TRAINING FOR SAFETY
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TRAINING FOR SAFETY. World Aviation Training Symposium Orlando 27th April 2010. John Bent Director Training Strategy proposed Pegasus Flight Academy - China. 1. The latest threat to crew training resources . USD 1.7 billion

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Training for safety

TRAINING FOR SAFETY

World Aviation Training Symposium

Orlando

27th April 2010

John Bent

Director Training Strategy

proposed Pegasus Flight Academy - China

1


Training for safety

The latest threat to crew training resources

USD 1.7billion

has just been lost to international airlines in one week

Source IATA

2


Training for safety

SAFETY - THE GOOD NEWS - 2009

  • IATA SAFETY REPORT 2009:

  • 2009 ACCIDENT RATE REDUCED: 0.71versus 0.81 in 2008[hull losses per million flights of Western-built jet aircraft]

  • = one per 1.4 million flights

    • SAFELY FLOWN: 2.3billion people on 35 million flights (27 million jet, 8 million turboprop)

    • LESS ACCIDENTS WESTERN BUILT TYPES: 19 vv 22 in 2008

    • LESS ACCIDENTS (all types) 90 vv 109 in 2008

    • LESS FATAL ACCIDENTS (all types): 18 vv 23 in 2008

3


Training for safety

SAFETY - THE BAD NEWS - 2009

×

  • IATA SAFETY REPORT 2009:

    • MORE FATALITIES: 685 vv 502 in20081.36 times worse

    • REGIONAL RATES WHICH ROSE:

      • ASIA PACIFIC: 0.86 vv 0.58 in 20081.48 times worse

      • M/E: 3.32 vv 1.89 in 20081.75 times worse

      • AFRICA: 9.94vv 2.12 in 20084.68 times worse

  • Runway excursionsand ground damage were main categories

  • Pilot handlingwas a contributing factor in 30% of all accidents.

4


Training for safety

ANY SENSE THAT 2009 RESULTS WERE BETTER COULD GENERATE COMPLACENCY

  • Longer term trends by type and regions remain disturbing

  • Complete elimination of accidents is unrealistic, but:

  • Any serious accident which could have been reasonably AVOIDED or MITIGATED was

an industry safety system failure

5


Training for safety

  • CREW TRAINING - UK CAA 2008:

  • Training is the best investment against catastrophic risk

  • The top catastrophic accident risks identified were:

    • LOC (loss of control)

    • CFIT (controlled flight into terrain)

    • Post-crash fire

    • Runway excursions and overruns

  • Crew judgment and actions are the most consistent causal factor in global catastrophic accidents

  • This situation will remain true for the foreseeable future

  • Crew-related issues dominate accident causal factors, featuring in 75% of fatal accidents

  • 6


    Training for safety

    • Major accident totals threaten levels not seen since 1990s

    • Totals threaten levels not seen since 1990s

    • ‘Last five-year’ accidents exceed previous five-year periods

    • “at this pace, we'll be turning the clock back 10 years in safety”

    FLIGHT SAFETY FOUNDATION:

    • Are today's airline pilots churned out by "pilot mills" that train to minimum standards?

    BUFFALO NEWS – DEC 2009:

    7


    Training for safety

    AN INDUSTRY WITH REMARKABLE CHALLENGES

    • Hardware growth has outstripped human-ware available

    • 911 and SARS discouraged steady expansion of training capacity

    • 2007-2008: aircraft were grounded without crews

    • Crew training rates inadequate; training trended to minimums

    • 2009 - global recession; reversal to surplus crews

    • Pilot layoffs and unpaid leave

    • Less pressure on training delivery, yet increased pilot mobility

    • Accidents on the rise; no surprise

    • Now volcanic ash

    Accidents & Incidents

    8


    Training for safety

    THE LONG TERM ACCIDENT RATE MAY EXCEED THAT COMMENSURATE WITH EXPANSION ALONE

    IF SO, WHY?

    9


    Training for safety

    TRAINING& SAFETY

    • The following slides depict a sample of just 40 airline accidents since 2005 (not exhaustive)

    • Detailed analysis is not intended

    • These tragic slides will be shown rapidly, aimed at the bigger picture, and to stay within my presentation time

    • As many as 35 of this sample (88%) may be concluded to have contained crew training as possible mitigants

    10


    Training for safety

    2 Aug 2005

    Air France A340 Toronto

    RUNWAY DEPARTURE: Could more effective training have mitigated?

    Undesired aircraft state- unstable approach in bad weather

    1

    11


    Training for safety

    14 Aug 2005

    Helios B737 Greece

    CREW INCAPACITATION: Could more effective training have mitigated?

