a balanced risk approach. SE–28 Pilot Response to Unexpected Events SOW This Safety Enhancement will be used to educate flight instructors and pilots on the need for preparing for unexpected events in the cockpit, focusing on: the importance of briefing for emergencies; positive transfer of controls; recognition and management of “startle response”. This work will also better prepare pilots for engine failure after takeoff. Work will include developing best practices, refining the takeoff pre-brief to emphasize what action will be taken dependent on current situation (altitude, airspeed, terrain, etc.) and recommend training/practicing the developed best practices on a regular basis. SE–30 Medications List for Pilots SOW To reduce the risk of pilot impairment or incapacitation from medications resulting in loss of control accidents, the Federal Aviation Administration (FAA) should implement programs to reduce the likelihood of the use, while flying, of prescription and over-the-counter medications that adversely affect the pilot’s ability to safely operate aircraft. Tools to improve pilot knowledge about the safe use of many medications are available to airmen from private advocacy groups such as Aircraft Owners and Pilots Association (AOPA), but the use of these tools is available only to members and not the entire GA community. As the regulatory agency, the FAA should strive, to the fullest extent possible, to improve pilot knowledge and prevent the use of any medications that could adversely affect flight safety. To this end, the Federal Aviation Administration (FAA) in conjunction with industry groups, academia, and the medical community should develop a medication list of approved or acceptable medications along with disqualifying medications that is easily available to all pilots and available online. The online tool should provide accurate aerospace medical guidance about the most common acceptable and unacceptable medications with recommended return to duty times following the use of these medications and provide information about drug interactions. The underlying conditions which the medication treats should be highlighted. SE–31 Test Pilot Utilization and E-AB Proficiency SOW The goal of this Safety Enhancement, once fully implemented, is to improve amateur built flight testing safety through greater understanding of test pilot qualifications and listing of test pilots willing to work with homebuilders. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 22 SE–32 Airman Certification Standards SOW For many years, the aviation training community has criticized the FAA’s airman testing standards and training materials as being outdated and out of touch with current technology and education/training methods. Industry also faulted the agency for piecemeal and unilateral efforts to make revisions. To address these issues, in September 2011 the FAA chartered the Airman Testing Standards and Training Aviation Rulemaking Committee (ARC) to make recommendations on the content, process, methodology, and priorities for updating airman testing standards and training material. The ARC included broad representation from the aviation community, including industry associations, universities, training providers, and professional associations. The ARC submitted its report and nine recommendations to the FAA on April 13, 2012. The ARC’s key recommendation on content called for the FAA to integrate knowledge, skills, and risk management for each major task in the current Practical Test Standards (PTS) into a single Airman Certification Standards (ACS) document. ARC members stated that this approach would improve and integrate testing and training by clearly mapping aeronautical knowledge and risk management to the flight proficiency skills as defined in the PTS. To accomplish this task and other ARC recommendations, the FAA accepted the ARC’s process and methodology recommendations to establish a stakeholder body of industry subject matter experts (SME). In August 2012, the FAA assigned this task to the Aviation Rulemaking Advisory Committee (ARAC), a formal standing committee comprised of representatives from aviation associations and industry. ARAC provides industry input in the form of information, advice and recommendations to be considered in the full range of FAA rulemaking activities, including regulatory support. The FAA announced the ARAC’s acceptance of this task through a Federal Register Notice published on September 12, 2012. This Notice described the task elements and solicited participants for the ARAC Airman Testing Standards and Training Working Group (ARAC ATST WG), which formed and began its work in November 2012. Members of the ARAC ATST WG are listed on the final page of this document. As stated in the Notice, the FAA specifically tasked the ARAC ATST WG to provide:  An integrated Airman Certification Standards (ACS) document that aligns the aeronautical knowledge testing standards required by 14 CFR Part 61 with the flight proficiency standards ("Areas of Operation") set out in 14 CFR Part 61 and the existing Practical Test Standards (PTS). Consistent with the ARC’s recommended prioritization, the FAA asked the ARAC ATST WG to develop complete ACS documents for the private pilot and flight instructor certificates and the instrument rating.  