22nd European Aviation Safety Seminar – Lisbon – 15/16 March 2010
CE Conference Summary
Agenda
Day 1 – Opening Remarks and Criminalisation
David McMillan – Eurocontrol
- 2 Concerns – economic turndown impact on safety and on SESAR development
- Increasing traffic levels will come back – this year it is 6.5% up globally
- ICAO HL Meeting in Mar 2010 looking at safety data and information
- Challenge is incident and high risk occurrence sharing
- Criminalisation is the major concern and is denying incident reporting
- Positive Culture of reporting is required to ensure that data is built.
EC proposal for occurrence reporting – Mike Ambrose
- There is an urgent requirement to guarantee reporting protection for those placing occurrences in to the system
- External agency interference – must not prevent accident investigation – the judiciary for example. Accident investigation should have priority!
- Air Accident Investigation capacity in Europe – there is a need for a central EU Team- an EU AAIB!
- To provide pooling of funds, training and investigation techniques
- EC should not have the role of determining the cause of accident – the aim should not to politicize air accident findings
- Support for victims for NOK is essential – but it should not have an impact on safety by driving a blame culture
- This sort of support should apply to all types of transport accident
Protecting the Integrity of Safety Reporting
Action Forcing Events – FSF Legal Attorney
- Increasing difficulty to investigate accidents across the globe due to interference by the judiciary
- Concorde trial is a classic example – and a total waste of resources and should be closed now.
- The initial Valuejet case murder/manslaughter judgement outcome was turned over after a judicial review after 2 years
- Linate- Milan case – due to the threat of criminalisation and legal action, ATC refused to put themselves forward to the investigation
- Montreal Convention has been only partially successful in waiving or limiting operator liability to facilitate a rapid and fair approach to aviation accidents
- Import that the victims have direct access to accident information in order to create a better, safer approach to accident reporting and criminal action
- ICAO must address this issue urgently – regulators are becoming targets for prosecutors and the industry is suffering accordingly
- There is a lack of capacity in safety and judicial authorities, an unclear role for EASA in investigation and a weakness in implementation of safety recommendations
- Kenyons can undertake an Airline Emergency Response Plan audit to ensure its viability and effectiveness
Session 1 – Current Issues
The Year 2009 in Review – David Learmount
- Fatalities – 749 – Accidents – 28 in commercial ops, but not including business aviation
- No significant improvement in safety since 2003
- Of 28 accidents, 16 were non-pax ops accidents
- Traffic fell significantly in 2009 which makes the figures even worse
- Comparing 1990s with 2000s – western built aircraft serious incidents and accidents, the later decade was improved by half.
- 1.32 in the last 5 years of the 1990s to 0.58 early part of 2000s – but last part of this decade is 0.55 – no real change
- New ideas are now needed to move safety forward in the next decade
- Late 1990s – saw data analysis improve to identify the real safety issues
- FSF ALAR and CFIT toolkits – TAWS came in – ASAP came in
- Live Issues beyond 2010 and beyond
- Accidents occur which pilots should have been able to manage
- Modern flight decks are more automated and reliable
- Are we seeing a remoting of pilots from the aircraft? – no longer mental and physical interactivity on the job
- 976 people killed and 7 LOC crashes into the sea in 10 years
- Flight’s Conclusion is still room for improvements and new ideas are now required to move safety forward
Operators Guide to Human Factors in Aviation OGHFA – Jean-Jaques Speyer
- Safety management strategies have now reached their limits and new approaches are now required to move safety to the next level
- Human factors training is considered a serious candidate as the new initiative to move aviation safety forward – which summarised in the OGHFA
- 85% of accidents involve human factors, of which 60% have HF as root cause
- OGHFA is a translation of academic theory into a practical Operations applications
- Human Factors cover direct factors such as design, potential factors such as stress and managing factors such as team work and SOPs
- The package is a safety-awareness tool for a wide range of aeronautical actors comprising:
- Briefing Notes
- Visuals
- Check Lists
- Skills to face uncertainty
- Human reliability is at its limits in pilots
- HF compensation mechanisms are able to create safety to reconcile operations with HF
