2. Training
=
Safety Generator
1
Saturday, March 7, 2009
3. Training
=
Safety Generator
Aviation Education & Training Summit
Dec 4/5, 2008
Beijing
1
Saturday, March 7, 2009
4. Training
=
Safety Generator
Aviation Education & Training Summit
Dec 4/5, 2008
Beijing
John Bent
Manager Flight Training Centre
1
Saturday, March 7, 2009
5. Training
=
Safety Generator
Aviation Education & Training Summit
Dec 4/5, 2008
Beijing
John Bent
Manager Flight Training Centre
1
Saturday, March 7, 2009
6. Training
=
Safety Generator
Aviation Education & Training Summit
Dec 4/5, 2008
Beijing
Dr Kwok Chan
John Bent
Head of Corporate Safety & Quality
Manager Flight Training Centre
1
Saturday, March 7, 2009
7. Training
=
Safety Generator
Aviation Education & Training Summit
Dec 4/5, 2008
Beijing
Dr Kwok Chan
John Bent
Head of Corporate Safety & Quality
Manager Flight Training Centre
Hong Kong Dragon Airlines Ltd
1
Saturday, March 7, 2009
9. PILOT TRAINING is an ingredient of The
Safety Management (SMS)
2
Aviation Summit Beijing
Saturday, March 7, 2009
10. PILOT TRAINING is an ingredient of The
Safety Management (SMS)
Training is key to safety outcomes
2
Aviation Summit Beijing
Saturday, March 7, 2009
11. PILOT TRAINING is an ingredient of The
Safety Management (SMS)
Training is key to safety outcomes
The Safety Management System (SMS) is mandated by ICAO
2
Aviation Summit Beijing
Saturday, March 7, 2009
12. PILOT TRAINING is an ingredient of The
Safety Management (SMS)
Training is key to safety outcomes
The Safety Management System (SMS) is mandated by ICAO
Full application of SMS must include training
2
Aviation Summit Beijing
Saturday, March 7, 2009
13. 3
Aviation Summit Beijing
Saturday, March 7, 2009
15. Volatility – 2000-2008
Hardware growth outstripped human-ware available
3
Aviation Summit Beijing
Saturday, March 7, 2009
16. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
3
Aviation Summit Beijing
Saturday, March 7, 2009
17. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
New entry aircraft grounded, and crew demand became critical
3
Aviation Summit Beijing
Saturday, March 7, 2009
18. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
New entry aircraft grounded, and crew demand became critical
Crew training could not keep up
3
Aviation Summit Beijing
Saturday, March 7, 2009
19. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
New entry aircraft grounded, and crew demand became critical
Crew training could not keep up
Now facing contraction in global recession
3
Aviation Summit Beijing
Saturday, March 7, 2009
20. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
New entry aircraft grounded, and crew demand became critical
Crew training could not keep up
Now facing contraction in global recession
Already pilot layoffs in some regions
3
Aviation Summit Beijing
Saturday, March 7, 2009
21. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
New entry aircraft grounded, and crew demand became critical
Crew training could not keep up
Now facing contraction in global recession
Already pilot layoffs in some regions
Reduced pressure on training delivery, but increase in pilot mobility
3
Aviation Summit Beijing
Saturday, March 7, 2009
22. Volatility – 2000-2008
Hardware growth outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
New entry aircraft grounded, and crew demand became critical
Crew training could not keep up
ry
to
ri
Now facing contraction in global recession
er
rt
Already pilot layoffs in some regions
u
o
is
Reduced pressure on training delivery, but increase in pilot mobility
y
lit
ti
a
ol
V 3
Aviation Summit Beijing
Saturday, March 7, 2009
27. Seeing through the recession
5
Aviation Summit Beijing
Saturday, March 7, 2009
28. Seeing through the recession
Despite the downturn ahead, the training industry must look
through to the other side
5
Aviation Summit Beijing
Saturday, March 7, 2009
29. Seeing through the recession
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
Aviation Summit Beijing
Saturday, March 7, 2009
31. PILOT TRAINING is the best investment against
catastrophic accident risk (UK CAA latest research):
6
Aviation Summit Beijing
Saturday, March 7, 2009
32. PILOT TRAINING is the best investment against
catastrophic accident risk (UK CAA latest research):
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
Aviation Summit Beijing
Saturday, March 7, 2009
34. PILOT TRAINING is the best investment against
catastrophic accident risk (UK CAA latest research):
7
Aviation Summit Beijing
Saturday, March 7, 2009
35. PILOT TRAINING is the best investment against
catastrophic accident risk (UK CAA latest research):
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
Aviation Summit Beijing
Saturday, March 7, 2009
36. Overview of 2007 vs. 2006
Courtesy of IATA
Source: IATA Safety Report 2007
8
Saturday, March 7, 2009
37. Regional Rate: Western-built Jet Hull
Losses
Courtesy of IATA
Source: IATA Safety Report 2007
9
Saturday, March 7, 2009
39. 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
Aviation Summit Beijing
Saturday, March 7, 2009
41. 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
Aviation Summit Beijing
Saturday, March 7, 2009
43. 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
Aviation Summit Beijing
Saturday, March 7, 2009
44. 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
Saturday, March 7, 2009
57. Again, thanks to training?
Technical failure &
depressurisation
+
Well Trained crew
=
Successful
emergency descent
and landing
= SAFE OUTCOME
20
Aviation Summit Beijing
Saturday, March 7, 2009
58. equipment
selection
design
work
training conditions
procedures culture
Systemic factors
[Dr Rob Lee & Dr Kwok Chan]
Aviation Summit Beijing 21
Saturday, March 7, 2009
59. 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]
