Aircraft Accident Prevention

1
Aircraft Accident Prevention
Sqdn Ldr Somchanok Tiamtiabrat
2
Reference

• Aviation Safety Program Management Handbook
• Technique of Safety Management

3
?????????

• ?.?.????? ???????????????
• ???????????????????? (?????????????????)
• ????????????????????(??????????????????)
• PHD.Candidate

4
?????????

• Diploma (DLI.) USA
• Flight Safety Officer USA
• Jet Engine Mishap Investigation USA
• OJT Aviation Safety OfficerUSA

5
?????????

• Air Force Safety Officer Singapore
• OSHA Workshop Singapore
• Emergency Management Australia
• Aircraft Accident Investigation NTSB
  USA

6
??????????

• ??????????????????? ???? 42 ?? 2541
• Safety Officer
• ????????????????????????
• ?????????????????????????????????????????

7
?????????

• ???????????????????????????
• ?????????????????????????????????????????????
• ????????????????
• ???????????????????????
• ????????????????????????????

8
?????????

• ???????????????????????????????
  ?????????????????????
• ????????????????????????????????
  ???????????????????
• ??????????????????????????????????????????????????
  ??????????????????????

9
???????????????

• ???????????????????????????????
  ??????????????????????????????????????????????????
  ?
• ?????????????????????????????????????????????
  ???????????????????????????????????????

10
Scope

• ???????????????????????????????
• ??????????????????????????????????????????????????
  ??????
• ????????????????????????????????
• ???????????????????????????
• ?????????????????????????
• ???????????????????????????????

11
Scope

• ??????????????????????????????????????????
• Case Study

12
???????????????

• ???????
• ???????????
• ??????????????? Basic ?????????????????????????
• ?????????????????????????
• ??????????????????????????????????????????????????
  ??????????????????????????????????

13
???????????????

• ?????????????
• ???????????????????????????????? Unsafe Uct
  ???????????? Unsafety Condition
  ????????????????????
• Human Factor Humen Error
• ???????????????????????????????????
• ????????????

14
Aviation Safety

• Involvement
• Aircrew
• Aircraft
• Airport
• Air Traffic Contral

15
Aviation Safety

• Aircrew
• Flightcrew
• Cabincrew
• Flight Training School
• Personnel Licensing

16
Aviation Safety

• Aircraft
• Design
• Fleet Selection
• Aircraft Maintenance
• Airworthiness of Aircraft
• Airworthiness Directive

17
Aviation Safety

• Airport
• Landside
• Runway Safety Area
• Aerodrome Design and Operation
• Facilitation

18
Aviation Safety

• Air Traffic Control
• Area Control
• Approach Control
• GroundTower Control
• Air Traffic Service

19
Aviation Safety

• ICAO
• Standard and Recommendation Practice
• 18 Annexs of Chicago Convention

20
Aviation Safety

• ????
• ???????????????????????????????????????????????
• ?????????????????????????????
• Safety Program ??????????????????????
• ????????????? ????? ??????? ??????????????????????
  ?????????????????????????????????????

21
Aviation Safety

• ????????
• ICAO ????????????????????????????????? Operators
  ???????
• ???????? Safety Management System SMS
  ??????????????
• Document 9859

22
Aviation Safety

• ????????
• ????? ????? ??????? ?????????????
  ?????????????????????????????????????????????
• Airport Safety Management System
• Air Traffice Service Safety Management System
• Airline Safety Management System

23
????????????????? (Define Safety)
24
????????????????? (Define Safety)
???????????

• ????????????????????
• ??????????
• ??????????????????
• ???????
• ???????????
• ??????
• ??????

25

• ????????????????????
• ?????????? ? ?????????????????????????
• ???????
• ??????????
• ????????????????
• ???????????????????????
• ??????????????????????????????????????????????????
  ???
• ?????????????????????????????????????????

26
????????????????? (Define Safety)
???????????
?????????????????????????????????????? ????
????????????????? ????????????????????? ??????????
?????????????

• ??????????

27
???????????

• ??????????????????

????????????????????????????????????? ?.?.????
?????????????????????????????????????????????????
?? ???????????????????????????????????????????????
?????????????????? ?????????????????????? ????????
?????????????????????????????????,????????????????
? ??????????????????? Substantial Damage
28
???????????

• ???????

