Opening: GutenmorgenmeineDamen und Herren, und vielen dank für die Gelegenheit zu Präsentieren ihnen heute.Es tut mir leid, aber mein Deutsch ist sehr rostig, so werde ich meine Präsentation in englischer Sprache geben
Today I will speak about Risk Management, Flight Data Monitoring and Protecting your assets.I have a passion for Safety in aviation, so my presentation is to highlight the value and cost benefit of implementing an FDM programme.To put this all in context, I’m going to start with a couple of quotes…And probably a couple of familiar graphics
Unfortunately, it doesn’t always work out that way.Excerpt from an NTSB report – it doesn’t matter which accidentThis is not a-typicalThe big question is: Do you think that this is the first time any of these situations has arisen with this particular crew?But Oh.. You say… we have a great safety reporting culture. The crew would tell us if they have problems….March 29, 2001, about 1901:57 mountain standard timeGulfstream III, N303GA, owned by Airbourne Charter, Inc., and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, Colorado.
So where’s the problem…In fact - Two-thirds of all fatal accidents involved a flight crew related primarycausal factorand 7% involved an aircraft related primarycausal factor.Three-quarters of all fatal accidents involved at least one flight crew related causal factor and 42% involved at least one aircraft related causal factor.So what’s going on up there?UK CAA, CAP 776
OK… maybe not always, and maybe not as complete a picture as we would likePatrick Hudson, Professor at Delft University, estimated some years ago that 75% of “events” go unreportedAnd that’s just the reactive stuff.We’re pretty good at reporting things that others noticed, or definitely will notice, But not so good where we either don’t think it’s important, or maybe when we don’t think we’ll get caught messing up.And of course there are the issues that the pilots did not detect.An example: One RW pilot flying offshore did not know he was close to Vortex Ring until the Flight Data Analyst asked him to review the flight. He turned white as a ghost.
That interaction between the flight crew and the technology is what this is all aboutYou only have 3 main levels. Most of those holes we talk about are at the top end of the model.This is closer to the truth as it is the organisation that has the resources to make or block these holes.If the organisation does it’s job, and the technology is appropriate and cared forThe people have many fewer holes to block.Much more effective in preventing an accident than having all the holes being blocked by the peopleThe heros… the ones that work against all odds to prevent an accident or recover from one that could have been much worseWe can’t leave it to the last resort – we have to get proactive.
Aircraft in motion represents the greatest hazard faced by an operation.And each of the threats firing arrows at your swiss cheeseIn between the “unwanted event” – in this case Loss of Separation – are the controls – the holes in the swiss cheese.If these controls fail, and you get to the unwanted event, you require recovery procedures to avoid catastropheThe yellow – a baaaad situation, such as: inadvertent IMC Or the worst - The red: Airborne contact with opposing trafficCLICK: Here I’ve circled all those threats and controls that are dependant on the flight crew having the resources (tools, training, equipment, wide awake, etc.) and the ability to do their job well
There are 2 tools for gathering operational flight data:Safety ReportingFlight Data MonitoringOf these two tools, only FDM is comprehensive and quantifiable.You get everything that the aircraft is capable of recording
Safety Reporting is important..You get real and valuable information, not to mention the 2-way communication you get with staff. Extremely important and I could do an entire presentation on its merits and the benefit to the SMSBut this presentation is about FDM… although we’ll see later how the 2 are relatedNow the real question – is do we get all the information we need this way?
Human beings, the technology they operate, and the organisation they work within, are the three sets of factors likely to be “implicated in breaching defenses put in place to avoid accidentsAnd how do accidents happen?
And to manage risk, ICAO says:“it must be data-driven and involve constant monitoring to either eliminate or reduce the risk to as low as reasonably practicable
ICAO further requires that the data collected is systematic, cover all areas of the operation and have the ability measure the results of the controls put in place to control that risk.And finally… the focus must first be on the highest risk.And what is that?
Flight Operations
And how much information do we have?Ah yes. But we get flight safety reports. Pilots put an ASR in whenever something goes wrongWe know of all the mistakes, errors, technical faults, whenever they don’t quite stick to SOPs…Right?So it makes sense to ensure we have data that is:SystematicCover all areasHave the ability to measure the resultsAnd most importantly – be able to focus on the area of highest riskAnd what is that?
