Image: © Bernal Sabori, CC-BY-SA 2.0, via Wikimedia Commons
This article is the tenth in a series on landmark events in aviation since Flight Safety Foundation was founded in 1945.
As with many aviation practices, flight data collection began with the Wright Brothers, who were known for their detailed record-keeping. They noted their early successes and failures, their research, and details of their flights. Other early pilots followed suit, keeping personal diaries that also served as aircraft logs.
Their efforts were the earliest precursors of the increasingly detailed data collection systems developed over the years and of today’s shared data analysis systems — with information gathered not only from flight data recorders and cockpit voice recorders but also from a succession of data-sharing programs that grew more sophisticated over the years.
By the time Flight Safety Foundation was established in 1945, rudimentary flight data recorders (FDRs) had been in use for six years. The hussenograph, invented in 1939 by two French engineers, recorded altitude and speed information on photographic film. During World War II, engineers in Finland and the United States separately developed systems that recorded data on materials that might survive a crash.
After the war, researchers in several nations modified and improved FDRs that relied on a variety of materials to record flight data. By 1958, Australian scientist David Warren designed a combined black box that housed an FDR and a cockpit voice recorder (CVR), reasoning that, in the minutes and seconds before an incident, “if it were a pilot error, or if it were something … known to the crew, they may have said something or done something. If only we could recapture those few seconds, it’d save all this argument and uncertainty [among investigators]; we’d know what it was.”
Initially, there was little interest from Australian aviation authorities. The British were more enthusiastic, however, and began planning to mandate use of the device in civil aircraft; at that point, Australia acted and in 1960 became the first country to make cockpit voice recorders mandatory.
Throughout the decade, other countries followed, and recording technology improved. The early FDR-CVR combinations used metal strips to record data and, later, magnetic tape, and by the 1990s, solid -state memory units.
Confidentiality
For about 50 years, other data has been collected through confidential, voluntary incident reporting systems, the largest of which is the U.S. National Aeronautics and Space Administration’s Aviation Safety Reporting System (ASRS). Founded in 1976, ASRS has collected hundreds of thousands of reports.
In subsequent years, similar incident reporting systems were established in at least one dozen other countries, including the U.K. Confidential Human Factors Incident Reporting Program (CHIRP), Canada’s Confidential Aviation Safety Reporting System, and Brazil’s Confidential Flight Safety Report.
Those programs and others are members of the International Confidential Aviation Safety Systems Group, which lists as one of its goals the identification of “solutions to common problems in the operation of [confidential aviation reporting systems].”
The Rise of FDA
As equipment became more sophisticated, so did new systems of data collection and analysis, including quick access recorders (QAR) and digital aircraft condition monitoring systems, both of which contain information used in flight data analysis (FDA), also known as flight operational quality assurance (FOQA), or flight data monitoring.
Flight Safety Foundation was among the first proponents of FOQA and, in the early 1990s, conducted an extensive analysis of the program for the FAA that pointed to its ability to “analyze the safety quality of [airline] operations and to detect subtle or insidious trends that can creep into daily operations,” according to a 1993 issue of the Foundation’s Flight Safety Digest. At the same time, the Foundation, urged the use of FOQA methods in U.S. carrier operations, noting that FOQA was already in place at more than 25 airlines outside the United States.
Today, more than 150 carriers worldwide have FOQA programs, as do all major U.S. carriers, although the FAA does not require its use.
Although FOQA was initially aimed at large commercial operations, Flight Safety Foundation, together with the National Business Aviation Association, developed C-FOQA, aimed at corporate operators. A demonstration project began in 2004, with two operators participating, and when results were announced three years later, the operators said the program had yielded substantial safety benefits, including helping to eliminate deviations from stabilized approach criteria.
A Systematic Approach
FOQA programs and other safety initiatives that rely on data collection and analysis have been an integral part of the safety management systems (SMS) implemented in recent decades at airlines, airports, regulatory authorities, and elsewhere. ICAO, which said in 2004 that SMS should be implemented in all safety-related disciplines, described the program as “a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures.”
Around the same time, Flight Safety Foundation said the program “offers airlines a more realistic picture of operational risks and an objective method to allocate constrained resources, while eventually enabling regulators to focus to system-level oversight.”
When Canadian Transport Minister Jean-Charles Lapierre announced the following year that the nation’s airlines would be required to implement an SMS, he said the program represents “a systematic, explicit, and comprehensive process for managing risks to safety … [complementing] the strong oversight program of inspections and audits already in place.”
Information Sharing
In 2008, the FAA began its Aviation Safety Information Analysis and Sharing (ASIAS) program, which attracted several dozen airline members that granted ASIAS access to deidentified data from their FOQA or aviation safety action programs (ASAPs), or both. The airlines had collected the data independently for years without a way to compare their safety performance indicators with broader trends from the industry.
ASIAS changed that, giving the FAA and participating airlines access to the data and the ability to search and analyze it. One of its early analyses aimed to discover the reason for unexplained terrain awareness and warning system alerts at several airports in mountainous terrain, and others were designed to assess the accuracy of terrain databases.
In 2015, the Foundation-led Global Safety Information Project (GSIP) formed to aid the international aviation community in responding to challenges identified through safety data collection and analysis. Related projects were designed to improve risk-management capabilities and information-sharing practices.
At the time, the Foundation wrote that aviation organizations were learning about risk through “numerous data sources, such as employee safety reports, flight data monitoring, audits, and various reports generated about operational conditions” — sources that were not necessarily public. GSIP’s goals included identifying ways to share findings from that data and to improve the aviation community’s understanding of risk.
Learning From Things That Go Right
More recently, the Foundation’s Learning From All Operations initiative called for a shift in data collection efforts to enable the industry “to learn not only from things that rarely go wrong but also from things that go right.”
In a 2021 paper introducing Learning From All Operations, the Foundation said, “Data collection needs to expand from a focus on hazardous events to analysis of routine operational data. While it will continue to be essential to identify hazards and manage risks, organisations should also analyse data that lead to new insights from everyday work across all types of outcomes — insights that enable learning that is more frequent, sensitive and timely.”
Traditionally, the focus has been on learning from accident and incident investigative reports about what not to do, but “although this may provide some protection against the recurrence of specific hazardous events, learning only from rare events means that learning only occurs rarely, and learning only from mishaps does not enable an organisation to take advantage of all opportunities,” the Foundation said.
This new focus is in place in some organizations, including ENAIRE, Spain’s air navigation manager, which began implementing new processes and policies in 2015 for normal operations monitoring (NOM) of what happens every day, including the actions of front-line operators, the factors influencing them, and the reasons behind their actions. This approach involves observing how air traffic controllers work and talking with them about how they do their jobs and why they do things in a particular way.
