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Royal Met Society Conference – Services to Aviation – 8th December 2010 – Imperial College London

Royal Met Society Conference – Services To Aviation – 8 December 2010 – Imperial College London

Agenda

Developments in Nat Weather for Aviation Services – Andy Wells

  • UK Met Service provision includes observation at aerodromes
  • ICAO dictates the requirement for aviation to be met by each States
    • World Met Org set the standards
  • World area weather forecast system has 2 centres producing global weather forecasts at Exeter and Kansas
  • Automated observing systems now deployed in UK airports for quieter periods of operations
  • Centralisation of Met Services is underway to produce a common weather picture
  • The aim is to better use of Met info in ATC planning and routing
  • 75% of Heathrow arrivals delays are caused by weather
  • Volcanic ash impact has similar effect
    • The Icelandic volcano erupted in April 10
    • Jagged ash particles can have serious adverse effects on ac and engines
    • Avoidance of visible ash has been the usual way to deal with the problem
      • Cloud and night time are not helpful for this approach
    • The revised ICAO/Eur/NAT approach is to identify high, medium and low ash density
  • Other European Developments
    • Single European Sky
      • Initial SES1 regulations issued in 2004 followed by Implementing Rules
      • SES II Regs and amendments to SES I Regs issued in 2009
    • Functional Airspace Blocks (FAB)
      • European Central FAB will take 75% of traffic
    • A State Performance Scheme will set binding EU-wide performance targets
      • Safety -monitor only
      • Capacity – delays
      • Environment – route efficiency
      • Cost effectiveness – Met costs
    • EASA has Met Services as part of its extension into aerodromes
      • Met service implementing rules will be developed
    • SESAR
      • SESARJU will facilitate decision-making on ATM for all stakeholders
      • SESAR brings in trajectory – based operations which moves Met provision from being advisory to becoming operational critical
      • Met is needed to enable ATM to manage weather uncertainty with confidence

Study into Climate optimised of Transatlantic Routes – Emma Irvine

  • International aviation and shipping is a minor contributor to global warming but a cut by 80% by 2025 is being demanded as a target for aviation
  • Aviation contributes around 2.5 % of climate change (Range varies 2-14%)
  • High level contrails are major contributors towards global warming
  • React4C Organisation is looking at optimising routes to reduce climate effect
  • Focus is on US-Europe North Atlantic routes with 300 flights per day
  • Contrailing – questions being asked whether to act or not on emissions from contrail production
  • UKFSC CE – Summary
    • This study asks more questions than it answers and was based on too many false assumptions

Scientific Challenges Around Volcanic Ash Advice – Professor Brian Golding

  • Regulatory Background
    • 1982 – BA 747 4 – engine loss initiated the International Airways Volcano Watch
    • 1991 – Volcanic Ash Advisory Centres established by ICAO
    • 2010 Iceland volcano erupted!
      • London VAAC has responsibility for Iceland eruptions
  • Melting ash – leading to overheating in the engine core
    • Safe ash quantities are being pursed by engine manufacturers
    • Ash problems are caused by accumulation not by instant impact
  • Optimum management requires knowledge of a great deal of data and some notice to analyse it
  • Major data source requirement is the origin of the plume and the contents within it, including particle size and density of the ash
  • Assumption is that the distribution is uniform vertically
  • Plume is observable by radar
  • But the variation in density is actually an order of magnitude
  • Products under developments are:
    • Average concentration levels from the plume
    • Improvement of source estimation
      • Climatology for given height and eruptions types
      • In situ observations
      • Downwind observation and inversion
      • Volcano simulation models
    • Forecasting the plume
      • Current model takes 6 days to spin up and provides a 5 day forecast
    • Predicting vertical extent
      • Extremely difficult to predict precisely which means no-fly buffer zones would be needed- not entirely helpful
    • Interpreting and fine tuning the forecast
      • Best achievable result is an error factor of 3
  • Satellite imagery tracks extent ht and ash load of plume in good weather
  • Lidar observations track extent and height of plume over land
  • Aerosol sonde samples provide a profile thro the plume
  • Civil contingencies ac can observe the plume using lidar
  • In a hazardous situation, communication of the risk must be clear and unambiguous
  • VA is issued as a Sigmet by code – very complex and changes regularly
    • Text comms
    • Graphical representations on sig weather charts
  • Individual aviation hazards are communicated as a digital graphics layer for user displays
  • Aviation winds are communicated as a 4D digital data streams – not possible yet!
  • Plume track is well modelled but vertical density is uncertain
  • Skilful modelling interpretation is required

Meterological Threat and Error Management – Rob Seaman UK Met Office

  • Over 23% of accident are directly related to the weather
  • How do you manage complex threats?
  • Threats need management asap to retain safety margins
  • This requires increases in workload for the pilot
    • Threats include CBs, icing, turbulence, poor vis low cloud, VA
  • 82% of CFITs occurs due poor weather
  • Press-on-itis often plays its part towards a negative outcome in an incident
  • TEM Management techniques include:
    • Anticipate – Wx Forecast
    • Recognise – interpretation of actual observations onboard and wx actuals
    • Recover safely using the weather alternate plan – strategic decision using pre-flight planning

Rich Jones
Chief Executive
UKFSC
14 Januray 2011

EU Aviation Safety Management towards 2020 – 26th January 2011 – Brussels

European Commission Conference Brussels – 26 January 2011
EU Aviation Safety Management towards 2020
CE Conference Summary

The Conference Programme

Key Messages

Patrick Goudou – EASA

  • Overall trend globally is for increasing aviation accidents and fatalities
  • Aviation safety is important to the EU citizen
  • EU aviation safety system is maturing well
  • Legal framework for Total Safety is in place at EASA
  • Safety Rules and standards are all under one roof in Cologne
  • Regulators have formed close partnerships with industry in Europe
    • But clearer roles for EU regulators and industry generally are needed
  • Move by EASA from prescriptive to performance-based rules
  • Move from uniform oversight to risk based oversight
  • European Aviation Safety Programme is at the heart of this change
  • Three elements – Rulemaking, Oversight, Safety assurance and promotion
  • Member State (MS)Safety programmes are needed as well as a European Safety Programme
  • Ultimate aim is have a globally common approach on FTL/Licensing/Safety
  • European Aviation Safety Plan:
    • Deals with high level and European wide safety concerns
    • Is based on risk analysis
    • Proposes organisational and technical actions
    • Co-ordinates with MS SSP
  • EASA formed the EASAC to formulate the European programme and plan
  • Safety data is an essential element of the programme – data needs to be acquired, shared and analysed
    • This will need a partnership between regulators and active participation from industry

DGCA France – Lessons from Setting up a State Safety Plan(SSP)

  • Three elements established – rulemaking, oversight , safety promotion
  • DGCA undertook to achieve the following :
    • France to be in the leading safest aviation CAT group in Europe
    • Reduce helo and GA accident rates
  • The Plan identifies strategic aims on safety culture, continuous improvement process
  • SSP has a management plan which is co-ordinated with the Accident Investigation Board and international aviation organisations
  • Risk portfolio process has been established
  • The 5 year SSP was sent to operators and placed on the internet in English
  • It targets airlines, airports and offers advice on non-stab approaches, runway excursions
  • It lays down challenges on safety performance indicators, safety objective setting, simplify regulation on safety priorities
  • Safety data and info exchange
    • Key element of SMS
    • More work needed on
      • Data confidentiality and exchange
      • Tools and techniques for data exchange and risk identification
  • Step by step approach is needed with the European SSP
  • Needs to build on good initial results
  • Seek regular meeting of the MS on EASA Management Board

Eurocontrol – European Organisation Management of Safety

  • Uberlingen and Linate accidents provided the wake-up call on safety management among ATC/ATM Providers
  • A number of approaches introduced to increase safety and measure the improvements
  • Just culture and incident reporting is fundamental but suffers from serious legal impediments
  • Key safety indicators are being developed and safety management maturity is improving significantly
  • The EVAIR scheme attempts to address incidents in partnership with industry
  • Skybrary website developed to provide a comprehensive safety information source
  • Next Eurocontrol Safety Plan will cover 2010 – 2014
    • Bridges the gap between now and SESAR introduction
    • Goals
      • Better KPIs – the Safety Council at EC indentified key indicators
      • Just culture needs further development
      • ATM Risk assessment tool is being developed with the FAA
      • Collaboration with SESAR

Sharing Safety Data beyond National Boundaries – Nancy Graham ICAO

  • Transparency of safety information and protection of the data are the key issues in establishing and understanding risk
  • Rapid action is another key requirement
  • Runway Excursion is a worrying trend – hence the Montreal RW Safety Conference
  • Difference identified between data and information
  • Need to move from rear view mirror to forward thinking – reactive to proactive
  • USOAP data is being used to identify major risks and placing resources
  • ICAO is developing ISTARS
    • An interoperable analysis tool for safety informationfor everyone to use – via a secure portal with restricted access
    • A public access site is being looked at for the future
  • ISTARS allows all to participate and provide a contribution
    • It is possible to question the figures and data provided
    • A dashboard is available to give a quick look on safety outcomes
    • Regional dashboard is also available
  • Future safety work in ICAO on safety
    • Assessment of States and their ability to respond to safety issues and the value to be gained by investing in a country in aviation safety initiatives is underway – using a World Bank tool.
  • Runway safety is involved in 40% of all accidents and is the current ICAO focus for safety work

Round Table Discussion – Members identified the following Priorities for 2020

  • A common risk assessment tool – Eurocontrol
  • Achieve and enhancing information data sharing – EASA
  • Encourage dialogue amongst all aviation disciplines – ICAO
  • Achieve a just culture and improve reporting levels- DGAC France
  • Sharing data sharing – DGC Romania
  • Implementing State safety Plans – EC

Dave Prior – Safety Management Process on Airlines

  • SMS is a key starting point but engagement across the company
  • Organisational failures and individual errors need to identified
  • Risk visibility and engagement for all – beyond the Safety dept
  • The CEO is the accountable manager and need to know the risks
  • An open reporting culture is key to the SMS value
    • Genuine and honest mistakes are not punished
    • But action can be taken against wilful rule breaking
  • A great deal of data is available but how do we get at the key action targets
  • Share info but under clear confidential conditions
  • Reporting is fragile and must be encouraged and protected

Nick Mower – Safety Data and how to best share it Regional

  • Europe has a proven record on safety but EASA is vital to raise the standards of safety right across Europe
  • EASA is a sausage-making rule maker at the moment and it needs to get involved in broader aspects of safety in due course
  • Extending best practice and indicative KPIs should be developed
  • A business plan is required from EASA
  • Business advantages need to be drawn from SESAR and NextGen
  • A centralised AAIB is important – not just an MOU!
  • EU register to have a single approved certification standard for all ac
  • EASA must focus on safety not making rules
  • A road map for EASA is required
  • SESAR and NextGen co-op is essential for efficiency

An ANSPs Perspective on Safety management – ENAV Italian ATC

  • Reporting is increasing across the Italian ATM organsiation
  • Runway Incursion (RI) is an important issue and significant success has been achieved by:
    • Runway safety team established
    • ENAV RI Prevention Plan
    • Systematic sharing of information
    • Problem fixing is also systematic
  • Training for ATC is the most important aspect for ENAV with introduction of new technology following on behind
  • Just culture is being pushed to develop reporting
  • ENAV responds to EVAIR queries at Eurocontrol within 4.5 days

Safety Management in Aerodromes – Al RuttenACI -Schipol

  • A proactive approach is vital amongst airport operators
  • ICAO Annex 14 and the ICAO Safety Management Manual are the reference on which ACI SMS is based
  • The Airside Safety Handbook continuous to be developed – 4th edition

Airline Views on aviation safety strategy for Europe

  • Safety lies at the heart of air transport
  • A common SMS standard across Europe is required

Just Culture in SMS – ECA

  • Accidents happen and need investigation but:
  • Not only what happened, by who and when but Why and how?
  • Organisational responsibility is a key element of an investigation

