2023-Safety-Report-FINAL
2023-Safety-Report-FINAL
2023-Safety-Report-FINAL
MARCH 2024
INTRODUCTION
A n analysis of data in the Foundation’s Aviation Safety Network (ASN) database reveals
that 2023 was one of the safest years on record for commercial airline operations. The
ASN data show that there were zero fatal accidents1 involving commercial jet airliners last
year. Additionally, the total number of accidents, including fatal and nonfatal events, fell to 94 last
year, compared to 121 in 2022. This decline in accidents also represents a significant improvement
when compared to the average of 115.8 accidents recorded per year from 2018 to 2022.
The absence of fatal commercial jet airliner accidents in 2023 is indeed a reason to be thankful
and serves as a reminder of the importance of continued vigilance in maintaining aviation as the
safest mode of transportation. But it is also important to recognize that 2023 witnessed seven
fatal accidents involving turboprop or piston-engine airliners. Those seven accidents resulted in
107 fatalities among passengers and crew and the death of one person on the ground. In addition,
corporate jets used in a variety of operational roles were involved in 32 accidents last year, seven
of which were fatal accidents.
ASN data show significant progress has been made in reducing the number of events in historically
high-risk accident categories, such as controlled flight into terrain, loss of control–in flight, and
runway excursions. Improvements in these areas have been made through advances in technology
and through the collaborative efforts of operators, manufacturers, and regulators, among others.
However, the absence of an accident is not evidence of the presence of safety. The aviation industry
experienced an unacceptably high number of high-profile incidents in 2023 that could have been
fatal accidents if not for a last-minute intervention or action by a pilot or air traffic controller or a
stroke of luck. One notable incident was the near-collision of a FedEx Boeing 767 and a Southwest
737 at Austin-Bergstrom International Airport in Texas, U.S., in February 2023. The two aircraft
came within 100 feet (30 m) of each other as the FedEx aircraft was attempting to land and the
Southwest jet was taking off from the same runway. A collision was avoided when the FedEx pilots
rejected their landing. In a dozen other similar serious incidents, crews barely avoided catastrophic
collisions. In the December 2023 Global Action Plan for the Prevention of Runway Incursions
(GAPPRI) report, the Foundation warned of the severe consequences of runway incursion risks if
proactive measures are not taken.
Just a few days into the new year, however, two accidents were recorded. On Jan. 2, 2024, a JAL
Airbus A350 collided with a Japanese coast guard de Havilland Dash 8 on the runway at Tokyo
Haneda International Airport, killing five of the six people in the coast guard airplane; all 379 JAL
passengers and crew escaped without serious injuries. On Jan. 5, 2024, an Alaska Airlines Boeing
737 MAX-9 door plug blew out minutes after takeoff from Portland (Oregon, U.S.) International
Airport; no one was seriously injured. These were preventable accidents and incidents that not
only threatened the safety of passengers and crew but also undermine the public’s confidence in
our industry.
1
The International Civil Aviation Organization (ICAO) defines an accident as an occurrence associated with the operation of an aircraft that
takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked,
in which a person is fatally or seriously injured as a result of being in the aircraft or in direct contact with any part of the aircraft or has direct
exposure to jet blast, or the aircraft sustains serious damage or structural failure. The complete definition is available here.
The near misses of the past year, the notable accidents in 2024, and the ongoing issues with
runway incursions and other serious safety and quality concerns signal that safety buffers within
the industry are being stretched thin, highlighting the need to pay attention to these alarms. The
industry is grappling with numerous challenges, including the recruitment, sourcing, and training
of tens of thousands of new workers; the rising demand for travel; and the need to accommodate
new and diverse types of operations within the airspace system. However, it also stands at the
threshold of opportunity to bolster the resilience and safety of the aviation system through
effective technological implementation, a deeper comprehension of human factors, a sustained
dedication to quality, and a steadfast focus on leadership and safety culture values.
In December 2023, the Foundation published the Global Action Plan for the Prevention of Runway
Incursions (GAPPRI). This effort involved more than 200 aviation experts from 80 organizations
around the world working together on the analysis of multiple global and regional datasets,
combined with insights garnered from operational expertise. This strategy extended beyond the
study of only hazardous events; the recommendations incorporate lessons from all operations —
• The frequency of runway incursions in the U.S. National Airspace System (NAS) during 2022
was 33 per 1 million takeoffs and landings. The number and rate of the most serious runway
incursions (Categories A and B) 2 are increasing. (Figures 1 and 2)
Category A and B Runway Incursions Reported at U.S. Airports
Figure 1:
35 number of Category A and B runway incursions reported at U.S. airports since 2005.
