flight data monitoring, risk, and protecting assets

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International Helicopter Safety Team (IHST) workshop presentation from HeliExpo 2013

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  • 1. FDM, Risk and Protecting your Assets Sonya Tietjen Principal, Safety Management Systems 4 March, Heli-Expo 2013: Las Vegas, NVAll rights reserved worldwide. Copyright 2013 Gael Ltd.Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright 2012 Gael Ltd.
  • 2. Agenda 1. The Problem 2. The Solution 3. The Benefits 1. Risk Management 2. Flight Data Monitoring 3. Protecting Your AssetsAll rights reserved worldwide. Copyright 2013 Gael Ltd.Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright 2012 Gael Ltd.
  • 3. 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.All rights reserved worldwide. Copyright 2013 Gael Ltd.Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright 2012 Gael Ltd.
  • 4. Causal Factors - Primary IHST 2006 (JHSAT) Flight CrewAll rights reserved worldwide. Copyright 2013 Gael Ltd.Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright 2012 Gael Ltd.
  • 5. The Problem?All rights reserved worldwide. Copyright 2013 Gael Ltd.Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright 2012 Gael Ltd.
  • 6. How accidents happen Organization Technology Humans Modified from J. Reason 1997All rights reserved worldwide. Copyright 2013 Gael Ltd.Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright 2012 Gael Ltd.
  • 7. BowTieXP: Loss of Separation Loss of Spacial Awareness Medical fitness and 6 monthly Simulator training including Maintenance of an effective Two Crew operations tests. recovery from unusual look-out attitudes Ref? - Reference to be added Ref? - Reference to be added RAP 1 - xx Ref? - Reference to be added Flight crew mishandling and mismanagement of the flight Compliance with procedures Effective cross cockpit Crew flight planning for other Multi crew ops including Training and testing (Line Training and testing (Base and checklist communication aircraft operations in the challenge and response Checks) checks) operational zone OM Pt.8 - Unit Orders OM Pt.6 Sct.1 - Definitions, OM Pt.5 Sct.1.1 - Duties of TM Pt.4 - Operation Line TM Pt.4 Sct.1 - General Rules and Requirements OM Pt.8.Sect 3.23 - Summary Captain and First Officer Training to Offshore Operations TM Pt.4 Sct.1 - General (AS332L1) H-02.01.01 Aircraft in motion (1) Aircraft System failures MEL controls for limiting routine preventitive Repetitive defect Flight Manual Emergency departures with maintenance management Check List actions unsevicabilities MS - Aircraft Mainteance MOE Pt.2 Sect.2.14 - Technical FM Sct.3 - Emergency MEL - Minimum Equipment List Schedule record control Procedures Ineffective Air Traffic Management D - Aircraft In motion Airborne: HE-20E GPS flight Tracking Provision of area information In field traffic communication Effective provision of area Loss of separation Airborne contact with