Direction générale de lAviation civile sub-directorate for safety and airspace directorate for...

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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I’m a regulator, I’m here to help !

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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


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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 …

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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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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

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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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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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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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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

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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

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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

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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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• To share lessons learned

• To exchange on different national/cultural contexts

• To converge towards international cooperation

INVITATION

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QUESTIONS ?

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