Training=Safety John Bent & Dr Kwok Chan

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  • Training=Safety John Bent & Dr Kwok Chan

    1. 1. 1 Saturday, March 7, 2009
    2. 2. Training = Safety Generator 1 Saturday, March 7, 2009
    3. 3. Training = Safety Generator Aviation Education & Training Summit Dec 4/5, 2008 Beijing 1 Saturday, March 7, 2009
    4. 4. Training = Safety Generator Aviation Education & Training Summit Dec 4/5, 2008 Beijing John Bent Manager Flight Training Centre 1 Saturday, March 7, 2009
    5. 5. Training = Safety Generator Aviation Education & Training Summit Dec 4/5, 2008 Beijing John Bent Manager Flight Training Centre 1 Saturday, March 7, 2009
    6. 6. Training = Safety Generator Aviation Education & Training Summit Dec 4/5, 2008 Beijing Dr Kwok Chan John Bent Head of Corporate Safety & Quality Manager Flight Training Centre 1 Saturday, March 7, 2009
    7. 7. Training = Safety Generator Aviation Education & Training Summit Dec 4/5, 2008 Beijing Dr Kwok Chan John Bent Head of Corporate Safety & Quality Manager Flight Training Centre Hong Kong Dragon Airlines Ltd 1 Saturday, March 7, 2009
    8. 8. 2 Aviation Summit Beijing Saturday, March 7, 2009
    9. 9. PILOT TRAINING is an ingredient of The Safety Management (SMS) 2 Aviation Summit Beijing Saturday, March 7, 2009
    10. 10. PILOT TRAINING is an ingredient of The Safety Management (SMS) Training is key to safety outcomes 2 Aviation Summit Beijing Saturday, March 7, 2009
    11. 11. PILOT TRAINING is an ingredient of The Safety Management (SMS) Training is key to safety outcomes The Safety Management System (SMS) is mandated by ICAO 2 Aviation Summit Beijing Saturday, March 7, 2009
    12. 12. PILOT TRAINING is an ingredient of The Safety Management (SMS) Training is key to safety outcomes The Safety Management System (SMS) is mandated by ICAO Full application of SMS must include training 2 Aviation Summit Beijing Saturday, March 7, 2009
    13. 13. 3 Aviation Summit Beijing Saturday, March 7, 2009
    14. 14. Volatility – 2000-2008 3 Aviation Summit Beijing Saturday, March 7, 2009
    15. 15. Volatility – 2000-2008 Hardware growth outstripped human-ware available 3 Aviation Summit Beijing Saturday, March 7, 2009
    16. 16. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity 3 Aviation Summit Beijing Saturday, March 7, 2009
    17. 17. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity New entry aircraft grounded, and crew demand became critical 3 Aviation Summit Beijing Saturday, March 7, 2009
    18. 18. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity New entry aircraft grounded, and crew demand became critical Crew training could not keep up 3 Aviation Summit Beijing Saturday, March 7, 2009
    19. 19. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity New entry aircraft grounded, and crew demand became critical Crew training could not keep up Now facing contraction in global recession 3 Aviation Summit Beijing Saturday, March 7, 2009
    20. 20. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity New entry aircraft grounded, and crew demand became critical Crew training could not keep up Now facing contraction in global recession Already pilot layoffs in some regions 3 Aviation Summit Beijing Saturday, March 7, 2009
    21. 21. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity New entry aircraft grounded, and crew demand became critical Crew training could not keep up Now facing contraction in global recession Already pilot layoffs in some regions Reduced pressure on training delivery, but increase in pilot mobility 3 Aviation Summit Beijing Saturday, March 7, 2009
    22. 22. Volatility – 2000-2008 Hardware growth outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity New entry aircraft grounded, and crew demand became critical Crew training could not keep up ry to ri Now facing contraction in global recession er rt Already pilot layoffs in some regions u o is Reduced pressure on training delivery, but increase in pilot mobility y lit ti a ol V 3 Aviation Summit Beijing Saturday, March 7, 2009
    23. 23. 4 Aviation Summit Beijing Saturday, March 7, 2009
    24. 24. AFTER RECESSION GROWTH WILL RESUME THIS BIG PICTURE WILL RETURN: 4 Aviation Summit Beijing Saturday, March 7, 2009
    25. 25. AFTER RECESSION GROWTH WILL RESUME THIS BIG PICTURE WILL RETURN: 4 Aviation Summit Beijing Saturday, March 7, 2009
    26. 26. 5 Aviation Summit Beijing Saturday, March 7, 2009
    27. 27. Seeing through the recession 5 Aviation Summit Beijing Saturday, March 7, 2009
    28. 28. Seeing through the recession Despite the downturn ahead, the training industry must look through to the other side 5 Aviation Summit Beijing Saturday, March 7, 2009
    29. 29. Seeing through the recession Despite the downturn ahead, the training industry must look through to the other side This time should be applied productively to embed best practice and be prepared to resume growth safely 5 Aviation Summit Beijing Saturday, March 7, 2009
    30. 30. 6 Aviation Summit Beijing Saturday, March 7, 2009
    31. 31. PILOT TRAINING is the best investment against catastrophic accident risk (UK CAA latest research): 6 Aviation Summit Beijing Saturday, March 7, 2009
    32. 32. PILOT TRAINING is the best investment against catastrophic accident risk (UK CAA latest research): From UK CAA Global Airline Safety Analysis: Crew judgement and actions remain the most consistent causal factor in global catastrophic accidents This situation will remain true for the foreseeable future Crew-related issues dominate accident causal factors, featuring in 75% of fatal accidents 6 Aviation Summit Beijing Saturday, March 7, 2009
    33. 33. 7 Aviation Summit Beijing Saturday, March 7, 2009
    34. 34. PILOT TRAINING is the best investment against catastrophic accident risk (UK CAA latest research): 7 Aviation Summit Beijing Saturday, March 7, 2009
    35. 35. PILOT TRAINING is the best investment against catastrophic accident risk (UK CAA latest research): The current top catastrophic accident risks identified are: LOS (loss of control) CFIT (controlled flight into terrain) Post-crash fire Runway excursions and overruns Quality pilot training at all levels remains the critical factor in preventing really serious accidents 7 Aviation Summit Beijing Saturday, March 7, 2009