A detailed proposal to align and, as appropriate, streamline and consolidate existing FAA guidance material (e.g., FAA H-series handbooks) with the integrated Airman Certification Standards documents developed in accordance with the first task. The FAA also asked the ARAC ATST WG to recommend a process for ongoing stakeholder review and revision of these materials. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 23  Proposed knowledge test item bank questions that are consistent with both the newly- developed Airman Certification Standards documents and the test question development principles set forth in the ARC's recommendations. In addition, the FAA asked the ARAC ATST WG to recommend methods that provide for expert outside review (“boarding”) of proposed questions while safeguarding the integrity of the testing process. The ARAC ATST WG submitted is final report with draft documents and recommendations to the ARAC and the FAA on September 20, 2013. Once this Safety Enhancement is fully implemented, the goal of introducing risk management into airman testing and training will be realized. SE–33 Safety Culture SOW In addition to the above intervention, both the first and second working groups analyzed several accidents in which the pilot exercised poor aeronautical decision making, weak safety culture, and/or poor judgment in managing risks. Additionally, several accidents involved a pilot exhibiting intentional non-compliance to the rules and regulations established to ensure a safe aviation system. It is the goal of this safety enhancement, once fully implemented, will establish an improve safety culture for general aviation. SE–34 Outreach SOW Specifically, the interventions below had an overall effectiveness and average feasibility score that justified the working group’s development of this Safety Enhancement. Each of this safety enhancement’s five topics has three outputs associated with them. The topics are based upon the following interventions, which will result in a separate educational outreach campaign.  #138 EDUCATION - FAA/ Industry promote education/outreach to include training on the importance of abiding by limitations and knowledge of aircraft performance when operating on edge of CG/weight envelope especially for specific aircraft. Also focus on take-off configuration and utilizing systems like an AOA indicator.  #188 TRAINING - Reduce accidents by reminding pilots that their primary duty is to fly the aircraft. FAA/Industry produce an outreach campaign to remind pilots of the importance of Aviate/Navigate/Communicate.  #141 TRAINING - FAA/ Industry encourage further scenario based training requirements for handling spatial disorientation. Spatial disorientation introduction/training will simulate the scenarios in which a pilot might encounter spatial disorientation.  #186 TRAINING - Goal: Reduce mountain flying accidents. FAA and associations work to emphasize the need for training and currency when flying in mountainous areas.  #157 EDUCATION - Encourage CFIs and airmen to establish, maintain and adhere to personal minimums. . Emphasize with CFIs the importance of teaching proper PIC decision making skills. Provide suggestions on how airman can develop their own General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 24 personal minimums. Develop outreach campaign to promote the identification and use of products and materials for the establishment, periodic review, and revision or modification of personal minimums as personal circumstances and needs change. 6.0 Task 6 The working group, as the pilot project, provided feedback to the GAJSC about what worked and what did not work with respect to this process to help assist with future working groups. The GAJSC’s first project following its reestablishment in 2011 was specifically chartered as a “pilot project” and each member of the GAJSC was asked to identify “lessons learned” during the work of the GAJSC to help adapt the CAST methodology to the GAJSC. Lessons learned from the accident analysis, accident selection and establishment of the working group include the need for a formalized membership process, approval of the methodology for narrowing down the volume of accidents, and the appropriate size of the working group. A joint meeting was held between the LOCWG and the SAT in January 2012 to summarize the lessons learned7 in preparation for future work. At the December, 2013 GAJSC meeting, the co-chairs of the LOCWGs presented the following lessons learned.  No need to segment aircraft by type  Create Safety Enhancements only o DIPs difficult to create and track o LOCWG 2.0 new SE format helped o Add as much specificity as possible  Make it clear who is going to what by when  Worked better to not segment en-route and departure from approach and landing o Common problems o Group member’s burn out – creativity lost Additionally, the co-chairs included the following recommendations for subsequent working groups  Focus on occurrence category o Prevent defining event = no accident o Multiple Interventions for unrelated issues  Process Improvements o OE x F score improvements  Account for how many times an intervention is used  Mix up groups to keep process fresh o Encourage active participation  New group membership o New ideas and expertise 7 See, Power Point, GAJSC – 3 Year Plan Framework – 01132012.pp General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 