LETTER FORMAT Please don’t change page size Flybe SMS and Flight Data Analysis 21/05/2009 Captain Neil Woollacott

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 2 The Flybe Fleets Q400 E 195

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 3 Flybe Today  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  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. Flybe is Europe’s largest and most successful regional airline

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 4 The Company encourages all personnel to report any event which is considered to be in the interests of Flight Safety 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. THE COMPANY FOLLOWS A A JUST CULTURE How Flybe’s Safety Reporting System work’s

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 5 The Safety Coordinator will o Cross reference will the CAP382 o Determine the descriptor & Risk Crew will submit ASRs on SafetyNet Safety & Quality will submit EORs on SafetyNet Safety & Quality will submit GORs on SafetyNet Require additional information MORs Closures Closure Report is submitted onto the Public Summary No additional information required Investigation findings are submitted to the Safety/ Quality Department who reviews and completes a compliance check Fleet Managers CAA Aviation Services Cabin SafetyGround SafetyEngineeringFlight Safety 25/11/08 MORs ASRsEORsGORs Ground Safety Engineering The investigation is allocated an owner Safety Report Process

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 6 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 ed to the CAA Incidents are sent through SafetyNet as an 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 Air Safety Reporting Process

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 7 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.

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A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 9 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 Objectives and Goals of the Safety Management System 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) Postholder Safety Meetings (monthly) Flight Ops Maintenance Ground Ops Health and Safety Postholders, Safety Coordinators Department Managers (as required) Production Meeting Operating Board (monthly) Chief Operating Officer Flybe Group Board Flybe Safety Committee (Quarterly Oversight) Non-Exec Director Central Safety Management System

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 10 The Flybe Top 5 Safety Concerns FLYBE SAFETY PLAN Loading Errors Q400 Landing Gear Altitude Deviations Human Factors/Discipline Ground De-Icing Effectiveness 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 Medium & High Risk The probability that the company will have a high risk event is remote in 2009/10

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 11 HAZARD IDENTIFICATION EVALUATION OF SCENARIOS AND CONSEQUENCES QUANTIFY RISK DECISION MAKING IMPLEMENTATION AND MONITORING RISK ANALYSIS & ASSESSMENT DATA COLLECTION The core of the Product Safety Monitoring Process is the RISK ANALYSIS & ASSESSMENT. Risk Analysis & Product Safety Monitoring

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 12 P r i o r i t y No Safety Relevance Potential for Primary cause for an accident Causing Operational disturbance Eventual Reduction on Safety Margin Potential contributing factor of an Accident Safety Concern No Safety Concern 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. Establishing Safety Priorities

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 13 Severity Classification Probability Level x= RI + Level of control Reflects the uncertainty regarding assumptions made and the knowledge and control of the related technology. Severity Classification 1 – Minor (Slight reduction of safety margins) (Routine changes of flight plan) 2 – Major (Significant reduction of safety margins) (Reduction of crew ability to cope with situation) (Phisical effects / injuries to occupants) 3 – Hazardous (Large reduction of safety margins) (Crew cannot be relied upon to implement defenses) (Injuries / death of small proportion of occupants) 4 – Catastrophic (possible loss of airplane with multiple fatalities) Probability Level 5 – Frequent ( P  ) 4 – Probable ( to ) May occur one or more times during the operational life of each airplane of the fleet 3 – Remote ( to ) Unlikely to occur to each airplane, but may occur several times during the operational life of the fleet 2 – Extremely remote ( to ) Not expected to occur to each airplane, but may occur a few times during the operational life of the fleet 1 – Extremely improbable (P  ) Not expected to occur PRELIMINARY RISK INDEX CALCULATION Establishing Safety Priorities – Risk Index

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 14 P r i o r i t y No Safety Relevance Potential for Primary cause for an accident Causing Operational disturbance Eventual Reduction on Safety Margin Potential contributing factor of an Accident I n d e x Immediate Action Required Action for Risk Reduction Improve System Reliability Monitor Using the Risk Analysis Tool, each issue receives an index number, indicating the related priority. Establishing Safety Priorities A B C D E

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 15 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:

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 16 FDM Flight Data Monitoring

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 17 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

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 18 Why use FDM ? The Heinrich Pyramid FDM Incidents For every major accident there are several less significant accidents, hundreds of reportable incidents and thousands of unreported Occurrences FDM gives more detail on the incidents, encourages more consistent reporting and fills in the void that we know very little about

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 19 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

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 20 Typical Management Process Flight Data Flight Safety Manager Data Replay, Analysis and Verification Cross check BASIS Review Meetings: FSM, Fleet Training Mgr (all data de-identified) Changes to Procedures, Manuals, Training and Flight Safety Investigations Besafe Mag Telephone Crew

LETTER FORMAT Please don’t change page size REMOTE BASES Download To PC MAIN BASES Replay & Analysis System Back-up System WLAN The Ground-Based System WAN data transfer Maintenance & Development Program development

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 22 Analysis System

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 23 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

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 24 Benefits Pilot knowledge & skill Gaps in the training system Operating procedures Environmental operating limitations CRM Culture at remote operating bases

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 25 Feed Back - Training Another deep landing 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

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 26 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

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 27 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

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 28 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.

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 29 Q400 Trend

A4 FORMAT Please don’t change page set up to A3, print to A3 paper and fit to scale 30 Long Flare – Location

LETTER FORMAT Please don’t change page size THANK YOU