FDM, Risk - IHST
FDM, Risk - IHST
FDM, Risk - IHST
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Sonya Tietjen<br />
Consultant, Aviation Safety<br />
26 September 2013<br />
London, UK<br />
<strong>FDM</strong>, <strong>Risk</strong><br />
… and Protecting your Assets<br />
1
Agenda<br />
1. The Problem<br />
2. The Solution<br />
3. The Benefits<br />
1. <strong>Risk</strong> Management<br />
2. Flight Data Monitoring<br />
3. Protecting Your Assets<br />
2
NTSB Report<br />
1. The flight crew made<br />
numerous procedural<br />
errors and deviations<br />
during the final approach<br />
segment of the VOR/DME<br />
approach.<br />
2. The crew demonstrated<br />
poor crew coordination<br />
during the accident flight.<br />
3. The flight crew was under<br />
pressure to land.<br />
3
Causal Factors - Primary<br />
<strong>IHST</strong> 2006 (JHSAT)<br />
Flight Crew<br />
4
The Problem?<br />
5
How accidents happen<br />
Threats<br />
Organization<br />
Technology<br />
Humans<br />
Modified from J. Reason 1997<br />
6
BowTieXP: Loss of Separation<br />
Loss of Spacial<br />
Awareness<br />
Medical fitness and 6 monthly<br />
tests.<br />
Ref? - Reference to be added<br />
Simulator training including<br />
recovery from unusual<br />
attitudes<br />
Ref? - Reference to be added<br />
Maintenance of an effective<br />
look-out<br />
RAP 1 - xx<br />
Two Crew operations<br />
Ref? - Reference to be added<br />
Flight crew mishandling<br />
and mismanagement of<br />
the flight<br />
Compliance with procedures<br />
and checklist<br />
OM Pt.8 - Unit Orders<br />
Effective cross cockpit<br />
communication<br />
OM Pt.6 Sct.1 - Definitions,<br />
Rules and Requirements<br />
Crew flight planning for other<br />
aircraft operations in the<br />
operational zone<br />
OM Pt.8.Sect 3.23 - Summary<br />
to Offshore Operations<br />
(AS332L1)<br />
Multi crew ops including<br />
challenge and response<br />
OM Pt.5 Sct.1.1 - Duties of<br />
Captain and First Officer<br />
Training and testing (Line<br />
Checks)<br />
TM Pt.4 - Operation Line<br />
Training<br />
TM Pt.4 Sct.1 - General<br />
Training and testing (Base<br />
checks)<br />
TM Pt.4 Sct.1 - General<br />
H-02.01.01 Aircraft in<br />
motion (1)<br />
Aircraft System failures<br />
MEL controls for limiting<br />
departures with<br />
unsevicabilities<br />
MEL - Minimum Equipment List<br />
routine preventitive<br />
maintenance<br />
MS - Aircraft Mainteance<br />
Schedule<br />
Repetitive defect<br />
management<br />
MOE Pt.2 Sect.2.14 - Technical<br />
record control<br />
Flight Manual Emergency<br />
Check List actions<br />
FM Sct.3 - Emergency<br />
Procedures<br />
Ineffective Air Traffic<br />
Management<br />
GPS flight Tracking<br />
RAP 1 - xx<br />
Provision of area information<br />
(NOTAMS)<br />
AIP.Vol 1. GEN 3.3 - Air Traffic<br />
Services<br />
In field traffic communication<br />
OM Pt.2 Sct.1.3.4.10 -<br />
Helicopter Operations<br />
Personnel Manning<br />
Effective provision of area<br />
contol of air traffic<br />
management<br />
AIP.Volume 2 - Aerodrome<br />
(AD)<br />
D - Aircraft In motion<br />
'Airborne': HE-20E<br />
Loss of separation<br />
with third party<br />
aircraft<br />
Identification of Opposing<br />
traffic<br />
SID Sect.04 - Listing of<br />
Interface Activities<br />
Establish Communication<br />
with opposing traffic<br />
SID Sect.07 - Hazard Register<br />
AIP.Vol 1 ENR 2 - Air Traffic<br />
Services Airspace<br />
Take avoiding action<br />
OM Pt.8.Sect 9 - Emergency<br />
Procedures<br />
Airborne contact with<br />
opposing traffic, Loss of<br />
aircraft and/or multiple<br />
