Flight Data Monitoring, Risk, and Protecting Assets
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Transcript of Flight Data Monitoring, Risk, and Protecting Assets
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
FDM, Risk and Protecting your Assets
Sonya TietjenPrincipal, Safety Management Systems
4 March, Heli-Expo 2013: Las Vegas, NV
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
1. The Problem2. The Solution3. The Benefits
4. Risk Management5. Flight Data Monitoring6. Protecting Your Assets
Agenda
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1. The flight crew made numerous procedural errors and deviations during the final approach segment of the VOR/DME approach.
2. The crew demonstrated poor crew coordination during the accident flight.
3. The flight crew was under pressure to land.
NTSB Report
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Causal Factors - Primary
IHST 2006 (JHSAT)
Flight Crew
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The Problem?
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Threats
How accidents happen
Organization
Technology
Humans
Modified from J. Reason 1997
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
BowTieXP: Loss of Separation
D - Aircraft In motion 'Airborne': HE-20E Loss of separation
with third party aircraft
H-02.01.01 Aircraft in motion (1)
Loss of Spacial Awareness
Medical fitness and 6 monthly tests.
Ref? - Reference to be added
Simulator training including recovery from unusual
attitudes
Ref? - Reference to be added
Maintenance of an effective look-out
RAP 1 - xx
Two Crew operations
Ref? - Reference to be added
Flight crew mishandling and mismanagement of
the flightCompliance with procedures
and checklist
OM Pt.8 - Unit Orders
Effective cross cockpit communication
OM Pt.6 Sct.1 - Definitions, Rules and Requirements
Crew flight planning for other aircraft operations in the
operational zone
OM Pt.8.Sect 3.23 - Summary to Offshore Operations
(AS332L1)
Multi crew ops including challenge and response
OM Pt.5 Sct.1.1 - Duties of Captain and First Officer
Training and testing (Line Checks)
TM Pt.4 - Operation Line Training
TM Pt.4 Sct.1 - General
Training and testing (Base checks)
TM Pt.4 Sct.1 - General
Aircraft System failures
MEL controls for limiting departures with unsevicabilities
MEL - Minimum Equipment List
routine preventitive maintenance
MS - Aircraft Mainteance Schedule
Repetitive defect management
MOE Pt.2 Sect.2.14 - Technical record control
Flight Manual Emergency Check List actions
FM Sct.3 - Emergency Procedures
Ineffective Air Traffic Management
GPS flight Tracking
RAP 1 - xx
Provision of area information (NOTAMS)
AIP.Vol 1. GEN 3.3 - Air Traffic Services
In field traffic communication
OM Pt.2 Sct.1.3.4.10 - Helicopter Operations
Personnel Manning
Effective provision of area contol of air traffic
management
AIP.Volume 2 - Aerodrome (AD)
Operations in adverse weather
Procedure (weather minima)
Ref? - Reference to be added
Weather (Flight Operations Limitations)
Ref? - Reference to be added
Actual Weather Reports/Information
RAP 2 - x
Training (interpretation of weather information, and
weather avoidance)
RAP 3 - xxx
Failure to install available safety improvement
system or to learn from experience Equipment Standardisation
and acceptance checks
QAM.7.5 - HFDM Process
Installation of Traffic avoidance systems (TCAS)
RAP 4 - xxxxx
Failure to learn from experience
HSE Management Review Board process
Ref? - Reference to be added
Occurrence reporting system
Ref? - Reference to be added
QA Audit of line management actions to resolve findings
Ref? - Reference to be added
Line management action to resolve findings
Ref? - Reference to be added
Non-compliance with mandatory requirements (levels and distance) for
seperation with third party aircraft. Training and testing (Base
checks)
TM Pt.4 Sct.1 - General
Training and testing (Line Checks)
TM Pt.4 - Operation Line Training
TM Pt.4 Sct.1 - General
Multi crew ops including challenge and response
OM Pt.5 Sct.1.1 - Duties of Captain and First Officer
Effective cross cockpit communication
OM Pt.6 Sct.1 - Definitions, Rules and Requirements
Multi crew ops including challenge and response
OM Pt.5 Sct.1.1 - Duties of Captain and First Officer
Compliance with procedures and checklist
OM Pt.8 - Unit Orders
Organisational Discipline
Ref? - Reference to be added
Airborne contact with opposing traffic, Loss of aircraft and/or multiple
fatality
C5 C5 C3 C5
Take avoiding action
OM Pt.8.Sect 9 - Emergency Procedures
Incorrect avoiding action taken
CAR 1996 and AIP requirements for standard collision avoidance actions
MCAR Pt.11 Chap.2 - Regulation of Movement Area
Installation and use of TCASMaintenance of Situational Awareness
OM Pt.2 Sct.12.34 - Adherence To Operating Procedures and
Co-Pilot's Responsibility