EASA Views on Safety Information – John Vincent

  • Total system approach needed to address the following concerns with safety data and information:
    • Fragmentation
    • Stop-start
    • Quality of data and coding
    • Training
    • Barriers to sharing
    • Criminalisation concerns
    • Poor integration`
  • There are important Trade-offs with safety data
    • Protection vs transparency
    • Sharingvs centralisation
    • Dissemination vs aggregation
    • Aggregation vs flexibility
    • De-ident vs rw data
  • A plan is being developed that collects the data and then uses it effectively

The full background to the Conference and the presentations are available on the European Commission Website at the following link:
http://ec.europa.eu/transport/air/events/2011_01_26_aviation_safety_conference_en.htm

Rich Jones
Chief Executive
UK Flight safety Committee

European Advisory Committee (EAC) – 1st March 2011 – Istanbul

European Advisory Committee Meeting – Istanbul – 1 March 2011

CE Meeting Summary

Agenda

New Members – Martin Chalk-ECA, EdPooley – Independant, Dave Gasson – Aviation Insurers Union, Tom Curran – Aer Lingus, Lufthansa Captain,

Future IASS/EASS Conferences

  • IASS Cairo in Sep cancelled- Singapore/Dublin alternatives tbc
  • Next EASS in Mar 12 – Brussels/Dublin/Prague13-15 March 2012

Presidents Report

  • Strategic issues
    • US aviation growth limited to 3% in next few years
    • Europe aviation growth expected to be around 4%
    • India and China will see massive growth and will be seeking leadership in aviation safety
    • EASA development – with a strong aviation safety record, it is expected that funding for aviation safety will be cut by EC/Govt
      • Regulation is undertaken by non-aviator staff in many States
    • Similar in US at the FAA –only investigators are not being cut!
  • Political developments in the Middle East – who is looking after safety?
  • Basic aviation risk assessment work being undertaken
    • Request for IOSA type approach in central Africa
    • Need to target those high risk countries where safety initiatives will be effective
    • Partnership with the World Food Programme – these high risk operators seek help on LOSA and other high risk undertakings
    • Need to establish a national constituency
  • Kevin Hiatt appointed New VP Operations (COS) at the FSF
  • Dep Director Technical – new appointment to back up Jim expected soon

Future for the FSF European Advisory Committee

  • 26 members currently – 30 max allowed on the EAC
  • Now well represented across all parts of Europe
  • Widely spread expertise across all disciplines in aviation
  • Past years, EAC have been concentrating on the arrangements for each EASS
  • Do we need to do more than the EASS organisation?
  • The OFGHA (Operator’s Guide to Human Factors in Aviation) was an excellent output from the EAC – now delivered
  • Other similar outputs from EAC maybe possible
  • A recent Discussion Paper on circling approaches and go-arounds involving some Members of the EAC (Eurocontrol/UKFSC) was produced from over 120 responses from external companies. Discussion Paper attached.

FSF – Technical Director’s Review – Jim Burin

  • Next EAC meeting is Call for Papers for next EASS on 1 Jun 11 at NLR, Holland
  • Major accidents in 2010 – 17 major commercial air transport accidents
    • Of which 7 were Runway Excursions
  • In 2011 – 2 major accidents so far
  • Business jets had 9 accidents in 2009
  • Bus jets – 8 accidents in 2010
  • Of all 2010 accidents, 80%were Approach and Landing (ALAR) accidents
    • Including 2 CFIT accidents
      • The FSF ALAR Toolkit update is readily available
      • FSF have held 34 ALAR workshops globally in the past 3 years
    • 2 Loss of Control accidents which involved the following factors:
      • Nogood visual references
      • IMC
      • Night
      • Over water
  • Autopilot involved
  • Initial aircraft movement such as banking or pitch – humanly imperceptible
  • Turn in wrong direction
  • Aviation accidents have halved every decade until the last decade
  • 2010 was an average year for commercial air transport accident losses
  • Good year from business jets and turboprops

AOBOther topic ideas for the EAC to consider in future work suggested :

  • De-icing communication between flight crew and de-icing teams
  • Virtual airlines
  • Accident Investigation exclusions

Rich Jones
Chief Exec
UKFSC
23 March 11

ESASI Regional Air Seminar – 7th-8th April 2011 – Lisbon

ESASI Regional Air Seminar – Lisbon 7/8 April 2011

Agenda

Netjets – Driving a Culture of Safety

  • 1000 pilots and 300 support staff in the company
  • Largest private aviation order just given to Bombardier for 300 ac
  • Operates to the same commercial ac rules and regs as airlines
  • 154 ac currently in service, flying to 800 airports
  • Clear business need to ensure that Netjets is as safe as any major airline
  • Company has no ac base which adds further challenges
    • Keeping ac supplied with current charts is one major issue
  • NetJets run specific training programmes to cover this planning and capability
  • Significant training facility in Portugal but crews come from 30 connecting hubs from around Europe
  • Face time with crews is vital and needs much work to be effective
  • Safety Department is large and has an internal reporting scheme based on:
    • Confidential reporting
    • MORs
    • FDM
    • Netjets Safety Committee
    • Safety Awareness Programme
    • Emergency Response Plan
      • Provides basic guidelines for employees
      • Six teams available with specific checklists for:
        • First Responders
        • EmergencyOps centre
        • Media handling
        • On site accident
        • Notification team
        • Family Assistance Team
      • Options to ensure business continuity
      • Three levels of response – red, yellow and orange
  • Future Focus
    • Enhance safety through proactive risk analysis using SMS, FDM, Trg

EU Regulation 996/2010 Implementation – EASA Rep

  • Reporting of all incident and accident reports are being collected from across Europe from Member States via ECCAIRS and deposited in the ECR
  • Comments on initial accident reports are solicited from the appropriate authorities and EASA
  • Final Accident Reports are collected from across Europe
  • 20 to 25 reports plus 20 final reports received by EASA each month
  • Participation in Accident Investigations in Europe
    • EASA may now be invited to send a representative to an accident investigation
  • EASA supports investigations by:
    • EASA remits and its organisation
    • Rules structure
    • Certification Specs
    • State standardisation reports
    • Organisations audit reports
    • Certification data
  • EASA has been debriefed on several recent Investigations and studies including:
    • Turkish Airlines
    • BAE ATP incident involving de-ice fluid jamming an elevator on take-off in Sweden
    • Study Gp looking at LOC trajectories during go-arounds
    • Helicopter crash in the North Sea – REDU
    • Airbus A380 engine incident – Singapore
      • Led to the first EASA AD
  • Safety recommendations
    • All MS safety recommendations to be registered in the ECR
    • In future, actions from all MS accidents should be registered with the EASA investigation authority within 90 days
  • The EASA Annual Safety Review will contain all MS recommendations
  • The ECR has:
    • 400,000 reports now registered
    • Historic info is being registered from some States
    • Most reports are operations focused
    • Several years of experience needed to gain real benefit from the ECR
  • Way Ahead for EASA in Accident Investigation
    • Promote quality checks of the ECR data
    • Implement the ECR process
    • Establish a dialogue with the Investigating Authorities Network

European Network of Civil Aviation Safety Authorities – Ulf Kramer

  • The EC Regulation 996/2010 requires a network of Investigators to be established
  • Composed of the Heads of the AAIBs of each State
  • 27 States are represented on the European Network
  • The EC must be closely relate to the Network and provide the necessary support to it
  • Network will also invite other third party country observers
  • Aims of the network are:
    • Recommendations to the EC on all aspects of safety investigations
    • Ensure co-operations among all who are involved in safety investigations including the justice dep, rescuers and regulators
    • Protect sensitive safety information
    • Close the gap between justice and the investigating authority
    • Assistance to families of the victims
    • Promote the sharing of information to improve flight safety
    • Arrange peer reviews , training, skills development
    • Identify best practice
    • Strengthening investigation capacity of the authorities and manage a framework to share resources
    • Provide appropriate assistance to other safety investigation authorities
    • Have access to the ECR database
    • On request, keep the EC regularly informed on safety investigations
    • The network will not provide information to any organisation who would threaten the independence of the network
  • First meeting of the Network takes place in April 2010 to get it off the ground

Interaction Between Investigation Parties – Mike Gamlin – Rolls Royce

  • Aviation is now international and governed by ICAO
  • Military incidents provide Rolls with another perspective on investigations
  • Rolls had to develop a global team to deal with their spread of products
  • Two centres in Indianapolis and Derby
    • These support all State investigations involving RR products
  • ICAO Annex 13
    • Requires specialist advisors to support investigations
  • Manufacturers Role
    • Key providers of technical expertise either directly or via company networks
    • Protocol is that these advisors are in the investigation team and should recognise the confidentiality of this position
  • Key Interactions with others
    • The public believe flying is safe by assumption
    • Reputation is key to continued operations and business
    • Who safeguards aviation safety – manufacturer or regulator?
    • Independent investigators are fundamental for confidence in safety
    • Technology is moving forward rapidly and is globally present

A380 DATA FOR INVESTIGATION – AIRBUS

  • Beyond the DFDR,A380 system architecture has a masses of data available
  • The FDR itself carries 3300 parameters recorded at 1024 words/sec
  • Data transmitted via ACARS depends on individual operators
  • Data available from the Network Server System includes:
    • Links between ac, airline ground, flightcrew, cabin crew
    • Electronic documentation
    • Communications
    • ACARS
    • Maintenance
    • Flight ops software
    • Trouble shooting
    • Servicing and fuelling
    • Passenger services
  • Three domains in the NSS
    • Avionics
    • Flt Ops
    • Comms and cabin domain
  • NSS Avionics contains:
    • Ac condition monitoring system
    • Post flt history – 64 legs recorded
    • Fault messages and flt deck and cabin effect history
    • System test history
    • Data loading system
    • E-logbook info
  • Flt Ops info
    • Pilot laptops and the spare
    • Navcharts
  • Information download
    • All info can be downloaded either in print or electronically
  • Fault code interpretation needs to be done via Airbus

Technology Innovations and Developments in the Boeing B787 to challenge and assist the accident investigators

  • B787 Range is 7650 – this brings additional passenger issues
  • Composite fuselage – 50% of the aircraft make-up
  • Wings and spars are made of composite
  • Wing flex at wing tip for normal weight is 12’ and 20’ max load
  • Disbond , delaminate, shear water absorption issues will occur
  • Fibres in the air at accident sites will require more care and protection
  • 787 passenger advantages include:
    • Larger windows
    • Automatic Window dimming
    • Cabin air quality imporvements
    • Vertical gust suppression – smoother ride
    • Cabin Pressure is lower in the 787
    • Humidity will be higher
  • Pax oxygen is using bottled oxygen @3000psi
  • Nitrogen generation system for fuel tank inert
  • Noise footprint is smaller with low noise engine nacelles with chevrons
  • 1000 kva 380-800kHz variable electricity generation on 787 whilst 777 has only240 kva
  • No physical CBs in Flt Deck
    • CB controls are by display only – therefore less wiring
    • Landing gear, brake system and nose gear steering all electric
  • Two identical FDRs – for redundancy, with 25 hours flight data time
  • Independentbattery power for the forward recorder
  • New Flt Control Functions
    • P-beta control law
      • Trim Wheel commands roll rate
      • Pedals command sideslip angle(Beta)
      • Opposes disturbances
      • Co-ordinated vertical and lateral control
    • Vertical gust suppression
    • Enhanced Stall Protection
    • Enhanced thrust asymmetry compensation
  • Common mode hazards to pitot static sensors
    • Move from federated speed to voted speed indicator
  • FDR transmits if unusual attitudes are detected
  • New manufacturers business models will bring in additional reps to accident investigations

