Safety Stream - · PDF fileSafety Stream. Economics of Safety Moderator: ... Captain Craig...

Safety

Stream

Economics of SafetyModerator:

Billy Nolen, Senior Vice President, Safety, Security and

Operations, A4A

Panelists:

John Duncan, Director, Flight Standards Service, Federal Aviation

Administration (FAA)

Alain Lumbroso, Economist, International Transport Forum of the

Organisation for Economic Co-Operation and Development (OECD)

Brian Pearce, Chief Economist, IATA

Thank You to Our Networking Break Sponsor:

Performance-based Regulations ~ Oversight

Moderator:

John Allen, Chief Safety Officer and Vice President, JetBlue Airways

Corporation

Panelists:



John Laughter, SVP Corporate Safety, Security and Compliance, Delta Airlines

Katherine Kendall, Head of Group Quality, Cathay Pacific, Chair IOSA Oversight

Council (IOC)

Panel Discussion -Performance-based

Regulations - Oversight

John Allen | VP Safety

IATA Safety & Ops Conf

7

Performance-based Regulations - Oversight

The Performance-based regulatory ProcessSetting the stage, Performance Based Regulation:

As its name implies, performance-based regulation (PBR) is a

regulatory approach that focuses on performance, as well as

the desired results and outcomes. As such, PBR differs from

the traditional, prescriptive regulatory approach in that it

emphasizes what must be achieved, rather than how the

desired results and outcomes must be obtained. To be

effective, regulatory decision-makers using a PBR approach

must give careful thought to the following questions:

Which results are most desirable?

Which activities (including monitoring) are most likely to yield

the desired results?

8

Performance-based Regulations - Oversight

The Performance-based regulatory ProcessSetting the stage, Performance Based Regulation (PBR):

As its name implies, performance-based regulation (PBR) is a

regulatory approach that focuses on performance, as well as

the desired results and outcomes. As such, PBR differs from

the traditional, prescriptive regulatory approach in that it

emphasizes what must be achieved, rather than how the

desired results and outcomes must be obtained. To be

effective, regulatory decision-makers using a PBR approach

must give careful thought to the following questions:

Which results are most desirable?

Which activities (including monitoring) are most likely to yield

the desired results?

The U.S. Nuclear Regulatory Commission

9

1920s Today

Evolution of U.S. Regulatory Oversight

Regulator

Oversight

Sophistication

licensing

& direct

inspectio

n 1940s

Use of

designee

s

Enhanced rulemaking &

compliance enforcement

1960s 1980s

National Air

Transportation

Inspections (NASIPS)

1990s

Data Analysis &

System Safety

SMS Oversight &

Compliance Philosophy

Support from NRC

NRC Also Adopting

This Philosophy

10

Performance-based Regulations - OversightSMS Interfaces Between Safety Risk

Management and Safety AssuranceIsn’t SMS a performance based rather

than compliance based system?

Is the regulator oversight acumen

changing to provide the appropriate

safety assurance in light of:?

• Compliance Philosophy

• Just Culture

• Change Management

• Safety Risk Management

• Safety Assurance

How is the relationship between the

airline and the regulator changing in the

performance-based SMS environment?

Is IOSA complementary, additive, or in

conflict with SMS quality?

Performance-based Regulations ~ Oversight

Moderator:


Corporation

Panelists:



John Laughter, SVP Corporate Safety, Security and Compliance, Delta Airlines

Katherine Kendall, Head of Group Quality, Cathay Pacific, Chair IOSA Oversight

Council (IOC)

Performance-based Regulations ~

Oversight

John Duncan

Director, Flight Standards Service

Federal Aviation Administration (FAA)


Oversight

John Laughter

SVP Corporate Safety, Security and Compliance

Delta Airlines

Safety Risk Management Safety Assurance (SRMSA)

John LaughterSVP Corporate Safety, Security, Compliance

DELTA AIR LINES, INC.

