Training=Safety John Bent & Dr Kwok Chan

Training
=
Safety Generator

1

Saturday, March 7, 2009

Training
=
Safety Generator
Aviation Education & Training Summit

Dec 4/5, 2008

Beijing

1


Training
=
Safety Generator

Dec 4/5, 2008

Beijing

John Bent

Manager Flight Training Centre

1


Training
=
Safety Generator

Dec 4/5, 2008

Beijing

Dr Kwok Chan
John Bent

Head of Corporate Safety & Quality

1


Training
=
Safety Generator

Dec 4/5, 2008

Beijing

Dr Kwok Chan
John Bent

Head of Corporate Safety & Quality

Hong Kong Dragon Airlines Ltd

1


2
Aviation Summit Beijing

PILOT TRAINING is an ingredient of The
Safety Management (SMS)

2


Training is key to safety outcomes

2



The Safety Management System (SMS) is mandated by ICAO

2



The Safety Management System (SMS) is mandated by ICAO

Full application of SMS must include training

2

3

Volatility – 2000-2008

3


Hardware growth outstripped human-ware available

3



911 and SARS discouraged steady expansion of training capacity

3




New entry aircraft grounded, and crew demand became critical

3





Crew training could not keep up

3






Now facing contraction in global recession

3







Already pilot layoffs in some regions

3








Reduced pressure on training delivery, but increase in pilot mobility

3





ry
to
ri

er
rt
u
o
is
Reduced pressure on training delivery, but increase in pilot mobility
y
lit
ti
a
ol
V 3

4

AFTER
RECESSION
GROWTH
WILL
RESUME

THIS BIG
PICTURE
WILL
RETURN:

4

5

Seeing through the recession

5


Despite the downturn ahead, the training industry must look

through to the other side

5


Despite the downturn ahead, the training industry must look

through to the other side

This time should be applied productively to embed best

practice and be prepared to resume growth safely

5

6

PILOT TRAINING is the best investment against
catastrophic accident risk (UK CAA latest research):

6


From UK CAA Global Airline Safety Analysis:

Crew judgement and actions remain 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


The current top catastrophic accident risks identified are:
LOS (loss of control)

CFIT (controlled flight into terrain)

Post-crash fire

Runway excursions and overruns

Quality pilot training at all levels remains the critical factor in
preventing really serious accidents

7

Overview of 2007 vs. 2006

Courtesy of IATA
Source: IATA Safety Report 2007
8


Regional Rate: Western-built Jet Hull
Losses

Courtesy of IATA
Source: IATA Safety Report 2007
9


10

Safety Trend?

Jan – July 2008, the number of fatal accidents soared 80% over H1
2007 (18 against 10 in H1 2007)
Since July 2008, there have been more frequent incidents and 3 further
fatal accidents (Kalita B747, Spanair MD80 (flaps?), Itek B737)
In recent years, accidents and incidents have been exposing Pilot
Training as a significant factor; for example:
Adam Air B737-400 (loss of control while both focussing on INS)

BA 319 (electrical failure and flight on standby instruments)

Pinnacle Airlines Bombardier CRJ200 –runway overrun –landing performance
calculation

Air Transat A330 – Azores – fuel management

10

11

Growth & Consequences

Assuming:
A reasonably fixed accident rate
No improvements to reduce accident rate
The projected doubling of the global fleet next 2 decades
Outcome:
A large increase in airline accidents
Reduced public confidence in airline travel?
Self-generated contraction?

11

12

Was training a factor?

In mid 2000, an Airbus A320 crashed at sea off

Bahrain International Airport and all 143 persons
on board were killed

12

Some ﬁndings - training & organisation
Crew performance capabilities and experience (Human
Perf -Training)
Cockpit authority gradient (HF/CRM -Training)
Crew personalities (CRM -Training)
Perception of a punitive attitude towards missed
approaches (Safety Culture)
Performance standards and monitoring (Safety System)
Supervisory oversight; ﬂight safety department
(Safety System)

Aviation Summit Beijing 13


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15

16

The Airline Food Chain

Safety standards where airline pilots come from?



