
The Human Contribution to Safety
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Committee on Emerging Trends in Aviation Safety
Transportation Research Board
Consensus Study Report
Transportation Research Board Special Report 361
Subscriber Categories: Aviation; safety and human factors
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Printed in the United States of America.
This publication was reviewed by a group other than the authors according to the procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the National Academy of Medicine.
This study was sponsored by the Federal Aviation Administration.
International Standard Book Number-13: 978-0-309-60557-1
Digital Object Identifier: http://doi.org/10.17226/29420
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AMY R. PRITCHETT (Chair), The Pennsylvania State University
ANN M. BISANTZ, State University of New York at Buffalo
DONALD E. BROWN, University of Virginia
SHERYL CHAPPELL, Private Consultancy
CODY H. FLEMING, Iowa State University
R. JOHN HANSMAN, JR., Massachusetts Institute of Technology
CHRISTOPHER A. HART, Hart Solutions LLC
KAREN MARAIS, Purdue University
PAUL MCCARTHY, International Federation of Air Line Pilot’s Associations
SHWETA MULCARE, SAIC, Inc.1
ASHOK N. SRIVASTAVA, Intuit
KATHLEEN M. SUTCLIFFE, Johns Hopkins University
TIMOTHY J. VOGUS, Vanderbilt University
LIDA BENINSON, Study Director, Consensus and Advisory Studies, Transportation Research Board
STEPHEN GODWIN, Scholar, Consensus and Advisory Studies, Transportation Research Board
THOMAS R. MENZIES, JR., Director, Consensus and Advisory Studies, Transportation Research Board
MARK HUTCHINS, Senior Program Officer, Consensus and Advisory Studies, Transportation Research Board
TIMOTHY MARFLAK, Program Coordinator, Consensus and Advisory Studies, Transportation Research Board
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1 Member of the committee through October 2025.
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This consensus study report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine (National Academies) in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
JOHN-PAUL CLARKE (NAE), University of Texas at Austin
HELENA CUNNINGHAM, Air Line Pilots Association, International
BECK HOOEY, NASA Ames Research Center
ZHIKA LEI, Pepperdine University and International Institute for Management Development (IMD) Business School
JANA PRICE, National Transportation Safety Board
JOSEPH SOBIERALSKI, Embry-Riddle Aeronautical University
ROBERT SUMWALT, Embry-Riddle Aeronautical University
LANCE WALLER, Emory University
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its
release. The review of this report was overseen by CHRIS HENDRICKSON (NAE), Carnegie Mellon University, and CRAIG PHILIP (NAE), Vanderbilt University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
The committee appreciates the support of the Federal Aviation Administration (FAA) staff in providing background information related to the Commercial Aviation Safety Team, the Aviation Safety Information Analysis and Sharing program, and the Annual Safety Culture Survey. The committee also thanks senior librarians Anne Marie Houppert and Rebecca Morgan, as well as the National Academies’ research library, for assistance with fact checking and literature searches.
This report was developed under the overall supervision of Thomas R. Menzies, Jr., Director of Consensus and Advisory Studies, Transportation Research Board (TRB). Lida Beninson, Senior Program Officer, TRB, served as the study director. She and Stephen Godwin, Scholar, TRB, assisted the study committee in the preparation of this report. Timothy Marflak of TRB provided support to the committee in arranging meetings.
The committee would like to thank the following individuals for providing input to this study:
HELENA CUNNINGHAM, Air Line Pilots Association
BARBARA HOLDER, Embry-Riddle Aeronautical University
CARL MACRAE, University of Nottingham
JAMES STARNES, Airline Dispatcher Federation
DIANE VAUGHAN, Columbia University
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Data Available for Enhanced Safety Analysis
Exemplar Use Cases of Transformative Aviation Safety Analysis
Longitudinal Assessment of Line-Oriented Flight Training and Similar Training Programs
Chapter Summary and Recommendations
5 FAA’S AVIATION SAFETY ORGANIZATION SAFETY CULTURE ASSESSMENT
AVS Briefings on Its Safety Culture Assessment
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The safety of the U.S. National Airspace System depends not only on aircraft, technologies, and infrastructure, but also on the performance of the people who operate, maintain, regulate, and oversee it. Pilots, air traffic controllers, mechanics, and dispatchers have a direct role in ensuring flight performance and the prevention of operational failures, while many other occupations, including flight attendants, inspectors, and certifiers, also provide safety-critical functions. As this workforce changes over time, it is essential to understand how those changes may influence aviation safety.
