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1.
FDM, Risk and Protecting your Assets
Sonya Tietjen
Principal, Safety Management Systems
4 March, Heli-Expo 2013: Las Vegas, NV
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2.
Agenda
1. The Problem
2. The Solution
3. The Benefits
1. Risk Management
2. Flight Data Monitoring
3. Protecting Your Assets
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3.
NTSB Report
1. The flight crew made
numerous procedural errors
and deviations during the final
approach segment of the
VOR/DME approach.
2. The crew demonstrated poor
crew coordination during the
accident flight.
3. The flight crew was under
pressure to land.
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4.
Causal Factors - Primary
IHST 2006 (JHSAT)
Flight Crew
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5.
The Problem?
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6.
How accidents happen
Organization
Technology
Humans
Modified from J. Reason 1997
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7.
BowTieXP: Loss of Separation
Loss of Spacial
Awareness
Medical fitness and 6 monthly Simulator training including Maintenance of an effective Two Crew operations
tests. recovery from unusual look-out
attitudes Ref? - Reference to be added
Ref? - Reference to be added RAP 1 - xx
Ref? - Reference to be added
Flight crew mishandling
and mismanagement of
the flight
Compliance with procedures Effective cross cockpit Crew flight planning for other Multi crew ops including Training and testing (Line Training and testing (Base
and checklist communication aircraft operations in the challenge and response Checks) checks)
operational zone
OM Pt.8 - Unit Orders OM Pt.6 Sct.1 - Definitions, OM Pt.5 Sct.1.1 - Duties of TM Pt.4 - Operation Line TM Pt.4 Sct.1 - General
Rules and Requirements OM Pt.8.Sect 3.23 - Summary Captain and First Officer Training
to Offshore Operations TM Pt.4 Sct.1 - General
(AS332L1) H-02.01.01 Aircraft in
motion (1)
Aircraft System failures
MEL controls for limiting routine preventitive Repetitive defect Flight Manual Emergency
departures with maintenance management Check List actions
unsevicabilities
MS - Aircraft Mainteance MOE Pt.2 Sect.2.14 - Technical FM Sct.3 - Emergency
MEL - Minimum Equipment List Schedule record control Procedures
Ineffective Air Traffic
Management D - Aircraft In motion
'Airborne': HE-20E
GPS flight Tracking Provision of area information In field traffic communication Effective provision of area Loss of separation Airborne contact with
(NOTAMS) contol of air traffic with third party opposing traffic, Loss of
RAP 1 - xx OM Pt.2 Sct.1.3.4.10 - management
AIP.Vol 1. GEN 3.3 - Air Traffic Helicopter Operations aircraft aircraft and/or multiple
Services Personnel Manning AIP.Volume 2 - Aerodrome Identification of Opposing Establish Communication Take avoiding action fatality
(AD) traffic with opposing traffic
OM Pt.8.Sect 9 - Emergency C5 C5 C3 C5
SID Sect.04 - Listing of SID Sect.07 - Hazard Register Procedures
Interface Activities AIP.Vol 1 ENR 2 - Air Traffic
Services Airspace
Operations in adverse
weather
Incorrect avoiding action
Procedure (weather minima) Weather (Flight Operations Actual Weather Training (interpretation of taken
Limitations) Reports/Information weather information, and
Ref? - Reference to be added weather avoidance) Maintenance of Situational Installation and use of TCAS CAR 1996 and AIP
Ref? - Reference to be added RAP 2 - x Awareness requirements for standard
RAP 3 - xxx collision avoidance actions
OM Pt.2 Sct.12.34 - Adherence
To Operating Procedures and MCAR Pt.11 Chap.2 -
Co-Pilot's Responsibility Regulation of Movement Area
Failure to install available
safety improvement
system or to learn from
experience Equipment Standardisation Installation of Traffic
and acceptance checks avoidance systems (TCAS) Failure to establish
communications with
QAM.7.5 - HFDM Process RAP 4 - xxxxx opposing traffic
Common Frequency for Blind Call on Guard frequency
aircraft in the operational 121.5 MHz
zone
Ref? - Reference to be added
Ref? - Reference to be added
Failure to learn from
experience
HSE Management Review Occurrence reporting system QA Audit of line management Line management action to
Board process actions to resolve findings resolve findings
Ref? - Reference to be added Lack of visual
Ref? - Reference to be added Ref? - Reference to be added Ref? - Reference to be added meteorological conditions
(VMC)
Installation and use of TCAS Division of workload (handling Maintenance of Situational
and non-handling pilots) IMC Awareness
Non-compliance with RAP 3 - xxx and VMC
mandatory requirements OM Pt.2 Sct.12.34 - Adherence
(levels and distance) for OM Pt.6 Sct.2.3 - Division of To Operating Procedures and
seperation with third party Crew Duties During Flight in Co-Pilot's Responsibility
aircraft. Training and testing (Base Training and testing (Line Multi crew ops including Effective cross cockpit Multi crew ops including Compliance with procedures Organisational Discipline I.M.C.
