Download - Flight Data Monitoring, Risk, and Protecting Assets

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FDM, Risk and Protecting your Assets

Sonya TietjenPrincipal, Safety Management Systems

4 March, Heli-Expo 2013: Las Vegas, NV


1. The Problem2. The Solution3. The Benefits

4. Risk Management5. Flight Data Monitoring6. Protecting Your Assets

Agenda


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.

NTSB Report


Causal Factors - Primary

IHST 2006 (JHSAT)

Flight Crew


The Problem?


Threats

How accidents happen

Organization

Technology

Humans

Modified from J. Reason 1997


BowTieXP: Loss of Separation

D - Aircraft In motion 'Airborne': HE-20E Loss of separation

with third party aircraft

H-02.01.01 Aircraft in motion (1)

Loss of Spacial Awareness

Medical fitness and 6 monthly tests.

Ref? - Reference to be added

Simulator training including recovery from unusual

attitudes


Maintenance of an effective look-out

RAP 1 - xx

Two Crew operations


Flight crew mishandling and mismanagement of

the flightCompliance 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)


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)

Operations in adverse weather

Procedure (weather minima)


Weather (Flight Operations Limitations)


Actual Weather Reports/Information

RAP 2 - x

Training (interpretation of weather information, and

weather avoidance)

RAP 3 - xxx

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

Failure to learn from experience

HSE Management Review Board process


Occurrence reporting system


QA Audit of line management actions to resolve findings


Line management action to resolve findings


Non-compliance with mandatory requirements (levels and distance) for

seperation with third party aircraft. Training and testing (Base

checks)


Training and testing (Line Checks)

TM Pt.4 - Operation Line Training




Effective cross cockpit communication

OM Pt.6 Sct.1 - Definitions, Rules and Requirements



Compliance with procedures and checklist

OM Pt.8 - Unit Orders

Organisational Discipline


Airborne contact with opposing traffic, Loss of aircraft and/or multiple

fatality

C5 C5 C3 C5

Take avoiding action

OM Pt.8.Sect 9 - Emergency Procedures

Incorrect avoiding action taken

CAR 1996 and AIP requirements for standard collision avoidance actions

MCAR Pt.11 Chap.2 - Regulation of Movement Area

Installation and use of TCASMaintenance of Situational Awareness

OM Pt.2 Sct.12.34 - Adherence To Operating Procedures and

Co-Pilot's Responsibility

Establish Communication with opposing traffic

SID Sect.07 - Hazard RegisterAIP.Vol 1 ENR 2 - Air Traffic

Services Airspace

Failure to establish communications with

opposing trafficBlind Call on Guard frequency

121.5 MHz


Common Frequency for aircraft in the operational

zone


Identification of Opposing traffic

SID Sect.04 - Listing of Interface Activities

Lack of visual meteorological conditions

(VMC)Maintenance of Situational

Awareness

OM Pt.2 Sct.12.34 - Adherence To Operating Procedures and

Co-Pilot's Responsibility

Division of workload (handling and non-handling pilots) IMC

and VMC

OM Pt.6 Sct.2.3 - Division of Crew Duties During Flight in

I.M.C.RAP 4 - xxxxx

Installation and use of TCAS

RAP 3 - xxx

Source: CGE Risk


1. Safety Reporting

2. Flight Data Monitoring

Two tools for Flight Ops data


Safety Reporting

Air Sa

fety

Repo

rt


Human beings, the technology they operate, and the organisation they work within, are the three sets of factorslikely to be “implicated in breaching defenses put in place to avoid accidents.”

J. Reason 1997

Breaching Defenses


“Hazard and risk management must be data-drivenand involve constant monitoring to either eliminateor reduce the risk to as low as reasonably practicable.”

ICAO 2009, Doc 9859

Risk Management


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 beon the area of highest risk.

ICAO 2009, Doc 9859


Flight Operations


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

Bottom Line: Flight Operations


1. Safety Reporting2. Flight Data Monitoring

Only FDM iscomprehensive and quantifiable

Two tools for Flight Ops data


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…

The Solution: FDM


FDM – W4’s:1. Who*2. What3. Where4. When

Safety Reporting5. Why

Safety Reporting + FDM = “W5s”


ThreatsOrganization

Technology

Humans

Modified from J. Reason 1997


The Good, the Bad, and the Ugly


Organisation

Technology

Humans

Protecting Your Assets


Complaint Management Turbulence Timing Airmanship

Marketing Liability Risk Management Professionalism

Humans (The Clients)


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

Humans (The Employees)


Pre-purchase / Pre-funding: Performance / Efficiency Proper handling Limits maintained

MRO: Faulty Equipment Limits maintained / exceeded Warranty issues

Technology (The Aircraft)


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

Organisation (The Company)


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)

FDM Resources

http://www.hfdm.org/

http://www.ihst.org/

http://www.caa.co.uk/


The highest risk to an operation is Flight

Without FDM, you really don’t have quality assurance on flight operations

Implement FDM

Wrap Up


FDM, Risk and Protecting your Assets

Sonya TietjenPrincipal, Safety Management [email protected]

Download - Flight Data Monitoring, Risk, and Protecting Assets

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