Transcript Flybe SMS and Flight Data Analysis

Flybe SMS and Flight Data Analysis
21/05/2009
Captain Neil Woollacott
The Flybe Fleets
E 195
Q400
2
Flybe Today
Flybe is Europe’s largest and most successful regional airline
 Serving 13 countries;
 Over 190 routes flown;
 Operating from 36 UK and 30 European
airports;
 Largest airline at 9 UK airports by flights;
 7.5m passengers 2008.
 Revenues of £536m in 2007/08, record
profits of £35.4 million.
 Fourth most spontaneously recalled
aviation brand in the UK;
 Operating 73 Aircraft;
 Over 500 flights a day.
3
How Flybe’s Safety Reporting System work’s
The Company encourages all personnel to
report any event which is considered to be
in the interests of Flight Safety
THE COMPANY FOLLOWS A
A JUST CULTURE
SafetyNet is a tool that enables pilots to
submit safety reports which come through to
the flight safety department where we can
quickly access the details and begin
investigations.
4
Safety Report Process
Safety & Quality will submit
GORs on SafetyNet
Crew will submit ASRs on
SafetyNet
Safety & Quality will submit
EORs on SafetyNet
The Safety Coordinator will
o Cross reference will the CAP382
o Determine the descriptor & Risk
MORs
CAA
The investigation
is allocated an owner
GORs
EORs
Ground Safety
Engineering
Flight Safety
Cabin Safety
ASRs
Fleet Managers
Ground Safety
Engineering
Flight Safety
Aviation Services
Investigation findings are submitted to the Safety/ Quality Department who reviews and completes a compliance check
Require additional information
No additional information required
Closure Report is submitted onto the Public Summary
25/11/08
5
MORs
Closures
Air Safety Reporting Process
Crew Complete an ASR
Central Safety will determine which department the ASR will go to
and then cross reference it with the CAP 382 to establish whether it
is reportable under the MOR scheme
MOR reports are emailed to the CAA
Incidents are sent through SafetyNet as an e-mail in a
PDF format to the relevant external investigator e.g.
ATC .
Providing that we have all the details a full investigation is
carried out. Notes and action responses are entered into
SafetyNet
When flight safety is satisfied that an investigation is complete,
it is closed
6
SafetyNet
Full electronic reporting system
Fully transportable
Easy to use
Full audit trail
Full trend facilities
Use at remote locations
Direct link with Flight Data System
Many default form types e.g Airprox,Birdstrike.
Approved Use by the CAA.
7
8
Objectives and Goals of the Safety Management System
Ensure that everyone understands safety responsibilities.
Develop and maintain a culture of safety
Equip people to carry out their tasks safely
Identify and minimise risks to safety and health
Develop safe systems of work
The Company promotes safety with others
Plans to mitigate the consequences of Accidents & other emergencies
Monitor safety performance
Central Safety Management System
Postholder Safety
Meetings (monthly)
Flight Ops
Maintenance
Ground Ops
Health and Safety
Postholders,
Safety Coordinators
Department Managers (as
required)
Operational Safety Meeting
(monthly)
Chair : Director Safety, Quality
& Training
Vice Chair : Head of Safety &
Quality
Director Aircraft Operations
Director Aviation Services
Post Holders
Safety Coordinators
HS&E Director
SMS Admin
Chief Officer (as required)
9
Production Meeting
Operating Board
(monthly)
Chief Operating Officer
Flybe Group
Board
Flybe Safety
Committee
(Quarterly Oversight)
Non-Exec Director
The Flybe Top 5 Safety Concerns
On analysing the safety statistics the Operational Safety Meeting have complied five key areas that
pose the highest safety risk to the company.
Flybe intends to focus on these key areas during 2009/10 within the Safety Plan
Human Factors/Discipline
Ground De-Icing
Effectiveness
Loading Errors
Q400 Landing Gear
FLYBE
SAFETY PLAN
Altitude
Deviations
Medium & High Risk
The probability that the company will have a high risk event
is remote in 2009/10
10
Risk Analysis & Product Safety Monitoring
DATA COLLECTION
HAZARD IDENTIFICATION
EVALUATION OF SCENARIOS
AND CONSEQUENCES
RISK ANALYSIS
& ASSESSMENT
QUANTIFY RISK
DECISION MAKING
IMPLEMENTATION
AND MONITORING
The core of the Product Safety
Monitoring Process is the RISK
ANALYSIS & ASSESSMENT.
11
Establishing Safety Priorities
Potential for Primary
cause for an accident
Potential contributing
factor of an Accident
The traditional approach divided the issues
into Safety Concern and No Safety Concern
categories. This approach is very subjective
and does not establish priorities for safety
related issues.
Eventual Reduction
on Safety Margin
Safety
Concern
Causing Operational
disturbance
No Safety
Concern
No Safety Relevance
12
Establishing Safety Priorities – Risk Index
Severity Classification
x
+
Probability
Level
Severity Classification
Level of
control
Probability Level
1 – Minor
(Slight reduction of safety margins)
(Routine changes of flight plan)
5 – Frequent ( P  10-3 )
=
RI
Reflects the uncertainty
regarding assumptions
made and the knowledge
and control of the related
technology.