????????????????????????????????????? ?.?.????
?????????? ????????? ????????????????? ?
?????????????????????????????????????? ????????
?????????????????? ????????????????????????????
???? ???????????????? ?????????
??????????????????? ? ??????????????????????????
?????????????????????????????????
29
????????????????? (Define Safety)
???????????
??????????????? Human Factor
?????????????????????????????????????????????????
???? ???? ??????????? ????????? ???????
????? ?????? ?????????? ???????????????? ???
????????????????????????????????????????????????
????????????????????? ???????????????
30
???????????
???????????????????
????????????????????????????????????? ?.?.????
????????? ???????? ???????????? ?????????? ?
?????????????????????????????????????????????
31
???????????
????????????
?????????????????? ? ???????????????????????????
???????????????????? ???????????????????????????
???????????????????????? ???????????????????????
?????????
32
???????????????????????????
33
Safety
34
Aviation Safety
35
Basic Conceptof Safety
36
Blood Priority
37
Safety First
38
Mission vs Safety
39
USAF Flight Class A Mishap Rates 1947-2002
Korean War
Vietnam War
Dessert Storm
Operation Enduring of Freedom
1947
1950
1970
1980
1960
1990
2000
40
Randomness of Damage and Injury
41
Aircraft Accident
42
First Fetal Accident in 1908 At Fort Myer Virginia
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
????????????????????????????????
48
Accident In Ramp
49
Aircraft Accident From Hydroplane
50
FOD
51
Bird Strike Near The Airport
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
Ground Accident At Taxi Way
56
C-141 Accident on The Ground ,Killed 84 troops
57
Aircraft Accident From Runway Incursion
58
Concord Accident Cause of FOD At The Runway
59
??????????????????????

• ?????????????????
• ??????????????????

60
?????????????????

• ???????????????? ????????????
• ???????? ??????? ????????????????

61
?????????????????

• ????????????????????????????????????
• ?????????????????????????

62
?????????????????????????????

• ??????????????????????????????????? Boeing 747
  ???????????? PANAM ????????????? Boeing 747
  ???????????? KLM
• ??????????? Los Rodeos ????? Tenerife
• ????? 27 ?????? 2520
• ????????????????????? 583 ??
• Panam ????????????? ?????? KLM ???????????????

63
?????????????????????????????

• ???????????????????????????????
• ????????????????????????????????
• ???????????????????????????????????????????
• ??????????????????????????????????????????????????
  ?
• ????????? Taxi back track ?????????????

64
??????????????????

• ?????????

65
????????? E.U. Bans Indonesian Airlines
Flights Thursday, Jun. 28, 2007 By AP/SLOBODAN
LEKIC
Indonesian airlines have been hit by a string of
accidents this year, leading the U.S. Federal
Aviation Authority in April to downgrade the
country's rating from its lowest category. Both
the FAA and the International Civil Aviation
Organization have warned that the country's civil
aviation procedures did not meet international
standards.
66
??????????????????

• ?????????
• ??????????????????????
• ??????????????????????
• ?????????????????

67
??????????????????

• ??????????????????????????????????????
• ???????????????????????????????????????
• ??????????????????????????????????????

68
??????????????????

• ????????????????????????????????????????????????

69
??????????????????

• ??????????????????????????
• Premium
• Deduction

70
??????????????????

• ????????????????????? ?????????????? ????????
• ??????????????????????????

71
??????????????????

• ?????????????????????

72
??????????????????

• ??????????????? ??????????????????
• ???????????????????????????????????
• ????????????????????
• ??????????????????????????????????????????????

73
?????? ???????
??????????????????????????????????????????????????
1 4
Military Aircraft AccidentCommercial Aircraft
More Than This
74
????????????????????????????????

• ??????
• ??????????????????????????????????????????????????
  ??? ??????????????????????????????????????????????
  ????????????????????????
• ??????????????????????????????????????????????????
  ????????????????????

75
??????????????????????????????????
76
Aircraft Accident Causation

• Man
• Machine
• Media
• Mission
• Management

77
??????????????????????????????

• Man ??
• Machine ???????????
• Media ???????????
• Mission ??????
• Management ?????????

78
??????????????????????????????

• Man
• ??????,?????????????,???????????????????????,
• ????????????????????????????
• ????????????????????????
• ?????????????????????????????
• ??????????????????????????????????????????

79
??????????????????????????????

• Man
• ????????????????????????
• ??????????????????????????????????????????????????
  ????????
• ????????????????,????????,????????????,???????????
  ????????????????????
• ????????? Human factor ???????????????????????????
  ?????????????????????????????????????????????

