flight data monitoring safety and... · 2020. 2. 4. · 8 chc safety & quality summit 2009...

1 CHC Safety & Quality Summit 2009

Vancouver, BC March 30, 2009

Lindsay Cunningham, American Eurocopter Joint Helicopter Safety Implementation Team

Stuart “Kipp” Lau, CAPACG, LLC. Joint Helicopter Safety Implementation Team

Flight Data Monitoring CHC Safety & Quality Summit 2009



CHC Safety and Quality Summit

•  Summit Theme: The Future of Human Error Management in Aviation

•  Session Theme: The role of Flight Data Monitoring in effectively managing human error and identifying vulnerabilities in the aviation system.

•  Key Deliverable: A path to global FDM implementation and cooperation amongst stakeholders.



Helicopter FDM & the Oil and Gas Industry

Operator Primary Industry (Secondary)

Bristow Oil and Gas (SAR)

Bristow/Air Logis7cs Oil and Gas

CHC Oil and Gas (SAR)

Cougar Helicopters Oil and Gas (SAR)

Era Avia7on Oil and Gas (EMS)

PHI Oil and Gas (EMS)

Arkansas Children’s Hospital EMS

Baldwin Avia7on Mul7/Organiza7onal‐based



Overview: •  Introduction – IHST FDM activities •  Brief FDM/FOQA history

– Airline and Helicopter •  Program management •  Practical applications of FDM

– Approved and non-approved programs

•  Available resources •  Discussion



Why are we here?

Reduce accidents…save lives!!!



JHSAT Standard Problem Statements:

Q: What other areas can be impacted by FDM?



US JHSAT Recommendations:

•  Utilize flight data monitoring systems such as HOMP or FOQA to evaluate flight operations and to address unsafe/undesirable flight crew habits.

•  Install flight data retrieval systems such as: –  Cockpit image recorder –  Flight parameter recorder –  Cockpit information recorder –  Quick Access Recorder (QAR) –  Multi-function data acquisition unit (MFDAU) –  Cockpit voice flight data recorder (CVFDR)

Source: Year 2000 U.S. JHSAT Report



Why do we need flight data?

•  Additional data source for information in accident investigation

•  Accident prevention due to operational oversight

•  Support implementation of flight data monitoring system (FOQA/HOMP/HUMS)

•  Can be utilized for training

•  Data validation in the event of an incident

•  Acquisition of fleet data for operator



Information Recommendation Strategies:

•  Install flight data retrieval systems, and utilize this equipment to implement flight data monitoring systems such as HOMP/FOQA/HUMS. –  Publish flight data retrieval & management system guidance for

industry –  Sponsor flight data monitoring workshop at Heli-Expo 2009 and

IHSS 2009 –  Encourage airframe and avionics Original Equipment

Manufacturers (OEMs) to develop and install low-cost flight data retrieval systems



Information Recommendation Strategies:

•  Work with accident investigation authorities to increase data gathered in accident investigations. –  Developed helicopter accident checklist to trigger deeper

investigation into unique aspects of helicopter operations –  Ongoing effort to support investigative authorities with data and

investigations and inform them of relevant industry safety issues –  Additional sources of information such as flight data retrieval

systems will augment information available to investigators



Flight Data Monitoring:

How can you fix what you don’t know?

How can you improve what you don’t measure?



Exploring FDM in HEMS – no formal programs, yet.

•  Recommendations from NTSB Hearings –  AAMS –  AMOA –  HAI

•  Flight data retrieval systems for helicopters

•  FOQA programs •  Interest from several operators such as Air

Methods, Tramahawk, OmniFlight, etc. •  IHST/FSF HEMS FOQA Trial



Initial Steps

Equipment •  Capable

Helicopters •  ARINC 429 •  Available in

HEMS fleet

Operators •  Interest in

FOQA •  Desire to

Partner •  Operate

capable equipment

Partner •  Gate

Keeper •  Contractual

Obligation •  Appropriate

number of helicopters

Equipment Manufacturer •  QARs •  In-kind

Support

Study Outcome •  Current

data adequate?

