Publications

Flight Operations Quality Assurance and Aviation Safety Action Programs

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

 

Slide 1
FEDERAL RAILROAD
ADMINISTRATION
CLOSE CALL WORKSHOP
APRIL 23-24, 2003

 

Slide 2
Safety Programs that increase the
Safety Margin and Reduce the
Accident Risk

Flight Operations Quality 
Assurance(FOQA) 
and 
Aviation Safety Action Programs(ASAP)

 

Slide 3
[illustration of a stylized terrestrial globe]

Flight Operations Quality 
Assurance 
FOQA

 

Slide 4
What is a FOQA Program?

A program designed to enhance 
safety through the controlled, 
automated recording and analysis 
of flight data generated during 
routine line operations.

 

Slide 5
FOQA Around the World
* European/Asian carriers have operated FOQA for more than 30 years
* A different litigious environment
* No fear of misuse by governing agencies, press
* Data is respected
* Long recognized need for anonymity in reporting

 

Slide 6
FOQA Around the World ...Continued
Mature FOQA programs have proven hull loss prevention statistics

[table entitled:] Accident Rates per Million Departures
[column 1:] Accident Type: Hull Loss/Hull Loss, Crew factor
[column 2:] Non-U.S. Carrier -- FOQA Users: 0.51/.020
[column 3:] European Carriers -- not using FOQA: 1.10/0.52
[column 4:] United States where most carriers are NOT using FOQA data: 060/0.37

 

Slide 7
Common Terms
* Parameter - A recorded value associated with a specific aircraft system or flight regime,  i.e. Altitude, Aileron Position and Fuel Flow, etc.
* Event - Detected operation of the aircraft that is unusual or beyond established limits
* Exceedence - The amount by which a detected event has gone beyond the established limits

 

Slide 8

 

Slide 9
Reporting Examples
* Aircraft Limitations
* Top 10 Events by total count
* High Rate of descent by arrival airport
* Top 9 low power approaches by arrival airport
* Approach Speed Event trending

 

Slide 10
[Bar graph] Aircraft Limitations/Number of Events:
3A - Flap placard/[number of events unspecified]
1A - Vmo/[number of events unspecified]
2A -Mmo/[number of events unspecified]
4 - Flap Out Over/[number of events unspecified]

 

Slide 11
[Bar graph] Top 1 Events for 1997/Number of Events:
22G - High Descent Rate Below 2000ft/[number of events unspecified]
75A - Low Power on Approach/[number of events unspecified]
21C -Bank Above 500ft/[number of events unspecified]
3A - Flap Placard Speed/[number of events unspecified]
48A - Late Land Flap/[number of events unspecified]
20C - Pitch Low at Landing/[number of events unspecified]
6A -Approach Speed High/[number of events unspecified]
91 - Roll Slowover/[number of events unspecified]
6C - Approach Speed High/[number of events unspecified]
6B -Approach Speed High 500-50ft/[number of events unspecified]

 

Slide 12
[Bar graph] High Rate of Descent by Arrival Airport/Event Percentage
BWI/[event percentage unspecified]
CLT/[event percentage unspecified]
DCA/[event percentage unspecified]
LGA/[event percentage unspecified]
MCO/[event percentage unspecified]
MIA/[event percentage unspecified]
MYR/[event percentage unspecified]
PIT/[event percentage unspecified]
TPA/[event percentage unspecified]

 

Slide 13
[Bar graph] Top 9 Low Power Approach/Event Percentage
BOS/[event percentage unspecified]
BWI/[event percentage unspecified]
CLT/[event percentage unspecified]
DCA/[event percentage unspecified]
LGA/[event percentage unspecified]
MYR/[event percentage unspecified]
PIT/[event percentage unspecified]
RDU/[event percentage unspecified]
TPA/[event percentage unspecified]

 

Slide 14
[Bar graph] CAS at 500ft relative Vref/Number of Events
[7 unlabeled bars]
10/[number of events unspecified]
7/[number of events unspecified]
5/[number of events unspecified]
2/[number of events unspecified]
0/[number of events unspecified]
-2/[number of events unspecified]
-5/[number of events unspecified]
-7/[number of events unspecified]
-10/[number of events unspecified]
[6 bars unlabeled]

 

Slide 15
[Bar graph entitled &##39;&##39;Initiatives to Reduce Unstabalized Approaches,&##39;&##39; with January to December, 1999 super-imposed on January to December, 1998, showing consistently-substantial but unspecified reductions for each corresponding month from 1998 to 1999.]

