Risk Management Assessement for Loss of Control In Flight

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A coursework for City University London, detailing a risk assessment carried out for Loss of Control -In Flight

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Risk Management Assessement for Loss of Control In Flight

  1. 1. School of Engineering and Mathematical Sciences POST GRADUATE Coursework submission form Complete the details below, attach the form to your coursework and submit as per coursework instructions Student Name Student Number Email address Address Programme ATM/ASM/AMM Word Count Module Title Coursework A or B Submission Deadline Submission Date DECLARATION: Iconfirmthattheworkismyown,thatIhavenotcopiedtheworkofothers,norallowedotherstocopymyworkandthatIhavereferencedtheworkofot herauthorsusedinanappropriateway.Ihavealsoreadandcompliedwiththeguidelinesonplagiarismassetoutinthestudenthandbook.I understandthattheuniversitymaymakeuseofplagiarismdetectionsoftwareandthatmyworkmaythereforebestoredonadatabasewhichis accessibletootherusersofthesamesoftware.Icertifythatthewordcountdeclarediscorrect. Acknowledgmentbystudent: Studentsshouldbeawarethat,whereplagiarismissuspected,aformalinvestigationwillbecar riedout,andactionmaybetakenunderthe university'srulesonAcademicMisconduct.Thismightresultinpenaltiesrangingfrommarkde ductiontowithdrawalfromtheuniversity. Lecturer / Tutor to complete: Feedback to student Final Mark If penalties were applied: Original mark: Marks deducted: Reason for deduction: RohitTomar rohithtomar@gmail.com 901, Nariman Tower, Nariman Road, Vile Parle (East), Mumbai 400057 ATM RISK MANAGEMENT 22nd June 2013 21st June 2012 RohitTomar 2 2336
  2. 2. CITY UNIVERISTY RISK MANAGEMENT MODULE [RISK ASSESSMENT OF LOSS OF CONTROL IN FLIGHT] Rohit Tomar 6/19/2013
  3. 3. 1 | P a g e Table of Contents List of Figures..................................................................................................................3 List of Table.....................................................................................................................3 1. Introduction ...............................................................................................................4 2. Define Risk................................................................................................................5 2.1 Risk Definition: Loss of Control in Flight (LOC-I) ................................................5 2.2 Hazard Definition:...............................................................................................5 2.3 Threats Definition: ..............................................................................................5 3. Identify Risk Involved ................................................................................................6 4. Assess Risk Factor ...................................................................................................7 4.1 Exposure ............................................................................................................9 4.2 Risk Factor .........................................................................................................9 4.3 Severity ..............................................................................................................9 4.4 Probability:..........................................................................................................9 4.4.1 System Control Failure ..............................................................................11 4.4.2 Loss of Power ............................................................................................11 4.4.3 Crew Incapacitation ...................................................................................11 4.4.4 Flight Management or Control Error...........................................................11 4.4.5 Environmental Factors ...............................................................................11 4.4.6 Aircraft Load ..............................................................................................11 4.4.7 Malicious Interference................................................................................12 4.4.8 Improper Procedures .................................................................................12 4.4.9 Risk Assessment for LOC – I for an Airline................................................12 4.4.10 Risk Acceptance ........................................................................................13 4.4.11 Conclusion .................................................................................................13
  4. 4. 2 | P a g e 5. Make control decisions............................................................................................13 6. References..............................................................................................................17
  5. 5. 3 | P a g e List of Figures Figure 1 ...........................................................................................................................4 Figure 2 ...........................................................................................................................6 Figure 3 ...........................................................................................................................8 Figure 4 ...........................................................................................................................8 Figure 5 .........................................................................................................................10 Figure 6 .........................................................................................................................10 List of Table Table 1 ............................................................................................................................7 Table 2 Risk Assessment Matrix .....................................................................................9 Table 3 Risk Assessment Matrix for LOC –I..................................................................12 Table 4 Risk Acceptance Criteria ..................................................................................13 Table 5 ..........................................................................................................................16
