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Flight Data Monitoring - IHST

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<strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong><br />

CHC Safety & Quality Summit 2009<br />

Lindsay Cunningham, American Eurocopter<br />

Joint Helicopter Safety Implementation Team<br />

Stuart “Kipp” Lau, CAPACG, LLC.<br />

Joint Helicopter Safety Implementation Team<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

1


CHC Safety and Quality Summit<br />

• Summit Theme: The Future of Human Error Management<br />

in Aviation<br />

• Session Theme: The role of <strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong> in<br />

effectively managing human error and identifying<br />

vulnerabilities in the aviation system.<br />

• Key Deliverable: A path to global FDM implementation and<br />

cooperation amongst stakeholders.<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

2


Helicopter FDM & the Oil and Gas Industry<br />

Operator<br />

Bristow<br />

Bristow/Air Logistics<br />

CHC<br />

Cougar Helicopters<br />

Era Aviation<br />

PHI<br />

Arkansas Children’s Hospital<br />

Baldwin Aviation<br />

Primary Industry (Secondary)<br />

Oil and Gas (SAR)<br />

Oil and Gas<br />

Oil and Gas (SAR)<br />

Oil and Gas (SAR)<br />

Oil and Gas (EMS)<br />

Oil and Gas (EMS)<br />

EMS<br />

Multi/Organizational‐based<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

3


Overview:<br />

• Introduction – <strong>IHST</strong> FDM activities<br />

• Brief FDM/FOQA history<br />

– Airline and Helicopter<br />

• Program management<br />

• Practical applications of FDM<br />

– Approved and non-approved<br />

programs<br />

• Available resources<br />

• Discussion<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

4


Why are we here?<br />

Reduce accidents…save lives!!!<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

5


JHSAT Standard Problem Statements:<br />

Q: What<br />

other areas<br />

can be<br />

impacted by<br />

FDM?<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

6


JHSAT Intervention Categories<br />

450<br />

400<br />

350<br />

300<br />

250<br />

200<br />

150<br />

100<br />

50<br />

0<br />

367<br />

275<br />

7<br />

173<br />

143<br />

119<br />

43 33 28<br />

Training<br />

Safety<br />

Management<br />

Information<br />

Maintenance<br />

Systems &<br />

Equipment<br />

Regulatory<br />

Instructional<br />

Infrastructure<br />

Frequency<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009


US JHSAT Recommendations:<br />

• Utilize flight data monitoring systems such as HOMP<br />

or FOQA to evaluate flight operations and to address<br />

unsafe/undesirable flight crew habits.<br />

• Install flight data retrieval systems such as:<br />

– Cockpit image recorder<br />

– <strong>Flight</strong> parameter recorder<br />

– Cockpit information recorder<br />

– Quick Access Recorder (QAR)<br />

– Multi-function data acquisition unit (MFDAU)<br />

– Cockpit voice flight data recorder (CVFDR)<br />

Source: Year 2000 U.S. JHSAT Report<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

8


Why do we need flight data?<br />

• Additional data source for information in accident<br />

investigation<br />

• Accident prevention due to operational oversight<br />

• Support implementation of flight data monitoring<br />

system (FOQA/HOMP/HUMS)<br />

• Can be utilized for training<br />

• <strong>Data</strong> validation in the event of an incident<br />

• Acquisition of fleet data for operator<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

9


Information Recommendation Strategies:<br />

• Install flight data retrieval systems, and utilize this<br />

equipment to implement flight data monitoring systems<br />

such as HOMP/FOQA/HUMS.<br />

– Publish flight data retrieval & management system guidance for<br />

industry<br />

– Sponsor flight data monitoring workshop at Heli-Expo 2009 and<br />

IHSS 2009<br />

– Encourage airframe and avionics Original Equipment<br />

Manufacturers (OEMs) to develop and install low-cost flight data<br />

retrieval systems<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

10


Information Recommendation Strategies:<br />

• Work with accident investigation authorities to increase<br />

data gathered in accident investigations.<br />

– Developed helicopter accident checklist to trigger deeper<br />

investigation into unique aspects of helicopter operations<br />

– Ongoing effort to support investigative authorities with data and<br />

investigations and inform them of relevant industry safety issues<br />

– Additional sources of information such as flight data retrieval<br />

systems will augment information available to investigators<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