    36. 36. Overview of 2007 vs. 2006 Courtesy of IATA Source: IATA Safety Report 2007 8 Saturday, March 7, 2009
    37. 37. Regional Rate: Western-built Jet Hull Losses Courtesy of IATA Source: IATA Safety Report 2007 9 Saturday, March 7, 2009
    38. 38. 10 Aviation Summit Beijing Saturday, March 7, 2009
    39. 39. Safety Trend? Jan – July 2008, the number of fatal accidents soared 80% over H1 2007 (18 against 10 in H1 2007) Since July 2008, there have been more frequent incidents and 3 further fatal accidents (Kalita B747, Spanair MD80 (flaps?), Itek B737) In recent years, accidents and incidents have been exposing Pilot Training as a significant factor; for example: Adam Air B737-400 (loss of control while both focussing on INS) BA 319 (electrical failure and flight on standby instruments) Pinnacle Airlines Bombardier CRJ200 –runway overrun –landing performance calculation Air Transat A330 – Azores – fuel management 10 Aviation Summit Beijing Saturday, March 7, 2009
    40. 40. 11 Aviation Summit Beijing Saturday, March 7, 2009
    41. 41. Growth & Consequences Assuming: A reasonably fixed accident rate No improvements to reduce accident rate The projected doubling of the global fleet next 2 decades Outcome: A large increase in airline accidents Reduced public confidence in airline travel? Self-generated contraction? 11 Aviation Summit Beijing Saturday, March 7, 2009
    42. 42. 12 Aviation Summit Beijing Saturday, March 7, 2009
    43. 43. Was training a factor? In mid 2000, an Airbus A320 crashed at sea off Bahrain International Airport and all 143 persons on board were killed 12 Aviation Summit Beijing Saturday, March 7, 2009
    44. 44. Some findings - training & organisation Crew performance capabilities and experience (Human Perf -Training) Cockpit authority gradient (HF/CRM -Training) Crew personalities (CRM -Training) Perception of a punitive attitude towards missed approaches (Safety Culture) Performance standards and monitoring (Safety System) Supervisory oversight; flight safety department (Safety System) Aviation Summit Beijing 13 Saturday, March 7, 2009
    45. 45. 14 Aviation Summit Beijing Saturday, March 7, 2009
    46. 46. 14 Aviation Summit Beijing Saturday, March 7, 2009
    47. 47. 15 Aviation Summit Beijing Saturday, March 7, 2009
    48. 48. 15 Aviation Summit Beijing Saturday, March 7, 2009
    49. 49. 16 Aviation Summit Beijing Saturday, March 7, 2009
    50. 50. 16 Aviation Summit Beijing Saturday, March 7, 2009
    51. 51. Aviation Summit Beijing 17 Saturday, March 7, 2009
    52. 52. The Airline Food Chain Safety standards where airline pilots come from? Aviation Summit Beijing 17 Saturday, March 7, 2009
    53. 53. Regional Rate: Western-built Turboprop Hull Losses 19 Courtesy of IATA Source: IATA Safety Report 2007 (CEO Brief) Saturday, March 7, 2009
    54. 54. 19 Aviation Summit Beijing Saturday, March 7, 2009
    55. 55. 19 Aviation Summit Beijing Saturday, March 7, 2009
    56. 56. 20 Aviation Summit Beijing Saturday, March 7, 2009
    57. 57. Again, thanks to training? Technical failure & depressurisation + Well Trained crew = Successful emergency descent and landing = SAFE OUTCOME 20 Aviation Summit Beijing Saturday, March 7, 2009
    58. 58. equipment selection design work training conditions procedures culture Systemic factors [Dr Rob Lee & Dr Kwok Chan] Aviation Summit Beijing 21 Saturday, March 7, 2009
    59. 59. People are components of a Safety System, not autonomous equipment selection design work training conditions Individual behaviour procedures culture Systemic factors [Dr Rob Lee & Dr Kwok Chan] Aviation Summit Beijing 21 Saturday, March 7, 2009
    60. 60. Incident / Accident The last defence Pilots Safety Barriers Airline ORG + / TRAINING Aviation Regulator Aircraft Manufacturer Courtesy Prof Reason 22 Aviation Summit Beijing Saturday, March 7, 2009
    61. 61. Again the Swiss Cheese! Incident / Accident The last defence Pilots Safety Barriers Airline ORG + / TRAINING Aviation Regulator Aircraft Manufacturer Courtesy Prof Reason 22 Aviation Summit Beijing Saturday, March 7, 2009
    62. 62. Again the Swiss Cheese! Incident / Accident The last defence Pilots Safety Barriers Airline ORG + / TRAINING Aviation Regulator Aircraft Manufacturer Flight Crew – our last line of defence Courtesy Prof Reason 22 Aviation Summit Beijing Saturday, March 7, 2009
    63. 63. 23 Aviation Summit Beijing Saturday, March 7, 2009
    64. 64. Pilot Competence is like a fuselage skin - it cannot be too thin 23 Aviation Summit Beijing Saturday, March 7, 2009
    65. 65. Pilot Competence is like a fuselage skin - it cannot be too thin UNSAFE UNSAFE UNSAFE UNSAFE 23 Aviation Summit Beijing Saturday, March 7, 2009
    66. 66. Pilot Competence is like a fuselage skin - it cannot be too thin UNSAFE UNSAFE UNSAFE UNSAFE 23 Aviation Summit Beijing Saturday, March 7, 2009
    67. 67. Pilot Competence is like a fuselage skin - it cannot be too thin UNSAFE UNSAFE UNSAFE UNSAFE 23 Aviation Summit Beijing Saturday, March 7, 2009
    68. 68. Pilot Competence is like a fuselage skin - it cannot be too thin UNSAFE UNSAFE UNSAFE UNSAFE 23 Aviation Summit Beijing Saturday, March 7, 2009
    69. 69. 24 Aviation Summit Beijing Saturday, March 7, 2009
    70. 70. The crust of it 24 Aviation Summit Beijing Saturday, March 7, 2009
    71. 71. The crust of it UNSAFE UNSAFE UNSAFE UNSAFE 24 Aviation Summit Beijing Saturday, March 7, 2009
    72. 72. The crust of it UNSAFE UNSAFE UNSAFE UNSAFE Competence 24 Aviation Summit Beijing Saturday, March 7, 2009
    73. 73. 25 Aviation Summit Beijing Saturday, March 7, 2009
    74. 74. The safety crust analysed 25 Aviation Summit Beijing Saturday, March 7, 2009
    75. 75. The safety crust analysed 25 Aviation Summit Beijing Saturday, March 7, 2009
    76. 76. 26 Aviation Summit Beijing Saturday, March 7, 2009
    77. 77. But what is Competency? 26 Aviation Summit Beijing Saturday, March 7, 2009
    78. 78. But what is Competency? Flying Hours are experienced and applied in many ways, and are no measure of competency 26 Aviation Summit Beijing Saturday, March 7, 2009
