Economics of Safety. Billy Nolen, Senior Vice President, Safety, Security and Operations, A4A Panelists:

Transcription

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2 Safety Stream

3 Moderator: Economics of Safety Billy Nolen, Senior Vice President, Safety, Security and Operations, A4A Panelists: John Duncan, Director, Flight Standards Service, Federal Aviation Administration (FAA) Alain Lumbroso, Economist, International Transport Forum of the Organisation for Economic Co-Operation and Development (OECD) Brian Pearce, Chief Economist, IATA

4 Thank You to Our Networking Break Sponsor:

5 Performance-based Regulations ~ Oversight Moderator: John Allen, Chief Safety Officer and Vice President, JetBlue Airways Corporation Panelists: John Duncan, Director, Flight Standards Service, Federal Aviation Administration (FAA) John Laughter, SVP Corporate Safety, Security and Compliance, Delta Airlines Katherine Kendall, Head of Group Quality, Cathay Pacific, Chair IOSA Oversight Council (IOC)

6 Panel Discussion - Performance-based Regulations - Oversight IATA Safety & Ops Conf John Allen VP Safety

7 Performance-based Regulations - Oversight Setting the stage, Performance Based Regulation: The Performance-based regulatory Process As its name implies, performance-based regulation (PBR) is a regulatory approach that focuses on performance, as well as the desired results and outcomes. As such, PBR differs from the traditional, prescriptive regulatory approach in that it emphasizes what must be achieved, rather than how the desired results and outcomes must be obtained. To be effective, regulatory decision-makers using a PBR approach must give careful thought to the following questions: Which results are most desirable? Which activities (including monitoring) are most likely to yield the desired results? 7

8 Performance-based Regulations - Oversight The U.S. Nuclear Regulatory Commission Setting the stage, Performance Based Regulation (PBR): The Performance-based regulatory Process As its name implies, performance-based regulation (PBR) is a regulatory approach that focuses on performance, as well as the desired results and outcomes. As such, PBR differs from the traditional, prescriptive regulatory approach in that it emphasizes what must be achieved, rather than how the desired results and outcomes must be obtained. To be effective, regulatory decision-makers using a PBR approach must give careful thought to the following questions: Which results are most desirable? Which activities (including monitoring) are most likely to yield the desired results? 8

9 Evolution of U.S. Regulatory Oversight Regulator Oversight Sophistication Data Analysis & System Safety National Air Transportation Inspections (NASIPS) SMS Oversight & Compliance Philosophy NRC Also Adopting This Philosophy Support from NRC Enhanced rulemaking & compliance enforcement 1920s licensing & direct inspectio n Use of designee s 1940s 1960s 1980s 1990s Today 9

10 Performance-based Regulations - Oversight Isn t SMS a performance based rather than compliance based system? Is the regulator oversight acumen changing to provide the appropriate safety assurance in light of:? Compliance Philosophy Just Culture Change Management Safety Risk Management Safety Assurance How is the relationship between the airline and the regulator changing in the performance-based SMS environment? Is IOSA complementary, additive, or in conflict with SMS quality? SMS Interfaces Between Safety Risk Management and Safety Assurance 10

11 Performance-based Regulations ~ Oversight Moderator: John Allen, Chief Safety Officer and Vice President, JetBlue Airways Corporation Panelists: John Duncan, Director, Flight Standards Service, Federal Aviation Administration (FAA) John Laughter, SVP Corporate Safety, Security and Compliance, Delta Airlines Katherine Kendall, Head of Group Quality, Cathay Pacific, Chair IOSA Oversight Council (IOC)

12 Performance-based Regulations ~ Oversight John Duncan Director, Flight Standards Service Federal Aviation Administration (FAA)

13 Performance-based Regulations ~ Oversight John Laughter SVP Corporate Safety, Security and Compliance Delta Airlines

14 Safety Risk Management Safety Assurance (SRMSA) John Laughter SVP Corporate Safety, Security, Compliance

15 OVERVIEW DELTA AIR LINES, INC.

16 OVERVIEW Background (Why) Program Structure (How) Benefits/Challenges Way Forward DELTA AIR LINES, INC.

17 BACKGROUND DELTA AIR LINES, INC.

18 SRMSA OBJECTIVE Enhance data sharing and cooperative efforts between Delta and the FAA in order to further aviation safety through risk-based, data-driven decision making in support of a fully functional Safety Management System (SMS) DELTA AIR LINES, INC.