checks) Checks) challenge and response communication challenge and response and checklist RAP 4 - xxxxx
Ref? - Reference to be added
TM Pt.4 Sct.1 - General TM Pt.4 - Operation Line OM Pt.5 Sct.1.1 - Duties of OM Pt.6 Sct.1 - Definitions, OM Pt.5 Sct.1.1 - Duties of OM Pt.8 - Unit Orders
Training Captain and First Officer Rules and Requirements Captain and First Officer
TM Pt.4 Sct.1 - General
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Source: CGE Risk
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8.
Two tools for Flight Ops data
1. Safety Reporting
2. Flight Data Monitoring
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9.
Safety Reporting
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10.
Breaching Defenses
Human beings, the technology
they operate, and the
organisation they work within,
are the three sets of factors
likely to be “implicated in
breaching defenses put in place
to avoid accidents.”
J. Reason 1997
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11.
Risk Management
“Hazard and risk management
must be data-driven
and involve constant monitoring
to either eliminate
or reduce the risk to
as low as reasonably practicable.”
ICAO 2009, Doc 9859
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12.
Data
The data collected must be
systematic, cover all areas of the
operation, and have the ability to
measure the results of controls put
in place […to control risk].
Finally,
the focus must first be
on the area of highest risk.
ICAO 2009, Doc 9859
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13.
Flight Operations
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14.
Bottom Line: Flight Operations
1. Human Factors are the
primary cause of incidents and
accidents
2. Flight is the highest area of
risk in operations
3. Flight is the operation of which
we have the least amount of
information
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15.
Two tools for Flight Ops data
1. Safety Reporting
2. Flight Data Monitoring
Only FDM is
comprehensive and quantifiable
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16.
The Solution: FDM
1. Records interaction between:
the technology (aircraft)
and the people (pilots)
2. Analyses interaction
for specific events (reactive)
undesirable trends (proactive)
3. So the organisation can do
something about it…
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17.
Safety Reporting + FDM = “W5s”
FDM – W4’s:
1. Who*
2. What
3. Where
4. When
Safety Reporting
5. Why
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Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.
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18.
Organization
Technology
Humans
Modified from J. Reason 1997
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19.
The Good, the Bad, and the Ugly
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20.
Protecting Your Assets
Organisation
Technology
Humans
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21.
Humans (The Clients)
Complaint Management
Turbulence
Timing
Airmanship
Marketing
Liability
Risk Management
Professionalism
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22.
Humans (The Employees)
CEO
Peace of mind from actually knowing
your aircraft are being operated in a
professional manner.
False accusation
Airspace breaches
Low flying
Poor airmanship
Management Support
Non-SOP Flying Requests
Documents observations
Procedures
Equipment
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23.
Technology (The Aircraft)
Pre-purchase / Pre-funding:
Performance / Efficiency
Proper handling
Limits maintained
MRO:
Faulty Equipment
Limits maintained / exceeded
Warranty issues
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24.
Organisation (The Company)
Return on Investment
Protecting your Assets
Marketing
Promotion of SMS
Risk Management
Monitoring – Quality Assurance
Ferry Flights
Flight Operations
Human Resources
Continuous Improvement
Training Programs
Enhancement
Validation
Efficiencies
Fuel efficiency
Maintenance
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25.
FDM Resources
Global Helicopter Flight Data Monitoring Community
(www.hfdm.org)
International Helicopter Safety Team
(www.ihst.org)
UK Civil Aviation Authority - CAP 739
(www.caa.co.uk)
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26.