11


<strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong>:<br />

How can you fix what you don’t know?<br />

How can you improve what you don’t measure?<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

12


Exploring FDM in HEMS – no formal programs, yet.<br />

• Recommendations from NTSB Hearings<br />

– AAMS<br />

– AMOA<br />

– HAI<br />

• <strong>Flight</strong> data retrieval systems for<br />

helicopters<br />

• FOQA programs<br />

• Interest from several operators such as Air<br />

Methods, Tramahawk, Omni<strong>Flight</strong>, etc.<br />

• <strong>IHST</strong>/FSF HEMS FOQA Trial<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

13


Initial Steps<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

14


<strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong> History<br />

• 1960s – FDM with British Airways and TAP Air<br />

Portugal<br />

• 1993 – FSF recommends FOQA beyond airlines<br />

• Late—1990s Airline FOQA becomes commonplace<br />

• 2002 – Final CAA HOMP trial paper issued<br />

• June 2005 – FSF/NBAA C-FOQA Trial<br />

• Late 2006 – New recorder technology enables GA<br />

FDM<br />

• 2008 – Bristow/Air Logistics FAA-approved HOMP<br />

• 2009 – <strong>IHST</strong>/FSF Helicopter FDM Trial<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

15


What is a flight data monitoring system?<br />

Current<br />

Intervention<br />

Point<br />

FDM<br />

Intervention<br />

Point<br />

1<br />

30<br />

300<br />

The accident that finally<br />

occurs.<br />

For the few incidents that<br />

are reported, which<br />

ultimately results in…<br />

Hundreds near misses,<br />

incidents and events go<br />

unreported…<br />

The Heinrich Pyramid<br />

<strong>Data</strong> from Appareo Systems LLC, Feb 2008<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

16


Question: Why <strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong>?<br />

• For every major accident there<br />

are several less significant<br />

accidents, hundreds of<br />

reportable incidents and<br />

thousands of unreported<br />

incidents.<br />

• Below this lie the normal<br />

variations present in all<br />

operations.<br />

Information sources added<br />

• FDM gives more detail on the<br />

incidents, encourages more<br />

consistent reporting and fills in<br />

the void below this that we know<br />

very little about. (HOMP Study)<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

17


<strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong> defined<br />

• Definition: “A systematic method of accessing, analyzing<br />

and acting upon information obtained from digital flight data<br />

records of routine operations to improve safety”<br />

• FDM involves the pro-active use of flight data to identify<br />

and address operational risks before they can lead to<br />

incidents and accidents. (HOMP Study – UK CAA, Shell<br />

Aircraft, Bristow and BA leads to adoption by UKOOA)<br />

• <strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong> (FDM) is the technology and<br />

methodology for collecting and analyzing data recorded in<br />

flight. (FAA)<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

18


Answer: Discovering the unknown!<br />

• The HOMP (trial) provided valuable new information on the risks<br />

associated with helicopter offshore operations.<br />

• Events have identified hazards which otherwise would not have<br />

come to light.<br />

• The operator has been able to take appropriate corrective and<br />

preventative measures.<br />

• The measurements are building a useful picture of everyday<br />

operations which has not previously available.<br />

• The HOMP has shown how pro-active use of flight data in a FDM<br />

program can significantly enhance the safety of helicopter offshore<br />

operations. (HOMP Study – www.caa.co.uk - CAA Paper 2002/02)<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

19


FDM by any other name…<br />

• FOQA – <strong>Flight</strong> Operational Quality Assurance (FAA)<br />

• FDA – <strong>Flight</strong> <strong>Data</strong> Analysis (ICAO)<br />

• FDM – <strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong> (CHC)<br />

