capt. b. de courville – air france – corporate safety departmentfsf iass– washington –...

Capt. B. de Courville – Air France – Corporate Safety Department FSF IASS– Washington – October 2013

For a better use of incident analysis and safety data

International Air Safety SummitFlight Safety Foundation

Capt. Bertrand de CourvilleWashington

31st October 2013


Worlwide Air Transport Safety Records (up to date)

Fatal accidents Multi-engine commercial aircraft Certified for more than 13 passengersSource: ASN - FSF http://aviation-safety.net/index.php/

Production Protection

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


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


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)


San Diego - 1978 - B727 – 2600 ft - Approach

Los Angeles – 1986DC9 – 6000ft - Approach



In 2002 … F/O safety report related to a non consequence eventHe reported having initially reacted the opposite way to a RA TCAS.

• 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



FDA (FOQA) algorithmDetecting and sharing opposite response to TCAS

3 sec pitch order opposite to RA

RA

t sec7 Consecutive sec

Sharing at a European level (Eurocontrol)



Airbus Safety Conference in Barcelona (2003)TCAS opposite response case presentedFDA algoritm offered to be sharedOne airline used it and found the same resultsThis became an industry issue and led to the TCAS 7.1

TCAS 7.0 TCAS 7.1

‘’Level Off’’



AccidentsOperations

Loss of control CFIT Mid air collision Runway collision Runway excursion Other damages/injuries (Flight)

Other damages/injuries (Ground)



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.

Managing Safety DefensesDissemination of lessons learnt


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.

Dissemination of lessons learntComparing Technical and Operational Events


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 ?

Dissemination of lessons learntTaking advantage of standardization


Surveys

FDM (FOQA)

Space of precursors

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Air Safety Reports

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* **SIB/SAFO

Dissemination of lessons learntImplementing safety watch as SMS component

LOSA


Dissemination of lessonsImplementing safety watch as SMS component

Internal monthly publication « safety watch »

Safety Promotion (awareness)Monthly Safety Publication

Hazard identificationMost significant events are

reviewed during Safety Action Groups Meeting

Summary (per accident families)


UC

UC

UC

UC

UC

UC

Undesired events

RunwayCollision

LOC

Other Damages(Ground)

CFIT

Mid-Air collision

Runway Excursion

Other Damages(Flight)

Control

What we must manage

DefensesRecovery

What we must manage

Altitude bustRunway Incursion, W&B errorAircraft system malfunction,

Loss of separation, etc.

Reporting channelsWhat we collect

Managing Safety DefensesAbout methodology


UC

UC

UC

UC

UC

UC

High RiskOperational

Events

RunwayCollision

LOC

Other Damages(Ground)

CFIT

Mid-Air collision

Runway Excursion

Other Damages(Flight)

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

Managing Safety DefensesAbout methodology


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

Managing Safety DefensesThe ARMS methodology as an example


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

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 continueBut 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



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?v=8WNBxNoCO1Q


Video 4

GA in Heavy

Rain


Managing Safety Defenses High risk to high reliability era through innovation

Weak transport system- Risk control based on individuals- Intensive training- Accident analysis

Safe transport system- Technology (acft & simulators)- Procedures,regulation, HF- Incident analysis

High reliability transport system- SMS: Beyond regulatory compliance- Evolution of training- Better use of safety data


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

Managing Safety DefensesA European (ECAST) Initative


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


Thank You

capt. b. de courville – air france – corporate safety departmentfsf iass– washington –...

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