    79. 79. But what is Competency? Flying Hours are experienced and applied in many ways, and are no measure of competency Quote: “Thinking only hours means you don’t know what competency is” Prof. Graham Hunt 26 Aviation Summit Beijing Saturday, March 7, 2009
    80. 80. But what is Competency? Flying Hours are experienced and applied in many ways, and are no measure of competency Quote: “Thinking only hours means you don’t know what competency is” Prof. Graham Hunt Competencies are established via task analysis, applied through instructional design, and validated by a performance measurement system – a lengthy but worthwhile process 26 Aviation Summit Beijing Saturday, March 7, 2009
    81. 81. 27 Aviation Summit Beijing Saturday, March 7, 2009
    82. 82. The Training Equation 27 Aviation Summit Beijing Saturday, March 7, 2009
    83. 83. The Training Equation 27 Aviation Summit Beijing Saturday, March 7, 2009
    84. 84. The Training Equation EXPERIENCE 27 Aviation Summit Beijing Saturday, March 7, 2009
    85. 85. The Training Equation + EXPERIENCE 27 Aviation Summit Beijing Saturday, March 7, 2009
    86. 86. The Training Equation + EXPERIENCE TRAINING 27 Aviation Summit Beijing Saturday, March 7, 2009
    87. 87. The Training Equation + EXPERIENCE TRAINING ” Education is the systematic, purposeful reconstruction of experience” Anon 27 Aviation Summit Beijing Saturday, March 7, 2009
    88. 88. 28 Aviation Summit Beijing Saturday, March 7, 2009
    89. 89. Accident Rate & Growth 28 Aviation Summit Beijing Saturday, March 7, 2009
    90. 90. Accident Rate & Growth The historical airline Accident Rate is very low, but: 28 Aviation Summit Beijing Saturday, March 7, 2009
    91. 91. Accident Rate & Growth The historical airline Accident Rate is very low, but: Doubling of global fleet will increase the number of accidents 28 Aviation Summit Beijing Saturday, March 7, 2009
    92. 92. Accident Rate & Growth The historical airline Accident Rate is very low, but: Doubling of The accident global fleet will RATE must be increase the further number of REDUCED accidents 28 Aviation Summit Beijing Saturday, March 7, 2009
    93. 93. 29 Aviation Summit Beijing Saturday, March 7, 2009
    94. 94. So STANDARDS must be RAISED Standards 29 Aviation Summit Beijing Saturday, March 7, 2009
    95. 95. So STANDARDS must be RAISED Standards 29 Aviation Summit Beijing Saturday, March 7, 2009
    96. 96. 30 Aviation Summit Beijing Saturday, March 7, 2009
    97. 97. BUT 30 Aviation Summit Beijing Saturday, March 7, 2009
    98. 98. BUT Resources & Quality 30 Aviation Summit Beijing Saturday, March 7, 2009
    99. 99. BUT Resources & Quality $$ As costs come under severe pressure, training resources can become static or shrink 30 Aviation Summit Beijing Saturday, March 7, 2009
    100. 100. BUT Resources & Quality $$ As costs come If no more under severe training can be pressure, added, QUALITY training must be resources can improved become static or shrink 30 Aviation Summit Beijing Saturday, March 7, 2009
    101. 101. 31 Aviation Summit Beijing Saturday, March 7, 2009
    102. 102. Flight to Quality – we have no choice 31 Aviation Summit Beijing Saturday, March 7, 2009
    103. 103. Flight to Quality – we have no choice Training process must be improved 31 Aviation Summit Beijing Saturday, March 7, 2009
    104. 104. Flight to Quality – we have no choice Training process must be improved Resource constraints demand a ‘Flight to Quality’ 31 Aviation Summit Beijing Saturday, March 7, 2009
    105. 105. 32 Aviation Summit Beijing Saturday, March 7, 2009
    106. 106. Quality of process is KEY 32 Aviation Summit Beijing Saturday, March 7, 2009
    107. 107. ent Quality of process is KEY Im m ove pr pr ov Don’t stop! s im e ou re inu c nt ru s llabu Tra co itm / sy in rfo inst s oces en n ruc g r esi prove p ors t t D Im Analyse Improve equipment data Ap ps Au pl loo re dit s y etric re mo ck be &v M ba alid st ate ed pr fe ac Measu se tic lo e C 32 Aviation Summit Beijing Saturday, March 7, 2009
    108. 108. 33 Aviation Summit Beijing Saturday, March 7, 2009
    109. 109. The healthy cycle 33 Aviation Summit Beijing Saturday, March 7, 2009
    110. 110. The healthy cycle 33 Aviation Summit Beijing Saturday, March 7, 2009
    111. 111. The healthy cycle 33 Aviation Summit Beijing Saturday, March 7, 2009
    112. 112. The healthy cycle 33 Aviation Summit Beijing Saturday, March 7, 2009
    113. 113. 34 Aviation Summit Beijing Saturday, March 7, 2009
    114. 114. Organisational & Safety Culture To raise the training bar, we need effective airline organisational and safety cultures in the background From January 2009, this will be mandated by ICAO under Doc 9859 Safety Management Systems (SMS) During a 1999 Symposium in Sydney, Professor Ron Westrum introduced his research into organisational cultures, which he categorised as: Generative, Bureaucratic, Pathological ICAO extended this model to SAFETY CULTURES, now published in the Safety Management Manual (SMM) 34 Aviation Summit Beijing Saturday, March 7, 2009
    115. 115. Prevention or cure? Accident Prevention; work to detect and correct Active Failures and Latent Threats before they lead to a catastrophic outcome Accidents Active Failures of event >> and Latent Serious incidents Threats Minor incidents Severity Normal operations Frequency of event, Quantity of data >> 35 Aviation Summit Beijing Saturday, March 7, 2009
    116. 116. Prevention or cure? Accident Prevention; work to detect and correct Active Failures and Latent Threats before they lead to a catastrophic outcome Accidents Active Failures of event >> and Latent Serious incidents Threats Minor incidents Severity Normal operations Frequency of event, Quantity of data >> 35 Aviation Summit Beijing Saturday, March 7, 2009
    117. 117. Prevention or cure? Accident Prevention; work to detect and correct Active Failures and Latent Threats before they lead to a catastrophic outcome REACTIVE Accidents Active Failures of event >> and Latent Serious incidents Threats Minor incidents Severity Normal operations Frequency of event, Quantity of data >> 35 Aviation Summit Beijing Saturday, March 7, 2009