• HFDM – Helicopter <strong>Flight</strong> <strong>Data</strong> <strong>Monitoring</strong> (Cougar)<br />

• HOMP – Helicopter Operations <strong>Monitoring</strong> Program<br />

(Bristow/Air Log)<br />

• LAMP* – Line Activity <strong>Monitoring</strong> Program (PHI)<br />

• HUMS – Health & Usage <strong>Monitoring</strong> Program (MX)<br />

• MOQA – Maintenance Operational Quality Assurance (MX)<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

20


What is FOQA?<br />

• <strong>Flight</strong> Operational Quality Assurance (FOQA) is<br />

an FAA program that standardizes the FDM<br />

process for interested parties. (AC 120-82)<br />

• FOQA versus ASAP Landscape – US Airlines<br />

Major Carrier<br />

Regional Carrier<br />

ASAP 93 percent 91 percent<br />

FOQA 86 percent 10 percent<br />

NTSB – FAA Shared Vision<br />

Conference 2008<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

21


What’s up with ASAP?<br />

• Aviation Safety Action Program – a voluntary reporting<br />

system for employees of certain certificate holders. A<br />

partnership between the FAA, certificate holder and 3 rd<br />

party such as a labor organization. (AC 120-66)<br />

• Easier to implement than FOQA – fewer barriers such as<br />

cost associated with fleet equipage and ground analysis<br />

stations (WBAT offered at no-cost)<br />

• ASAP in the news – In 2008, a number of US airlines<br />

suspended their ASAP (Delta, American, US Airways)<br />

over concerns of program management. Most have<br />

reconciled differences and have crafted new MOUs.<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

22


Lessons learned: Airlines<br />

• Over 30 years of FDM experience<br />

• A mature global system (ICAO mandate)<br />

• Active information sharing through the following<br />

(US example):<br />

– Over 5 years of infoshare meetings<br />

– Current Aviation Safety Information and Sharing<br />

(ASIAS) process<br />

• Following sequence of slides courtesy of the <strong>Flight</strong><br />

Safety Foundation<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

23


•There were no fatalities or injuries<br />

•There was no mechanical damage to<br />

the aircraft<br />

•No Air Safety reports were submitted<br />

(assumed)<br />

Therefore, no investigation was<br />

carried out and no lessons were<br />

learned –<br />

Except perhaps by the crew concerned<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

24


If we can detect this ………….<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

25


…………maybe we can prevent this…………..<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

26


Best Practices<br />

using<br />

understanding<br />

analysing<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

27


FOQA produces results:<br />

Hull losses as % of total hulls flying<br />

0.4 %<br />

0.3 %<br />

0.2 %<br />

World average<br />

Last 28 FOQA users<br />

Middle 11 FOQA users<br />

First 6 FOQA users<br />

0.1 %<br />

0 %<br />

Source : Skandia<br />

1976-1982 1983-1989 1990-1996<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