Regional Rate: Western-built Turboprop Hull Losses

19
Courtesy of IATA
Source: IATA Safety Report 2007 (CEO Brief)


19

20

Again, thanks to training?
Technical failure &
depressurisation

+
Well Trained crew

=
Successful
emergency descent
and landing

= SAFE OUTCOME

20

equipment
selection
design

work
training conditions

procedures culture
Systemic factors
[Dr Rob Lee & Dr Kwok Chan]


People are components of a Safety System, not autonomous

equipment
selection
design

work
training conditions

Individual behaviour
procedures culture
Systemic factors
[Dr Rob Lee & Dr Kwok Chan]


Incident / Accident
The last defence

Pilots

Safety Barriers Airline ORG + /
TRAINING

Aviation Regulator

Aircraft Manufacturer

Courtesy Prof Reason 22

Again the Swiss Cheese!
Incident / Accident
The last defence

Pilots

TRAINING

Aviation Regulator



Again the Swiss Cheese!
Incident / Accident
The last defence

Pilots

TRAINING

Aviation Regulator


Flight Crew – our last line of defence

23

Pilot Competence is like a fuselage skin - it
cannot be too thin

23

Pilot Competence is like a fuselage skin - it
cannot be too thin

UNSAFE
UNSAFE

UNSAFE UNSAFE

23

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The crust of it

24

The crust of it
UNSAFE UNSAFE

UNSAFE UNSAFE

24

The crust of it
UNSAFE UNSAFE

UNSAFE UNSAFE
Competence

24

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The safety crust analysed

25

26

But what is Competency?

26


Flying Hours are experienced and applied in many ways, and are
no measure of competency

26



Quote: “Thinking only hours means you don’t know what
competency is” Prof. Graham Hunt

26



Quote: “Thinking only hours means you don’t know what
competency is” Prof. Graham Hunt

Competencies are established via task analysis, applied through
instructional design, and validated by a performance
measurement system – a lengthy but worthwhile process

26

27

The Training Equation

27


EXPERIENCE

27


+
EXPERIENCE

27


+
EXPERIENCE TRAINING

27


+
EXPERIENCE TRAINING

” Education is the systematic, purposeful
reconstruction of experience” Anon

27

28

Accident Rate & Growth

28


The historical airline Accident Rate is very low, but:

28



Doubling of
global ﬂeet will
increase the
number of
accidents

28



Doubling of
The accident
global ﬂeet will
RATE must be
increase the
further
number of
REDUCED
accidents

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29

So STANDARDS must be RAISED

Standards

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30

BUT

30

BUT
Resources & Quality

30

BUT
Resources & Quality

$$ As costs come
under severe
pressure,
training
resources can
become static
or shrink

30

BUT
Resources & Quality

$$ As costs come
If no more
under severe
training can be
pressure,
added, QUALITY
training
must be
resources can
improved
become static
or shrink

30

31

Flight to Quality – we have no choice

31


Training process must be improved

31


Training process must be improved

Resource constraints demand a
‘Flight to Quality’

31

32

Quality of process is KEY

32

ent
Quality of process is KEY
Im m
ove
pr
pr
ov Don’t stop!
s im
e
ou
re
inu
c
nt
ru s
llabu
Tra co
itm
/ sy
in rfo
inst s
oces
en n
ruc g r
esi prove p
ors t t D Im
Analyse Improve equipment
data Ap
ps Au
pl
loo
re
dit
s y
etric
re mo
ck be &v
M
ba alid
st
ate
ed pr
fe ac
Measu

se tic
lo e
C

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The healthy cycle

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Organisational & Safety Culture

To raise the training bar, we need effective airline organisational and
safety cultures in the background

From January 2009, this will be mandated by ICAO under Doc 9859
Safety Management Systems (SMS)

During a 1999 Symposium in Sydney, Professor Ron Westrum
introduced his research into organisational cultures, which he
categorised as: Generative, Bureaucratic, Pathological

ICAO extended this model to SAFETY CULTURES, now published in
the Safety Management Manual (SMM)

34

Prevention or cure?
Accident Prevention; work to detect and correct Active Failures and
Latent Threats before they lead to a catastrophic outcome

Accidents
Active Failures
of event >>

and Latent Serious incidents
Threats

Minor incidents
Severity

Normal operations

Frequency of event, Quantity of data >>
35

Prevention or cure?