    118. 118. Prevention or cure? Accident Prevention; work to detect and correct Active Failures and Latent Threats before they lead to a catastrophic outcome REACTIVE Accidents Active Failures of event >> and Latent Serious incidents Threats Minor incidents PROACTIVE Severity Normal operations Frequency of event, Quantity of data >> 35 Aviation Summit Beijing Saturday, March 7, 2009
    119. 119. 36 Aviation Summit Beijing Saturday, March 7, 2009
    120. 120. The COST of REACTIVE! of event >> Severity Frequency of event, Quantity of data >> 36 Aviation Summit Beijing Saturday, March 7, 2009
    121. 121. The COST of REACTIVE! $$$$-Very expensive lessons Accidents of event >> Serious incidents $$$-Expensive lessons Minor incidents Costly lessons Normal operations: Severity •Errors Virtually free lessons •In-service problems •Non-optimal performance Frequency of event, Quantity of data >> 36 Aviation Summit Beijing Saturday, March 7, 2009
    122. 122. 37 Aviation Summit Beijing Saturday, March 7, 2009
    123. 123. Our training objective? 37 Aviation Summit Beijing Saturday, March 7, 2009
    124. 124. Our training objective? TO SERVE THE SAFETY MANAGEMENT SYSTEM 37 Aviation Summit Beijing Saturday, March 7, 2009
    125. 125. Aviation Summit Beijing 38 Saturday, March 7, 2009
    126. 126. THREAT: ICAO SMM 1.3.3 The air transport industry’s future viability may well be predicated on its ability to sustain the public’s perceived safety while travelling. The management of safety is therefore a prerequisite for a sustainable aviation business How is SMS defined? SMS (ICAO Definition) from the SMM 1.4.2: An SMS is an organised approach to managing safety, including the necessary organisational structures, accountabilities, policies, and procedures Aviation Summit Beijing 38 Saturday, March 7, 2009
    127. 127. To serve SMS with training, we need to understand the threats: 39 Aviation Summit Beijing Saturday, March 7, 2009
    128. 128. To serve SMS with training, we need to understand the threats: 39 Aviation Summit Beijing Saturday, March 7, 2009
    129. 129. 40 Aviation Summit Beijing Saturday, March 7, 2009
    130. 130. 15 System Safety threats today 40 Aviation Summit Beijing Saturday, March 7, 2009
    131. 131. 15 System Safety threats today 1. Global economic turmoil: ‘indiscriminate resource cutting’ - key safety generators may be lost in the culling process 40 Aviation Summit Beijing Saturday, March 7, 2009
    132. 132. 15 System Safety threats today 1. Global economic turmoil: ‘indiscriminate resource cutting’ - key safety generators may be lost in the culling process 2. Reduced experience: Expansion has shrunk the average volume and depth of experience of pilots and instructors 40 Aviation Summit Beijing Saturday, March 7, 2009
    133. 133. 15 System Safety threats today 1. Global economic turmoil: ‘indiscriminate resource cutting’ - key safety generators may be lost in the culling process 2. Reduced experience: Expansion has shrunk the average volume and depth of experience of pilots and instructors 3. Pilot production pressure: Expansion & pilot mobility in crisis adds unplanned pressure on training systems, impacting quality 40 Aviation Summit Beijing Saturday, March 7, 2009
    134. 134. 15 System Safety threats today 1. Global economic turmoil: ‘indiscriminate resource cutting’ - key safety generators may be lost in the culling process 2. Reduced experience: Expansion has shrunk the average volume and depth of experience of pilots and instructors 3. Pilot production pressure: Expansion & pilot mobility in crisis adds unplanned pressure on training systems, impacting quality 4. Training System lag: It may take years to ramp up training capacity; during which time, quality may surrender to demand 40 Aviation Summit Beijing Saturday, March 7, 2009
    135. 135. 41 Aviation Summit Beijing Saturday, March 7, 2009
    136. 136. 15 System Safety threats today 41 Aviation Summit Beijing Saturday, March 7, 2009
    137. 137. 15 System Safety threats today 5. Management perception: From ICAO SMM Doc 9859 AN/460 (2006),12-13: “Weak Management may see training as an expense rather than an investment in the future viability of the organisation” 41 Aviation Summit Beijing Saturday, March 7, 2009
    138. 138. 15 System Safety threats today 5. Management perception: From ICAO SMM Doc 9859 AN/460 (2006),12-13: “Weak Management may see training as an expense rather than an investment in the future viability of the organisation” 6. Automation: Modern airliner design has reduced operational risk, but weakened traditional piloting skills when systems degrade 41 Aviation Summit Beijing Saturday, March 7, 2009
    139. 139. 15 System Safety threats today 5. Management perception: From ICAO SMM Doc 9859 AN/460 (2006),12-13: “Weak Management may see training as an expense rather than an investment in the future viability of the organisation” 6. Automation: Modern airliner design has reduced operational risk, but weakened traditional piloting skills when systems degrade 7. Regulatory Lag: Rules take time to change; eg. Basic CPL licencing standards of 1944 are still applied today 41 Aviation Summit Beijing Saturday, March 7, 2009
    140. 140. 15 System Safety threats today 5. Management perception: From ICAO SMM Doc 9859 AN/460 (2006),12-13: “Weak Management may see training as an expense rather than an investment in the future viability of the organisation” 6. Automation: Modern airliner design has reduced operational risk, but weakened traditional piloting skills when systems degrade 7. Regulatory Lag: Rules take time to change; eg. Basic CPL licencing standards of 1944 are still applied today 8. Commercial priorities: In the highly competitive airline environment commercial objectives are accorded ‘front office’ status 41 Aviation Summit Beijing Saturday, March 7, 2009
    141. 141. 42 Aviation Summit Beijing Saturday, March 7, 2009
    142. 142. 42 Aviation Summit Beijing Saturday, March 7, 2009
    143. 143. 9. Training seen as back-office: Crew training, a significant non-line cost, may be treated as a 'back office’ activity 42 Aviation Summit Beijing Saturday, March 7, 2009
    144. 144. 9. Training seen as back-office: Crew training, a significant non-line cost, may be treated as a 'back office’ activity 10. Shrinking resources: As operating costs have escalated, commercial departments tend to view minimum regulatory standards as MAXIMUM budgetary targets 42 Aviation Summit Beijing Saturday, March 7, 2009
