WATS 10 ‘Training for Safety’ John Bent 1 TRAINING FOR SAFETY John Bent Director Training Strategy proposed Pegasus Flight Academy - China World Aviation

WATS 10 ‘Training for Safety’ John Bent1

TRAINING FOR SAFETY

John BentDirector Training Strategy

proposed Pegasus Flight Academy - China

World Aviation Training SymposiumOrlando

27th April 2010


The latest threat to crew training resources

USD 1.7billion has just been lost to international airlines in one week

Source IATA


IATA SAFETY REPORT 2009:

2009 ACCIDENT RATE REDUCED: 0.71 versus 0.81 in 2008 [hull losses per million flights of Western-built jet aircraft]

= one per 1.4 million flights

SAFELY FLOWN: 2.3 billion people on 35 million flights

(27 million jet, 8 million turboprop)

LESS ACCIDENTS WESTERN BUILT TYPES: 19 vv 22 in 2008

LESS ACCIDENTS (all types) 90 vv 109 in 2008

LESS FATAL ACCIDENTS (all types): 18 vv 23 in 2008

SAFETY - THE GOOD NEWS - 2009

✔


IATA SAFETY REPORT 2009:

MORE FATALITIES: 685 vv 502 in 2008 1.36 times worse

REGIONAL RATES WHICH ROSE:

• ASIA PACIFIC: 0.86 vv 0.58 in 2008 1.48 times worse

• M/E: 3.32 vv 1.89 in 2008 1.75 times worse

• AFRICA: 9.94 vv 2.12 in 2008 4.68 times worse

Runway excursions and ground damage were main categories

Pilot handling was a contributing factor in 30% of all accidents.

SAFETY - THE BAD NEWS - 2009

×


ANY SENSE THAT 2009 RESULTS WERE BETTER COULD GENERATE COMPLACENCY

Longer term trends by type and regions remain disturbing

Complete elimination of accidents is unrealistic, but:

Any serious accident which could have been reasonably AVOIDED or MITIGATED was

an industry safety system failure


Training is the best investment against catastrophic risk

The top catastrophic accident risks identified were:1. LOC (loss of control) 2. CFIT (controlled flight into terrain)3. Post-crash fire4. Runway excursions and overruns

Crew judgment and actions are the most consistent causal factor in global catastrophic accidents

This situation will remain true for the foreseeable future Crew-related issues dominate accident causal factors,

featuring in 75% of fatal accidents

CREW TRAINING - UK CAA 2008:


Major accident totals threaten levels not seen since 1990s

Totals threaten levels not seen since 1990s

‘Last five-year’ accidents exceed previous five-year periods

“at this pace, we'll be turning the clock back 10 years in

safety”

FLIGHT SAFETY FOUNDATION:

Are today's airline pilots churned out by "pilot mills" that

train to minimum standards?

BUFFALO NEWS – DEC 2009:

WATS 10 ‘Training for Safety’ John Bent

Hardware growth has outstripped human-ware available

911 and SARS discouraged steady expansion of training capacity

2007-2008: aircraft were grounded without crews

Crew training rates inadequate; training trended to minimums

2009 - global recession; reversal to surplus crews

Pilot layoffs and unpaid leave

Less pressure on training delivery, yet increased pilot mobility

Accidents on the rise; no surprise

Now volcanic ash

AN INDUSTRY WITH REMARKABLE CHALLENGES

8

Accidents & Incidents


THE LONG TERM ACCIDENT RATE MAY EXCEED THAT COMMENSURATE WITH EXPANSION ALONE

IF SO, WHY?


TRAINING & SAFETY

The following slides depict a sample of just 40 airline

accidents since 2005 (not exhaustive)

Detailed analysis is not intended

These tragic slides will be shown rapidly, aimed at the

bigger picture, and to stay within my presentation time

As many as 35 of this sample (88%) may be concluded

to have contained crew training as possible mitigants


Air France A340 Toronto 2 Aug 2005RUNWAY DEPARTURE: Could more effective training have mitigated?

Undesired aircraft state- unstable approach in bad weather

1


Helios B737 Greece14 Aug 2005CREW INCAPACITATION: Could more effective training have mitigated?

Tech and procedures?