Aviation Summit Beijing 21
Saturday, March 7, 2009
60. Incident / Accident
The last defence
Pilots
Safety Barriers Airline ORG + /
TRAINING
Aviation Regulator
Aircraft Manufacturer
Courtesy Prof Reason 22
Aviation Summit Beijing
Saturday, March 7, 2009
61. Again the Swiss Cheese!
Incident / Accident
The last defence
Pilots
Safety Barriers Airline ORG + /
TRAINING
Aviation Regulator
Aircraft Manufacturer
Courtesy Prof Reason 22
Aviation Summit Beijing
Saturday, March 7, 2009
62. Again the Swiss Cheese!
Incident / Accident
The last defence
Pilots
Safety Barriers Airline ORG + /
TRAINING
Aviation Regulator
Aircraft Manufacturer
Flight Crew – our last line of defence
Courtesy Prof Reason 22
Aviation Summit Beijing
Saturday, March 7, 2009
77. But what is Competency?
26
Aviation Summit Beijing
Saturday, March 7, 2009
78. But what is Competency?
Flying Hours are experienced and applied in many ways, and are
no measure of competency
26
Aviation Summit Beijing
Saturday, March 7, 2009
79. But what is Competency?
Flying Hours are experienced and applied in many ways, and are
no measure of competency
Quote: “Thinking only hours means you don’t know what
competency is” Prof. Graham Hunt
26
Aviation Summit Beijing
Saturday, March 7, 2009
80. But what is Competency?
Flying Hours are experienced and applied in many ways, and are
no measure of competency
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
Aviation Summit Beijing
Saturday, March 7, 2009
85. The Training Equation
+
EXPERIENCE
27
Aviation Summit Beijing
Saturday, March 7, 2009
86. The Training Equation
+
EXPERIENCE TRAINING
27
Aviation Summit Beijing
Saturday, March 7, 2009
87. The Training Equation
+
EXPERIENCE TRAINING
” Education is the systematic, purposeful
reconstruction of experience” Anon
27
Aviation Summit Beijing
Saturday, March 7, 2009
90. Accident Rate & Growth
The historical airline Accident Rate is very low, but:
28
Aviation Summit Beijing
Saturday, March 7, 2009
91. Accident Rate & Growth
The historical airline Accident Rate is very low, but:
Doubling of
global fleet will
increase the
number of
accidents
28
Aviation Summit Beijing
Saturday, March 7, 2009
92. Accident Rate & Growth
The historical airline Accident Rate is very low, but:
Doubling of
The accident
global fleet will
RATE must be
increase the
further
number of
REDUCED
accidents
28
Aviation Summit Beijing
Saturday, March 7, 2009
97. BUT
30
Aviation Summit Beijing
Saturday, March 7, 2009
98. BUT
Resources & Quality
30
Aviation Summit Beijing
Saturday, March 7, 2009
99. BUT
Resources & Quality
$$ As costs come
under severe
pressure,
training
resources can
become static
or shrink
30
Aviation Summit Beijing
Saturday, March 7, 2009
100. BUT
Resources & Quality
$$ 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
Aviation Summit Beijing
Saturday, March 7, 2009
102. Flight to Quality – we have no choice
31
Aviation Summit Beijing
Saturday, March 7, 2009
103. Flight to Quality – we have no choice
Training process must be improved
31
Aviation Summit Beijing
Saturday, March 7, 2009
104. Flight to Quality – we have no choice
Training process must be improved
Resource constraints demand a
‘Flight to Quality’