25  Ensure NTSB data is pulled and available prior to start  Quality control after initial safety enhancement approval o Multiple versions and changes of SEs after submission o Utilize sharepoint technologies The LOCWG followed a hybrid of processes established by CAST’s JSAT and Joint Safety Implementation Team (JSIT). Based on the JSAT and JSIT process handbooks and the lessons learned in the development of the LOCWG process, the following process is recommended as a baseline for future GAJSC working groups. The LOCWG used the JSAT Process Handbook, Rev. D and JSIT Process Handbook, Rev. B to generate its unique process for GA. IV. Areas of Focus for Further Study and Technical Studies The LOCWG identified several areas warranting further attention and, in some cases, study based on the root cause analysis conducted. Medical Issues and Medications The LOCWG examined the frequency with which medical issues were involved in fatal GA accidents, including the use of over the counter medications, prescription medications, and the use of illegal drugs by pilots involved in GA accidents. While the NTSB only rarely identifies drugs or medical issues as causal to GA accidents, the LOCWG identified a great number of accidents in which autopsy identified drugs at rates that likely affected the pilot’s ability to deal with stressful situations or, in other cases, are known to cause drowsiness and impeded ability to focus. The GAJSC approved three SEs intend to mitigate the risk from pilots not fully understanding the use of over the counter medications or prescription drugs. Part 23 Regulatory Reform Aviation Rulemaking Committee In parallel to the GAJSC, the FAA in 2011 created a new Aviation Rulemaking Committee (ARC), which was the result of the Part 23 Certification Process Study developed jointly by the FAA and industry in 2009. Several members of the GAJSC also participate in the Part 23 General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 26 ARC. The DIPs in SE–25, SE–26, and SE–27 are specifically targeted for implementation using the expertise of the Part 23 ARC, but some of the work is already being carried out directly by the FAA’s ACE‒100. Inclusion of E–LSA in GA Accident Metrics The experimental–light sport aircraft (E‒LSA) accident data was not fully considered when the FAA identified the baseline data was identified for its GA accident metrics; that is, 1.12 fatal accidents per 100,000 hours average during 2006‒20088. The majority of E‒LSA aircraft at that time were still being operated under exemptions to 14 CFR part 103 (“two place ultralight trainers”) and not N registered. Because these aircraft were not N registered, they were not part of the FAA or NTSB fatal accident statistics. The SAT initiated a cursory review of E‒LSA accidents and identified between 3 (2009) and 11 (2011) unregistered/previously E‒LSA fatal accidents per year since the regulatory transition of E‒LSA. During the baseline years, the unregistered fatal accident count in the United States included 11 (2006), 8 (2007), and 4 (2008) fatal accidents. However, the FAA required N registrations for these aircraft as of January 31, 2008. It subsequently issued exemptions for N number registration until January 31, 2010. As a result, some two-place ultralight fatal accidents were included in annual rates beginning in 2008, and all such fatal accidents were included in the annual rates beginning in 2010. This fleet has a higher fatal accident rate than the rest of GA, which the FAA did not take into account when setting its baseline metric of 1.12 per 100,000 hours. As a result, the baseline metric may be off by as much as 3 percent. This in turn could make achievement of the 2018 target rate more difficult. The SAT volunteered to further review the effect of these previously unregistered fatal accidents on the FAA’s accident metric and 2018 fatal accident rate target. General Aviation Accident Metric The GAJSC, the SAT, and the LOCWG discussed in great detail the applicability of the current GA safety metrics (that is, number of fatal accidents per 100,000 hours) for GA and its various segments. It was noted that experimental amateur-built aircraft typically do not conduct point to point flying, but instead conduct short flights, often in the pattern, compared to cross country flying direct, at flight levels, for hours with an autopilot engaged. The discussions resulted in the tasking of the SAT, with CGAR’s support, to review and determine whether more appropriate metrics exist for GA. Crashworthiness and Survivability Through the analysis of the first and second working group, several accidents included information that led group members to speculate that the crash could have been survivable if better crashworthiness standards were in place. Both standard problem statements and interventions were drafted to improve aircraft crashworthiness. However, after consideration, it was decided crashworthiness and survivability were outside the scope of the working group’s tasking because (1) accident investigation data did not contain information 8 The FAA’s original safety metric for GA was established based on a 1996–1998 baseline with the target year of 2007 and based on fatal accidents. Industry and FAA reworked the metric and goal in 2008 based on a commitment to shift to a rate-based metric and goal. The change was enabled by enhancements to the GA activity survey that resulted in an acceptable statistical error for flight exposure data. