The Flight Operations Monitoring System:A Bundled Approach for Synergistic Safety Management

Jean-Jacques Speyer

Airbus Flight Operations Support1,Rond Point Maurice Bellonte

31707 Blagnac CedexFrance

jean-jacques.speyer@airbus.com

AbstractIn this paper, we describe the new Airbus approachfor integrated safety management. For any aircraftmanufacturer safety is the single most important as -pect of its business. Corporate shareholders, custom-ers and employees depend on it for the success of itsproducts and for continued allegiance to our brand.The most effective and strategic way to herald safetyis to establish, maintain and develop a positive safetyculture. (1) Several complementary programs andtools have been developed throughout the years, andseparately presented to customer airlines. These toolspertain to the Line Oriented Monitoring System, tothe Line Observation Assessment System and to theAircrew Incident Reporting System. Their overall aimwas to improve aircraft design, operations and proce-dures as well as training standards, both by means ofquantitative and qualitative data.

Introduction

Simply put, an Aerospace Manufacturer must be re-sponsible for the impact on safety of everything it doesand always keep in mind risks of incidents and acci-dents. Since safety ultimately depends on the aircraftin the field, the best leverage to reduce risks is ob-tained from enhancing airline flight operations them-selves. This indirect strategy is implemented by meansof dedicated instrum ents for airline safety measure-ments as flight operations are inevitably being dele-gated to Airbus customers. The contemporary view offlight safety management is to take into account riskexposure and manage the risk portfolio by means ofcontinuous measurements and comparisons by region,by period, by fleet, by routes and by safety issue.

The initial approach with individual tools was in-strumental in fostering the Airbus safety culture: it cre-ated a “bottom-up” spirit whereby a subsequent “topdown” management review helped generate an overall Copyright © 2002, American Association for Artificial

Intelligence(www.aaai.org). All rights reserved.

Airbus policy. We have now decided to merge depart-mental efforts in order to present a powerful, overallpolicy for line operations monitoring and safety en-hancement. This can be summarized around 2 axes:

• To provide airlines with a Flight Operations Monitor-ing package, including tools, methods and servicesto help enhancing their Flight Operations Standardsand Safety level:

- Airbus Flight Operations monitoring tools,

LOMS , LOAS and AIRS software,

- Handbooks to support Flight Operations methods andprocedure,

- Additional services for assistance to implementationby operators.

• To implement ways and means for data and informa-tion sharing between Airbus and Airlines for:

- Improvement of AIRBUS aircraft,

- Continuous improvement of SOPs and training,

- Feedback to the Airlines on lessons- learned in Safetyand Flight operations monitoring.We can really state that a positive/safety culture is

being instilled as this policy has received top man-agement endorsement and commitment with regard toits implementation. Shared beliefs, practices and atti-tudes have effectively been bundled around this policyof measuring and improving flight operations quality.Whilst similar initiatives may have been taken at vari-ous institutional, governmental or regulatory levels(ICAO, FAA, JAA, FSF, IATA), Airbus Industrie canstate that its measurement and data-driven approach isgoing to become an essential industry initiative to sup-port risk assessment and management. An innovativeapproach was adopted through event risk assessmentand safety management : this entails challenging exist-ing safety strategies linked to event families and riskdomains (flight operations, design, maintenance, load-ing, traffic) by revisiting their underlying beliefs andassumptions (qualitative approach by means of opera-tional analysis in trade-oriented approach) and by veri-

HCI-Aero 2002 9

From: HCI-02 Proceedings. Copyright © 2002, AAAI (www.aaai.org). All rights reserved.

fying the statistical distribution (quantitative approachby means of benchmarking in database-oriented ap-proach) of their confirmations or negations. In so doingwe will effectively delegate the instruments for meas-uring flight operations quality to the airline customersthemselves yet support them throughout to best distrib-ute and cascade efforts around.

Flight Operations Monitoring:The Airbus Concept

The purpose of a Flight Operations Monitoring programis to implement a prevention system undertaking cor-rective actions to avoid flight operations incidents toreap lessons learned from any occurrences.

Quantitative Information fromFlight Data AnalysisThis approach pertains to the routine collection andanalysis of flight data to provide more informationabout, and greater insight to, the total flight operationsenvironment. The aim is to provide a feedback forsafety management, raising to the surface errors andoperational deviations that can be considered as “pre-cursors” of accidents or incidents but which are not al-ways directly visible. This part of the Flight OperationsMonitoring system is also called FOQA (Flight Opera-tions Quality Assurance). FOQA is restricted to flightdata analysis.