- A situational awareness process which involves simply thinking ahead in order to identify the potential problems and make decisions on a straightforward analysis path
- To change the situation positively and to be aware of the issues
- OGHFA Framework is based on the following influences:
- Personal
- Organisational
- Environmental
- Informational
- OGHFA is a means to apply Threat and Error Management
- Examples of HF awareness over situational examples – in phases of flight are provided in the OGHFA package
- OGHFA is freely available on Skybrary website
Reducing the Risk of Runway Excursions – Jim Burin FSF
- RW incursions have been high profile in the past but REs are higher risk and more prevalent
- 40,000 ALAR Toolkits are on the street now and 32 ALAR workshops have been carried out globally
- Top factors are inadequate CRM and poor professional judgement
- New ALAR data has been included in the ALAR Toolkit revision
- 1995- 2007 there have been 1007 RE accidents
- Runway Safety Initiative
- Incursions – rare but high energy with high fatality potential
- Confusion
- Excursions – land on runway surface then depart
- In 2008, 97 accidents of which 38 were REs
- In 2009, 89 Accidents of which 36 were REs
- Stabilised Approaches are the key requirement for operators
- True no fault go-around policy
- Training in decision making is essential
- Airports have a part to play – design, lighting, signage, approach aids, RFFS, ATC – encouraging stab approach and timely information
- 1995 -2008 – 1429 RW excursions total
- 80% of REs are during landing – the rest are at TO
- 45% Take-off REs caused by abort after V1
- 35% Landing REs caused by not going-around
- Conclusions
- RIs reductions are decreasing
- REs are more common and the most common fatalities
- Unstable approaches increase RE risk
- Failure to go-around is a major RE cause
- Contaminated RW increases RE risk
- Universal standards for contamination measurement and reporting needed
- Establish coherent SOPs for Stab app and go-around
- Land in the touchdown zone
- Energy = mass x V2 – so don’t be fast!!
- Effect of reverse thrust is more effective on contam runways
- Calculations are useful but the conditions must also be applied
- Reducing risk of Runway Excursions – more advice on the FSF website
- IATA has RERR Toolkit CD
- FSF has the ALAR Toolkit – update out in April 2010
BA 777 – Fuel Icing – Chief Safety Pilot at Boeing
Detailed investigation facts are already available in the AAIB report.
Solutions
- Fuel Oil Heat Ex design modified to skim the tubes which protrude on the face to make them flat against the face in order to eliminate the key for ice to stick on the face
- In the QR Instructions – fuel flows are increased at certain times to eliminate any sticky ice build in the feed pipes at specific times of vulnerability in the phases of flight.
Flight Time Limits and Fatigue Risk Management – Emma Romig, Boeing
- A Boeing/China CAA study compared FTL on crew productivity and efficiency between geographic regions
- Areas of time lims – duty day, block times, minimum rest periods were considered
- Historically, 85 hours was set as a max per month in 1933 and was based on no specific evidence.
- This was uplifted to 100 hours per month in WW2 in US – again non-scientific based
- UK CAA CAP 371 issued in 1975 – some scientific baseline
- The Boeing/China CAA study built rosters and schedules and analysed the productivity and alertness
- An airline normally takes its schedule and timetable and then adopts a crew roster process
- Alertness models were developed which is based on mathematical function to predict alertness and cognitive performance based on:
- Sleep/wake history
- Circadian rhythms
- US rules seek 8hrs min rest, block time limits but no effects from nos of flts or time of day
- China rules – min 10 hours rest, block and duty time lims – small effects from nos and time of day
- EU rules – min 10 hours rest, block and duty times lims – some time of day and nos of flts taken into account
- The study found that the most productive roster is the worst for alertness levels!
- The aim is to get the best of both – productivity and alertness
- Study Recommendations were:
- Keep start of day the same as much as possible
- Select a roster solution, try it, analyse the alertness and productivity, re-iterate it and try that – until the optimum point is reached
- ICAO is now developing advice.
- EASA and the FAA are reviewing their rules.
- China is now revising its rules in line with this study outcomes
- An formal Fatigue Risk Management System approach offers the optimum protection and productivity
Regional Airline Fatigue Study/Survey – Ben Winfree and Ken Nagel
- The Survey collected information on demographics, rest patterns, FRMS, company policy, flt times – confidentialno names.
