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15.12 Conclusion
Operational risk management provides a logical and systematic means of identifying and
controlling risk. Operational risk management is not a complex process, but does require
individuals to support and implement the basic principles on a continuing basis. Operational risk
management offers individuals and organizations a powerful tool for increasing effectiveness and
reducing accidents. The ORM process is accessible to and usable by everyone in every
conceivable setting or scenario. It ensures that all FAA personnel will have a voice in the critical
decisions that determine success or failure in all our operations and activities. Properly
implemented, ORM will always enhance performance.
FAA System Safety Handbook, Chapter 16: Operational Safety in Aviation
December 30, 2000
Chapter 16: Operational Safety in Aviation
16.1 GLOBAL AVIATION INFORMATION NETWORK (GAIN).................................................. 1
16.2 FLIGHT OPERATIONS QUALITY ASSURANCE PROGRAM (FOQA) ............................... 4
16.3 SPECIAL SAFETY STUDIES AND DATA ANALYSIS............................................................ 5
16.4 OPERATOR’S FLIGHT SAFETY HANDBOOK (OFSH)......................................................... 6
FAA System Safety Handbook, Chapter 16: Operational Safety in Aviation
December 30, 2000
16-1
16.0 Operational Safety in Aviation
This chapter summarizes recent initiatives and other related activities appropriate to operational safety in
aviation. The Global Aviation Information Network (GAIN) program is discussed. Special safety studies
and data analyses directed to aircraft performance risk assessment are presented, and the Operator’s Flight
Safety Handbook (OFSH is summarized and discussed.
Many years ago Heinrich conducted a statistical study of accidents and determined that out of 300
incidents, one fatal accident may occur. This provided a general analogy of a ratio of 1 to 300. Years later,
Frank Byrd conducted a similar study and noted that out of 600 incidents, one fatal accident occurred,
indicating a ratio of 1 to 600. Figure 16-1 illustrates the concept that for every accident or incident that is
reported, there may be a much larger number that are not reported.
It is important to identify incidents that could have resulted in accidents. An incident is any occurrence that
could have resulted in an accident, i.e., fatal harm. But since the harm did not occur, it is considered an
incident. The point is that all incidents that could have resulted in an accident should be reported to
determine the relevant factors associated with that incident.
INCIDENTS
ACCIDENTS
UNREPORTED
OCCURRENCES
Heinrich Pyramid
Figure 16-1
16.1 Global Aviation Information Network (GAIN)
The Federal Aviation Administration (FAA) first proposed a Global Analysis and Information Network
(GAIN) in May 1996 for the worldwide collection, analysis, and dissemination of safety information to
help the aviation community reach the goal of zero accidents. GAIN was envisioned by the FAA as a
FAA System Safety Handbook, Chapter 16: Operational Safety in Aviation
December 30, 2000
16-2
privately owned and operated international information infrastructure that would use a broad variety of
worldwide aviation data sources together with comprehensive analytical techniques to assist in identifying
emerging safety concerns.
As the aviation community exchanged ideas on the GAIN concept over the first 2 ½ years after its
announcement, a variety of descriptions were applied to GAIN by various segments of the aviation
community. The GAIN Steering Committee considered various comments and recommendations on GAIN
and agreed upon the following description of GAIN in January 1999:
“GAIN promotes and facilitates the voluntary collection and sharing of safety information by and among
users in the international aviation community to improve safety.”
The Steering Committee also changed the meaning of the GAIN acronym to “ Global Aviation Information
Network” to better define the program.
The GAIN organization consists of the Steering Committee, Working Groups, Program Office, and a
planned Government Support Team.
The Steering Committee consists of industry stakeholders (airlines, manufacturers, employee groups and
their trade associations) that set high-level GAIN policy, issue charters to direct the Working Groups, and
guide the Program Office. Represented on the GAIN Steering Committee are Airbus Industrie, Air France,
Air Line Pilots Association (ALPA), Air Transport Association (ATA), Boeing Commercial Airplane
Group, British Airways, Continental Airlines, Flight Safety Foundation, International Association of
　
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