• Flight data analysis requires equipping aircraft withspecialized devices (Quick Access Recorders,PCMCIA cards…) to systematically capture flightdata collected on the aircraft’s DFDR.

Data are processed in a centralized ground station, inorder to qualify and quantify deviations from standardoperating procedures and Company policies. These de-viations are then compiled in a database as events andthen statistically processed to produce reports perform-ing trend analysis and identifying potential risks.

Qualitative Information fromLine Operations Assessment Surveys

In line operations surveys crew performance is rated byCheck Captains, using standard evaluation sheets dur-ing Rolling Audits or line checks.

Evaluation sheets are compiled to produce statisticalreports on crew performance in:

• Crew resource management,

• Communication,

• Application of SOPs,

• Etc…

Besides the coincidental spelling similarity, theLOAS approach is in essence very close to the LOSAinitiatives currently being spurred in aviation safetycircles. LOSA acquires direct, first-hand data on thesuccessful recovery from errors by flight crews duringnormal line flights. It is aimed at collecting data onsuccessful human performance; and this is indeed afirst in our industry, since aviation has traditionally col-lected data on failed human performance, such as anaccident or incident investigation. Crews must not bemade to think that they are being given a check-ride.Observers are not to discipline or critique crews , theyonly collect data. LOSA data are confidential and de-identified to ensure anonymity.

Qualitative Information fromAircrew Incident Reporting SystemsCrew reporting provides the individual crewmember orcollective perception of the event occurrence and is anessential element to establish a diagnosis when lookingfor causes from symptoms. As technological advanceshave led to aviation product development, new ad-vances in information management and decision sup-port technologies have made possible improvements inaviation safety monitoring, analysis and alerting (2).Reportable occurrences are hence being systematicallytracked either for their direct safety content, either fortheir value as precursors. A reportable occurrence isunderstood to be any incident, fault, malfunction, de-viation or technical defect that endangers or could en-danger the safe operation of the aircraft or its occu-pants or which could lead to an unsafe condition in theaircraft.

We have hereby to distinguish between mandatoryand voluntary incident reporting. The mandatory chan-nel is obligatory, reports have to be submitted in nameof the whole cockpit crew and may be forwarded by theairline to the airworthiness authorities if safety hasbeen significantly threatened. The voluntary channel isvoluntary, reports may be submitted at the discretion ofan individual crewmember and could become invalu-able information if a safety hazard and/or safety pre-cursor was encountered, and also helping to understandwhy an event happened if safety was imperiled.

Confidentiality and BlameThe potential apportionment of blame is linked withthe cultural tendency to attribute guilt in the process ofdetermining the cause of an event (3). Local events arehereby unveiled linked with direct acting responsibili-ties, but they hide systemic human factors that did setthe stage behind the scene. Effective risk managementsystems can only operate successfully within an orga-

10 HCI-Aero 2002

nizational culture, which endorses and promotes feed-back and remediation. The key for an appropriate orga-nizational safety climate is management cooperationand commitment to blame-free reporting. Voluntarydisclosure should protect the organizations and indi-viduals from outright punitive actions by promoting ajust culture of accountability. Blame allocation bymanagement on the other hand precludes any chanceof seeing confidential safety reporting systems develop,as crew would simply abstain to divulge voluntary re-ports.

Risk Analysis and Decision-MakingA Flight Operations Monitoring System combines datawith other sources and with operational experience todevelop objective information to enhance:

• Training effectiveness,

• Operational procedures,

• Maintenance and engineering procedures,

• Air traffic control procedures.

44AIRBUS Flight Operations Monitoring Approach

MEASURE THE PERFORMANCEMEASURE THE PERFORMANCE

Trend AnalysisRisk AssessmentDecision making

What & Why

ANALYSE DATAANALYSE DATAOperationSafetyTraining

LAUNCH ACTIONSLAUNCH ACTIONS

Crewobservation

Flight CrewReporting

Flight Data Monitoring

(FOQA)

Analysis methodsAction plan

LOMS LOAS AIRS

Tools for detection of deviationsfrom normal operations

Training

assistance

Statistical report

Trend analysis

Risk assessment

Figure 1: The Flight Operations Monitoring Concept

The major and most critical step of a Flight OperationsMonitoring program is to perform a pertinent interpreta-tion of the results, and to decide upon the most appro-priate and efficient actions. This implies the establish-ment of accurate risk assessment methods and guide-lines for decisions based on detected risks.

