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
- FDM, Risk and Protecting your Assets Sonya Tietjen Principal, Safety Management Systems 4 March, Heli-Expo 2013: Las Vegas, NV 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.
- Agenda 1. The Problem 2. The Solution 3. The Benefits 1. Risk Management 2. Flight Data Monitoring 3. Protecting Your Assets 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.
- 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.
- Causal Factors - Primary IHST 2006 (JHSAT) Flight Crew 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.
- 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.
- How accidents happen Organization Technology Humans Modified from J. Reason 1997 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.
- 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 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. Source: CGE Risk
- Two tools for Flight Ops data 1. Safety Reporting 2. Flight Data Monitoring 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.
- Safety Reporting 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.
- 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 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.
- 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 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.
- 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 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.
- Flight Operations 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.
- 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 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.
- Two tools for Flight Ops data 1. Safety Reporting 2. Flight Data Monitoring Only FDM is comprehensive and quantifiable 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.
- 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.
- Safety Reporting + FDM = “W5s” FDM – W4’s: 1. Who* 2. What 3. Where 4. When Safety Reporting 5. Why 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.
- Organization Technology Humans Modified from J. Reason 1997 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.
- The Good, the Bad, and the Ugly 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.
- Protecting Your Assets Organisation Technology Humans 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.
- Humans (The Clients) Complaint Management Turbulence Timing Airmanship Marketing Liability Risk Management Professionalism 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.
- 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 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.
- Technology (The Aircraft) Pre-purchase / Pre-funding: Performance / Efficiency Proper handling Limits maintained MRO: Faulty Equipment Limits maintained / exceeded Warranty issues 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.
- 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 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.
- 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.
- Wrap Up The highest risk to an operation is Flight Without FDM, you really don’t have quality assurance on flight operations Implement FDM 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.
- 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.
Editor's Notes
- 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