direction générale de laviation civile sub-directorate for safety and airspace directorate for...
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direction générale de l’Aviation civile
13-14 September 2005
sub-directorate for safety and airspace
directorate for strategic and technical affairs
oint Aviation Authorities
Monitoring Normal OperationsA European perspective
Stéphane DEHARVENGTHead of Human Factors programme
Presented by
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
I’m a regulator, I’m here to help !
- 3 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
A message from the JAA Human Factors Steering Group (HFStG)
RegulatorsRegulators European organisationsEuropean organisations
AEA, AEI, ITF, IFA, ECA, EAAPS, EAAP
Active sub groupsActive sub groups (including practitioners in the field)
Certification & Design; Ops & Licensing; Maintenance
ObserversObservers
FAA-US, Boeing, Airbus
oint Aviation Authorities
- 4 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
General comments• « Normal operations monitoring » is a welcome addition in the
context of Safety Management Systems
• The idea is simple, but the implementation is complex– Must be useful to the airline safety management
– Must be adapted to the airline context (regulatory, social,…)
– No unique solution exists
The story behind the HFStG contribution …
- 5 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
A much more complex story…
LOSA
FDAFDA ASAPASAP
Extract from: GAIN Asia-Pacific Regional Conference, Tokyo November 14-15, 2002
The Safety Triangle
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
The cast
MANAGEMENT LINE PILOTS
Flight Safety Officer / Safety Management System
OPERATIONS
Incidents, accidents
FDM (FOQA) ASR
Confidential reporting (ASAP)
SurveyQuality
Assurance
Training feedback
Simulator or line checks
- 7 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
The untold story
OPERATIONS
Flight Safety Officer / Safety Management System
Incidents, accidents
FDM (FOQA) ASR
Confidential reporting (ASAP)
SurveyQuality
Assurance
Simulator or line checks debriefings
Training feedback
MANAGEMENT LINE PILOTS
Contacts with instructor or CRM trainer
Jump seat observations
INDIVIDUAL
Crew discussions
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
What is their message ?
• They speak about risk and PRECURSORS
• PRECURSOR ?– Pilot practice
– Context
– System defense vulnerability
• Each is telling a different story from their perspective– Frequency (FDM, survey)
– Details on operational context (informal feedback, « stories »)
– On demand or always active
““Angel” Performance vs.Angel” Performance vs.““Natural” PerformanceNatural” Performance
Threats Threats AreAre the Context the Context + internal threats
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
A precursor : The hole in the cheese
E Error
LC Latent condition
D Deviation
C Element of context
Failure ofa defense
PRECURSOR
E D CPractice
+LC
Context
CC
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
Visibility
Accidents
Incidents
P
P
P
Operations / Production
Sensorson demand
oralwaysactive
LC LC
Requirements, Organization, Management
LC
E
E D
DE
C
C
C
REX
ASR
Informal feedback
Line checks, etc…
Investigation
FDM
Survey
+
-
LC
LC
Failure of a defense
PRECURSOR
E D CPractice
+LC
Context
CC
several defensesFailure of
LOSA
A look at the cheese
- 11 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
How does it work ? An example :
79 similar cases : detection thanks to C/L or parameters surveillance during taxiing
Informal feedback (1 captain)
« Aborted take-off due to flaps config error »
Interview of the crewAnalysis : High probability of error
Questionnaire to line pilots
Instantiation of the risk : precursor = ( E + D + LC) + ( C + C )
Corrective action : task to be accomplished right after engine run-up
300 responses
+ Context: high workload during taxiign or interruption of the task
No action because of lack of feedback validity
E
LC
CC
C
EE
D
- 12 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
Some final ideasHow to make it work for you ?
• There is no such thing as A UNIQUE SAFETY method.
• You need to be aware of the strengths and weaknesses of your sensors (or lack of sensors).
• You need to address both management needs and pilot needs, because :– Management provides the resources to enable safety
– You cannot be safe without supporting your pilots to manage their own practices.
• Normal operations monitoring should be supported as a complementary objective, not as a specific tool (see next slide)
because it supports the process to understand professional practices
- 13 -
13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
Normal Operations Monitoring : Suggested principles
1. Structured method for collecting data on pilots’ activity during normal flights
2. Joint management / pilot association sponsorship
3. Voluntary crew participation
4. De-identified, confidential, and safety-minded data collection
5. Targeted data collection instrument
6. People accepted and trained, and calibrated for implementing the method
7. Trusted data collection site
8. Evaluation of data validity
9. Data derived targets for enhancement
10. Feedback of results to the line pilots
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
• To share lessons learned
• To exchange on different national/cultural contexts
• To converge towards international cooperation
INVITATION
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13-14 September 2005
direction générale de l’Aviation civile
directorate for strategic and technical affairs
sub-directorate for safety and airspace
oint Aviation Authorities
QUESTIONS ?