OVERVIEW


OVERVIEW

• Background (Why)• Program Structure (How)• Benefits/Challenges• Way Forward


BACKGROUND


SRMSA OBJECTIVE

Enhance data sharing and cooperative efforts between Delta and the FAA

in order to further aviation safety through risk-based, data-driven decision making

in support of a fully functional Safety Management System (SMS)


SAFETY CULTURE

Encourage open hazard reporting, collaborative and continuous data analysis, risk-based decision making, and safety data sharing

SWOA

LOSA

ASAP

Hotline

Audits/IEP/Investigations

FDM FOQAVPP

Industry Data STEADES ASIAS

SWOA LOSA

SRMSA


SAFETY ASSURANCE DATA


PROGRAM STRUCTURE


STRUCTURE

Noncompliance Discovered(No Enforcement Action)

FAA Access to Delta Data

Delta Access to FAA Data

FAA Participates As Desired/Requested

Enhances Collaboration, Prioritization of Resources, and Risk-Based Decisions

Voluntary Self DisclosureProcess

Corrective Action Monitoring

FAA Access to Delta Data

Delta Access to FAA Data

FAA Participates As Desired/Requested

Prompt Notification


CRITERIA

1. Be inadvertent and must not appear to involve criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification.

2. The apparent violation does not indicate a lack, or reasonable question, of qualification of the certificate holder.

3. Immediate action, satisfactory to the FAA, is taken upon discovery to terminate the conduct that resulted in an apparent violation.

4. The certificate holder has developed or is developing a comprehensive fix and schedule of implementation satisfactory to the FAA. The comprehensive fix includes a follow up.


DATA COLLECTION


Share safety information

Communicate cross-divisional concerns

Develop safety risk mitigation strategies

Airport Customer

Service/Cargo

Operations / Customer

Center

Flight Operations

In-Flight ServiceTechnical

Operations

Integrated Safety Round Table (ISRT)

Safety PromotionSharing and Communicating


BENEFITS / CHALLENGES


BENEFITS / CHALLENGES

• Better Communication and Understandingof safety issues

• Improved Risk Management

• Prioritized List of Hazards to allocate resources

• Improved Allocation of Resources

• Continual Improvement in the level of safety throughout the carrier’s SMS by working collaboratively

• Utilize FAA and Delta data to promote an environment and a set of practices that best Fosters Safety and Compliance through Open Sharing of data

• Select the Best Set of Processes to prevent noncompliance of incidents

• Handling of Repeat Violations

• Cultural Shifts (Delta and FAA)

Benefits Challenges


WAY FORWARD


WAY FORWARD

• Processing of all risk and safety issues by the carrier

• Carriers use Safety Risk Management processes (SMS) for non-compliance and other safety issues

• Simplifying risk management onto a single platform

• FAA is a full partner during safety risk sessions

• Full access for FAA of Delta’s Safety and Operational Systems


Thank You


Oversight

Katherine Kendall

Head of Group Quality, Cathay Pacific

Chair IOSA Oversight Council (IOC)

IATA Operational Safety Audit

Presented by: Kathy Kendall, Cathay Pacific Airways, Chairperson IOC

IOSA Program – History

Program development was initiated in 2001

First Audit conducted in September 2003

Some Highlights Since Inception

Upgrade of Standards to include all cargo operations and passenger

flights without cabin crew

In 2010, upgrade of Standards to incorporate all elements of SMS

contained in the ICAO Framework for SMS

E-IOSA introducing continuous internal assessments (special project and

BMA)

34

IOSA Program – Purpose

35

Reduce the number of audits in the airline industry

Improve worldwide airline safety levels

IOSA Program Overview

Some 950 IOSA Standards and

Recommended Practices (ISARPs) include

ICAO safety and security provisions and

industry best practices from ICAO Annexes

1, 2, 6, 8, 17, 18 and 19

ISARPs revised annually by 94 SMEs from

IOC and IOSA Technical Groups

Available to all commercial passenger &

cargo airlines, regardless of IATA

membership status

36

Americas

92

Europe

165

Africa & Middle East

66Asia-Pacific

61

China & North Asia

34

Statistics - IOSA Registered

AirlinesDisplayed online to public (www.iata.org/registry)

Data: April 19 2017

Total: 418

Airlines

37

http://www.iata.org/registry

38

IOSA Vision

To be the leader of operational safety auditing in an accident-free world.

Strategic Pillars

Safety Support and uphold improvement

of global safety levels through implementation of IOSA

Maintain and advance IOSA as world's leading operational safety Standard

Support consistent implementation of SMS

Adopt applicable ICAO safety requirements from the Annexes to the Convention on International Civil Aviation

Effectiveness Minimize the number of

redundant audits through effective use of IOSA

Continuously improve effectiveness of IOSA Program processes and protocols

Ensure robust Audit Program infrastructure is in place

Constantly seek opportunities to simplify the program processes

Integrity Protect and promote the

integrity of the IOSA Program Apply and continuously

strengthen control over Audit processes

Operate in full alignment with IATA's vision and mission

Exercise effective oversight over Audit Organizations

39

Enhanced IOSA

Background

Enhanced IOSA as response to industry’s feedback

Program change to focus on the implementation aspect of Standards

and ensure continuous conformity

Implementation was a transitioned approach for full implemention by

September 2015

Enhanced IOSA applicable to all renewal audits

Four Pillars

Enhanced IOSA will facilitate the incorporation of four pillars in airline operations:

40

Auditing

Standardization

Reliability of

Airline’s Quality

Assurance

Functions

Continuous

Conformity with

IOSA Standards

Focus on

Implementation

of IOSA

Standards

Enhanced IOSA

41

IOSA and Regulators

ICAO Endorsement

35th Session of ICAO Assembly:

“recognized value of IOSA as complementary measure to the regulatory oversight activities of States.”

and stated that IOSA

“.. will need the continued support of regulatory authorities worldwide..”

42

IOSA and Regulators

ICAO Endorsement

38th Session of ICAO Assembly:

“The Commission expressed its support for the IOSA programme and recommended that ICAO continue its support of IOSA and the additional elements under Enhanced IOSA as a complementary source of information for State safety oversight activities.”

43

IOSA and Regulators

Complementary to

ICAO USOAP Program

AMC to EASA

regulations for Code-

Share arrangements, as

source for evaluation of

TCOs and for risk-

based oversight of EU

CAAs

ICAO/EASA FAA/ CAAC

Accepted by FAA

under DOT/FAA

Code-share Safety

Guidelines

CAAC Advisory

Circular for code-

share safety audits

Other Regulators

Trafi Finland reduces

national oversight cycles

using IOSA audit results

Turkey, Chile,

Madagascar, Brazil,

Costa Rica, Panama,

etc. support and use

IOSA

Focus on IOSA Strategic Pillars – Effectiveness and Integrity

Continuous Improvement

44

EASA uses IOSA for three different purposes

As result, EASA conducted assessment of IOSA program in Feb 2016

Recommendations are being addressed through action plan (BMA)

EASA Assessment 2016

45

Subgroup of the IOC conducted an assessment of IATA QA programs

in 2016

Recommendations are being addressed through action plan and have

been integrated and aligned with EASA recommendations (BMA)

IOC Assessment of IATA Quality 2016

46

47

Interrelationship of all Quality Activities

- Historical Auditor audit assignments

- Auditor assessments

- Auditor qualifications

- Auditor QC performance

- Auditing techniques - Evidence sampling- Technical assessments

- Risk Model- Performance

monitoring- Data extraction- Audit results &

data analysis

Data, Risk, Performance driven Quality Activities

Digital Transformation Project Vision

Data Management Approach

IOSA as Collaboration Platform

Digital Re-mastering of the Audit Program and Quality

Assurance Processes

48

49

THANK YOU

Performance-based Regulations – Oversight

Moderator:


Corporation

Panelists:



Katherine Kendall, Head of Group Quality, Cathay Pacific, Chair IOSA

Oversight Council (IOC)

John Laughter, SVP Corporate Safety, Security and Compliance, Delta

Airlines

Workshop LuncheonPresented by:

Opening the Walled Garden:

GE’s Leading-Edge Approach to Flight Analytics

Namsan II Room, Level Two

12:30 – Lunch Provided

Maintenance SafetyModerator:

Michel Gaudreau, Senior Vice President of Corporate Safety, Security, and

Compliance, Korean Air

Panelists:

Martin Eran-Tasker, Technical Director, Association of Asia Pacific Airlines

(AAPA)

Captain Craig Hoskins, Vice President for Safety and Technical Affairs,

Airbus Americas

Rick Howell, General Manager, Group Safety and Security, Cathay Pacific

Dr. William Johnson, Chief Scientific and Technical Advisor, Maintenance

Human Factors, Federal Aviation Administration (FAA)

Maintenance Safety

Dr. William Johnson

Chief Scientific and Technical Advisor,

Maintenance Human Factors

Federal Aviation Administration (FAA)

Topic 1:Fleet Age and Human Factors Hazards

Dr. Bill Johnson

Chief Scientific and Technical Advisor


[email protected]

678.777.3873

Federal AviationAdministration

People who perform the job

Environment for work - Organizational and physical

Actions (tasks) performed for job

Resources like equipment, tools, procedures, and more

Pear.wmv

Topic 2:Maintenance Practices – Ensuring Compliance

Dr. Bill Johnson

Chief Scientific and Technical Advisor


[email protected]

678.777.3873

Federal AviationAdministration

“Everybody talks about

the weather, but nobody

does anything about it.”