AF447 LATEST REPORT – BEA

  • Phase 4 recovery financed by industry and French Govt cost 12.5mil dollars
  • Woods Hole Oceanagraphic Institute provided significant support equipment
    • Three Remus 6000 on the m/v Alucia
  • Each REMUs positions using transponders suspended above the seabed
  • Each REMUS operates sideways looking radar and then takes photos at 3 mteres above seabed level
  • Sat 2 April 2011 Remus detected a possible wreckage
  • Sun 3 April confirmed the wreckage site
  • Crash Site is 200mrs by 600 meters in a 17,000 sqn kilo search area
  • The wreckage is on a flat seabed site at 3900 meter depth – deepest sea depth in the area
  • There are 1000s of picture and a mosaic of them is being built of the entire site
  • The grid had been searched at Phase 1and within 30 days of the accident but nothing seen or heard
    • Transponder/hydrophone was not capable of detection with only 2 km range; this capability shortfall is being addressed
  • Analysis of nine past LOC accidents from FL300 and above showed that all ac fell within 20 nms of the point of LOC.
  • Full study details of trhe background analysis is on the BEA website
  • Phase 5 request for bids to raise the wreckage recovery posted 2 months ago
  • Five excellent technical bids received
  • Three preselected from the bids with final selection made on 7 April
  • Conclusion
    • Success is the Result of a big team effort
    • Too early to identify a crash scenario
    • Priority for recovery is toget the recorders

Human Factors in Take-off Performance Related and Incidents – Paul Hannant

  • MK Airlines accident at Halifax briefed
  • Crew composition:
    • 2 captains, one FO and 2 Flt Engineers, loadmaster, Gnd Eng
  • In all calc – 800 kgs of spares and crew not accounted for
  • Ac crashed on take-off with no rotation and long tail strike til stab came off
  • Airfield services lighting failed due to cable break by crash – fire station was powered off
  • Huge environmental fuel lake near to the site (100 tons of fuel onboard)
  • Crew log indicated that the planned trip was outside duty period
  • Calculations should have used 350 tonnes out of Halifax but in fact only 250 tonnes from previous airfield take-off was used instead
  • A Boeing laptop was also available as a new planning tool
  • Wrong weight was used for Halifax runway which caused wrong performance calculation and the failure to get airborne
  • Fatigue issues were at play due to circadian rhythm at worst point for all crew
  • Causal factors – insufficient thrust applied due to incorrect performance figures and tiredness
  • James Reason says production and protection needs to be balanced, but production affords the resource to provide the protection
  • Production principles are direct and readily appreciated but protection requirements are not.

Take-Off Performance Monitoring – AAIB

  • Inputs for performance calculations consist of:
    • Runway data
    • Runway Conditions
    • Weather
    • Take-off mass
    • Take-off configuration
  • Calculations are then carried out to derive the performance requirements using Performance charts or the electronic flight bag
    • Outputs generated are thrust de-rate and V speeds calculations
  • What happens when it goes wrong?
    • Rejected take-off
    • Rotate early and tail strike
    • Climb established at reduced speed
  • Some classic examples of accidents and incidents resulting from these errors:
    • Montego Take-off using FMS mass of 120t instead of 236t
    • ZFW used instead of take-off mass at Manchester
    • A340 Heathrow – using anding instead of take-off weight in FMS
    • Melbourne Emirates – 100 tons out on selected weight in FMS
    • DC8 freighter at Manston – calcs correct but wrong runway length
  • BEA have produced a Report on erroneous parameters at Take-Off
  • ATSB issued a similar study early in 2011
  • Northolt and Leeds Bradford incidents were caused through partial brake bindreducingtake-off performance
  • Issues to be addressed:
    • No performance measurement of acceleration for the pilot
    • FMS and Calculations – but also dragging brakes and runway contam
  • Possible solutions
    • Take –off performance monitoring
    • Onboard ac weighing systems being developed
    • Data entry using human factors solutions
    • Residual brake pressure warning
    • Runway distance markers
    • Take off monitoring system
      • Incorrect weight vspeeds
      • Brakes on during take-off
      • Runway contam
  • Canada TSB have recommended several authorities to develop a spec for take-off monitoring system
  • TOPMS
    • Basic system- Acceleration monitoring system
    • Advanced – monitors speeds and has relative position – GPS
  • Pilot are unable to reliably detect abnormally low acc rate
    • No monitoring of target sped or distance to go
  • Examples of basic system
    • Assumes no reduced thrust on take off
    • Some small ac use
    • Use a known take-off database and compare the actual rate and warn if insufficient
    • Warning comes early enough to avoidhigh speed RTO
  • Advanced Examples
    • GPS to measure pos on runway
    • Measure acc and speed and warn if insufficient
    • Could use on contaminated runway too
    • Could be used on restricted thrust take-off to extrapolate ahead
  • A Cranfield model to display this TOPMS has been developed
  • Past reports on performance error include:
    • NTSB 1970 report – recommended distance to go markers
    • NTSB 1982 report – sought an acceleration performance monitor
    • SAE Standard 1987
    • NASA Study- acceleration predictions were 2 ac lengths
    • AIA 1997 Study – objections of a complex display for pilots and nuisances warnings , cannot make it accurate enough, runway contam measurementis too unpredictable, effect of runway slope variability
  • Regulator actions
    • TC Canada -cannot establish a requirement for ac equipment
    • EASA response to AAIB rec awaited – internal debate 2 years on
  • Manufacturer action
    • Boeing doing some human factor errors changes to data entry
    • Airbus developing TOS (take-off secure) function
      • Warns ‘Not on FMS RW!’And brake to vacate system
    • Honeywell Smart runway with TOPMS at early development stage
  • Safety Message:
    • Reiterate safety reccs on TOPMS

Maintenance Related Helicopter Accidents and Lessons Learned

  • SE Asia is the major problem area for helo maintenance error
  • Larger helicopter rates are lower than small helicopters after service
  • Typical Maintenance errors leading to accidents are:
    • Replacement of oil in a gearbox forgotten
    • Tightening of a control coupling forgotten
    • Fuel coupling tightening forgotten
    • Incorrect installation of a control coupling
  • Eurocopter states that there is no such thing as routine maintenance
  • Accident example – BO105
    • Crash due to lack of fuel in the supply tank system although fuelin the main tank
    • No engine malfunction
    • Maintenance on the day before involving fuel pump leak fix
    • Mechanic fixed the leak but did not connect the fuel low light due to insufficient time to complete.
    • The pilot made a fuel pump switch usage error and did not get a fuel low light
    • He did not his upper harness fixed properly so he was killed on an impact with the control panel

Triggered Transmission Of Safety Data

  • New technologies to protect safety data in recorders during accidents needed after AF447 crash,
  • Working gp established and 2 meetings of the Flt data WG held so far
  • Aim to extend the duration of emission of the ULB attached to the FDR
  • Low freq ULB for greater detection range to be fitted
  • Increase Regular position data transmission – AF447 had every 10 mins
  • Deployable ELT/FDR being considered by Airbus
  • Triggered data transmission Concept to determine:
    • When to start tx after an emergency parameter is detected
    • Continuous connectivity with the satellite in a Unusual Position can be an issue due aerial blanking
  • Trigger criteria questions:
    • Increase appropriate probability to 100% receipt of info
    • Need to avoid nuisance transmissions
  • In a LOC accident,what indications are available:
    • Stall warning, high pitch, low speed
  • 68 LOC incidents and accidents were considered and analysed
    • Normal flight of 3600 hours of flights also studied
  • Results:
    • Criteria considered – Roll angle, roll rate, v/s, pitch angle, overspeed, GPWS warning
    • 100% detection rates can be achieved
    • Warning times to enable successful tx – 50% of incidents had 30 seconds or more to tx sending data using satcom
    • Each of 68 accidents was simulated on 597 geo points on earth
    • 82% of transmissions were successful and site position established within 4 nms
    • Iridium study using fighters using 2 or 4 antennae were successful for connectivity to satellites
  • ELT Issues
    • Destruction of ELT by fire
    • Immersion
    • Cable separation
  • Current Leostar or Geostar satellites have a delay of upto 50 secs for reception of tx data
  • Next gen Meostra will locate beacons on a single burst
    • Multiple transmission paths allow reliable receipt of tx by sat
  • Conclusion
    • Robust emergency detection criteria is possible
    • Significantreduction in search area down to 4 nms is tech feasible
    • Auto beacon activation will be coming in next gen MEOSTAR
    • ICAO are working now towards Annex 6 modification by 2018

Accidents – The Airline Perspective – Tom Curran Aer Lingus

  • Aer Lingus have an all Airbus Fleet
  • The airline has a duty of care to customers, staff and the public
  • There is a strong awareness of the effect and extent of the consequences of an accident at Aer Lingus
    • An 330 crash with 300+ killed would have a national impact for 4m population in Ireland
  • Safety at the airline is based on SMS which includes:
    • MORs
    • ASRs
    • Safety Assessments
    • Audits
    • Incident Investigations
    • ERPs
  • EU Reg 996/2010 requires the airline to have:
    • Validated list of all persons onboard asap but within 2 hours
    • A plan to assist victims and families of an aircraft accident
    • To achieve this, the airline has following arrangements:
      • 200 trained personnel
      • Pass/NoK reconciliation database
      • Based at hotel near accident location
      • Call centre for next of kin
      • Equipment provided by the operator includes phones, printer, fax
      • Transportation for families relatives
    • Family Assistance Teams
      • Trained personnel to provide practical assistance to survivors
  • Other information and assistance available at:
    • IATA Response Planning Gp
    • UK Emergency Response Committee
    • NTSB ‘Chicago’ meeting
  • Assistance available from airlines for accident investigators include:
    • Trained and equipped investigation team – who know the airline and culture
    • Audits and investigations
    • Risk assessments
    • Aircraft wreckage recovery
  • For consideration by ESASI:
    • Two operators and one ATC union have been removed from investigation recently so -Is sufficient guidance on the rules and protocols of accident investigations?
  • Could ESASI offer Training on:
    • Investigation
    • Bio-hazard
    • Protocols
    • Primacy
    • Release of info
    • Media relation
    • Equipment?

Media In a High Profile Accident – Chris Macgregor

  • AT accidents trigger worldwide media interest
  • Info and mis-info can now be shared instantly at a button click
  • One billion internet users every month to feed info
  • High profile accident creates opportunities for many
  • Annex 13 vs media coverage is an issue for Airbus
  • Good news is not good headlines
  • Race to report first not accuracy
  • Internet take on QF32:
    • Memphis belle like ac
    • Facts versus media appreciation
  • Leak of confidential info from investigations on the internet is unacceptable and losses trust
  • Challenges
  • Immediate release of public info
  • Reprints from the general press rather than professional journalist
  • Pressure on Annex 13
    • Comms crisis can harm investigation
    • RAeS picture criticised for publishing the QF 32 picture
  • Annex 13 is challenged as is the relationship with the investigating authorities
  • Minimise speculation
  • More data but much less time
  • Investigation by internet is not acceptable

PRESENTATIONS available at: Esasi.eu/pres/index.html User esasi2011pw Tapestry1745

Rich Jones
UKFSC
18 April 2011

EASS – European Aviation Safety Seminar – 1st-3rd March 2011 – Istanbul, Turkey

European Aviation Safety Seminar – 2-3 March 2011 – Istanbul, Turkey

CE Seminar Summary

Agenda

Full Presentations will be made available on the UKFSC website when published by the FSF.

