Continuous Improvement Loops in Aviation—Part 2

Commercial aviation is among the safest modes of transport. This is thanks to a continuing improvement process spanning decades (and still ongoing). In this series of posts I will look at how aviation safety improved, using the passenger safety instructions as an example. My first post showed you how it was before the FAA and how it is now. This post looks in particular how the passenger safety institutions (i.e., the cards and the briefings) improved since 1940 thanks to the FAA. Now, pay attention!

Structured Improvement by the FAA

In 1938, the Civil Aeronautics Administration, the predecessor of the FAA, was established. Their first major investigation was the crash of a Douglas DC-3, the Lovettsville air disaster, in 1940, issuing their first recommendations (not yet related to passenger instructions). But another crash in 1943 of an American Airlines Flight 63 with a DC-3 from Louisville, KY, to Memphis, TN, lead to improvements in Passenger Safety Instructions.

This crash caused many deaths simply because the stewardesses forgot a safety latch and could not open the door. Twenty of the twenty-two occupants died, many in the subsequent fire. The emergency exits were also not visible, and only one passenger escaped. The Civil Aeronautics Administration ruled that exits need to be illuminated, and that there have to be emergency exits in the first place, and that they can be opened from the inside or outside. They also ordered a redesign of the doors.

Around 1940, ditching instructions for water landings were also often included. Still, accidents were not seen as preventable but as a part of life.

Post-War Safety Information

In 1961, United Air Lines Flight 859 crashed in Denver, Colorado. While the crash was mild, the fire killed eighteen people and injured many more. This accident was thoroughly studied by the FAA. As a result, quite a few cabin safety measures were introduced. In 1963, the FAA introduced proposed regulations for various cabin safety measures, including enhanced exit signs and markings, mandatory evacuation demonstrations by airlines, and required passenger safety briefings. Safety instructions and safety cards became mandatory in 1965, focusing on seat belts, emergency exits, and smoking regulations.

In 1967 an amendment to the safety card regulations were proposed, requiring a card be given to every passenger over twelve years of age, and the cards must be specific to the aircraft (i.e., not a general fleet card for all types of aircraft used by the airline as before. Having five plane layouts to choose from makes it hard to find the right emergency exit in an emergency.). However, this was rejected by the airlines as being unreasonable. Only after some modifications was this regulation passed.

Switching Text for Images in the 1970s

Up until the 1970s, the safety card instructions were usually mostly text with some images. But more and more images took over, and text was reduced or even completely eliminated. Nowadays text is much less common on safety cards, making them easy to understand regardless of language ability. This coincided with a number of fatal accidents that should have been survivable. One of these fatal accidents was the Allegheny Airlines Flight 485 crashed in 1971. All but one passenger survived the initial impact, but twenty-seven died after failing to open the emergency exit. Only two passengers survived. As a result, the FAA suggested among others that the flight attendants physically point to the exits during the briefing. However, this was rejected.

A suggestion A-74-113 from 1974 from a general meeting on safety improvements, however, was implemented, requiring standardized guidance to the air transport industry on effective methods and techniques for conveying safety information to passengers. As we will see, however, getting the attention of the passengers remains difficult. An accepted suggestion A-76-026 focused on information on supplemental oxygen both on the safety cards and the briefings.

Video Safety Instructions from the 1980s

Around 1980, with increasing technology, safety videos became common. The oldest one I found was from Air Canada from the 1980s. It is quite a blast from the past, with 80s hairstyles and computer graphics and all. Yet, these were still on the initiative of the airlines.

The crash of Pilgrim Airlines Flight 458 in 1982 lead to suggestion A-82-070 to again review oral briefings, including information on the stowage of carry-on baggage.  Suggestion A-83-045 aimed to review safety information that is most useful and needed by passengers and how to convey them, but this did not succeed.

The emergency landing of the burning Air Canada Flight 797 in 1983 led, among other suggestions, to the installation of smoke detectors and tactile markers for exits (suggestion A-83-081), but this was accepted only in a modified form. The crash of Eastern Air Lines Flight 855 in 1983 lead to suggestion A-84-044, recommending not only the showing of how to use the life vest but also how to get the life vest from underneath of your seat, but this was rejected.

The report “Airline Passenger Safety Education” from 1985 again required not only the mentioning of the emergency exits, but that the flight attendants physically point to the exits. Vaguely phrased they also suggested to develop methods to improve passenger motivation to listen to safety information (A-85-93, accepted), improved safety cards (A-85-95, accepted), better pre-flight safety briefings (A-85-098, unacceptable), and again how to get the safety vest (A-85-099, rejected), and more.

Refining Instructions in the 1990s and 2000s

Suggestion A-91-052 was about including information on the lights guiding to the emergency exits on both the card and the briefing. This was accepted. Suggestion A-00-87 even required a minimum comprehension testing for safety briefing cards, but this was rejected, and you don’t have to take a test on the safety briefing before being allowed to fly. The water landing of US Airways flight 1549 in 2009 (better known as the miracle on the Hudson) again tried to use creative and effective methods of overcoming passengers‘ inattention and providing them with safety information, but this also did not work.

Overall, you can see a continuous improvement in aviation, making safety instructions and safety cards continuously better. As with any continuous improvement, it is never complete, and new safety recommendations are issued every year. At the time of writing, the latest recommendation was A-25-002 on helicopter routes at Ronald Reagan Washington National Airport due to the 2025 Potomac River mid-air collision. Now, go out, keep on improving the safety of your operations, and organize your industry!

Selected Sources

Among the many sources, including FAA reports, I found the following series of articles very readable:

The History of Safety Cards, Part One; Part Two, Part Three, Part Four, Part Five, Part Six, and Part Seven.

You can look up safety suggestions on the NTSB website Carol Search, where you will find the full FAA safety reports.

Explanations for the safety suggestion rating can be found here.