61ST INTERNATIONAL
UKFSC CE SEMINAR SUMMARY
· The Seminar Agenda
Day
1 – 28 Oct 08 – AM Session – INTRODUCTIONS
· The Pres and CEO FSF offered the following keynotes in his introduction:
o Importance of continuing rigorous SMS Implementation across Govt/Regulator/Boardroom and Operations
o Finance and trust difficulties causing serious concerns in the industry
o There is a danger that safety reporting and focus would be moved off the agenda
o
In the
o The industry needs to get ready for the next generation:
§ Demographics and middle class growth
§ Middle class will grow by 2Bn and they will want to travel
§ 28% increase in air travel predicted
§ Insufficient numbers of regulators in many States
§ Shortage of numbers in pilots, engineers and regulators
o We must break the cycle of repetition of the same mistakes by sharing information in ever growing amounts
§ 1986 and MD 80 crashed – no slats then 2009 Spanair happened!
§
§ Smoke and fire incidents
§ Runway excursions
·
IFA President addressed the
following in his keynote speech:
o
Human Factors needs much more
work in engineering
o
SMS Implementation is
fundamental
o
Fatigue management must improve
in maintenance
o
Rigour required in contract
writing when outsourcing
o
‘Safety costs’ and ‘Quality
costs’ – but failure is even more costly!
§
For example – ETOPS has meant
safer and cheaper operations
·
FAA Administrator –Safety
o When identifying risk, it is essential that an internal examination of your organisation is undertaken
o Low accident rates do not mean we can not get any lower.
o Sharing of safety information is vital for effective risk assessment
o Through trends we must ident accident precursors
o
Prior to
o Data analysis models and tools are essential but fused analysis of all sources is the key to a full understanding
o ‘Data will set us free’ but we must mange risk but we must do it together!
·
Accident Review 2008 –
o Commercial Jet Aircraft flying - 20,933 of which 19277 are western built
o Commercial Turbo prop - 6418 of which 4830 are western built.
o Business jets – 15055
o Commercial Jet Accidents this year – 16 major (6 ALAR, 5 LOC and 2 CFIT)
o 27 Turbo (25% CFIT)
o 10 Business Jets
o ALAR accident trends – 7 in 96 and 11 in 07!
o 5 icing accidents this year
o The Challenges:
§ Safety Culture
· What we do round here!
· What you do when no one is watching!
· Everyone has one – some good some bad!
· You can’t buy one – it must be cultivated/built/positive!
· SMS does not mean you have a positive culture
o Summary:
§ An average to poor year so far!
§ Loss of Control dominate the fatalities
§ Where have the lessons learnt gone?
§ Make aviation safer by reducing the RISK of an accident!
· Global Safety Initiatives
o CAST – aim is to offer world leadership in air safety
o CAST is seeking to establish regional safety teams – ECAST
o
Helicopter safety team HEST –
EHEST in
o
o FOQA TAWS Analysis
o ALAR Team activities
o Global Aviation Safety Roadmap
o GASR and GASP – (Safety Plan)
· Criminaliation of Aviation Accidents
o It is vital that just culture is established and preserved
o Medics reported 2% of errors in the 1980s
o To Err is human – but so is not to report!
o Criminalisation is not an effective safety tool – except in cases of sabotage or wilful or reckless misconduct
§ In the Spanair case, 3 engineers have been charged
§ Concorde – numerous people are still being targeted after 7 years
§ Uberlingen – the ATC controller was murdered
§ Accident info is going directly to court in the Helios case
§
The
o There is precious little protection to prevent prosecutors from using safety info in criminal cases
o Aviation suffers in the long run
o QUESTION –
§ Is there enough protection for those collecting safety data?
§ When does a bad mistake turn into gross negligence?
§ Should we be educating courts and the law enforcers?
·
Day 1 – 28 Oct 08 – PM Session
- LOSS OF CONTROL
o
Spatial
disorientation examples were used by the NTSB to advocate the need for
Upset Recovery Training to be made mandatory in the
o The senior safety pilot at Boeing reported on a programme of simulator work to evaluate the effectiveness of Upset recovery training in the simulator training. The programme used 10 pilots to fly 3 events and consisted of a 30 minute slot per pilot.
§ The outcome of the trail indicated significant value from the training in terms of consistency and timing of responses to Upset recovery
o Fedex reported on the introduction of Upset Recovery training to counter LOC. They have an academics phase which addresses the critical knowledge required before they demonstrate the appropriate techniques and procedures in the sim and during in-flight training.
§ The sim has the right look in terms of instruments but does not provide the right feel!