Wrap Up
The highest risk to an
operation is Flight
Without FDM, you really don’t
have quality assurance on
flight operations
Implement FDM
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27.
FDM, Risk and Protecting your Assets
Sonya Tietjen
Principal, Safety Management Systems
SonyaT@GaelQuality.com
All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.
Opening: GutenmorgenmeineDamen und Herren, und vielen dank für die Gelegenheit zu Präsentieren ihnen heute.Es tut mir leid, aber mein Deutsch ist sehr rostig, so werde ich meine Präsentation in englischer Sprache geben
Today I will speak about Risk Management, Flight Data Monitoring and Protecting your assets.I have a passion for Safety in aviation, so my presentation is to highlight the value and cost benefit of implementing an FDM programme.To put this all in context, I’m going to start with a couple of quotes…And probably a couple of familiar graphics
Unfortunately, it doesn’t always work out that way.Excerpt from an NTSB report – it doesn’t matter which accidentThis is not a-typicalThe big question is: Do you think that this is the first time any of these situations has arisen with this particular crew?But Oh.. You say… we have a great safety reporting culture. The crew would tell us if they have problems….March 29, 2001, about 1901:57 mountain standard timeGulfstream III, N303GA, owned by Airbourne Charter, Inc., and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, Colorado.
So where’s the problem…In fact - Two-thirds of all fatal accidents involved a flight crew related primarycausal factorand 7% involved an aircraft related primarycausal factor.Three-quarters of all fatal accidents involved at least one flight crew related causal factor and 42% involved at least one aircraft related causal factor.So what’s going on up there?UK CAA, CAP 776
OK… maybe not always, and maybe not as complete a picture as we would likePatrick Hudson, Professor at Delft University, estimated some years ago that 75% of “events” go unreportedAnd that’s just the reactive stuff.We’re pretty good at reporting things that others noticed, or definitely will notice, But not so good where we either don’t think it’s important, or maybe when we don’t think we’ll get caught messing up.And of course there are the issues that the pilots did not detect.An example: One RW pilot flying offshore did not know he was close to Vortex Ring until the Flight Data Analyst asked him to review the flight. He turned white as a ghost.
That interaction between the flight crew and the technology is what this is all aboutYou only have 3 main levels. Most of those holes we talk about are at the top end of the model.This is closer to the truth as it is the organisation that has the resources to make or block these holes.If the organisation does it’s job, and the technology is appropriate and cared forThe people have many fewer holes to block.Much more effective in preventing an accident than having all the holes being blocked by the peopleThe heros… the ones that work against all odds to prevent an accident or recover from one that could have been much worseWe can’t leave it to the last resort – we have to get proactive.
Aircraft in motion represents the greatest hazard faced by an operation.And each of the threats firing arrows at your swiss cheeseIn between the “unwanted event” – in this case Loss of Separation – are the controls – the holes in the swiss cheese.If these controls fail, and you get to the unwanted event, you require recovery procedures to avoid catastropheThe yellow – a baaaad situation, such as: inadvertent IMC Or the worst - The red: Airborne contact with opposing trafficCLICK: Here I’ve circled all those threats and controls that are dependant on the flight crew having the resources (tools, training, equipment, wide awake, etc.) and the ability to do their job well
There are 2 tools for gathering operational flight data:Safety ReportingFlight Data MonitoringOf these two tools, only FDM is comprehensive and quantifiable.You get everything that the aircraft is capable of recording
Safety Reporting is important..You get real and valuable information, not to mention the 2-way communication you get with staff. Extremely important and I could do an entire presentation on its merits and the benefit to the SMSBut this presentation is about FDM… although we’ll see later how the 2 are relatedNow the real question – is do we get all the information we need this way?
Human beings, the technology they operate, and the organisation they work within, are the three sets of factors likely to be “implicated in breaching defenses put in place to avoid accidentsAnd how do accidents happen?
And to manage risk, ICAO says:“it must be data-driven and involve constant monitoring to either eliminate or reduce the risk to as low as reasonably practicable
ICAO further requires that the data collected is systematic, cover all areas of the operation and have the ability measure the results of the controls put in place to control that risk.And finally… the focus must first be on the highest risk.And what is that?