Some basic keys toward success in the implementa-tion phase are (4):

• Top management commitment in endorsing a candidpro-active safety culture, heralding accountability incooperation with all organizational levels and in co-operation with relevant industrial associations (pi-lots, cabin staff, engineers, dispatchers, etc.),

• Crew cooperation is hereby fundamental and theprogram must actively demonstrate a non-punitivepolicy. The main objective of any Flight OperationsMonitoring program is to improve safety by identify-ing trends, not by divulging individual acts,

• An accurate identification of potential risks requiresthe correlation by experts of results coming from thethree types of tools,

• Only operational pilots experienced on the aircrafttype being analyzed and training to risk assessmentcan accurately diagnose shortcomings under the formof safety precursors or threats,

• The FOQA department has to focus on monitoringfleet trends aggregated from numerous operationsrather than pointing out specific events: the value ofusing aggregated FOQA data greatly exceeds that ofa single flight assessment when trying to determinethe root causes of systemic problems that need to becorrected,

• A well-structured de-identification system distribut-ing confidential information to relevant departmentsbut not sterilizing it to full anonymity,

• An efficient communication system is essential:while ensuring the confidentiality of data and theprotection of the pilots, it shall timely inform therelevant people on risk assessment, allowing them tolaunch adequate preventive and/or corrective ac-tions.

The Airbus Flight OperationsMonitoring Package

This package now includes:

• The three types of Monitoring tools,

• Handbooks detailing Flight Operations Monitoringmethods and techniques,

• Operational services for implementing Flight Opera-tions Monitoring, tailored to Operator’s needs.

Figure 2: The integrated FOMS Package

Monitoring Tools

The Flight Data Analysis (FOQA) Tool:

• To record what happened during the flights.

HCI-Aero 2002 11

• To process quantitative data extracted from theFlight data recorder to measure the deviations com-pared to standard flight path.

• To correlate data for trend analysis and fleet opera-tion assessment.

Figure 3: The Flight Operations Monitoring ConceptOverall Individual Exceedances by Phase of Flight

The tool proposed here is the LOMS (Line Opera-tions Monitoring System) which is an advanced com-puter program that uses the systematic routine down-load of Optical Quick Access Recorders to assistFOQA department in the daily monitoring of flight ac-tivity. This system provides statistical analysis withrisk assessment demonstrated in recorded deviationsfrom standard flight profiles. The output of LOMS proc-essing is a flight path monitoring, aircraft handling as-sessment and risk analysis on the fleet level and itscrew population as a group. This system covers the op-erations monitoring and feedback system in compli-ance with the promotion of risk awareness and themanaged FOQA program specified in JAR-OPS 1.037.It is also compatible with the FAA requirements onflight data management and system integrity topics (5).

Figure 4: Flight Profile Visualisation

Because the accurate definition of the deviationsfrom normal operations is a key element for a compre-

hensive flight data analysis, Airbus proposes its FlightProfile Specifications, to be integrated in any flightdata monitoring system. A Flight profile is the set ofreferences to which the flight data are compared in theflight data monitoring process. Each time the flightdata deviates from a reference value, an event is trig-gered.

Flight Profile Data. Because the accurate definition ofthe deviations from normal operations is a key elementfor a comprehensive flight data analysis, Airbus pro-poses its Flight Profile Specifications, to be integratedin any flight data monitoring system. A Flight profile isthe set of references to which the flight data are com-pared in the flight data monitoring process. Each timethe flight data deviates from a reference value, anevent is triggered.

The Flight Profile includes parameter filters, addi-tional parameter computation, and event detection al-gorithms. On a scale of risk, deviations from the stan-dard flight profile are classified into three severity lev-els allowing risk assessment of events and trends as abasis for remedial actions to be implemented:

• Low severity: yellow

• Medium severity: Amber

• High severity: red

The severity levels have been set to ensure compli-ance with the Flight Operations Regulations the air-craft limitations and the Airbus standard procedures.The events and deviations have been defined by opera-tional and flight engineers and has been validated dur-ing specific flight tests. They are finalized and vali-dated through thousands of flights in partnership withsome Airbus operators. The events triggered could besingle punctual events around 100 are monitored) aswell as potential risk situations resulting of the combi-nation of single events.

The following situations are currently monitored:

• Continuously Low during final

• Continuously Slow during final

• Continuously High during final

• Continuously Fast during final

• Continuously Steep during final

• Over Rotation at Take Off

• Under Rotation at Take Off

• Low Energy Take Off

• High Energy Take Off

• Tail Strike Risk at Take Off

• Low Energy Situation in Approach

12 HCI-Aero 2002

Figure 5: Flight Profile Analysis

• High Energy Situation in Approach Late Offset inShort Final

• Poor Bracketing on Final

• Roll Oscillations prior to Flare

• Wing Strike Risk at Landing

The standard flight profiles are implemented andoperational onLOMS. AIRBUS provides operators withthe standard Flight profiles specifications related to allthe configurations of Aircraft. Having the specificationsavailable allows the Airlines to program them in theirown flight data management system.

