1. direction générale de lAviation civile sub-directorate for safety and airspace directorate for strategic and technical affairs 13-14 September 2005 Monitoring Normal Operations A European perspective Stéphane DEHARVENGT Head of Human Factors programme Presented by

2. - 2 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace Im a regulator, Im here to help !

3. - 3 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace A message from the JAA Human Factors Steering Group (HFStG) Regulators European organisations AEA, AEI, ITF, IFA, ECA, EAAPS, EAAP Active sub groups Active sub groups (including practitioners in the field) Certification & Design; Ops & Licensing; Maintenance Observers FAA-US, Boeing, Airbus

4. - 4 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace 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 …

5. - 5 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace A much more complex story… LOSA FDA ASAP Extract from: GAIN Asia-Pacific Regional Conference, Tokyo November 14-15, 2002 The Safety Triangle

6. - 6 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace The cast MANAGEMENTLINE PILOTS Flight Safety Officer / Safety Management System OPERATIONS Incidents, accidents FDM (FOQA) ASR Confidential reporting (ASAP) Survey Quality Assurance Training feedback Simulator or line checks

7. - 7 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace The untold story OPERATIONS Flight Safety Officer / Safety Management System Incidents, accidents FDM (FOQA) ASR Confidential reporting (ASAP) Survey Quality Assurance Simulator or line checks debriefings Training feedback MANAGEMENTLINE PILOTS Contacts with instructor or CRM trainer Jump seat observations INDIVIDUAL Crew discussions

8. - 8 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace 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. Natural Performance Threats Are the Context + internal threats

9. - 9 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace A precursor : The hole in the cheese E Error LC Latent condition D Deviation C Element of context Failure of a defense PRECURSOR ED C Practice + LC Context C C

10. - 10 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace Visibility Accidents Incidents P P P Operations / Production Sensors on demand or always active LC Requirements, Organization, Management LC E E D D E C C C REX ASR Informal feedback Line checks, etc… Investigation FDM Survey + - LC Failure of a defense P RECURSOR ED C Practice + LC Context C C several defenses Failure of LOSA A look at the cheese

11. - 11 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace 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 crew Analysis : 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 ELC C C CE E D

12. - 12 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace Some final ideas How 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

13. - 13 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace 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

14. - 14 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace To share lessons learned To exchange on different national/cultural contexts To converge towards international cooperation INVITATION

15. - 15 - 13-14 September 2005 direction générale de lAviation civile directorate for strategic and technical affairs sub-directorate for safety and airspace QUESTIONS ?