Sonya Tietjen Consultant, Aviation Safety 26 September 2013 London, UK FDM, Risk and Protecting your Assets 1
Agenda 1. The Problem 2. The Solution 3. The Benefits 1. Risk Management 2. Flight Data Monitoring 3. Protecting Your Assets 2
NTSB Report 1. The flight crew made numerous procedural errors and deviations during the final approach segment of the VOR/DME approach. 2. The crew demonstrated poor crew coordination during the accident flight. 3. The flight crew was under pressure to land. 3
Causal Factors - Primary IHST 2006 (JHSAT) Flight Crew 4
The Problem? 5
How accidents happen Threats Organization Technology Humans Modified from J. Reason 1997 6
BowTieXP: Loss of Separation Loss of Spacial Awareness Medical fitness and 6 monthly tests. Ref? - Reference to be added Simulator training including recovery from unusual attitudes Ref? - Reference to be added Maintenance of an effective look-out RAP 1 - xx Two Crew operations Ref? - Reference to be added Flight crew mishandling and mismanagement of the flight Compliance with procedures and checklist OM Pt.8 - Unit Orders Effective cross cockpit communication OM Pt.6 Sct.1 - Definitions, Rules and Requirements Crew flight planning for other aircraft operations in the operational zone OM Pt.8.Sect 3.23 - Summary to Offshore Operations (AS332L1) Multi crew ops including challenge and response OM Pt.5 Sct.1.1 - Duties of Captain and First Officer Training and testing (Line Checks) TM Pt.4 - Operation Line Training TM Pt.4 Sct.1 - General Training and testing (Base checks) TM Pt.4 Sct.1 - General H-02.01.01 Aircraft in motion (1) Aircraft System failures MEL controls for limiting departures with unsevicabilities MEL - Minimum Equipment List routine preventitive maintenance MS - Aircraft Mainteance Schedule Repetitive defect management MOE Pt.2 Sect.2.14 - Technical record control Flight Manual Emergency Check List actions FM Sct.3 - Emergency Procedures Ineffective Air Traffic Management GPS flight Tracking RAP 1 - xx Provision of area information (NOTAMS) AIP.Vol 1. GEN 3.3 - Air Traffic Services In field traffic communication OM Pt.2 Sct.1.3.4.10 - Helicopter Operations Personnel Manning Effective provision of area contol of air traffic management AIP.Volume 2 - Aerodrome (AD) D - Aircraft In motion 'Airborne': HE-20E Loss of separation with third party aircraft Identification of Opposing traffic SID Sect.04 - Listing of Interface Activities Establish Communication with opposing traffic SID Sect.07 - Hazard Register AIP.Vol 1 ENR 2 - Air Traffic Services Airspace Take avoiding action OM Pt.8.Sect 9 - Emergency Procedures Airborne contact with opposing traffic, Loss of aircraft and/or multiple fatality C5 C5 C3 C5 Operations in adverse weather Procedure (weather minima) Ref? - Reference to be added Weather (Flight Operations Limitations) Ref? - Reference to be added Actual Weather Reports/Information RAP 2 - x Training (interpretation of weather information, and weather avoidance) RAP 3 - xxx Maintenance of Situational Installation and use of TCAS Awareness OM Pt.2 Sct.12.34 - Adherence To Operating Procedures and Co-Pilot's Responsibility CAR 1996 and AIP requirements for standard collision avoidance actions MCAR Pt.11 Chap.2 - Regulation of Movement Area Incorrect avoiding action taken Failure to learn from experience Failure to install available safety improvement system or to learn from experience Equipment Standardisation and acceptance checks QAM.7.5 - HFDM Process Installation of Traffic avoidance systems (TCAS) RAP 4 - xxxxx Common Frequency for Blind Call on Guard frequency aircraft in the operational 121.5 MHz zone Ref? - Reference to be added Ref? - Reference to be added Failure to establish communications with opposing traffic Non-compliance with mandatory requirements (levels and distance) for seperation with third party aircraft. Training and testing (Base checks) TM Pt.4 Sct.1 - General Training and testing (Line Checks) TM Pt.4 - Operation Line Training TM Pt.4 Sct.1 - General Multi crew