Publications

United Airlines Safety Culture

  • 23
  • Apr
  • 2003
SUBJECT: Risk Reduction Program
KEYWORDS: C3RS
Workshop: Improving Railroad Safety through Understanding Close Calls
Captain Hank Krakowski Presentation

 

Slide 1
[United Airlines logo]

UNITED AIRLINES
Safety Culture
An evolution of learning & cooperation

 

Slide 2
[United Airlines logo]

State of
UNITED AIRLINES
Chapter 11 - Update

Airline is running well ?Excellent operational and safety performance
#1 On-time in 2002
No significant Safety or Reliability issues
Negotiated agreements with labor

 

Slide 3
[United Airlines logo]

Mission:  Find Truth ?Facilitate Change

Mechanisms

* Independent Safety Department
* Self disclosure
    Employee > Company > Unions > FAA
* Partnership between Management, Unions and Regulators
* Evolution to systems auditing & continuous improvement

 

Slide 4

[United Airlines logo]

Safety at United
An engine of Continuous Improvement

[flow chart of operations safety auditing, reports, and data]

Mission:  Find Truth ?Facilitate Change

 

Slide 5
[United Airlines logo]

Safety Programs - Flight
Safety Training

Watershed Event ?1978

United alarmed by UAL DC-8 fuel starvation accident Portland, Ore
Crew members aware of danger but silent due to human factors


All crewmembers now trained to Inquire, Discuss and Advocate
Captain authority is strengthened not undermined through CRM tools
Pilot simulator checks equally evaluate CLR / CRM and flight skills

(CRM  Crew Resource Management)

 

Slide 6
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

FOQA ?Flight Operations Quality Assurance

Data driven analysis

60% of UAL aircraft equipped with FOQA recorders
Program has saved engines, aircraft and lives
FAA / industry working to aggregate de-identified data
Very labor sensitive

 

Slide 7
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

FOQA ?Flight Operations Quality Assurance

* Aircraft FOQA Data downloaded
* Data aggregated & deidentified
   Trend Data Identified
     Unstable approaches
     TCAS RA’s
     Flap / Speed exceedances
* Flight management and ALPA analyze
   Changes to procedures/training

 

Slide 8
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

FOQA ?Flight Operations Quality Assurance

ALPA Exceedence Guidance Team reviews IDENTIFIED data
If significant ?Crew is Contacted
   Gross exceedances
   Significant over limits
Discussion is between EGT / Crew Only 
   Learning Environment

 

Slide 9
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

FOQA ?Flight Operations Quality Assurance

Routine Trending Data
  Engines & systems

Non Routine Event
  Download requested
    Engine surge
    Flap overspeed

 

Slide 10
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

Quality Assurance Auditing

Shift in Philosophies 

Compliance police (Traditional)

Systems & Processes (ISO 9000)
(JQRT Joint Quality Review Team)

Identifies:
  Non-compliance (direct violations)
  Non-conformance (written procedures different from practice)
  Significant concerns (oversight & systems weak)

 

Slide 11
[United Airlines logo]

Safety Programs
Safety Auditing

Quality Assurance Auditing
B747 near - accident

Engine failure shortly after takeoff
IFR conditions
First Officer flying
Crew late in recognizing engine failure
First officer reacted improperly
Came within 100?of hill top

 

Slide 12
[United Airlines logo]

Safety Programs
Safety Auditing

Quality Assurance Auditing
B747 near - accident

Full FAA / UA compliance at takeoff
People &##39;&##39;felt&##39;&##39; problems existed
COO directs audit of training center
263 findings (all corrected)
  Proficiency
  Scheduling
  Long range relief pilots
FAA joint experiment (JQRT)
Ability to keep self interests at bay

 

Slide 13
[United Airlines logo]


Safety Programs - Flight
Safety Auditing

FSAP ?Flight Safety Awareness Program

Provides atmosphere for open and honest discussion
  - Management
  - Union
  - Crews
  - FAA

Provides protections for Company & Crews (unless willful disregard or intentional)

Requires solid agreements & understandings between unions / management / FAA

 

Slide 14
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

FSAP ?Flight Safety Awareness Program

Pilots electronically submit reports
Altitude deviations
Missed communications
Security issues

Safety department collects reports
Ranks risk 
Assigns taxonomies

Weekly Event Review Committee meetings
(QA Management, ALPA & FAA)

Three options:  
  Close issue outright or with recommendations
  Letter of No Action
  Notice of Violation

 

Slide 15
[United Airlines logo]

Safety Programs - Flight
Safety Auditing

FSAP ?Flight Safety Awareness Program

* DSAP  (Dispatch Safety Awareness Program)
    Began program in October 2002
    Already effective (deficient employee out of service)

* MSAP  (Maintenance Safety Awareness Program)
    Revisiting concept with new union leadership (IAM)

VISION:  FSAP + DSAP + MSAP will create a total safety analysis culture overall and traverse departmental barriers

 

Slide 16
[United Airlines logo]

Recent FSAP/ASAP example

DEN B737 ice damaged engines
* Very unusual event
* Probable cause atmospherics / procedures mismatch
* Employee groups very different to work with
* Serious immediate safety issue took too long to resolve

 

Slide 17

[United Airlines logo]

Safety at United
An engine of Continuous Improvement

[flow chart of operations safety auditing, reports, and data]

Mission:  Find Truth ?Facilitate Change

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