fatality<br />
C5 C5 C3 C5<br />
Operations in adverse<br />
weather<br />
Procedure (weather minima)<br />
Ref? - Reference to be added<br />
Weather (Flight Operations<br />
Limitations)<br />
Ref? - Reference to be added<br />
Actual Weather<br />
Reports/Information<br />
RAP 2 - x<br />
Training (interpretation of<br />
weather information, and<br />
weather avoidance)<br />
RAP 3 - xxx<br />
Maintenance of Situational Installation and use of TCAS<br />
Awareness<br />
OM Pt.2 Sct.12.34 - Adherence<br />
To Operating Procedures and<br />
Co-Pilot's Responsibility<br />
CAR 1996 and AIP<br />
requirements for standard<br />
collision avoidance actions<br />
MCAR Pt.11 Chap.2 -<br />
Regulation of Movement Area<br />
Incorrect avoiding action<br />
taken<br />
Failure to learn from<br />
experience<br />
Failure to install available<br />
safety improvement<br />
system or to learn from<br />
experience<br />
Equipment Standardisation<br />
and acceptance checks<br />
QAM.7.5 - H<strong>FDM</strong> Process<br />
Installation of Traffic<br />
avoidance systems (TCAS)<br />
RAP 4 - xxxxx<br />
Common Frequency for Blind Call on Guard frequency<br />
aircraft in the operational<br />
121.5 MHz<br />
zone<br />
Ref? - Reference to be added<br />
Ref? - Reference to be added<br />
Failure to establish<br />
communications with<br />
opposing traffic<br />
Non-compliance with<br />
mandatory requirements<br />
(levels and distance) for<br />
seperation with third party<br />
aircraft.<br />
Training and testing (Base<br />
checks)<br />
TM Pt.4 Sct.1 - General<br />
Training and testing (Line<br />
Checks)<br />
TM Pt.4 - Operation Line<br />
Training<br />
TM Pt.4 Sct.1 - General<br />
Multi crew ops including<br />
challenge and response<br />
OM Pt.5 Sct.1.1 - Duties of<br />
Captain and First Officer<br />
HSE Management Review<br />
Board process<br />
Ref? - Reference to be added<br />
Effective cross cockpit<br />
communication<br />
OM Pt.6 Sct.1 - Definitions,<br />
Rules and Requirements<br />
Occurrence reporting system<br />
Ref? - Reference to be added<br />
Multi crew ops including<br />
challenge and response<br />
OM Pt.5 Sct.1.1 - Duties of<br />
Captain and First Officer<br />
QA Audit of line management<br />
actions to resolve findings<br />
Ref? - Reference to be added<br />
Compliance with procedures<br />
and checklist<br />
OM Pt.8 - Unit Orders<br />
Line management action to<br />
resolve findings<br />
Ref? - Reference to be added<br />
Organisational Discipline<br />
Ref? - Reference to be added<br />
Lack of visual<br />
meteorological conditions<br />
(VMC)<br />
Installation and use of TCAS Division of workload (handling Maintenance of Situational<br />
and non-handling pilots) IMC<br />
Awareness<br />
RAP 3 - xxx<br />
and VMC<br />
OM Pt.2 Sct.12.34 - Adherence<br />
OM Pt.6 Sct.2.3 - Division of To Operating Procedures and<br />
Crew Duties During Flight in Co-Pilot's Responsibility<br />
I.M.C.<br />
RAP 4 - xxxxx<br />
7<br />
Source: CGE <strong>Risk</strong>
Two tools for Flight Ops data<br />
1. Safety Reporting<br />
2. Flight Data Monitoring<br />
8
Safety Reporting<br />
9
Breaching Defenses<br />
Human beings, the technology<br />
they operate, and the<br />
organisation they work within,<br />
are the three sets of factors<br />
likely to be “implicated in<br />
breaching defenses put in place<br />
to avoid accidents.”<br />
J. Reason 1997<br />
10
<strong>Risk</strong> Management<br />
“Hazard and risk management<br />
must be data-driven<br />
and involve constant monitoring<br />
to either eliminate<br />
or reduce the risk to<br />