  6. 6. 4 | P a g e 1. Introduction This risk assessment is performed to define the risk of Loss of Control in Flight for an Airline. Historical data from Boeing Statistical summary of commercial jet airplane accidents worldwide operations 1959-2011 shows that Loss of Control in Flight (LOC-I) has been attributed as the reason for highest number of accidents and fatalities as compared to other causes. As per the statistical data from Boeing, a total of 18 accidents caused by LOC-I resulted in more than 1400 fatalities and thus an important area for study of Flight Safety. Figure 1 This assessment would use secondary research data available to define the risk and analyze the threats that an airline is exposed to during its operations which can cause Loss of Control in Flight. This assessment would also aim to provide some
  7. 7. 5 | P a g e decisions that would aim to eliminate the risks or mitigate the risks to a controllable level for the Airline. 2. Define Risk 2.1 Risk Definition: Loss of Control in Flight (LOC-I) As per ICAO Aviation Occurrence Categories Definition and Usage Notes – June 2004 (4.1) Loss of Control - In-flight (LOC-I) is referred to when aircraft control is lost during the airborne phases. ‘Loss of Control In-flight is an extreme manifestation of a deviation from intended flight path’ (Skybrary, 2010). 2.2 Hazard Definition: The hazard in this risk assessment would be Loss of Control In Flight (LOC-I) as it’s an unacceptable situation for an Airline and cause Harm, Injury, Loss of Life and Inconvenience to the passengers. 2.3 Threats Definition: NASA Aviation Safety Program conducted a study of the loss on control problems and compiled a list of casual factors that contributed to loss of control. The factors were segregated in to 3 categories 1) Pilot or Human Induced 2) Environmentally Induced 3) Systems Induced For performing the risk analysis, we would use the factors categorized by Skybrary which is in line with the categories defined in the NASA Report, however more specific in terms of defining the causing effects of each of the threats and the situation which can lead to release of these threats and cause a risk of LOC-I. The threats as per Skybrary report which would be used for risk assessment in this study are 1) Systems control failure 2) Loss of power 3) Crew Incapacitation
  8. 8. 6 | P a g e 4) Flight Management or control error 5) Environmental factors 6) Aircraft Load 7) Malicious interference This report would in additional to the 7 factors consider an 8th Factor of Improper procedure as same is not clearly reflected in the skybrary report. 3. Identify Risk Involved In order to identify the risks involved based on the threats; secondary data from NASA Aviation Safety Program has been used for an initial risk assessment study. A statistical summary developed in NASA Aviation Safety Program report supports to categorize the risk of the occurrence of In-Flight loss of control based on the contributing factors, see Figure 2. Figure 2 Leading this risk identification based on the report from NASA Figure 2, the threats to be analyzed can be categorized as below Identified Threats as per Skybrary Categorized as per NASA Figure 2 Comments Systems Control Failure Systems Induced Loss of Power Systems Induced Loss of power can also occur due to
  9. 9. 7 | P a g e incorrect operation of the a/c, however we will consider that in Procedure deviation in this analysis Crew Incapacitation Systems Induced An unfit pilot or unfit pilot operating an aircraft would be considered in Improper Procedures Flight Management or Control Error Systems Induced Environmental Factors Environmentally Induced Aircraft Load Pilot or Human Induced Malicious Interference Pilot or Human Induced Improper Procedures Pilot or Human Induced Table 1 4. Assess Risk Factor Secondary data from NASA Report will be used to perform the risk assessment of the contributing factors or threats identified which can cause the risk of loss of control in flight. The NASA report records data from various operators and produced important benchmarks like Figure 3 and Figure 4 crucial towards this risk assessment.
  10. 10. 8 | P a g e Figure 3 Figure 4 The figures 3 & 4 highlights that the probability of an LOC –I occurrence is higher in the Asia Region except China and the lowest in China, and improper procedures have a higher probability of becoming the cause of such an occurrence as compared to other factors.
  11. 11. 9 | P a g e This report would use the risk assessment matrix as used in City University London by Prof. Morten Kjellesvig in his Risk Management Course as in Table 2 PROBABILITY SEVERITY Low (1) Low (2) Medium (3) High (4) High (5) High (5) 5 10 15 20 25 High (4) 4 8 12 16 20 Medium (3) 3 6 9 12 15 Low (2) 2 4 6 8 10 Low (1) 1 2 3 4 5 Table 2 Risk Assessment Matrix 4.1 Exposure Using table 2 for carrying out the risk assessment, it is taken into account that the Exposure rate will remain the same. The reason for the exposure remaining the same being that the aircraft is exposed to the risk of loss of control every time it takes flight and during every flight the threats exist and can cause the occurrence of LOC-I. For calculation purpose the Exposure rate is taken as 3 and is kept constant. 4.2 Risk Factor The risk factor for the risk assessment is calculated as Risk Factor = Probability x Severity + Exposure 4.3 Severity The severity of this case is kept at 5 i.e. very high, this is to indicate that if any of the threats get released and cause a Loss of Control In Flight it can lead to a maximum damage of fatalities and loss of lives and aircraft as depicted in Figure 1 by Boeing. 4.4 Probability: At the outset, data based approach would be used to determine the highest level of probability of the risk of LOC – I occurring for an Airline. Figure 6, the percentage of accidents has reduced to nearly 1 or less than 1 accident per million departures and the downward trend in the graph indicates the improvements in Aircrafts and operations that has taken place over the years, hence it would be wise to set the maximum probability
