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- 1Accident Rate1 in 10^-7
- 2De Havilland Comet # hull loss26 hull loss accidents
- 3EGPWSo Enhanced Ground Proximity Warning Systems
- 4TCASTraffic Collision Avoidance Systems
- 5ADSAutomatic Dependant Surveillance
- 6Technology improvements- Engine Reliability
- EGPWS
- Windshear alerting
TCAS
Electronic Checklists
FDRS: Flight Data Recording System
CVRS: Cockpit Voice Record - 7Basic Quality Tools:• Flow charts
• Pareto charts
• Cause and effect diagrams
• Control charts
• Check sheets
• Scatter diagrams
• Histograms - 8Management and Planning Tools• Tree Diagram
• Affinity Diagram
• Activity Network Diagram
• Interrelationship Diagram
• Matrix Diagram
• Priorities Matrix
• Process Decision Program Chart - 9The Four SMS Components:• Safety Policy: Establishes senior management’s commitment to continually improve safety, define the methods, processes and organisational structure needed to meet safety goals
• Safety Assurance: evaluates the effectiveness of implemented risk control strategies, and supports the identification of new hazards
• Safety Risk Management: the need for and adequacy of new or revised risk controls based on the assessment of acceptable risk
• Safety Promotion: Includes training, communication and other actions to create a positive safety culture within all levels of the workforce - 10Key behaviours which management commitment include:o Inclusion of Safety Goals into strategic plans
o Regular management review of the SMS
o Executive management involvement - 11Operations Risks:• Risks incurred by the organisations day to day activities
• These risks usually involve people, systems and processes and are generally mitigated by internal senior and middle management
• Common examples include:
o Hazardous activities affecting safety
o Inadequate financial processes leading to inefficient control
o IT back-up systems leading to loss of information - 12Strategic Risks:• Risks to do with the company positioning itself within its operating environment
• Generally dealt with at board level
• Common examples include:
o Low cost competition
o Alliance decisions
o Pricing issues - 13Compliance Risks:• Risks incurred by not adhering to external regulations and legislation
• Common examples include:
o Heavy penalties
o Cessation of operations
o Loss of reputation - 14Financial Risks:• Risks incurred by the organisations management of currency and shareholder value
• Generally, involve the way that fuel and aircraft lease/ purchase costs are managed with respect to fluctuating exchange rates and to the underlying value of the company and company financial structures
• Two common hedging risks include:
o Oil price hedging
o Currency hedging
• Both are conducted at fairly high levels within an organisation - 15Safety Risk Management Processes:• The following processes are an inherent part of Safety Risk Management:
o Systems Description and Task Analysis
o Hazard Identification
o Risk Analysis and Assessment
o Controlling Risk
o Residual and Substitute Risk
o System Operation Monitoring - 16Safety Culture ElementsJust Culture
Reporting Culture
Learning Culture - 17Just Culture:• An organisational culture which promotes fairness, where employees are not punished for genuine errors or mistakes, but are still accountable for deliberate violations
- 18Reporting Culture:• An organisational culture where employees are encouraged to report their own mistakes, organisational issues or operational deficiencies without fear of reprisal
- 19What Text changes the emphasis of the definition of “safety” to be more applied and includes actions to reduce the potential harm or loss• ICAO (Annex 19)
- 20Production vs. Protection:• In low hazard ventures, the emphasis is on production rather than protection
• In high hazard ventures, there is a need to balance production and protection
o If you want to have high production, you need to increase your resources on protection
o The “can do” organisation attempts too much production without putting the appropriate defences in place (accident) - 21• Modern aircraft generate how much data?about 10 TB per engine per hour
- 22FOQA/FDM/MOQA???
- 23LOSA areas of critique???
