onsdag 4. november 2015

Kebnekaiseulykken tatt opp på Flight Safety`s IASS 2015


Tuesday, November 3 

Day two in Miami...

We hope that you all enjoyed the fantastic opening reception last night sponsored by Airbus. Nobody wanted to leave when they had to end the music and the night ended. Thank you very much to Airbus for hosting such a wonderful evening!



Please join us in thanking our other day two sponsors: Turkish Airlines for breakfast, Gulfstream for the morning break, the wonderful lunch from Embraer, and Airworks for our afternoon break.

Immediately prior to the morning break, we had the opportunity to present the FSF-Airbus Human Factors in Aviation Safety Award to Tony Kern, CEO of Convergent Performance. It is always a pleasure to recognize excellence in aviation safety. For all the information about this award, please click here.

Jon Beatty, Tony Kern and Craig Hoskins of Airbus


Thanks again to our day two sponsors!

 





 
Session III - Training and Operations 
"Resilience: An Industry Perspective"
We started Session III on Tuesday morning with a presentation from Harry Nelson, executive operational advisor to Product Safety, Airbus, on resilience in the aviation industry. This resilience is about people and is very dependent on the type of leadership in the organization. Nelson shared the story of a former CEO of Alcoa and something he said: "Safety should never be a priority - it should be a pre-condition. It's like breathing." Nelson demonstrated how to model a resilient pilot with a pyramid concept and how when threats, errors, distraction, startle or fatigue impact a pilot, it can lead to cascading systemic failures until something checks that cascade - resilience can help with that. Nelson summarized one of the challenges with developing resiliency in your organization is the relative rarity of serious incidents so that there are fewer opportunities to learn from these incidents. The use of data collection and analysis from normal operations is imperative to help provide more learning opportunities.

Flight Data: Then, Now and Coming Soon"

In the context of many oversimplified news media reports in the wake of aircraft disappearances stating that fixed digital flight data recorders (DFDRs) are obsolete technology and that emergency locator transmitters are ineffective in locating such aircraft (because that is not their purpose), technical realities of substituting deployable DFDRs or rapidly evolving real-time telemetry solutions are more complex than even aviation safety professionals may realize, said Mike Poole, CEO, Plane Sciences.
Poole cited several unresolved issues with deployable DFDRs and telemetry/telemetry on demand: in the first case, reliable crash-detection sensors come into play, and extensive military experience shows a poor record of performance; in the case of telemetry, key questions are the need for massive new infrastructure, the effect on thousands of airborne aircraft if ground systems fail, much higher cost than DFDRs, and which state owns the DFDR data when an accident occurs.
Poole proposed a "universal, real-time flight incident recorder and event detection" system, from which data are kept by the state of occurrence. Ideal future systems involving telemetry also should provide new capabilities such as on-demand data streaming, streaming activation by the flight crew and activation by onboard conditions to notify all interested parties in real time about situations such as TCAS RAs and EGPWS/TAWS alerts, opening the possibility of assistance to airborne crews from ground-based experts or virtual copilots.
"Leadership Development for Pilots"
Red Bull Stunt pilots use these sorts of words to describe what makes for good airmanship: experience, judgment, decision-making, respect, awareness of the big picture, and can't be too careful. Other qualities are charisma, assertiveness, stress and workload management, risk perception, mental preparation, and personal reflection. These are the qualities of a good leader, according to Martin Ergeth, Product Manager Human Factors Training, Lufthansa Flight Training, and also should be present to make a good pilot.

Ergeth discussed the Lufthansa Leadership Program and how it involves leadership training for the air crew every two years. The training includes instruction and guidance from experts from many different fields. The benefits to this plan include a flight crew trained in leadership and better prepared for new opportunities and growth.