2


16 Aug 2005

LOSS OF CONTROL: Could more effective training have mitigated? loss of control in cruise; a/c overload, stall?

W Caribbean MD82 Venezuala

“The pilots may have lacked basic instrument flying skills due to

continuous over reliance on automated flight.

Did they monitor their instruments? Indications should have

alerted them of subtle airspeed decay as the aircraft was

overloaded and at too high a FL...”

3


Bellview B737 Lagos 23 Oct 2005

LOSS OF CONTROL: Could more effective training have mitigated? - Unknown as yet

The airplane impacted ground at a speed of around 400 knots in a near wings level attitude with both engines at takeoff thrust. All 111 passengers and 6 crew perished

in the crash.

Nigerian Authorities promised a final report in 2007, but has not come to light so far.

4


29 Sep 2006

COLLISION: Could more effective training have mitigated? Procedures, situational awareness, TCAS?

GOL B737-800 Brasil

5


29 Nov 2007IMPACT WITH TERRAIN: Could more effective training have mitigated? - heading, situational awareness = controlled flight into terrain (CFIT)?

AtlasJet MD83 at Isparta

6


7 Mar 2007OVERRAN RUNWAY: Could more effective training have mitigated?

Crew resource management (authority gradient)

Garuda B737 Yogyakarta

7


4 May 2007

CRASHED AFTER TAKE-OFF: Could more effective training have mitigated? - took-off into heavy TS

Kenya Airways B737 Douala

According to the former minister, “the Camerounian State is not to be blamed as the pilot was asked not to fly due bad weather”.

The Kenya Airways Boeing 737-800 suddenly disappeared from radar screens two minutes after take-off from the Douala

International Airport during a heavy thunderstorm.

8


17 Jul 2007

RUNWAY EXCURSION: Could more effective training have mitigated? Undesired aircraft state - reverser inoperative procedures

TAM A320 Sao Paolo

9


BA B777 Heathrow17 Jan 2008

LOSS OF POWER: Could more effective training have mitigated? NO: Sound airmanship displayed - AAIB report

10


Belgavia CRJ100 Yerevan14 Feb 2008DE-ICING PROCEDURES: Could more effective training have mitigated?

Loss of control -refused advice to de-ice for take off

11


21 Feb 2008FLEW INTO TERRAIN: Could more effective training have mitigated?

- failed to align NAV pre-take off = Situational Awareness + CFIT

ATR42 nr Merida

12


15 Apr 2008RUNWAY OVERRUN: Could more effective training have mitigated?

Overrun - tyre burst after V1; tried to stop

Hewa Bora DC95 Goma

13


25 May 2008RUNWAY OVERRUN: Could more effective training have mitigated?

Procedures; slow rejected take off?

Kalitta B747 Brussels

14


30 May 2008RUNWAY DEPARTURE: Could more effective training have mitigated?

Undesired aircraft state - landing performance?

TACA A320 Tegucigalpa

15


10 Jun 2008RUNWAY DEPARTURE: Could more effective training have mitigated?

Undesired aircraft state - landing performance?

Sudan Airways A310 Khartoum

16


6 Jul 2008

GO AROUND FAILED: Could more effective training have mitigated? Undesired aircraft state-approach to wrong runway

USA Jet DC91 Saltillo

17


20 Aug 2008DEPARTED RUNWAY: Could more effective training have mitigated?

Flaps not set for take-off -undesired aircraft state - procedures

Spanair MD82 Madrid

18


Itek Air B732 Bishkek 24 Aug 2008LOST CONTROL ON APPROACH: Could more effective training have

mitigated? Undesired aircraft state – visual awareness?

19


30 Aug 2008FLEW INTO TERRAIN: Could more effective training have mitigated?

crew resource management, situational awareness

Conviasa B737 Latacunga

20


Aeroflot-Nord B735 Perm14 Sep 2008LOST CONTROL ON APPROACH: Could more effective training have

mitigated? Recent formal ruling that pilot was drunk, CRM?

Since this accident Russia's transport ministry signed

an agreement with Boeing aimed at improving air

transport safety in the country. The memorandum,

identifies provision of training for flight crew and

technical personnel and the development of training

infrastructure as crucial areas

21


27 Nov 2008LOST CONTROL: Could more effective training have mitigated?

test flight procedures training (BEA)?

