Présentation PowerPoint - Flight Safety Foundation

Présentation PowerPoint - Flight Safety Foundation

For a better use of incident analysis and safety data International Air Safety Summit Flight Safety Foundation Capt. Bertrand de Courville Washington 31st October 2013 Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Worlwide Air Transport Safety Records (up to date) Fatal accidents Multi-engine commercial aircraft Certified for more than 13 passengers Source: 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 Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Less catastrophic accidents Challenges 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 Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, 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) Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining Three significant safety case studies related to three different risks and corrective actions A risk of loss of control (1995) A risk of runway collision (1999) A risk of mid air collision (2002)

Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining Three significant safety case studies related to three different risks and corrective actions A risk of loss of control (1995) A risk of runway collision (1999) A risk of mid air collision (2002) Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining San Diego - 1978 - B727 2600 ft - Approach Los Angeles 1986 DC9 6000ft - Approach

Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining In 2002 F/O safety report related to a non consequence event He 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

Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining FDA (FOQA) algorithm Detecting and sharing opposite response to TCAS RA 3 sec pitch order opposite to RA t sec 7 Consecutive sec Sharing at a European level (Eurocontrol) Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013

Managing Safety Defenses Monitoring, checking and maintaining Airbus Safety Conference in Barcelona (2003) TCAS opposite response case presented FDA algoritm offered to be shared One airline used it and found the same results This became an industry issue and led to the TCAS 7.1 TCAS 7.0 TCAS 7.1 Level Off Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses Monitoring, checking and maintaining Operations

Accidents Loss of control CFIT Mid air collision Runway collision Runway excursion Other damages/injuries (Flight) Other damages/injuries (Ground) Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013

Managing Safety Defenses Dissemination of lessons learnt 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. Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Dissemination of lessons learnt Comparing Technical and Operational Events 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. Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Dissemination of lessons learnt Taking advantage of standardization 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 ? Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Dissemination of lessons learnt

Implementing safety watch as SMS component * * * * * * ** * * * ** * * * * * * * * * * * * LOSA *

* * * * * * * * * * *** * * * * * * * * * Surveys *

* * Space of precursors SIB/SAFO ? Capt. B. de Courville Air France Corporate Safety Department Air Safety Reports FDM (FOQA) FSF IASS Washington October 2013 Dissemination of lessons Implementing safety watch as SMS component Internal monthly publication safety watch Summary (per accident families)

Safety Promotion (awareness) Monthly Safety Publication Hazard identification Most significant events are reviewed during Safety Action Groups Meeting Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses About methodology What we must manage What we must manage Control Defenses Recovery Reporting

What we channels UC collect UC UC UC UC UC Undesired events Altitude bust Runway Incursion, W&B error Aircraft system malfunction, Loss of separation, etc. Capt. B. de Courville Air France Corporate Safety Department

LOC CFIT Runway Collision Mid-Air collision Runway Excursion Other Damages (Flight) Other Damages (Ground) FSF IASS Washington October 2013 Managing Safety Defenses About methodology 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 ? LOC

UC CFIT UC Safety Watch UC High Risk Operational Events UC Runway Collision Mid-Air collision Runway Excursion

UC UC Other Damages (Flight) Control barriers Capt. B. de Courville Air France Corporate Safety Department Recovery barriers Other Damages (Ground) FSF IASS Washington October 2013 Managing Safety Defenses The ARMS methodology as an example 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

Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses GA decision: a critical safety barrier 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 ? Degraded visibility at low height Not stabilized at 1000/500 floor Wind above limits Severe turbulence Destabilized at low height EGPWS Sink rate or Pull Up Wake turbulence Windshear

Tail wind and wet/contam. rwy Deep landing Instrument failures (in IMC) Runway occupied Bounced landing Runway/airport confusion Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses GA 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 continue But 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 Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 Managing Safety Defenses GA decision: a critical safety barrier 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 Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013 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 Capt. B. de Courville Air France Corporate Safety Department

FSF IASS Washington October 2013 Managing Safety Defenses A European (ECAST) Initative 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 Capt. B. de Courville Air France Corporate Safety Department FSF IASS Washington October 2013

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

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