    Tech and procedures?

    2

    12


    Training for safety

    16 Aug 2005

    W Caribbean MD82 Venezuala

    LOSS OF CONTROL: Could more effective training have mitigated?

    loss of control in cruise; a/c overload, stall?

    “The pilots may have lacked basic instrument flying skills due to continuous over reliance on automated flight.

    Did they monitor their instruments? Indications should have alerted them of subtle airspeed decay as the aircraft was overloaded and at too high a FL...”

    3

    13


    Training for safety

    23 Oct 2005

    Bellview B737 Lagos

    LOSS OF CONTROL: Could more effective training have mitigated? - Unknown as yet

    The airplane impacted ground at a speed of around 400 knots in a near wings level attitude with both engines at takeoff thrust. All 111 passengers and 6 crew perished in the crash.Nigerian Authorities promised a final report in 2007, but has not come to light so far.

    4

    14


    Training for safety

    29 Sep 2006

    GOL B737-800 Brasil

    COLLISION: Could more effective training have mitigated?

    Procedures, situational awareness, TCAS?

    5

    15


    Training for safety

    29 Nov 2007

    AtlasJet MD83 at Isparta

    IMPACT WITH TERRAIN: Could more effective training have mitigated?

    - heading, situational awareness =controlled flight into terrain (CFIT)?

    6

    16


    Training for safety

    7 Mar 2007

    Garuda B737 Yogyakarta

    OVERRAN RUNWAY: Could more effective training have mitigated?

    Crew resource management (authority gradient)

    7

    17


    Training for safety

    4 May 2007

    Kenya Airways B737 Douala

    CRASHED AFTER TAKE-OFF: Could more effective training have mitigated? - took-off into heavy TS

    According to the former minister, “the Camerounian State is not to be blamed as the pilot was asked not to fly due bad weather”.

    The Kenya Airways Boeing 737-800 suddenly disappeared from radar screens two minutes after take-off from the Douala International Airport during a heavy thunderstorm.

    8

    18


    Training for safety

    17 Jul 2007

    TAM A320 Sao Paolo

    RUNWAY EXCURSION: Could more effective training have mitigated?

    Undesired aircraft state - reverser inoperative procedures

    9

    19


    Training for safety

    17 Jan 2008

    BA B777 Heathrow

    LOSS OF POWER: Could more effective training have mitigated?

    NO: Sound airmanship displayed - AAIB report

    10

    20


    Training for safety

    14 Feb 2008

    Belgavia CRJ100 Yerevan

    DE-ICING PROCEDURES: Could more effective training have mitigated?

    Loss of control -refused advice to de-ice for take off

    11

    21


    Training for safety

    21 Feb 2008

    ATR42 nr Merida

    FLEW INTO TERRAIN: Could more effective training have mitigated?

    - failed to align NAV pre-take off = Situational Awareness + CFIT

    12

    22


    Training for safety

    15 Apr 2008

    Hewa Bora DC95 Goma

    RUNWAY OVERRUN: Could more effective training have mitigated?

    Overrun - tyreburst after V1; tried to stop

    13

    23


    Training for safety

    25 May 2008

    Kalitta B747 Brussels

    RUNWAY OVERRUN: Could more effective training have mitigated?

    Procedures; slow rejected take off?

    14

    24


    Training for safety

    30 May 2008

    TACA A320 Tegucigalpa

    RUNWAY DEPARTURE: Could more effective training have mitigated?

    Undesired aircraft state - landing performance?

    15

    25


    Training for safety

    10 Jun 2008

    Sudan Airways A310 Khartoum

    RUNWAY DEPARTURE: Could more effective training have mitigated?

    Undesired aircraft state - landing performance?

    16

    26


    Training for safety

    6 Jul 2008

    USA Jet DC91 Saltillo

    GO AROUND FAILED: Could more effective training have mitigated?

    Undesired aircraft state-approach to wrong runway

    17

    27


    Training for safety

    20 Aug 2008

    Spanair MD82 Madrid

    DEPARTED RUNWAY: Could more effective training have mitigated? Flaps not set for take-off -undesired aircraft state - procedures

    18

    28


    Training for safety

    24 Aug 2008

    Itek Air B732 Bishkek

    LOST CONTROL ON APPROACH: Could more effective training have mitigated? Undesired aircraft state – visual awareness?

    19

    29


    Training for safety

    30 Aug 2008

    Conviasa B737 Latacunga

    FLEW INTO TERRAIN: Could more effective training have mitigated?

    crew resource management, situational awareness

    20

    30


    Training for safety

    14 Sep 2008

    Aeroflot-Nord B735 Perm

    LOST CONTROL ON APPROACH: Could more effective training have mitigated?Recent formal ruling that pilot was drunk, CRM?

