Flybe SMS and Flight Data Analysis

21/05/2009

Captain Neil Woollacott

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The Flybe Fleets

Q400

E 195

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Flybe Today

Serving 13 countries;

Over 190 routes flown;

Operating from 36 UK and 30 European

airports;

Largest airline at 9 UK airports by flights;

7.5m passengers 2008.

Revenues of £536m in 2007/08, record

profits of £35.4 million.

Fourth most spontaneously recalled

aviation brand in the UK;

Operating 73 Aircraft;

Over 500 flights a day.

Flybe is Europe’s largest and most successful regional airline

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The Company encourages all personnel to report any event which is considered to

be in the interests of Flight Safety

SafetyNet is a tool that enables pilots to submit safety reports which come through to the flight safety department where we can quickly access the details and begin

investigations.

THE COMPANY FOLLOWS A

A JUST CULTURE

How Flybe’s Safety Reporting System work’s

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The Safety Coordinator will o Cross reference will the CAP382o Determine the descriptor & Risk

Crew will submit ASRs on SafetyNet

Safety & Quality will submit EORs on SafetyNet

Safety & Quality will submit GORs on SafetyNet

Require additional information

MORs Closures

Closure Report is submitted onto the Public Summary

No additional information required

Investigation findings are submitted to the Safety/ Quality Department who reviews and completes a compliance check

Fleet Managers

CAA

Aviation ServicesCabin Safety Ground Safety EngineeringFlight Safety

Flight Safety

25/11/08

MORs

ASRsEORsGORs

Ground Safety Engineering

The investigation is allocated an owner

Safety Report Process

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Crew Complete an ASR

Central Safety will determine which department the ASR will go to and then cross reference it with the CAP 382 to establish whether it is reportable under the MOR scheme

MOR reports are emailed to the CAA

Incidents are sent through SafetyNet as an e-mail in a PDF format to the relevant external investigator e.g. ATC .

Providing that we have all the details a full investigation is carried out. Notes and action responses are entered into SafetyNet

When flight safety is satisfied that an investigation is complete, it is closed

Air Safety Reporting Process

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SafetyNet

Full electronic reporting system

Fully transportable

Easy to use

Full audit trail

Full trend facilities

Use at remote locations

Direct link with Flight Data System

Many default form types e.g Airprox,Birdstrike.

Approved Use by the CAA.

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Ensure that everyone understands safety responsibilities. Develop and maintain a culture of safety Equip people to carry out their tasks safely Identify and minimise risks to safety and health Develop safe systems of work The Company promotes safety with others Plans to mitigate the consequences of Accidents & other emergencies Monitor safety performance

Objectives and Goals of the Safety Management System

Operational Safety Meeting (monthly)

Chair : Director Safety, Quality & Training

Vice Chair : Head of Safety & Quality

Director Aircraft OperationsDirector Aviation Services

Post HoldersSafety Coordinators

HS&E DirectorSMS Admin

Chief Officer (as required)

Postholder Safety Meetings (monthly)

Flight OpsMaintenanceGround Ops

Health and Safety

Postholders,Safety Coordinators

Department Managers (as required)

Production MeetingOperating Board

(monthly)Chief Operating Officer

Flybe Group Board

Flybe Safety Committee

(Quarterly Oversight)Non-Exec Director

Central Safety Management System

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The Flybe Top 5 Safety Concerns

FLYBESAFETY PLAN

Loading Errors

Q400 Landing Gear

Altitude Deviations

Human Factors/DisciplineGround De-Icing

Effectiveness

On analysing the safety statistics the Operational Safety Meeting have complied five key areas that pose the highest safety risk to the company.

Flybe intends to focus on these key areas during 2009/10 within the Safety Plan

Medium & High RiskThe probability that the company will have a high risk event

is remote in 2009/10

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HAZARD IDENTIFICATION

EVALUATION OF SCENARIOS AND CONSEQUENCES

QUANTIFY RISK

DECISION MAKING

IMPLEMENTATION AND MONITORING

RISK ANALYSIS & ASSESSMENT

DATA COLLECTION

The core of the Product Safety The core of the Product Safety Monitoring Process is the RISK Monitoring Process is the RISK ANALYSIS & ASSESSMENT.ANALYSIS & ASSESSMENT.

Risk Analysis & Product Safety Monitoring

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P r

i o

r i t

y

No Safety Relevance

Potential for Primary cause for an accident

Causing Operational disturbance

Eventual Reduction on Safety Margin

Potential contributing factor of an Accident

Safety Concern

No Safety Concern

The traditional approach divided the issues into Safety Concern and No Safety Concern categories. This approach is very subjective and does not establish priorities for safety related issues.

Establishing Safety Priorities

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Severity ClassificationProbability

Levelx = RIRI+ Level of control

Reflects the uncertainty regarding assumptions made and the knowledge and control of the related technology.

