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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.
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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
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Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.
The Problem?




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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




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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

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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


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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


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Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.
Flight Operations




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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

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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




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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.

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Flight Data Monitoring, Risk, and Protecting Assets

  • 1. 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.
  • 2. 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.
  • 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. 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.
  • 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. 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.
  • 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 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
  • 8. 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.
  • 9. 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.
  • 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 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.
  • 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 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.
  • 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 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.
  • 13. 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.
  • 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 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.
  • 15. 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.
  • 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. 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.
  • 18. 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.
  • 19. 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.
  • 20. 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.
  • 21. 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.
  • 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 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.
  • 23. 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.
  • 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 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.
  • 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. 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.
  • 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.

Editor's Notes

  1. 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
  2. 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
  3. 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.
  4. 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
  5. 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.
  6. 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.
  7. 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
  8. 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
  9. 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?
  10. 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?
  11. 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
  12. 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?
  13. Flight Operations
  14. 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?
  15. 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
  16. 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.
  17. 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.
  18. 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’.
  19. FW: Exceedance of control limits – control surface or structural damageControl surface and structural damage due to exceedance of control limitsExceeding engine temperature ratio