 

Slide 16
[Page 18-32-4 from USAir B-737-300/400 Pilot&##39;s Handbook reproduced. Schematic diagram entitled, &##39;&##39;Descent Planning Guide for Visual Approaches,&##39;&##39; showing descent from 5000ft to landing, through 15 DME, 10 DME, 5 DME, 3, DME.  Other details omitted from this description.]

 

Slide 17
[Front page of &##39;&##39;Waypoints&##39;&##39; Issue #2, July 1999, cover article: Unstabilized Approaches from the FOQA Point of View]

 

Slide 18
[This slide is a collage of four separate items.]

[1:]
&##39;&##39;Don&##39;t compromise SAFETY...
it&##39;s YOUR choice!
Just say ..... go around&##39;&##39;

[2:]
&##39;&##39;Just say .... &##39;go around&##39; &##39;&##39;

[3:]
[Graph entitled] &##39;&##39;B737 Landing&##39;&##39;

[4:]
[Graph entitled] &##39;&##39;b737 Go-Around&##39;&##39;

 

Slide 19
[Bar graph entitled &##39;&##39;High Rate of Descent Below 2000 feet (22G)&##39;&##39; illustrating the relative percentage decrease from 1998 to 1999 by corresponding month:]

Jan 34%
Feb 13%
Mar 19%
Apr 26%
May 62%
Jun 67%
Jul 55%
Aug 57%
Sep 63%
Oct 41%
Nov 67%
Dec 53%

 

Slide 20
[Bar graph entitled &##39;&##39;Low Power Approach (75A)&##39;&##39; illustrating the relative percentage change from 1998 to 1999 by corresponding month:]

January 39% [decrease]
February 18% [decrease]
March 41% [decrease]
April 24% [decrease]
May 48% [decrease]
June 52% [decrease]
July 50% [decrease]
August 16% [decrease]
September 68% [decrease]
October 11% [increase]
November 26% [decrease]
December 35% [decrease]

 

Slide 21
[Bar graph entitled &##39;&##39;Low Pitch at Landing (20C)&##39;&##39; illustrating the relative percentage change from 1998 to 1999 by corresponding month:]

January 72% [decrease]
February 63% [decrease]
March 52% [decrease]
April 50% [decrease]
May 58% [decrease]
June 83% [decrease]
July 67% [decrease]
August 0% [even]
September 45% [decrease]
October 50% [increase]
November 22% [increase]
December 57% [decrease]

 

Slide 22

 

Slide 23

 

Slide 24

 

Slide 25
Crew Feedback is Essential
* FOQA Bulletin Board
* &##39;&##39;Event of the Month&##39;&##39;
* Crew contact by ALPA Gatekeeper
* Monthly data available to Fleet Manager
* Promotion through Company Safety Publication
* Airport analysis page FOQA alert

 

Slide 26
[illustration of a stylized terrestrial globe]

Ultimately ...
the industry will recognize that FOQA is the highest level of safety management

 

Slide 27
Introduction to ASAP

[US Airways Aviation Safety Action Program logo]

 

Slide 28
[US Airways Aviation Safety Action Program logo]

* A Corporate Commitment at the highest level to Air Safety is a prerequisite for ASAP
* A Corporate Non-reprisal policy must be put in place

 

Slide 29
[Safety on Line, February 1997, page 2]

New Mananagement Supports Safety

1996 brought new leadership to the Corporation as well as a rededication to USAir&##39;s Non-Reprisal Policy.

USAir Non-Reprisal Policy

[highlighted text:]
USAir is committed to the safest flight operatiopn possible.
USAir will not initiate disciplinary proceedings against an employee who discloses an incident or occurrence involving flight safety.  This policy shall not apply to information provided to the company by a source other than the employee.

 

Slide 30
[US Airways Aviation Safety Action Program logo]

* The Corporate Safety Mandate must be Subscribed to by all levels of Airline Management
* The employee is the ultimate corporate safety information provider.

 

Slide 31
[US Airways Aviation Safety Action Program logo]

AIRLINE COMMITMENT, RESPONSE, AND ACCOUNTABILITY

* Airline management must commit to provide personnel and staff support.  At ALPA carriers, Air Safety personnel are a valuable resource.
* Airline’s response to ERT recommendations must cross departmental  boundaries:  system operational control, dispatch, maintenance, flight, etc.  ASAP must have the full support of senior airline operations management.
* ASAP system accountability must allow documented response to ERT recommendations both within the airline and from the FAA.

 

Slide 32
[US Airways Aviation Safety Action Program logo]

The ASAP Report is the backbone of an air carrier ASAP program.

