operational performance monitoring -...
TRANSCRIPT
Flight Path Management
Simon Harlow
Head of Flight Standards / Test Pilot
Bond Offshore Helicopters
Operational Performance
Monitoring
Simon Stewart
Safety Director / Head of Training
Babcock Mission Critical Services
Safety Through Collaboration
Flight Path Management
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The Hot Topics
Issue Causes Barriers
Uncontrolled
flight into
terrain
• Handling Error
• System malfunction • Helicopter
Design
• Systems
• Skill /
Training
• Procedures
Controlled flight
into terrain
• Handling Error
• Disorientation
• System malfunction
Wrong Deck
Landing
• Navigation Error
• Disorientation
• System malfunction
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Accident
“Swiss Cheese” Accident Model
Event
Barrier
Weakness in Barrier
(like holes in Swiss
Cheese)
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Accident
“Swiss Cheese” Accident Model
Event
Safety Through Collaboration
Accident
“Swiss Cheese” Accident Model
Design Systems Training Procedures
Latent
Failures
Event
Safety Through Collaboration
The Hot Topics
Issue Causes Barriers
Uncontrolled
flight into
terrain
• Handling Error
• System malfunction • Helicopter
Design
• Systems
• Skill /
Training
• Procedures
Controlled flight
into terrain
• Handling Error
• Disorientation
• System malfunction
Wrong Deck
Landing
• Navigation Error
• Disorientation
• System malfunction
Safety Through Collaboration
What we are doing '..
• Sharing best practise
• Stabilised Approach
• Investigating the problem and solutions
• Wrong Deck Landing Working Group
• 80 reported WDL in last 5 years (suspect there are more
unreported)
• Helicopter –Terrain Awareness Warning System
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Wrong Deck Landing Working Group
• Commenced under EHOC (nearing completion)
• To be presented to IOGP Aviation Safety
Committee in October 2015
• Aim to include prevention checklist in next IOGP
Aircraft Management Guidelines (AMG).
• Key Event Findings
• 90% Good day VMC, low workload, multi-stop (2nd or later),
rarely shuttling
• 10% IFR
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Wrong Deck Landing Working Group
• Key Recommendation Area
• Multiple recommendations for operator,
logistics and helideck personnel
• Improvements to future installation
signage and lighting
• Review global naming conventions
• Level and quality of reporting needs to
improve!
• Remove the opportunities for human error!
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Accident Current Proposed Improvement
Warning
TimeMode(s)
Warning
TimeMode(s)
G-BEON 15.0 6 24.0 4 +9.0
G-TIGH 4.0 6 17.0 3 +13.0
G-BLUN 7.0 1, 2, 4 & 6 8.0 1 & 2 +1.0
G-REDU 4.5 6 16.0 1 & 2 +11.5
HTAWS – New Warnings
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Human Error
• Human Performance is the single greatest
contributor to both accidents and the prevention
of accidents.
• We rely on the human not to make errors
• We rely on the human to provide safety barriers
• Do we know how reliable we are?
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What is the chance of
Cognitive Failure
AA
BB
CC
DD
EE
FF
1 in 100 0001 in 100 000
1 in 10 0001 in 10 000
1 in 10001 in 1000
1 in 1001 in 100
1 in 101 in 10
1 in 11 in 1
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Supervision Error
• We rely on the human to monitor other humans
• Do we know how reliable our supervisors are?
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What is the chance of
Supervision Error?
AA
BB
CC
DD
EE
FF
1 in 100 0001 in 100 000
1 in 10 0001 in 10 000
1 in 10001 in 1000
1 in 1001 in 100
1 in 101 in 10
1 in 11 in 1
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• Cognitive Failure
• Low Stress 1 in 1000
• High Stress 1 in 10
• Supervision Error
• 1 in 10
Human Error
Source: WASH-1400 (NUREG-75/014)
NUREG/CR-1278
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Accident
Take Human Factors into account
everywhere!
Design Systems Training Procedures
Event
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Complexity
Can we understand the sources of error better?
How do we build resilience?
Different generations
in service
Aircraft Systems
Operating Environment
Human Performance (Limitations)
Errors have more
complex consequences
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Operational Performance Monitoring
Threat and Error Management
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Operational Performance Monitoring
links to other workstreams
Automation Monitoring Flight Path
Management
Information
Exchange
We need to understand what people are really doing in the
day to day operation so we can use that information to
continuously improve and create error tolerant cockpits
That improvement supports crew in doing their jobs even
better (design, training, leadership/culture, standards, and
performance management)
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Key issues:• Automation feedback can be inadequate
• Differences between types and manufacturer philosophies
• A pilot can have an incomplete and/or inaccurate mental picture
of the aircraft state or flight path
Fatigue
Abnormal event
Knowledge Error
Complexity
Training
Understand
the issues
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Pilot Error Accidents (Offshore)
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Human Error
“Human error is a symptom of trouble deeper in the
system.” 1
“Underneath every simple, obvious story is a deeper,
more complex story.”1
1 Prof. Sidney Dekker
“The key question in any organizational accident is not
who blundered but how and why did the defences fail?”2
2 Prof. James Reason
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Crew Resource Management (CRM)
• CRM was originally developed to address crew errors &
error avoidance
• Threat and Error Management (TEM) is the 6th
Generation of this program with a focus on error
management and the concept of threat identification
and management
• Find ways to get crews to report on Threat and Error
Management of operational issues.
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Supporting resilience:
Threat & Error Management training
• To enable crew to
identify threats
proactively and
manage them
• To train crews to
understand the nature
of human error and to
work more effectively
as a team to improve
operational safety
each flight
Adapted from FAA/Industry TEM/LOSA training
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Are pilots doing what we expect?pilot interaction with automation
• Pilot monitoring has been shown to be a
causal factor in several accidents
• To better understand how people really
monitor information in the cockpit, we can
find ways to better support build best
practice
Methods
• Pilot Survey
• Eye-tracking PF & PM concurrent
• Compound performance measures (Situational Awareness, subjective, etc.)
• Controls (workload, etc.)
Pictures are from the BA / Thomson monitoring project (parallel fixed wing research)
Fundamental research which can improve training across our industry
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Understanding risk leads to better barriers and
controls for pilots
Adapted from FAA/Industry TEM/LOSA training
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Operational Performance Monitoring
Change Management
Act & learn
Performance Management
Detection & notification
There are specific initiatives drawn from
the safety strategy such as;
• Safety Leadership (values,
attitudes, behaviours)
• Performance measurement
driving data driven risk
management and evidenced
based training
• Evolution of crew behaviours
through training, information
and support
• Working with regulators and
industry partners to drive safety
standards Risk Assessment
Inquiry & recommendation
Data from daily operations helps us better support effective human performance
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What we know''
• Aircraft Systems are getting more complex
• The consequences of errors are getting more
complex
• Humans are NOT getting more complex
• Error rates are not decreasing
• Different Generations of Helicopter pose
different problems
• There is not a single silver bullet
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Where next?
• What we cannot do:
Tell crews not to make mistakes….
Rely on procedural barriers…..
• We must understand human performance issues.
• So''''''
• How do we deal with differing levels of technology?
• How can we design an error tolerant cockpit?
• Where should we concentrate our efforts?