31
Aviation Summit Beijing
Saturday, March 7, 2009
106. Quality of process is KEY
32
Aviation Summit Beijing
Saturday, March 7, 2009
107. 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
32
Aviation Summit Beijing
Saturday, March 7, 2009
114. 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
Aviation Summit Beijing
Saturday, March 7, 2009
115. 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
Aviation Summit Beijing
Saturday, March 7, 2009
116. 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
Aviation Summit Beijing
Saturday, March 7, 2009
117. Prevention or cure?
Accident Prevention; work to detect and correct Active Failures and
Latent Threats before they lead to a catastrophic outcome
REACTIVE
Accidents
Active Failures
of event >>
and Latent Serious incidents
Threats
Minor incidents
Severity
Normal operations
Frequency of event, Quantity of data >>
35
Aviation Summit Beijing
Saturday, March 7, 2009
118. Prevention or cure?
Accident Prevention; work to detect and correct Active Failures and
Latent Threats before they lead to a catastrophic outcome
REACTIVE
Accidents
Active Failures
of event >>
and Latent Serious incidents
Threats
Minor incidents
PROACTIVE
Severity
Normal operations
Frequency of event, Quantity of data >>
35
Aviation Summit Beijing
Saturday, March 7, 2009
119. 36
Aviation Summit Beijing
Saturday, March 7, 2009
120. The COST of REACTIVE!
of event >>
Severity
Frequency of event, Quantity of data >>
36
Aviation Summit Beijing
Saturday, March 7, 2009
121. 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
Frequency of event, Quantity of data >>
36
Aviation Summit Beijing
Saturday, March 7, 2009
126. 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
Aviation Summit Beijing 38
Saturday, March 7, 2009
127. To serve SMS with training, we need to
understand the threats:
39
Aviation Summit Beijing
Saturday, March 7, 2009
128. To serve SMS with training, we need to
understand the threats:
39
Aviation Summit Beijing
Saturday, March 7, 2009
130. 15 System Safety threats today
40
Aviation Summit Beijing
Saturday, March 7, 2009
131. 15 System Safety threats today
1. Global economic turmoil: ‘indiscriminate resource cutting’ - key
safety generators may be lost in the culling process
40
Aviation Summit Beijing
Saturday, March 7, 2009
132. 15 System Safety threats today
1. Global economic turmoil: ‘indiscriminate resource cutting’ - key
safety generators may be lost in the culling process
2. Reduced experience: Expansion has shrunk the average volume
and depth of experience of pilots and instructors
40
Aviation Summit Beijing
Saturday, March 7, 2009
133. 15 System Safety threats today
1. Global economic turmoil: ‘indiscriminate resource cutting’ - key
safety generators may be lost in the culling process
2. Reduced experience: Expansion has shrunk the average volume
and depth of experience of pilots and instructors
3. Pilot production pressure: Expansion & pilot mobility in crisis
adds unplanned pressure on training systems, impacting quality
40
Aviation Summit Beijing
Saturday, March 7, 2009
134. 15 System Safety threats today
1. Global economic turmoil: ‘indiscriminate resource cutting’ - key
safety generators may be lost in the culling process
2. Reduced experience: Expansion has shrunk the average volume
and depth of experience of pilots and instructors
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
Aviation Summit Beijing
Saturday, March 7, 2009
136. 15 System Safety threats today
41
Aviation Summit Beijing
Saturday, March 7, 2009
137. 15 System Safety threats today
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
Aviation Summit Beijing
Saturday, March 7, 2009
138. 15 System Safety threats today
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”
6. Automation: Modern airliner design has reduced operational risk, but
weakened traditional piloting skills when systems degrade
41
Aviation Summit Beijing
Saturday, March 7, 2009