    Since this accident Russia's transport ministry signed an agreement with Boeing aimed at improving air transport safety in the country.   The memorandum, identifies provision of training for flight crew and technical personnel and the development of training infrastructure as crucial areas  

    21

    31


    Training for safety

    27 Nov 2008

    ANZ A320 nr Perpignan

    LOST CONTROL: Could more effective training have mitigated?

    test flight procedures training (BEA)?

    22

    32


    Training for safety

    20 Dec 2008

    Continental B737 Denver

    RUNWAY OVERRUN: Could more effective training have mitigated?

    Undesired aircraft state -failed take-off & runway overrun?

    23

    33


    Training for safety

    15 Jan 2009

    US Air A320 Hudson River

    TRAINING & EXPERIENCE SAVED THE DAY!

    An example to study

    24

    34


    Training for safety

    12 Feb 2009

    Colgan Air DH8D Buffalo

    LOST CONTROL: Could more effective training have mitigated?

    - procedures, icing and stall recovery training?

    A change trigger

    25

    35


    Training for safety

    25 Feb 2009

    Turkish B737 Amsterdam

    LOST CONTROL ON APPROACH: Could more effective training have mitigated? Automation reliance & monitoring?

    An automation threat?

    26

    36


    Training for safety

    23 Mar 2009

    Fedex MD11 Tokyo

    FLIPPED ON LANDING: Could more effective training have mitigated?

    Undesired aircraft state -known handling issues in strong gusts?

    27

    37


    Training for safety

    9 Apr 2009

    Aviastar BAe 146 Wamena

    IMPACT WITH TERRAIN: Could more effective training have mitigated?

    Undesired aircraft state-loss of control; circling in low cloud base?

    28

    38


    Training for safety

    29 Apr 2009

    Bako Air B737 Massamba

    CRASHED AFTER TAKE-OFF: Could more effective training have mitigated? As yet unknown but aircraft stored for 1 year?

    29

    39


    Training for safety

    1 June 2009

    Air France A330 Atlantic

    LOST CONTROL: Could more effective training have mitigated?

    - inadequate evidence as yet

    30

    40


    Training for safety

    30 Jun 2009

    Yemenia A310 East Africa

    LOST CONTROL: Could more effective training have mitigated?

    Undesired aircraft state - missed approach in big twin; as yet unknown

    31

    41


    Training for safety

    14 Jul 2009

    Caspian Tu 154 nr Tehran

    IMPACTED TERRAIN: Could more effective training have mitigated?

    -as yet unknown

    32

    42


    Training for safety

    24 Jul 2009

    Aryan Airlines IL62 Mashhad (Iran)

    OVERRAN RUNWAY: Could more effective training have mitigated?

    -Technical (gear?), late landing, but as yet unknown

    33

    43


    Training for safety

    4 Aug 2009

    Bangkok Awys ATR72 Koh Samui

    RUNWAY EXCURSION: Could more effective training have mitigated?

    Departed runway in strong winds and rain - as yet unknown

    34

    44


    Training for safety

    21 Oct 2009

    Sudan Awys B707F Sharjah

    LOST CONTROL: Could more effective training have mitigated?

    Lost control during initial climb and crashed – as yet unknown

    35

    45


    Training for safety

    19 Nov 2009

    Cpgn African Avn MD82 Goma

    OVERRAN RUNWAY: Could more effective training have mitigated?

    Overran runway in ‘rainy conditions’ - as yet unknown

    36

    46


    Training for safety

    22 Dec 2009

    American Airlines 738 Kingston

    OVERRAN RUNWAY: Could more effective training have mitigated?

    Overran runway in heavy rain - as yet unknown

    37

    47


    Training for safety

    2 Jan 2010

    Compagnie B727-200 Kinshasa

    RUNWAY EXCURSION: Could more effective training have mitigated?

    Veered off runway on landing - heavy rain

    38

    48


    Training for safety

    24 Jan 2010

    Taban Air TU 154 Mashad Iran

    RUNWAY EXCURSION: Could more effective training have mitigated?

    Landing in fog with medical emergency

    Flight International

    39

    49


    Training for safety

    25 Jan 2010

    Ethiopian 738 Nr Beirut

    CRASHED IN DEPARTURE: Could more effective training have mitigated?

    Lost height and impacted Mediterranean (WX?) - as yet unknown

    40

    50


    Training for safety

    LESSONS FROM THIS SAMPLE?

    • 1. That most accident risksrealised could be foreseen in training!