ANZ A320 nr Perpignan

22


20 Dec 2008RUNWAY OVERRUN: Could more effective training have mitigated?

Undesired aircraft state -failed take-off & runway overrun?

Continental B737 Denver

23


US Air A320 Hudson River15 Jan 2009TRAINING & EXPERIENCE SAVED THE

DAY!

An example to study

24


Colgan Air DH8D Buffalo 12 Feb 2009LOST CONTROL: Could more effective training have mitigated?

- procedures, icing and stall recovery training?

25

A change trigger


25 Feb 2009 Turkish B737 Amsterdam LOST CONTROL ON APPROACH: Could more effective training have

mitigated? Automation reliance & monitoring?

26

An automation threat?


23 Mar 2009FLIPPED ON LANDING: Could more effective training

have mitigated? Undesired aircraft state -known handling issues in

strong gusts?

Fedex MD11 Tokyo

27


9 Apr 2009IMPACT WITH TERRAIN: Could more effective training have mitigated?

Undesired aircraft state-loss of control; circling in low cloud base?

Aviastar BAe 146 Wamena

28


29 Apr 2009CRASHED AFTER TAKE-OFF: Could more effective training have

mitigated? As yet unknown but aircraft stored for 1 year?

Bako Air B737 Massamba

29


1 June 2009 Air France A330 Atlantic

LOST CONTROL: Could more effective training have mitigated? - inadequate evidence as yet

30


Yemenia A310 East Africa30 Jun 2009LOST CONTROL: Could more effective training have mitigated?

Undesired aircraft state - missed approach in big twin; as yet unknown

31


Caspian Tu 154 nr Tehran14 Jul 2009IMPACTED TERRAIN: Could more effective training have mitigated?

-as yet unknown

32


Aryan Airlines IL62 Mashhad (Iran) 24 Jul 2009OVERRAN RUNWAY: Could more effective training have mitigated?

-Technical (gear?), late landing, but as yet unknown

33


Bangkok Awys ATR72 Koh Samui4 Aug 2009RUNWAY EXCURSION: Could more effective training have mitigated?

Departed runway in strong winds and rain - as yet unknown

34


Sudan Awys B707F Sharjah21 Oct 2009LOST CONTROL: Could more effective training have mitigated? Lost control during initial climb and crashed – as yet unknown

35


Cpgn African Avn MD82 Goma 19 Nov 2009OVERRAN RUNWAY: Could more effective training have mitigated?

Overran runway in ‘rainy conditions’ - as yet unknown

36


American Airlines 738 Kingston22 Dec 2009OVERRAN RUNWAY: Could more effective training have mitigated?

Overran runway in heavy rain - as yet unknown

37


Compagnie B727-200 Kinshasa2 Jan 2010RUNWAY EXCURSION: Could more effective training have mitigated?

Veered off runway on landing - heavy rain

38


Taban Air TU 154 Mashad Iran24 Jan 2010

RUNWAY EXCURSION: Could more effective training have mitigated? Landing in fog with medical emergency

Flight International

39


Ethiopian 738 Nr Beirut25 Jan 2010CRASHED IN DEPARTURE: Could more effective training have mitigated?

Lost height and impacted Mediterranean (WX?) - as yet unknown

40


LESSONS FROM THIS SAMPLE?1. That most accident risks realised could be

foreseen in training!

2. That reactive is easier then proactive!

3. That 35 of the 40 accidents sampled (88%) may

count as probable human factors and training

[LOSS OF CONTROL / undesired aircraft state

(irrecoverable departure from normal operational parameters) & controlled flight

into terrain]

4. That today we still DO NOT focus a

commensurate amount of pilot training on human

factors! (it’s more like 10%?)

5. We must mitigate accidents with TRAINING


Back to the 2009 IATA REPORT

Runway excursions and ground damage

were main categories Pilot handling was a contributing factor in

30% of all accidents

So what’s happening in 2010 ?