Key Presentation Summaries

STALL TRAINING, APPROACH TO STALL TRAINING, IMPENDING STALL TRAINING –  BOEING

  • The Wing – stall occurs when performing a variety of manoeuvres
  • Pilot responses – pull up on a wing already degraded
  • Trg has evolved over the years warned pilots about stalls
  • LOC leads to 2 x more fatalities than CFIT
  • Examples:
    • Turkish
    • Buffalo
    • Challenger
    • Thomsonfly
  • Stall warnings occurred but pilots were not trained to respond correctly
  • Today most stall trg occur in the sim between 5-10K feet
  • Often based on no height loss and max power – both negative trg
  • Stall training should be routine and regular
  • Conclusions:
    • Stall must be trained for regularly
    • Ac are built with the systems to warn and prevent
    • Address the current negative trg on current trg sessions

Stall Recovery Procedure – Airbus

  • Lots of stalls in certification during ac development
  • Need to share it with the operational community
  • New procedure is based on a key item for recovery:
    • APPLY NOSE DoWN PITCH CONTROL TO REDUCE AOA

 

  • Generic Template Is As Follows:

 

  • At the first indication of stall
    • Autopilot and autothrottle —————————-Disconnect
    • Nose down pitch control – apply until out of stall
    • Nose down pitch trim ————————-as needed
    • Thrust …………………………………………………..as needed
    • Speed brakes …………………………………………..retract

 

  • Need to check that the sim is representative when approaching the stall
  • Stall undertaken in sim in degraded law in clean and with flap
  • All tests show that apply full thrust and maintain altitude often leads to worse stall condition
  • More buffet approaching the stall in the sim than the ac
    • The recommendation is that the sim response is changed to address this issue
  • Side issues
    • The G –break is difficult to see in a test flight – therefore more difficult for line pilots
    • Recovery sequence – stick forward – is the same in sim and for real
    • Low speed trg for A320 in normal law and degraded law tested with Airbus test pilots:
  • Conclusion
    • Stall recovery trg is possible in the Sim
    • Low alt exercise with some startle
    • Instructors need training on this issue

Approach to Stall Training – Captain Paul Kolisch- Mesaba Airlines

  • Inadvertent stall events are a feature of business jets
  • 2009 ATR stalled on approach and crashed, but no fatalities
  • In the US – practical test standards now being introduced which aim at:
    • Recognition and recovery
  • Noticeable that pilots are nearly always fight against the Stick pusher

Technology to help reduce Loss of Control Incidents – Don Bateman Honeywell

  • 32% of LOC accidents due to special disorientation
    • The Russian ADI layout varies from the western aversion and research has been undertaken into the value of each format
    • A combination of both format for the instrument could be helpful in avoiding mis-reading of the instruments in times of stress or unusual positions
    • Existing autopilot could be used for soft protection in roll.
  •  Another useful piece of instrument development would to introduce a pre-alert on airspeed to alert the pilot to an undetected loss of airspeed.
    • On EGPWS, it would be straightforward to add a speed alert system which called the speed
  • A virtual box at the end of the runway could be drawn in the GPWS so that a ‘check flap’ alert could be sounded before each take-off
  • Vortex projections could be drawn on the tails of TCAS/ADS_B responses
  • Simple low tech solutions could reduce LOC and would require minimum change to ac fits
    • Simple recovery indications and aural warnings to provide the correct pilot actions would be easy to develop and fit
  • There have been many human factor studies on aural warnings which could be exploited in these developments

Tailwind Landings – How to Offset the Risk- John Spouge DNV

  • There are always problems between safety and environment when considering tailwinds
  • Controllers often have to produce practical decisions but problems associated with tailwinds include:
    • Higher ground speed
    • Increased rate of descent
    • Elongated flare
    • Longer landing runs
    • Missed approach more likely
    • Higher take-off speed
    • Lower take-off gradients
  • ICAO states that PANS ATM says noise abatement should not be a factor and that tailwind exceeding 5 kts or 15 kts crosswind should be avoided
  • The choice of runway in use requires the Controller to consider the following:
    • Measured wind
    • Wx forecast
    • Traffic situation
    • Pilot reports
    • Ac behaviour
    • Other safety issues
      • Adverse wx
    • But a change of runway may be necessary to avoid tailwind effects
  • An attempt has been made to estimate the risks of tailwind landings by:
    • Statistical analysis of accidents and incidents
    • Risk modelling plus expert judgement
  • This analysis concludes that a tailwind landing between 5-10 kts increases the risk of an overrun by 3 times.
  • Practical mitigations to reduce tailwind risk:
    • Limit tailwind to precision approaches
    • Limit tailwind to dry runways
    • Limit tailwind to maximum runway available
    • Improve wind speed information
    • Consistent go-round decision points
  • These mitigations were applied by a large European airport where 15% of landings involved a tailwind and reduced the overrun risks by 30%
  • If tailwind landings were increased from 5kts to 7 kts, long landings increased by 21%
  • Conclusions:
    • Increased tailwind speed landings increase risk
    • Explicit risk estimates can be used to focus risk mitigations
    • Mitigations reduce risk but do not eliminate it altogether
    • Safety must be taken into account by airport when trying to manage environmental issues

Landing Long – Why does it happen – Gerard Van Es, NLR

  • No formal definition
  • Often used 2000-2500 ft from the threshold
  • For short runways
    • 25-33% of the runway length
  • 40% of all landing overruns a lon landing
    • Overrun increases by a factor of 40% with deep landings
  • Methodology
    • Data base – worldwide landing overrun data
      • Commercial operator data
      • Expert knowledge
  • Airborne distance = final approach #flare #float (threshold to touchdown)
  • Approach speed is linear with landing depth
    • Too fast =too long
  • 44% of overruns had high speed landing
  • Unstabilised approaches are related to overruns
  • 13% of overruns involved too high at threshold
  • 20% of long landings were too high at the threshold
  • Approach guidance has an affect – instrument or visual
  • Early flares leading to floating
    • 20% of overruns due to floating
    • 10% of long landings due to floating
    • Attempt to bleed off speed
  • Tailwind increasing tailwind
  • 15% OF LONG LANDINGS
  • 52% of long landings involved a tailwind
  • Touch down markers and an aiming point
    • ICAO = 400m DA =2400m
      • 300m less than 2400m
  • The aiming point position appears to be a factor in overruns
  • An aiming point at 495m had a 14% above average overruns
  • Runway length has an impact
  • Location of the runway exit has a major impact –
    • 15 times more long landings when using exits near the runway end
    • Crews land shorter when aiming for high speed exits
  • Runway slope and visual effects
    • Downslope means long landings
  • Lost of visual reference due to sudden change of visibility
    • 15% of long landings due to heavy rain
  • Wide runways can give vis illusions
  • Ac flares higher on wide runways
  • Several factos influence long landings
    • High speed
    • High on approach
    • Early flare and floating
    • Tailwind/wind shear
    • Approach type
    • Aiming point marker location
    • Runway exit location
    • Visual issues – width and slopes
    • Aiming point position

Go around decision and manoeuvre and how to make it safe-  Bertrand de Courville

  • Stats show that there are 1 or 2 go Rounds per 1000 arrivals
    • Short Haul pilots do 1 per year
    • Long haul pilots do 1 per 5/10 years
  • Main reasons
    • ATC
    • Unstab approach
    • Lack of references – tailwind, x wind
    • Deep landings
    • Other situations
  • These overruns happen day and night with well trained crews
    • We do not learn and they are re-occurring
  • Insufficient defences for runway overrun and CFIT
  • If they were a 25% reduction on accident could be achieved
  • Failure to go round
  • Failure to undertake a safe manoeuvre
  • On initial approach – time available to talk and organise
  • On finals the pilot is focused on landing and capacity is also focused
  • The decision to discontinue the approach will depend on relevant information effectively delivered
  • Key threats:
    • Who is measuring the depth of water on the runway?
    • Task sharing by both pilots
    • PIREPs as a normal procedure and trained for
    • Sim training
    • Communication – the first officer must be capable to call for a go-round
      • This needs to briefed during initial training
    • Degraded visibility in sims is an important enhancement
    • FDM and reporting programme is important
  • The Key risks of Go-round manoeuvres are:
    • Low altitude and speed
    • Reduced margins
    • Simultaneous changes of attitude, thrust flight path
    • Trim/ATC ac config
    • Passenger perception
    • These are rarely performed
    • Often trained with single engine
    • Cockpit scan poor – end up reading the FMS not flying the ac
    • Mode change awareness
    • Following the flight director not the attitude during the scan

Situational Awareness and the automated Cockpit -Turkish FSO

  • Analysis of the Turkish Airline accident in Amsterdam
  • RA malfunction displayed 8 feet for a portion of the flt
  • Incorrect value enabled RETAR mode for landing
  • Auto-land commenced – disconnect the auto-throttle- speed lost
    • But high on glide and throttle would be back anyway
  • Autopilot Trim back to maintain altitude
  • Throttle was upped but it kept throttling back
  • Crew knew the RA was wrong! But not aware of the RA height and auto throttle interconnection!
  • Turkish were unaware as a user
  • The component functioned incorrectly not fail so no warning indicator
  • No drastic changes or red and amber so no suspicion of a problem
  • Monitoring is difficult in this situation – how suspicious should we be?
  • What does automation mean – not ‘automatic’ – humans inputs are required
  • Expectation of a pilot when the automation goes wrong
    • Depend on the complexity of the system, automation provides feedback or not
    • Automation is a cost saving exercise
    • Human complacencies reduces situational awareness
    • Active to passive is a key concerns
  • Limited experience of pilots on the line relative to test pilots
  • Problems with automation
    • Automation can fail partially
    • Auto failure can have unexpected results
    • Some fails are detected and easier to deal
    • Some failures are complex and interconnect to other systems
    • Human is the last line of protection or intervention when auto goes wrong
    • Human has little time to intervene because of system design

Volcanic Ash – Maria Cruz Garcia de Dios – Eurocontrol

  • A VA Visualisation Tool – EVITA developed by Eurocontrol
  • AFTM contributes to safe ops by controlling flow of air traffic
  • Optimise the flow of traffic by reducing delays and overloads
  • Uses technologies as a decision support tool
  • Volcanic ash impact
    • 54% flts cancelled
    • 100k flights
    • 1% of all traffic
  • Individual state decisions based on ICAO – lack of experience and harmonisation
  • Significant airspace issues taken on an individual state basis
  • Eurocontrol produced charts of the airspace being affected
  • UK CAA and UK Met office acted first an d produced a chart where it was unsafe to fly and other where a risk assessed flt was possible
  • Eurocontrol produced a chart absorbing this info
  • A European political response was also produced to activate a VA crisis cell to address future VA events
  • EACCC- facilitate management of crisis situations in Europe
  • Activated when unusual circumstances occur in European aviation
    • IAVW – predict ash
    • Science
    • Ash thresholds – manufacturers
    • ATM operational response
  • Volcanic ash scenario test workshop will follow
  • Op common problems and solutions
  • Safety first avoid hazards
  • Sound information required
  • This information is issued as Visualisation Interactive tool
  • Ash concentration, data danger areas
  • Graphical representations
    • Static
    • Dynamic
  • The tool works through use airspace query tool
    • A dynamic display of the volcanic ash
    • VA at various levels
    • Display of airports affected
    • Also download in a textual way
    • Provide flt planning support
    • A 3D profile
    • Routes affected can be displayed
    • Reduce the number of NOTAMs
  • In questions, Eurocontrol confirm that the tool will provide an easily understood and distributed presentation for the crews in the cockpit in a timely fashion.
  •  London City – has a last landing lights – should this be pushed out to all airports

How Has Economic Deregulation Affected Safety Regulation – Martin Chalk ECA

  • Regulation originally fed towards the State and a single Aviation Authority
  • Now several airlines have several States and authorities – who is providing oversight
  • Is regulators in competition for AOCs and airlines good for safety?
  • 831 reduced to 579 in the CAA despite an increase in air traffic between 831 to 579
  • Malta wants to be the preferred State for registration on its website
    • Using its maritime register as a reason for doing it
    • Most lost vessels in the world belong to Cambodia, Cyprus and Malta
  • EU Ops requires a natural crew for sim but an NAA allows 2 first officers to do sims together
  • Responsibility for providing accommodation sits with the crew at home base. But home base is being changed for a week at a time to enable the airline to abrogating its need to pay for accommodation National authority refuses to act
  • A major airline does not assess an assessing captain to be fatigued
  • EU, Sth America is where this deregulation has happened but safety has stalled
  • Solution may be to allocate AOC payment according to basing
  • Will outcome/performance based safety be sufficiently robust to meet regulator competition??????????????/
  • A single regulator could be the answer, but how long will that be