  12. 12. 10 | P a g e for an occurrence of an accident due to LOC-I as 4 instead of 5. This can be further justified by Figure 5 which shows that LOC-I accidents are 0.10 accident per million flight hours. Figure 5 Figure 6
  13. 13. 11 | P a g e 4.4.1 System Control Failure Probability is set at Low Level 2 which is based on the NASA Report as in Figure 3. As depicted in Figure 3 the system failure caused 5 LOC-I occurrences as compared to Improper procedures, which caused the highest number of LOC-I accidents and would be graded as Probability Level 4 as explained in Point 4.4. 4.4.2 Loss of Power Loss of power is analyses only with respect to System Failure and is thus given the same probability level as System Control Failure, Level 2. An Event of Loss of Power due to actions of the Pilots is taken into consideration under Improper Procedures. 4.4.3 Crew Incapacitation Crew incapacitation can be a resultant effect of either System Failure like rapid decompression or smoke or fire which can be caused either due to human factor or systemic failure. In this analysis under Crew Incapacitation we would only consider system failure and cover the human factor related failure under Improper Procedures. The probability level for this is thus set at 2. 4.4.4 Flight Management or Control Error A Flight Management or Control error can occur either due to system failure or due to incorrect procedures followed by the Pilots. This can also be caused when Pilot is not sufficiently trained on the Aircraft Systems and their actions cause a control error. In this assessment, flight management or control error only encompasses systemic failure and pilot induced errors are covered under Improper Procedures. The probability level for this is thus set at 2. 4.4.5 Environmental Factors Based on the NASA report as in Figure 3, Environmental factors accounted for a total of 5 Accidents of LOC – I, this is half of the number of accidents caused by improper procedures and is thus set to a level of 2. 4.4.6 Aircraft Load Incorrect loading on an aircraft can cause the aircraft to be out of trim, there are procedures that are to be followed during the loading of the aircraft and since there is a
  14. 14. 12 | P a g e human interface to this procedure, it is considered to be of equal probability as improper procedures and set at highest level of 4. 4.4.7 Malicious Interference After the September 9/11 attacks on USA, security at airports has been a prime focus for all countries and airlines are equally more stringent in security procedures in areas of high risk of malicious activities. It would still be incorrect to rule out this risk or term it low as, airline by the nature of its business is always a target for malicious interference and the probability of such a threat is being maintained at medium level of 3. 4.4.8 Improper Procedures NASA’s report as shown in Figure 3 clearly attributes Improper procedures as the highest contributing factor for the cause of LOC-I accidents. Improper procedures encompass all the activities in which any personnel related with the aircraft is installed, including but not limited to, Maintenance Engineers, Pilots, Quality Managers, Auditors and also Stake Holders. With the involvement of all the personnel at all levels under the improper procedures, the probability level for this threat is maintained at the highest level of 4 4.4.9 Risk Assessment for LOC – I for an Airline. Risks Probability Severity Exposure Risk Factor System Control Failure 2 5 3 13 Loss of Power 2 5 3 13 Crew Incapacitation 2 5 3 13 Flight Management or Control Error 2 5 3 13 Environmental Factors 2 5 3 13 Aircraft Load 4 5 3 23 Malicious Interference 3 5 3 18 Improper Procedures 4 5 3 23 Table 3 Risk Assessment Matrix for LOC –I
  15. 15. 13 | P a g e 4.4.10 Risk Acceptance The Risk acceptance criteria for this analysis is based on City University Model and shown in Table 4 Risk Factor Criteria of Acceptance 1-6 May be acceptable, however, review task to see if risk can be reduced 7-14 Task should only proceed with appropriate management authorization, where possible the task should be redefined to take account of the threats involved or the risk should be reduced further prior to task commencement 15-25 Task must not proceed. It should be redefined or further control measures put in place to reduce risk. The controls should be reassessed for adequacy prior to task commencement. Table 4 Risk Acceptance Criteria 4.4.11 Conclusion Based on the risk assessment performed, the risk of LOC – I in airline ranges from 13 to 23, under the Risk Acceptance Criteria, and hence all the threats are required to be analyzed and control decision have to be implemented to lower the risk for the airline. 5. Make control decisions Based on the risk assessment, this report proposes certain control decisions prioritizing based on risk factor. The proposed control decisions are as below
  16. 16. 14 | P a g e Risks Risk Factor Proposed Control Decision Aircraft Load 23 a) Ensure Load and trim is handled by only certified and trained personnel. b) Ensure the training is of current standards. c) Ensure audits are performed to highlight any non-compliance. d) Promote reporting of incorrect load and trim information effectively among the ground employees. e) Ensure the above control actions are in place before performing the activities. Improper Procedures 23 a) All procedures to be documented in the manuals and are communicated through to all the employees. b) Pilots to be fully trained on recovering aircrafts from LOC-I. c) Aircraft Unusual Attitude Recovery Training in all Full Flight Simulator Type Conversion and Recurrent Training Programmes (Skybrary, 2013) d) More time devoted to training multi crew pilots for the monitoring role (Skybrary, 2013) e) A dedicated Flight Safety Department for constant monitoring of flight safety data from FDM and Pilot reports and corrective actions to be implemented.