DURING THE FIRST 120 DAYS OF 2010, NOT MUCH HAS CHANGED


RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page1)

2 Jan Compagnie Africaine Aviation B727-200, Kinshasa (Congo) Veered off runway on landing3 Jan Air Berlin B737-800, Dortmund (Germany)

Rejected takeoff - runway overrun8 Jan Air Berlin B737-800, Nuremberg (Germany)

Veered off runway on take off9 Jan Yas Air IL76, Kiev (Ukraine)

Runway excursion on landing15 Jan Iran Air F100, Isfahan (Iran)

Nose gear collapse on landing16 Jan Iran Air A300-600, Stockholm (Sweden)

Went off runway on line up for take off19 Jan PSA Airlines CRJ2, Charleston (USA)

Overran runway on take off

Source: Aviation Herald7



19 Jan Lion Air B737-900, Padang (Indonesia) Runway excursion on landing

21 Jan Aeromexico Connect E145, Tijuana (Mexico) Went off runway on landing

22 Jan Skywest CRJ7, Winnipeg (Canada) Overran runway on landing

25 Jan West Air CRJ2 Longyearbyen (Norway) Veered off runway on landing

27 Jan Cimber AT72, Bornholm (Denmark) Veered off runway on landing28 Jan Bulog AN26, Wamena (Indonesia)

Overran runway on landing30 Jan Donavia B737-400, Rostov (Russia)

Overran runway on landing



RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page3)31 Jan Skyservice A320, Varadero (Cuba)

Hard landing – three tyres blown4 Feb Yakutia AN24, Yakutsk (Russia)

Rejected take-off but airborne / gear up8 Feb Shasheen B737-200, Peshawar (Pakistan)

Departed runway on landing10 Feb KLM B737-300, Schiphol (Netherlands)

Took off on taxiway13 Feb Batavia B737-200, Surabaya (Indonesia)

Nose gear skidded on line up – tyres blew18 Feb Shuttle America Embraer ERJ-170, Cleveland (USA)

Overran the runway on landing22 Feb Spring Airlines A320-200, Shenyang (China)

Landed tail first – structural damageSource: Aviation Herald21


RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page4)24 Feb Ethiopian Airlines B737-700, Lubumbashi (Congo)Departed taxiway after landing

24 Feb Air Canada Airbus A321-200, Toronto (Canada)Landed without ATC clearance

25 Feb Lion Air B 737, Padang (Indonesia)Main gear departed paved surface

26 Feb Garuda Indonesia B 737-800, Perth (Australia)Entered RWY 06 after landing - no clearance

26 Feb Aeroflot A320-200, Oslo Gardermoen (Norway)Took off on taxiway

1 Mar Air Tanzania B737-200, Mwanza (Tanzania) Veered off the departure runway 3017 Mar Shaheen Air International B737-200, Peshawar (Pakistan) Overran the runway on landing




22 Mar Aviastar TU-204-100, Moscow Domodedovo (Russia Landed about 1000 meters short of rwy 14R

23 Mar China Airlines B747-400F, Anchorage, (USA) Struck its tail onto the departure runway

24 Mar Cargojet B727-200, Moncton, (Canada) Overran runway 06 while landing

24 Mar Asiana A321-200, Omitama (Japan) Overran runway 21L by about 30 meters

25 Mar Westjet B737-800, Cancun (Mexico) Tail strike during takeoff

25 Mar Air Madagascar B737-300, Nossi-be (Madagascar) Main gear off the paved surface after landing

5 Apr Egypt Air A330-200, Cairo (Egypt) Wrong taxiway - impacted two light poles

(wrong park position entered into FMS – wing damage)Source: Aviation Herald35


RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page6)8 Apr PSA Airlines CRJ-200, Charleston, WV (USA)

Overran runway - rejected takeoff at high speed 13 Apr Merpati Nusantara B737-300, Manokwari (Indonesia)

Overran runway while landing21 Apr Cargojet B727-200, Moncton (Canada)

Overran runway 06 while landing

Source: Aviation Herald

38 (Since 1st Jan 2010)


Is our collective industry eye still off the SAFETY ball?

http://encarta.msn.com/g.asp?gl=0ENNAR/sea_msn&ds=http://encarta.msn.com/find/Concise.asp?z=1&pg=2&ti=761564189


THE BIG QUESTIONSHOULD INDUSTRY ACCEPT THAT

ACCIDENT & INCIDENT RATES:

(1) ARE AS LOW AS ECONOMICALLY VIABLE?

OR

(2) MUST BE FURTHER REDUCED?