The Line Assessment Tool: The tool earmarked hereis the LOAS (Line Operations Assessment System).The Line Operations Assessment System is a computerprogram dedicated to collect, analyze and archive theobservations made by the Check Captains and CabinCrew Auditors trained to use a system of crew behaviornotation with a scoring method and key word descrip-tors. The resultant scores are used to evaluate patternsof group behavior as well as individual assessmentsappropriate to line check. LOAS compiles inspectionand evaluations of line activity in an active analyticalprocess. In an active mode, it provides the recom-mended rolling audit. The output is a cumulative seriesof scored evaluations of crew performance such as:

• CRM behavior

• Application of SOP’s

• Cabin crew interface

• Operations support

• Route infrastructure

LOAS (Line Operation Assessment Survey) uses theUniversity of Texas Data Collection Methodologycalled LOSA (Line Operation Safety Audit) and isbased on threat and error management as a most effi-cient means for risk precursor identification (6).

Figure 6: Statistical Reporting Analysis

The Aircrew Incident Reporting Tools: Beforecommitting itself, Airbus Industrie critically reviewedeight operational reporting approaches:

• BASIS, British Airways Safety Information System,

• ICAO ADREP, ICAO’s Accident/Incident Data Re-porting System

• ECC-AIRS, a pilot study on the feasibility of an ECreporting system,

• MORS, the Mandatory Occurrence System of theUK CAA,

• OASIS and SIAM of the former Bureau of Air SafetyInvestigation in Australia, now ATSB,

• CHIRP, the Confidential Human Factors IncidentReporting Program in the UK,

• ASRS, the Aviation Safety Reporting System fromNASA in the US,

• EUCARE, now extinct but formerly developed forthe European Community at the TU-Berlin,

These systems were found to vary according to sev-eral dimensions:

• objectives of the system,

• definition of “relevant event”,

• sophistication of the safety model,

• confidentiality,

• reporting format,

• coding and analysis systems,

• feedback and information transfer.

• The tool retained is the AIRS (Aircrew Incident Re-porting System) part of the BASIS Safety Informa-tion System developed by British Airways. AIRS caninterface with existing BASIS modules.

Initial AIRS Initially, AIRBUS INDUSTRIE convincedBritish Airways (7) to develop a human factors modulein 1996 (HFR). The objective of the voluntary reportingprocess linked with HFR was to collect and analyzeconfidential data to understand the latent or systemic

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conditions as well as the behavioral aspects behind op-erational events.

Figure 7: Process for Reporting Acknowledgmentand Analysis

Developed in cooperation with British Airways,AIRS initially vowed to introduce voluntary confiden-tial human factors reporting capability to better under-stand man-machine related events occurring in flight.The agreement enabled Airbus Industrie to distributethis module’s software free of charge to subscribing air-lines provided a license contract would be signed aftercourse delivery in Toulouse.

The supporting Windows software of HFR allows:

• Storing of the completed questionnaires from flight& cabin in a standardized way,

• Translating the raw data into useful information foranalyzing and updating,

• Human Factors filtering in order to identify trends.

AIRS does not have the trend analysis function built-in, but data could be treated with other tools. AIRSruns on any IBM compatible PC and Airbus offers as-sistance to administer the system through dedicatedcourses being run at its home base in Toulouse. Thebasic safety model of HFR is centered around thepromise that any crew action and/or behavior is medi-ated by the following four influences:

• Organizational influences, under the responsibility ofthe organization,

• Informational influences, likewise

• Personal influences, under the responsibility of theindividual(s) (him)(her)self/(themselves)

• Environmental, neither under control of the organiza-tion or of the persons involved.The course aims to deliver a language of 64 key-

words in association with software having the “lookand feel” of the other BASIS modules. The course andsoftware delivery does not commit airlines to have tosend reports back to Airbus. If the option to do this is

however taken, proper de-identification is recom-mended.

Lessons learned from initial AIRS Making an air-line-oriented system available to customers induced afeedback flow of contextual reporting constituted ofboth Air Safety and Human Factors reports, mostly per-taining to mandatory ones (about 90 % ASR’s) with asizable chunk of voluntary ones (10 % HFR’s).

Whereas we received 700 airline reports in severalsuccessive saccadic waves from 5 operators over thelast 2 years, we received also over 5000 Safety Infor-mation Exchange reports for directed empirical analy-sis.