139. 15 System Safety threats today
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”
6. Automation: Modern airliner design has reduced operational risk, but
weakened traditional piloting skills when systems degrade
7. Regulatory Lag: Rules take time to change; eg. Basic CPL licencing
standards of 1944 are still applied today
41
Aviation Summit Beijing
Saturday, March 7, 2009
140. 15 System Safety threats today
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”
6. Automation: Modern airliner design has reduced operational risk, but
weakened traditional piloting skills when systems degrade
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
Aviation Summit Beijing
Saturday, March 7, 2009
141. 42
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Saturday, March 7, 2009
142. 42
Aviation Summit Beijing
Saturday, March 7, 2009
143. 9. Training seen as back-office: Crew training, a significant non-line
cost, may be treated as a 'back office’ activity
42
Aviation Summit Beijing
Saturday, March 7, 2009
144. 9. Training seen as back-office: Crew training, a significant non-line
cost, may be treated as a 'back office’ activity
10. Shrinking resources: As operating costs have escalated,
commercial departments tend to view minimum regulatory standards
as MAXIMUM budgetary targets
42
Aviation Summit Beijing
Saturday, March 7, 2009
145. 9. Training seen as back-office: Crew training, a significant non-line
cost, may be treated as a 'back office’ activity
10. Shrinking resources: As operating costs have escalated,
commercial departments tend to view minimum regulatory standards
as MAXIMUM budgetary targets
11. Delayed effect of sub-optimal training: The impact of less effective
training may not be seen for years
42
Aviation Summit Beijing
Saturday, March 7, 2009
146. 9. Training seen as back-office: Crew training, a significant non-line
cost, may be treated as a 'back office’ activity
10. Shrinking resources: As operating costs have escalated,
commercial departments tend to view minimum regulatory standards
as MAXIMUM budgetary targets
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
Aviation Summit Beijing
Saturday, March 7, 2009
149. 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
Aviation Summit Beijing
Saturday, March 7, 2009
150. 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
Aviation Summit Beijing
Saturday, March 7, 2009
151. 44
Aviation Summit Beijing
Saturday, March 7, 2009
152. 44
Aviation Summit Beijing
Saturday, March 7, 2009
153. 15. Inadequate system measurement: leads to subjective opinion-
based judgment; ‘more of the same’ or new untested training
processes
44
Aviation Summit Beijing
Saturday, March 7, 2009
154. 15. Inadequate system measurement: leads to subjective opinion-
based judgment; ‘more of the same’ or new untested training
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
Aviation Summit Beijing
Saturday, March 7, 2009
155. 15. Inadequate system measurement: leads to subjective opinion-
based judgment; ‘more of the same’ or new untested training
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
Aviation Summit Beijing
Saturday, March 7, 2009
157. Threat & Error Management (TEM) provides a
useful framework in crew training & safety
45
Aviation Summit Beijing
Saturday, March 7, 2009
158. Threat & Error Management (TEM) provides a
useful framework in crew training & safety
TEM assumes that Threats & Errors are:
45
Aviation Summit Beijing
Saturday, March 7, 2009
159. Threat & Error Management (TEM) provides a
useful framework in crew training & safety
TEM assumes that Threats & Errors are:
Inevitable - part of the territory
45
Aviation Summit Beijing
Saturday, March 7, 2009
160. Threat & Error Management (TEM) provides a
useful framework in crew training & safety
TEM assumes that Threats & Errors are:
Inevitable - part of the territory
External conditions or events that must be managed during
normal, everyday flights, in order to maintain safety margins.