AS GROWTH RESUMES, IF THE ACCIDENT RATE REMAINS UNCHANGED

Expansion of

the global fleet

will increase

the number

of accidents

The accident

RATE must be

DRIVEN

DOWN

further

62


ALTHOUGH THE RATE IS LOW RELATIVE TO ACTIVITY:

A doubling of the fleet next 20 years at same rate could result in

10,000 fatalities or more; tragedies with commercial

consequences for passenger growth

SO WE MUST ACT

To hold accidents down to 150 and a possible 5,000 fatalities,

we must HALVE the accident rate NOW


THE BRIC COUNTRIES (Brazil, Russia, India, & China)

ARE MOST EXPOSED – NEXT 20 YEARS

Source: ACI Sept 08THE BRICS WILL EXCEED USA BY 2027


IN CHINA ALONE: 20 YEAR PROJECTIONS FOR NEW AIRCRAFT:

65

Pre-recession projection: 3,800 airframes

Post recession-REVISED projection:

2,800 airframes

New airline pilots required (including 8,000

retirements): 41,600

Source: manufacturers and IATA


THE VERDICT: ‘RATES MUST BE FURTHER REDUCED’!

This month in Montreal, ICAO announced an action plan to:

Lead a safety information exchange

Coordinate efforts to establisha global safety information exchange to enable analysis of key safety indicators

Work with IATA and the FAA, to "facilitate the collection, analysis and dissemination of safety information provided

by states and industry partners throughout the international aviation community”

But these actions will take a LONG TIME. Improved training is an obvious action which can be taken NOW


ACTION - THE CHALLENGES:


DOEPS [DEFENCE OF ESTABLISHED PROCESS SYNDROME]?

Change is not easy; defense of ‘status quo’ is

A long established process is understood

Prejudice (conclusions without the facts) is a great time saver

New processes are more acceptable once widely

adopted

NAAs and Training Organisations prefer not to be ‘first’

THE CHANGE CHALLENGE


BUT:

Hundreds of thousands of safe flights are not news

Airline accidents are immediate media drama

Public perceptions form with the first media bite

THE SAFETY CHALLENGE ANOMALY (AREN’T WE SAFE ENOUGH?)

Approx 18,000 airliners are continuously in operation; that’s approx 2,700,000

passengers in flight

Safe enough to relax? NO, that’s complacency


As hardware and technology improved: crew dependence on automation increased raw piloting and monitoring skills regressed technology was perceived to reduce training need human factors became more exposed as common cause

In parallel, recent rapid growth: reduced average experience on airliner flight decks encouraged new entry criteria for pilots (generation ‘G’ and beyond may pose even more challenges) placed increasing pressure on training systems forced cost savings into crew training programmes

THE SKILL & EXPERIENCE LOSS CHALLENGE (UNCOMFORTABLE SYSTEMIC MIX):


Washington Post, 29 June 2009 “Automated systems are often designed to relieve humans of tasks

that are repetitive. “When such algorithms become sophisticated, however, humans

start to relate to them as if they were

“The autopilot on a plane, the cruise control on a car, automated speed control systems in mass transit, are all conveniences but

fellow human beings”

“The more reliable the system, the more likely it is that humans in charge will ‘switch off’ and lose their concentration, and the greater the likelihood

can become crutches”

that a confluence of unexpected factors that stymie the algorithm will produce catastrophe”

THE AUTOMATION CHALLENGE


THE PROCESS CHALLENGE

INDUSTRY > ICAO DEVELOP BEST PRACTICE

NEW SARPS TO NAA TRAINING ORGANISATION APPLIES NAA REQUIREMENTS PLUS LOCAL ENHANCEMENTS

CUSTOMER NEED DEFINED

REGULATION & FACILITATION

VERIFICATION

COMPETENT SAFE PILOTS INPUTS TO SELECTION

AUDITS: 1) TRAINING ORG BY CUSTOMER & NAA2) NAA BY ICAO

FEEDBACK ANALYSIS

COMPULSORY REPORTING: CUSTOMER & TRAINING ORG TO NAA NAA TO ICAO

Continuous improvement

IS THIS REALLY HAPPENNING?