The
30
25
20
15
10
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Year
Cat. A Cat. B
• In the United States, the most frequent contributor to runway incursion events is pilot
deviation. Over a recent five-year span, pilot deviation accounted for 64 percent of the
incursions, followed by vehicle/pedestrian deviation (19 percent), and operational incidents
related to air traffic controllers (17 percent).
• In the United States, general aviation aircraft were involved in 70 percent of the runway
incursion incidents during the five-year period.
• In the same international review of 68 runway incursion accidents and serious incidents,
several events involved controllers not checking compliance with potentially critical
clearances.
• The rate of reported runway incursion incidents increased during the period from January
2
Category A is a serious incident in which a collision was narrowly avoided. Category B is an incident in which separation decreases and
there is a significant potential for collision, which may result in a time critical corrective/evasive response to avoid a collision.
• The majority of runway incursion incidents involving aircraft taxiing across a runway
without clearance occur during the after-landing phase.
Category A and B Incursion Rate for Part 121 and Part 135 Carriers
1.80 2 The number of Category A and B runway incursions per 1 million departures incurred by Part 121 and
Figure
Part 135 carriers since 2005.
1.60
1.40
1.20
Incursions per 1 million departures
1.00
0.80
0.60
0.40
0.20
0.00
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Airliner Accidents
There were no commercial jet airliner3 fatal accidents in 2023 and seven turboprop and piston
engine airliner fatal accidents. Those seven accidents, five of which involved Cessna 208 Caravans,
resulted in 107 fatalities among passengers and crew and one ground fatality. Three of the fatal
accidents occurred in nonscheduled passenger operations, one in scheduled passenger operations
and one in cargo operations. The other two fatal accidents occurred in passenger operations, but
the type of operation is unknown.
The total number of airliner accidents, including both fatal and nonfatal accidents involving jet-,
piston-, and turboprop-powered aircraft, declined 22 percent to 94 in 2023 from 121 the previous
year. The 94 accidents in 2023 also represent a decline of nearly 22 percent from the average of
115.8 accidents per year in the five-year 2018-2022 period.
For the second year in a row in 2023, turbulence-related accidents were the most frequent
accident type. However, the number of accidents in the high-risk category (runway excursions,
LOC-I and CFIT), was 63 percent less in 2023 than the annual average for the five-year 2018–2022
period.
3
In the ASN database, airliners are defined as aircraft originally certificated to carry 14 or more passengers.
Turbulence
RE
GCOL
ARC
UNK
SCF-NP
LOC-I
CFIT
CABIN The categories shown within the black box
RAMP accounted for more than 90 percent of
SCF-PP airliner accidents from 2018 through 2023.
USOS
BIRD
Accident Categories
EVAC
RI
AMAN
WILD
OTHR
MAC
LOC-G
ICE
FUEL
F-NI
ADRM
CTOL
WSTRW
0 5 10Number of Accidents15 20 25
50
40
30
20
10
During the period under review (2018–2023), turbulence events occurred more often in North
America and Asia and less often in Europe and Africa. North America accounted for 41 percent of
all accidents, but for 51 percent of all turbulence accidents. Asia accounted for 16 percent of all
accidents but 26 percent of all turbulence accidents. The United States had the most turbulence-
related accidents, with 59, and there were 16 in Japan. Together, these two countries accounted for
63 percent (72 of 117) of all turbulence accidents during the review period.
Turbulence has long been a leading cause of injuries to airplane occupants, particularly flight
attendants, in nonfatal accidents, and incidences of turbulence are expected to increase because
of climate change, IATA said in 2018 when launching its Turbulence Aware program. In a Safety
Research Report4 published in 2021, the U.S. National Transportation Safety Board (NTSB) said
that from 2009 through 2018, turbulence-related accidents accounted for more than one-third of
all accidents involving U.S. scheduled airlines.
According to the ASN database, there were three wind shear/thunderstorm-related accidents
in 2023. Together, turbulence and wind shear/thunderstorm accidents represent more than 25
percent of all airliner accidents last year. During the previous five years, those two categories
combined represented roughly 17 percent of total airliner accidents.