Rich Jones
UK FSC
18 Apr 2011

Airport Operators Assocation – Ops & Safety Conference – 20th/21st June 2011 – Leeds

Airport Operators Association Ops and Safety Conference – Oulton Hall Leeds -20/21 June 2011
CE Summary

Agenda

INTRODUCTION

  • Current challenges for the AOA
    • OFCOM spectrum charging
    • S Band radar sell off
    • New CAA Driving CAP development
    • European Matters – EASA expansion into aerodromes
    • CAA Future Airspace Strategy
    • Runway friction measurement and reporting
    • PR Nav application
    • SESAR
    • Contingency Planning – are we prepared?
  • AOA messages are:
    • Promote the UK aviation industry
    • Influence policy reviews going on in Government
    • CAT makes £18billion pounds contribution per year to the UK economy
    • Commitment to environmental and sustainable aviation programme
    • Improve UK airports – but seek a fair tax bill from Govt
    • Get involved with the Airport Collaborative Decision Making

EASA AERODROME RULEMAKING – Sarah Doherty CAA

  • CAA expect minimum change with the transition of aerodromes to EASA
  • Timescales and the process are well known – but much is uncertain too
  • UK Aerodromes in scope are 52. Those involved are:
    • Aerodromes open to public use
    • 800m of paved surface
    • Public helicopter operations
    • Commercial air traffic
    • Have an instrument approach or departure including GPS derived
  • Three working groups dealing with the process:
    • ADR 001 Aerodrome operator and authority requirements
    • ADR 002 Aerodrome operations
    • ADR 003 Aerodrome design and characteristics
  • Rules will be based on ICAO Annex 14 SARPs and best practices
  • Rules comprise of:
    • Basic Regulations/Essential Requirements
      • These are already written, will not change and legally binding
      • Implementing Rules (IR) sit below the BR and are used to implement the BR – also legally binding
      • Under IRs sit Certification Specifications/AMC/Guidance material – not legally binding
      • Alternative AMCs can be proposed by operators and be approved by the NAA
      • GM can be ignored by NAAs as required
  • Rule Structure
    • Authority Rules/Organisation Rules/etc
  • Certification Specs are mainly drawn from Annex 14 SARPs
  • NAAs will agree with aerodromes on which CS they must meet or ask that they demonstrate an equivalent level of safety(ELOS)
  • Special conditions can also be applied where special difficulties exist
  • Accepted deviations can apply – grandfathering in other terms
  • Once an aerodrome demonstrates the required characteristics and capabilities, an operating licence will be issued by the NAA
  • Existing CAA Aerodrome licences will be converted to EASA licences in due course
  • Timescales
    • Rulemaking finishes in July 2011
    • NPA will be published in Nov 2011
    • 3 NPAs sent out – one for each ADR team – 3 months consultation
    • Comment response documents out in Oct 2012
    • Rules in place from 2014
  • ANO will change depending on the final EASA Rules
  • CAA Collaboration with industry through workshops
  • Publication of requirements on the CAA web
  • CAA EASA Transition Steering Gp will be formed
  • First workshop is on 13 Oct at Gatwick to prepare airports for dealing with the EASA NPA
  • Next workshop is in Jan/Feb 2012 – during the NPA process
  • CAA will still issue UK aerodromes with licences and run audits

 
AIRPORT COLLABORATIVE DECISION MAKING (A-CDM) – Mark Burgess –BAA

  • A-CDM is a Eurocontrol programme which is pan European
  • 30 airports are undergoing the programme – 4 finished so far
  • A-CDM aim is share data between airport partners to improve delivery
  • Airlines, airports, handlers and ATC working together to collate:
    • Flt tracking and planning from initial planning to take-off
    • A pre departure tool is used to flow the take-off schedule
    • Interface information sharing with Eurocontrol is the key to final delivery which aims at providing plus/minus 5 min accuracy
  • A-CDM is about targets and commitments to achieve them
  • Failure to meet the targets could have penalties applied
  • Culture change amongst contributors and players will be significant
  • Key A-CDM components are:
    • Off block times – leave the gate
    • Start approval time – Start engine approval
    • Target take-off- specific take-off times
  • Benefits include
    • Increased predictability of operations and better situational awareness
    • Reduce taxi times and emissions
    • Optimal use of available airport infrastructure
  • Key target measurement of benefit is to achieve a 10% improvement
  • Partnership obligations are key to success of A-CDM
  • Crews will need to call for start within a +/minus 5 minutes timeframe
  • Trials (LOTS) are about to start at Heathrow with BMI
  • Full go-ahead with A-CDM at Heathrow by October 2011
  • A-CDM is the performance based way ahead

FUTURE AIRSPACE STRATEGY(FAS), TRANSITION ALT  AND PBN – Stu Lindsay – CAA DAP

  • The overarching FAS will be published in July 2011

Transition Altitude – Why change?

  • Safety benefits accrued from simplification of airspace and procedures, both within and beneath the airspace in question
  • Reduces level busts
  • Infringements reduced
  • Reduced cockpit workload
  • TA needs to be common in FABs for altimeter setting
  • It is a SES objective and supports other technology
  • Improves continuous climbs and descents
  • TA Change – Risks
    • Reach agreement on one level to suit all States and operational practices
    • Complexity of upgrade
    • Costs and time taken
    • Roll-out risks – training for ATC and pilots
  • What is the plan for TA change
    • Establish and harmonise a European Task Force
    • Subject to agreement by all stakeholders
    • Target date is late 2013/early 2014

Performance Based Navigation (PBN) – UK/Irish FAB

  • UK/Irish FAB PBN Policy has been developed
  • PBN Policy sets out a specific framework which takes into account:
    • Current status of UK PBN development (RNav and RNP airspace routes and procedures)
    • Operators who are keen to use ac PBN equipment
  • The PBN Policy is out for consultation through NATMAC
  • The London Airspace Management Programme (LAMP) is starting and is absorbing the previous TCN and TCS airspace project which takes on PBN
  • Northern Terminal Control Area (NTCA) is being re-designed with extensive use of PBN ac capabilities
  • PBN design work is being handed over to 5 contractors within 1 year
  • The CAA is keen to implement PBN

Nav Infrastructure Planning

  • In the near to mid term, SESAR and GNSS with VOR/DME back up
  • EGNOS was made available to aviation in March 11
  • NATS will decommission all 10 NDBs en route
  • Rationalisation of VORs from 47 to 29
  • There are consequences for the Midlands from the VOR rationalisation plan
  • Proposals and solutions will require wide consultations with the public

WITNESS EXPERIENCE AND PREPARING FOR THE LEGAL PROCESS – Andy Smith

  • Witness Preparation = Why do it? – you may be called as an expert witness
  • An expert witness is a person with expert knowledge on specific subject who could express an opinion on a incident
  • As soon as an incident happens – you should commence prep immediately
  • Refresh your memory – notes, CVR, tape recorders
  • Arrive in good time at the court
  • Stay out of the court itself until called
  • Always speak the truth – do not exaggerate
  • Show proper respect in the court
  • Appear confident
  • Listen, then pause before answering
  • If you don’t understand the question – say so
  • Refer to Notes – with permission
  • Remain cool and calm
  • When dismissed from the box – do not discuss the case
  • Monitor your mental picture of yourself – do not worry about yourself image
  • Monitor your physical sensations
    • Sweating, dry mouth blushing
  • Body language
    • Eye contact and facial expressions
    • Head movements
    • Smile – it makes a positive attitude and a smiley face is a liked face
    • Not a fixed grin
    • Shoulders back – hands do not fidget – comfortable stances
    • Positive stance and lean forward
  • Avoid Negative attitude
    • Arms folded is seen as defensive
    • Arms held loosely at the side is open
  • Clean and well dressed and neat, Wear a tie or scarf
  • Why?
    • To fail to prepare means to prepare to fail
    • Aim to be better equipped and more confident
  • Four ways to prepare
    • Learn from others‘ experiences
    • Refresh your memory of the incident
    • Familiarise yourself with court routine and the legal system
    • Get yourself organised
      • Read your personal notes several times
      • Don’t guess distances – measure them
      • Speak clearly

EAPRI VERSION 2 – Bengt Collin – Eurocontrol

  • EAPRI 2 has double the recommendations in EAPRI 1(over 100)
  • RIs have increased significantly in the Europe in 10 years – 1400 this past year , of which 22 were the highest risk and 80 second highest risk
  • Importance of speaking english by all involved on the airport emphasised
  • English pilots can also be a problem because they use colloquial language sometimes – not aviation english
  • Signs and markings need to checked that they are ICAO compliant
  • Limitations on transport on the manoeuvre area- one airport once had 2800 vehicles airside, before reducing it to 260 and then to 80 vehicles
  • Work in progress notifications needs work– better communications, NOTAMs
  • Put a procedure in place if drivers get lost – each airport must have a plan
  • Airside vehicle training is vital
  • Clearance for ac and vehicles to enter the runway need to be marked down somewhere and not just rely on being remembered
  • Was that for us? – a pilot or vehicle driver should always ask if unsure
    • Expectation bias is a major problem with R/T clearances
  • Check the use of frequencies – excessive use is a major problem
  • No late runway changes for pilots on approach
  • Local runway safety team are key drivers to prevent RIs – do RI campaigns
  • Main message – always keep working on the Runway Safety Plan

HSE AREAS OF ACTION – Christine Barringer, HSE

  • Govt agenda – review of HSE announced in March 2011which aims to:
    • Steps to eliminate unqualified H&S consultants
    • Shift HSE focus to high risk areas
    • Simplify HSE legislation
      • Abolish gold plating and expand lesson sharing
      • Reduce the compensation culture
  • Comments invited on HSE legislation under the Red Tape challenge
    • Check the HSE website on how to get involved
  • Launch the HSE register for qualified H&S consultants
  • Oversight of major hazard industries to be major focus
  • Review of RIDDOR – 3 day injuries report requirement may change to 7 day r
  • Better target and reduce inspections by one third
  • Health and safety made simple – a new HSE website
  • HSE Strategy
    • Need for strong leadership
    • Build competence
    • Involve the workforce
    • Make Safer workplaces
    • Prevent death and injury at the work place is the HSE focus whilst taking a 35% cut in funding
  • HSE Future Aims
    • Ease the burden of bureaucracy
    • Cost recovery – charges levied on companies by HSE if action needed to taken by HSE to address safety issues
  • Commercial Air Transport safety
    • Mishandling of luggage is the biggest risk
    • Working with IATA to improve this problem
    • H&S on the ramp and Human Factors are being reviewed
    • Airside DVD has been welcomed by the industry

GHOST – The CAA Ground Handling Ops Safety Team – Kirsten Riensema, CAA

  • Established GHOST in 2009
  • Significant 7 Task Forces in 2010/2011
  • CAA Stakeholder Conference held in 2010
  • CAA Safety Plan being developed and published shortly
  • CAA Strategic Plan – the challenge for the CAA in the next 5 years
    • Enhancing aviation safety
      • Renew CAA approach to safety regulation
      • Improve safety standards worldwide
      • Develop UK State safety Plan
  • GHOST Aims and Objectives
    • Mitigate ground safety risk in concert with industry
    • Specialist sub gps – 4teams to focus on specific
    • Safety performance Indicators identified
    • MOR scheme for use by ground handlers is being pushed
      • MORs are being increased significantly
    • Loading Sub Gp is a key gp since this is a serious problem
    • Collisions between ac and vehicles are down – but what about reporting levels
    • Safety in the Balance DVD completed and issued
    • Self auditing checklist for ground handling
    • New driving CAA CAP developing well
    • CAP 642 is being reviewed
    • HF ground handling gp is standing up
    • Recommendations on safety oversight from the CAA
    • GHOST website is now up and running
  • AOB
    • CAA ATC and ATM is joining together into a single department

CAA REVIEW OF HUMAN FACTORS – Jim Reed, CAA

  • Human Factors can be encapsulated in the SHEL model developed in 1972
  • SHEL was the result of a joint academic and operational initiative which placed the human condition in the middle of the various elements that make up any process or undertaking
  • HF is anything that affects human performance
  • The CAA HF Review Phase 1 Report was published in March 2011 andn identified the need for work in the following areas:
    • HF Governance
    • HF Regulation
    • Training
    • Standards
    • Data and research to support HF work
  • Guiding principles for HF development
    • Integrated approach
    • Shared understanding of data/risks/language
    • Relevant application
    • Practical benefit
    • Demonstrable value
  • The CAA is developing its HF Strategy and will be engaging with EASA
  • Work will include:
    • HF consequences in Runway Incursions, Runway excursions, Ramp Damage
    • Establishing links between HF training and safety performance
    • Assess safety training and its impact on individuals – do they apply it or disregard it?