Clearly, the ability to ask intelligent questions froma data set is the key to time-efficient and meaningfulincident analysis. This type of work cannot be carriedout by a database analyst unless he or she is also anaviation expert or has guidance from an expert. Nor canit be carried out by aviation experts unless they areknowledgeable in database manipulation and at leastbasic statistics. Both types of expertise are needed atthe manufacturer level to extract meaningful informa-tion from large data sets: complementary clinical andstatistical analyses have to coexist to trigger actionpoints as well as to enable filtering/sorting into mainoccurrence families.

As such, AIRS processing is promising but still re-source-heavy:

• There is a need for pre-filtering to sort out relevantevents and manage the flow ; this can be performedby the airline’s Airbus field representative,

• There is a desire to reinforce the existing In ServiceOccurrence process (ISO) with AIRS reports, pro-vided timely pre-filtering occurs, avoiding duplica-tion, complementing with human factors information; the ISO channel funneled by field representatives,is part of regular Line Oriented Follow Up (LOFU)and consists in the collection and analysis of in-service events (reported and potential events with aview towards traceable precursors) in order to per-form operations, maintenance and engineering-oriented feedback,

• There is a requirement for keyword analyses to groupSIE events into In Service Problem families to helpcorrelate events and derive intelligent questions.

Evolved AIRSWith this experience in mind the objective is to haveAIRS evolve into a system for better use of both airsafety and human factors reports. This will hinge on anagreement with British Airways to include ASR’s inthe AIRS package hereby uniting both mandatory(ASR-part) and voluntary (HFR-part) channels. It will

14 HCI-Aero 2002

also be important to include trending in the AIRSpackage and indications are that agreement will alsobe reached on this important point. But the biggest pro-gress will reside in the possibility to send both ASR’sand HFR’s to Toulouse as e-mail attachments if air-lines so choose and to give BASIS access to both theResident Customer Support Representatives and to AIengineers. Provided a proper confidential and effectivede-identification procedure is managed, this will resultin less retyping by the Airbus representative and to abetter visibility to airline safety reports. The BASISsystem is very popular because of its wide distributionand overall user friendliness. Hence, Airbus Industrie isresolutely oriented towards the evolved Aircrew Inci-dent Reporting System:

• For Airbus this will expand towards the possibility toconsult the ARS’s with the filtering and trendingfunctions of BASIS,

• For airlines this will expand possibilities to get use-ful lessons learned not only from Airbus but alsofrom operators themselves especially if a user com-munity for ASR/HFR reporting already exists.

• As with regard to implementation, if the ResidentCustomer Support Manager is given the BASIS soft-ware:

• He/she will get a better visibility of operator’s re-ports,

• He/she will use filtering/graphical functions,

• He/she will be able to efficiently download to Airbusheadquarters for swift feedback action.

Conclusion

The Airbus Policy on a comprehensive Flight Opera-tions Monitoring Package should pay a lasting contri-bution to breed safety cultures with its customers. Thepackaged approach makes more sense than the modu-lar one as it adds value to potential risk management.It is well aligned with contemporary safety initiativesseen at ICAO, at the FSF, at CAST and JSIT/JSAT. Itprovides a federated approach to inject lessons learned:

• For both airline and manufacturer’s return of experi-ence,

• For risk assessment activities and safety perform-ance metrics based on safety performance measure-ments and real operational performance data,

• Bridged across several safety package modules.It is also well in line with IATA whose STEADES

program is essentially airline-oriented, representing ourcustomers and also relying on a curtailed version of

BASIS, i.e. BASIS Lite. And it is well positioned toplay a distinct and significant role in the deployment ofa major world safety initiative, the Global Aviation In-formation Network, i.e. GAIN. GAIN promotes and fa-cilitates voluntary collection and sharing of safety in-formation by and among users in the international avia-tion community and amongst other accomplishments itwill:

• Foster the use of existing analytical methods andtools and the development of new methods and tools.

• Promote and facilitate the development and imple-mentation of systems to support the global sharing ofaviation safety information.Besides the promise for better return of experience in

the safety arena (design, operations & training), an-other added benefit not mentioned to now, valid forboth the airline customers and the manufacturer is abetter protection against liability and legal exposure.With this packaged approach aiming to implement apositive safety culture, Airbus has put in place aunique approach to help its customers decrease risks ofincidents and accidents.

As such the Flight Operations Monitoring System(FOMS) proposed by Airbus Industrie is fully in linewith contemporary safety ideas which provide an in-valuable contribution towards safety management bycross-linking safety information channels.

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