19 SAFETY CULTURE SRMSA ASAP Hotline SWOA SWOA LOSA LOSA Industry Data STEADES ASIAS Audits/IEP/ Investigations VPP FDM FOQA Encourage open hazard reporting, collaborative and continuous data analysis, risk-based decision making, and safety data sharing DELTA AIR LINES, INC.

20 SAFETY ASSURANCE DATA DELTA AIR LINES, INC.

21 PROGRAM STRUCTURE DELTA AIR LINES, INC.

22 STRUCTURE Noncompliance Discovered (No Enforcement Action) Prompt Notification Voluntary Self Disclosure Process FAA Access to Delta Data Delta Access to FAA Data FAA Participates As Desired/Requested Corrective Action Monitoring FAA Access to Delta Data Delta Access to FAA Data FAA Participates As Desired/Requested Enhances Collaboration, Prioritization of Resources, and Risk-Based Decisions DELTA AIR LINES, INC.

23 CRITERIA 1. Be inadvertent and must not appear to involve criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification. 2. The apparent violation does not indicate a lack, or reasonable question, of qualification of the certificate holder. 3. Immediate action, satisfactory to the FAA, is taken upon discovery to terminate the conduct that resulted in an apparent violation. 4. The certificate holder has developed or is developing a comprehensive fix and schedule of implementation satisfactory to the FAA. The comprehensive fix includes a follow up. DELTA AIR LINES, INC.

24 DATA COLLECTION DELTA AIR LINES, INC.

25 Safety Promotion Sharing and Communicating Integrated Safety Round Table (ISRT) Airport Customer Service/Cargo Flight Operations In-Flight Service Operations / Customer Center Technical Operations Share safety information Communicate cross-divisional concerns Develop safety risk mitigation strategies DELTA AIR LINES, INC.

26 BENEFITS / CHALLENGES DELTA AIR LINES, INC.

27 BENEFITS / CHALLENGES Benefits Better Communication and Understanding of safety issues Improved Risk Management Prioritized List of Hazards to allocate resources Improved Allocation of Resources Continual Improvement in the level of safety throughout the carrier s SMS by working collaboratively Utilize FAA and Delta data to promote an environment and a set of practices that best Fosters Safety and Compliance through Open Sharing of data Select the Best Set of Processes to prevent noncompliance of incidents Challenges Handling of Repeat Violations Cultural Shifts (Delta and FAA) DELTA AIR LINES, INC.

28 WAY FORWARD DELTA AIR LINES, INC.

29 WAY FORWARD Processing of all risk and safety issues by the carrier Carriers use Safety Risk Management processes (SMS) for noncompliance and other safety issues Simplifying risk management onto a single platform FAA is a full partner during safety risk sessions Full access for FAA of Delta s Safety and Operational Systems DELTA AIR LINES, INC.

30 Thank You DELTA AIR LINES, INC.

31 Performance-based Regulations ~ Oversight Katherine Kendall Head of Group Quality, Cathay Pacific Chair IOSA Oversight Council (IOC)

32 IATA Operational Safety Audit Presented by: Kathy Kendall, Cathay Pacific Airways, Chairperson IOC

33 IOSA Program History Program development was initiated in 2001 First Audit conducted in September 2003 Some Highlights Since Inception Upgrade of Standards to include all cargo operations and passenger flights without cabin crew In 2010, upgrade of Standards to incorporate all elements of SMS contained in the ICAO Framework for SMS E-IOSA introducing continuous internal assessments (special project and BMA) 34

34 IOSA Program Purpose Reduce the number of audits in the airline industry Improve worldwide airline safety levels 35

35 IOSA Program Overview Some 950 IOSA Standards and Recommended Practices (ISARPs) include ICAO safety and security provisions and industry best practices from ICAO Annexes 1, 2, 6, 8, 17, 18 and 19 ISARPs revised annually by 94 SMEs from IOC and IOSA Technical Groups Available to all commercial passenger & cargo airlines, regardless of IATA membership status 36

36 Statistics - IOSA Registered Airlines Displayed online to public ( Americas 92 Europe 165 China & North Asia 34 Total: 418 Airlines Africa & Middle East 66 Asia-Pacific 61 Data: April