Flight Operations
And how much information do we have?Ah yes. But we get flight safety reports. Pilots put an ASR in whenever something goes wrongWe know of all the mistakes, errors, technical faults, whenever they don’t quite stick to SOPs…Right?So it makes sense to ensure we have data that is:SystematicCover all areasHave the ability to measure the resultsAnd most importantly – be able to focus on the area of highest riskAnd what is that?
There are 2 tools for gathering operational flight data:Safety ReportingFlight Data MonitoringOf these two tools, only FDM is comprehensive and quantifiable.You get everything that the aircraft is capable of recording
The data collected on the Super Puma tells you a lotHow the aircraft reacted and interacted with the controlsHow the PIC reactedThe resulting ASR and investigation will add to the quantifiable data withhow the crew (no pax) got out, with only one minor injuryinvestigation and report would tell you the about the Ground run after maintenanceNow the problem with this one, is that FDM was installed, but as it was a maintenance run, there was not PCMCI card in the Quick Access Recorder, so no operational data could be collected.The bottom picture has an FDR, and in this situation you would pull the data for the investigationNow neither of these situations are unique, and as both are “accidents”, they are investigatedBut what if it was a close call - landing late, unstable approach, malfunction, or in the case of the SuperPuma – a gust of wind on a top heavy helicopter just makes the one wheel lift up a bit… Incidentally – a large investigation quite a number of years ago using recorded flight data CLICK: (due to “this event”) determined how to avoid a roll over in the super puma. It’s unfortunate that history continues to repeat itself in various waysOne: in business ops you may not know it ever happened – that wonderful “what happens in Vegas stays in Vegas”Second, you cannot routinely analyse the precursers. One commercial airline Safety Manager told me rather cynically that “we never had an unstable approach until we put FDM in place”.So you want robust informationYes – to hold individuals accountable for their actionsBut also to give them the tools to improve their performanceAs well as the overall performance of the operation through training, procedures, and awareness.
That interaction between the flight crew and the technology is what this is all aboutYou only have 3 main levels. Most of those holes we talk about are at the top end of the model.This is closer to the truth as it is the organisation that has the resources to make or block these holes.If the organisation does it’s job, and the technology is appropriate and cared forThe people have many fewer holes to block.Much more effective in preventing an accident than having all the holes being blocked by the peopleThe heros… the ones that work against all odds to prevent an accident or recover from one that could have been much worseWe can’t leave it to the last resort – we have to get proactive.
The goodthe badand the uglyNow the “bad” is a screenshot where one of these 2 fire-fighters posted themselves on FacebookAnd another client sent it off to a gentleman named Paul Spring, owner of Phoenix HeliFlight and this aircraft.Paul has graciously given me free license to use his material – and he uses it himself for presentations such as thisThe pilot was a contractor who will no longer work for Phoenix HeliflightAs Paul says… The individuals on the skids were willing participants and maybe even instigatorsso Phoenix uses these photos during training to educate Pilots and Firefighters of the consequences.Phoenix’s HFDM equipment includes cockpit voice and video recorders, the presence of which may have discouraged any thought of such a reckless & stupid actNow… incidentally, as you’re by now thinking I’m ignoring the “Good guys”This is not true. Much can be learned about good SOPs from the guys that do things right in difficult situations.But more about that in a minute.Pilot: R.G. (full time employee)• 2,099 PIC Single Engine R/W & F/W• On July 22, 2007 our AS350 BA was returning to home base after a day of Initial Attack standby. The pilot with his crew of 4woodland firefightersonboard had been in level cruise at 1000 feet AGL for 20 minutes when the helicopter descendedabruptly……. 1 person dead & his family devastated• 4 persons injured• 1 helicopter destroyed• The company’s reputation threatened• With the pilot’s testimony the Transportation Safety Board of Canada concluded that the helicopter was flown into“servo transparency” following a “sudden high speed descent”.The TSB final report stated “It was reported that the pilot had previously flown in a similar manner on other flights whentransiting between bases, with sudden climbs, descents, and pull-ups. Some of the passengers reportedly were discomfortedby the maneuvers; however, no complaints were submitted to the management at ASRD or Phoenix Heli-Flight”.• The helicopter involved had no HFDMrecorder so if everyone had died, the causemay have been ‘undetermined’.
FW: Exceedance of control limits – control surface or structural damageControl surface and structural damage due to exceedance of control limitsExceeding engine temperature ratio