· ADS-B Safety Strategies
o The ADS-B Co- chair of the FAA ARAC briefed on ADS-B. He covered the following points:
§ The technology is proven and capable with demos shown positive benefits – analysis indicates the possibility of reducing accidents by 40%.
§ The Committee Report on ADS-B has 36 recommendations.
§ In the current business case, the benefits barely met the costs.
§ Key safety benefits are:
· Improved situational awareness
· Increased operational assurance
· Enhanced weather avoidance
· Reduced surface movement errors
§ The challenges are:
· Frequency spectrum alignment
· Antennae diversity requirements
· Avionics costs
·
TCAS/
· Investment capital is in short supply
Day
2 – 29 Oct 08 – AM Session-
·
Accident Classification
o
A new form of accident
classification was introduced by IATA in 2007 which takes a
·
Non Punitive FOQA Programme
o
The FOQA Manager from Shanghai
Airways described the challenges of introducing a non-punitive FDM/FOQA
programme into the Chinese culture
·
The
o
This CAST Initiative was
described by the Senior Director Safety at Continental
§ Air safety has never been better but we need to continue
§ Accident rates are low but flying is on the increase
§
o
The benefits of
o
The outputs are directed
studies on concerns identified and setting of priorities - already identified runway safety and Terrain
awareness warning
o
Known risks included – ATC
procedures, flight deck automation, training on advanced manoeuvres, aircraft
state awareness, precision approaches
o
Benchmarking underway on
unstable approaches, TCAS RAs and TAWS
o
In the
o
Under ASAP, each airline will
provide its FOQA data to MITRE who will fuse it.
·
Risk Management Choices – Head of Research
o
The method used by the
o The process is as follows:
§
A strategic analysis pyramid is
constructed from
§
World fatal accidents are then
factored into the
§
The main risks areas are then identified
and prioritised and a view taken of world risks against
§ Analysis teams are assembled to produce action plans to address the risks identified.
§ Data is also analysed to attempt to identify precursor events for future risk assessment purposes.
o
The
§ Increasing numbers of safety reports does not indicate increasing risks
§ Money spent on safety initiatives does not mean dead money
· Insurance premiums are reduced
· Fewer high profile events means less spent of marketing to attract customers back.
· Regulatory oversight can focus on compliance and real performance
· Skybrary – Aviation Safety Website
Day
2 – 29 Oct 08 – PM Session – PANEL DISCUSSION ON SMS
The Moderator
Qantas
Transport
Panel
Discussion
MAINTENANCE
·
Moving from a Penalty Driven Culture – the Manager’s Dilemma
Actions to
Consider
o
Are We Learning the Lessons? –
·
Maintenance errors and MEDA
investigations show that the number of errors being made has not reduced in the
past 10 years.
· Aircraft are still being delivered to the line with serious defects – cross controls, servo disconnects for example
· Factors are varied but include individual technique and procedural errors, poor supervisory levels, soft copy manuals, inaccurate manuals.
· The CHIRP MEMS Group has undertaken a Management review covering engineering capability, trust and safety performance. The results show that the higher the level of management targeted for questions the higher the effectiveness of the companies’ SMS.
· The Issues revealed by the SMS Review are as follows:
o Leadership – They are business people not safety orientated. Safety should be part of the business plan along with the error costs.
o Trust of the employee in a company’s SMS is reflected in the just culture and the value and trust placed in an individual.
o Effectiveness of training and the confidence of the work force to use new skills – this is often not measured and a Tick Box ttaining is used.
o Line Management – has a poor understanding of of the safety role and what the standards of safety should be.
o Risk Assessment – carried out by specialists only , when it should be done by everyone involved.
Day
3 – 30 Oct 08 – AM Session - EMERGING
CHALLENGES
·
A Collective Approach to Aircraft Maintenance
· Design Engineers must work together with Maintenance Engineers to address safety issues in each other environment.
· Accidents have proven that Maintenance schedule extension is not an advisable strategy for maintainers, particularly when it comes to fatigue.
· Incorrect parts or correct parts incorrectly fitted lead to failure and accidents.
·
The demise of Ansett
· The following recommendations were offered:
o Use both design and maintenance engineers in manufacturers and airlines
o Use Human Factor experts to examine maintenance schedule changes
o Respect time-specific inspection schedules
·
Errors and Influence of Working Patterns and Fatigue
· There is no clear answer on the part played by fatigue in maintenance error (ME)
·
FAA figures indicate that 8.3%
of accidents in the
· No accident reports state the rosters or degree of night working that may have been involved prior to the accident.