"Resilience in Simultaneous Approach Operations: Exploiting the RNP-AR Accuracy and Integrity"
As required navigation performance (RNP) instrument flight procedures proliferate among aircraft operators based on standards published long ago by ICAO, there has been a need to capitalize on the potential resiliency and integrity they bring for safely reducing aircraft separation from the radar-based standards of 1,000 ft vertically and 3 nm horizontally, said Sheila Conway, associate technical fellow, The Boeing Company.
Recently, such capabilities have been tested in Seattle, Washington, U.S., to implement monitored simultaneous approaches to parallel runways. The NASA ASRS reports she studied for background identified self-reported descriptions of operational errors and incidents in which flight crews were uncomfortable about the level of safety or their own actions, Conway said, but the great majority of relevant reports concerned problems such as ATC-crew miscommunication or procedural confusion that occurred at an earlier point than the final approach course - that is, before the special monitoring occurs.
"We fly these [procedures already] against a 100-percent threat from terrain," she said, noting that with built-in PBN protections, "We want to get rid of the 1,000 ft [vertical separation] and use the most efficient path by using lateral separation [such as] curved segments ... and no changes to procedures of equipment. ... We want stable approaches and energy management from top of descent ... to avoid risks or a hazardous state to begin with."
Conway urged airports to be very cautious in implementing PBN capabilities for simultaneous parallel approaches, including the potential for increases of TCAS RAs and their mitigation by redesigning instrument approach procedures to resolve non-safety-critical/nuisance TCAS alerts.


"The Need for Near Real-Time Runway Condition Reporting"
What is the problem we are trying to solve?" asked Logan Jones, an aircraft performance engineer working at Airbus. As Jones explained, pilots do get information about the condition of a runway from ATC and other pilots, but need to think beyond if the runway is wet or icy and how those conditions will impact the braking performance of an individual aircraft. He further explained that the modern aircraft is collecting an enormous amount of data and we need to figure out how to make that data usable for everyone with new technologies.

Nicolas Daveau, also an aircraft performance engineer working at Airbus, continued the presentation by discussing a technology being studied by Airbus called CORSAIR. He discussed how information is collected during the landing, processed and then transmitted to the ground. CORSAIR is not a replacement for current technology, Davaeu clarified, but it is a complement. Airbus continues to work with the FAA and some partner airlines who are helping to validate the technology. He also called for standardization on runway condition descriptions and a common agreement on how this data is shared and used.


"Top 5 Eurocontrol Operational Safety Priorities"
Everyone loves a top 10 or top 5 list, but how are those lists compiled? In the case of identifying the top 5 safety priorities for Eurocontrol, Tzvetomir Blajev, operational safety coordinator, Eurocontrol and FSF European Advisory Committee chairman, explained the research and analysis that went into this determination. The first challenge was that there are so many factors in accident or incident. Which factors should make a top 5 list? Blajev outlined the deliberate process that led to the creation of a model to analyze the barriers to preventing an accident and the analysis of each barrier. The team at Eurocontrol looked at a number of runway incursions and separation infringement en route over a set period and looked at the scenario trigger and determined how many times a barrier fell and how many times it worked. This highlighted where the priorities need to be. With that, Blajev and his team determined that the top five safety priorities are:
  1. Risk of operation without transponder or with a dysfunctional one.
  2. ACAS RA not followed
  3. "Blind spot" - (inefficient conflict detection with the closest aircraft)
  4. Controller Detection of occupied runway
  5. Sudden High Energy Runway Conflict
Session IV - Human Performance
"Managing Automation or Managing Aircraft Flight Path: How Does Operational Policy Need to Evolve"
Recent accidents and incidents continue to show vulnerabilities in pilot management of automated systems, with consequential flight path deviations. Kathy Abbott, chief scientific and technical advisor for Flight Deck Human Factors, US Federal Aviation Administration (FAA), explained that to guide pilots in managing automated systems, most operators have an automation policy, and they vary significantly from each other. However, the focus on managing automated systems is not always well integrated with managing the flight path of the aircraft, and may distract from the tasks associated with flight path management.
Her presentation covered several areas of note, such as a concern about deteriorating manual flight skills that has caused the FAA to call for airlines to look for more opportunities to manually fly the aircraft. She also pointed to better management of automated systems, better monitoring and intervention by the pilot flying and the pilot monitoring, as well as some other issues that are addressed by a good flight path management policy.
According to Abbott, operators should have a clearly stated flight path management policy that includes the following topics:
* The responsibility for flight path management remains with the pilots at all times.
* Focus the policy on flight path management, rather than automated systems.
* Manual flight operations: when and where.
* Automated systems as tools to support flight path management, including operational use and autoflight mode awareness.
* Clearly define and distinguish between pilot flying and pilot monitoring roles.
* Encourage pilots to tell air traffic "unable" when appropriate.
* Distinguish between guidance (where is the guidance information coming from) and control (who or what is controlling the airplane).