The training industry has had great difficulty preparing for the

next growth phase, as enterprise resources have been decimated

Belt tightening prevented widespread adoption of best practice;

mostly ‘more of the same’ prevailed

The next growth surge can be seen on a closer horizon

Seeing through the recession

73

THE TIME & RESOURCE CHALLENGE (THERE’S LIMITED TIME TO ACT)


THE MANAGEMENT PERCEPTION CHALLENGE

Training practitioners usually agree that TRAINING IMPROVEMENTS ARE

NEEDED, but what about

CAPA Management survey 2009 >>


TRAINING AS A PRIORITY: Current priorities are not training!

Source: Centre for Asia Pacific Aviation Survey, Sept 09

Weak D

em

and

Fundin

g &

Capit

al R

ai...

Oil P

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Vola

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Opera

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Regula

tory

Iss

ues

Envir

onm

enta

l Is

sues

Quality

of

Tra

inin

g

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Short Term Challenges: What will be the 3 biggest challenges for your business over the NEXT 12 MONTHS?


TRAINING AS A CHALLENGE: A greater spread of opinions on the key issues - medium term

Oil P

rice

Vola

tility

Weak D

em

and

Fundin

g &

Capit

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Opera

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Quality

of

Tra

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0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Medium Term Challenges: What will be the 3 biggest challenges for your business over the NEXT 1-3 YEARS?

Source: Centre for Asia Pacific Aviation Survey, Sept 09


How can crew training be enhanced if company

executives don’t see the need?


INDUSTRY ACTION?

CONVINCE DECISION MAKERS THAT WE HAVE A PROBLEM [ICAO, IATA, FAA ARE CLEARLY CONVINCED]

ENHANCE CREW TRAINING; THE CONTROLLABLE VARIABLE

As hardware cannot be changed rapidly (we have what we have) Crew Training (both airline & GA) must be driven rapidly

towards:

more relevance; proactive to risk & SMS

higher quality & continuous improvement

more sustainability & topicality (recurrent)


FIND THE LOWEST HANGING FRUIT

79


Chairman of the Flight Training Department, Embry Riddle ‐Aeronautical University:

“Our experience and research lead us to believe a successful airline pilot candidate preparation program should embrace a methodology to weed out unsuccessful candidates prior to their employment by the airlines”

IMPROVE SELECTION Remarks to Aviation sub-committee, US House of

Representatives, June 2009:

TOO OBVIOUS? Yes but much more can be done

USD 5,000 more invested in Selection could reduce system risk, and save >USD 50,000 downstream


RAISE TRAINING STANDARDS - EVERYWHERE

81


Cost reductions (‘more’ training cannot easily be

added)

Quality, and relevance must rise

RAISE QUALITY - EVERYWHERE


Much airspace is shared by GA & Airlines One airline supply pipeline is GA Effective early training is vital throughout aviation Many best practices developed for airline operations

could be cross pollinated into GA training

TAKE A MORE GLOBAL HOLISTIC APPROACH

GENERAL AVIATION

Must wheels b

e re-in

vented?


FIND THE QUALITY DRIVERS

Without data, aviation safety is at the mercy of opinion

QA or SMS requires performance data to analyse

This data comes from multiple sources (in airlines):

For example >>


Whole Airline:

IATA OPERATIONAL SAFETY AUDIT (IOSA)

Flight Operations

LINE OPERATIONAL SAFETY AUDIT (LOSA)

USE INDUSTRY EXTERNAL DATA

85

Whole Airline Industry:

GLOBAL SAFETY DATA(ICAO, IATA, FSF..)


USE LOSA (LINE OPERATIONAL SAFETY AUDIT) DATA

After 10 years, and more than 6,000 LOSA flights…

- over 90% of flights exhibited observable crew errors

Numerous events were precipitated by an error made by the

captain, unchallenged by other crew members (reluctance to

challenge, expressed as ‘authority gradient’ (G. Hofstede)

50% of LOSA-observed errors went undetected by the crew

32% of errors were intentional noncompliance (Violations)

86


LOSA DATA SHOWS WHAT CREWS DO RIGHT

87


Emeritus Professor Bob Helmreich (University of Texas), champion

of LOSA & TEM (Threat & Error Management), in October 2006:

“After 10 years of examining how flight crews manage errors

(LOSA data), it is clear that all successful crews do two things: -

No Surprise! But much more can be done

88

1. Cooperate to rigorously monitor and cross check to

make sure they pick up threats and errors early, and

2. Actively engage in checking and verifying every

setting and action which can affect safety.”