- Results carried out in US and Europe with 1329 pilot responses were as follows|:
- 96% of pilots say they are flying fatigue
- That they need an FRMS
- Working conditions in regional airlines have not changed in 20 years
- Equipment and procedures have changed significantly
- Busy days, late and early starts, numerous landings, unpredictability and small airports are common challenges
- 41% commute to their jobs – via another flight!
- 28% hold another job other than flying
- Flt duty and scheduling are concerns to many
- 65% are on duty 20 days or less
- Unpredictability of rosters is a serious stress factor – several had no roster
- Sleep loss and circadian rhythms – average need 8 hours
- Insufficient sleep takes 2 full nights to correct
- Before 0700 depart or after 2300 land – circadian rhythms will be hit
- Last night flights are regularly late by 2 hours
- 79% started their down time 30 mins or less after landing
- 74% had more than 10 hours rest time
- 42.5% felt they needed 10-12 hours
- Significant nos of pilots used alcohol and drugs to sleep
- 97% pilots felt tired in the cockpit
- 85% pilots rest their eyes during the cruise
- 90% think approach and landing is effected the worst by fatigue
- 90% of pilots did not have FRMS in their company
- Recommended Activity was as follows:
- Benefits of FRMS in SMS
- Easily integrated into SMS
- Increased knowledge of fatigue risk exposure
- Reduction in oversight requirements
- Conclusion
- 98% pilots are concerned with fatigue
- Many want to know more about education to handle fatigue threats
Airspace Infringement Safety Initiative – Alexander Krastev, Eurocontrol
- Infringements are on the increase around Europe -13% in the past year
- Reporting culture may have helped this increase to a degree
- However Stats 2006 – 2008 show a reduction in seriousness of infringement
- An infringement will distract, delay and disrupt operations and can mean a loss of separation and risk of collision
- Eurocontrol established an action plan to address this issue in conjunction with other ANSPs
- 3000 reports were collected and 300 analysed to identify the causal and contributory factors
- Of all Infringements,10.6% are commercial flts –Mil flts – 9.3% and GA – 80%
- 40% of infringements occur in Terminal zones of which Nav failures are 16%
- 116 potential measures were identified and 42 accepted in the draft plan which after comments was issued in late 2009
- Infringements planning advice was generic, leaving detailed action to the knowledgeable local authorities
- Harmonise basic navigation skills for ppl holders
- Ensure refresher training
- Competence checks
- R/T skills in basic trg
- Other Improvements:
- Harmonise and simplify airspace
- Review and simplify the airspace structure
- Improve basic management of restricted airspace
- Implement standard crossing procedures for VR traffic
- Consistent use of colours in charting
- Improve AIS information
- Provide NOTAMs in friendly enhanced form
- Implement a one stop shop for flight info and planning
- Harmonise FIS provision in Europe
- Improve system support – transponders etc
- Improve controller co-ordination with local flying clubs
- Raise awareness among flying clubs and instructors
- Support to the GA safety events and efforts
- Plan Implementation timeline – 2010 -2013
- Benefits
- Identify systemic causes
- Share best practice
- Implement effective risk reduction measures
- Avoid over regulation
17000 Safety Professionals: the Air Traffic Safety Action Program: ATSAP – Joseph Teixeira, FAA
- Aim of the program is to identify hazards and reduce risks
- To fuel proactive transition to NextGen
- Modelled along the lines of airline non-punitive reporting
- ATC were asked to file reports of safety concerns
- Analyst Gp was set up to look at the data
- ATSAP data analyst have now collected 12000 reports and taxonomied the results
- 83% of these reports would not have been known by any other means.
- Examples of findings from the ATSAP include:
- After Lexington, several issues identified for runway safety including poor signage on the runway resulting in the increased incursion risk
- Airlines were missing high speed turns caused through new flap settings for fuel savings
- Chicago getting 7 new runways and introduced a 250 kt speed lim which did not stand out on the chart – and ac were breaking the speed accordingly
- The chart was changed, the speed lim highlighted and no further violations occurred
- Dallas/FW – Parallel take-offs on runway headings but ac actually closing on the climb and breaking separation rules – ATSAP info is being analysed to identify the reason for this phenomena
- The ATSAP is beginning to be used in conjunction with ASIAS FOQA airline data to address the safety issues.
