Pr

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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
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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/
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

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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

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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)

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Managing Safety DefensesMonitoring, checking and
maintaining
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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 (1995)
• A risk of runway collision (1999)
• A risk of mid air collision (2002)

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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 (1995)
• A risk of runway collision (1999)
• A risk of mid air collision (2002)

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Managing Safety DefensesMonitoring, checking and
maintaining
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In 2002 F/O safety report related to a non
consequence eventHe reported having initially
reacted the opposite way to a RA TCAS.
Managing Safety DefensesMonitoring, checking and
maintaining

• 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

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FDA (FOQA) algorithmDetecting and sharing
opposite response to TCAS
Managing Safety DefensesMonitoring, checking and
maintaining
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Managing Safety DefensesMonitoring, 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
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Managing Safety DefensesMonitoring, checking and
maintaining
Operations
Accidents
?

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

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Managing Safety DefensesDissemination 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.

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Dissemination of lessons learntComparing
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.
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Dissemination of lessons learntTaking 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 ?

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Dissemination of lessons learntImplementing
safety watch as SMS component

Space of precursors


























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Dissemination of lessonsImplementing 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

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Managing Safety DefensesAbout methodology
Altitude bust Runway Incursion, WB
error Aircraft system malfunction, Loss of
separation, etc.
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Managing Safety DefensesAbout 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 ?

Safety Watch
Control barriers
Recovery barriers
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Managing Safety DefensesThe 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

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Managing Safety DefensesGA 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 ?

• 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

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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 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

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Managing Safety DefensesGA 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?v8WNBxNoCO1Q
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Managing Safety Defenses High risk to high
reliability era through innovation
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Managing Safety DefensesA 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
•  

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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

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• Thank You