•  Include H-FOQA?



Flight Data Monitoring History

•  1960s – FDM with British Airways and TAP Air Portugal

•  1993 – FSF recommends FOQA beyond airlines •  Late—1990s Airline FOQA becomes commonplace •  2002 – Final CAA HOMP trial paper issued •  June 2005 – FSF/NBAA C-FOQA Trial •  Late 2006 – New recorder technology enables GA

FDM •  2008 – Bristow/Air Logistics FAA-approved HOMP •  2009 – IHST/FSF Helicopter FDM Trial



What is a flight data monitoring system?

The Heinrich Pyramid

300

30 1

Hundreds near misses, incidents and events go unreported…

For the few incidents that are reported, which ultimately results in…

The accident that finally occurs.

Data from Appareo Systems LLC, Feb 2008

Current Intervention Point

FDM Intervention Point



Question: Why Flight Data Monitoring?

•  For every major accident there are several less significant accidents, hundreds of reportable incidents and thousands of unreported incidents.

•  Below this lie the normal variations present in all operations.

•  FDM gives more detail on the incidents, encourages more consistent reporting and fills in the void below this that we know very little about. (HOMP Study)

Information sources added



Flight Data Monitoring defined

•  Definition: “A systematic method of accessing, analyzing and acting upon information obtained from digital flight data records of routine operations to improve safety”

•  FDM involves the pro-active use of flight data to identify and address operational risks before they can lead to incidents and accidents. (HOMP Study – UK CAA, Shell Aircraft, Bristow and BA leads to adoption by UKOOA)

•  Flight Data Monitoring (FDM) is the technology and methodology for collecting and analyzing data recorded in flight. (FAA)



Answer: Discovering the unknown!

•  The HOMP (trial) provided valuable new information on the risks associated with helicopter offshore operations.

•  Events have identified hazards which otherwise would not have come to light.

•  The operator has been able to take appropriate corrective and preventative measures.

•  The measurements are building a useful picture of everyday operations which has not previously available.

•  The HOMP has shown how pro-active use of flight data in a FDM program can significantly enhance the safety of helicopter offshore operations. (HOMP Study – www.caa.co.uk - CAA Paper 2002/02)



FDM by any other name…

•  FOQA – Flight Operational Quality Assurance (FAA) •  FDA – Flight Data Analysis (ICAO) •  FDM – Flight Data Monitoring (CHC) •  HFDM – Helicopter Flight Data Monitoring (Cougar) •  HOMP – Helicopter Operations Monitoring Program

(Bristow/Air Log) •  LAMP* – Line Activity Monitoring Program (PHI)

•  HUMS – Health & Usage Monitoring Program (MX) •  MOQA – Maintenance Operational Quality Assurance (MX)



What is FOQA?

•  Flight Operational Quality Assurance (FOQA) is an FAA program that standardizes the FDM process for interested parties. (AC 120-82)

•  FOQA versus ASAP Landscape – US Airlines Major Carrier Regional Carrier

ASAP 93 percent 91 percent

FOQA 86 percent 10 percent

NTSB – FAA Shared Vision Conference 2008



What’s up with ASAP? •  Aviation Safety Action Program – a voluntary reporting

system for employees of certain certificate holders. A partnership between the FAA, certificate holder and 3rd party such as a labor organization. (AC 120-66)

•  Easier to implement than FOQA – fewer barriers such as cost associated with fleet equipage and ground analysis stations (WBAT offered at no-cost)

•  ASAP in the news – In 2008, a number of US airlines suspended their ASAP (Delta, American, US Airways) over concerns of program management. Most have reconciled differences and have crafted new MOUs.



Lessons learned: Airlines •  Over 30 years of FDM experience •  A mature global system (ICAO mandate) •  Active information sharing through the following

(US example): – Over 5 years of infoshare meetings – Current Aviation Safety Information and Sharing

(ASIAS) process •  Following sequence of slides courtesy of the Flight

Safety Foundation



• There were no fatalities or injuries • There was no mechanical damage to the aircraft • No Air Safety reports were submitted (assumed)

Therefore, no investigation was carried out and no lessons were

learned – Except perhaps by the crew concerned



If we can detect this ………….