Charles Dudley Warner, 1875

Five Slides

Challenges

R&D

Solutions

Compliance Challenges

# 1 Cause in Human Error Study ( Johnson, et al , 2000)

#1-2 of 10 Top Contributing Factors to Error (UKCAA, 2004)

31% MX Error, 51% Follow Procedures (Walker 2005. Oil Rigs)

#1 Cause of FAA letters of Investigation (FAA, 2015)

Research and Development

FAA HF R&D (1989-2004…)

Technical Publications Workshop

FAA Operator’s Manual

CAST SE 170 (2016)

See:www.humanfactorsinfo.com

SolutionsInsure root causes analyses

Quantify financial loss

Leverage voluntary reports

Process improvement

Take this challenge seriously

CULTURE-LEADERSHIP-COMMITMENT

Thank You,

Dr. Bill Johnson

Maintenance Safety

Rick Howell

General Manager, Group Safety and Security

Cathay Pacific

Maintenance Errors – One of SG Top 10 Issues

“Noncompliance with maintenance procedures

poses a risk to global aviation. Establishing an

enhanced understanding and communication of

human factor related issues in the aircraft

engineering and maintenance environment is

essential.”

The Challenge & Opportunity

Although maintenance errors low contributor to

accidents (2008-2016 = 11% of accidents) failure

modes often require mitigation by flight crews &

therefore, reducing the number of events will

enhance safety by negating the use of the ‘last line

of defense’

IATA Survey on Maintenance Errors

IATA therefore commissioned an exploratory study

into ‘maintenance errors’ by Dr. Martin Smith, CEO

Presage Group Inc.

Some ‘initial’ findings are as follows:

Global Maintenance Error Study

Despite great efforts to engage the response rate was very low plus very low scores obtained on the culture of compliance indicates a systemic problem within the maintenance industry showing that maintenance errors do present a significant threat

Only 53% of respondents felt that their company supports safety when competing with commercial outcomes (i.e. maintaining operational schedules, etc.)

Study showed that those individuals who admitted to non

compliance scored lower on all aspects of situational awareness

(SA) that those that stated they were compliant

In addition those admitting non-compliance also scored lower

when compared to other airline employee groups (i.e. flight crews)

Findings indicate maintenance employees perform critical work

functions and activities without the necessary level of SA to

maintain safety, utilize effective risk management strategies and

maintain operational compliance

The findings indicate that respondents are not listening to or engaging their instincts to effectively monitor safety and compliance to procedures

Contributing factors supporting these findings are complacency, stress around timelines, and multiple distractions

Other factors, such a reliance on experience (I’ve done this many times before!), which 58% of respondents noted, can drive an otherwise professionally minded technician away from following documented processes and completing tasks from memory

Summary

Low response rate

Low adherence to SOP’s is common

Currently no effective management oversight and/or effective engagement of this problem

No surprises here! Has not changed much over time

NEXT STEPS: the full survey results are being presented to OPC for determination of a suitable way forward

Event 1: Classic ‘event’ from airline perspective – why do we

not learn?

In Aug 2015, A330-300 was modified by AEO to comply with EASA AirwothinessDirective (AD)

On 19 Aug 2015, while enrouting from TPE-NGO, the flight crew detected an anomaly during the routine system scan - the Yellow Hydraulic System indicated in the amber band without ECAM warning. The Blue Hydraulic System was between the green band and amber band and the indication slowly decreased until the ECAM low level warning was triggered.

The aircraft was diverted to (KIX) Osaka and landed safely, vacated the runway and stopped on the adjacent taxiway. Emergency services reported leaking hydraulic fluid. The aircraft was shut down and towed to the apron

What happened

Maintenance had been carried out by MRO concurrently all three hydraulic systems prior to the flight

The maintenance involved the replacement of the HP manifold check valves of all three hydraulic systems at the same maintenance input

They were installed with the transit ‘O’ ring instead of the correct ‘O’ ring seal which resulted in the hydraulic leaks

In addition, back up ring found missing on BLUE and GREEN systems 5 additional aircraft had also been modified and were immediately

inspected 1 aircraft found in same condition where transit ‘O’ rings had not been

replaced on all 3 systems

The Component

Findings

MRO did not follow Procedures, AEO Accomplishment Instructions and did not assign different maintenance teams

No ETOPS note on the AEO

Focused on the technical instruction steps

Lapsed - Hydraulics manifold is part of Critical Systems

Why do we not learn…………………………………………….?

Event 2: A321 Tail-strike on touchdown……..