Section 132 of the Aircraft Certification, Safety, and Accountability Act of 20201 directed the National Academies of Sciences, Engineering, and Medicine to conduct a 10-year series of studies examining emerging hazards in commercial aviation. The studies are intended to identify, categorize, and analyze emerging safety trends and to provide Congress, the Federal Aviation Administration, industry, and other stakeholders with advice on improving the identification, monitoring, understanding, and mitigation of aviation safety risks.
This report is the third in that series. Whereas the first report examined aviation safety data sources and analytic methods for identifying emerging risks, and the second examined safety during transformative changes in aircraft technologies and operations, this report focuses on the human contribution to safety. It examines how changes in the commercial aviation workforce may affect safety, how operational and safety data can be used
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1 Section 132 of the Aircraft Certification, Safety, and Accountability Act of 2020 (enacted as Division V of the Consolidated Appropriations Act, 2021, Pub. L. 116-260).
to detect and monitor those effects, and how safety culture supports safe operations and effective regulatory oversight.
An interdisciplinary committee with expertise in aviation operations, human factors, safety management, organizational behavior, engineering, data analytics, and regulatory oversight conducted this study. The committee gathered information through technical briefings, reviews of scientific and professional literature, and analyses of relevant data sources. The findings and recommendations presented in this report represent the consensus judgment of the committee’s members, who served without compensation in the public interest.
| AC | Advisory Circular |
| ADS-B | Automatic Dependent Surveillance-Broadcast |
| AI | artificial intelligence |
| AIM | Aeronautical Information Manual |
| AOV | Air Traffic Safety Oversight Service |
| AQP | Advanced Qualification Program |
| ASAP | Aviation Safety Action Program |
| ASIAS | Aviation Safety Information Analysis and Sharing |
| ASM | Aviation Safety Management |
| ASR | Automatic Speech Recognition |
| ASRS | Aviation Safety Reporting System |
| ATC | Air Traffic Control |
| ATO | Air Traffic Organization |
| ATP | airline transport pilot |
| ATSA | Air Traffic Skills Assessment |
| ATSAP | Air Traffic Safety Action Program |
| AVS | Aviation Safety office of FAA |
| AWIPS | Advanced Weather Interactive Processing System |
| CAMI | Civil Aerospace Medical Institute |
| CAST | Commercial Aviation Safety Team |
| CBT | computer-based training |
| CFR | Code of Federal Regulations |
| CPC | Certified Professional Controllers |
| CPC-IT | CPC In Training, previously certified at a different facility |
| CRM | crew resource management |
| DFDR | digital flight data recorder |
| EFB | electronic flight bag |
| EOSDIS | Earth Observing System Data and Information System |
| FAA | Federal Aviation Administration |
| FOQA | Flight Operations Quality Assurance |
| FRMS | Fatigue Risk Management System |
| FY | Fiscal Year |
| GADM | Global Aviation Data Management |
| GAO | U.S. Government Accountability Office |
| IAEA | International Atomic Energy Agency |
| IASMS | in-time aviation safety management system |
| ICAO | International Civil Aviation Organization |
| LLM | Large Language Model |
| LOFT | line-oriented flight training |
| LOSA | Line Operations Safety Audit |
| LSTM | long short-term memory |
| MRO | maintenance, repair, and overhaul |
| N3C | National COVID Cohort Collaborative |
| NAS | National Airspace System |
| NASA | National Aeronautics and Space Administration |
| NEA | Nuclear Energy Agency |
| NLP | Natural Language Processing |
| NOTAM | Notice to Airmen |
| NTSB | National Transportation Safety Board |
| PARC | Performance-based Operations Aviation Rulemaking Committee |
| PATCO | Professional Air Traffic Controllers Organization |
| PF | pilot flying |
| PM | pilot monitoring |
| QAR | quick access recorder |
| RA | risk assessment |
| SA | safety assurance |
| SFDPS | System Flight Data Public Service |
| SMS | safety management system |
| SWIM | System-Wide Information Management |
| USDOT | U.S. Department of Transportation |
| VHF | very high frequency |
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