Severity Classification 1 – Minor (Slight reduction of safety margins) (Routine changes of flight plan)

2 – Major (Significant reduction of safety margins) (Reduction of crew ability to cope with situation) (Phisical effects / injuries to occupants)

3 – Hazardous (Large reduction of safety margins) (Crew cannot be relied upon to implement defenses) (Injuries / death of small proportion of occupants)

4 – Catastrophic (possible loss of airplane with multiple fatalities)

Probability Level

5 – Frequent ( P 10-3 )

4 – Probable ( 10-3 to 10-5 ) May occur one or more times during the operational life of each airplane of the fleet

3 – Remote ( 10-5 to 10-7 )Unlikely to occur to each airplane, but may occur several times during the operational life of the fleet

2 – Extremely remote ( 10-7 to 10-9 ) Not expected to occur to each airplane, but may occur a few times during the operational life of the fleet

1 – Extremely improbable (P 10-9 )Not expected to occur 

PRELIMINARY RISK INDEX CALCULATION

Establishing Safety Priorities – Risk Index

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P r

i o

r i t

y

No Safety Relevance

Potential for Primary cause for an accident

Causing Operational disturbance

Eventual Reduction on Safety Margin

Potential contributing factor of an Accident

I n

d e

x

14

13

12

11

10

9

8

7

6

5

4

3

2

Immediate Action Required

Action for Risk Reduction

Improve System Reliability

Monitor

Using the Risk Analysis Tool, each issue receives an index number, indicating the related priority.

Establishing Safety Priorities

A

B

C

D

E

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  Immediate Risk Reduction

Risk Reduction System Review

RI 14 13 12 11 10 9 8

Define Action 12 hours

2 days

3 days

1 Months

2 Months

3 Months

6 Months

Action Availability

24 hours

4 days

1 week 2 Months

3 Months

6 Months

18 Months

Time for Action Accomplishment

Next Flight

50 FH

100FH

A*- 5A*

5A*- C*

1 C*

2 C*

* Consider the equivalent to the “A” or ”C” check flight hour interval for the applicable fleet

Time-Reference Table for Action Planning

Using the RIUsing the RI, the safety priority of each issue can be directly perceived by all , the safety priority of each issue can be directly perceived by all involved areas of the company using a involved areas of the company using a Time-ReferenceTime-Reference chart: chart:

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FDM

Flight Data Monitoring

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What Is FDM ?

Definition“A systematic method of accessing, analysing

and acting upon information obtained from digital

flight data records of routine operations

to improve safety”

FDM involves the pro-active use of flight data to identify and address operational risks before

they can lead to incidents and accidents

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Why use FDM ?

The Heinrich Pyramid

Accidents

UnreportedOccurrences

Incidents

Accidents

UnreportedOccurrences

Incidents

FDM Incidents

For every major accident there are several less significant

accidents, hundreds of reportable incidents and thousands of unreported

Occurrences

FDM gives more detail on the incidents, encourages more

consistent reporting and fills in the void that

we know very little about

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Important Ingredients

Important ingredientsA non-punitive company policy/open safety culture

The Flight Safety Manager must be

Trusted by crews to be impartial and maintain confidentiality

Supported and trusted by management

The system and its technology will be worthless

(or destructive) if the human factors are wrong

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Typical Management Process

Flight Data

Flight Safety ManagerData Replay, Analysis

and Verification Cross check BASIS

Review Meetings:FSM, Fleet Training Mgr (all data de-identified)

Changes to Procedures,

Manuals, Training and Flight Safety Investigations

BesafeMag

TelephoneCrew

REMOTE BASES

Download To PC

MAIN BASES

Replay & Analysis System

Back-up System

WLAN

The Ground-Based System

WAN data

transfer

Maintenance &

Development

Program development

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Analysis System

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Flight Data Analysis

Event analysisDetects exceedences of pre-defined operational

envelopes and provides information on the extremes of the operation.

Measurement analysisTakes a set of measurements on every flight

and provides information on the whole operation – quantifies normality

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Benefits

Pilot knowledge & skill

Gaps in the training system

Operating procedures

Environmental operating limitations

CRM

Culture at remote operating bases

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Feed Back - Training

Another deep landing

FDM lessons can be fed back into the training process

Information can identify areas for improvements in training

Events can be used to highlight key safety-related points

Data can be used to improve pilot techniques

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Feed Back - Engineering

Enables continuous checking of FDR parameters

Data can be used to troubleshoot pilot reported problems (e.g. event created to trap intermittent engine fault)

Data can be used to assess structuralimpact of events (e.g. hard landing)

Data can be used to detect misuse which could impact reliability

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Summary

FDM provides valuable information on the

risks associated with new areas of operation

Events can identify hazards which otherwise

may not come to light

The Company can take appropriate corrective

and preventative measures

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Summary

The measurements will build a useful picture

of everyday operations which has not previously

been available

The FDM programme gives us a pro-active

use of flight data which significantly enhances

the safety of our operation.

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Q400 Trend

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Long Flare – Location

THANK YOU