28


Beyond safety…<br />

• Operational benefits of FOQA<br />

• Orange County (KSNA) Noise Study<br />

• Problem – legacy “alternate”<br />

departure procedure mandated by<br />

airport property leases<br />

• Procedure required “deep cutback” of<br />

thrust – noise monitored by airport<br />

authority (3 rd type of TO procedure)<br />

• High bypass turbofans introduced<br />

• Legacy aircraft no longer operate into<br />

SNA – procedure remained<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

29


Troublesome procedure<br />

• FOQA studies showed high rate of<br />

the following events:<br />

– Pitch High on Takeoff<br />

– High Rotation Rate<br />

– Climb Speed Low<br />

• AQP data indicated high number<br />

of unsuccessful departures.<br />

• Actual observed “stick shaker”<br />

events and one reported bird strike<br />

at high pitch/low energy<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

30


SNA Noise Study – a success story<br />

• Airline study involved:<br />

– Simulator trials<br />

– Actual flight test utilizing all takeoff procedures and<br />

engine combinations<br />

• Airport Authority waived noise violations during test<br />

flights<br />

• Results validated simulator trials and procedure was<br />

changed industry wide<br />

• Airline conducting study benefited from increased<br />

operational flexibility, fuel savings and a wider safety<br />

margin<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

31


How did others learn from this lesson?<br />

OLD – individual silos<br />

New – free flow of information<br />

UAL<br />

UPS<br />

DL<br />

AMR<br />

SWA<br />

JBLU<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

32


Model for the helicopter industry<br />

Example – S-76 operators (segments, locale, etc.)<br />

Current – individual silos<br />

Future – free flow of information<br />

EMSI<br />

OFI-<br />

Gulf<br />

VIPI<br />

OFI –<br />

N.ATL<br />

Heli<br />

EMSI-<br />

CAN<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

33


Program Management Decisions<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

34


FOQA is not a “silver bullet”<br />

<strong>Flight</strong> Operational Quality<br />

Assurance Programs are only<br />

effective when coupled with an<br />

active SMS in a “just culture.”<br />

<strong>Flight</strong> Operational Quality Assurance (FOQA) is only effective when coupled with an active SMS in a “just culture.”<br />

NO<br />

YES<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

35


Caution!<br />

• Upon implementation - organizations<br />

must be prepared for immediate results –<br />

following AC 120-82 will reduce the<br />

likelihood of a surprise.<br />

• Be aware of the different emotions<br />

associated with FOQA implementation<br />

– “Geez that’s neat”<br />

– “Wow, we’re collecting a lot of data”<br />

– “Crap, how do we manage all of this<br />

information”<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

36


Program Management Decisions<br />

• Process begins with<br />

needs assessment.<br />

• Include all stakeholders<br />

Maintenance<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

37


MOST Model<br />

Maintenance<br />

Engine trend monitoring<br />

Exceedance reports<br />

HUMS<br />

Trouble shooting<br />

Fuel savings<br />

Operations<br />

Insurance reductions<br />

Automated data transfer from<br />

aircraft<br />

Automated OOOI reporting<br />

Automated billing<br />

Fuel savings<br />

Automated aircraft tracking<br />

Training<br />

Provide feedback to<br />

instructor/students (e‐debrief)<br />

Validation of training programs<br />

Training footprint analysis and<br />

adjustment<br />

Safety<br />

Fleet oversight<br />

SOP adherence<br />

ID of adverse safety trends<br />

Uncover threats and errors<br />

Mitigate risk<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

38<br />

38


Program Management Decisions<br />

• Corporate Infrastructure<br />

– Size of company<br />

– Safety organization<br />

– IT department<br />

• Personnel<br />

–Cost<br />

• FT/PT FMT<br />

• <strong>Flight</strong> Qualified?<br />

• Revenue/productivity lost<br />

– Training<br />

• Workforce stability<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

39


Program Management Decisions<br />

• Approved versus “nonapproved”<br />

or informal<br />

• Establish program IAW<br />

AC 120-82<br />

(recommendation)<br />

• Different motives (next)<br />

– Air Logistics/Bristow<br />

–PHI<br />

• Incentives of FAAapproved<br />

programs<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

40


A tale of two tail rotors:<br />

Air Logistics HOMP<br />

• Pro-active FDM system<br />

• Integral part of SMS<br />

• Customer requirement<br />

• Employee acceptance<br />

• Offshore operations<br />

• Monitors Bell 206/407<br />

(ALERTS) and S-76 and<br />

S-92 w/ <strong>Flight</strong>scape<br />

• FAA-approved status<br />

PHI’s LAMP<br />

• Pro-active FDM system<br />

• Integral part of SMS<br />

• Customer requirement<br />

• Employee acceptance<br />

• Offshore operations<br />

• Monitors S-76 and S-92<br />

w/ <strong>Flight</strong>scape<br />

• Non-approved status<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

41


One size doesn’t fit all…<br />

• Both organizations made a corporate decision on the<br />

status of their program (explained in detail in respective<br />

HeliExpo presentations posted on www.ihst.org site).<br />

PHI explains:<br />

• No PHI objections to an FAA Approved Program, and we<br />

may decide to move that direction in the future<br />

• Our program has developed extremely well and has<br />

become quite robust<br />

• Has been very effective as is…<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

