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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. The latest threat to crew training resources . USD 1.7 billion

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TRAINING FOR SAFETY

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  1. TRAINING FOR SAFETY World Aviation Training Symposium Orlando 27th April 2010 John Bent Director Training Strategy proposed Pegasus Flight Academy - China 1

  2. The latest threat to crew training resources USD 1.7billion has just been lost to international airlines in one week Source IATA 2

  3. ✔ 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. THE LONG TERM ACCIDENT RATE MAY EXCEED THAT COMMENSURATE WITH EXPANSION ALONE IF SO, WHY? 9

  10. 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

  11. 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

  12. 14 Aug 2005 Helios B737 Greece CREW INCAPACITATION: Could more effective training have mitigated? Tech and procedures? 2 12

  13. 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

  14. 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

  15. 29 Sep 2006 GOL B737-800 Brasil COLLISION: Could more effective training have mitigated? Procedures, situational awareness, TCAS? 5 15

  16. 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

  17. 7 Mar 2007 Garuda B737 Yogyakarta OVERRAN RUNWAY: Could more effective training have mitigated? Crew resource management (authority gradient) 7 17

  18. 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

  19. 17 Jul 2007 TAM A320 Sao Paolo RUNWAY EXCURSION: Could more effective training have mitigated? Undesired aircraft state - reverser inoperative procedures 9 19

  20. 17 Jan 2008 BA B777 Heathrow LOSS OF POWER: Could more effective training have mitigated? NO: Sound airmanship displayed - AAIB report 10 20

  21. 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

  22. 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

  23. 15 Apr 2008 Hewa Bora DC95 Goma RUNWAY OVERRUN: Could more effective training have mitigated? Overrun - tyreburst after V1; tried to stop 13 23

  24. 25 May 2008 Kalitta B747 Brussels RUNWAY OVERRUN: Could more effective training have mitigated? Procedures; slow rejected take off? 14 24

  25. 30 May 2008 TACA A320 Tegucigalpa RUNWAY DEPARTURE: Could more effective training have mitigated? Undesired aircraft state - landing performance? 15 25

  26. 10 Jun 2008 Sudan Airways A310 Khartoum RUNWAY DEPARTURE: Could more effective training have mitigated? Undesired aircraft state - landing performance? 16 26

  27. 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

  28. 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

  29. 24 Aug 2008 Itek Air B732 Bishkek LOST CONTROL ON APPROACH: Could more effective training have mitigated? Undesired aircraft state – visual awareness? 19 29

  30. 30 Aug 2008 Conviasa B737 Latacunga FLEW INTO TERRAIN: Could more effective training have mitigated? crew resource management, situational awareness 20 30

  31. 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

  32. 27 Nov 2008 ANZ A320 nr Perpignan LOST CONTROL: Could more effective training have mitigated? test flight procedures training (BEA)? 22 32

  33. 20 Dec 2008 Continental B737 Denver RUNWAY OVERRUN: Could more effective training have mitigated? Undesired aircraft state -failed take-off & runway overrun? 23 33

  34. 15 Jan 2009 US Air A320 Hudson River TRAINING & EXPERIENCE SAVED THE DAY! An example to study 24 34

  35. 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

  36. 25 Feb 2009 Turkish B737 Amsterdam LOST CONTROL ON APPROACH: Could more effective training have mitigated? Automation reliance & monitoring? An automation threat? 26 36

  37. 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

  38. 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

  39. 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

  40. 1 June 2009 Air France A330 Atlantic LOST CONTROL: Could more effective training have mitigated? - inadequate evidence as yet 30 40

  41. 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

  42. 14 Jul 2009 Caspian Tu 154 nr Tehran IMPACTED TERRAIN: Could more effective training have mitigated? -as yet unknown 32 42

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 2 Jan 2010 Compagnie B727-200 Kinshasa RUNWAY EXCURSION: Could more effective training have mitigated? Veered off runway on landing - heavy rain 38 48

  49. 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

  50. 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

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