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For a better use of incident analysis and safety data International Air Safety Summit Flight Safety Foundation Capt. Bertrand de Courville Washington – PowerPoint PPT presentation

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Title: Pr


1
For a better use of incident analysis and safety
data
International Air Safety Summit Flight Safety
Foundation Capt. Bertrand de Courville Washington
31st October 2013
2
Worlwide Air Transport Safety Records (up to date)
Fatal accidents Multi-engine commercial aircraft
Certified for more than 13 passengers Source
ASN - FSF http//aviation-safety.net/index.php/
Risk exposure
Safety barriers
  • Production/Protection balance management
  • Environmental changes are continuously affecting
    both sides
  • Corrections, adjustments and adaptations are
    permanently needed
  • Major improvements need imagination and joint
    innovations

3
Less catastrophic accidentsChallenges and
opportunities
  • Less fatal accidents potentially leads to
  • Unclear trends and correlation between accident
    scenarios
  • Focus on the most recent catastrophic accident
    and consequently less resources to address other
    accident risks
  • A significant risk awareness and safety
    commitment erosion at all level
  • More than ever, learning from accidents is not
    sufficient. Further safety improvement suppose to
    introduce innovations in the way
  • we monitor, check and maintain critical safety
    barriers
  • we analyze worldwide serious incidents
  • we disseminate the most significant outcomes

4
Managing Safety DefensesMonitoring, checking and
maintaining
  • Three significant safety case studies related to
    three different risks and corrective actions
  • A risk of loss of control (1994)
  • A risk of runway collision (1998)
  • A risk of mid air collision (2002)

5
Managing Safety DefensesMonitoring, checking and
maintaining
6
Managing Safety DefensesMonitoring, checking and
maintaining
  • Three significant safety case studies related to
    three different risks and corrective actions
  • A risk of loss of control (1995)
  • A risk of runway collision (1999)
  • A risk of mid air collision (2002)

7
Managing Safety DefensesMonitoring, checking and
maintaining
  • Three significant safety case studies related to
    three different risks and corrective actions
  • A risk of loss of control (1995)
  • A risk of runway collision (1999)
  • A risk of mid air collision (2002)

8
Managing Safety DefensesMonitoring, checking and
maintaining
9
In 2002 F/O safety report related to a non
consequence eventHe reported having initially
reacted the opposite way to a RA TCAS.
Managing Safety DefensesMonitoring, checking and
maintaining
  • A simple risk assessment rates this scenario as a
    high risk one
  • This event was published in our monthly safety
    bulletin
  • The publication triggered two other reports
    relating similar events
  • A FDA algorithm was implemented to monitor
    opposite response
  • This issue was shared and published in
    Eurocontrol ACAS bulletin

10
FDA (FOQA) algorithmDetecting and sharing
opposite response to TCAS
Managing Safety DefensesMonitoring, checking and
maintaining
11
Managing Safety DefensesMonitoring, checking and
maintaining
  • Airbus Safety Conference in Barcelona (2003)
  • TCAS opposite response case presented
  • FDA algoritm offered to be shared
  • One airline used it and found the same results
  • This became an industry issue and led to the TCAS
    7.1

TCAS 7.0
TCAS 7.1
Level Off
12
Managing Safety DefensesMonitoring, checking and
maintaining
Operations
Accidents
?
  • Loss of control
  • CFIT
  • Mid air collision
  • Runway collision
  • Runway excursion
  • Other damages/injuries (Flight)
  • Other damages/injuries (Ground)

13
Managing Safety DefensesDissemination of lessons
learnt
  • Whenever a critical aircraft system failure
    affecting airworthiness aspects is identified
    through an incident, manufacturers and/or
    authorities may decide a check of an aircraft
    type fleet worldwide because there is a
    significant probability that the same failure
    already have or could occur somewhere else. AD
    could be published.
  • Similarly, serious incident related to pure
    operational issues may reveal critical
    operational failures that could reflect a much
    wider industry problem. But there is no process
    to check further the existence of the same
    weaknesses, in other airlines/organisations.