Rich Jones
Chief Executive
UK Flight Safety Committee
23 June 2011

International Air Safety Seminar – 31st October – 3rd November 2011 – Singapore

International Air Safety Seminar – Singapore – 31 October – 3 November 2011
CE Seminar Summary



INTRODUCTION
 
Bill Voss – President and CEO FSF

  • An interesting year – some are now saying safety is fixed.   Money invested in safety is reducing and proactive safety is working well
  • New approach and changes required to face the new challenges coming into the industry
  • Safety design and automation has saved many lives but we have failed to note how the pilot job has changed. He now intervenes when abnormal ops occur
    • We are using 1970s training for the 2011 requirement – a new world
  • The Captain sets the tone on oversight, not the company
  • Regulators are understaffed to meet the requirements of the job
    • Can we afford to let the issues/regulation go?

 
QF32 – Captain Richard De Crespigny
Introduction

  • Accident rate stands at 1per 32M flight miles–
  • 10 to power 6 is the acceptable safety rate and the certification goes beyond this
  • The QF 32 incident was highly unprecedented – ‘a black swan’
  • Airbus has new orders for over 4000 ac – it has built 2700 so far
  • Qantas pilots are required to do 4 check sims per year plus a route check

The Incident

  • Climbing out of Singapore – at 7000’, 2 booms heard – went into an altitude hold – with ECAM warning bells going off every 15 seconds for an hour
  • Captain’s main focus was ‘fly the airplane’
  • 88 ACARS messages sent within 1 second to Qantas
  • Crew needed to go through 60 checklists pages
  • Based on wreckage on the ground – engine cowls, Tweets were received that a Qantas ac had crashed
  • The first Cabin announcement was made by the checking captain to re-assure the passengers
  • Although the A380 has no jettison system, the ac had 7 fuel leaks from the left wing
  • Over 100 wing hits and 200 fuselage penetrations resulting from the engine debris
  • The calm approach of the flightdeck and cabin crew was notable
  • The first that the CEO knew of the problem was a phone call from the financial sector asking why Qantas shares had plummeted.
  • The RB211/Trent engine had suffered an uncontained disk failure. The original engine was designed 40 years ago and this was first ever disk failure
  • 760 electrical system wires lost and every system on the ac was affected
  • Checklists were stopped regularly and each action questioned- but then continued especially switching off the hyd pumps
  • Six issues effecting the balance for landing were discussed at length
  • Eight fuel tanks lost from 11 available – transfer from right wing tanks to left leaking tanks was stopped
  • After much crew uncertainty about the fuel system and the associated checklist actions, the Captain decided to analyse what was working rather than what is not
    • Too many failures for the crew to understand and follow
  • Performance figures showed that all but 100meters of the 4000 metres runway available would be required
  • Captain decided a slow speed Control check was required before the approach – these are are not written in the Boeing or Airbus checklist
  • Calculations showed that airspeed had a 3 knots margin between stall and too much speed on the approach
    • Speed too high by 3 knots would have meant going off the runway

Landing and Evacuation

  • The brakes indicated 900C as the ac stopped meaning they would reach 2000C
  • Evacuation decision had to consider hot brakes and fuel leaking from the left wing
  • On shutdown, all the electrics failed and all but one radio was lost.
  • Engine no one remained running and would not shut down – needed excessive water to shut it off
  • Evacuate decision discussed – much concern about the possible illogical action by pax on leaving the ac
  • Decision to wait for further information before evacuation – it took 2 hours to get people off via the steps
  • The passengers were briefed by the Captain in the terminal before the press could speak to them
  • Captain understood his responsibilities for the passengers and he provided his mobile phone number to allow them to call him if they had problems – no calls
  • Human factors
    • Mentoring of young pilots to be able to deal with these Black swan events
    • Deliberate practice of these major incidents is required

 
2011 YEAR IN REVIEW

  • 14 Major accidents so far in 2011
  • In CAT, 2 Runway Excursions and 5 CFIT, which is the worst for 8 years.
    • 5 accidents involving Eastern built jets – 36% of all accidents
  • Of all 42 CFIT accidents, 2 had TAWS which worked fine in both cases
  • No LOC in 2011 – has never happened before!
  • Challenges
    • Automation interaction and training
      • automation failures rarely happen, incidents occur when the system does not do as the pilot wanted but it does do as it is designed
      • Question is should there be more or less automation
    • Professionalism
      • What you do – your profession
      • How you do it – your professionalism
    • Approach and Landing
      • Runway Safety awareness is increasing
      • Excursions – due mainly to a failure to go-round
      • Decision to go-round
      • LOSA shows that 4% of approaches are unstable – 3% of which go round!
      • Airbus stats show 3.5% of approaches are unstable – 1.4% of which go-round
  • FSF Safe Landing Go-round Guidelines
    • A series of factors that combine to increase risk of an excursion have been identified:
      • Fly a stabilised approach
      • Ht at Threshold Crossing should be 50 Feet
      • Speed at Threshold +10 Knots
      • Tailwind is no more than 10 Kts for Non-Contam runway No More than zero on Contam runway
      • Touchdown On Centreline At Touchdown Aim point
    • After Touchdown, prompt transition to desired deceleration
      • Brakes
      • Spoilers/Speed Brakes
      • Thrust Reversers
        • Once thrust reversers are activated go round option has gone
      • No more than 80 kts with 2000 feet of runway remaining
  • Conclusions
    • Accident Stats show 2011 was good for commercial jets
    • Average year for turbo jet
    • CFIT accidents are back
    • Automation debate goes on
    • Professionalism is vital
    • Safe Landing Guidelines are available
  • FSF Goal – Make Aviation Safer by reducing the risk of an accident

 
CONTINUOUS MONITORING AND OVERSIGHT PROGRAMME – Henri Gourdji ICAO
 

  • Programme started in 1999 – focus on licensing and airworthiness using USOAP
  • Outcome from audit of States showed many deficiencies
    • Re-audit of problem areas showed general improvements
  • Next stage to audit other areas such as aerodromes/ANSPs etc which demonstrated lack of oversight overall
  • Continuous monitoring approach has been brought in to address the audit shortfalls – but poor level of disclosure
  • Now a widened knowledge has been introduced for States but now a limited release of safety information to the public is to follow
  • Sharing safety information is key to the effectiveness of safety oversight
  • ICAO objective is to share by international and regional organisations is the
  • Consistent with the SMS concept and proactive approach
  • Long term cost effective
  • Oversight is ensuring effective implementation of SARPS
    • 8 critical elements of safety oversight
    • Independence, organisation, training, procedures, guidance to industry, certification, effective surveillance, follow-up action on issues
    • Most challenging is training and numbers of qualified staff
  • Critical elements of an effective Safety Oversight Programme
    • Effective implementation of safety related SARPs
    • Safety defensive tools of a safety oversight programme
  • Collection of safety info
  • Safety risk profile determination in each State
  • Update of LEI and status of SSCs
  • Prioritization and conduct of SOAps
  • New agreement of sharing safety information between organisations
  • ICAO/FAA/EASA/IATA – sharing info to reduce risks to civil aviation by exchanging and pooling information
    • Only non-confidential info is being shared so far
  • Bilateral agreement with EU and ICAO
    • USOAP – review with other orgs
  • Pool resources and identify sharing info is a key element
  • State Safety Risk Profile establishes targets and measures results
    • Risks and targets
    • Reactive and proactive and predictive risk assessments
    • Accounts for traffic growth
    • Reviews State Action Plans and decides if it has been effective and helps them plan improvements where they have failed to do so
    • Jeopardise public safety concern – 12 states with 15 close!
  • States can undertake an ICAO audit to identify a fresh start and prioritise the actions required
  • Aim is to do away with snap shots and go to continuous oversight
  • Info available on a States status to all States on the web
  • Transition over the next 2 years to make CAT to be more efficient and be live by 2013
  • UOAP CMA – website
    • Established online framework for State and public access
  • ISTAR ICAO Safety Trend Analysis and Reporting System is widely available with de-identified safety data
  • Complementing USOAP with industry led audits
    • Regulators
    • Airlines
    • Air Services Providers
    • Aerodromes

 
BRISTOWS – TARGET ZERO
 
Summary of this presentation provided on UKFSC website under External Meetings/Seminars – Shell Aviation Safety Conference.
 
UNACCEPTALE OUTCOMES PRECURSORS REVISITED – Ed Pooley
 

  • Operational risk management at a large ac operator is challenging due to very few accidents from which to devise mitigations
  • Precursors to unacceptable outcomes could provide new information upon which to act
  • Filling gaps in precursor availability offers additional safety enhancements to improve flight training and provide measures of success
  • Problem – making the reality fit the model
  • Unacceptable outcome means an accident or significant loss of life or a serious incident where an accident was narrowly avoided
  • Identifying Precursor Events – Examples
    • Mid-Air Collisions
      • Loss of prescribed separation in controlled airspace
      • lack of awareness of close proximity when no sep minima are prescribed
      • TCAS RA or STCA activation
      • Level busts
    • Ground collisions
    • Runway Excursions (Take-off and landing)
    • LOC events
  • Precursor Identification
    • Opportunities to use FDM for precursors, but not the sole source
      • Response from the crew depends on individual pilot competence
    • Traditional approach to training and assessment is not delivering the required standard
    • Reliability of ac and equipment changes/reduces exposure and skill level
      • Pilots must be able to respond to the unexpected
    • Bank of representative scenarios and unpredictable training scenarios
    • Licence Revalidation
      • Training first then assessment
    • Leverage on ATQP
      • Ensure the changes are overseen by a body of flight ops expertise not just those charged with delivering training
  • Solutions
    • FDM does not inform risk management of all unacceptable outcomes to same extent
    • Changes to the content and tracking of pilot training is the way ahead

 
EVALUATION AND ENHANCING OF OPERATIONAL PERFORMANCE – LOSA- IRANAIR
 

  • Threat and error management is the key element in addressing high risk operations
  • LOSA introduced by Iranair
  • Conclusions
    • Large numbers of errors are due to the lack of efficient training
    • LOSA data is best source of data to improve training, CRM, and refine SOPs
    • Technical errors can be used by training and to develope documentation

 
FLIGHT OPERATIONS RISK ASSESSMENT SYSTEM (FORAS) – Taiwan University
 

  • Proactive risk assessment of flight ops enhanced by fuzzy logic rather than probability theory
  • Fuzzy logic attempts to replicate and apply human input/error
  • Web based tool with traffic light indicators being developed to indicate the level of risk in a specific operation
  • Who can use FORAS
    • Senior management – to make strategic decisions about:
      • Risk due to inadequate crew rest
      • Insufficient flight crews
    • Safety Department – to identify:
      • Which risk factor is most crucial
      • Why has risk increased for specific flt sectors
    • Dispatchers
      • How will risk index change after a crew change
    • Flt Crews
  • The system analyses crew competence in language, experience, by individual and then by crew to work towards a risk level for each sector
  • Fuzzy interference engine feeds into the human factor assessment to the mechanical risk
  • Critical risk factors to identify the most important and impactful on the risk assessment