There are 2 tools for gathering operational flight data:Safety ReportingFlight Data MonitoringOf these two tools, only FDM is comprehensive and quantifiable.You get everything that the aircraft is capable of recording
The data collected on the Super Puma tells you a lotHow the aircraft reacted and interacted with the controlsHow the PIC reactedThe resulting ASR and investigation will add to the quantifiable data withhow the crew (no pax) got out, with only one minor injuryinvestigation and report would tell you the about the Ground run after maintenanceNow the problem with this one, is that FDM was installed, but as it was a maintenance run, there was not PCMCI card in the Quick Access Recorder, so no operational data could be collected.The bottom picture has an FDR, and in this situation you would pull the data for the investigationNow neither of these situations are unique, and as both are “accidents”, they are investigatedBut what if it was a close call - landing late, unstable approach, malfunction, or in the case of the SuperPuma – a gust of wind on a top heavy helicopter just makes the one wheel lift up a bit… Incidentally – a large investigation quite a number of years ago using recorded flight data CLICK: (due to “this event”) determined how to avoid a roll over in the super puma. It’s unfortunate that history continues to repeat itself in various waysOne: in business ops you may not know it ever happened – that wonderful “what happens in Vegas stays in Vegas”Second, you cannot routinely analyse the precursers. One commercial airline Safety Manager told me rather cynically that “we never had an unstable approach until we put FDM in place”.So you want robust informationYes – to hold individuals accountable for their actionsBut also to give them the tools to improve their performanceAs well as the overall performance of the operation through training, procedures, and awareness.
That interaction between the flight crew and the technology is what this is all aboutYou only have 3 main levels. Most of those holes we talk about are at the top end of the model.This is closer to the truth as it is the organisation that has the resources to make or block these holes.If the organisation does it’s job, and the technology is appropriate and cared forThe people have many fewer holes to block.Much more effective in preventing an accident than having all the holes being blocked by the peopleThe heros… the ones that work against all odds to prevent an accident or recover from one that could have been much worseWe can’t leave it to the last resort – we have to get proactive.
The goodthe badand the uglyNow the “bad” is a screenshot where one of these 2 fire-fighters posted themselves on FacebookAnd another client sent it off to a gentleman named Paul Spring, owner of Phoenix HeliFlight and this aircraft.Paul has graciously given me free license to use his material – and he uses it himself for presentations such as thisThe pilot was a contractor who will no longer work for Phoenix HeliflightAs Paul says… The individuals on the skids were willing participants and maybe even instigatorsso Phoenix uses these photos during training to educate Pilots and Firefighters of the consequences.Phoenix’s HFDM equipment includes cockpit voice and video recorders, the presence of which may have discouraged any thought of such a reckless & stupid actNow… incidentally, as you’re by now thinking I’m ignoring the “Good guys”This is not true. Much can be learned about good SOPs from the guys that do things right in difficult situations.But more about that in a minute.Pilot: R.G. (full time employee)• 2,099 PIC Single Engine R/W & F/W• On July 22, 2007 our AS350 BA was returning to home base after a day of Initial Attack standby. The pilot with his crew of 4woodland firefightersonboard had been in level cruise at 1000 feet AGL for 20 minutes when the helicopter descendedabruptly……. 1 person dead & his family devastated• 4 persons injured• 1 helicopter destroyed• The company’s reputation threatened• With the pilot’s testimony the Transportation Safety Board of Canada concluded that the helicopter was flown into“servo transparency” following a “sudden high speed descent”.The TSB final report stated “It was reported that the pilot had previously flown in a similar manner on other flights whentransiting between bases, with sudden climbs, descents, and pull-ups. Some of the passengers reportedly were discomfortedby the maneuvers; however, no complaints were submitted to the management at ASRD or Phoenix Heli-Flight”.• The helicopter involved had no HFDMrecorder so if everyone had died, the causemay have been ‘undetermined’.
FW: Exceedance of control limits – control surface or structural damageControl surface and structural damage due to exceedance of control limitsExceeding engine temperature ratio