37 IOSA Vision To be the leader of operational safety auditing in an accident-free world. Safety Support and uphold improvement of global safety levels through implementation of IOSA Maintain and advance IOSA as world's leading operational safety Standard Support consistent implementation of SMS Adopt applicable ICAO safety requirements from the Annexes to the Convention on International Civil Aviation Strategic Pillars Effectiveness Minimize the number of redundant audits through effective use of IOSA Continuously improve effectiveness of IOSA Program processes and protocols Ensure robust Audit Program infrastructure is in place Constantly seek opportunities to simplify the program processes Integrity Protect and promote the integrity of the IOSA Program Apply and continuously strengthen control over Audit processes Operate in full alignment with IATA's vision and mission Exercise effective oversight over Audit Organizations 38

38 Enhanced IOSA Background Enhanced IOSA as response to industry s feedback Program change to focus on the implementation aspect of Standards and ensure continuous conformity Implementation was a transitioned approach for full implemention by September 2015 Enhanced IOSA applicable to all renewal audits 39

39 Enhanced IOSA Four Pillars Enhanced IOSA will facilitate the incorporation of four pillars in airline operations: Continuous Conformity with IOSA Standards Focus on Implementation of IOSA Standards Reliability of Airline s Quality Assurance Functions Auditing Standardization 40

40 IOSA and Regulators ICAO Endorsement 35 th Session of ICAO Assembly: recognized value of IOSA as complementary measure to the regulatory oversight activities of States. and stated that IOSA.. will need the continued support of regulatory authorities worldwide.. 41

41 IOSA and Regulators ICAO Endorsement 38 th Session of ICAO Assembly: The Commission expressed its support for the IOSA programme and recommended that ICAO continue its support of IOSA and the additional elements under Enhanced IOSA as a complementary source of information for State safety oversight activities. 42

42 IOSA and Regulators ICAO/EASA Complementary to ICAO USOAP Program AMC to EASA regulations for Code- Share arrangements, as source for evaluation of TCOs and for riskbased oversight of EU CAAs FAA/ CAAC Accepted by FAA under DOT/FAA Code-share Safety Guidelines CAAC Advisory Circular for codeshare safety audits 43 Other Regulators Trafi Finland reduces national oversight cycles using IOSA audit results Turkey, Chile, Madagascar, Brazil, Costa Rica, Panama, etc. support and use IOSA

43 Continuous Improvement Focus on IOSA Strategic Pillars Effectiveness and Integrity 44

44 EASA Assessment 2016 EASA uses IOSA for three different purposes As result, EASA conducted assessment of IOSA program in Feb 2016 Recommendations are being addressed through action plan (BMA) 45

45 IOC Assessment of IATA Quality 2016 Subgroup of the IOC conducted an assessment of IATA QA programs in 2016 Recommendations are being addressed through action plan and have been integrated and aligned with EASA recommendations (BMA) 46

46 Interrelationship of all Quality Activities - Historical Auditor audit assignments - Auditor assessments - Auditor qualifications - Auditor QC performance - Risk Model - Performance monitoring - Data extraction - Audit results & data analysis - Auditing techniques - Evidence sampling - Technical assessments Data, Risk, Performance driven Quality Activities 47

47 Digital Transformation Project Vision Data Management Approach IOSA as Collaboration Platform Digital Re-mastering of the Audit Program and Quality Assurance Processes 48

48 THANK YOU 49

49 Performance-based Regulations Oversight Moderator: John Allen, Chief Safety Officer and Vice President, JetBlue Airways Corporation Panelists: John Duncan, Director, Flight Standards Service, Federal Aviation Administration (FAA) Katherine Kendall, Head of Group Quality, Cathay Pacific, Chair IOSA Oversight Council (IOC) John Laughter, SVP Corporate Safety, Security and Compliance, Delta Airlines

50 Workshop Luncheon Presented by: Opening the Walled Garden: GE s Leading-Edge Approach to Flight Analytics Namsan II Room, Level Two 12:30 Lunch Provided

51 Maintenance Safety Moderator: Michel Gaudreau, Senior Vice President of Corporate Safety, Security, and Compliance, Korean Air Panelists: Martin Eran-Tasker, Technical Director, Association of Asia Pacific Airlines (AAPA) Captain Craig Hoskins, Vice President for Safety and Technical Affairs, Airbus Americas Rick Howell, General Manager, Group Safety and Security, Cathay Pacific Dr. William Johnson, Chief Scientific and Technical Advisor, Maintenance Human Factors, Federal Aviation Administration (FAA)

52 Maintenance Safety Dr. William Johnson Chief Scientific and Technical Advisor, Maintenance Human Factors Federal Aviation Administration (FAA)