 
RUNWAY EXCURSIONS –REDUCING THE RISKS  – Panel Event
 

  • Landing overruns – 40% of all accidents – Possible Mitigations
    • Onboard technology – recognise unstable approaches, landing performance monitoring
    • Harmonisation – Runway condition and ac performance(TALPA RC)
    • Training of pilots – long landing avoidance, use of brakes, spoilers, speed, thrust reversers
      • Runway papis set for a B747 – B737 will land long
    • Better information for pilots – winds and runway conditions
  • Landing Veer-offs
    • Unambiguous procedures for allowable crosswinds on slippery runways
    • Better info for pilots on winds and runway conditions
  • Take-off Overruns
    • Engine failure is the normal expectation but this is not usual reason
    • Unsafe flight conditions – pilots need to be trained to know them
  • Take-off Veeroffs
    • Unambiguous procedures for allowable crosswinds on slippery runways
    • Better informed pilots about actual wind and runway conditions

 
SPEEDBRAKES AND STOPPING DISTANCE DYMYSTIFIED – Tom Lange, Boeing
 

  • GAP of understanding among pilots on stopping distances and devices
  • Many underestimate the importance of speedbrakes
  • Airlines should mandate a crew assessment of landing distance for every landing
  • Certified data and advisory data for stopping distances is provided by the manufacturer
  • Certified data provides landing in accordance with the regulations and comprises
    • No reversers
    • Max braking
    • Dry runway
    • Adds 67% factor
  • Advisory Data comprises
    • Dry runways
    • Max manual braking
    • With reverse thrust
    • Spoilers provide significant stopping factor – 63% on dry and 92% on wet
  • FCOM Procedures Boeing
    • For Landing
      • Thrust lever closed
      • speedbrake lever up – deploy immediately
      • autobrakes op
      • thrust reversers deployed
      • Callouts by NPF
    • Rejected Take-Off
      • Use speedbrake
      • Follow manufacturers guidance
      • Train the PNF duties!

 
 OPERATIONAL LANDING DISTANCES  – Lars Kornstaedt, Airbus
 

  • Airbus along with other manufacturers are implementing the FAA TALPA ARC
    • Common rules for airports, manufacturers and operators
  • Shared basis for operational landing performance
    • Realistic air distance, friction and physical affects
  • Standardised performance
  • Runway Assessment Matrix framework in place for all players providing
    • Contaminant type and depth
    • MU
    • Pireps
    • Driver assessment on controllability
  • The latter 2 inputs can be used to downgrade only
  • TALPA Rules in a nutshell
    • provide runway status reports
    • publish realistic landing performance with a 15% margin
    • provides a systemic landing assessment check
  • Airbus is publishing data for all its ac types for 2013
    • Complementary info which uses the TALPA matrix as the entry point for all operators

 
CIRCLING APPROACHES – FSF EAC Group
 

  • Circling approach survey undertaken producing 100 responses
  • How big is the risk?
    • 304 fatalities for 2009 and 2010
    • 20% of the fatalities for 2010
  • Runway aligned landings are 25% safer than circling approach landings
  • Definition of a circling approach – an extension of an instrumented approach procedure which provides for visual circling of the aerodrome prior to landing
  • Survey demonstrated no common understanding on when the crew commenced descent to touchdown from MDA(H)
  • Different ac have different minima
  • No extended downwind
  • Unpredictable go-round from circling approaches
  • Two standards for assumptions exist on circling approach – ICAO and TERPS
  • Bank angles and speed criteria are different
  • Do you know where the runway is?
    • how to initiate the turn on to the runway
  • Managing the hazard at source – Typical Operator-applied risk mitigations
    • Add Margins above MDA/H
    • Minimum cloud requirements
    • Increased visibility
    • Daylight only
  • EAC FSF will provide Circling approach criteria and best practice once work is complete

 
NEW STALL RECOVER PROCEDURES – Airbus
 

  • Draft Airbus circular provides best practice for stall recovery training
  • Prevention is the key – preferred option
  • Proper recognition of signs of approaching stall is necessary
  • Proper decision making to avoid stall events by intercepting the error chain early
  • Recognition of stall and approach stall is the key at which point, commit nose down pitch control to reduce AOA
  • Training methods provided by Airbus
    • Academic training
      • Basic aerodynamics and flt techniques
      • Startle factor
      • Share related stall incidents and accidents
    • Briefing guides
    • Procedure data package
    • Flt crew manual
    • Manoeuvre based training:
      • Pilot awareness – ac handling and flying skills
      • Develop motor skills
      • Low energy situation – highlight ‘speed-speed’ function
      • Stall recovery clean and alternate law
      • Low altitude recovery
      • High altitude handling in alternate law
    • Scenario based training
      • Flt management skills, flying skills
      • Line ops simulations concept using realistic scenario
      • Startle surprise factor
      • Response of the pilot is to over responsive
  • Make the risk visible through TEM and CRM
  • Sims are OK up to the stall but not beyond this
    • Need to avoid negative training
  • Sim instructors should know the limitations of their sim devices
  • Facilitation rather than instruction!
  • Stall trg during a career
    • whole pilot life stall training needed
    • some stall event each time
    • refresher trg on academics
    • scenario based trg is important
  • Core conclusion
    • Do the action for approach and full stall
    • Stall standardisation trg is important
    • Recurrent stall training should be undertaken

 
ENHANCING PILOT TRAINING WITH SAFETY DATA – Charles Hogeman, ALPA
 

  • Challenges
    • Economic pressures on training requirements
    • Too much to cover in recurrent training
    • Lower flight experience levels of the pilots
    • FAA may stipulate higher flt hours levels in near future
    • Training and evaluation on manual flying required
  • Potential solutions
    • line oriented training approach
    • competency based training
    • advanced simulation
    • Improvements in discerning cognitive skills
    • improvement in instructor /evaluator training
  • Data Sources
    • FOQA/FDM
    • Aviation Safety Action Plan
    • LOSA
    • Sensitive training data from AQP
  • Anecdotal single event – B747 – leading to a review of lessons
    • Single engine fail – in fact an compressor stall misidentified, after take-off from SFO
    • Nearly hitting the ground – 100’ over housing
    • No realistic compressor stall scenarios available
    • Operator questioned training intervals for long haul
    • Check of pilot proficiency not happening
    • Changes introduced
      • Trained to this event
      • V2 cuts were instituted
      • Sim fidelity improvements
      • Long haul pilots recurrent trg intervals shortened
      • Focus on ‘fly the airplane’
      • Institute a train for proficiency philosophy
    • Conclusions
      • Single source data is still data
      • Train to handle startle factor
      • Implementing training program changes requires line familiar and knowledgeable people
      • Incidents don’t mean we shouldn’t change

 
 
ADAPTING COSTING METHODS TO SAFETY – USING FINANACIAL TOOLS TO SHOW VALUE IN SAFETY PROCESSES  – John Cox
 
Background

  • Has aviation become so safe that safety improvements don’t add sufficient value?
  • Historical safety programmes have always been reactive
  • Need to continue to lower accident rates
  • Can senior management justify the costs of additional programs to lower an already low risk?
  • Travelling public perceive accident numbers, not the rate of accidents
  • Risks of political over reactions
    • Colgan – hours, fatigue
    • Reputational issues
  • Proactive safety programmes have been successful in the past
    • Crew resource management
    • Predictive wind shear

 
Making a business case for safety programmes

  • Traditionally, fixed costs were not included in the calculations of accident and incidents
  • Variable costs were included but often only in direct costs
  • Traditional costing methods did not provide the true organisational costs
  • Due to Silos of responsibilities – stovepiped in departments
  • Senior management often do not fully account for multi-depart costs
  • The ABC costing management tool assigns more indirect costs into direct costs
    • To test the ABC method, as accurate data as possible was used for the best results
    • ABC accounting is consistent with SMS
    • Initial problem with ABC was the input time required, so the method was modified and renamed time based ABC (TBABC) 
    • TBABC was applied to a diversion of an ac after it suffered smoke in the cabin.
    • Costs included use of the evacuation slides and provision of a rescue plane
      • Not only direct costs but fixed costs suitably pro-rated was used
    • The actual cost was $131,000 for the rescue – if no slides used in the diversion then reduction to $67,000
    • To recover these costs would require the airline to fly 550 more pax to generate the lost revenue over 16 months
    • Typically, the example airline incurred 13 diversions per year – at a cost of $796,000 – then year on year
    • Plus customer services to address the pax needs
    • Take a safety program cost which could reduce this by 75% for example
    • TDABC is time and labour intensive initially but high quality data
    • TDABC prediction is important for a credible case
    • Organisational cost must be drawn within the analysis
    • Training and technology can be accounted for in this system and then used to justify safety measures – technology and training investment and not a cost!!

 
DAY 3
 
SCIENCE GUIDED SCHEDULING – Jeppeson
 

  • Scheduling Crew Management programme being developed by Jeppeson in co-operation with Finnair
  • Experience of the programme so far:
    • KPI on fatigue can be controlled
    • Effect on safety and efficiency can be assessed
    • Easy to use by planners
    • Optimise the schedule quickly
    • Good data for use in future safety equivalence
    • Can quantify changes to the schedule

 
FATIGUE RISK MANAGEMENT IN AVIATION ENVIRONMENTS – MAINTENANCE   – Bill Johnson – FAA Human Factors
 

  • Fatigue as a contributing factor to the following accidents:
    • Littlerock – Pilot awake for 31 hours – FO on a 3 day 6 leg seq (crews)
    • Charlotte – flt control misrig (maintenance)
    • Kirksville – CRM extended hours minimum hours (crews)
    • Lexington – wrong runway (crew, ATC)
  • We know
    • What fatigue is
    • What causes it
    • How to measure it
    • How it affects performance generally and specifically
    • What the countermeasures are
  • The Challenge- Who must take action?
    • For the Company – less manpower is good
    • For Labour – more money for overtime is good
    • For Science – needs to become applied not academic
    • For the Regulator – looking out for the consumer
  • Next Steps
    • Need to generate a collective will to address fatigue challenges
    • Improve investigative techniques
    • Regulate guide FRMS
    • Measure the impact of FRMS
    • Reinforce the business case
  • Valuable fatigue information is freely available at www.mxfatigue.com including:
    • 2 hour CD
    • Award winning 20 minute on fatigue
    • Web based fatigue risk assessment tool
    • Return on investment methodology software

 
FUNCTIONAL CHECK FLIGHTS  – Panel Discussion
 

  • Outcomes of FSF Vancouver Conference on Check Flights
    • Airlines demanded improved guidance from the manufacturers
    • Set up a Working Gp to advise on the way forward
  • Best Practice
    • Only do Flt Checks if absolutely necessary
    • Need for thorough preparation
    • Supporting engineering documentation is required
    • Personnel/pilots selected to undertake the task is important
    • Training for Flt Check pilots is strongly advised
    • Tech prep and engineering information must be considered
    • Crew briefing – all involved must know what is required of them
    • ATC liaison – book airspace and pre- brief ATC on your Check content
  • Prudent weather limits – set them
  • Flt check during daylight hours only
  • Get the crewing right and no pax
  • Golden Rules
    • Priorities’ must be right
    • Plan the sortie and fly the plan
    • Decide in the brief what the break off points are
    • If things are not right, stop the check
    • Take care with any breaks into the test sequence
    • Identify check points
    • Don’t add tests or ad lib the Check
    • Don’t consider looking at certification test points – these are for specialists only
    • Be failure minded and assume it may well go wrong
  • Functional Check Flights FSF Working Gp
    • Documentation output from WG split into 3 parts
      • Generalities including working process
      • Ground checks
      • Flight checks
        • Flt check content has been agreed but the low speed check is problematical and manufacturers prefer that it is not done
        • However, some airframe/sensor work may need this low speed check so a process is being developed to enable this
  • EASA regs on maintenance check flight are under development
    • Nothing formalised at this stage by WG
    • EASA WG started in June
    • Draft NPA should be complete mid 2013
    • TORs for maintenance, not functional check flt – a separate WG will cover functional
    • TOR based on recommendation of French BEA and UKCAA accident and incidents
  • Pilot requirements
    • Compromise reached by using 2 levels of check
      • Complex and non-complex ac – EASA definitions
      • Level A – Flt using SOPs
      • Level B Others flts (specific manoeuvres possible)
    • Non-complex ac – No Trg for level A – use a standard pilot
    • Complex ac – Captain needs a follow a trg course
    • Trg syllabus agreed for airplanes and helicopters
      • Course will cover all ac types but a heli course also to be developed
        • Difference trg to be considered by operators for diff ac types
      • Renewal – not needed if a Level B check is undertaken every 2 years or they have to undertake a renewal check
    • Ops Manual – specific chapter in the Ops Manual to perform maintenance flts
    • Process to launch a check flight
    • Where to insert the specific regs nearly agreed