The incidences of turbulence-related accidents are far higher among Part 121 (scheduled
operations) carriers than among Part 135 (commuter and on-demand) operators, and flight
attendants are the most likely people on board airliners to be seriously injured, the NTSB report
said. This is likely due in part to the fact that Part 121 aircraft often are larger than Part 135
aircraft and carry more passengers and cabin crew, which increases the potential for injuries if an
aircraft encounters severe, unexpected turbulence.
Runway Excursions: The ASN database shows there were five runway excursion accidents
involving airliners in 2023, which is a significant reduction from the 2018–2022 period, when then
there was an average of more than 18 runway excursion accidents per year. There were 25 runway
excursion accidents in 2020, during which much of the commercial aviation industry was shut
down due to the pandemic, but only six in 2021 as the industry began to recover.
Runway excursions occur frequently, but usually are not fatal. In 2023, of five runway excursion
accidents, one was a fatal accident. In that accident, an Embraer EMB-110P1 Bandeirante crashed
at Barcelos Airport in Amazonas, Brazil, during heavy rain. After touching down, it ran off the
4
“Preventing Turbulence-Related Injuries in Air Carrier Operations Conducted Under Title 14 Code of Federal
Regulations Part 121,” Safety Research Report, NTSB/SS-21/01 PB2021-100927, Adopted Aug. 10, 2021.
Since 2018, there have been nine fatal runway excursion accidents resulting in 101 fatalities
among passengers and crew. All but one of the nine occurred during the landing phase of flight.
The worst fatal runway excursion accident during the period occurred in March 2018 when a
US-Bangla Airlines de Havilland Dash 8 veered off the runway while landing at Kathmandu, Nepal,
resulting in 51 fatalities among the 71 passengers and crewmembers.
Since 2018, 82 percent of the 97 excursion accidents in the ASN database occurred during landing,
with more veer-offs than overruns. Unstable approaches and failure to go around were the most
common contributing factors. Other contributing factors included flight crew handling errors
(speed and directional control), contaminated runways, crosswinds, late or inaccurate reports on
runway conditions and/or weather, mechanical failures or gear collapses, and failure to reject the
takeoff before V1.5
In the period under review, runway excursion accidents occurred disproportionately more often in
Asia, Africa, and South America and less often in Europe and North America.
Asia, Africa, and South America accounted for 35 percent of all accidents during the period, but 49
percent of all runway excursion accidents.
Because of the complexity of risk factors involved in runway excursions — such as stability
of the approach, stability of the landing, condition of the runway, capabilities of the aircraft,
and instructions from air traffic control, among others — prevention requires coordination
among numerous stakeholders, including operators, airports, air navigation service providers,
manufacturers, and regulators. In 2021, the Foundation and EUROCONTROL, working with more
than 100 aviation professionals from 40 organizations, published the Global Action Plan for the
Prevention of Runway Excursions (GAPPRE), which provides recommendations and guidance
materials to a variety of stakeholders. The Foundation’s 2017 Go-Around Decision-Making and
Execution (GADM&E) Project report also contains valuable data and recommendations.
Ground Collision (GCOL): In 2023, there were 14 ground collision (GCOL) accidents, but in
four cases the accident is counted twice because it involved a collision between two commercial
aircraft. Those four cases resulted in damage to eight aircraft. The other six events involved
collisions between an aircraft and ground equipment or between a commercial aircraft and a non-
commercial aircraft. The five-year average for GCOL accidents is 15.8 per year. The worst year was
2019, when there were 28 accidents. Ground collision accidents usually occur during pushback or
taxi operations at an airport. If a collision occurs during a runway incursion, that event is included
in the runway incursion category.
Abnormal Runway Contact (ARC): In 2023, there were 15 abnormal runway contact (ARC)
accidents, slightly more than the average of 13.2 per year during the 2018-2022 period. None of
the 15 ARC accidents in 2023 were fatal. ARC includes any landing or takeoff involving abnormal
runway or landing surface contact. Included in this category are hard and heavy landings, long/
fast landings, off-center landings, and crabbed landings. Included in the 2023 accidents were five
tail strikes, one main landing gear collapse, one failure of a nose landing gear to extend, and one
5
V1 is the maximum speed at which a rejected takeoff can be safely initiated in an emergency.
