61st International Air Safety Seminar (IASS)Honolulu, Hawaii – 28-30 October 2008
CE SEMINAR SUMMARY
Day 1 – 28 Oct 08 – AM Session – INTRODUCTIONS AND ACCIDENT REVIEW
- 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 US, there are 13000 standards and 30000 specs to be adhered to in the airline industry – this may be as far as we can go with compliance using rules and regs!
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!
§ ATR icing incidents just keep on happening
§ 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 Lexington, there were 116 type incidents in 5 years
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 Review2008 – Jim Burin FSF
o Full Presentation
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
§ 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 Europe
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 Lexington case continues
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 US.
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 ofconsistency 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!
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/FMS upgrades
· Investment capital is in short supply
Day 2 – 29 Oct 08 – AM Session- DATA ANALYSIS AND SHARING
o A new form of accident classification was introduced by IATA in 2007 which takes a USC model where human factors are included in a threat and error management framework. Click here for the detailed paper.
- 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
o This CAST Initiative was described by the Senior Director Safety at Continental Airlines. His key points on ASIAS were:
§ Air safety has never been better but we need to continue
§ Accident rates are low but flying is on the increase
§ ASIAS is the response to these challenges
o The benefits of ASIAS are to identify and monitor trends, evaluate risks and formulate interventions
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 US, the ASAP – aviation safety action plan is being established with MITRE, and independent data gathering company, acting as the analytical arm and safeguard of the data.
o Under ASAP, each airline will provide its FOQA data to MITRE who will fuse it.
- Risk Management Choices – Head of Research CAAUK
o The method used by the CAA to identify risk and then manage it was briefed. Click for paper .
o The process is as follows:
§ A strategic analysis pyramid is constructed from MORs received by the CAA
§ World fatal accidents are then factored into the UK fatal reports
§ The main risks areas are then identified and prioritised and a view taken of world risks against UK specific risks
§ 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 CAA work does incur cultural battles along the way:
§ 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 oversightcan focus on compliance and real performance
- Skybrary – Aviation Safety Website
- The Skybrary Project – the production of a Safety Knowledge Website was briefed.
Day 2 – 29 Oct 08 – PM Session – PANEL DISCUSSION ON SMS
- The SMS Panelists each offered the following perspectives on SMS as it applied to their company or situation:
- SMS is a proactive, predictive mode approach to safety
- From Jan 2009, SMS is to be implemented in accordance with the ICAo SM Manual
- Individual States will be responsible for oversight
- If you can’t measure, you can’t manage!
- An airline is a system of systems
- The negative approach to SMS is that it costs money, time and effort and will take several years to install.
- Many airlines already have the basic building blocks in place – IOSA provides them
- Having a Ferrari does not make you a good driver! Effective SMS requires a positive safety culture
- In simple terms, SMS requires you to:
- Identify risk – incident and accident reports
- Assess risk – no need for great complexity
- Manage risk – form an action plan to mitigate it
- Integration and communication – bring the relevant people together
- In Qantas it has been evolutionary and needed to be engineered
- The initial focus is on data
- Multiple feeds into the database
- Manage the risks through action plans
- Measure the outcomes of the action plans
- Integrate the information
- Very similar to an Enterprise Risk approach with a causal framework
- From the Regulator’s view, it is a hard journey.
- Significant changes were needed to the regulations
- Audits are out and assessments are in.
- With 1200 AOCs and 2000 airports, the TCCN approach had to change.
- Airports have needed an SMS since 2005.
- Standardisation is a vital component for airports
- The basic components of SMS are already available in most companies; just some minor re-alignment is required with the help of the Regulator.
- The Regulator’s FOIs need to trained to do a different job – need to focus on systems – and change management to organisations is fundamental.
- Integration of SMS across the entire organisation is key. Motivation and leadership will be required.
- Data is essential to take informed decisions, take effective action and to report on the success of the action.
- SMS must be simple to follow and be understood right across the organisation.
MAINTENANCE AND HUMAN FACTORS
- Moving from a Penalty Driven Culture – the Manager’s Dilemma
- How do your managers measure success – aircraft availability, turn-round times?
- How does the workforce see it – make the bottom line, do it for less?
- How does a Manager get an accurate assessment of the risks being taken?
- Does your company want to know what’s going on?
- Isn’t that what safety and quality people are for?
- It may be time for a Management Review!
Actions to Consider
- Develop a reliable data set and identify the need for change
- Determine your organisation’s cultural maturity
- Ensure the Accountable Manager understands his role
- Provide Safety Mangers with a consistent understanding of SMS
- Get safety and quality improvements aligned with the cost of errors in the business plan
- Evolve a just culture
- Management must commit to change to achieve change
- Senior management must emphasise safety.
- Senior management must accept criticism and encourage feedback
- Do safety culture surveys
- Take a candid look inside your organisation
- Are We Learning the Lessons? – Mick Skinner CHIRP UK
· 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 Airlines resulted from a poorly written maintenance schedule change on the 767 by Boeing.
· 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 US and 26% worldwide are caused by ME.
· 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
· Measures required to reduce tiredness:
o CRM is not as effective in maintenance
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 Maldives is setting time limits – NZ and Canada are following suit
- 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
- 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
o Full Briefing Paper.
· Over $500M is being spent each year on Runway safety measures including:
o Airfield lighting and indictators
o GPS voice advisories and moving maps
o Ground based ASDE_X to provide in-cockpit alerts
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
· Full briefing paper.
· 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
· ImprovedHazard Detection and warnings to crews
· Improved control over runway crossings
· Tell the pilot where he is on the airfield
· Landing performance indications
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 US airports
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.
Chief ExecutiveUK Flight Safety Committee
26 November 2008