GATE-TO-GATE SAFETY. Improving aviation safety by better understanding and handling of interfaces

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1 GATE-TO-GATE SAFETY Improving aviation safety by better understanding and handling of interfaces Alfred Roelen National Aerospace Laboratory Flight Safety and Aircraft Operations Department

2 Cooperative effort Funding by Dutch Directorate General of Civil Aviation Dutch Civil Aviation Authority US Federal Aviation Administration

3 Definition of the problem The aviation system is complex many different organisations many different activities (processes) constant information exchange between and within organisations What if information exchange and co-operation does not run smoothly? Potential safety threat!

4 Sky above Uberlingen, Germany 1 July 2002

5 Boeing 737, Brisbane, Australia, 18 January 2001 Aircraft encountered mircoburst windshear while conducting a go-around from runway 19 at Brisbane during an intense thunderstorm. There was no effective mutual exchange of information between ATC and flight crew about the weather conditions at the airport. Boeing 737, VH-TJX, Brisbane, Australia, January 18, 2001

6 FedEx MD-11, Newark, 31 July Emergency response hampered because nobody seemed to know what cargo the aircraft was carrying.

7 Fine Air Douglas DC-8, 7 August 1997, Miami Exchange of aircraft was not communicated to the loaders. Accident aircraft was loaded according to instructions to a different aircraft.

8 Training Load handling Design & Construct Maintenance Operations ATC Rules & Cert. Meteo Emergency response

9 INDUSTRY SAFETY OVERSIGHT Design and Manufacturing Maintenance Flight Operations Training ATC service provision Airport operations Certification / airworthiness Maintenance inspection Flight standards and Inspection Licensing ATC standards Aerodrome standards

10 Pilot study Objectives: Identify whether systematic analysis of interfaces can indeed lead to safety improvements. Identify main interface issues. Means: Analysis of 54 accidents and incidents

11 Results Pilot Study Analysis confirms that interface problems contribute to accidents and incidents. Main interface disciplines and interfaces: Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response

12 Operations - ATC Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Poor communication

13 Operations - ATC - Meteo Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Poor collection and dissemination of weather information

14 Operations - ATC - Emergency response Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Incomplete information

15 Operations - Flight crew training Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Training does not match real world

16 Manufacturing - Maintenance - Operations Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Ambiguous maintenance and inspection information

17 Manufacturing - Certification - Operations Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Poor dissemination of lessons learned

18 Operations - Load handling Maintenance Flight crew training Load handling Manufacturing Operations Air Traffic Control Rulemaking & Certification Meteo Emergency response Poor communication of loading instructions

19 How are we going to address the issue? International effort required FAA - CAA Netherlands set the example ICAO and FSF involvement is desired. Multidisciplinary effort required. Needs to be harmonised with CAST, FAST and CPS. Systematic analysis of solutions in the field of Organisation Technology Safety culture Regulations

20 FSF involvement Action plan has been developed for FSF-led international initiative. To be discussed during workshop on 21 September 04.

21 REGULATION ORGANISATION SAFETY CULTURE TECHNOLOGY SOLUTIONS GENERIC INTERFACE PROBLEMS AVIATION SYSTEM SINGULAR INTERFACE PROBLEMS ACCIDENTS AND INCIDENTS

22 Timing 2003 First workshop NLR Amsterdam PILOT STUDY 2004 PHASE A Second workshop FSF Washington PHASE B 2005 Not repeating other initiatives? Sufficient potential for safety improvement? Proper Plan of Action? 2005 Working group activities 2006 Integration and further analysis 2007 Implement Presentations of results from working groups Final set of tools and recommendations

23 Link with causal model Gate-to-gate safety Provides insight Causal model Allows prioritisation

24 Conclusions Safety can be improved if interface problems are systematically solved. Main interface problems have been identified. International multidisciplinary effort is needed. Preliminary action plan will be discussed at FSF workshop in September.