The approach was normal and stable throughout

Flare was normal and touchdown unremarkable. Pitch angle 4.6 degrees andground spoilers out

2 seconds after touchdown, faults related to the ELAC* (DIRECT PITCH LAWand L/R aileron fault) occurred and appeared on ECAM, and the aircraftreverted to DIRECT PITCH LAW

The tail contacted the surface of the runway when the aircraft pitch attitudeincreased rapidly (within 2 sec) and to 11.3 deg, which exceeded the A321 tailcontact geometry limits of 9.5 deg

ENG inspections of aircraft confirmed that the damage was limited to external abrasion of the fuselage skin panels in the underside ofthe aft tail section area, and minor damage to two underlying stringers.

External fuselage skin damage only from FR64 to FR69Max Length = 10ftMax Width = 19”

Confidential / Restricted distribution

Findings – New threats

The tail strike was the result of the combination of factors:

Direct law engagement leading to deactivate the nose down pre-command,available in normal law, that counters the pitch up effect of the groundspoilers’ deflection.

The degradation to the Direct Law was induced by an Elevator and AileronComputer (ELAC) fault (software issue) during this critical phase of flight,

ELAC 97 software installed but ELAC 98 available but not installed. ELAC 98removed the potential of this occurring but was not a mandatory SB. Is thisa (management / risk assessment) maintenance error?

We have not learnt to handle ‘classic’ ME situations yet and now we have‘new’ types of ME to manage

Maintenance SafetyModerator:

Michel Gaudreau, Senior Vice President of Corporate Safety, Security, and

Compliance, Korean Air

Panelists:

Martin Eran-Tasker, Technical Director, Association of Asia Pacific Airlines

(AAPA)

Captain Craig Hoskins, Vice President for Safety and Technical Affairs,

Airbus Americas

Rick Howell, General Manager, Group Safety and Security, Cathay Pacific

Dr. William Johnson, Chief Scientific and Technical Advisor, Maintenance

Human Factors, Federal Aviation Administration (FAA)

Thank You to Our Networking Break Sponsor:

Ground Ops SafetyModerator:

Max Corsi, Head, Ground Operations, Air Transat, Chair ISAGO

Oversight Council (GOC)

Panelists:

Stephen Creamer, Director Air Navigation Bureau, ICAO

Ashish Jain, Senior Vice President Network Operations, Qatar

Airways

Yogesh Parekh, Head of Internal Audit (Operations), John Menzies

Plc

Tim Steeds, Director of Safety and Security, British Airways

ISAGO Registered Provider - Performance

Unsustainable Growth

2235 37 38 35 44 44 43 4137

108 116134

155

193215

253 252

2

28

105121

175

240

298

351

428

0

50

100

150

200

250

300

350

400

450

2008 2009 2010 2011 2012 2013 2014 2015 2016

Pool Members Audits Performed Stations on the Registry

The New

WHAT WILL IT LOOK LIKE?

IATA

Charter

of

Professional

Auditors

GOA

GOA

GOA

GOA

IATA

GSP Audit Requests

– Annual Allocation

Professionals

Trained and

Qualified by IATA

Entities Contracted

by IATA to

Administer AuditsFunding

GSPs

Airlines

Purchase of an

Audit Report

IATA Administration and Oversight

Audit

Registration

Fees

Audit Report

Sales

ISAGO – New Operational Audit Model

What’s in it for me?

Self-Regulatory environment

Reduction of risk in Ground

Operations

Driving global harmonization

and standardization

Cost sharing model

Transparent Registration

scheme of Providers

Validation of SMS

implementation by Providers

Duplicate audits reduction

Transition plan

Ground Ops SafetyModerator:

Max Corsi, Head, Ground Operations, Air Transat, Chair ISAGO

Oversight Council (GOC)

Panelists:

Stephen Creamer, Director Air Navigation Bureau, ICAO

Ashish Jain, Senior Vice President Network Operations, Qatar

Airways

Yogesh Parekh, Head of Internal Audit (Operations), John Menzies

Plc

Tim Steeds, Director of Safety and Security, British Airways

(2008-2017)

(2018 and Beyond)

IATA-Led Workshops

Flight Data Connect – Namsan V

Insight into IATA ’s Operational Efficiency Tools –

Namsan II

Integrated Management Solutions (IMX) – Namsan I

SkyFusion – Namsan VINote: All rooms are located upstairs on Level Two.

Conference DinnerSponsored by:

Location: Grand Ballroom

Time: 19:30

Please Bring Your Ticket for Entry

Safety Stream - · PDF fileSafety Stream. Economics of Safety Moderator: ... Captain Craig...

Documents

Transcript of Safety Stream - · PDF fileSafety Stream. Economics of Safety Moderator: ... Captain Craig...