- 24Human Factors Limitations• Limited memory capacity
• Limited processing capacity
o Lack of multi-tasking capability
• Limits imposed by stressors
o Tunnel vision
• Limits imposed by fatigue and other physiological factors
• Poor group dynamics
• Cultural influences - 25What do flight crews do to fly safely from A to B?• Manage operational complexity = Threat Management
• Manage their own errors = Error Management
• Manage induced aircraft deviations = Undesired Aircraft State Management
• = Safe Operation - 26Line Operations Safety AuditDefined by ICAO Doc 9803
- 27Background of LOSA??? The University of Texas- Human Factors Research Project???The University of Texas- Human Factors Research Project
• Early CRM research
• FAA funded (AAR-100) presentations and publications
• Research on LOSA and TEM
• Formation of The LOSA Collaborative
• ICAO Handbook 9803
- FAA Advisory Circular (120.90) - 28LOSA Operating Characteristics1. Jumpseat observations during regular (line) operations
2. Anonymous, confidential and non- punitive data collection
3. Voluntary crew participation
4. Trusted and trained observers
5. Joint management/ pilot sponsorship
6. Systematic observation instrument based on TEM
Secure data collection repository
7. Data verification roundtables
8. Data- derived targets for enhancement
9. Feedback of results to line pilots
• If the project does not meet all 10 characteristics it is not a LOSA as defined by ICAO
• The characteristics enhance pilot trust, increase probability of observing natural performance
• LOSA value - 29Threats Defintion• Threats are events or errors that originate outside the flight crews influence but require their attention and management in order to maintain adequate safety margins
• They provide the Operational Environment and Context in which flight crews operate - 30Types of ThreatsEnvironmental Threats
o Adverse weather
o ATC events/ errors
o Terrain
Organisational Threats
o Operational time pressure
o Cabin events/ errors
o Maintenance events/ - 31Error Defintiona deviation from organisational and/ or crew intentions or expectations
- 32Undesired Aircraft State DefinitionA flight crew induced aircraft state that clearly reduces safety margins
- 33Error TypesHandling:
o Automation
o Flight control
Procedural:
o Briefing
o Callout
o Checklist
Communication:
o Crew to external
o Pilot to Pilot - 34UAS exampleso Incorrect A/C configurations
o Vertical deviations- altitude
o Lateral deviations- heading
o Speed too high - 35What % of LOSA flights include a UAS30%
- 36Crews with at least one intentional non-compliance error are ____?2-3 times more likely to mismanage threats and errors
- 37• New Risk Controls are often implemented in response to major findings. These can be in the form of:o New or additional training
o New procedures
o New limitations etc. - 38Some of these tools include:o BASIS: British Airways Safety Information System
o ADREP: ICAO Accident / Incident Data Reporting System
o ASIAS: Aviation Safety Information Analysis and Sharing
o FMEA: Failure Mode Effects Analysis
o HFACS: Human Factors Analysis and Classification System - 39HFACS System• An accident and incident analysis tool which is based on Reason’s Swiss Cheese Model
• designed to help safety investigators define the latent and active failures in Reasons model for a given investigation - 40Active failures:encompass the unsafe acts that can be directly linked to an accident- such as pilot error
- 41Latent failures:include contributory factors that may lie dormant for days, weeks, months, or until they contribute to the accident
- 42HFACS describes four levels of failure, which correspond to the layers in Reasons modelo Unsafe acts
o Preconditions for unsafe acts
o Unsafe supervision
o Organisational factors - 43Unsafe Acts:Unsafe acts can either be errors and violations
• Errors are the mental and physical activities which fail to achieve their intended outcome. These may be skill-based errors, decisional errors and perceptual errors
• Violations are the wilful disregard for rules and regulations that govern the safety of a flight. They may be routine or exceptional violations - 44Preconditions for Unsafe Acts:These are things which may influence individual performance on a given day
o Analysis includes looking at the condition of the operator, environmental, and personnel factors - 45Unsafe Supervision Categorieso Inadequate supervision
o Planned inappropriate operations
o Failure to correct a problem
Supervisory violations - 46Organisational Influences• Fallible decisions of upper level management can directly affect supervisory practices and the conditions and actions of operators
• Unfortunately these organisational errors often go unnoticed by safety professionals because they don’t have a clear framework with which to investigate them
• Generally, the most elusive latent failures are due to resource issues, organisational climate and operational processes - 47Human Factors Digests- Human Factors Digest no. 15Made by ICAO
- 48Human Factors Training ManualICAO Doc 9683
- Edited compilation of the series of ICAO Human Factors Digests. Its target audience includes senior training, operational and safety personnel in industry and regulatory bodies
- Part 1: HF Basics
- Part 2: HF Training + curriculum - 49Why integrate HF in SMS- They enhance each other
- 50Aus integration of HF into SMSCAO 82.3 and CAO 82.5 require RPT AOC holders to ensure that an SMS is established in their organisations and that HF is integrated into their SMS processes
- 51Aus HF Training for Safety Critical StaffCAAP SMS- 3 (1) operators in Australia are required to conduct HF/ NTS training and assessment for their Safety Critical Staff
• Includes:
o Flight crew
o Cabin crew
o Flight operations officers/ Flight dispatchers - 52• Typically, for a medium to large airline, the NTS program would include:o A 2-3 day initial NTS training course (FC and CC separate)
o A 1 day refresher NTS course each year (FC and CC combined)
o Assessment of FC NTS during simulator checks and line checks
o Assessment of CC NTS during annual emergency procedures revaildation - 53Ways of Dealing with Hazards• Eliminate the hazard: The operation or activity is cancelled because risks exceed the benefits of continuing the operation or activity
• Reduce the hazard level: The frequency of the operation or activity is reduced, or action is taken to reduce the magnitude of the consequences of the accepted risks
• Provide safety devices: Measures are taken to reduce the risk using technology or safety equipment
• Provide warnings or advisories: Measures are taken to raise awareness of operators to the risks associated with the operating environment
• Provide safety procedures: Measures are taken to standardise operations utilising the safest procedures which are available - 54Risk Controls and processControl = Mitigation of risk
Four steps involved in hazard control:
o Ensure that the hazard is recognised and identified
o Determine and select hazard controls
o Assign responsibility for implementing control
o Measure and monitor the effectiveness of the control - 55Hierarchy of Risk Controlso Eliminate the hazard (avoid)
o Reduce the hazard level
o Provide safety devices
o Provide warnings or advisories
o Provide safety procedures (SOPs) - 56Three principal risk defences in aviationtechnology, training, regulations/ procedures
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- hardcore 106 Safety Systems Karteikarten am 106 sutdy notes, erstellt von Matt Barnes am 23/10/2016.
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