Culture – Session III
Identifying and Utilizing Precursors – Michel Tremaud, Airbus
- Prevention of incidents is a shared challenge – ac ops, environment, manufacturers, engineers, etc
- It requires hazard and risk severity and probability to be assessed
- Hazard related risk factors can then be identified
- Causal sequences will follow – and then chains and precursors can be considered
- Op Risk
- Development of hazard related risks
- Risk level changes with changing conditions
- Systemic risk
- Cross boundary risks
- Precursors
- Precursors are weak signals which can provide early warnings
- Found through uneventful occurrences
- Inconsequential deviations – in FDM, in LOSA
- Context and circumstances are critical pre-conditions
- Precursors are commonly known but often forgotten
- It is necessary to work back from an event to the precursor
- Example of a ftr ac with a fire indication on an ILS – the pilot decidedsimply to continue and land
- Analysis of this event was then used by Airbus to address other similar events in terms of developing the QRH – actions include ‘flying the airplane’
- Analytical Tools – dependency models
- Establish hierarchy and rels between risk factors defences and control
- Describe causal sequences leading to a given outcome
- Capture dependencies
- Measure robustness
- Generate automatic warnings
- Classification systems
- Assist identification and encode individual occurrences
- Enable statistical analysis
- Functional Hazard Analysis
- Workflow analysis
- Fault tree analysis
- Checklists
- Mapping
- Matrix
- Qualitative and Quantative analysis
- Objective data to establish the facts
- Subjective data adds layers from SMEs and expert judgement
- These need to be integrated
- Implicit Safety Models
- Operating Assumptions
- Design principles, SOPs and trg concepts
- Airmanship prior behaviour
- Knowledge of systems and how to operate it
- There is a need to challenge assumptions!!!
- Cross boundary risks
- ATC, pilots, engineers, cabin crews, regulators
- Risk variation with changing conditions
- Dispatch under MEL
- Crew factors
- Experience
- Route familiarity
- Duty day
- Weather conditions
- Nav aids – and letdown aids
- WIP
- Risk assessment tools are in abundance
- Change induced risk
- All change carries a risk and must be assessed
- Organisation
- Policies, processes, procedures
- Products
- Formulate Problem statements
- Do we have a problem?
- What went wrong
- Quantify the problem
- Evaluate solutions
- Interventions – identify them
- Hazards – Technical, OP standards, trg, safety awareness
- Deploying interventions
- ICAO, universities, FSF – all need to work together
- Aviation Safety Enhancement loop
- Tools – Observed deviations –Op and HF Factors – Prevention strategies and back to Tools
- Continuous learning is essential
Rejecting a Take-Off after V1 – Why it still happens – Gerard van Es, NLR
- Two rejects this year in US and Europe already
- Rejects occur for various reasons
- High speed RTOs are normally limited to
- Operational Stats indicate that 1 in every 1800 TOs is an RTO
- Each pilot has a 1 in 25 year chance long haul and 1 in 4 year for regional pilots
- Most RTOs are less than 60 kts -therefore high speed very rare
- Remedial Action on High Speed RTOs was taken in 89
- Take-off safety trg aid (TOSTA) was produced in 1989
- RTO video in 1993
- So why do they continue after TOSTA and other dedicated training and briefings?
- Data analysis – Annex 13 definition,
- Of 135 events of abort after V1 identified – 90% ended in excursion
- After TOSTA – the rate reduced by 25% but there may be other reasons other TOSTA awareness for this reduction
- Reasons for RTO
- Majority of RTOs are not engine related!
- Engine failures are easy to be identified and indicated and felt
- Others are not so easy to ident and are not trained for
- Pilot Reaction Times
- Humans respond in 3 phases – recognise, decide, react
- Qantas did some trials work – eng fail to first call takes 2 secs. First call to react takes up to 8 secs
- Cranfield – did a similar trial
- Transfer of controls
- On most airlines, RTO decision rests with Captain and control is transferred to Captain during RTO, if required.