45
Aviation Summit Beijing
Saturday, March 7, 2009
161. Threat & Error Management (TEM) provides a
useful framework in crew training & safety
TEM assumes that Threats & Errors are:
Inevitable - part of the territory
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
Aviation Summit Beijing
Saturday, March 7, 2009
163. WHY & WHEN do we make errors?
Aviation Summit Beijing 46
Saturday, March 7, 2009
164. WHY & WHEN do we make errors?
We need to measure to find out
Aviation Summit Beijing 46
Saturday, March 7, 2009
165. WHY & WHEN do we make errors?
We need to measure to find out
e.g. in industry, the Six Sigma
process >>
Aviation Summit Beijing 46
Saturday, March 7, 2009
166. WHY & WHEN do we make errors?
We need to measure to find out
e.g. in industry, the Six Sigma
process >>
Define, measure, analyse, improve, control
Aviation Summit Beijing 46
Saturday, March 7, 2009
167. WHY & WHEN do we make errors?
We need to measure to find out
e.g. in industry, the Six Sigma Or in aviation terms:
process >>
Define, measure, analyse, improve, control
Aviation Summit Beijing 46
Saturday, March 7, 2009
168. WHY & WHEN do we make errors?
We need to measure to find out
e.g. in industry, the Six Sigma Or in aviation terms:
process >>
Define, measure, analyse, improve, control
Aviation Summit Beijing 46
Saturday, March 7, 2009
169. WHY & WHEN do we make errors?
We need to measure to find out
e.g. in industry, the Six Sigma Or in aviation terms:
process >>
Define, measure, analyse, improve, control
Aviation Summit Beijing 46
Saturday, March 7, 2009
171. 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
Aviation Summit Beijing
Saturday, March 7, 2009
175. 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)
Aviation Summit Beijing 49
Saturday, March 7, 2009
176. 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”
Aviation Summit Beijing 49
Saturday, March 7, 2009
180. Understanding WHY - Intentional Non-compliance
Predictors of Violation:
Courtesy Prof Patrick Hudson 51
Aviation Summit Beijing
Saturday, March 7, 2009
181. Understanding WHY - Intentional Non-compliance
Predictors of Violation:
Expectation Expectation that rules will have to be bent to get
the work done
Courtesy Prof Patrick Hudson 51
Aviation Summit Beijing
Saturday, March 7, 2009
182. Understanding WHY - Intentional Non-compliance
Predictors of Violation:
Expectation Expectation that rules will have to be bent to get
the work done
The feeling that one has the ability and experience
Powerfulness to do the job without slavishly following the
procedures
Courtesy Prof Patrick Hudson 51
Aviation Summit Beijing
Saturday, March 7, 2009
183. Understanding WHY - Intentional Non-compliance
Predictors of Violation:
Expectation Expectation that rules will have to be bent to get
the work done
The feeling that one has the ability and experience
Powerfulness to do the job without slavishly following the
procedures
Opportunities Seeing opportunities that present themselves for
short cuts or to do things ‘better’
Courtesy Prof Patrick Hudson 51
Aviation Summit Beijing
Saturday, March 7, 2009
184. Understanding WHY - Intentional Non-compliance
Predictors of Violation:
Expectation Expectation that rules will have to be bent to get
the work done
The feeling that one has the ability and experience
Powerfulness to do the job without slavishly following the
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
Courtesy Prof Patrick Hudson 51
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188. Emeritus Professor Bob Helmreich (University of
Texas), champion of LOSA & TEM, in October 2006:
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189. 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: -
Aviation Summit Beijing 53
Saturday, March 7, 2009
190. 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
Aviation Summit Beijing 53
Saturday, March 7, 2009
191. 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.”