· Under Annex 13, Flt crew work patterns are always covered as are their licenses, experience and duty times – but NOT for the maintainers involved.
· There are some working time rules around; ICAO mentions them in its SMM but not specifically targeted at maintenance crews.
· Night working has limitations:
o Lack of facilities – many are closed at night
o Less supervision and mentoring
o Working environment and lighting is poorer
o Circadian effects increase susceptibility to error
o Schedule pressures
o Distraction
· Measures required to reduce tiredness:
o
o Support for nights ops needs to increase
o Critical repair items need more care
o Remuneration for longer overtime has established bad habits
o Shift patterns lead to excessive fatigue
o Tiredness can lead to over confidence and lowering of standards
· What are regulators doing about it?
o
· Organisational Design for Safety Oversight Effectiveness
· Major challenges are emanating from changes in automation, the complexity of the environment and dynamics of technology.
o These challenges can be met through SMS since the answers lay in organisational support, relationship development and motivation
o The Next Gen and SESAR era will bring much greater interdependencies of data and voice exchange and the part that the human plays in it. Safety needs to heed these changes.
o The aim must be to augment human performance with an increased situational awareness and minimisation of errors. – human factors, organisation, technology and environment all need attention in SMS – it is not just data!
o SMS means leadership, people management, policy, resources. Process and results
o Inter-organisational vulnerabilities will be key to identifying the dangers. SMS needs to recognise vulnerabilities, identify sensible actions and manage and monitor implementations
Unmanned
Aerial Systems; Mitigating Hazards
· Click for Paper.
RUNWAY
SAFETY
·
FSF Runway Safety Initiative
· Click for Paper.
· The initiative is divided into 3 areas; Incursions, Excursions, Confusion and is a 2 year programme of work which involves the manufacturers and includes:
o Unstable approaches
o Airport design, lighting and markings, runway conditions
o ATC – their influence on stable approaches
· Accident Data involving Runway safety -1995 – 2007
o 1323 accidents not including GA
· 10 incursions (0.7%)
· 379 excursions (28.5%)
· 4 confusion (0.3%)
o The major target is therefore excursions.
· The way ahead is to ident high risk areas and formulate action plans
· There is much going on with incursions, some activity on excursions and nothing on confusion
·
Technical Aspects of the Initiative
· Over $500M is being spent each year on Runway safety measures including:
o Airfield lighting and indictators
o
o Ground based ASDE_X to provide in-cockpit alerts
o ADS-B
o Weather radar modifications to detect conflict on runways/approach.
o Stabilised approach monitoring
o Deep land and distance to go advisories
o Improving runway infrastructure
o Improning ATC and cockpit procedures
o Go-rounds – No fault go-round encouragement
o Low cost cockpit tools
·
Direct –to –Pilot Warnings
· CAASD/MITRE Corporation are undertaking trials to identify effective warnings direct to the pilot. Examples of systems under investigation:
o Take –off hold lights on runways – in trial these have led to a 90% reduction in incidents
o Additional red lead on lights prior to the runway
o Runway intersection lights
o Final approach lighting and audio systems to warn of potential conflict
· Results so far indicate positive benefits from runway lighting mods, but that audio systems on final approach are more effective than lights.
·
NTSB
Most Wanted List of Runway Warning Systems
· Improved Hazard Detection and warnings to crews
· Improved control over runway crossings
· Tell the pilot where he is on the airfield
· Landing performance indications
· Specifically:
o A ground movement safety system to prevent runway incursions which feeds directly to the crew
o Runways should only be crossed when cleared specifically to do so, and at one runway at a time.
o An alert tied into the moving map of the airport which audibly alerts the crew if they go wrong – including runway length available.
o Distance to go information on landing
· The Current Status of Recommendations with the FAA is as follows:
o
Ground safety systems are being
installed in 35 largest
o Runway crossing procedures have yet to be accepted
o Moving map alerts not yet cleared but are being closely considered
o Landing distances not yet accepted
· Key Factors in runway related accidents are:
o Night time operations
o Low experience tower personnel
o Readily identifiable conflict situations being overlooked
· Where to next:
o Lower cost conflict warning systems for smaller airports
o Fully automated hazard detection and warning for vehicles and aircraft
o An evolution of ADS-B
o Better control of runway crossings
o Move awareness and warnings to the cockpit for quicker response times
o Conduct performance calculations for each arrival using best data available – and do not be afraid to reject a landing
A
copy of the IASS 2008 CD is available from the Fairoaks office.
Rich
Jones
Chief
Executive UK Flight Safety Committee