- Difficulties and delays can occur on the transfer
- Data analysis inconclusive – reports do not record who was flying
- Conclusion:
- TOSTA did not necessarily change the RTO stats
- Pilots vary in reaction times to make decisions
- 82% of high speed RTOs are not engine related
- TOSTA is not well known among today’s pilots community
- RTO reasons have not changed
- 44% of RTOs should have been conducted differently
- Detect – decide –react is taken into account in V1 calculations
- What to do
- TOSTA is valid – promote it
- Use should not be limited to large jet operators
- Revision of some of the RTO topics may be of value
- Train pilots for RTO events other than engine failure in sims
- Conduct unexpected aborts during sim trg
Role Of Extra Crew On The Flight Deck For To And Landing– Ed Pooley
- Range of approaches among airlines on the risks of third crew members on the flight deck
- Do extra crew make a difference? – Numerous Examples
- Turkish B737 Accident at Schipol
- FO on UT as PF – QFO inn Observer seat
- Minor tech fault known – LH Rad alt feeds the auto throttle
- Auto pilot ILS approach
- ILS GS approached
- Melbourne Emirates A330 Tail scrape
- 100 ton error on TOW for a 14 hour flt not spotted by the 3 crew involved
- B767 on a dark night commenced a gentle 70 degree wingover which was not identified by any of the 3 pilots initially– RTB safely to New York
- Jamaica incident – an erroneous A330 take-off weight and thrust calculations based on 120 tonnes a not 210 tonnes as it should be.
- What are the objectives of the third crew?
- Early stage line training augmentation
- Long haul additional awareness
- Does it work?
- How the 3rd pilot intervenes
- Practical limitations on the 3rd pilot
- What guidance is provided in the respective Ops manual
- Who qualifies to be a 3rd pilot
- Role guidance on
- Substitution – assistance – monitoring – intervention
- A review of a couple of airlines revealed how role guidance is given
- Ops manual contains only generic trg and often relies on ad hoc briefing on day
- Is monitoring effective? Not seen to be so, so far
- Monitoring outside the crew is different to monitoring as PF/PF
- It is easier, unless and until intervention is required
- Are 2 monitors better than one?
- Some evidence of success – some errors are trapped – R/T useful
- Intervention is often delayed because its perceived as interference – unless proper guidance is provided
- Conclusion
- Lack of clear definition for the 3rd pilot
- Intervention strategies are required
- Current arrangements fail to achieve focus on infrequent and unexpected
- No sound evidence that an extra crew in each case leads to enhanced error management
- There is an over reliance on pre-flight briefings
- Insufficient clarity so far in ASR or FDR data to evaluate the value of third crew
- FDM can identify when power is added to get airborne in terms of revealing incidents of incorrect performance calculation
- Adding such relevant data capture and analysis not a major task
- Is the balance between PIC discretion on the duties of extra crew members and those reflected in SOPs correct?
- Is the presence of the third crew captured in company ASRs?
Can Airlines Achieve One Level of Safety by having One Level of Trg – Paul Miller,UPS
- In the case of LOC accidents, do crews involved know enough about Icing, the Aerodynamics of icing and how to recover from an upset?
- These crews were all trained and certified
- In the case of Runway Excursions, did crews know how to decide – how to make decisions about the landing conditions, tailwind effects, decrease braking action effects and un-grooved runway landings
- Why are crews not learning from others?
- How to address these shortfalls
- How to learn the lessons which are readily available
- Is there sufficient invest in qualified and quality training and safety departments?
- We should be training like we fly – and avoid mismatch and negative training.
- Every pilot should know that better pilots than them have crashed aircraft
- Integration of safety and training, in terms of programmes and departments, is a key contribution towards continuously improving safety in operations.
- Methods of integration
- ASAP prog
- FOQA
- Event reports
- Weekly training – safety meetings
- AQP
- Risk rated from safety events into trg
- Risks from safety audits
- Initial qualification and recurrency qualification can be addressed
- Regulatory oversight should be focussed on the trg and safety
- The Safety Dep and the Trg Dep relationship is key
- There must be a positive connection between safety and training
- Observations from poorly co-ordinated safety and training departments:
- Discourages incident reporting
- Safety reports are not acted upon
- Safety does not function and connect into training
- Airlines should be interested in safety as should the Regulator
- Practice and technique
- Communication is key
- Rapid responses vital
- Every airline should be training to the same level
- CRM
- FAA ATP and Rating
- Is competency by checking as good as by training
- Measurement of training is possible by marking the following:
- Proficiency
- Sophistication
- Substance
- Safety integrated into training is the essential target for airlines in order to achieve an acceptable level of safety
- It is up to the Safety Dept to provide valuable data which the training department should be keen to receive – Safety Dept must communicate with training and make themselves an invaluable source of ideas and issues
Aerospace Performance Factor (APF) – A new view of safety information – Kenneth Neubauer
- The objective of the APF is to closely link operations to safety.