    • 2. That reactive is easier then proactive!

    • That 35 of the 40 accidents sampled (88%) may count as probable human factors and training [LOSS OF CONTROL / undesired aircraft state(irrecoverable departure from normal operational parameters) & controlled flight into terrain]

    • That today we still DO NOT focus a commensurate amount of pilot training on human factors! (it’s more like 10%?)

    • 5. We must mitigate accidents with TRAINING

    51


    Training for safety

    Back to the 2009 IATA REPORT

    • Runway excursionsand ground damage were main categories

    • Pilot handlingwas a contributing factor in 30% of all accidents

    • So what’s happening in 2010?

    52


    Training for safety

    DURING THE FIRST 120 DAYS OF 2010, NOT MUCH HAS CHANGED

    53


    Training for safety

    RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page1)

    2 JanCompagnieAfricaine Aviation B727-200, Kinshasa (Congo) Veered off runway on landing

    3 JanAir Berlin B737-800, Dortmund (Germany) Rejected takeoff - runway overrun

    8 JanAir Berlin B737-800, Nuremberg (Germany) Veered off runway on take off

    9 JanYas Air IL76, Kiev (Ukraine) Runway excursion on landing

    15 JanIran Air F100, Isfahan (Iran) Nose gear collapse on landing

    16 JanIran Air A300-600, Stockholm (Sweden) Went off runway on line up for take off

    19 JanPSA Airlines CRJ2, Charleston (USA) Overran runway on take off

    7

    Source: Aviation Herald

    54


    Training for safety

    RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page2)

    19 JanLion Air B737-900, Padang (Indonesia) Runway excursion on landing

    21 JanAeromexico Connect E145, Tijuana (Mexico) Went off runway on landing

    22 JanSkywestCRJ7, Winnipeg (Canada) Overran runway on landing

    25 JanWest Air CRJ2 Longyearbyen (Norway) Veered off runway on landing

    27 JanCimberAT72, Bornholm (Denmark) Veered off runway on landing

    28 JanBulogAN26, Wamena (Indonesia) Overran runway on landing

    30 JanDonavia B737-400, Rostov (Russia) Overran runway on landing

    14

    Source: Aviation Herald

    55


    Training for safety

    RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page3)

    • 31 Jan SkyserviceA320, Varadero (Cuba)

      • Hard landing – three tyres blown

  • 4 FebYakutiaAN24, Yakutsk (Russia)

    • Rejected take-off but airborne / gear up

  • 8 FebShasheen B737-200, Peshawar (Pakistan)

    • Departed runway on landing

  • 10 Feb KLM B737-300, Schiphol (Netherlands)

    • Took off on taxiway

  • 13 Feb Batavia B737-200, Surabaya (Indonesia)

    • Nose gear skidded on line up – tyresblew

  • 18 Feb Shuttle America Embraer ERJ-170, Cleveland (USA)

    • Overran the runway on landing

  • 22 Feb Spring Airlines A320-200, Shenyang (China)

    • Landed tail first – structural damage

  • 21

    Source: Aviation Herald

    56


    Training for safety

    RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page4)

    • 24 Feb Ethiopian Airlines B737-700, Lubumbashi (Congo)

      • Departed taxiway after landing

  • 24 Feb Air Canada Airbus A321-200, Toronto (Canada)

    • Landed without ATC clearance

  • 25 Feb Lion Air B 737, Padang (Indonesia)

    • Main gear departed paved surface

  • 26 Feb Garuda Indonesia B 737-800, Perth (Australia)

    • Entered RWY 06 after landing - no clearance

  • 26 Feb Aeroflot A320-200, Oslo Gardermoen (Norway)

    • Took off on taxiway

  • 1 MarAir Tanzania B737-200, Mwanza (Tanzania) Veered off the departure runway 30

  • 17 MarShaheen Air International B737-200, Peshawar (Pakistan) Overran the runway on landing

  • 28

    Source: Aviation Herald

    57


    Training for safety

    RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page5)

    22 MarAviastar TU-204-100, Moscow Domodedovo (Russia Landed about 1000 meters short of rwy 14R

    23 Mar China Airlines B747-400F, Anchorage, (USA) Struck its tail onto the departure runway

    24 Mar Cargojet B727-200, Moncton, (Canada) Overran runway 06 while landing

    24 Mar Asiana A321-200, Omitama (Japan) Overran runway 21L by about 30 meters

    25 Mar Westjet B737-800, Cancun (Mexico) Tail strike during takeoff

    25 Mar Air Madagascar B737-300, Nossi-be (Madagascar) Main gear off the paved surface after landing

    5 AprEgypt Air A330-200, Cairo (Egypt) Wrong taxiway - impacted two light poles(wrong park position entered into FMS – wing damage)