…………maybe we can prevent this…………..



Best Practices



FOQA produces results:

0 %

0.1 %

0.2 %

0.3 %

0.4 %

1976- 1982 1983- 1989 1990- 1996

World average

First 6 FOQA users

Middle 11 FOQA users

Last 28 FOQA users

Source : Skandia



Beyond safety… •  Operational benefits of FOQA •  Orange County (KSNA) Noise Study •  Problem – legacy “alternate”

departure procedure mandated by airport property leases

•  Procedure required “deep cutback” of thrust – noise monitored by airport authority (3rd type of TO procedure)

•  High bypass turbofans introduced •  Legacy aircraft no longer operate into

SNA – procedure remained



Troublesome procedure

•  FOQA studies showed high rate of the following events: –  Pitch High on Takeoff –  High Rotation Rate –  Climb Speed Low

•  AQP data indicated high number of unsuccessful departures.

•  Actual observed “stick shaker” events and one reported bird strike at high pitch/low energy



SNA Noise Study – a success story

•  Airline study involved: –  Simulator trials –  Actual flight test utilizing all takeoff procedures and

engine combinations •  Airport Authority waived noise violations during test

flights •  Results validated simulator trials and procedure was

changed industry wide •  Airline conducting study benefited from increased

operational flexibility, fuel savings and a wider safety margin



How did others learn from this lesson?

OLD – individual silos

UAL

UPS

DL

AMR

SWA

JBLU

New – free flow of information

UAL UPS

JBLU SWA AMR

DL



Model for the helicopter industry

Current – individual silos

EMSI

OFI - Gulf

VIPI

OFI-N.ATL

Heli

EMSI-Can

Future – free flow of information

EMSI OFI- Gulf

EMSI- CAN

Heli OFI – N.ATL

VIPI

Example – S-76 operators (segments, locale, etc.)



Program Management Decisions

•  In-house •  3rd- Party

Structure

•  Approved (FAA)

•  Informal

Status •  Traditional •  Light

Recorder

Technology



FOQA is not a “silver bullet”

FOQA Interest

Senior Mgt

Support

Employee Group

Support

SMS within a

just culture

Flight Operational Quality Assurance (FOQA) is only effective when coupled with an active SMS in a “just culture.”

Flight Operational Quality Assurance Programs are only effective when coupled with an active SMS in a “just culture.”

NO

YES



Caution!

•  Upon implementation - organizations must be prepared for immediate results – following AC 120-82 will reduce the likelihood of a surprise.

•  Be aware of the different emotions associated with FOQA implementation –  “Geez that’s neat” –  “Wow, we’re collecting a lot of data” –  “Crap, how do we manage all of this

information”




• In-house • 3rd- Party

Structure

• Approved (FAA)

• Informal

Status • Traditional • Light Recorder

Technology

•  Process begins with needs assessment.

•  Include all stakeholders

Maintenance Maintenance Operations

Training Safety

HOMP



MOST Model  Maintenance

Engine trend monitoring Exceedance reports HUMS Trouble shooting Fuel savings

 Safety Fleet oversight SOP adherence ID of adverse safety trends Uncover threats and errors Mitigate risk

 Opera7ons Insurance reduc7ons Automated data transfer from aircraS Automated OOOI repor7ng Automated billing Fuel savings Automated aircraS tracking

 Training Provide feedback to instructor/students (e‐debrief) Valida7on of training programs Training footprint analysis and adjustment

38

Maintenance Operations

Training Safety

HOMP





Structure


•  Informal


Recorder

Technology

•  Corporate Infrastructure –  Size of company –  Safety organization –  IT department

•  Personnel –  Cost

•  FT/PT FMT •  Flight Qualified? •  Revenue/productivity lost

–  Training •  Workforce stability





Structure

• Approved (FAA)

•  Informal


Recorder

Technology

•  Approved versus “non-approved” or informal

•  Establish program IAW AC 120-82 (recommendation)