42


FOQA Benefits – FAA approved programs<br />

• Enforcement incentives –FAR violations will not be<br />

pursued if revealed only by FOQA and receive<br />

corrective action and do not involve criminal or<br />

intentional actions.<br />

• <strong>Data</strong> protection –FOQA data will be de-identified and<br />

protected from Freedom of Information Act (FOIA)<br />

release under FAR Part 193. –FAA Legal Office will<br />

defend any attempts to override Part 193 by other<br />

authorities. (FAA AFS-230)<br />

• Future industry information sharing is key to<br />

establishing a global FDM community – ASIAS<br />

process relies on information from “approved”<br />

programs<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

43


Program Management Decisions<br />

• Technology Selection<br />

– Fleet types (stability)<br />

– Common across fleets<br />

• Fleet equipage survey<br />

– What’s installed?<br />

• Available equipment<br />

• STC versus 337<br />

installations<br />

• Ground analysis tools<br />

– Web-based<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

44


FDM Process – the 4 R’s<br />

• Record<br />

– Aircraft flight data<br />

(FDR/DFDAU/QAR/WQAR)<br />

– Light Recorder (Appareo ALERTS)<br />

• Retrieve<br />

– Manual, electronic or wireless<br />

• Review<br />

– Validate, classify and analyze with ground<br />

analysis station<br />

• Report<br />

– FMT review, meaningful findings and<br />

recommendations, group review to<br />

determine operational and training impact.<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

45


A quick recap…<br />

• Properly managed<br />

SMS components<br />

convert data into<br />

useful information and<br />

the end user gains<br />

knowledge based on<br />

facts that reduce risk<br />

and increase safety*<br />

*enhanced, thanks to Dick Healing, R3 Consulting<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

46


What is a flight data monitoring system?<br />

•Involves capturing and analyzing flight data to determine<br />

if the pilot, aircraft systems, or aircraft itself deviated from<br />

“normal” operating conditions<br />

•<strong>Data</strong> allows analysts to investigate predefined<br />

exceedances for corrective action and trend analysis<br />

•Designed to respond to normally unreported events to<br />

modify procedures and behavior in a non-punitive<br />

manner and thereby prevent accidents.<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

47


Challenges of flight data monitoring systems:<br />

•Resistance from the pilot community; an effective<br />

flight data management program must be nonpunitive…JUST<br />

CULTURE!<br />

•Non-standard format of flight data; for operators with<br />

mixed equipment, a standard data format must be<br />

developed for effective data analysis.<br />

•Diversity of helicopter operations; diverse operating<br />

environment and requirements make it difficult to set<br />

standard “event triggers”<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

48


Proven Benefits of flight data monitoring systems:<br />

•Significant increase in safety and reduction of accidents<br />

•Airline industry for more than a decade<br />

•Offshore helicopter operations<br />

•Significant cost savings<br />

•Modified procedures impending failure detections<br />

•Source of empirical data for operations analysis and<br />

evaluation of existing and new procedures and programs<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

49


FDM Resources<br />

1. FAA – inform local POI and AFS-230<br />

2. FAA – AC 120-82 (FOQA)/AC 120-92<br />

(SMS)<br />

3. FAA – AC 120-66 (ASAP)<br />

4. FSF – <strong>Flight</strong> Safety Digest 1998 and<br />

other resources at<br />

www.flightsafety.org<br />

5. Vendors on display<br />

6. <strong>IHST</strong> FDM Tool Kit (release date TBD)<br />

7. FDM Workshop participants<br />

8. HOMP Study – www.caa.co.uk -CAA<br />

Paper 2002/02<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

50


Discussion/Questions?<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

51


THANK YOU –<br />

STUART “KIPP” LAU<br />

VICE PRESIDENT OF FDM SERVICES<br />

SLAU@CAPACG.COM<br />

CHC Safety & Quality Summit 2009<br />

Vancouver, BC March 30, 2009<br />

52

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