REACTIVE
Accidents
Active Failures
of event >>

Threats

Minor incidents
Severity

Normal operations

35

Prevention or cure?

REACTIVE
Accidents
Active Failures
of event >>

Threats

Minor incidents

PROACTIVE
Severity

Normal operations

35

36

The COST of REACTIVE!
of event >>
Severity

36

The COST of REACTIVE!

$$$$-Very expensive lessons
Accidents
of event >>

Serious incidents $$$-Expensive lessons

Minor incidents Costly lessons

Normal operations:
Severity

•Errors
Virtually free lessons
•In-service problems
•Non-optimal performance

36

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Our training objective?

37

Our training objective?

TO SERVE
THE SAFETY MANAGEMENT
SYSTEM

37

THREAT: ICAO SMM 1.3.3
The air transport industry’s future viability may well be predicated
on its ability to sustain the public’s perceived safety while travelling.
The management of safety is therefore a prerequisite for a
sustainable aviation business

How is SMS deﬁned?

SMS (ICAO Deﬁnition) from the SMM 1.4.2:

An SMS is an organised approach to managing safety, including the
necessary organisational structures, accountabilities, policies, and
procedures



To serve SMS with training, we need to
understand the threats:

39

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15 System Safety threats today

40


1. Global economic turmoil: ‘indiscriminate resource cutting’ - key
safety generators may be lost in the culling process

40



2. Reduced experience: Expansion has shrunk the average volume
and depth of experience of pilots and instructors

40




3. Pilot production pressure: Expansion & pilot mobility in crisis
adds unplanned pressure on training systems, impacting quality

40




3. Pilot production pressure: Expansion & pilot mobility in crisis
adds unplanned pressure on training systems, impacting quality

4. Training System lag: It may take years to ramp up training
capacity; during which time, quality may surrender to demand

40

41


5. Management perception: From ICAO SMM Doc 9859 AN/460
(2006),12-13: “Weak Management may see training as an expense
rather than an investment in the future viability of the organisation”

41



6. Automation: Modern airliner design has reduced operational risk, but
weakened traditional piloting skills when systems degrade

41




7. Regulatory Lag: Rules take time to change; eg. Basic CPL licencing
standards of 1944 are still applied today

41




7. Regulatory Lag: Rules take time to change; eg. Basic CPL licencing
standards of 1944 are still applied today

8. Commercial priorities: In the highly competitive airline environment
commercial objectives are accorded ‘front ofﬁce’ status

41

42

9. Training seen as back-office: Crew training, a significant non-line
cost, may be treated as a 'back office’ activity

42

10. Shrinking resources: As operating costs have escalated,
commercial departments tend to view minimum regulatory standards
as MAXIMUM budgetary targets

42


11. Delayed effect of sub-optimal training: The impact of less effective
training may not be seen for years

42


11. Delayed effect of sub-optimal training: The impact of less effective
training may not be seen for years

12. Reduced career interest: The ‘passion’ for aviation is not so
evident today. Recruits often place piloting as 3rd or 4th priority

42

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13. Airline in-house ‘ﬁxes’: Airline-developed training which is not
approved by the manufacturer may become a latent threat. (For
example, the probable impact of airline-designed jet-upset training
on a fatal A300 accident in USA)