Unknown: Accidents are categorized as “unknown” if there is not sufficient information to place
them in other categories. There were 12 accidents in 2023 in this category. The average for the
previous five years was 8.4 per year. Three of the 12 accidents in 2023 were fatal accidents,
resulting in 20 fatalities. The worst accident occurred on Oct. 29, 2023, when a Cessna 208B
Grand Caravan operated by ART Táxi Aéreo was destroyed when it crashed in a heavily wooded
area shortly after takeoff from Rio Branco–Plácido de Castro International Airport, Brazil. All 12
people on board were killed. For many of the accidents in this category, little is known about what
happened during the flight or the aircraft crashed without any communication from the flight
crew. As accident investigations are completed, many of these accidents may be recategorized.
In the previous five years, there were 42 accidents in the unknown category, 11 of which were
fatal accidents resulting in 219 fatalities. In the 2018-2022 period, there was a lack of evidence or
a missing investigation in 21 of the accidents; eight accidents involved some form of mechanical
failure (engine, flaps, electrical fire, landing gear, or other part failures); nine involved collisions
with something on takeoff, approach, taxi, or landing; and the remainder involved issues like
foreign object damage, cargo fires, and possible weight and balance issues.
System Component Failure–Non Powerplant (SCF-NP): There were eight SCF-NP accidents
in 2023, about equal to the average per year for the previous five years. Four of the 2023 events
were gear collapses, two involved hydraulic failure, one was a burst tire, and the other was a
pressurization problem. For the six-year 2018-2023 period, there were 47 accidents, including one
fatal accident. The fatal accident occurred in September 2022, when a float-equipped de Havilland
Canada DHC-3T Turbine Otter that was en route to its destination abruptly pitched down and
crashed in the water in Mutiny Bay, Washington, U.S. All 10 people aboard were killed. The
NTSB determined that the probable cause was the in-flight unthreading of a clamp nut from the
horizontal stabilizer trim actuator, which resulted in the stabilizer moving to an extreme trailing-
edge-down position.
Nearly all of the SCF-NP accidents during the review period resulted in substantial damage to the
aircraft. At least one involved injury to passengers. More than half of the accidents occurred during
the landing phase, but 11 occurred during the ground phase, six during takeoff, one during initial
climb, and three during the en route phase. Generally, these events were caused by landing gear
malfunctions that resulted in a landing gear collapse while operating (28) or a failure to extend or
retract (three). Other mechanical failures involved flight controls, pressurization, tires, windows,
brakes, cargo door, damage to landing gear, damage to a generator, and foreign object damage
(FOD). Insufficient or incorrect maintenance was related to at least five events.
Loss of Control-In Flight (LOC-I): In 2023, there were three airliner LOC-I accidents, of which
two were fatal, resulting in 73 fatalities among passengers and crew. The worst of the two fatal
LOC-I is considered a high-risk accident category because these accidents often are fatal. During
the 2018–2022 period, there were 31 LOC-I accidents, and 20 of them, or 65 percent, were fatal
accidents resulting in 846 fatalities among passengers and crew and seven ground fatalities. Two
of the three worst fatal LOC-I accidents since 2018 were the Boeing 737 MAX crashes in Indonesia
and Ethiopia, which together resulted in 346 fatalities. Also included in the total is the accidental
January 2020 shootdown of a Ukraine International Airlines Boeing 737-800 near Tehran, Iran, by
Iranian air defense forces, which resulted in 176 fatalities.
Ten accidents in 2018–2022 involved aerodynamic stalls, some because of icing conditions and
others because of excessive pitch and slow airspeeds. Improper response to downdrafts, wind
shear or crosswinds was noted in six of the accidents, and four involved excessive maneuvers.
Other conditions included loss of situational awareness in severe weather, inadvertent activation
of go-around mode, and engine failure.
Controlled Flight Into Terrain (CFIT): Like LOC-I accidents, CFIT accidents are a high-risk
category because of the likelihood of fatalities. However, neither of the two CFIT accidents that
occurred in 2023 was a fatal accident.
During the 2018–2022 period, there were 27 CFIT accidents, or an average of 5.4 per year. Fifteen
of the accidents during the five-year period were fatal, resulting in 111 fatalities among passengers
and crew. One of the worst accidents during the period occurred on July 6, 2021, when an Antonov
An-26B-100 being operated by Kamchatka Aviation Enterprise on a scheduled domestic flight in
Russia struck a cliff while on approach to Palana Airport on the Kamchatka Peninsula. Twenty-
eight passengers and crew were killed in the accident.