    145. 145. 9. Training seen as back-office: Crew training, a significant non-line cost, may be treated as a 'back office’ activity 10. Shrinking resources: As operating costs have escalated, commercial departments tend to view minimum regulatory standards as MAXIMUM budgetary targets 11. Delayed effect of sub-optimal training: The impact of less effective training may not be seen for years 42 Aviation Summit Beijing Saturday, March 7, 2009
    146. 146. 9. Training seen as back-office: Crew training, a significant non-line cost, may be treated as a 'back office’ activity 10. Shrinking resources: As operating costs have escalated, commercial departments tend to view minimum regulatory standards as MAXIMUM budgetary targets 11. Delayed effect of sub-optimal training: The impact of less effective training may not be seen for years 12. Reduced career interest: The ‘passion’ for aviation is not so evident today. Recruits often place piloting as 3rd or 4th priority 42 Aviation Summit Beijing Saturday, March 7, 2009
    147. 147. 43 Aviation Summit Beijing Saturday, March 7, 2009
    148. 148. 43 Aviation Summit Beijing Saturday, March 7, 2009
    149. 149. 13. Airline in-house ‘fixes’: Airline-developed training which is not approved by the manufacturer may become a latent threat. (For example, the probable impact of airline-designed jet-upset training on a fatal A300 accident in USA) 43 Aviation Summit Beijing Saturday, March 7, 2009
    150. 150. 13. Airline in-house ‘fixes’: Airline-developed training which is not approved by the manufacturer may become a latent threat. (For example, the probable impact of airline-designed jet-upset training on a fatal A300 accident in USA) 14. Embedded paradigms: A long strong safety record = a safe future? Perhaps not! Comfort can lead to organisational complacency. [Possible examples: US airline M & As (1980s), Townsend Thoresen Ferries, British Rail, well-respected major airlines, NASA, nuclear, oil, and other transport / high technology industries] 43 Aviation Summit Beijing Saturday, March 7, 2009
    151. 151. 44 Aviation Summit Beijing Saturday, March 7, 2009
    152. 152. 44 Aviation Summit Beijing Saturday, March 7, 2009
    153. 153. 15. Inadequate system measurement: leads to subjective opinion- based judgment; ‘more of the same’ or new untested training processes 44 Aviation Summit Beijing Saturday, March 7, 2009
    154. 154. 15. Inadequate system measurement: leads to subjective opinion- based judgment; ‘more of the same’ or new untested training processes From ICAO SMM AN/460 (2006),12-13: “Regardless of their experience level, all employees benefit from feedback on hazards identified, safety actions taken, safety lessons learned” 44 Aviation Summit Beijing Saturday, March 7, 2009
    155. 155. 15. Inadequate system measurement: leads to subjective opinion- based judgment; ‘more of the same’ or new untested training processes From ICAO SMM AN/460 (2006),12-13: “Regardless of their experience level, all employees benefit from feedback on hazards identified, safety actions taken, safety lessons learned” It’s not a quality system if it’s not measured 44 Aviation Summit Beijing Saturday, March 7, 2009
    156. 156. 45 Aviation Summit Beijing Saturday, March 7, 2009
    157. 157. Threat & Error Management (TEM) provides a useful framework in crew training & safety 45 Aviation Summit Beijing Saturday, March 7, 2009
    158. 158. Threat & Error Management (TEM) provides a useful framework in crew training & safety TEM assumes that Threats & Errors are: 45 Aviation Summit Beijing Saturday, March 7, 2009
    159. 159. Threat & Error Management (TEM) provides a useful framework in crew training & safety TEM assumes that Threats & Errors are: Inevitable - part of the territory 45 Aviation Summit Beijing Saturday, March 7, 2009
    160. 160. Threat & Error Management (TEM) provides a useful framework in crew training & safety TEM assumes that Threats & Errors are: Inevitable - part of the territory External conditions or events that must be managed during normal, everyday flights, in order to maintain safety margins. 45 Aviation Summit Beijing Saturday, March 7, 2009
    161. 161. Threat & Error Management (TEM) provides a useful framework in crew training & safety TEM assumes that Threats & Errors are: Inevitable - part of the territory External conditions or events that must be managed during normal, everyday flights, in order to maintain safety margins. Events which increase operational complexity, posing a safety risk to the flight at some level 45 Aviation Summit Beijing Saturday, March 7, 2009
    162. 162. Aviation Summit Beijing 46 Saturday, March 7, 2009
    163. 163. WHY & WHEN do we make errors? Aviation Summit Beijing 46 Saturday, March 7, 2009
    164. 164. WHY & WHEN do we make errors? We need to measure to find out Aviation Summit Beijing 46 Saturday, March 7, 2009
    165. 165. WHY & WHEN do we make errors? We need to measure to find out e.g. in industry, the Six Sigma process >> Aviation Summit Beijing 46 Saturday, March 7, 2009
    166. 166. WHY & WHEN do we make errors? We need to measure to find out e.g. in industry, the Six Sigma process >> Define, measure, analyse, improve, control Aviation Summit Beijing 46 Saturday, March 7, 2009
    167. 167. WHY & WHEN do we make errors? We need to measure to find out e.g. in industry, the Six Sigma Or in aviation terms: process >> Define, measure, analyse, improve, control Aviation Summit Beijing 46 Saturday, March 7, 2009
    168. 168. WHY & WHEN do we make errors? We need to measure to find out e.g. in industry, the Six Sigma Or in aviation terms: process >> Define, measure, analyse, improve, control Aviation Summit Beijing 46 Saturday, March 7, 2009
    169. 169. WHY & WHEN do we make errors? We need to measure to find out e.g. in industry, the Six Sigma Or in aviation terms: process >> Define, measure, analyse, improve, control Aviation Summit Beijing 46 Saturday, March 7, 2009
    170. 170. 47 Aviation Summit Beijing Saturday, March 7, 2009
    171. 171. Measurement? We measure lots already There are reservoirs of airline data But it’s rarely integrated or analysed Apart from QAR / FOQA, and crew performance, we also use more holistic measures, such as >>> 47 Aviation Summit Beijing Saturday, March 7, 2009