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e 27 needed to determine an accident could have been survivable and (2) working group members did not have the subject matter expertise needed to conduct an analysis. It is, however, the recommendation of the working groups that, if the GAJSC determines further study is warranted, a future working group be assembled to do a proper analysis of the accident reports to recommend improvements to crashworthiness and survivability standards for aircraft design and certification. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A1–1 Appendix 1 — LOCWG 1.0 Charter Working Group Loss of Control – Approach and Landing Accidents April 26, 2011 A. Background The General Aviation Joint Steering Committee (GAJSC) chartered a Safety Analysis Team (SAT) to conduct a review of fatal general aviation accidents for 2001 through 2010. The SAT reviewed 2,472 fatal general aviation accidents based on CAST/ICAO Common Taxonomy Team (CICTT) categories and identified Loss of Control (LOC) accidents as the most prevalent accident type with 1,259 fatal accidents during the SAT timeframe. Industry and Government have agreed to purpose a data-driven approach to identifying high priority safety initiatives for general aviation and jointly agree to work toward the mitigation of accident causes. The GAJSC is being proposed [has] chartered a pilot project to study the Loss of Control accidents, specifically those occurring during the approach and landing phase of flight, and determine the contributing factors and intervention strategies. While the focus of this pilot project is approach and landing, the SAT expects to continue analysis of LOC accidents and may charter a future working group to look at other types of LOC accidents. B. Tasks 1. The working group will conduct an in-depth analysis and review of the LOC approach and landing accidents provided to the working group by the SAT. The SAT has established a statistically acceptable process to reduce the 279 approach and landing accidents that occurred during 2001 through 2010 into a data-set that can be practically reviewed by the working group within the timeframe provided. 2. The working group will review and determine the level of applicability of other work done in the area of LOC and approach and landing accidents. This work includes the Flight Safety Foundations Approach and Landing Accident Reduction (ALAR) tool-kit. 3. The working group will develop and prioritize safety intervention strategies that will reduce the potential for LOC approach and landing fatal accidents. In addition to documenting its analysis results and recommended intervention strategies, the working group will also document its assumptions regarding the analysis. 4. The working group will present the prospective interventions identified for implementation to the GAJSC for review and approval. The analysis and rationale for how all the intervention strategies were dispensed will be included in the report. 5. Following the approval of the GAJSC of the interventions, the working group will develop a detailed implementation plan for each intervention. 5.1 Each implementation plan will contain:  Prioritized implementation strategies  Parties responsible for action  Major implementation milestones  Metrics to monitor progress in meeting these milestones, and  Metrics for tracking success of the interventions. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A1–2 5.2 The working group will present each detailed implementation plan to the GAJSC for review and approval. 6. The working group, as the pilot project, will provide feedback to the GAJSC about what worked and what did not work with respect to this process to help assist with future working groups. C. Products The working group will deliver the following to the GAJSC:  Progress reports  A report documenting analysis and recommendations on mitigation strategies  An implementation plan for review and approval  Detailed implementation plans, including metrics for monitoring effectiveness of mitigation strategies. D. Membership The working group will include representatives with the appropriate technical background provided by industry and Government including several members from the SAT that can further assist with the data analysis. E. Resources The GAJSC participating organizations agree to provide appropriate financial, logistical, and personnel resources necessary to carry out this charter and approved implementation strategies. The working group will primarily use conference calls for the technical meetings, but have the discretion to also meet face-to-face at the discretion of the working group government/industry co-chairs. F. Schedule The working group is expected to exist for nine months, but can be extended at the discretion of the GAJSC. The working group is requested to target its deliverables as follows:  September 2010: Report documenting analysis and recommendations for mitigations.  