Safety Enhancement Action: Implementers: (Select all that apply) Statement of Work: Total Financial Resources: Total: $1.2M Output 1: $0.6M Output 2: $0.6M Relation to Current Aviation Community Initiatives: Performance Goal Indicators: Safety Enhancement SE 197.1 ASA Training - Policy and Training for Non-Normal Situations Each air carrier clearly states a policy, reinforced in training, that emphasizes establishing controlled and stabilized flight as the primary consideration during non-normal situations. Air Carrier Research Organization Industry Association Labor Organization Commercial Aviation Safety Team (CAST) Manufacturer Joint Implementation Measurement and Data Regulator Analysis Team (JIMDAT) Other (specify) A CAST study of 18 loss-of-control accidents and incidents showed that in many situations the flight crew did not make controlling the airplane their primary objective during non-normal situations. In many of these events, the flight crew did not apply workload management or crew coordination skills and did not initiate or complete the appropriate non-normal checklist after the airplane entered an upset. To improve flight crew proficiency during upsets or non-normal situations, air carriers should emphasize through training and standard operating procedures (SOPs) the importance of controlling and stabilizing the airplane before evaluating non-normal situations. CAST Safety Enhancement (SE) 26 LOC Policies and Procedures Standard Operating Procedures (SOP) Estimated Risk Reduction 2018 10.9% 2025 10.9% 2035 10.9% The estimated risk reduction scores assume the following implementation levels for the U.S. commercial air carrier system: 93% by the end of 2018 Revised policy and training will be in place by end of 2015 2017 02 02 SE 197.1 Page 1 of 6
Training programs begin training pilots in 2016 All pilots will receive training by end of 2018 (for 93% of operations) 93% by the end of 2025 All pilots in aligned air carriers will have at least two rounds of triennial recurrent training 93% by the end of 2035 All pilots in aligned air carriers will have at least two rounds of triennial recurrent training Implementation Implementation will be assessed through CAST SE Tracking Process and/or tracking by airline industry associations. Key Milestones: Effectiveness Effectiveness will be assessed by monitoring the following metrics: Narrative pilot reports (e.g., Aviation Safety Action Program (ASAP) or Aviation Safety Reporting System (ASRS)) indicate a reduction in incidents that indicate flight crew distraction or inappropriate initial control responses to alerts or upset. Flight Operational Quality Assurance (FOQA) metrics show a reduction in incidents involving incorrect or problematic control responses to stall warning (defined as not immediately reducing angle of attack). Flow time (mo) Start Date Target Completion Date Output 1: 12 8/31/2013 8/31/2014 Output 2: 24 8/31/2014 (end OP1) 8/31/2016 Completion: 36 8/31/2013 8/31/2016 Potential Obstacles: Detailed Implementation Plan Notes: None Supporting CAST Intervention Strategies IS 1250 To improve flight crew ability to prioritize critical tasks under time constraints, airlines/operators should emphasize during initial and recurrent training the importance of establishing controlled and stabilized flight prior to troubleshooting suspected system or engine failures. IS 23 Airlines/operators should ensure that regularly scheduled recurrent training (e.g., Line oriented flight training (LOFT)) emphasizes crew cooperation and working together to maximize safe operations. 2017 02 02 SE 197.1 Page 2 of 6
CICTT Code: Output 1: Description: Loss of Control Inflight (LOC I) Policy published at all air carriers emphasizing the importance of flying the aircraft and crew coordination in non-normal situations. National Air Carrier Association (NACA) Lead Organization: Supporting Organizations: Air Carriers Air Line Pilots Association (ALPA) Airlines for America (A4A) Allied Pilots Association (APA) Federal Aviation Administration (FAA) Flight Standards Service (AFS) Regional Airline Association (RAA) Implementers: (Select all that apply) Actions: Air Carrier Industry Association Commercial Aviation Safety Team (CAST) Joint Implementation Measurement and Data Analysis Team (JIMDAT) Research Organization Labor Organization Manufacturer Regulator Other (specify) 1. Airline industry associations will communicate with their air carrier members, explaining the analysis undertaken by CAST regarding loss of airplane state awareness, the role of improper prioritization of tasks in non-normal situations, and the purpose of the CAST Safety Enhancement (SE). 2. Air carriers will review their policies and procedures for handling non-normal situations to ensure they clearly include the following concepts: a) Fly the airplane first (establish controlled and stabilized flight); b) Practice crew coordination (e.g., determine who will fly the aircraft, who will read the checklist, who will communicate with air traffic control (ATC)); c) Identify the non-normal situation and correct checklist; d) Identify the appropriate time to complete the non-normal checklist (e.g., if on takeoff, complete the after takeoff checklist first if the situation does not require immediate attention); and e) Complete the appropriate checklist. 3. Based on the review, air carriers will revise their manuals, as necessary, to include the information above. 4. Air carriers will coordinate with pilot labor organizations to communicate the policies, ensure they are understood by the line pilot community, and gather feedback. 5. Air carrier actions are considered complete for this output when the air carrier has reviewed and 2017 02 02 SE 197.1 Page 3 of 6