Aviation Summit Beijing 53
Saturday, March 7, 2009
192. 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.”
Obvious? Yes; but real evidence from normal
operations
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193. One of the variables we can
control is training 54
Saturday, MarchBeijing
Aviation Summit 7, 2009
194. 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
195. RAISING THE BAR - TYPE RATING INSTRUCTORS
55
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196. RAISING THE BAR - TYPE RATING INSTRUCTORS
55
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197. 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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198. 56
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199. 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
56
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200. 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
56
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201. 57
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202. Training can never be perfect – there are
always areas to improve >
57
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204. MPL embodies best practice
58
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205. MPL embodies best practice
Despite some commentary suggesting a ‘failure’ of MPL
(due to recent MPL graduate job losses), MPL is: -
58
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206. MPL embodies best practice
Despite some commentary suggesting a ‘failure’ of MPL
(due to recent MPL graduate job losses), MPL is: -
the result of 6 years of industry development to replace an
outdated 60 year-old airline training process
58
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207. MPL embodies best practice
Despite some commentary suggesting a ‘failure’ of MPL
(due to recent MPL graduate job losses), MPL is: -
the result of 6 years of industry development to replace an
outdated 60 year-old airline training process
an ICAO approved programme and license
58
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Saturday, March 7, 2009
208. MPL embodies best practice
Despite some commentary suggesting a ‘failure’ of MPL
(due to recent MPL graduate job losses), MPL is: -
the result of 6 years of industry development to replace an
outdated 60 year-old airline training process
an ICAO approved programme and license
a set of powerful airline pilot training tools, demanding new
standards in the airline pilot training process
58
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209. MPL embodies best practice
Despite some commentary suggesting a ‘failure’ of MPL
(due to recent MPL graduate job losses), MPL is: -
the result of 6 years of industry development to replace an
outdated 60 year-old airline training process
an ICAO approved programme and license
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
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212. The instructors Art
Advanced training equipment will not fully
compensate for ineffective instruction
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213. The instructors Art
Advanced training equipment will not fully
compensate for ineffective instruction
An effective instructor can however compensate
for training equipment limitations
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Saturday, March 7, 2009
214. The instructors Art
Advanced training equipment will not fully
compensate for ineffective instruction
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
Aviation Summit Beijing 59
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217. Human Factors Training
Human factors remain central triggers in accidents and incidents
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218. 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!
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219. 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)
Aviation Summit Beijing 60
Saturday, March 7, 2009
220. 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)
A training objective is to instill continuous embedded awareness,
eg. TEM in MPL
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223. Training improvements summary
Enhanced Instructor training and oversight
1.
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Saturday, March 7, 2009
224. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
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225. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
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226. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
Driven by performance feedback
4.
Aviation Summit Beijing 61
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227. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
Driven by performance feedback
4.
Training devices tailoured to training task and learning phase (eg. APT
5.
Trainers)
Aviation Summit Beijing 61
Saturday, March 7, 2009
228. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
Driven by performance feedback
4.
Training devices tailoured to training task and learning phase (eg. APT
5.
Trainers)
Embedded human factors / TEM.
6.