"Go Around - The Most Effectual But Elusive Decision in Accident Reduction Today: The FSF Reports - How to Improve Go Around Compliance and Execution"
Bill Curtis, co-chair, FSF Go Around Decision Making and Execution Project, started his presentation with a brief overview of the research that The Presage Group had conducted at the request of Flight Safety Foundation in support of this project. Two separate studies were done - one with the pilots and one with management and they showed a significant level of non-compliance during an unstable approach. And data shows that 54% of accident might be prevented by a go around. "No other decision has such an impact on aviation safety," Curtis said. The Go Around study is a comprehensive examination of why this happens and what can be done to address it. The research reveals the need for more awareness for flight crews through stable approach monitoring and alerting systems. We need to remove the subjectivity from the decision to go around through active communication during approach and landing.
Tzvetomir Blajev, also co-chair of the project, continued with a brief look at the main findings and recommendations of the project. Some of the recommendation include the need for simple procedures for go around from all altitudes, more training and awareness and to ensure that monitoring is not affected by experience level of the flight crew. The next steps is the production of the final report and continuing to work on the specific issue of the revised go around criteria with industry assistance. FSF is working with airlines, pilot groups and regulators to conduct some trials of these criteria.

"Enhanced Low Vision Operations"

Increasingly aircraft are being equipped with head up displays and enhanced vision systems fully integrated for flight operations and especially beneficial in the airport environment, according to Ken Elliot, technical director, Jetcraft Corporation,  This safety system may be operated in place of existing Category II and later III equipment and being cockpit-centric, does not require the same ground infrastructure, thereby opening up thousands of runway ends for Cat II equivalent and enhanced surface operations.
Furthermore the implementation of new flight rules introduces the first major change in final approach,runway touchdown and roll out operations since ILS was introduced in 1941. The new FAA FAR 91.176A rule due for release in 2015 is also expected to migrate worldwide.
Some of this is futuristic technology and things can always happen, but the industry is moving toward these changes, Elliot acknowledged. He reviewed the developments in PBN that are in the works, that would incorporate technologies such as GBAS, EFVS, SVGS, MMR, and new technology on the surface. Elliot finished his presentation warning about some of the issues, including vulnerabilities in GPS and the cost of the new equipment, that will need to be addressed. 
"The Dragon in the Cockpit: Western Aviation Concepts and Chinese Value System"

In his presentation  Allen Batteau, associate professor at Wayne State University, discussed his research into the differences between Eastern and Western thought processes. Batteau, a cultural anthropologist whose research partner is Jing Hung-Sying, a professor at National Cheng Kung University in Taiwan, stressed that Western thinking is linear whereas Eastern or Chinese thought processing is around a circle and more two dimensional. "The thought process in the East is completely different than in the West," he said. This can be an issue is aviation because systems automation is based on Western thought processes which "doesn't always work well in the East."
Batteau said his goal is to start a dialog about the cultural differences to promote greater harmony. I the meantime he offered this advice: "Allow more margin for error in a cross-cultural situation."
"The Kebnekaise Accident From a Human Factor Point of View"

Britt-Marie Karlin, a flight safety analyst with the Swedish Transport Agency, closed the day with a detailed account of a March 15, 2012, fatal accident in which a Royal Norwegian Air Force Lockheed C-130J-30 slammed into Mount Kebnekaise, the highest peak in Sweden, while on its way to a Kiruna Airport in Sweden. Karlin explained a series of factors that led the flight crew to fly too low and to impact the mountain just a few hundred feet below is 6,932 ft peak. "There was no indication they took evasive action," she said of the crew. Among the factors cited by Karlin were poor flight planning, a crew decision to turn the aircraft's terrain awareness warning system to tactical mode and the fact that the air traffic controller was unaccustomed to traffic approaching Kiruna from the West, instead of from the south. The five people on the aircraft were killed.


   


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