    35

    Source: Aviation Herald

    58


    Training for safety

    RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page6)

    8 Apr PSA Airlines CRJ-200, Charleston, WV (USA) Overran runway - rejected takeoff at high speed

    13 Apr Merpati Nusantara B737-300, Manokwari (Indonesia) Overran runway while landing

    21 Apr Cargojet B727-200, Moncton (Canada) Overran runway 06 while landing

    38 (Since 1st Jan 2010)

    Source: Aviation Herald

    59


    Training for safety

    Is our collective industry eye still off the SAFETY ball?

    60


    Training for safety

    THE BIG QUESTION

    SHOULD INDUSTRY ACCEPT THAT ACCIDENT & INCIDENT RATES:

    (1) ARE AS LOW AS ECONOMICALLY VIABLE?

    OR

    (2) MUST BE FURTHER REDUCED?

    61


    As growth resumes if the accident rate remains unchanged

    AS GROWTH RESUMES, IF THE ACCIDENT RATE REMAINS UNCHANGED

    Expansion of the global fleet will increase the number of accidents

    The accident RATE must be DRIVEN DOWN further

    62


    Training for safety

    ALTHOUGH THE RATE IS LOW RELATIVE TO ACTIVITY:

    A doubling of the fleet next 20 years at same rate could result in

    10,000 fatalities or more; tragedies with commercial consequences for passenger growth

    SO WE MUST ACT

    To hold accidents down to 150 and a possible 5,000 fatalities, we must HALVE the accident rate NOW

    63


    The bric countries brazil russia india china are most exposed next 20 years

    THE BRIC COUNTRIES(Brazil, Russia, India, & China) ARE MOST EXPOSED – NEXT 20 YEARS

    THE BRICS WILL EXCEED USA BY 2027

    Source: ACI Sept 08


    Training for safety

    IN CHINA ALONE: 20 YEAR PROJECTIONS FOR NEW AIRCRAFT:

    Pre-recession projection: 3,800 airframes

    Post recession-REVISED projection: 2,800airframes

    New airline pilots required (including 8,000 retirements): 41,600

    Source: manufacturers and IATA

    65


    Training for safety

    THE VERDICT: ‘RATES MUST BE FURTHER REDUCED’!

    • This month in Montreal, ICAO announced an action plan to:

    • Lead a safety information exchange

    • Coordinate efforts to establisha global safety information exchange to enable analysis of key safety indicators

    • Work with IATA and the FAA, to "facilitate the collection, analysis and dissemination of safety information provided by states and industry partners throughout the international aviation community”

    But these actions will take a LONG TIME. Improved training is an obvious action which can be taken NOW

    66


    Training for safety

    ACTION - THE CHALLENGES:

    67


    Training for safety

    THE CHANGE CHALLENGE

    • Change is not easy; defense of ‘status quo’ is

    • A long established process is understood

    • Prejudice (conclusions without the facts) is a great time saver

    • New processes are more acceptable once widely adopted

    • NAAs and Training Organisations prefer not to be ‘first’

    DOEPS[DEFENCE OF ESTABLISHED PROCESS SYNDROME]?

    68


    Training for safety

    THE SAFETY CHALLENGE ANOMALY (AREN’T WE SAFE ENOUGH?)

    Approx 18,000 airliners are continuously in operation; that’s approx 2,700,000 passengers in flight

    • BUT:

      • Hundreds of thousands of safe flights are not news

      • Airline accidents are immediate media drama

      • Public perceptions form with the first media bite

    Safe enough to relax? NO, that’s complacency

    69


    Training for safety

    THE SKILL & EXPERIENCE LOSS CHALLENGE

    (UNCOMFORTABLE SYSTEMIC MIX):

    • As hardware and technology improved:

      • crew dependence on automation increased

      • raw piloting and monitoring skills regressed

      • technology was perceived to reduce training need

      • human factors became more exposed as common cause

    • In parallel, recent rapid growth:

      • reduced average experience on airliner flight decks

      • encouraged new entry criteria for pilots (generation ‘G’ and beyond may pose even more challenges)

      • placed increasing pressure on training systems

      • forced cost savings into crew training programmes

    70


    Training for safety

    THE AUTOMATION CHALLENGE

    Washington Post, 29 June 2009 

    “Automated systems are often designed to relieve humans of tasks that are repetitive.