80
(No Transcript)
81
(No Transcript)
82
??????????????????????????????

• Machine
• ??????????,????????????????????????,????????????
  ??????????
• ???????????????
• ??????????????????????????

83
??????????????????????????????

• Media
• ??????????????????????????
• ????????? ???????????
• ?????????????????
• ???????
• ????????????????????????

84
??????????????????????????????

• Media , Medium
• ??????????????????????????
• ?????????????????????
• ???????????????????????????????

85
??????????????????????????????

• ?????????????????????
• ??????????????????????????????????????????
• ???????????????????
• ?????????,??,????????,????????

86
??????????????????????????????

• ??????????????????????????????????????????????
• ??????????????????????????????????????????????????
  ???????
• ??????????????????????????????
• ?????????????????????
• ?????????????????????????????????

87
???????????

• ??????????????
• ??????????????????? ?????????????????????????,
  ????????????????????
• ??????????????????????????? ????????????????????
  ????????????????????

88
??????????????????????????????

• Mission
• ??????????????????????????
• ????????????????????????????????????????
• ???????
• ?????????
• ??????????????????

89
(No Transcript)
90
??????????????????????????????

• Management
• ???????????????????????????
• ?????????????????
• ????????????????
• ?????????????????

91
????????????????????????
???????????????????
92
?????????????????????????
93
?????????????????????????
1. ??????????? 2. ???????????????????????? 3.
Life Change Unit Theory 4. Reason Model
94
?????????????????????????
??????????????????? ??????????????????????????????
??????????????????????????????????????????????????
??????? ????? Reason Model ???????????????????????
??????????????????????????????????????????????????
???? ?????????????????????????????????????????????
????
95
Heinrich Domino Theory (?.?.1920)
???????? ?????????
??????????? ???????
??????????
??????????
????????/???? ?????????????
96
Heinrich Domino Theory (?.?.1920)
???????? ?????????
??????????? ???????
??????????
??????????
????????/???? ?????????????
97
Heinrich Domino Theory (?.?.1920)

• 1.??????????????????????? ??? ???????????????????
• ?????????????????????? ??????????????????????????
• ??????????????????????????????
• ??????????? ??????????

98
Heinrich Domino Theory (?.?.1920)

• 2.????????????????????
• ?????????????????????????????????
• ???????????????????????????

99
Heinrich Domino Theory (?.?.1920)

• 3.????????????????????? ???? ?????????????????
• ???????????????????????????????????????
• ?????????????????????????????????

100
Heinrich Domino Theory (?.?.1920)

• ???????????????????????? ????????????????????
  ?
• ?????????????????????????
• ????????????????????????????????? ???
  ?????????????????
• ????????????????????? ?????????????????
  ????????????

101
???????????????????????? Heinrichs Triangle
Theory
102
????????????????????????Heinrichs Triangle
Theory

• ?????????????? ??????????????????????????
  ???????????????????????????????????
• ??????????????????????????????????????????????????
  ????????????????????????????
• ??????????????????????????????????????????

103
???????????????????????? Heinrichs Triangle
Theory
Accident
Incident
Hazard Unreported
104
????????????????????????Heinrichs Triangle
Theory

• ??????????????????????????????????????
• ??????????????????????????????????????????????????
  ???????? ???? ???????????????????????????????????

105
???????????????????????? Heinrichs Triangle
Theory
????????????????????
???????????
Accident

• ???????
• ?????
• ???????

Incident Report

• ???????
• ?????
• ???????

Hazard Report
106
?????????????????????????? Life
Change Unit Theory

• ????????????????????? ????????????????????????
• ????????????????????????????????????????????
• ??????????????????????????????????????????????
• ??????????????? ????? 2 ??
  ?????? LCU (life change unit) ???? 300
  LCU ?????? ????????????????????????????????? 79
  ??????????

107
?????????????????????????? Life
Change Unit Theory

• ????????? ????? LCU
• ?????????????????????? 100
• ??????????? 73
• ????????????? 65
• ????????????????????????? 63
• ?????????? ???????? 53
• ?????????? 50
• ?????????????????? 47
• ????????????? 200,000 ??? 31

108
Reason Model
Latent Failure
Active Failure
Reason Model ?????????????????????????????
??????????????????????????????????
??????????????????????????????????????????????????
?????
109
Reason Model
??????????
???????????????????????????
??????????????????????????????????????????????????
?????????????????????? ????
?????????????????????????????????????????????????

