Lessons Learned Federal Aviation

Administration

From Aviation
Accidents
Creation of a Web-Based
Knowledge System

Presented to: The National Academy of Sciences

By: Daniel I. Cheney, Manager, Safety Programs

Federal Aviation Administration
Background

During the 1990’s and early 2000’s,

several major airplane accidents
occurred which exposed errors in:
– Airplane design
– Airline operations
– Maintenance programs
and the processes linking them
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Administration
Washington, D.C.; April 18-19, 2011
These accidents included:

– Trans World Airways Flight 800

– Swissair Flight 111
– American Eagle Flight 4184
– Alaska Airlines Flight 261

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Administration
Washington, D.C.; April 18-19, 2011
TWA Flight 800

747 crash off the coast of Long Island, NY

– Center fuel tank exploded in flight
• Flawed assumptions regarding fuel tank components

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Administration
Washington, D.C.; April 18-19, 2011
Swissair Flight 111

MD-11 crash off the coast

of Nova Scotia

– Electrical Arc resulted in

cabin insulation material that
burned aggressively
• Flawed assumptions regarding
burn characteristics

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Administration
Washington, D.C.; April 18-19, 2011
Alaska Flight 261

MD-80 crash off the

coast of California

– Loss of control resulting

from failure of horizontal
stabilizer trim jackscrew
• Inadequate lubrication

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Administration
Washington, D.C.; April 18-19, 2011
American Eagle
Flight 4184
ATR 72 crash near
Roselawn, Indiana

– Ice contaminated wing

surface and loss of
airplane control
• Ice built up on unexpected
areas of wing

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

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Administration
Washington, D.C.; April 18-19, 2011
 Accident
Awareness
• The FAA identified lack of
accident knowledge as
key factor in several major
accidents

• Awareness of specific
accidents not widespread
throughout aviation
community

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

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

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Administration
Washington, D.C.; April 18-19, 2011
FAA Initiative

• The FAA has now developed a web based

“Lessons Learned from Transport
Airplane Accidents” library
– Threat based
– Search/sort capability

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Administration
Washington, D.C.; April 18-19, 2011
Purpose of Accident
Library

• Stop and reverse the loss of costly lessons

• Maintain and improve the safety of an already
very safe international aviation system

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

• A web-based Accident Library is now

available to enhance the safety of an already
very safe international aviation system

– Currently available at: http://accidents-ll.faa.gov/

– 57 accident modules; more added each year
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Administration
Washington, D.C.; April 18-19, 2011
The Lessons
Learned web
site will now be
demonstrated
@
accidents-ll.faa.g
ov/

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