4 – Probable ( 10-3 to 10-5 )
May occur one or more times during the operational life of each
airplane of the fleet
2 – Major
(Significant reduction of safety margins)
(Reduction of crew ability to cope with situation)
(Phisical effects / injuries to occupants)
3 – Remote ( 10-5 to 10-7 )
Unlikely to occur to each airplane, but may occur several times
during the operational life of the fleet
3 – Hazardous
(Large reduction of safety margins)
(Crew cannot be relied upon to implement defenses)
(Injuries / death of small proportion of occupants)
2 – Extremely remote ( 10-7 to 10-9 )
Not expected to occur to each airplane, but may occur a few
times during the operational life of the fleet
4 – Catastrophic
(possible loss of airplane with multiple fatalities)
1 – Extremely improbable (P 10-9 )
Not expected to occur
PRELIMINARY RISK INDEX CALCULATION
13
Establishing Safety Priorities
14
Potential for Primary
cause for an accident
13
A
12
11
Potential contributing
factor of an Accident
10
9
Using the Risk
Analysis Tool, each
Immediate
Action
issue receives an
Required
index number,
indicating the related
priority.
B Action for Risk
Reduction
8
Eventual Reduction
on Safety Margin
7
C
6
5
Causing Operational
disturbance
4
3
No Safety Relevance
2
14
Improve System
Reliability
D
E
Monitor
Time-Reference Table for Action Planning
Using the RI, the safety priority of each issue can be directly perceived by all
involved areas of the company using a Time-Reference chart:
Immediate Risk
Reduction
Risk Reduction
RI
Define Action
System
Review
14
13
12
11
10
9
8
12
2
3
1
2
3
6
hours days
days
Months Months Months Months
Action
24
4
1 week 2
3
6
18
Availability
hours days
Months Months Months Months
Time for Action Next
Accomplishment Flight 50 FH 100FH A*- 5A* 5A*- C* 1 C*
2 C*
* Consider the equivalent to the “A” or ”C” check flight hour interval for the applicable fleet
15
FDM
Flight Data Monitoring
16
What Is FDM ?
Definition
“A systematic method of accessing, analysing
and acting upon information obtained from digital
flight data records of routine operations
to improve safety”
FDM involves the pro-active use of flight data
to identify and address operational risks before
they can lead to incidents and accidents
17
Why use FDM ?
For every major accident there
are several less significant
accidents, hundreds of
reportable incidents and
thousands of unreported
Occurrences
The Heinrich Pyramid
Accidents
Incidents
FDM Incidents
Unreported
Occurrences
FDM gives more detail on the
incidents, encourages more
consistent reporting and
fills in the void that
we know very little about
18
Important Ingredients
Important ingredients
A non-punitive company policy/open safety culture
The Flight Safety Manager must be
Trusted by crews to be impartial and maintain confidentiality
Supported and trusted by management
The system and its technology will be worthless
(or destructive) if the human factors are wrong
19
Typical Management Process
Flight
Data
Telephone
Crew
Besafe
Mag
Flight Safety Manager
Data Replay, Analysis
and Verification
Cross check BASIS
Changes to
Procedures,
Manuals, Training and
Flight Safety
Investigations
Review Meetings:
FSM, Fleet Training Mgr
(all data de-identified)
20
The Ground-Based System
Program development
REMOTE BASES
MAIN BASES
WAN
data
transfer
Download To PC
Maintenance
&
Development
WLAN
Replay & Analysis
System
Back-up
System
Analysis System
22
Flight Data Analysis
Event analysis
Detects exceedences of pre-defined operational
envelopes and provides information on the
extremes of the operation.
Measurement analysis
Takes a set of measurements on every flight
and provides information on the whole
operation – quantifies normality
23
Benefits
Pilot knowledge &
skill
Environmental
operating
limitations
Gaps in the
training system
CRM
Culture at remote
operating bases
Operating
procedures
24
Feed Back - Training
FDM lessons can be fed back into the
training process
Information can identify areas for
improvements in training
Events can be used to highlight key
safety-related points
Data can be used to improve pilot techniques
Another deep landing
25
Feed Back - Engineering
Enables continuous checking of FDR parameters
Data can be used to troubleshoot pilot reported problems
(e.g. event created to trap intermittent engine fault)
Data can be used to assess structural
impact of events (e.g. hard landing)
Data can be used to detect misuse
which could impact reliability
26
Summary
FDM provides valuable information on the
risks associated with new areas of operation
Events can identify hazards which otherwise
may not come to light
The Company can take appropriate corrective
and preventative measures
27
Summary
The measurements will build a useful picture
of everyday operations which has not previously
been available
The FDM programme gives us a pro-active
use of flight data which significantly enhances
the safety of our operation.
28
Q400 Trend
29
Long Flare – Location
30
THANK YOU