110
Unsafe Act

• ?????????????????

111
?????????????????????

• ???????????????????????????????????????
• ?????????????????????????
• ?????????????????????
• ??? Latent Failure

112
?????????????????????????????????????

• ???????????????? ?? ????????? ???????????????????
  
• ?????? ??????? ????????????? ??????????? ATC
  ?????????????????
• ???????????????????????????????? ????????????????
• ???????????????????
• ????????????? ?????????????????????????????????
  ???? ???? ???? ?????????????????
• ????????????????????????????????????????????????

113
1. ???????????????????????????????

• ?????????
• ????????????????????????????
• ?????????????????
• ???????? ??????????????
• ???????????????????????????
• ?????????
• ?????????????????????????????

114
2. ???????????????????????????????????????

• ?????????????????????????
• ?????????????????????????
• ???????????????????????????????????
• ??????????? ?????????? ????????????
• ??????????????????
• ?????????????????????????

115
3. ???????????????????????????????????????????????
?

• ??????????????????????????????????????????????????
  
• ???????
• ???????????
• ????????
• ???????????
• ??????????????????????????????
• Thermal stress

116
4. ?????????????????????????????????????

• ???????????????? ?? ????????? ???????????????????
  
• ???????????????????
• ?????? ??????? ????????????? ??????????? ATC
  ?????????????????
• ???????????????????????????????? ????????????????
• ????????????? ?????????????????????????????????
  ????
• ???? ???? ?????????????????
• ????????????????????????????????????????????????

117
4. ?????????????????????????????????????

• ????????????????????????????????????????????
• ?????????????????? ?????????????????????????????
• ???????
• ????????????
• ????????????????????????????????????????

???????????
118
Reason Model????????????????????????????????????
???????????????????????????????????????????????
?????????????????
119
???????????????????????????????????? Reason Model

• By
• Sqdn Ldr Somchanok Tiamtiabrat
• Aviation Safety Division

120
Aircraft Accident From Hydroplane
121
Date 23 September 1999Airline Qantas
AirwaysFlight No. 1Aircraft
B747-400Location Bangkok, ThailandFatalities
0407
122
Qantus ??????????

• ????????? Qantus ???????????????????? Boeing 747
• ???????????????
• ??????????????????????????????? ???????
• ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ? In Brace Position ??????????????????????????

123
Qantus ??????????

• ???????????????????
• ??????????????????????????????????????????????????
  
• ???????????????????????
• ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ??????? Flap ?????? Half Flap
• ??????????????????? Hydroplane ???????????????????
  ?

124
Qantus ??????????

• ???????????????????
• ???????????????????????????????????????????????
  200 ????
• ??????????????????????????????? Substantial
  Damage ???????????????????????????????

125
Qantus ??????????

• ATSB ??? Australia ???????????????????????????????
  ???????????????????? Reason Model
  ????????????????????????????????????????????

126
Qantus ??????????

• Unsafe Act
• ??????????????????????????????????????????????????
  ????????????????????
• ???????????????????????????????????????
  Hydroplane
• ???????????????????? Copilot ????????????????? Go
  around ????????? Captain ?????????????????????????
  ??????????????????

127
Qantus ??????????

• Pre Condition for Unsafe Act
• ????????????????????????????
• ????????????????????

128
Qantus ??????????

• Supervision
• ?????????????????????????????????????????????????
• ??????????????????????????????????????????????????
  ???????????????????????????????????????????????
• ??????????????????????????????????????????????????
  ?????????????????????????????? Hydroplane

129
Qantus ??????????

• Organization
• ??????????? ATSB ??????????????
• ?????????????????????????? Australia
  ?????????????????????????????? Safety System
  ????????????????????
• ATSB ?????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ??
• Organizational Factor

130
Qantus ??????????

• Organization
• ??????????????????????????????????????????????
  CASA ?????????????????????????????????????????????
  ????????????????????? Standard Operation
  Procedure ??? Qantus

131
Qantus ??????????

• Organization
• ????????????????????? CASA ???????????????????????
  Qantus ??????????????????????????????????????????
  ??????? ????????????? Half Flap
• ??????????????????????????????????????????????????
  ????????????????????????????????

132
???????????????????????????????

• Man
• Unsafe Act
• ???????????????????????????????????????????????
• ??????????????????????????????????????????????????
  ?????????????????????????????