 

Slide 33
[illustration of an Aviation Safety Action Program (ASAP) Report form]

 

Slide 34
[illustration of a Mandatory Reporting Events placard listing Air Safety and Cabin Safety Reporting Events]

 

Slide 35
[US Airways Aviation Safety Action Program logo]

KEY ELEMENTS OF ASAP
* PROACTIVE SAFETY PROBLEM IDENTIFICATION AND RESOLUTION
* STRONG REPORTING INCENTIVES
* ASSOCIATION WITH NASA ASRS 
* AIRLINE AND EMPLOYEE COMMITMENT, RESPONSE, AND ACCOUNTABILITY
* FLIGHT SAFETY BENEFITS TO AIRLINES, PILOTS, THE FAA, AND THE TRAVELING PUBLIC

 

Slide 36
[US Airways Aviation Safety Action Program logo]

ASAP&##39;s Value to the Airline . . .

ASAP builds mutual trust through cooperative safety 
relationship between employees, ALPA, the FAA, and an 
airlines management.
* ASAP teamwork encourages preventative, rather than reactive, response.  This cooperation requires that all parties to the agreement abandon traditional roles in favor of consensus recommendations for solutions to joint concerns.
* Non-disciplinary corrective action provides strong reporting incentive and instills employee confidence in Event Review Team recommendations.

 

Slide 37
[US Airways Aviation Safety Action Program logo]

. . . ASAP&##39;s Value to the Airline . . .

ASAP provides a cross-disciplined approach to problem 
solving that is efficient and effective in the following ways:
* Promotes cooperation and accountability between airline departments.
* Provides better utilization of safety personnel resources.
* Establishes direct-line communication for important real-time safety information to airline managers.
* Reveals a clearer, more accurate view of the safety of airline operations.
* Complements AQP, CRM, Internal Safety Audit, FOQA, and Air Carrier Voluntary  Self-Disclosure Programs.

 

Slide 38
[US Airways Aviation Safety Action Program logo]

. . . ASAP&##39;s Value to the Airline
Bottom Line
ASAP maximizes the input of employees as an airline’s most valuable safety resource and offers a corrective-action approach for safety problem resolution and the prevention of incidents and accidents.

 

Slide 39
[US Airways Aviation Safety Action Program logo]

POTENTIAL VALUE OF ASAP TO THE AIRLINE INDUSTRY
* ASAP properly implemented and operated provides increased safety problem identification and resolution leading to accident and incident prevention strategies.
* ASAP accident and incident prevention strategies may be shared industry-wide.
* ASAP can promote FAA enforcement by ensuring compliance through corrective action.
* ASAP can assist the NTSB with proactive recommendations, preventing accidents.
* ASAP can lead to improvements in National Air Space operations.

 

Slide 40
[US Airways Aviation Safety Action Program logo]

PROACTIVE SAFETY PROBLEM SOLVING
Equal participation from airline management, the employee association, and The FAA is the building block for employee confidence and the overall success of ASAP.

 

Slide 41
[US Airways Aviation Safety Action Program logo]

STRONG REPORTING INCENTIVES
Sole-source protection
Corrective action, non-punitive approach:
* Airline:  Comprehensive employee community feedback and education of safety problem identification and resolution
* FAA:  Administrative action or no action in lieu of legal enforcement action taken against reporting crew

Confidentiality-ASAP report handled in a confidential manner by ERT - no record kept in a employee’s airline personnel file
Anonymity provided after event review and corrective action completed

 

Slide 42
[US Airways Aviation Safety Action Program logo]

FLIGHT CREW FEEDBACK OF SAFETY INFORMATION IS ESSENTIAL FOR PROGRAM SUCCESS
* Reporting of real-time safety events prevents the reoccurrence of same and similar incidents.
* Identification of safety problems
* Highlighting of safety problem solutions, and 
* The monitoring of the flight crews?response to the identified problems and solutions which confirm safety enhancement

 

Slide 43
[reprinted from &##39;&##39;Safety Online USAirways Corporate Safety&##39;&##39; newsletter:]

Lessons Learned

The following are incidents involving altitude deviations that have been brought into the Safety Partnership with the FAA. They are intended to Provide insight into the events in the hope that everyone may learn from their experience....

 

Slide 44
[reproduction of an USAirways Altitude Awareness Alert]

 

Slide 45
[reproduction of an USAirways Pilot Aviation Safety Action Program (ASAP) Safety Bulletin #01-01, February 27, 2001, ref.: Altitude Deviations]

 

Slide 46

 

Slide 47

 

Slide 48

 

Slide 49

 

Slide 50

 

Slide 51

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