- APF developed with easyJet/FAA/USNavy College/Imp College co-operation
- Bring ops to safety by integrating safety in it, by breaking silos and merging data sources
- Shifts focus from reactive to predictive
- It works through a 5 step approach:
- Determine organisational safety factors
- Safety Dep get feeds from all other areas – ATC, airport, eng, etc
- Determine available information
- Uses current info not new info, but which is normally held within silos
- Determine what available info is able to influence.
- Determine the level of importance of the various data
- APF allows norms to be established and drift from the standard to be recognised quickly
- Allows decision makers to identify problems early and apply resources to address it
- It supports ICAO SMS requirements
- It is proactive and detects drift
- Supports HILAS (Human Integration into Lifecycle of Aviation Systems) Improvements
- Increases safety performance reporting frequency
- Supports the easyJet System Integrated Risk Assessment model
- Conclusions
- Improve company efficiencies
- Improve insurance status
- Move towards operational risk forecasting
Criminal Prosecution and Safety Reporting – Hans Houtman
- People make mistakes
- Frontline operators are proud and want to do the job properly
- Does punishment eradicate errors?
- From the HF perspective, we need to identify errors
- It is choice – safety and no prosecution – or prosecution and no safety
- Gross negligence is the line to be identify in the process
- An Investigation into this issue was carried out as to why people do not report. Outcomes were:
- Fear of prosecution
- Poor knowledge of the law
- In General Aviation, no reporting
- Poor feedback to the reporters
- Not registered on the FDM
- Lots of paperwork
- Fear for reputation
- Don’t know what to report
- Not reporting is seen by
- Judges as suspect
- Media as a wrong signal to society
- Several other industries suffer similar issues on safety
- Changes in culture
- There is a need to handle uncertainties
- Framework of rules to handle risky activities
- Loss of trust in science and politics
- More penal code means less reporting
- Less safety means more penal code
Managerial Communication: Key to Continuous Engagement and Competitive Advantage – Randy Ramdass, Continental Airlines
- Companies that communicate effectively with their workforce perform 20% better
- Staff turnover is 20% less if communication is effective
- In tech ops, most managers are strong technically but not good at comms
- Continental undertook a study to:
- Learn what value stems from the team and policy initiatives
- Identify individual management styles and identify those that co-workers find the most effective
- How to best communicate with the employees
- Learn how to use company resources best and develop the poorer skills and resources
- Get the common goal and mission of the company known
- Interact with other division leaders and get their views
- Run management meetings to seek continuous improvement and implement strategies
- Crew meetings – consistency in message
- Team Initiatives to seek improvements and efficiencies
- Impact of adopting the lessons from this approach has been:
- Reduced numbers of damage to ac in maintenance from 14 per annum down to 2.
- Personnel Injuries reduced significantly
Maintaining a High Level of Safety in Remote Operations – Adrian Young, Denim Air
- Denim operating in Remote Operations – with numerous threats such as gravel runways in Afghanistan and UAS operations sharing the same airspace
- The major hazard to these ops is the lack of information and data available
- Insufficient information on the airspace and airfields being used
- Risk assessments and acceptable levels are the key elements which must be carried out by the company
- Infrastructure, ground security and remoteness all have their safety challenges
- Data knowledge is very poor in these regions
- As well as geographically a long way from civilisation, ‘Remote’ might mean unusual situations and circumstances too – Nigeria for example
- Oil and gas companies do not run their ops themselves they charter this responsibility to others – for good reason!
- Obstacle data is a particularly serious problem in many remote ops
- Safety can be at a lesser level than we would ideally wish it to be!
- SMS is the key to pulling these safety info sources together
- Ground handling efficiencies and security of the airport are difficult too
- What is normal – what is safe?
- The company has a check list 30 items which are analysed to identify the risks
- Regulatory compliance does not work for Remote Operations and alleviations can not be used
- Conclusions
- The structure of the tools to undertake remote ops is important under SMS
- EU Ops does not address remote ops adequately and could be modified to help EU AOC holders to remote operations
- Commonality of charts would be helpful
Rich Jones
Chief Executive
UKFSC
27 March 2010