Flight Data Monitoring, Risk, and Protecting Assets

FDM, Risk and Protecting your Assets
Sonya Tietjen
Principal, Safety Management Systems

4 March, Heli-Expo 2013: Las Vegas, NV
All rights reserved worldwide. Copyright © 2013 Gael Ltd.
Q-Pulse is a registered trademark of Gael Products Ltd. All rights reserved worldwide. Copyright © 2012 Gael Ltd.

Agenda
1. The Problem
2. The Solution
3. The Benefits

1. Risk Management
2. Flight Data Monitoring
3. Protecting Your Assets


NTSB Report
1. The flight crew made
numerous procedural errors
and deviations during the final
approach segment of the
VOR/DME approach.
2. The crew demonstrated poor
crew coordination during the
accident flight.
3. The flight crew was under
pressure to land.

Causal Factors - Primary
IHST 2006 (JHSAT)

Flight Crew

The Problem?


How accidents happen
Organization

Technology

Humans

Modified from J. Reason 1997

BowTieXP: Loss of Separation
Loss of Spacial
Awareness
Medical fitness and 6 monthly Simulator training including Maintenance of an effective Two Crew operations
tests. recovery from unusual look-out
attitudes Ref? - Reference to be added
Ref? - Reference to be added RAP 1 - xx
Ref? - Reference to be added

Flight crew mishandling
and mismanagement of
the flight
Compliance with procedures Effective cross cockpit Crew flight planning for other Multi crew ops including Training and testing (Line Training and testing (Base
and checklist communication aircraft operations in the challenge and response Checks) checks)
operational zone
OM Pt.8 - Unit Orders OM Pt.6 Sct.1 - Definitions, OM Pt.5 Sct.1.1 - Duties of TM Pt.4 - Operation Line TM Pt.4 Sct.1 - General
Rules and Requirements OM Pt.8.Sect 3.23 - Summary Captain and First Officer Training
to Offshore Operations TM Pt.4 Sct.1 - General
(AS332L1) H-02.01.01 Aircraft in
motion (1)

Aircraft System failures

MEL controls for limiting routine preventitive Repetitive defect Flight Manual Emergency
departures with maintenance management Check List actions
unsevicabilities
MS - Aircraft Mainteance MOE Pt.2 Sect.2.14 - Technical FM Sct.3 - Emergency
MEL - Minimum Equipment List Schedule record control Procedures

Ineffective Air Traffic
Management D - Aircraft In motion
'Airborne': HE-20E
GPS flight Tracking Provision of area information In field traffic communication Effective provision of area Loss of separation Airborne contact with
(NOTAMS) contol of air traffic with third party opposing traffic, Loss of
RAP 1 - xx OM Pt.2 Sct.1.3.4.10 - management
AIP.Vol 1. GEN 3.3 - Air Traffic Helicopter Operations aircraft aircraft and/or multiple
Services Personnel Manning AIP.Volume 2 - Aerodrome Identification of Opposing Establish Communication Take avoiding action fatality
(AD) traffic with opposing traffic
OM Pt.8.Sect 9 - Emergency C5 C5 C3 C5
SID Sect.04 - Listing of SID Sect.07 - Hazard Register Procedures
Interface Activities AIP.Vol 1 ENR 2 - Air Traffic
Services Airspace
Operations in adverse
weather
Incorrect avoiding action
Procedure (weather minima) Weather (Flight Operations Actual Weather Training (interpretation of taken
Limitations) Reports/Information weather information, and
Ref? - Reference to be added weather avoidance) Maintenance of Situational Installation and use of TCAS CAR 1996 and AIP
Ref? - Reference to be added RAP 2 - x Awareness requirements for standard
RAP 3 - xxx collision avoidance actions
OM Pt.2 Sct.12.34 - Adherence
To Operating Procedures and MCAR Pt.11 Chap.2 -
Co-Pilot's Responsibility Regulation of Movement Area
Failure to install available
safety improvement
system or to learn from
experience Equipment Standardisation Installation of Traffic
and acceptance checks avoidance systems (TCAS) Failure to establish
communications with
QAM.7.5 - HFDM Process RAP 4 - xxxxx opposing traffic
Common Frequency for Blind Call on Guard frequency
aircraft in the operational 121.5 MHz
zone
Failure to learn from
experience
HSE Management Review Occurrence reporting system QA Audit of line management Line management action to
Board process actions to resolve findings resolve findings
Ref? - Reference to be added Lack of visual
Ref? - Reference to be added Ref? - Reference to be added Ref? - Reference to be added meteorological conditions
(VMC)
Installation and use of TCAS Division of workload (handling Maintenance of Situational
and non-handling pilots) IMC Awareness
Non-compliance with RAP 3 - xxx and VMC
mandatory requirements OM Pt.2 Sct.12.34 - Adherence
(levels and distance) for OM Pt.6 Sct.2.3 - Division of To Operating Procedures and
seperation with third party Crew Duties During Flight in Co-Pilot's Responsibility
aircraft. Training and testing (Base Training and testing (Line Multi crew ops including Effective cross cockpit Multi crew ops including Compliance with procedures Organisational Discipline I.M.C.
checks) Checks) challenge and response communication challenge and response and checklist RAP 4 - xxxxx
TM Pt.4 Sct.1 - General TM Pt.4 - Operation Line OM Pt.5 Sct.1.1 - Duties of OM Pt.6 Sct.1 - Definitions, OM Pt.5 Sct.1.1 - Duties of OM Pt.8 - Unit Orders
Training Captain and First Officer Rules and Requirements Captain and First Officer
TM Pt.4 Sct.1 - General