  17. 17. 15 | P a g e f) Ensure actions are in place before undertaking the activity. Malicious Interference 18 a) Security Procedures in place, b) Promotion of safety among employees to identify any malicious activities c) Promotion of vigilance among all employees. d) Security Audit to be performed on regular basis. System Control Failure 13 a) Monitoring and compliance with all AD’s on the aircraft systems and controls. b) Monitoring of Aircraft defects via a reliability program. c) Weekly Review of Aircraft incidents and defects and invoked MEL’s Loss of Power 13 a) Monitoring and compliance with all AD’s on the aircraft systems and controls. b) Monitoring of Aircraft defects via a reliability program. c) Weekly Review of Aircraft incidents and defects and invoked MEL’s Crew Incapacitation 13 a) Monitoring and compliance with all AD’s on the aircraft systems and controls. b) Monitoring of Aircraft defects via a reliability program. c) Weekly Review of Aircraft incidents and defects and invoked MEL’s Flight Management or Control Error 13 a) Monitoring and compliance with all AD’s on the aircraft systems and controls. b) Monitoring of Aircraft defects via a reliability program.
  18. 18. 16 | P a g e c) Weekly Review of Aircraft incidents and defects and invoked MEL’s Environmental Factors 13 a) Monitoring and compliance with all AD’s on the aircraft systems and controls. b) Monitoring of Aircraft defects via a reliability program. c) Weekly Review of Aircraft incidents and defects and invoked MEL’s. d) Ensuring all NOTAM’s are followed and communicated to the required personnel. e) Ensuring Flight reports are communicated to other pilots for environmental factors. Table 5 The above control decisions that have been proposed within this report can now be evaluated for a cost-benefit analysis and based on the decisions of the same, the risk assessment of LOC-I will be recalculated post the decisions based on cost-benefit analysis. The same would then again be presented to analyze if the actions have resulted in achieving the desired effect of lowering the risk to the desired level or acceptable level for the airline.
  19. 19. 17 | P a g e 6. References Bateman, Don. ‘Some Thoughts on Reducing the Risk of Aircraft Loss of Control’. Available at http://www.skybrary.aero/bookshelf/books/1372.pdf [Accessed 07 June 2013]. Boeing (2012). ‘Statistical summary of commercial jet airplane accidents worldwide operations 1959-2011’. Available at http://www.boeing.com/news/techissues/pdf/statsum.pdf [Accessed 07 June 2013]. Brooks, L Randall (2010). Loss of control in flight training foundations and solutions. Istanbul: European Airline Training Symposium Edwards, Christopher and Lombaerts, Thomas (2010), Fault Tolerant Flight Control A Benchmark Challenge. Springer. Verlag Berlin ICAO (2004). ‘Aviation Occurrence Categories Definition and Usage Notes’. Available at http://www.cast-safety.org/pdf/cictt_occurrence-category0804.pdf [Accessed 07 June 2013]. Jacobson, Steven R. (2010). ‘Aircraft Loss of Control Casual Factors and Mitigation Challenges’. Available at http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20100039467_2010042011.pdf [Accessed 07 June 2013]. Learmount, David (2012). ‘Loss of control – training the wrong stuff?’ London: Flight Global. Available at http://www.flightglobal.com/news/articles/in-focus-loss-of- control-training-the-wrong-stuff-367220/ [Accessed 07 June 2013]. NTSB (2009). Review of U.S. Civil Aviation Accidents – Review of Aircraft Accident Data 2007-2009. Available at http://www.ntsb.gov/doclib/reports/2011/ara1101.pdf [Accessed 07 June 2013]. Reisinger, Dr. Ing Dieter (2011). Loss of control in flight – an accident type that raises questions about today’s training. Available at http://www.uni-
  20. 20. 18 | P a g e graz.at/isap11/ISAP11%20Loss%20of%20Control%20in%20Flight_Intro_Reisinger. pdf [Accessed 20 June 2013]. Rogers, Daniel.E (2011). Loss of Control – In Flight: Upset Recovery Skills – Based Training. Utah Valley University. Available at http://flyacro.us/D.%20Rogers%2010486518%20Research%20Paper%20Final%20 Submission.pdf [Accessed 07 June 2013]. Skybrary (2013) http://www.skybrary.aero/index.php/Loss_of_Control [Accessed 20 June 2013].

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