Most of the CFIT accidents that occurred during the 2018–2022 period involved adverse weather
conditions, such as low visibility and ceilings, fog, and snow. Many happened in mountainous
terrain. In addition, the majority of accidents involved operational shortcomings of some kind,
including visual flight rules flights continuing into instrument meteorological conditions,
descent below established minimums, deviations from established routes, and late or improper
go-arounds. Many of the deviations and descents below minimums could be characterized as
intentional noncompliance, a factor that some believe may be under-recognized in accident
investigations. Of the total of 27 CFIT accidents since 2018, 12 occurred during cargo operations.
Cabin: In the six-year period 2018-2023, there were 23 events that occurred in passenger cabins
that are considered accidents because of the seriousness of the injuries suffered by crew and/or
passengers. None of the events were fatal. Nineteen of these events involved crew injuries, and six
involved passenger injuries. Generally, these events were caused by falls in or outside the aircraft,
tripping over something, collisions with galley carts, hot liquid spills, and the aircraft abruptly
changing speed, among other reasons. There was one cabin-related accident in 2023, and the
average for the 2018-2022 period was 4.6 per year.
Ramp: There were three ramp accidents in 2023, two in the United States and one in Germany.
System Component Failure–Powerplant (SCF-PP): In 2023, there were three SCF-PP accidents,
two of which were engine fire-related, and one of which was a flameout. None of the accidents
were fatal. In the previous five-year period, there were an average of 3.4 accidents per year.
In the six-year period 2018-2023, there were 21 SCF-PP accidents. Five of these accidents were
fatal, resulting in 11 fatalities among passengers and crew and one ground fatality. Eight of the 21
accidents happened during the en route flight phase, with the others being divided among
takeoff (four), initial climb (two), approach (three), and one each during landing or standing.
Most involved loss of thrust in one of the engines. Other factors included fire or fire warnings,
uncontained failures (two), ingestion of something or someone, fuel starvation, heavy vibrations,
and compressor stalls. Often these created conditions in which pilots had to shut down an engine,
or deal with complete power loss or flameouts. The loss of engine operation in many cases led to a
forced landing.
Runway Excursions
Loss of Control
ARC
UNK
SCF-NP
The categories included in the black box
GCOL accounted for 84 percent of corporate jet
BIRD accidents in 2023 and 82 percent in 2018-2022.
TURB
SCF-PP
Accident Categories
USOS
CFIT
RI
WILD
ADRM
RAMP
CABIN
0 2 4 6 8 10 12 14 16
Number of Accidents
6
The following are the ICAO aircraft designators for the corporate jet models covered in this analysis: ASTR, BE40, C25A, C25B, C25C, C25M,
C500, C501, C510, C525, C526, C550, C551, C55B, C560, C56X, C650, C680, C68A, C700, C750, CL30, CL35, CL60, DJET, E545, E550, E50P,
E55P, EA50, F2TH, F900, FA10, FA20, FA50, FA5X, FA6X, FA7X, FA8X, G150, G250, G280, G650, GA4C, GA5C, GA6C, GA7C, GA8C, GALX, GL5T,
GL7T, GLEX, GLF3, GLF4, GLF5, GLF6, GSPN, HA4T, HDJT, HF20, LJ23, LJ24, LJ25, LJ28, LJ31, LJ35, LJ40, LJ45, LJ55, LJ60, LJ70, LJ75, LJ85,
FLIGHT SAFETY FOUNDATION | 2023 SAFETY REPORT
MS76, MU30, PC24, PRM1, S601, SF50, SJ30, SJET, SP33, WW24
11 |
Corporate Jet Fatal Accidents
12
Figure 6 Corporate Jet Fatal Accidents, 1990-2023 (Blue bars represent annual number of fatal accidents; orange
line indicates the rolling average.)
10
Fatal Accidents
In the six years from 2018 through 2023, corporate jets were involved in 203 accidents, slightly
more than half of which (110) occurred during the landing phase. Of those 203 events, 40 were
fatal accidents resulting in 148 fatalities among passengers and crew and five ground fatalities.
The Foundation’s analysis of corporate jet accident data focused on six accident categories, which
accounted for approximately 84 percent of accidents in 2023 and 82 percent of the accidents
during 2018–2022 period (Figure 5).