    “When such algorithms become sophisticated, however, humans start to relate to them as if they were

    fellow human beings”

    “The autopilot on a plane, the cruise control on a car, automated speed control systems in mass transit, are all conveniences but

    can become crutches”

    “The more reliable the system, the more likely it is that humans in charge will ‘switch off’ and lose their concentration, and the greater the likelihood

    that a confluence of unexpected factors that stymie the algorithm will produce catastrophe”

    71


    Training for safety

    THE PROCESS CHALLENGE

    CUSTOMER NEED DEFINED

    • COMPETENT SAFE PILOTS

    • INPUTS TO SELECTION

    REGULATION

    & FACILITATION

    FEEDBACK ANALYSIS

    IS THIS REALLY HAPPENNING?

    Continuous improvement

    • INDUSTRY > ICAO

    • DEVELOP BEST PRACTICE

    • NEW SARPS TO NAA

    • TRAINING ORGANISATION

    • APPLIES NAA REQUIREMENTS

    • PLUS LOCAL ENHANCEMENTS

    • COMPULSORY REPORTING:

      • CUSTOMER & TRAINING ORG TO NAA

      • NAA TO ICAO

    VERIFICATION

    • AUDITS:

      • TRAINING ORG BY CUSTOMER & NAA

      • NAA BY ICAO

    72


    Training for safety

    THE TIME & RESOURCE CHALLENGE (THERE’S LIMITED TIME TO ACT)

    Seeing through the recession

    • The training industry has had great difficulty preparing for the next growth phase, as enterprise resources have been decimated

    • Belt tightening prevented widespread adoption of best practice; mostly ‘more of the same’ prevailed

    • The next growth surge can be seen on a closer horizon

    73


    Training for safety

    THE MANAGEMENT PERCEPTION CHALLENGE

    Training practitioners usually agree that TRAINING IMPROVEMENTS ARE NEEDED, but what about

    CAPA Management survey 2009 >>

    74


    Training as a priority current priorities are not training

    TRAINING AS A PRIORITY: Current priorities are not training!

    Source: Centre for Asia Pacific Aviation Survey, Sept 09


    Training as a challenge a greater spread of opinions on the key issues medium term

    TRAINING AS A CHALLENGE: A greater spread of opinions on the key issues - medium term

    Source: Centre for Asia Pacific Aviation Survey, Sept 09


    Training for safety

    How can crew training be enhanced if company executives don’t see the need?

    77


    Training for safety

    INDUSTRY ACTION?

    • CONVINCE DECISION MAKERS THAT WE HAVE A PROBLEM [ICAO, IATA, FAA ARE CLEARLY CONVINCED]

    • ENHANCE CREW TRAINING; THE CONTROLLABLE VARIABLE

      • As hardware cannot be changed rapidly (we have what we have) Crew Training (both airline & GA) must be driven rapidly towards:

        • more relevance; proactive to risk & SMS

        • higher quality & continuous improvement

        • more sustainability & topicality (recurrent)

    78


    Training for safety

    FIND THE LOWEST HANGING FRUIT

    79


    Training for safety

    IMPROVE SELECTION

    Remarks to Aviation sub-committee, US House of Representatives, June 2009:

    Chairman of the Flight Training Department, Embry‐Riddle Aeronautical University:

    “Our experience and research lead us to believe a successful airline pilot candidate preparation program should embrace a methodology to weed out unsuccessful candidates prior to their employment by the airlines”

    TOO OBVIOUS? Yes but much more can be done

    USD 5,000 more invested in Selection could reduce system risk, and save >USD 50,000 downstream

    80


    Training for safety

    RAISE TRAINING STANDARDS - EVERYWHERE

    81


    Raise quality everywhere

    RAISE QUALITY - EVERYWHERE

    82


    Training for safety

    TAKE A MORE GLOBAL HOLISTIC APPROACH

    GENERAL AVIATION

    • Much airspace is shared by GA & Airlines

    • One airline supply pipeline is GA

    • Effective early training is vital throughout aviation

    • Many best practices developed for airline operations could be cross pollinated into GA training

    Must wheels be re-invented?

    83


    Training for safety

    FIND THE QUALITY DRIVERS

    • Without data, aviation safety is at the mercy of opinion

    • QA or SMS requires performance data to analyse

    • This data comes from multiple sources (in airlines):

    For example >>

    84


    Training for safety

    USE INDUSTRY EXTERNAL DATA

    Flight Operations

    LINE OPERATIONAL SAFETY AUDIT (LOSA)

    Whole Airline:

    IATA OPERATIONAL SAFETY AUDIT

    (IOSA)

    Whole Airline Industry:

    GLOBAL SAFETY DATA

    (ICAO, IATA, FSF..)