ops including challenge and response OM Pt.5 Sct.1.1 - Duties of Captain and First Officer HSE Management Review Board process Ref? - Reference to be added Effective cross cockpit communication OM Pt.6 Sct.1 - Definitions, Rules and Requirements Occurrence reporting system Ref? - Reference to be added Multi crew ops including challenge and response OM Pt.5 Sct.1.1 - Duties of Captain and First Officer QA Audit of line management actions to resolve findings Ref? - Reference to be added Compliance with procedures and checklist OM Pt.8 - Unit Orders Line management action to resolve findings Ref? - Reference to be added Organisational Discipline Ref? - Reference to be added Lack of visual meteorological conditions (VMC) Installation and use of TCAS Division of workload (handling Maintenance of Situational and non-handling pilots) IMC Awareness RAP 3 - xxx and VMC OM Pt.2 Sct.12.34 - Adherence OM Pt.6 Sct.2.3 - Division of To Operating Procedures and Crew Duties During Flight in Co-Pilot's Responsibility I.M.C. RAP 4 - xxxxx 7 Source: CGE Risk
Two tools for Flight Ops data 1. Safety Reporting 2. Flight Data Monitoring 8
Safety Reporting 9
Breaching Defenses Human beings, the technology they operate, and the organisation they work within, are the three sets of factors likely to be implicated in breaching defenses put in place to avoid accidents. J. Reason 1997 10
Risk Management Hazard and risk management must be data-driven and involve constant monitoring to either eliminate or reduce the risk to as low as reasonably practicable. ICAO 2009, Doc 9859 11
Data The data collected must be systematic, cover all areas of the operation, and have the ability to measure the results of controls put in place [ to control risk]. Finally, the focus must first be on the area of highest risk. ICAO 2009, Doc 9859 12
Flight Operations 13
Flight Ops: Bottom Line 1. Human Factors are the primary cause of incidents and accidents 2. Flight is the highest area of risk in operations 3. Flight is the operation of which we have the least amount of information 14
Two tools for Flight Ops data 1. Safety Reporting 2. Flight Data Monitoring Only FDM is comprehensive and quantifiable 15
The Solution: FDM 1. Records interaction between: the technology (aircraft) and the people (pilots) 2. Analyses interaction for specific events (reactive) undesirable trends (proactive) 3. So the organisation can do something about it 16
Safety Reporting + FDM = W5s FDM W4 s: 1. Who* 2. What 3. Where 4. When Safety Reporting 5. Why 17
Threats Organization Technology Humans Modified from J. Reason 1997 18
The Good, the Bad, and the Ugly 19
Protecting Your Assets Organisation Technology Humans 20
Humans (The Clients) Complaint Management Turbulence Timing Airmanship Marketing Liability Risk Management Professionalism 21
Humans (The Employees) CEO Peace of mind from actually knowing your aircraft are being operated in a professional manner. False accusation Airspace breaches Low flying Poor airmanship Management Support Non-SOP Flying Requests Documents observations Procedures Equipment 22
Technology (The Aircraft) Pre-purchase / Pre-funding: Performance / Efficiency Proper handling Limits maintained MRO: Faulty Equipment Limits maintained / exceeded Warranty issues 23
Organisation (The Company) Return on Investment Protecting your Assets Marketing Promotion of SMS Risk Management Monitoring Quality Assurance Ferry Flights Flight Operations Human Resources Continuous Improvement Training Programs Enhancement Validation Efficiencies Fuel efficiency Maintenance 24
FDM Resources Global Helicopter Flight Data Monitoring Community (www.hfdm.org) International Helicopter Safety Team (www.ihst.org) UK Civil Aviation Authority - CAP 739 (www.caa.co.uk) 25
Wrap Up The highest risk to an operation is Flight Without FDM, you really don t have quality assurance on flight operations Implement FDM 26
FDM, Risk and Protecting your Assets Sonya Tietjen Consultant, Aviation Safety Sonya@Tietjen.ca www.hfdm.org Thank You 27