43

13. Airline in-house ‘ﬁxes’: Airline-developed training which is not
approved by the manufacturer may become a latent threat. (For
example, the probable impact of airline-designed jet-upset training
on a fatal A300 accident in USA)

14. Embedded paradigms: A long strong safety record = a safe
future? Perhaps not! Comfort can lead to organisational
complacency. [Possible examples: US airline M & As (1980s), Townsend
Thoresen Ferries, British Rail, well-respected major airlines, NASA, nuclear, oil, and
other transport / high technology industries]

43

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15. Inadequate system measurement: leads to subjective opinion-
based judgment; ‘more of the same’ or new untested training
processes

44

processes

From ICAO SMM AN/460 (2006),12-13:

“Regardless of their experience level, all employees benefit from feedback
on hazards identified, safety actions taken, safety lessons learned”

44

processes

From ICAO SMM AN/460 (2006),12-13:

“Regardless of their experience level, all employees benefit from feedback
on hazards identified, safety actions taken, safety lessons learned”

It’s not a quality system if it’s not
measured

44

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Threat & Error Management (TEM) provides a
useful framework in crew training & safety

45


TEM assumes that Threats & Errors are:

45



Inevitable - part of the territory

45




External conditions or events that must be managed during
normal, everyday ﬂights, in order to maintain safety margins.

45




External conditions or events that must be managed during
normal, everyday ﬂights, in order to maintain safety margins.

Events which increase operational complexity, posing a
safety risk to the ﬂight at some level

45

WHY & WHEN do we make errors?



We need to measure to ﬁnd out



e.g. in industry, the Six Sigma
process >>



e.g. in industry, the Six Sigma
process >>

Deﬁne, measure, analyse, improve, control



e.g. in industry, the Six Sigma Or in aviation terms:
process >>

Deﬁne, measure, analyse, improve, control



47

Measurement?

We measure lots already
There are reservoirs of airline data
But it’s rarely integrated or analysed
Apart from QAR / FOQA, and crew performance,
we also use more holistic measures, such as >>>

47

Airline external audits
Whole Airline:

IATA OPERATIONAL SAFEY AUDIT
(IOSA)
Flight Operations

LINE OPERATIONS AUDIT
SYSTEM
(LOAS)

Flight Operations

LINE OPERATIONAL SAFEY AUDIT
(LOSA)



Benefits of measurement; Crew errors:

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,
not challenged by other crew members (reluctance to
challenge,
expressed as ‘authority gradient’ (G.Hofstede), has been
shown to
vary with national culture

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

32% of errors were intentional noncompliance (Violations)



Benefits of measurement; Crew errors:

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,
not challenged by other crew members (reluctance to
challenge,
expressed as ‘authority gradient’ (G.Hofstede), has been
shown to
vary with national culture

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

32% of errors were intentional noncompliance (Violations)

Preventing pilot error is impossible – “To err is human”



50

Intentional
Non –
Compliance?
50

Courtesy Prof Patrick Hudson 51

Understanding WHY - Intentional Non-compliance
Predictors of Violation:



Expectation Expectation that rules will have to be bent to get
the work done



the work done

The feeling that one has the ability and experience
Powerfulness to do the job without slavishly following the
procedures



the work done

procedures

Opportunities Seeing opportunities that present themselves for
short cuts or to do things ‘better’



the work done

procedures

Opportunities Seeing opportunities that present themselves for
short cuts or to do things ‘better’

Inadequate work planning and advance
Planning preparation, leading to working ‘on the ﬂy’ and
solving problems as they arise


LOSA data has also indicated what crews
do RIGHT



Emeritus Professor Bob Helmreich (University of
Texas), champion of LOSA & TEM, 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.”







actively engage in checking and verifying every


setting and action which can affect safety.”

Obvious? Yes; but real evidence from normal
operations



One of the variables we can
control is training 54

Saturday, MarchBeijing
Aviation Summit 7, 2009

Still the question that Every Airline wants answered is:
“What is the most likely cause of a future accident
IN OUR AIRLINE” ?