revised its policies and manuals as recommended. 6. Airline industry associations will track implementation of their member carriers and report progress to JIMDAT and CAST. Financial Resources: Total: $0.6 (2.4 Full Time Equivalent (FTE)) Itemized Resources: Air carriers: 2.2 FTE (assumes 0.04 FTE per carrier) Associations: 0.1 FTE (assumes ~0.05 0.1 FTE per association) Labor Orgs: FAA AFS: 0.1 FTE (assumes ~0.05 0.1 FTE per association) Inspector resources required for normal review and acceptance or approval, as applicable, of airline manuals. Notes: For labor, 1 FTE = $250K 55 air carriers are represented by three CAST-member airline industry associations: Airlines for America (A4A) Regional Airline Association (RAA) National Air Carrier Association (NACA) 2 pilot labor organizations are represented at CAST Air Line Pilots Association (ALPA) Coalition of Air Line Pilots Associations (CAPA, represented by Allied Pilots Association) Output Notes: Assumes manual revisions occur as part of normal airline update cycle Time Line: 12 months Target Completion Date: 8/31/2014. Completed October 2014. Output 2: Description: Flight crew training syllabuses at each air carrier reviewed and amended, as necessary, to emphasize the air carrier s policy relating to the handling of non-normal situations as stated in Output 1. Training should emphasize the importance of flying the airplane and crew coordination. Lead Organization: National Air Carrier Association (NACA) Supporting Organizations: Air Carriers Airlines for America (A4A) Federal Aviation Administration (FAA) Flight Standards Service (AFS) Regional Airline Association (RAA) 2017 02 02 SE 197.1 Page 4 of 6
Implementers: (Select all that apply) Actions: Air Carrier Industry Association Commercial Aviation Safety Team (CAST) Joint Implementation Measurement and Data Analysis Team (JIMDAT) Research Organization Labor Organization Manufacturer Regulator Other (specify) 1. Air carrier training organizations will review and amend, as necessary, their ground and flight training syllabuses to ensure they emphasize the concepts below: a) Fly the airplane first (establish controlled and stabilized flight); b) Crew coordination (e.g., determine who will fly the aircraft, who will read the checklist, who will communicate with air traffic control); c) Identify the non-normal situation and correct checklist; d) Identify the appropriate time to complete the non-normal checklist (e.g., if on takeoff, complete the after takeoff checklist first if the situation does not require immediate attention); and e) Complete the appropriate checklist. 2. Air carrier actions are considered complete for this output when the following are accomplished: a) The air carrier has revised training in accordance with the recommendations of Output 1, as necessary, and b) All pilots employed by the carrier have received the training (initial or recurrent). 3. Airline industry associations will track implementation of the SE at their member carriers, and report progress and completion to CAST. Financial Resources: Total: $0.6M (2.4 Full Time Equivalent (FTE)) Itemized Resources: Air carriers: 2.15 FTE (assumes 0.02 FTE at all 55 air carriers to review syllabuses, and 0.07 FTE at additional 15 carriers to update syllabuses) Associations: FAA AFS: 0.25 FTE (assumes ~0.05-0.1 FTE per association to track implementation and coordinate with CAST) Inspector resources required for normal review and approval of airline training programs as part of duties performed. Notes: For labor, 1 FTE = $250K 55 air carriers are represented by three CAST-member airline industry associations: Airlines for America (A4A) Regional Airline Association (RAA) National Air Carrier Association (NACA) 2017 02 02 SE 197.1 Page 5 of 6
Output Notes: Assumes all carriers will review their syllabuses (40 hours) and 25 percent of the 55 air carriers would need to amend syllabuses (120 hours) Assumes amended training does not add time to current flight crew training footprint; rather, current training is revised and improved Assumes revised concepts will be included in initial and recurrent training Assumes training revisions will occur as part of normal airline training program update cycle Time Line: 12 months from completion of Output 1 to have new training programs in place 24 months from completion of Output 1 to have all pilots through revised training Target Completion Date: Reference Material Supporting CAST Intervention Strategies 8/31/2016. Completed 2/2/2017 based on air carrier industry association member implementation surveys. NOTE: This section lists applicable CAST Intervention Strategies (IS) used to develop the actions in this detailed implementation plan (DIP). These ISs are listed to provide traceability and supporting rationale for the recommended actions. IS recommendations may be wholly or only partly represented in the DIP, based on a final determination of feasible actions during DIP development. IS 1250 To improve flight crew ability to prioritize critical tasks under time constraints, airlines/operators should emphasize during initial and recurrent training the importance of establishing controlled and stabilized flight prior to troubleshooting suspected system or engine failures. IS 23 Airlines/operators should ensure that regularly scheduled recurrent training (e.g., Line oriented flight training (LOFT)) emphasizes crew cooperation and working together to maximize safe operations. 2017 02 02 SE 197.1 Page 6 of 6