•  Different motives (next) –  Air Logistics/Bristow –  PHI

•  Incentives of FAA-approved programs



A tale of two tail rotors: Air Logistics HOMP •  Pro-active FDM system •  Integral part of SMS •  Customer requirement •  Employee acceptance •  Offshore operations •  Monitors Bell 206/407

(ALERTS) and S-76 and S-92 w/ Flightscape

•  FAA-approved status

PHI’s LAMP •  Pro-active FDM system •  Integral part of SMS •  Customer requirement •  Employee acceptance •  Offshore operations •  Monitors S-76 and S-92

w/ Flightscape •  Non-approved status



One size doesn’t fit all… •  Both organizations made a corporate decision on the

status of their program (explained in detail in respective HeliExpo presentations posted on www.ihst.org site).

PHI explains: •  No PHI objections to an FAA Approved Program, and we

may decide to move that direction in the future •  Our program has developed extremely well and has

become quite robust •  Has been very effective as is…



FOQA Benefits – FAA approved programs • Enforcement incentives –FAR violations will not be

pursued if revealed only by FOQA and receive corrective action and do not involve criminal or intentional actions.

• Data protection –FOQA data will be de-identified and protected from Freedom of Information Act (FOIA) release under FAR Part 193. –FAA Legal Office will defend any attempts to override Part 193 by other authorities. (FAA AFS-230)

•  Future industry information sharing is key to establishing a global FDM community – ASIAS process relies on information from “approved” programs





Structure


•  Informal


Recorder

Technology

•  Technology Selection –  Fleet types (stability) –  Common across fleets

•  Fleet equipage survey –  What’s installed?

•  Available equipment •  STC versus 337

installations •  Ground analysis tools

–  Web-based



FDM Process – the 4 R’s •  Record

–  Aircraft flight data (FDR/DFDAU/QAR/WQAR)

–  Light Recorder (Appareo ALERTS) •  Retrieve

–  Manual, electronic or wireless

•  Review –  Validate, classify and analyze with ground

analysis station

•  Report –  FMT review, meaningful findings and

recommendations, group review to determine operational and training impact.



A quick recap…

•  Properly managed SMS components convert data into useful information and the end user gains knowledge based on facts that reduce risk and increase safety*

*enhanced, thanks to Dick Healing, R3 Consulting



What is a flight data monitoring system?

• Involves capturing and analyzing flight data to determine if the pilot, aircraft systems, or aircraft itself deviated from “normal” operating conditions

• Data allows analysts to investigate predefined exceedances for corrective action and trend analysis

• Designed to respond to normally unreported events to modify procedures and behavior in a non-punitive manner and thereby prevent accidents.



Challenges of flight data monitoring systems:

• Resistance from the pilot community; an effective flight data management program must be non-punitive…JUST CULTURE!

• Non-standard format of flight data; for operators with mixed equipment, a standard data format must be developed for effective data analysis.

• Diversity of helicopter operations; diverse operating environment and requirements make it difficult to set standard “event triggers”



Proven Benefits of flight data monitoring systems:

• Significant increase in safety and reduction of accidents • Airline industry for more than a decade • Offshore helicopter operations

• Significant cost savings • Modified procedures impending failure detections

• Source of empirical data for operations analysis and evaluation of existing and new procedures and programs



FDM Resources 1.  FAA – inform local POI and AFS-230 2.  FAA – AC 120-82 (FOQA)/AC 120-92

(SMS) 3.  FAA – AC 120-66 (ASAP) 4.  FSF – Flight Safety Digest 1998 and

other resources at www.flightsafety.org

5.  Vendors on display 6.  IHST FDM Tool Kit (release date TBD) 7.  FDM Workshop participants 8.  HOMP Study – www.caa.co.uk - CAA

Paper 2002/02



Discussion/Questions?



THANK YOU –

STUART “KIPP” LAU VICE PRESIDENT OF FDM SERVICES

[email protected]

flight data monitoring safety and... · 2020. 2. 4. · 8 chc safety & quality summit 2009...

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