53 Topic 1: Fleet Age and Human Factors Hazards Dr. Bill Johnson Chief Scientific and Technical Advisor Maintenance Human Factors Federal Aviation Administration

54 People who perform the job Environment for work - Organizational and physical Actions (tasks) performed for job Resources like equipment, tools, procedures, and more

55 Topic 2: Maintenance Practices Ensuring Compliance Dr. Bill Johnson Chief Scientific and Technical Advisor Maintenance Human Factors Federal Aviation Administration

56 Everybody talks about the weather, but nobody does anything about it. Charles Dudley Warner, 1875

57 Five Slides Challenges R&D Solutions

58 Compliance Challenges # 1 Cause in Human Error Study ( Johnson, et al, 2000) #1-2 of 10 Top Contributing Factors to Error (UKCAA, 2004) 31% MX Error, 51% Follow Procedures (Walker Oil Rigs) #1 Cause of FAA letters of Investigation (FAA, 2015)

59 Research and Development FAA HF R&D ( ) Technical Publications Workshop FAA Operator s Manual CAST SE 170 (2016)

60 See:

61 See:

62 Solutions Insure root causes analyses Quantify financial loss Leverage voluntary reports Process improvement Take this challenge seriously CULTURE-LEADERSHIP-COMMITMENT

63 Thank You, Dr. Bill Johnson

64 Maintenance Safety Rick Howell General Manager, Group Safety and Security Cathay Pacific

65 Maintenance Errors One of SG Top 10 Issues Noncompliance with maintenance procedures poses a risk to global aviation. Establishing an enhanced understanding and communication of human factor related issues in the aircraft engineering and maintenance environment is essential.

66 The Challenge & Opportunity Although maintenance errors low contributor to accidents ( = 11% of accidents) failure modes often require mitigation by flight crews & therefore, reducing the number of events will enhance safety by negating the use of the last line of defense

67 IATA Survey on Maintenance Errors IATA therefore commissioned an exploratory study into maintenance errors by Dr. Martin Smith, CEO Presage Group Inc. Some initial findings are as follows:

68 Global Maintenance Error Study Despite great efforts to engage the response rate was very low plus very low scores obtained on the culture of compliance indicates a systemic problem within the maintenance industry showing that maintenance errors do present a significant threat Only 53% of respondents felt that their company supports safety when competing with commercial outcomes (i.e. maintaining operational schedules, etc.)

69 Study showed that those individuals who admitted to non compliance scored lower on all aspects of situational awareness (SA) that those that stated they were compliant In addition those admitting non-compliance also scored lower when compared to other airline employee groups (i.e. flight crews) Findings indicate maintenance employees perform critical work functions and activities without the necessary level of SA to maintain safety, utilize effective risk management strategies and maintain operational compliance

70 The findings indicate that respondents are not listening to or engaging their instincts to effectively monitor safety and compliance to procedures Contributing factors supporting these findings are complacency, stress around timelines, and multiple distractions Other factors, such a reliance on experience (I ve done this many times before!), which 58% of respondents noted, can drive an otherwise professionally minded technician away from following documented processes and completing tasks from memory

71 Summary Low response rate Low adherence to SOP s is common Currently no effective management oversight and/or effective engagement of this problem No surprises here! Has not changed much over time NEXT STEPS: the full survey results are being presented to OPC for determination of a suitable way forward

72 Event 1: Classic event from airline perspective why do we not learn? In Aug 2015, A was modified by AEO to comply with EASA Airwothiness Directive (AD) On 19 Aug 2015, while enrouting from TPE-NGO, the flight crew detected an anomaly during the routine system scan - the Yellow Hydraulic System indicated in the amber band without ECAM warning. The Blue Hydraulic System was between the green band and amber band and the indication slowly decreased until the ECAM low level warning was triggered. The aircraft was diverted to (KIX) Osaka and landed safely, vacated the runway and stopped on the adjacent taxiway. Emergency services reported leaking hydraulic fluid. The aircraft was shut down and towed to the apron

73 What happened Maintenance had been carried out by MRO concurrently all three hydraulic systems prior to the flight The maintenance involved the replacement of the HP manifold check valves of all three hydraulic systems at the same maintenance input They were installed with the transit O ring instead of the correct O ring seal which resulted in the hydraulic leaks In addition, back up ring found missing on BLUE and GREEN systems 5 additional aircraft had also been modified and were immediately inspected 1 aircraft found in same condition where transit O rings had not been replaced on all 3 systems

74 The Component

75 Findings MRO did not follow Procedures, AEO Accomplishment Instructions and did not assign different maintenance teams No ETOPS note on the AEO Focused on the technical instruction steps Lapsed - Hydraulics manifold is part of Critical Systems Why do we not learn.?

