FSF Panel Addresses Safety Solutions Based on 2025 Data

At the recent Flight Safety Foundation (FSF) Business Aviation Safety Summit, the first panel session shifted the conversation from keynote speaker Michael Graham, vice chair of the NTSB, and his highlights from the January 2025 KDCA midair collision to the topic, “Transforming 2025 Safety Findings into Future Solutions.”

“As we started formulating this year's agenda,” said Paige Kroner, FSF director, member relations, “we know that looking at the past incidents and accidents can help protect our future safety. Thank you to Michael Graham for helping us set the tone for this week's conversation.”

The annual safety report based on FSF’s Aviation Safety Network (ASN) data highlights broad industry patterns, Kroner explained. “ASN helps turn real-world history into practical, identifying trends. Our 2025 safety report data shows that our ecosystem is under increasing pressure with rising demand, more operational complexity, and a need to keep strengthening the basics. The ASN data points out that corporate jet accidents increased in 2025, and fatal accidents reached the highest level we’ve seen in the last nine years of ASN data. The data points to phases of flight where attention is needed most, where most accidents occur: during landing, followed by loss of control in flight and controlled flight into terrain.”

Asked about the one lesson that safety leaders can carry into 2026, panelist Susie Scott, director of transportation at Oliver Wyman-Vector, focused on resiliency. “If you think about what resiliency means, it means being able to anticipate, monitor, learn, and respond,” she said. “We do a good job monitoring lagging indicators, and I don’t think we are leveraging the data…that we have, to train to be resilient, and really anticipating.

“I loved what Michael Graham was saying about…the DCA [accident], because I look at the world through the lens of safety margin erosion. If you think about what is happening in our system, it’s becoming incredibly complex…all those things [lining up] in [the] Swiss cheese [model]…and nobody was noticing. People weren’t necessarily paying attention, and that’s because we’re still looking at lots of lagging data that, in many ways, is just an inventory of numbers.”

Adam Duszak, Gulfstream Aerospace flight test chief of safety, explained that “a reporting culture is key for situational awareness.” In relation to the KDCA accident, he wondered about the culture among the entities involved. “To have all those players come together from that airport and have safety needs, [it] is critical to discuss those type of things. So for me, situational awareness and culture is absolutely critical.”

“The most important lesson that we learned from last year is that the risks that we know that we don’t act upon are more dangerous than the risk that we don’t know,” said Embraer air safety engineer Daniel Marimoto. “Yet you see that all the time…deviations from SOPs and established norms and regulations. You have to start working at the base of the pyramid, [with a] safety management system [SMS], where everything that is reported to you is analyzed…and if that process means that mitigation action is necessary, you act on it. You just don’t stop there. So you have to come up with mitigating actions. Those mitigating actions have to have somebody responsible for them; otherwise, nobody will do anything. And there has to be a follow-up…to see if they are implemented.”

Getting back to the topic of resilience, Kroner asked the panelists what that word means to each of them.

Scott related a story about a safety review stemming from an airline that had to remove a passenger’s bag when that person got off the airplane at an intermediate destination. Although the airline used a sophisticated baggage-tracking system, the bag wasn’t in the bin that the system had recorded.

After punishing the handler who put the bag in the wrong bin by sending him home for a week without pay, the airline decided to interview him to find out what happened. “A couple of weeks later,” Scott recalled, “we had the conversation with this particular individual, and he was very apologetic. The airplane was late, and there was pressure to get it loaded. He was the only person on baggage duty and was using a new scanner, and handlers were supposed to scan each bag as it was loaded. The airline also required handlers to lift every bag with two hands.

“I don’t know about you,” Scott said, “but I’ve only got two hands. So how was he supposed to, on his own, use the scanner and load all the bags with two hands? I don’t know, but I’ll tell you what he did do. There’s the cart with all the bags. He got his scanner [and scanned them], and then he started loading them in the front bin. When the front bin was full, he took that cart to the back and stuck the rest in there, so the weight and balance was off. The point I’m making is we would never have known that had we not taken the time to go and learn from this individual what was actually happening in his world.”

“I think resilience means that you have to start a project or design a system, not just for the function, but for the failure,” Marimoto added. “What I mean is all systems, regardless of how good they are, will eventually fail. You have to design a system that, when it fails, it doesn’t affect the operation of the aircraft. So of course it means to design a backup system. It has to be a backup system that people know how to use, that is reliable, easy to use, especially under pressure, because if you’re using it, it’s because something already failed.”

Duszak explained how Gulfstream’s flight test operation conducts technical reviews or anything that might involve elevated risk. “We go through hazard analysis. Think of anything that possibly could go wrong, from the smallest nuance to significant structural issues. From there, we push it to the safety review board to go through the test points.”

If there is an anomaly during the testing, he said, “You come back, land, and we’re going to have another technical review and look at the data and figure out, ‘Why did the jet do what it wasn’t expected to do?’ Then run through that analysis and possibly another safety review board before we send that crew back out to do additional testing.”

During flight tests, the pilots are augmented by flight test engineers in the cabin, watching the same instrumentation that is in the cockpit. “You work as a strong team to ensure they don’t miss anything as they’re doing those test points, and backing each other up. And if the test point didn’t go as it was supposed to go, where they didn’t hit the correct airspeed or angle, guess what? You are going to do it again and continue to back each other up. It’s all about teamwork.”

“Now that we have SMS [safety management systems],” Scott said, “this has given us lots of benefits. The risk assessment work that’s being done across the industry has opened our eyes to lots of things that we might not have otherwise seen. There is now an opportunity to start to weave some of these ideas around resilience directly into the SMS, because that’s the kind of framework everyone’s using.”

There remains a disconnect between the data that is being gathered by aircraft and what changes result from analyzing that data, Kroner pointed out.

“High-tech aircraft…report a lot of things,” according to Marimoto, “and we have the data. We hardly get surprised when there’s an accident and the final report comes out, and the findings are usually things that we have seen in the past. The question is not, ‘What did we know?’ It is, ‘Why didn’t we act more?’ As leaders, we have to start not looking at any expense related to safety…as a cost, but as an investment. That’s the most challenging thing that we have as a professional, because when we do our work properly, nothing happens. We don’t generate money for the company. So it’s hard for us to sell what we do to upper-level management unless something bad happens; then they see our value. We have to start using the data to show people who have the power of making decisions that it is much better to act on the smaller indicators to prevent them from getting together and becoming a bigger problem in the future.”

SMS doesn’t work if it isn’t seen as important by every person in the company, Scott explained. “SMS has to be owned by everybody, but I do think that the person who is listed as the accountable executive, we need to do a better job educating that person on exactly what it really means. There are lots of times in safety organizations [where] it’s seen as a cost center. We need to do a better job of educating the senior leaders in some of our organizations of what SMS is really for. Safety people need to start talking a different language…the language of the [chief financial officer].”