May 2012: An implementation plan including metrics for monitoring effectiveness of mitigations. G. Specific Resources The GAJSC recognizes that the LOC working group will be the pilot project for the new joint-FAA-industry safety program for general aviation and as a result the organizations providing personnel resources to this project are asked for discretion in possible changes in the need for resources. However, based on an initial assessment, it is expected that the working group consist of two co-chairs and representatives from government and industry. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A1–3 H. LOC Approach and Landing Membership Name Organization Email Kevin Clover (Co-Chair) FAA kevinclover@faasafety.gov David Oord (Co-Chair) AOPA David.Oord@aopa.org I. Approved This charter was approved by the GAJSC on April 26, 2011. Bruce Landsberg, Industry Co-Chair Tony Fazio, Government Co-Chair General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A2–1 Appendix 2 — LOCWG 1.0 Participants Working Group Co-Chairs Industry – David Oord, Aircraft Owners and Pilots Association (AOPA) FAA – Kevin Clover, FAA General Aviation and Commercial Division (AFS−850) Working Group Members Aircraft Owners and Pilots Association (AOPA) ‒Kristine Hartzell Aircraft Electronic Association (AEA) - Ric Peri Aviation Insurance Association (AIA) - Steve Meyers, Thomas Hollinger Center for General Aviation Research (CGAR) - Alan Stolzer and Dave Esser (Embry-Riddle Aeronautical University), Jim Higgins and Dana Siewert (University of North Dakota) FAA, Flight Standards - Robert Potts, Jim Watson FAA, Small Aircraft Division, ACE−100 - Lowell Foster, David Sizoo, Jim Brady FAA, Office of Accident Investigation and Prevention, AVP−100 - Tony James FAA, Office of Accident Investigation and Prevention, AVP−210 – Corey Stephens, Patrick Forrester, and Sean Hafner Garmin - Bill Van Zwoll General Aviation Manufacturers Association (GAMA) - Kate Fraser Hawker Beechcraft Corporation - Robert Ramey Jeppesen - Richard Fosnot, Martin Plumleigh National Air Transport Association – Lindsey McFarren Society of Aviation Flight Educators (SAFE) - Jeff Edwards General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A3–1 Appendix 3 — LOCWG 1.0 Meetings August 3−September 1, 2011—Aircraft Electronics Association, Kansas City, Missouri October 2−27, 2011—University of North Dakota, Grand Forks, North Dakota November 29−December 1, 2011—Aircraft Owners and Pilots Association, Frederick, Maryland January 10−12, 2012—Embry-Riddle Aeronautical University, Daytona Beach, Florida February 7−9, 2012—FAA, Long Beach FSDO, Long Beach, California March 20−22, 2012—Jeppesen, Denver, Colorado April 10−12, 2012—Boeing, Seattle, Washington General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A4–1 Appendix 4 — LOCWG 2.0 Charter Working Group Loss of Control – En-route and Departure Accidents September 1, 2012 A. Background The General Aviation Joint Steering Committee (GAJSC) chartered a Safety Analysis Team (SAT) to conduct a review of fatal general aviation accidents for 2001 through 2010. The SAT reviewed 2,472 fatal general aviation accidents based on CAST/ICAO Common Taxonomy Team (CICTT) categories and identified Loss of Control (LOC) accidents as the most prevalent accident type with 1,259 fatal accidents during the SAT timeframe. Industry and Government have agreed to purpose a data-driven approach to identifying high priority safety initiatives for general aviation and jointly agree to work toward the mitigation of accident causes. The GAJSC is being proposed [has] chartered a pilot project to study the Loss of Control accidents, specifically those occurring during the en-route and departure phase of flight, and determine the contributing factors and intervention strategies. B. Tasks 1. The working group will conduct an in-depth analysis and review of the LOC en-route and departure accidents provided to the working group by the SAT. The SAT has established a statistically acceptable process to reduce the 120 en-route and departure accidents that occurred during 2001 through 2010 into a data-set that can be practically reviewed by the working group within the timeframe provided. 2. The working group will review and determine the level of applicability of other work done in the area of LOC and approach and landing accidents. This work includes the Flight Safety Foundations Approach and Landing Accident Reduction (ALAR) tool-kit. 3. The working group will develop and prioritize safety intervention strategies that will reduce the potential for LOC en-route and departure fatal accidents. In addition to documenting its analysis results and recommended intervention strategies, the working group will also document its assumptions regarding the analysis. 4. The working group will present the prospective interventions identified for implementation to the GAJSC for review and approval. The analysis and rationale for how all the intervention strategies were dispensed will be included in the report. 5. Following the approval of the GAJSC of the interventions, the working group will develop a detailed safety enhancement for each intervention. 5.1 Each enhancement will contain:  Prioritized implementation strategies  Parties responsible for action  Major implementation milestones  Metrics to monitor progress in meeting these milestones, and  Metrics for tracking success of the interventions. 