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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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slide1

TRAINING FOR SAFETY

World Aviation Training Symposium

Orlando

27th April 2010

John Bent

Director Training Strategy

proposed Pegasus Flight Academy - China

1

slide2

The latest threat to crew training resources

USD 1.7billion

has just been lost to international airlines in one week

Source IATA

2

slide3

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

slide4

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

slide5

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

slide6

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

slide7

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

slide8

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

slide10

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

slide11

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

slide12

14 Aug 2005

Helios B737 Greece

CREW INCAPACITATION: Could more effective training have mitigated?

Tech and procedures?

2

12

slide13

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

slide14

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

slide15

29 Sep 2006

GOL B737-800 Brasil

COLLISION: Could more effective training have mitigated?

Procedures, situational awareness, TCAS?

5

15

slide16

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

slide17

7 Mar 2007

Garuda B737 Yogyakarta

OVERRAN RUNWAY: Could more effective training have mitigated?

Crew resource management (authority gradient)

7

17

slide18

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

slide19

17 Jul 2007

TAM A320 Sao Paolo

RUNWAY EXCURSION: Could more effective training have mitigated?

Undesired aircraft state - reverser inoperative procedures

9

19

slide20

17 Jan 2008

BA B777 Heathrow

LOSS OF POWER: Could more effective training have mitigated?

NO: Sound airmanship displayed - AAIB report

10

20

slide21

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

slide22

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

slide23

15 Apr 2008

Hewa Bora DC95 Goma

RUNWAY OVERRUN: Could more effective training have mitigated?

Overrun - tyreburst after V1; tried to stop

13

23

slide24

25 May 2008

Kalitta B747 Brussels

RUNWAY OVERRUN: Could more effective training have mitigated?

Procedures; slow rejected take off?

14

24

slide25

30 May 2008

TACA A320 Tegucigalpa

RUNWAY DEPARTURE: Could more effective training have mitigated?

Undesired aircraft state - landing performance?

15

25

slide26

10 Jun 2008

Sudan Airways A310 Khartoum

RUNWAY DEPARTURE: Could more effective training have mitigated?

Undesired aircraft state - landing performance?

16

26

slide27

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

slide28

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

slide29

24 Aug 2008

Itek Air B732 Bishkek

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

19

29

slide30

30 Aug 2008

Conviasa B737 Latacunga

FLEW INTO TERRAIN: Could more effective training have mitigated?

crew resource management, situational awareness

20

30

slide31

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

slide32

27 Nov 2008

ANZ A320 nr Perpignan

LOST CONTROL: Could more effective training have mitigated?

test flight procedures training (BEA)?

22

32

slide33

20 Dec 2008

Continental B737 Denver

RUNWAY OVERRUN: Could more effective training have mitigated?

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

23

33

slide34

15 Jan 2009

US Air A320 Hudson River

TRAINING & EXPERIENCE SAVED THE DAY!

An example to study

24

34

slide35

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

slide36

25 Feb 2009

Turkish B737 Amsterdam

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

An automation threat?

26

36

slide37

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

slide38

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

slide39

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

slide40

1 June 2009

Air France A330 Atlantic

LOST CONTROL: Could more effective training have mitigated?

- inadequate evidence as yet

30

40

slide41

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

slide42

14 Jul 2009

Caspian Tu 154 nr Tehran

IMPACTED TERRAIN: Could more effective training have mitigated?

-as yet unknown

32

42

slide43

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

slide44

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

slide45

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

slide46

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

slide47

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

slide48

2 Jan 2010

Compagnie B727-200 Kinshasa

RUNWAY EXCURSION: Could more effective training have mitigated?

Veered off runway on landing - heavy rain

38

48

slide49

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

slide50

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

slide51

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

slide52

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

slide54

RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page1)

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

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

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

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

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

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

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

7

Source: Aviation Herald

54

slide55

RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page2)

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

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

22 Jan SkywestCRJ7, Winnipeg (Canada) Overran runway on landing

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

27 Jan CimberAT72, Bornholm (Denmark) Veered off runway on landing

28 Jan BulogAN26, Wamena (Indonesia) Overran runway on landing

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

14

Source: Aviation Herald

55

slide56

RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page3)

  • 31 Jan SkyserviceA320, Varadero (Cuba)
      • Hard landing – three tyres blown
  • 4 Feb YakutiaAN24, Yakutsk (Russia)
      • Rejected take-off but airborne / gear up
  • 8 Feb Shasheen 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

slide57

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 Mar Air Tanzania B737-200, Mwanza (Tanzania) Veered off the departure runway 30
  • 17 Mar Shaheen Air International B737-200, Peshawar (Pakistan) Overran the runway on landing

28

Source: Aviation Herald

57

slide58

RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page5)

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

35

Source: Aviation Herald

58

slide59

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

slide61

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

slide63

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

slide65

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

slide66

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

slide68

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

slide69

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

slide70

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

slide71

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

slide72

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

slide73

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

slide74

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

slide78

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

slide80

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

slide83

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

slide84

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

slide85

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

slide86

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

slide88

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

slide89

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

slide90

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

slide91

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

slide92

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

92

slide93

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

slide94

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

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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

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MPL STATUS MARCH 2010:

  • 77

GRADUATED:

800

STUDENTS IN TRAINING:

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

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Training Comparison:

Source: IATA

MPL delivers more instructional hours than CPL

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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

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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

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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) >

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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

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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!

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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

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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

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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?

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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

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slide109

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

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