 

  • FSF website – reports from the Vancouver available

 
QUANTIFYING FATIGUE- David Powell Air New Zealand
 

  • Traditional tests were carried out in the past by ANZ which showed predictably that fatigue on overnighters was significantly higher.
  • A top of descent alertness survey was undertaken by both pilots
    • Uses a simple 1-7 self assessment recorded on the FMS to be registered at the top of descent – check with each other
    • Jun09 – May 10 showed that short haul was fine but long haul was higher risk and fatiguing
  • Methodology is
    • Cheap and easy to apply
    • Monitors any and all operations
    • Avoids formal studies
    • Integrated with safety monitoring – FOQA
  • How much fatigue =how much effect on safety? Other investigations include:
    • easyjet – LOSA
    • Qantas – sim checks
    • Thomas – LOSA compared to prior sleep
    • French regional airlines – FOQA
    • Moore-Ede – unstable approaches

 
MAKING SENSE OF SHARED SAFETY DATA – Replacement Lecture Bob Dodd
 

  • Data sharing history
    • IDEAS 1985 –
    • CFIT TF
    • GAIN and CAST
    • STEADES
    • ASIAS
    • Global Safety Information Exchange
  • Filing cabinet problem – incompatibility between
    • Safety reports
    • investigations
    • Flight Data
  • Risk is a bolt-on
  • Integration by Neurons (human-led integration)
    • humans are good at stories but not at data and risk analysis
    • new initiatives can make things worse
  • Is there a better way?
    • Let risk drive data not data drive risk
    • Better understanding of risk is required
    • Bowtie model recommended as an organising structure

 
 
GOOGLE EARTH SYNTHESIS OF ACCIDENTS  – Boeing  
 

  • A tool which synthesises several sources of data including FDM information onto Google Earth and displays a variety of parameters on a simple to understand visualisation of an accident

 
TCAS RA DOWNLINK  Helios Nick McFarlane
 

  • Collision avoidance – TCAS RA downlink offers an additional safety nets
  • STCA and TCAS are available but are not interacting directly with each other
  • Many RAs are not reported due to high workload and separation will be broken
  • TCAS RA Downlink shows controller when RAs are in force and allows the Controller to be much more situationally aware
  • Some ANSPs are adopting the capability but others are not!

 
Rich Jones
Chief Exec
UKFSC 
14 Nov 11

MAST – 15th April 2009 – Heathrow Meeting

MAST Meeting Heathrow – 15 April 2009
CE Meeting Summary

AGENDA

ITEM 2. Concern and Countermeasure Review Outcomes
Pushback WG in Feb 09 was successful with 20 GH Reps and associated airport Reps attending.

Flightglobal Flight Safety Conference – 12th September 2013

Flightglobal Flight Safety Conference 2013
CE Report

David Learmount

DL opened the conference with a look at the current safety landscape, starting with a comparison of UK and Norwegian ops in the North Sea. Since 1997 (after a major Norwegian review) the UK has 4 fatal accidents and 10 non-fatal whereas Norway has had a single non-fatal. But all the UK accidents could have occurred in Norway (EC225 fatigue failures etc). His conclusion was that the difference was too large to ignore and a major study was required. Note: Parliament, CAA and UK Helicopter Safety Steering Gp have all set up reviews of North Sea safety.

The second theme was crew skills. There have been 15 CAT LOC accidents since 2000, with 1400 people dying in serviceable aircraft. New aircraft were easy, predictable but complex, with OJT required for real depth of knowledge. Increased reliability had fostered unquestioning trust, automation meant reduced practice at physical tasks and computers had removed the need for calculation. LOC was a pilot problem and the onus was on the regulators to modernise training requirements that were essentially unchanged since the days of the DC-6.

Giancarlo Buono (IATA)

An overview of global stats showed a 50% reduction in fatalities compared with 2012, ‘problem’ areas for western-built jets appeared to be Asia-Pacific (0.47) and CIS (1.94) per million flights. With turbo-props and eastern-built jets the leaders were CIS (4.23), ASPAC (3.02) and AFI (5.27). While African safety was improving it was still 4-12 times worse than comparable European sectors. IATA was taking a regional approach with priority on runway excursions and ground damage. Tailstrikes were a common problem but there was no simulation currently available. An enhanced IOSA would develop organisational management capability and improve the regulatory interface.

Ground damage cost the industry $US 4Bn per year in direct costs alone and the trend was increasing. A new ISAGO manual had been issued, aligned with IGOM, and work had been done on SMS for ground service providers. IATA now had a Global Safety Information Centre, with the database being fed from IOSA, STEADES, ISAGO, FDX (FDM sharing), accident reports etc.

IATA believes Lithium batteries present an industry-wide risk that has already led to 3 fatal hull losses. Billions of batteries are shipped annually by air. Updated ICAO guidance would be in place by end of the year and IATA DG regs were being amended to improve handling. Screening of cargo was necessary to capture rogue or improperly packed shipments.

Panel Discussion: SMS – Reviewing the first years of implementation
Conor Nolan (Aer Lingus); Sigurd Schjoett (Air Greenland); Fernando Val (GOL)

  • SMS is an engine that runs safety performance. All the parts need to be present.
  • Air Greenland asked for voluntary participation and achieved 90% buy-in. All players get all the data. There was a sense that an over-formal system (rigidity) had led to some data loss.
  • Board commitment was crucial, requirements need to be properly articulated.
  • The regulatory stick was not always helpful for securing Board involvement. A better way was to assign benefits up front and then show how safety performance contributes to the bottom line.
  • Safety culture was important but crews needed the right reporting tools.
  • Air Greenland was putting a scratch pad on EFBs for contemporaneous notes.
  • There was no major correlation between FDM and reporting rates.
  • A good reporting culture could mean a deluge of reactive data, crews needed to be encouraged to consider and report new hazards (proactive…)

Discussion on Risk: John DeLeeuw (American Airlines) and Jussi Laaksonen (Flybe Finland)

The discussion started with a brief description of the US FOQA programme, including the need for gatekeepers and data validation for context. Only 2% of AA pilots GA from an unstable approach, but typical response from crew contacts was that they flew one GA in 9 months compared with 50 landings per month, so landing was comfort zone! The debate stayed in GA territory, the Flybe rep noting that difficult approaches tended to be stable; short and contaminated runways generated higher arousal levels and hence fewer mistakes. Regularly reviewed hazard registers were preferable to tribal knowledge.

John deGiovanni (United): Finding the next accident…

Opening premise was the need to understand the events that drove safety costs: personal injury, operational impacts, out-days, regulator impact, training etc. UAs injury bill was over $100m USD per annum, with aircraft damage over $12M, with 96% of events down to HF. There had been 41 vehicle collisions in the previous 3 years, all down to ‘brake failure’. Normalisation of deviation was an issue; assumptions needed to be clarified and validated by analysis and test.

“Attitudes drive accidents.” Change models were important (Kotter etc) but resources for change were crucial. Communications breakdowns were at the root of most accidents. Self-disclosure programmes work, but people needed to change their mindsets from ‘Make Do’ (improvise, whatever it takes, get it done…) to Can Do (right tools, do it correctly, practical thinking, teamwork etc). All close calls should be reviewed and questionable behaviours addressed. Coaching was required for addressing behaviours, as soft skills are the hardest to train – closed loop communication should be used: correct in real time, personal discussion, understand the ‘why’?, get verbal commitment, reinforce the positive, and thank…)

Discussion: Corporate Financial Interests vs SMS (Kevin Baines, Steve Solomon)

  • Safety and profitability should go hand in hand but finance and safety are often treated ifferently. Safety risk management should be a Board concern.
  • All medium and high risk events should lead to management actions.
  • False assumption that execs understand safety management.
  • Look at industry-wide risks and add local specifics.
  • ‘Black ops’ are common, be alert for them.
  • “People don’t report if they think you’re not listening.”

Dr Nicklas Dahlstrom (Emirates) Understanding HF risk in your system

Safety changes over time (eg attitudes to smoking), with main improvements in technology, SOPs and HF/CRM training. A systemic approach is needed, considering technology, people and organisation. We use machine metaphors for everything, but safety is not a machine. Reliability is not absolute because there will always be random arisings. A reliability-based approach learns from failure, has limited operator actions and trains for the likely. A resilience approach learns from success, has competent operator actions and trains for the unlikely.

Data collection focuses on numbers, but narratives are also important (quantitative and qualitative), the industry’s main weakness being over-data, under-analysis. Need to consider HF for effective identification and understanding of risk.

Training for resilience means developing expertise rather than just experience and knowledge. This requires: motivation through active learning, effortful study and practice (focused at the next level), feedback on progress and reflection on failures and successes. Industry needs to move from compliance to competence and from standardisation to customisation. Individual training needs should be identified, train the individual for specifics (not everyone for everything) and train proactively, not just in response to failures.

Ratan Khatwa (Honeywell) Human-centric design of next-gen weather radar.

Wx encounters can be significant and costly: delays and cancellations cost the US economy $18Bn in 2008. Turbulence is the leading cause of injuries in non-fatal accidents. Common factor in all encounters has been failure to provide or gain crew awareness of wx in sufficient time. 64% of all incidents have shown poor tilt control by crew. New system (IntuVue) has 3D volumetric scanning out to 320nm and 60K ft. Automated mode will show information relevant to FPLN, tactical (manual) mode allows examination of wx vertical profile. Displays include hail and lightning icons.

Jim Pegram (easyJet) Data: where, how, what…

Over-concentration on data can provide a false sense of security. EasyJet operates over 40K sectors per month, generating 10 GB of flight data for analysis, 105,000 reporters producing 30,000 ASRs per year. Triggers are required to identify problem areas. ASRs are automatically logged and distributed to investigators (or filed) on a 5-level system. Databases are populated with post-investigation information as well. Reporting has been simplified and made easier with forms populated from other databases (eg crewing) wherever possible.

David Owens (Airbus) The power of data for training

Training needs to provide real skills to manage real risks. Evidence-based training focuses on training criticality. The OEMs will respond to identified threats – eg Airbus has developed ROPS to help mitigate the threat of runway excursions – and technology can assist. The Airbus threat model looks at repetitive/foreseeable events (evidence) and the unique/unforeseeable (no evidence, Black Swan events). But the same competences apply to both scenarios: procedures, communication, flight path management, leadership and decision making, situational awareness, workload management and knowledge.
Data sharing is required, this is best achieved at the manufacturer level, which allows FDM lessons to be applied at the design level. It also allows for the challenging and calibration of assumptions, and learning from normal operations. For example, global data shows that on 50% of all A320 approaches, the AP is disconnected above 1000ft, with 10% disconnecting above 3000ft; similar trends are seen for ATHR. 14% of pilots disconnect the flight directors on approach. 50% of pilots going around above 1200 don’t use TOGA (contrary to the SOP). Global GA rates (Airbus) are currently 0.29% (1 in 340) for short haul and 0.41% (1 in 240) for long haul. This sort of data is useful for benchmarking and baseline-setting.

Dai Whittingham
Chief Exec
3 October 2013

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