    172. 172. Aviation Summit Beijing 48 Saturday, March 7, 2009
    173. 173. Airline external audits Whole Airline: IATA OPERATIONAL SAFEY AUDIT (IOSA) Flight Operations LINE OPERATIONS AUDIT SYSTEM (LOAS) Flight Operations LINE OPERATIONAL SAFEY AUDIT (LOSA) Aviation Summit Beijing 48 Saturday, March 7, 2009
    174. 174. Aviation Summit Beijing 49 Saturday, March 7, 2009
    175. 175. Benefits of measurement; Crew errors: After 10 years, and more than 6,000 LOSA flights… - over 90% of flights exhibited observable crew errors Numerous events were precipitated by an error made by the captain, not challenged by other crew members (reluctance to challenge, expressed as ‘authority gradient’ (G.Hofstede), has been shown to vary with national culture 50% of LOSA-observed errors went undetected by the crew 32% of errors were intentional noncompliance (Violations) Aviation Summit Beijing 49 Saturday, March 7, 2009
    176. 176. Benefits of measurement; Crew errors: After 10 years, and more than 6,000 LOSA flights… - over 90% of flights exhibited observable crew errors Numerous events were precipitated by an error made by the captain, not challenged by other crew members (reluctance to challenge, expressed as ‘authority gradient’ (G.Hofstede), has been shown to vary with national culture 50% of LOSA-observed errors went undetected by the crew 32% of errors were intentional noncompliance (Violations) Preventing pilot error is impossible – “To err is human” Aviation Summit Beijing 49 Saturday, March 7, 2009
    177. 177. 50 Aviation Summit Beijing Saturday, March 7, 2009
    178. 178. Intentional Non – Compliance? 50 Aviation Summit Beijing Saturday, March 7, 2009
    179. 179. Courtesy Prof Patrick Hudson 51 Aviation Summit Beijing Saturday, March 7, 2009
    180. 180. Understanding WHY - Intentional Non-compliance Predictors of Violation: Courtesy Prof Patrick Hudson 51 Aviation Summit Beijing Saturday, March 7, 2009
    181. 181. Understanding WHY - Intentional Non-compliance Predictors of Violation: Expectation Expectation that rules will have to be bent to get the work done Courtesy Prof Patrick Hudson 51 Aviation Summit Beijing Saturday, March 7, 2009
    182. 182. Understanding WHY - Intentional Non-compliance Predictors of Violation: Expectation Expectation that rules will have to be bent to get the work done The feeling that one has the ability and experience Powerfulness to do the job without slavishly following the procedures Courtesy Prof Patrick Hudson 51 Aviation Summit Beijing Saturday, March 7, 2009
    183. 183. Understanding WHY - Intentional Non-compliance Predictors of Violation: Expectation Expectation that rules will have to be bent to get the work done The feeling that one has the ability and experience Powerfulness to do the job without slavishly following the procedures Opportunities Seeing opportunities that present themselves for short cuts or to do things ‘better’ Courtesy Prof Patrick Hudson 51 Aviation Summit Beijing Saturday, March 7, 2009
    184. 184. Understanding WHY - Intentional Non-compliance Predictors of Violation: Expectation Expectation that rules will have to be bent to get the work done The feeling that one has the ability and experience Powerfulness to do the job without slavishly following the procedures Opportunities Seeing opportunities that present themselves for short cuts or to do things ‘better’ Inadequate work planning and advance Planning preparation, leading to working ‘on the fly’ and solving problems as they arise Courtesy Prof Patrick Hudson 51 Aviation Summit Beijing Saturday, March 7, 2009
    185. 185. Aviation Summit Beijing 52 Saturday, March 7, 2009
    186. 186. LOSA data has also indicated what crews do RIGHT Aviation Summit Beijing 52 Saturday, March 7, 2009
    187. 187. Aviation Summit Beijing 53 Saturday, March 7, 2009
    188. 188. Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM, in October 2006: Aviation Summit Beijing 53 Saturday, March 7, 2009
    189. 189. Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM, in October 2006: “After 10 years of examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two things: - Aviation Summit Beijing 53 Saturday, March 7, 2009
    190. 190. Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM, in October 2006: “After 10 years of examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two things: - cooperate to rigorously monitor and cross check to  make sure they pick up threats and errors early, and Aviation Summit Beijing 53 Saturday, March 7, 2009
    191. 191. Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM, in October 2006: “After 10 years of examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two things: - cooperate to rigorously monitor and cross check to  make sure they pick up threats and errors early, and actively engage in checking and verifying every  setting and action which can affect safety.” Aviation Summit Beijing 53 Saturday, March 7, 2009
    192. 192. Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM, in October 2006: “After 10 years of examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two things: - cooperate to rigorously monitor and cross check to  make sure they pick up threats and errors early, and actively engage in checking and verifying every  setting and action which can affect safety.” Obvious? Yes; but real evidence from normal operations Aviation Summit Beijing 53 Saturday, March 7, 2009
    193. 193. One of the variables we can control is training 54 Saturday, MarchBeijing Aviation Summit 7, 2009
    194. 194. Still the question that Every Airline wants answered is: “What is the most likely cause of a future accident IN OUR AIRLINE” ? AND HOW DO WE PREVENT IT? One of the variables we can control is training 54 Saturday, MarchBeijing Aviation Summit 7, 2009
    195. 195. RAISING THE BAR - TYPE RATING INSTRUCTORS 55 Aviation Summit Beijing Saturday, March 7, 2009
    196. 196. RAISING THE BAR - TYPE RATING INSTRUCTORS 55 Aviation Summit Beijing Saturday, March 7, 2009
    197. 197. RAISING THE BAR - TYPE RATING INSTRUCTORS Airline management has clear control of training, for the production of safe (or less safe) outcomes 55 Aviation Summit Beijing Saturday, March 7, 2009
