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Flight Data Monitoring, Risk, and Protecting Assets

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International Helicopter Safety Team (IHST) workshop presentation from HeliExpo 2013

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Flight Data Monitoring, Risk, and Protecting Assets

  1. 1. FDM, Risk and Protecting your Assets Sonya Tietjen Principal, Safety Management Systems 4 March, Heli-Expo 2013: Las Vegas, NVAll 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.
  2. 2. Agenda 1. The Problem 2. The Solution 3. The Benefits 1. Risk Management 2. Flight Data Monitoring 3. Protecting Your AssetsAll 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.
  3. 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.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.
  4. 4. Causal Factors - Primary IHST 2006 (JHSAT) Flight CrewAll 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.
  5. 5. The Problem?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.
  6. 6. How accidents happen Organization Technology Humans Modified from J. Reason 1997All 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.
  7. 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-Pilots 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-Pilots 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 - GeneralAll 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. Source: CGE Risk
  8. 8. Two tools for Flight Ops data 1. Safety Reporting 2. Flight Data MonitoringAll 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.
  9. 9. Safety ReportingAll 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.
  10. 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 1997All 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.
  11. 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 9859All 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.
  12. 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 9859All 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.
  13. 13. Flight OperationsAll 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.
  14. 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 informationAll 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.
  15. 15. Two tools for Flight Ops data 1. Safety Reporting 2. Flight Data Monitoring Only FDM is comprehensive and quantifiableAll 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.
  16. 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…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.
  17. 17. Safety Reporting + FDM = “W5s”  FDM – W4’s: 1. Who* 2. What 3. Where 4. When  Safety Reporting 5. WhyAll 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.
  18. 18. Organization Technology Humans Modified from J. Reason 1997All 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.
  19. 19. The Good, the Bad, and the UglyAll 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.
  20. 20. Protecting Your Assets  Organisation  Technology  HumansAll 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.
  21. 21. Humans (The Clients)  Complaint Management  Turbulence  Timing  Airmanship  Marketing  Liability  Risk Management  ProfessionalismAll 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.
  22. 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  EquipmentAll 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.
  23. 23. Technology (The Aircraft)  Pre-purchase / Pre-funding:  Performance / Efficiency  Proper handling  Limits maintained  MRO:  Faulty Equipment  Limits maintained / exceeded  Warranty issuesAll 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.
  24. 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  MaintenanceAll 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.
  25. 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)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.
  26. 26. Wrap Up  The highest risk to an operation is Flight  Without FDM, you really don’t have quality assurance on flight operations  Implement FDMAll 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.
  27. 27. FDM, Risk and Protecting your Assets Sonya Tietjen Principal, Safety Management Systems SonyaT@GaelQuality.comAll 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.

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