14
Dissemination of lessons learntComparing
Technical and Operational Events
  • Arcraft systems related incident
  • Very efficient and structured dissemination
    process of lessons learnt whenever an incident
    reveals key airworthiness aspects of aircraft
    systems or technical issues.
  • A fleet could be inspected and measures taken
    within a few week with immediate measures
  • Flight operations related incident
  • No formal and structured processe to encourage
    further  inspection  worldwide of specific
    operational issue discovered in operational
    incident
  • Predictive aspects of key operational (non
    airworthiness) related failures Not used to
    prevent accident worldwide.
  • Accidents still needed to consider repetitive
    incidents and trends

The most significant safety failures found in
every single high risk operational incidents,
should inspire further check across the industry
and, when needed, safety actions.
15
Dissemination of lessons learntTaking advantage
of standardization
  • Worlwide harmonization bring opportunities
  • More standardized policies, procedures, practices
    and training makes more  predictable 
    operational failures
  • Most of safety issues detected and addressed in a
    single airline are also a concern in other
    airlines.
  • Do we take enough advantage of this ?

16
Dissemination of lessons learntImplementing
safety watch as SMS component

Space of precursors


























?
























17
Dissemination of lessonsImplementing safety
watch as SMS component Internal monthly
publication  safety watch 
Summary (per accident families)
  • Safety Promotion (awareness)
  • Monthly Safety Publication
  • Hazard identification
  • Most significant events are reviewed during
    Safety Action Groups Meeting

18
Managing Safety DefensesAbout methodology
Altitude bust Runway Incursion, WB
error Aircraft system malfunction, Loss of
separation, etc.
19
Managing Safety DefensesAbout methodology
  • Identified high risk operational event. Could it
    happen to us ?
  • No. Can we prove it ?
  • Yes. Do we monitor the risk? Can we prevent
    better ?

Safety Watch
Control barriers
Recovery barriers
20
Managing Safety DefensesThe ARMS methodology as
an example
  • Risk Assessment of Individual Safety Events
  • ERC Event Risk Classification
  • Idendify Safety Issue
  • Reactive, preparing the proactive approach
  • Risk Assessment of Safety Issues
  • SIRA Safety Issues Risk Assessement
  • Proactive or Predictive
  • Risk Assessment of operational changes
  • (Management of Change)
  • SIRA Safety Issues Risk Assessement
  • Proactive or Predictive

21
Managing Safety DefensesGA decision a critical
safety barrier
  • GA decision making is a barrier against landing
    accidents risk.
  • Is this barrier robust? Are our crews performing
    well? What training?
  • How do we know for these threats or unsafe
    conditions ?
  • Wind above limits
  • Severe turbulence
  • Wake turbulence
  • Windshear
  • Instrument failures (in IMC)
  • Runway occupied
  • Runway/airport confusion
  • Degraded visibility at low height
  • Not stabilized at 1000/500 floor
  • Destabilized at low height
  • EGPWS Sink rate or Pull Up
  • Tail wind and wet/contam. rwy
  • Deep landing
  • Bounced landing

22
Managing Safety DefensesGA decision a critical
safety barrier
  • Degraded visibility at low height (rain showers,
    fog patches)
  • When ground, approach lights and some runway
    lights are in sight, we may think they still
    sufficient visual cues to continue
  • But we may not be aware that the horizontal
    visibility has reduced to a few hundreds of
    meters, below the minimum needed to detect and
    correct accurately deviations. Why ?
  • More resources are needed to keep visual contact
    and control the flight path. Pilot corrections
    are delayed and become inaccurate. Vertical or
    lateral deviations may develop without being
    detected.
  • PF alone have not any more resources to decide a
    go around. Again PM role is key !
  • Many runway overrun or landing short accidents
    are related to this type of situations which are
    not met during training

23
Managing Safety DefensesGA decision a critical
safety barrier
  • Degraded visibility at low height (rain showers)
  • When a single good video equals hundreds of words
  • A training opportunity through Youtube

www.youtube.com/watch?v8WNBxNoCO1Q
24
Managing Safety Defenses High risk to high
reliability era through innovation
25
Managing Safety DefensesA European (ECAST)
Initative
  • High Risk Incident Review initative
  • Objective
  • To identify the most significant safety barrier
    failures from individual high risk incidents,
    susceptible to inspire further check by safety
    professional throughout civil aviation.
  •  
  • Tasks (Extract)
  • To agree on an review method and to document this
    method.
  • To analyse High Risk Incidents using the agreed
    method
  • To disseminate its findings to the wider aviation
    community
  •  

26
Conclusion
  • Further safety improvements need innovation and
  • Better Safety board efforts around the world to
    comply with ICAO Annex 13 regarding investigation
    and communication about high risk incidents
  • Formal and structured worldwide dissemination
    processes of key safety failure identified in
    high risk operational incidents still to be
    developed
  • Adoption of a common barrier based model to be
    used both in high risk incident analysis and
    safety data mining

27
  • Thank You
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