    198. 198. 56 Aviation Summit Beijing Saturday, March 7, 2009
    199. 199. Quality in Control A quality system is based on understanding and controlling variation TRAINING IS A KEY VARIABLE A quality system is measured by the degree to which a set of standards are met - REGULATORY & OPERATIONAL A quality system is management methodology driven by data PERFORMANCE MEASUREMENT IN SMS A quality system focuses on projects that will produce measurable business results > ACCIDENT RATE REDUCTION 56 Aviation Summit Beijing Saturday, March 7, 2009
    200. 200. Quality in Control A quality system is based on understanding and controlling variation TRAINING IS A KEY VARIABLE A quality system is measured by the degree to which a set of standards are met - REGULATORY & OPERATIONAL A quality system is management methodology driven by data PERFORMANCE MEASUREMENT IN SMS A quality system focuses on projects that will produce measurable business results > ACCIDENT RATE REDUCTION 56 Aviation Summit Beijing Saturday, March 7, 2009
    201. 201. 57 Aviation Summit Beijing Saturday, March 7, 2009
    202. 202. Training can never be perfect – there are always areas to improve > 57 Aviation Summit Beijing Saturday, March 7, 2009
    203. 203. 58 Aviation Summit Beijing Saturday, March 7, 2009
    204. 204. MPL embodies best practice 58 Aviation Summit Beijing Saturday, March 7, 2009
    205. 205. MPL embodies best practice Despite some commentary suggesting a ‘failure’ of MPL (due to recent MPL graduate job losses), MPL is: - 58 Aviation Summit Beijing Saturday, March 7, 2009
    206. 206. MPL embodies best practice Despite some commentary suggesting a ‘failure’ of MPL (due to recent MPL graduate job losses), MPL is: -  the result of 6 years of industry development to replace an outdated 60 year-old airline training process 58 Aviation Summit Beijing Saturday, March 7, 2009
    207. 207. MPL embodies best practice Despite some commentary suggesting a ‘failure’ of MPL (due to recent MPL graduate job losses), MPL is: -  the result of 6 years of industry development to replace an outdated 60 year-old airline training process  an ICAO approved programme and license 58 Aviation Summit Beijing Saturday, March 7, 2009
    208. 208. MPL embodies best practice Despite some commentary suggesting a ‘failure’ of MPL (due to recent MPL graduate job losses), MPL is: -  the result of 6 years of industry development to replace an outdated 60 year-old airline training process  an ICAO approved programme and license  a set of powerful airline pilot training tools, demanding new standards in the airline pilot training process 58 Aviation Summit Beijing Saturday, March 7, 2009
    209. 209. MPL embodies best practice Despite some commentary suggesting a ‘failure’ of MPL (due to recent MPL graduate job losses), MPL is: -  the result of 6 years of industry development to replace an outdated 60 year-old airline training process  an ICAO approved programme and license  a set of powerful airline pilot training tools, demanding new standards in the airline pilot training process This is exactly what the training industry needs – relevance, focus and quality, in areas such as >> 58 Aviation Summit Beijing Saturday, March 7, 2009
    210. 210. Aviation Summit Beijing 59 Saturday, March 7, 2009
    211. 211. The instructors Art Aviation Summit Beijing 59 Saturday, March 7, 2009
    212. 212. The instructors Art Advanced training equipment will not fully compensate for ineffective instruction Aviation Summit Beijing 59 Saturday, March 7, 2009
    213. 213. The instructors Art Advanced training equipment will not fully compensate for ineffective instruction An effective instructor can however compensate for training equipment limitations Aviation Summit Beijing 59 Saturday, March 7, 2009
    214. 214. The instructors Art Advanced training equipment will not fully compensate for ineffective instruction An effective instructor can however compensate for training equipment limitations More relevant instructor entry criteria and improved training is needed, such as that prescribed by MPL Aviation Summit Beijing 59 Saturday, March 7, 2009
    215. 215. Aviation Summit Beijing 60 Saturday, March 7, 2009
    216. 216. Human Factors Training Aviation Summit Beijing 60 Saturday, March 7, 2009
    217. 217. Human Factors Training Human factors remain central triggers in accidents and incidents Aviation Summit Beijing 60 Saturday, March 7, 2009
    218. 218. Human Factors Training Human factors remain central triggers in accidents and incidents As Daniel Maurino (ICAO) stated in 1991, Human Factors is not just CRM! Aviation Summit Beijing 60 Saturday, March 7, 2009
    219. 219. Human Factors Training Human factors remain central triggers in accidents and incidents As Daniel Maurino (ICAO) stated in 1991, Human Factors is not just CRM! Modern Flight Crew must be taught to recognise human limitations through all phases of operations (TEM) Aviation Summit Beijing 60 Saturday, March 7, 2009
    220. 220. Human Factors Training Human factors remain central triggers in accidents and incidents As Daniel Maurino (ICAO) stated in 1991, Human Factors is not just CRM! Modern Flight Crew must be taught to recognise human limitations through all phases of operations (TEM) A training objective is to instill continuous embedded awareness, eg. TEM in MPL Aviation Summit Beijing 60 Saturday, March 7, 2009
    221. 221. Aviation Summit Beijing 61 Saturday, March 7, 2009
    222. 222. Training improvements summary Aviation Summit Beijing 61 Saturday, March 7, 2009
    223. 223. Training improvements summary Enhanced Instructor training and oversight 1. Aviation Summit Beijing 61 Saturday, March 7, 2009
    224. 224. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Aviation Summit Beijing 61 Saturday, March 7, 2009
    225. 225. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Aviation Summit Beijing 61 Saturday, March 7, 2009
    226. 226. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Driven by performance feedback 4. Aviation Summit Beijing 61 Saturday, March 7, 2009