76 Event 2: A321 Tail-strike on touchdown.. The approach was normal and stable throughout Flare was normal and touchdown unremarkable. Pitch angle 4.6 degrees and ground spoilers out 2 seconds after touchdown, faults related to the ELAC* (DIRECT PITCH LAW and L/R aileron fault) occurred and appeared on ECAM, and the aircraft reverted to DIRECT PITCH LAW The tail contacted the surface of the runway when the aircraft pitch attitude increased rapidly (within 2 sec) and to 11.3 deg, which exceeded the A321 tail contact geometry limits of 9.5 deg

77 Confidential / Restricted distribution ENG inspections of aircraft confirmed that the damage was limited to external abrasion of the fuselage skin panels in the underside of the aft tail section area, and minor damage to two underlying stringers. External fuselage skin damage only from FR64 to FR69 Max Length = 10ft Max Width = 19

78 Findings New threats The tail strike was the result of the combination of factors: Direct law engagement leading to deactivate the nose down pre-command, available in normal law, that counters the pitch up effect of the ground spoilers deflection. The degradation to the Direct Law was induced by an Elevator and Aileron Computer (ELAC) fault (software issue) during this critical phase of flight, ELAC 97 software installed but ELAC 98 available but not installed. ELAC 98 removed the potential of this occurring but was not a mandatory SB. Is this a (management / risk assessment) maintenance error? We have not learnt to handle classic ME situations yet and now we have new types of ME to manage

79 Maintenance Safety Moderator: Michel Gaudreau, Senior Vice President of Corporate Safety, Security, and Compliance, Korean Air Panelists: Martin Eran-Tasker, Technical Director, Association of Asia Pacific Airlines (AAPA) Captain Craig Hoskins, Vice President for Safety and Technical Affairs, Airbus Americas Rick Howell, General Manager, Group Safety and Security, Cathay Pacific Dr. William Johnson, Chief Scientific and Technical Advisor, Maintenance Human Factors, Federal Aviation Administration (FAA)

80 Thank You to Our Networking Break Sponsor:

81 Ground Ops Safety Moderator: Max Corsi, Head, Ground Operations, Air Transat, Chair ISAGO Oversight Council (GOC) Panelists: Stephen Creamer, Director Air Navigation Bureau, ICAO Ashish Jain, Senior Vice President Network Operations, Qatar Airways Yogesh Parekh, Head of Internal Audit (Operations), John Menzies Plc Tim Steeds, Director of Safety and Security, British Airways

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83 ISAGO Registered Provider - Performance

84 Unsustainable Growth Pool Members Audits Performed Stations on the Registry

85 The New WHAT WILL IT LOOK LIKE?

86 ISAGO New Operational Audit Model Professionals Trained and Qualified by IATA Entities Contracted by IATA to Administer Audits GSP Audit Requests Annual Allocation Funding IATA Charter of Professional Auditors GOA GOA GOA GOA IATA Audit Registration Fees Audit Report Sales GSPs Airlines Purchase of an Audit Report IATA Administration and Oversight

87 What s in it for me? Self-Regulatory environment Reduction of risk in Ground Operations Driving global harmonization and standardization Cost sharing model Transparent Registration scheme of Providers Validation of SMS implementation by Providers Duplicate audits reduction

88 Transition plan

89 Ground Ops Safety Moderator: Max Corsi, Head, Ground Operations, Air Transat, Chair ISAGO Oversight Council (GOC) Panelists: Stephen Creamer, Director Air Navigation Bureau, ICAO Ashish Jain, Senior Vice President Network Operations, Qatar Airways Yogesh Parekh, Head of Internal Audit (Operations), John Menzies Plc Tim Steeds, Director of Safety and Security, British Airways

90 ( ) (2018 and Beyond)

91 IATA-Led Workshops Flight Data Connect Namsan V Insight into IATA s Operational Efficiency Tools Namsan II Integrated Management Solutions (IMX) Namsan I SkyFusion Namsan VI Note: All rooms are located upstairs on Level Two.

92 Conference Dinner Sponsored by: Location: Grand Ballroom Time: 19:30 Please Bring Your Ticket for Entry