One of the 14 runway excursions in 2023 was a fatal accident. In November, a Learjet 35A
operating as an air ambulance was destroyed when it crashed at Cuernavaca International Airport
in Mexico. Two pilots and two passengers were killed.
During the 2018–2023 period, seven of the 84 runway excursion accidents recorded were fatal
accidents, resulting in 21 fatalities among passengers and crew and one person on the ground.
The worst of the fatal accidents occurred on March 29, 2020, when an Israel Aerospace Industries
1124A Westwind II crashed following a rejected takeoff from Manila-Ninoy Aquino International
Airport in the Philippines and burst into flames. Eight passengers and crew were killed.
Runway excursions are far more prevalent after landing than during the takeoff phase. Of the 84
excursion accidents reported for the 2018–2023 period, 72 occurred during the landing phase.
Analysis of a broader ASN data set including corporate jets and commercial airliners showed that
Loss of Control (LOC-I): After runway excursions, LOC-I accidents usually are the most common
accident type. There were three corporate jet LOC-I accidents in 2023, but in the five-year 2018–
2022 period, there were 24, or an average of 4.8 per year. One LOC-I accident last year was fatal
and resulted in a total of eight fatalities.
In the five-year 2018–2022 period, 16 of the 24 LOC-I accidents were fatal accidents resulting
in 80 fatalities among passengers and crew. The worst year for fatalities was 2021, when five
accidents resulted in 27 fatalities. The worst fatal LOC-I accident during the period involved a
Canadair Challenger 601-3A corporate jet that crashed in desert terrain during a flight from Las
Vegas, Nevada, U.S., to Monterrey, Mexico. All 13 passengers and crew were killed.
Aerodynamic stalls remain a leading cause of LOC-I accidents, and about 25 percent of these
accidents involved stalls. More specifically, a stall during a circling approach remains a significant
factor in LOC-I accidents. Another contributor is spatial disorientation.
Abnormal Runway Contact (ARC): There were three abnormal runway contact accidents in
2023, none of which were fatal. In the previous five-year period, there were 14 abnormal runway
accidents, or an average of 2.8 per year. None of the ARC accidents during the period was fatal.
In at least two of the accidents during the five-year period, the crew did not lower the landing
gear, and in other events, a part failed, causing the gear to collapse. In two cases, improper
maintenance had been performed on the landing gear, and one case involved a runway excursion
and landing gear collapse following a rejected takeoff. In two of the 2023 accidents, the aircraft
landed hard after a stable approach and gear failed upon touchdown. Both accidents are still under
investigation.
Unknown (UNK): There were five accidents in 2023 that qualify as unknown, which means there
is not enough information available about the event to put the accident in a more specific category.
In the previous five years, there were an average of 1.8 accidents of unknown causes per year,
which is more than in any year in the prior five years. Four of the unknown accidents in 2023 were
fatal accidents, which equals the total for the previous five years. During the six-year period under
review, there were eight fatal accidents. This category also accounted for 24 fatalities in five of the
seven events. For many of the other accidents, little is known about what happened; in some cases,
the aircraft crashed without any communication from the flight crew before they died. As accident
investigations are completed, some of these accidents may be recategorized.
In the previous five years, there were 15 accidents that are categorized as unknown. Contributing
factors in this group of accidents included mechanical failures; collisions with something on
takeoff, approach or landing; mishaps during taxiing; and damage during armed conflicts.
In the previous five years, there were 12 SCF-NP accidents, two of which were fatal. On Sept. 4,
2022, a Cessna 551 Citation II/SP was destroyed when it crashed into the Baltic Sea while en route
from Spain to Germany. Radio communication indicated a pressurization problem, and fighter
escorts took photos showing an incapacitated pilot in the left seat and his oxygen mask hanging
unused in its place. An investigation continues, but it is suspected that the plane crashed into the
Baltic Sea after fuel was exhausted. The other fatal accident occurred in January 2018, when a
Gulfstream G150 cabin became pressurized while the aircraft was on the ground. The captain of
the aircraft died from injuries sustained when he was struck by the cabin door which blew open
with excessive force. The remaining accidents in the 2018–2022 period involved gear collapses,
pressurization failures during flight, and brake fires.
Bird Strike: There was one bird strike accident in 2023. In the previous five years, there were
eight accidents, or 1.8 per year, on average. None of the accidents during the review period was
fatal. In every event, significant damage occurred to the aircraft, and these events happened in
nearly every phase of flight. All but one of the reported accidents occurred in the United States,
which likely is related to the country’s extensive business aviation traffic and to the emphasis that
U.S. Federal Aviation Administration puts on encouraging operators to report bird and wildlife
strikes.