Source: CGE Risk

Two tools for Flight Ops data

1. Safety Reporting



Safety Reporting


Breaching Defenses
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 accidents.”

J. Reason 1997


Risk Management

“Hazard and risk management
must be data-driven
and involve constant monitoring
to either eliminate
or reduce the risk to
as low as reasonably practicable.”

ICAO 2009, Doc 9859


Data
The data collected must be
systematic, cover all areas of the
operation, and have the ability to
measure the results of controls put
in place […to control risk].

Finally,
the focus must first be
on the area of highest risk.

ICAO 2009, Doc 9859


Flight Operations


Bottom Line: Flight Operations
1. Human Factors are the
primary cause of incidents and
accidents

2. Flight is the highest area of
risk in operations

3. Flight is the operation of which
we have the least amount of
information


Two tools for Flight Ops data

1. Safety Reporting

Only FDM is
comprehensive and quantifiable


The Solution: FDM
1. Records interaction between:
 the technology (aircraft)
 and the people (pilots)
2. Analyses interaction
 for specific events (reactive)
 undesirable trends (proactive)
3. So the organisation can do
something about it…


Safety Reporting + FDM = “W5s”
 FDM – W4’s:
1. Who*
2. What
3. Where
4. When

 Safety Reporting
5. Why


Organization

Technology

Humans

Modified from J. Reason 1997

The Good, the Bad, and the Ugly


Protecting Your Assets

 Organisation

 Technology

 Humans


Humans (The Clients)
 Complaint Management
 Turbulence
 Timing
 Airmanship
 Marketing
 Liability
 Risk Management
 Professionalism


Humans (The Employees)
 CEO
 Peace of mind from actually knowing
your aircraft are being operated in a
professional manner.
 False accusation
 Airspace breaches
 Low flying
 Poor airmanship
 Management Support
 Non-SOP Flying Requests
 Documents observations
 Procedures
 Equipment


Technology (The Aircraft)
 Pre-purchase / Pre-funding:
 Performance / Efficiency
 Proper handling
 Limits maintained

 MRO:
 Faulty Equipment
 Limits maintained / exceeded
 Warranty issues


Organisation (The Company)
 Return on Investment
 Protecting your Assets
 Marketing
 Promotion of SMS
 Risk Management
 Monitoring – Quality Assurance
 Ferry Flights
 Flight Operations
 Human Resources
 Continuous Improvement
 Training Programs
 Enhancement
 Validation
 Efficiencies
 Fuel efficiency
 Maintenance


FDM Resources
Global Helicopter Flight Data Monitoring Community
(www.hfdm.org)

International Helicopter Safety Team
(www.ihst.org)

UK Civil Aviation Authority - CAP 739
(www.caa.co.uk)


Wrap Up
 The highest risk to an
operation is Flight

 Without FDM, you really don’t
have quality assurance on
flight operations

 Implement FDM

FDM, Risk and Protecting your Assets
Sonya Tietjen
Principal, Safety Management Systems
SonyaT@GaelQuality.com

Flight Data Monitoring, Risk, and Protecting Assets

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