133
Human Factor
134
Human Factor

• focuses on how people interact with tasks,
  machines (or computers), and the environment with
  the consideration that humans have limitations
  and capabilities. Often, human factors will study
  the human within the system to ensure that we
  understand the limitations of the human within
  the current structure, product, or process

135
???????????
??????????????? Human Factor

• ?????????????
• ??????????
• ??????????????????????????? ???? ???????????
  ????????? ??????? ????? ?????? ??????????
  ???????????????? ???
• ??????????????????????????????????
• ???????????????????????????????????

136
??????????????? Human Factor

• ??????????????????????????
• ???????????
• ?????????
• ???????
• ?????
• ??????
• ??????????
• ????????????????
• ??????????????????????????????????
• ?????????????????? ?????????????????

137
Human Error
138
Human Error

• Error
• ?? Result ????????????????????????????????????????
  
• Human Error ????????????????????

139
Human Error

• Human Error ????????????????????
• ??????????????????????
• ??????????????????
• ?????????????????
• ????????????????????

140
Human Error

• Human Error ????????????????????
• ???????????????????????????????????
• ?????????????????????????????????????
• ????????????????????
• ??????????????????????????????????

141
Human Error

• Human Error ????????????????????
• ????????????????????????????????????? Mistake
• ??????????????????????????????????????????????????
  ?????????? ?????????????????????

142
Human Error

• ??????????????????
• ?????????????????????
• ??????????????????
• ????????????????????

143
(No Transcript)
144
Human Error

• Mistake ???????
• ????????????? Knowledge Base
• ???????????????????? ????????????????? Rule Base

145
??????????????????? ??????????????????????????????
??????????????????????????????? Human Error
146
Human Error Prevention

• 2 approaches
• Engineer
• Administrative

147
Annual Departure and Flight Hours
148
Certified Jet Airplane (greater than 6,000 lbs)
149
Accidents and Fatallities
150
(No Transcript)
151
??????????????????????????????????????????
152
?????????????????????????

• ????????????????????????????
• ??????????????
• ???????????????????????
• ?????????????????????????

153
?????????????????????????

• ???????????????????????
• ???????????????????????????
• ??????????????????
• ????????????????????????????
• ???????????????????????????

154
?????????????????????????

• ???????????????????????
• ????????????????????????
• ???????????????????????????
• ????????????????????????????????

155
?????????????????????????

• ???????????????????????
• ?????????????????????????????????????????
• Reason Theory

156
?????????????????????????

• ???????????????????????
• Human Factor
• ???????????????????????????????
• ??????????????????????????????????????????????????
  ????????
• ?????????????????????????????????

157
?????????????????????????

• ?????????????????????????????????????????????????
• ??????????????????????????????????????????????????
  ?????
• ??????????????????
• ?????????????????

158
????????????????????????????

• ??????????????????????????? Passive Accident
  Prevention
• ??????????????????????????? Active Accident
  Prevention

159
?????????????????????????

• Aviation Safety System
• Before The Fact
• Identify
• Analyze
• Control The Method
• Evaluate

160
?????????????????????????

• Identify
• ???????????????????????????
• Unsafe Act
• Unsafe Condition

161
?????????????????????????

• Identify
• ???????????????????????????
• ?????????????????????
• ?????????
• ????????????
• ?????????
• Ect...

162
?????????????????????????

• Analyze
• ???????????????????????????
• ???????????????????????????????
• ????????????????????????????
• ???????????????????????
• ?????????????????
• ??????????????????????????????????????

163
?????????????????????????

• ???????????????????
• Analyze
• ???????????????????????????
• ????????????????????????
• ?????????????????????????????????????

164
?????????????????????????

• ???????????????????
• Analyze
• Operation Risk Management

165
?????????????????????????

• Control The Method
• ???????????????????????????????????????
• Enginnering
• Enforecment
• Education

166
?????????????????????????

• Control The Method
• ???????????????????????????????????????
• ????????????? ???????? ??????????
• ?????????????? ???????
• ??????????????????
• ????????????????????????????????

167
?????????????????????????

• Control The Method
• Evaluate
• ??????????????????????
• ???????????????????????????????????????????????
• ????????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????????

168
??????????????????????????????????????????

• Identify
• Analyze
• Control

Identify
Analyze
Control
169
??????????????????????????????????????????

• Safety Management System
• Structure
• Responsibility
• Safety Officer
• Committee

170
??????????????????????????????????????????

• Safety Management System
• Reporting system
• Audit
• Training Program
• Safety Analysis and Statistics
• Emergncy Response
• Accident Investigation