AND HOW DO WE PREVENT IT?

One of the variables we can
control is training 54

Saturday, MarchBeijing
Aviation Summit 7, 2009

RAISING THE BAR - TYPE RATING INSTRUCTORS

55

RAISING THE BAR - TYPE RATING INSTRUCTORS

Airline management has clear control of training,
for the production of safe (or less safe) outcomes

55

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Quality in Control

A quality system is based on understanding and controlling variation
TRAINING IS A KEY VARIABLE

A quality system is measured by the degree to which a set of
standards are met - REGULATORY & OPERATIONAL

A quality system is management methodology driven by data
PERFORMANCE MEASUREMENT IN SMS

A quality system focuses on projects that will produce measurable
business results >

ACCIDENT RATE REDUCTION
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Training can never be perfect – there are
always areas to improve >

57

58

MPL embodies best practice

58


Despite some commentary suggesting a ‘failure’ of MPL
(due to recent MPL graduate job losses), MPL is: -

58


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

58


 an ICAO approved programme and license

58


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

58


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

This is exactly what the training industry needs – relevance, focus and
quality, in areas such as >>

58

The instructors Art



The instructors Art

Advanced training equipment will not fully
compensate for ineffective instruction



The instructors Art

An effective instructor can however compensate
for training equipment limitations



The instructors Art

An effective instructor can however compensate
for training equipment limitations
More relevant instructor entry criteria and
improved training is needed, such as that
prescribed by MPL



Human Factors Training




Human factors remain central triggers in accidents and incidents





As Daniel Maurino (ICAO) stated in 1991, Human Factors is not just CRM!






Modern Flight Crew must be taught to recognise human limitations

through all phases of operations (TEM)






Modern Flight Crew must be taught to recognise human limitations

through all phases of operations (TEM)

A training objective is to instill continuous embedded awareness,

eg. TEM in MPL



Training improvements summary




Enhanced Instructor training and oversight
1.




1.

More task-focussed, competency-based, quality embedded programmes
2.




1.

2.

Programme design for continuous improvement
3.




1.

2.

3.

Driven by performance feedback
4.




1.

2.

3.

4.

Training devices tailoured to training task and learning phase (eg. APT
5.
Trainers)




1.

2.

3.

4.

5.
Trainers)

Embedded human factors / TEM.
6.




1.

2.

3.

4.

5.
Trainers)

6.

Mandated uniforms in simulator training – raising crew ﬁdelity
7.




1.

2.

3.

4.

5.
Trainers)

6.

Mandated uniforms in simulator training – raising crew ﬁdelity
7.

Training driven from operations and safety sensing systems
8.



62

For example:
Uniforms in
simulation

62

For example:
Uniforms in
simulation
 A zero cost
option - all crews
have uniforms!

62

For example:
Uniforms in
simulation
 A zero cost
option - all crews
have uniforms!

 Matches crew
ﬁdelity with
simulator ﬁdelity

62

For example:
Uniforms in
simulation
 A zero cost
option - all crews
have uniforms!

 Matches crew
ﬁdelity with
simulator ﬁdelity

 Creates a more
professional
atmosphere in
training

62

63

The bottom line -Training

63


We are highly exposed to ineffective training

63



Airlines need to offer comfortable and safe air travel as a long term

proﬁtable business plan

63





Resource ﬂow must be maintained to the vital organs of safety

culture

63






culture

Effective crew training is an investment which protects safety

margins for years to come

63






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

63

Measurement
is vital to
improvement



‘Take-aways’



‘Take-aways’
To avoid additional cost, we must optimise what we have



‘Take-aways’

But to improve, we must measure!



‘Take-aways’


Measurement embedded in the

training process, and instructor’s task



‘Take-aways’




TEM embedded in all training footprints



‘Take-aways’




TEM embedded in all training footprints

As QUANTITY shrinks, QUALITY must grow



Training=Safety John Bent & Dr Kwok Chan

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