5.2 The working group will present each safety enhancement to the GAJSC for review and approval. General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A4–2 6. The working group will provide feedback to the GAJSC about what worked and what did not work with respect to this process to help assist with future working groups. C. Products The working group will deliver the following to the GAJSC:  Progress reports  A report documenting analysis and recommendations on mitigation strategies  An implementation plan for review and approval  Safety Enhancements, including metrics for monitoring effectiveness of mitigation strategies. D. Membership The working group will include representatives with the appropriate technical background provided by industry and Government including several members from the SAT that can further assist with the data analysis. E. Resources The GAJSC participating organizations agree to provide appropriate financial, logistical, and personnel resources necessary to carry out this charter and approved implementation strategies. The working group will primarily use face-to-face meetings scheduled at the discretion of the working group government/industry co-chairs. F. Schedule The working group is expected to exist for twelve months, but can be extended at the discretion of the GAJSC. The working group is requested to target its deliverables as follows:  Report documenting analysis and recommendations for mitigations.  An implementation plan including metrics for monitoring effectiveness of mitigations. G. LOC En-route and Departure Membership Name Organization Email Kevin Clover (Co-Chair) FAA kevinclover@faasafety.gov David Oord (Co-Chair) AOPA David.Oord@aopa.org H. Approved This charter was approved by the GAJSC on September 1, 2012. Bruce Landsberg, Industry Co-Chair Tony Fazio, Government Co-Chair General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A5–1 Appendix 5 — LOCWG 2.0 Participants Working Group Co-Chairs Industry – David Oord, Aircraft Owners and Pilots Association (AOPA) FAA – Kevin Clover, FAA General Aviation and Commercial Division (AFS−850) Working Group Members Aircraft Electronic Association (AEA) - Ric Peri Center for General Aviation Research (CGAR) - Alan Stolzer (Embry-Riddle Aeronautical University), Jim Higgins and Dana Siewert (University of North Dakota) Experimental Aircraft Association (EAA) – Tom Charpentier FAA, Flight Standards – Mike Haley, Jim Watson, and Larry Wells FAA, Small Aircraft Division, ACE−100 - Lowell Foster, David Sizoo, Jim Brady FAA, Office of Accident Investigation and Prevention, AVP−100 - Tony James FAA, Office of Accident Investigation and Prevention, AVP−210 – Corey Stephens FAA, Office of Aerospace Medicine (AAM) – Dr. Nicholas Webster Garmin – Chris Benson General Aviation Manufacturers Association (GAMA) - Kate Fraser Beechcraft Corporation - Robert Ramey Jeppesen - Martin Plumleigh Lancair Owners and Builders Organization (LOBO) – Jeff Edwards National Business Aviation Association (NBAA) – Peter Korns Partnership to Enhance General Aviation Safety, Accessibility, and Sustainability (PEGASAS) – Stephen K. Cusick and Scott R. Winter Society of Aviation Flight Educators (SAFE) – Doug Stewart General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A6–1 Appendix 6 — LOCWG 2.0 Meetings September 11−13, 2012—Aircraft Electronics Association, Kansas City, Missouri November 6−8, 2012—National Transportation Safety Board Training Center, Ashburn, Virginia January 15−17, 2013—Aircraft Owners and Pilots Association, Frederick, Maryland March 5−7, 2013—Embry-Riddle Aeronautical University, Daytona Beach, Florida April 23-25, 2013 – Boeing, Seattle, Washington June 18-20, 2013 – Bombardier, Dallas, Texas August 13-15, 2013 – ATP, Brisbane, CA General Aviation Joint Steering Committee Final Report of the Loss of Control Working Groups P a g e A7–1 Appendix 7 — Accident Selection Process Methodology for JSC SAT Accident Selection In order to provide a quantitative framework for investigation of selected focal areas, the Safety Analysis Team (SAT) will utilize appropriate and empirically-based vetting protocols which will endeavor to provide a meaningful foundation for the team's subsequent analyses. The underlying foundation of the methodology will use the following principles: (1) Preprocessing of the search criteria will be as exhaustive as practical; (2) Random selection (each resultant accident report will have an equal probability of being selected) will be utilized; and (3) During the post analytical process, pruning and/or outlier removal will only occur when there exists a substantial lack of information contained in the report that was not readily apparent in the preprocessing tasks, when an accident report was inaccurately and obviously misclassified, or when there is a justifiable basis to believe the report will not materially contribute to the focal area. Preprocessing The National Transportation Safety Board's (NTSB's) aviation accident database and its associated interactive search capability will be utilized in the selection of accidents needed for further inquiry. Unless otherwise directed by the JSC or by the majority of the SAT, all accident selections will utilize the following criteria: Investigation Type: Accident Injury Severity: Fatal (with Non-Fatal augmentation; see below) Category: Airplane Operation: All General Aviation* Report Status: Probable Cause *SAT may decide to include 135 reposition and other non-revenue flights If desired by a