Establish Communication with opposing traffic
SID Sect.07 - Hazard RegisterAIP.Vol 1 ENR 2 - Air Traffic
Services Airspace
Failure to establish communications with
opposing trafficBlind Call on Guard frequency
121.5 MHz
Ref? - Reference to be added
Common Frequency for aircraft in the operational
zone
Ref? - Reference to be added
Identification of Opposing traffic
SID Sect.04 - Listing of Interface Activities
Lack of visual meteorological conditions
(VMC)Maintenance of Situational
Awareness
OM Pt.2 Sct.12.34 - Adherence To Operating Procedures and
Co-Pilot's Responsibility
Division of workload (handling and non-handling pilots) IMC
and VMC
OM Pt.6 Sct.2.3 - Division of Crew Duties During Flight in
I.M.C.RAP 4 - xxxxx
Installation and use of TCAS
RAP 3 - xxx
Source: CGE Risk
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1. Safety Reporting
2. Flight Data Monitoring
Two tools for Flight Ops data
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Safety Reporting
Air Sa
fety
Repo
rt
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Human beings, the technology they operate, and the organisation they work within, are the three sets of factorslikely to be “implicated in breaching defenses put in place to avoid accidents.”
J. Reason 1997
Breaching Defenses
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“Hazard and risk management must be data-drivenand involve constant monitoring to either eliminateor reduce the risk to as low as reasonably practicable.”
ICAO 2009, Doc 9859
Risk Management
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Data
The data collected must be systematic, cover all areas of the operation, and have the ability to measure the results of controls put in place […to control risk].
Finally, the focus must first beon the area of highest risk.
ICAO 2009, Doc 9859
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Flight Operations
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1. Human Factors are the primary cause of incidents and accidents
2. Flight is the highest area of risk in operations
3. Flight is the operation of which we have the least amount of information
Bottom Line: Flight Operations
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1. Safety Reporting2. Flight Data Monitoring
Only FDM iscomprehensive and quantifiable
Two tools for Flight Ops data
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1. Records interaction between: the technology (aircraft) and the people (pilots)
2. Analyses interaction for specific events (reactive) undesirable trends (proactive)
3. So the organisation can do something about it…
The Solution: FDM
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FDM – W4’s:1. Who*2. What3. Where4. When
Safety Reporting5. Why
Safety Reporting + FDM = “W5s”
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
ThreatsOrganization
Technology
Humans
Modified from J. Reason 1997
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The Good, the Bad, and the Ugly
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Organisation
Technology
Humans
Protecting Your Assets
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Complaint Management Turbulence Timing Airmanship
Marketing Liability Risk Management Professionalism
Humans (The Clients)
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CEO Peace of mind from actually knowing your
aircraft are being operated in a professional manner.
False accusation Airspace breaches Low flying Poor airmanship
Management Support Non-SOP Flying Requests Documents observations
Procedures Equipment
Humans (The Employees)
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Pre-purchase / Pre-funding: Performance / Efficiency Proper handling Limits maintained
MRO: Faulty Equipment Limits maintained / exceeded Warranty issues
Technology (The Aircraft)
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Return on Investment Protecting your Assets
Marketing Promotion of SMS Risk Management
Monitoring – Quality Assurance Ferry Flights Flight Operations Human Resources
Continuous Improvement Training Programs Enhancement Validation
Efficiencies Fuel efficiency Maintenance
Organisation (The Company)
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Global Helicopter Flight Data Monitoring Community (www.hfdm.org)
International Helicopter Safety Team(www.ihst.org)
UK Civil Aviation Authority - CAP 739 (www.caa.co.uk)
FDM Resources
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The highest risk to an operation is Flight
Without FDM, you really don’t have quality assurance on flight operations
Implement FDM
Wrap Up
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.All rights reserved worldwide. Copyright © 2013 Gael Ltd.
FDM, Risk and Protecting your Assets
Sonya TietjenPrincipal, Safety Management [email protected]