    85


    Training for safety

    • After 10 years, and more than 6,000 LOSA flights…

      • - over 90% of flights exhibited observable crew errors

  • Numerous events were precipitated by an error made by the captain,unchallenged by other crew members (reluctance to challenge, expressed as ‘authority gradient’ (G. Hofstede)

  • 50% of LOSA-observed errors went undetected by the crew

  • 32% of errors were intentional noncompliance (Violations)

  • USE LOSA (LINE OPERATIONAL SAFETY AUDIT) DATA

    86


    Training for safety

    LOSA DATA SHOWS WHAT CREWS DO RIGHT

    87


    Training for safety

    Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM (Threat & Error Management), in October 2006:

    “After 10 years of examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two things: -

    • Cooperate to rigorously monitor and cross check to make sure they pick up threats and errors early, and

    • Actively engage in checking and verifying every setting and action which can affect safety.”

    No Surprise! But much more can be done

    88


    Training for safety

    USE AIRLINE INTERNAL DATA

    Flight Operations

    SELECTION CRITERIA & DATA

    (& downstream performance: another presentation!)

    Safety Dept

    FOQA / QAR DATA & CONFIDENTIAL REPORTS

    Flight Operations & Training Dept

    CREW PERFORMANCE DATA

    (training progress, PCs / route checks)

    FUTURE INITIATIVE:

    Flight Operations & Training Dept

    SIMULATOR PERFORMANCE DATA

    89


    Training for safety

    OK SO WHAT’S NEW?

    • Not much, most airlines collect these data already

    • But how many airlines analyse, organise, and collate this data into a REAL TIME system ‘health check’?

    Airline training systems would benefit immediately; through more rapid response to new threats

    90


    Training for safety

    CAPITALISE ON CURRENT INITIATIVES

    • ITQI(IATA Training & Qualification Initiative)

    • Active development of Type VII FSTD ATC Simulation

    • Active development of Upset Recovery Training (URT) standards (RAeSInternational Committee - aviation training in extended envelopes– ICATEE)

    • Improved type training programmes; eg. APT3(Airbus Pilot Training)& B787 type training – all embedded with TEM (Threat & Error Management)

    • ATSAS(Aircrew Training Standards & Safety - safety data driving training)

    • NGAP(ICAO Next Generation Aviation Professionals) Initiative – March 2010

    91


    Training for safety

    Recognise the new Airline Pilot License MULTI-CREW PILOTS LICENCE (MPL) after 60 years of almost no change

    92


    Training for safety

    MPL concentrates best practice

    • Despite controversy, MPL is: -

      • the result of 6 years of industry development to replace an outdated 60 year-old airline training process

      • initially very well received: after the Alteon Beta trial (small sample, but impressive base training results)

      • an ICAO approved programme and license

      • a set of powerful airline pilot training tools, demanding new standards in the airline pilot training process

    Just what the training industry needs: relevance + focus + quality >

    93


    Training for safety

    National MPL regulations are now in place in:

    • Armenia, Australia, Canada, Chile, China, Denmark, France, Germany, Ghana, Latvia, Maldives, Netherlands, Pakistan, Philippines, Singapore, Sweden, Switzerland, Syrian Arab Republic, Thailand, UAE, United Kingdom, Hong Kong (22)

    MPL is now under development, trail, or use in:

    Australia, China, Denmark, Germany, Philippines, Singapore, Sweden, Switzerland, United Kingdom, Hong Kong… (10)

    By operators:

    Former Alteon-Boeing Flight Training-CAAC, CAAC-CAFUC, CAPA- Sterling, Lufthansa, Swiss, OAA-Flybe, FTE-Flybe, CAE-Air Asia, Kaufer-Air Berlin, SATA-Tiger Airways, L.U.S.A.-City Airline & Skyways, Alpha Aviation, and proposed Pegasus Flight Academy China (13)

    Source: IATA

    94


    Training for safety

    MPL under TRIAL – some challenges

    • Prior to the next growth surge, self funded pilot applicants prefer the old CPL route to ensure a job on graduation

    • MPL beta syllabus: variations in structure and spread:-

      • Some orgs still apply twins and jets to the MPL syllabus, distracting students with up to three non-airline types

      • Many orgs still apply old pre-ICAO 9625 FSTD categories

      • Some orgs conduct MPL in three separate global locations

      • Aircraft flight training spread: 80 - 130 hours

      • Simulator flight training spread: 155 - 292 hours

      • Course duration spread: 14 - 36 mths

  • But as the superior performance of MPL graduates is more widely seen, operators will eventually demand MPL

  • Data Source IATA & Tng Orgs

    95


    Training for safety

    MPL STATUS MARCH 2010:

    • 77

    GRADUATED:

    800

    STUDENTS IN TRAINING:

    Data Source: IATA & EASA MPL Advisory Board 16/17.3.10

    96


    Training for safety

    Training Comparison:

    Source: IATA

    MPL delivers more instructional hours than CPL

    97


    Training for safety

    MPL THROWS OUT SPECIAL CHALLENGES:

    UPSET RECOVERY TRAINING (URT): Actual flight in training aircraft

    +

    Simulator training

    • Upset Recovery Training (URT) – still maturing [but WGs underway include the RAeSInternational Committee for Aviation Training in Extended Envelopes (ICATEE) to report next year]

    • ATC simulation – maturing in Type VII FSTD (Flight Simulation Training Device)

    • Instructor qualifications & training – higher standards

    98


    Training for safety

    HONE THE INSTRUCTOR’S ART – THAT HUGELY FERTILE VARIABLE!

    • Advanced training equipment + ineffective instruction = learning barrier

    • Poor training equipment + effective instruction = learning catalyst

    • MPL requires more appropriate (1) instructor training and (2) training devices

    • More relevant instructor entry criteria + improved instructor training = essential for MPL, however challenging!

    99


    Training for safety

    IMBIBE GOOD AIRMANSHIP (the consistent use of good judgment & well-developed skills (Kern 96) – STUDY EVENTS

    SOMETIMES PROCEDURES & CHECKLISTS MAY NOT BE ENOUGH:

    > Volcanic ash All Engines out - BA 9 - June 82

    Lost Hydraulics - Sioux City United 232 July 89 >

    > Power loss & ditching - US Airways Flt 1549 Jan 09

    Cathay A330 – both engines fluctuated - thrust stuck @ 70% N1 asymmetric - landed at 230kts - April 10 (subject to inquiry underway) >

    100


    Training for safety

    TRAINING ENHANCEMENT SUMMARY:

    • Enhanced Instructor training and oversight

    • More LOFT (LINE ORIENTED FLIGHT TRAINING) training

    • More task-focussed, competency-based, quality embeddedprogrammes(as in MPL)

    • Programmes designed for continuous improvement

    • Driven by performance & SMS feedback

    • Training devices designed to training task and learning phase (as in MPL, APT)

    • Embedded human factors / threat & error management (TEM) (as in MPL)

    • Mandated uniforms in simulator training – raising crew fidelity

    101


    Training for safety

    UNIFORMS IN SIMULATION

    (an easy option; what’s the problem here?)

    • Zero cost - all crews have uniforms!

    • Matching crew fidelity with simulator fidelity

    • Creating a more professional atmosphere in simulator training

    SO WHY THIS?

    Let’s just fix it!

    102


    Training for safety

    103


    Training for safety

    THE BOTTOM LINE

    • Long term the industry is highly exposed to ineffective training

    • Airlines need to offer comfortable and safe air travel as a long term profitable business plan

    • Resource flow must be maintained to the vital organs of a positive safety culture

    • Effective crew training is an investment which protects safety margins for years to come

    • Training must deliver efficient best practice, with relevance and continuous improvement

    104


    Training for safety

    ONE LIGHT SWITCH FOUND!

    • From the 2009 FAA safety call to action speech (Randy Babbitt):

    • “That day is today”

    • We must know more about pilot performance over a pilot’s entire career

    • Good, effective training has to be at the top of our list 

    • We need to ensure we’re meeting and exceeding the standards

    • The fundamentals of quality training are clear and direct

    • One of the quickest ways to spread excellence is to cross-pollinate 

    • We need to share so that we’re all at the highest level possible

    • We have some great opportunities to look at best practices …..

    105


    Training for safety

    Two Parting questions

    • Are airline COOs & CFOs AWARE of Training as the critical safety priority to address today?

    • Will budgetary maximums be ‘regulatory training minimums’ next financial year?

    106


    Training for safety

    TRAINING & SAFETY ‘TAKE-AWAYS’

    • OPTIMISE BEST PRACTICE - minimiseadditional cost

    • MEASURE to continuously improve

    • EMBED MEASUREMENT into the training process, and instructor’s task

    • EMBED TEM into all training thinking

    • If QUANTITY shrinks, QUALITY must grow

    SAFETY GROWS FROM EFFECTIVE TRAINING

    107


    Training for safety

    Thank You!

    108


    Training for safety

    ENTER THE PROPOSED

    Pegasus Flight Academy

    Best practice safety-driven training

    founded on MPL in one location

    Aimed at higher training standards

    + expanded safety margins

    109


    Training for safety

    110


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