Call to Action
The aviation industry has made significant safety progress over the decades, but the Foundation
and other industry stakeholders are continually in pursuit of greater improvement. Technology
has had a positive impact on the decline in the number of midair collisions, CFIT accidents, and,
to a lesser extent, LOC-I accidents and runway excursions. Safety also is improved by changes
to processes and behavioral norms. As safety performance improvement has slowed in recent
years, there is often an even greater need to strengthen SOPs and weak links in the chain of events
leading to an accident. The Foundation believes there is still much to learn from the worldwide
accident record about prioritizing accident-reduction efforts in the accident categories discussed
in this report.
Safety Culture — Given the importance of a robust safety culture and the need to drive safety
improvements as operations increase, it is imperative for operators, manufacturers, regulators,
and other stakeholders to combat complacency and maintain an active focus on actions and
policies that will help reduce risk. These include strict adherence to safety protocols and SOPs,
regular safety training, promoting personal and collective responsibility for safety, collaborating
on risk identification and mitigation, and sharing safety information up and down and across
organizations.
Runway Excursions — Excursions are a significant risk for all sectors of aviation. The Foundation
strongly encourages the implementation of recommendations made in the GAPPRE and GADM&E
reports. In advance of the coming European Union Aviation Safety Agency mandate that large
aircraft operated in commercial air transport be equipped with a runway overrun awareness
and alerting system, some manufacturers are already equipping their fleets. The technology has
not been in the fleet long enough to measure its effectiveness, but the Foundation believes this
technology has potential to reduce excursions and equipage should be encouraged.
Runway Incursion — The Foundation also is concerned about the ongoing risk of runway
incursions, particularly in light of the incursion events reported since the start of 2023, and
believes it is important to raise awareness of this safety risk. In December, the Foundation released
the Global Action Plan for the Prevention of Runway Incursions (GAPPRI) and strongly encourages
all relevant aviation stakeholders to review the document and its recommendations.
Ground Damage — The risk of a ground collision and resulting damage requires precautions as
part of regular procedures in flight operations, ground operations, maintenance, and elsewhere.
As the industry acquires a large number of new, inexperienced personnel, the interfaces between
operational areas can lead to risks that may have been handled more capably by seasoned
professionals. The Foundation highly recommends that operators and maintenance and ground
handling organizations reinforce safety norms and proper procedures among front-line workers
when daily activities are conducted. Investment in proper training also is critical. In addition, the
Foundation supports the practical use of technology solutions, such as anti-collision systems, to
reduce ground damage occurrences.
LOC-I — Despite some recent improvement, this area still needs attention and better compliance
with checklist procedures. When pressures to meet schedules clash with SOPs, operators need
to practice healthy crew resource management efforts and recognize that risk must be managed
within the boundaries of an acceptable process. If the process is not serving the needs of flight
crewmembers, it must be revisited and revised accordingly. Operators and regulators must ensure
that the training of flight crewmembers is carried out in the spirit of International Civil Aviation
Organization Annex 6 Part 1 Chapter 9 Para 9.3.1, which covers training in knowledge and skills
related to human performance.
CFIT — Despite improvement, risks persist, with loss of situational awareness in instrument
meteorological conditions one of the most common occurrences in this accident category. As
with LOC-I, ensuring the quality of flight crew training is paramount. If aircraft are equipped with
terrain warning systems, operators should regularly monitor adherence and response to these
warnings, and if aircraft are not equipped with these systems, operators should ensure additional
The Foundation chose to focus on accident categories that are sizeable and relevant around the
world. Making significant safety progress requires focusing on the circumstances and causes of
accidents in the categories that account for the majority of accidents and more than 90 percent of
all fatalities. Technology improvements likely will continue to address some of the causes of these
accidents, but human attention to details, revising processes to ensure the highest confidence of
safe outcomes and applying the necessary lessons learned from the mistakes of the past also play
an important role and will require actions on several fronts. As we have noted in our analysis, not
every region of the world or every sector is experiencing similar results, and solutions may need
to be focused on unique experiences and challenges. The Foundation will continue to look for
opportunities to improve the overall risk picture for the industry, and undoubtedly, improvements
will require great collaboration among stakeholders.