    227. 227. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Driven by performance feedback 4. Training devices tailoured to training task and learning phase (eg. APT 5. Trainers) Aviation Summit Beijing 61 Saturday, March 7, 2009
    228. 228. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Driven by performance feedback 4. Training devices tailoured to training task and learning phase (eg. APT 5. Trainers) Embedded human factors / TEM. 6. Aviation Summit Beijing 61 Saturday, March 7, 2009
    229. 229. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Driven by performance feedback 4. Training devices tailoured to training task and learning phase (eg. APT 5. Trainers) Embedded human factors / TEM. 6. Mandated uniforms in simulator training – raising crew fidelity 7. Aviation Summit Beijing 61 Saturday, March 7, 2009
    230. 230. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Driven by performance feedback 4. Training devices tailoured to training task and learning phase (eg. APT 5. Trainers) Embedded human factors / TEM. 6. Mandated uniforms in simulator training – raising crew fidelity 7. Training driven from operations and safety sensing systems 8. Aviation Summit Beijing 61 Saturday, March 7, 2009
    231. 231. Training improvements summary Enhanced Instructor training and oversight 1. More task-focussed, competency-based, quality embedded programmes 2. Programme design for continuous improvement 3. Driven by performance feedback 4. Training devices tailoured to training task and learning phase (eg. APT 5. Trainers) Embedded human factors / TEM. 6. Mandated uniforms in simulator training – raising crew fidelity 7. Training driven from operations and safety sensing systems 8. Aviation Summit Beijing 61 Saturday, March 7, 2009
    232. 232. 62 Aviation Summit Beijing Saturday, March 7, 2009
    233. 233. For example: Uniforms in simulation 62 Aviation Summit Beijing Saturday, March 7, 2009
    234. 234. For example: Uniforms in simulation 62 Aviation Summit Beijing Saturday, March 7, 2009
    235. 235. For example: Uniforms in simulation  A zero cost option - all crews have uniforms! 62 Aviation Summit Beijing Saturday, March 7, 2009
    236. 236. For example: Uniforms in simulation  A zero cost option - all crews have uniforms!  Matches crew fidelity with simulator fidelity 62 Aviation Summit Beijing Saturday, March 7, 2009
    237. 237. For example: Uniforms in simulation  A zero cost option - all crews have uniforms!  Matches crew fidelity with simulator fidelity  Creates a more professional atmosphere in training 62 Aviation Summit Beijing Saturday, March 7, 2009
    238. 238. 63 Aviation Summit Beijing Saturday, March 7, 2009
    239. 239. The bottom line -Training 63 Aviation Summit Beijing Saturday, March 7, 2009
    240. 240. The bottom line -Training We are highly exposed to ineffective training 63 Aviation Summit Beijing Saturday, March 7, 2009
    241. 241. The bottom line -Training We are highly exposed to ineffective training Airlines need to offer comfortable and safe air travel as a long term profitable business plan 63 Aviation Summit Beijing Saturday, March 7, 2009
    242. 242. The bottom line -Training We are highly exposed to ineffective training Airlines need to offer comfortable and safe air travel as a long term profitable business plan Resource flow must be maintained to the vital organs of safety culture 63 Aviation Summit Beijing Saturday, March 7, 2009
    243. 243. The bottom line -Training We are highly exposed to ineffective training Airlines need to offer comfortable and safe air travel as a long term profitable business plan Resource flow must be maintained to the vital organs of safety culture Effective crew training is an investment which protects safety margins for years to come 63 Aviation Summit Beijing Saturday, March 7, 2009
    244. 244. The bottom line -Training We are highly exposed to ineffective training Airlines need to offer comfortable and safe air travel as a long term profitable business plan Resource flow must be maintained to the vital organs of safety culture Effective crew training is an investment which protects safety margins for years to come Training must deliver efficient best practice, with relevance and continuous improvement 63 Aviation Summit Beijing Saturday, March 7, 2009
    245. 245. Aviation Summit Beijing 64 Saturday, March 7, 2009
    246. 246. Measurement is vital to improvement Aviation Summit Beijing 64 Saturday, March 7, 2009
    247. 247. Aviation Summit Beijing 65 Saturday, March 7, 2009
    248. 248. ‘Take-aways’ Aviation Summit Beijing 65 Saturday, March 7, 2009
    249. 249. ‘Take-aways’ To avoid additional cost, we must optimise what we have Aviation Summit Beijing 65 Saturday, March 7, 2009
    250. 250. ‘Take-aways’ To avoid additional cost, we must optimise what we have But to improve, we must measure! Aviation Summit Beijing 65 Saturday, March 7, 2009
    251. 251. ‘Take-aways’ To avoid additional cost, we must optimise what we have But to improve, we must measure! Measurement embedded in the training process, and instructor’s task Aviation Summit Beijing 65 Saturday, March 7, 2009
    252. 252. ‘Take-aways’ To avoid additional cost, we must optimise what we have But to improve, we must measure! Measurement embedded in the training process, and instructor’s task TEM embedded in all training footprints Aviation Summit Beijing 65 Saturday, March 7, 2009
    253. 253. ‘Take-aways’ To avoid additional cost, we must optimise what we have But to improve, we must measure! Measurement embedded in the training process, and instructor’s task TEM embedded in all training footprints As QUANTITY shrinks, QUALITY must grow Aviation Summit Beijing 65 Saturday, March 7, 2009
    254. 254. ‘Take-aways’ To avoid additional cost, we must optimise what we have But to improve, we must measure! Measurement embedded in the training process, and instructor’s task TEM embedded in all training footprints As QUANTITY shrinks, QUALITY must grow Aviation Summit Beijing 65 Saturday, March 7, 2009
    255. 255. Aviation Summit Beijing 66 Saturday, March 7, 2009
    256. 256. Aviation Summit Beijing 66 Saturday, March 7, 2009
    257. 257. Aviation Summit Beijing 67 Saturday, March 7, 2009
    258. 258. Aviation Summit Beijing 67 Saturday, March 7, 2009

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