Aviation Summit Beijing 61
Saturday, March 7, 2009
229. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
Driven by performance feedback
4.
Training devices tailoured to training task and learning phase (eg. APT
5.
Trainers)
Embedded human factors / TEM.
6.
Mandated uniforms in simulator training – raising crew fidelity
7.
Aviation Summit Beijing 61
Saturday, March 7, 2009
230. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
Driven by performance feedback
4.
Training devices tailoured to training task and learning phase (eg. APT
5.
Trainers)
Embedded human factors / TEM.
6.
Mandated uniforms in simulator training – raising crew fidelity
7.
Training driven from operations and safety sensing systems
8.
Aviation Summit Beijing 61
Saturday, March 7, 2009
231. Training improvements summary
Enhanced Instructor training and oversight
1.
More task-focussed, competency-based, quality embedded programmes
2.
Programme design for continuous improvement
3.
Driven by performance feedback
4.
Training devices tailoured to training task and learning phase (eg. APT
5.
Trainers)
Embedded human factors / TEM.
6.
Mandated uniforms in simulator training – raising crew fidelity
7.
Training driven from operations and safety sensing systems
8.
Aviation Summit Beijing 61
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232. 62
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233. For example:
Uniforms in
simulation
62
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234. For example:
Uniforms in
simulation
62
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235. For example:
Uniforms in
simulation
A zero cost
option - all crews
have uniforms!
62
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236. For example:
Uniforms in
simulation
A zero cost
option - all crews
have uniforms!
Matches crew
fidelity with
simulator fidelity
62
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237. 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
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238. 63
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239. The bottom line -Training
63
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240. The bottom line -Training
We are highly exposed to ineffective training
63
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241. The bottom line -Training
We are highly exposed to ineffective training
Airlines need to offer comfortable and safe air travel as a long term
profitable business plan
63
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242. The bottom line -Training
We are highly exposed to ineffective training
Airlines need to offer comfortable and safe air travel as a long term
profitable business plan
Resource flow must be maintained to the vital organs of safety
culture
63
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243. The bottom line -Training
We are highly exposed to ineffective training
Airlines need to offer comfortable and safe air travel as a long term
profitable business plan
Resource flow must be maintained to the vital organs of safety
culture
Effective crew training is an investment which protects safety
margins for years to come
63
Aviation Summit Beijing
Saturday, March 7, 2009
244. The bottom line -Training
We are highly exposed to ineffective training
Airlines need to offer comfortable and safe air travel as a long term
profitable business plan
Resource flow must be maintained to the vital organs of safety
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
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249. ‘Take-aways’
To avoid additional cost, we must optimise what we have
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Saturday, March 7, 2009
250. ‘Take-aways’
To avoid additional cost, we must optimise what we have
But to improve, we must measure!
Aviation Summit Beijing 65
Saturday, March 7, 2009
251. ‘Take-aways’
To avoid additional cost, we must optimise what we have
But to improve, we must measure!
Measurement embedded in the
training process, and instructor’s task
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252. ‘Take-aways’
To avoid additional cost, we must optimise what we have
But to improve, we must measure!
Measurement embedded in the
training process, and instructor’s task
TEM embedded in all training footprints
Aviation Summit Beijing 65
Saturday, March 7, 2009
253. ‘Take-aways’
To avoid additional cost, we must optimise what we have
But to improve, we must measure!
Measurement embedded in the
training process, and instructor’s task
TEM embedded in all training footprints
As QUANTITY shrinks, QUALITY must grow
Aviation Summit Beijing 65
Saturday, March 7, 2009
254. ‘Take-aways’
To avoid additional cost, we must optimise what we have
But to improve, we must measure!
Measurement embedded in the
training process, and instructor’s task
TEM embedded in all training footprints
As QUANTITY shrinks, QUALITY must grow
Aviation Summit Beijing 65
Saturday, March 7, 2009