as low as reasonably<br />
practicable.”<br />
ICAO 2009, Doc 9859<br />
11
Data<br />
The data collected must be<br />
systematic, cover all areas of the<br />
operation, and have the ability to<br />
measure the results of controls put<br />
in place […to control risk].<br />
Finally,<br />
the focus must first be<br />
on the area of highest risk.<br />
ICAO 2009, Doc 9859<br />
12
Flight Operations<br />
13
Flight Ops: Bottom Line<br />
1. Human Factors are the<br />
primary cause of incidents<br />
and accidents<br />
2. Flight is the highest area<br />
of risk in operations<br />
3. Flight is the operation of<br />
which we have the least<br />
amount of information<br />
14
Two tools for Flight Ops data<br />
1. Safety Reporting<br />
2. Flight Data Monitoring<br />
Only <strong>FDM</strong> is<br />
comprehensive and<br />
quantifiable<br />
15
The Solution: <strong>FDM</strong><br />
1. Records interaction between:<br />
– the technology (aircraft)<br />
– and the people (pilots)<br />
2. Analyses interaction<br />
– for specific events (reactive)<br />
– undesirable trends (proactive)<br />
3. So the organisation can do<br />
something about it…<br />
16
Safety Reporting + <strong>FDM</strong> = “W5s”<br />
• <strong>FDM</strong> – W4’s:<br />
1. Who*<br />
2. What<br />
3. Where<br />
4. When<br />
• Safety Reporting<br />
5. Why<br />
17
Threats<br />
Organization<br />
Technology<br />
Humans<br />
Modified from J. Reason 1997<br />
18
The Good, the Bad, and the Ugly<br />
19
Protecting Your Assets<br />
– Organisation<br />
– Technology<br />
– Humans<br />
20
Humans (The Clients)<br />
– Complaint Management<br />
• Turbulence<br />
• Timing<br />
• Airmanship<br />
– Marketing<br />
– Liability<br />
– <strong>Risk</strong> Management<br />
– Professionalism<br />
21
Humans (The Employees)<br />
• CEO<br />
– Peace of mind from actually<br />
knowing your aircraft are being<br />
operated in a professional<br />
manner.<br />
• False accusation<br />
– Airspace breaches<br />
– Low flying<br />
– Poor airmanship<br />
• Management Support<br />
– Non-SOP Flying Requests<br />
– Documents observations<br />
• Procedures<br />
• Equipment<br />
22
Technology (The Aircraft)<br />
• Pre-purchase / Pre-funding:<br />
– Performance / Efficiency<br />
– Proper handling<br />
– Limits maintained<br />
• MRO:<br />
– Faulty Equipment<br />
– Limits maintained /<br />
exceeded<br />
– Warranty issues<br />
23
Organisation (The Company)<br />
• Return on Investment<br />
– Protecting your Assets<br />
• Marketing<br />
– Promotion of SMS<br />
– <strong>Risk</strong> Management<br />
• Monitoring – Quality Assurance<br />
– Ferry Flights<br />
– Flight Operations<br />
– Human Resources<br />
• Continuous Improvement<br />
– Training Programs<br />
– Enhancement<br />
– Validation<br />
• Efficiencies<br />
– Fuel efficiency<br />
– Maintenance<br />
24
<strong>FDM</strong> Resources<br />
Global Helicopter Flight Data Monitoring<br />
Community (www.hfdm.org)<br />
International Helicopter Safety Team<br />
(www.ihst.org)<br />
UK Civil Aviation Authority - CAP 739<br />
(www.caa.co.uk)<br />
25
Wrap Up<br />
• The highest risk to an<br />
operation is Flight<br />
• Without <strong>FDM</strong>, you really<br />
don’t have quality assurance<br />
on flight operations<br />
• Implement <strong>FDM</strong><br />
26
<strong>FDM</strong>, <strong>Risk</strong><br />
… and Protecting your Assets<br />
Sonya Tietjen<br />
Consultant, Aviation Safety<br />
Sonya@Tietjen.ca<br />
www.H<strong>FDM</strong>.org<br />
Thank You<br />
27
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