Safety Dept

FOQA / QAR DATA & CONFIDENTIAL REPORTS

Flight Operations

SELECTION CRITERIA & DATA (& downstream performance: another presentation!)

USE AIRLINE INTERNAL DATA

89

Flight Operations & Training Dept

CREW PERFORMANCE DATA(training progress, PCs / route checks)

FUTURE INITIATIVE:Flight Operations & Training Dept

SIMULATOR PERFORMANCE DATA


OK SO WHAT’S NEW?

90

Not much, most airlines collect these data already

But how many airlines analyse, organise, and collate this

data into a REAL TIME system ‘health check’?

Airline training systems would benefit immediately; through more rapid response to new threats


ITQI (IATA Training & Qualification Initiative)

Active development of Type VII FSTD ATC Simulation

Active development of Upset Recovery Training (URT)

standards (RAeS International Committee - aviation training in extended

envelopes– ICATEE)

Improved type training programmes;

eg. APT3 (Airbus Pilot Training) & B787 type training – all embedded with

TEM (Threat & Error Management)

ATSAS (Aircrew Training Standards & Safety - safety data driving training)

NGAP (ICAO Next Generation Aviation Professionals) Initiative – March 2010

91

CAPITALISE ON CURRENT INITIATIVES


Recognise the new Airline Pilot License

MULTI-CREW PILOTS LICENCE (MPL)

after 60 years of almost no change

92


MPL concentrates best practiceDespite controversy, MPL is: -

the result of 6 years of industry development to

replace an outdated 60 year-old airline training process

initially very well received: after the Alteon Beta trial

(small sample, but impressive base training results)

an ICAO approved programme and license

a set of powerful airline pilot training tools,

demanding new standards in the airline pilot training

process

Just what the training industry needs: relevance + focus + quality >

93


National MPL regulations are now in place in:Armenia, Australia, Canada, Chile, China, Denmark, France, Germany, Ghana, Latvia, Maldives, Netherlands, Pakistan, Philippines, Singapore, Sweden, Switzerland, Syrian Arab Republic, Thailand, UAE, United Kingdom, Hong Kong (22)

By operators:

94

MPL is now under development, trail, or use in:

Australia, China, Denmark, Germany, Philippines, Singapore, Sweden, Switzerland, United Kingdom, Hong Kong… (10)

Source: IATA

Former Alteon-Boeing Flight Training-CAAC, CAAC-CAFUC, CAPA- Sterling, Lufthansa, Swiss, OAA-Flybe, FTE-Flybe, CAE-Air Asia, Kaufer-Air Berlin, SATA-Tiger Airways, L.U.S.A.-City Airline & Skyways, Alpha Aviation, and proposed Pegasus Flight Academy China (13)


Data Source IATA & Tng Orgs

Prior to the next growth surge, self funded pilot applicants prefer the old CPL route to ensure a job on graduation

MPL beta syllabus: variations in structure and spread:- Some orgs still apply twins and jets to the MPL syllabus,

distracting students with up to three non-airline types Many orgs still apply old pre-ICAO 9625 FSTD categories Some orgs conduct MPL in three separate global locations Aircraft flight training spread: 80 - 130 hours Simulator flight training spread: 155 - 292 hours Course duration spread: 14 - 36 mths

But as the superior performance of MPL graduates is more widely seen, operators will eventually demand MPL

MPL under TRIAL – some challenges


MPL STATUS MARCH 2010:

77

96

GRADUATED:

800Data Source: IATA & EASA MPL Advisory Board 16/17.3.10

STUDENTS IN TRAINING:


Training Comparison:

97

275

65

210

120

201.5

90.5111

56

0

50

100

150

200

250

300

Instruction Time Flight A/C FSTD Instruction

FSTD type 1v & V11 Instruction

Hou

rs

Kind of Training

Multi-Crew Pilot License (290 hrs- proposal)

JAR ATPL(A) Standard Integrated Course incl. T/R

MPL delivers more instructional hours than CPL

Source: IATA


MPL THROWS OUT SPECIAL CHALLENGES:

Upset Recovery Training (URT) – still maturing [but WGs underway include the RAeS International Committee for Aviation Training in Extended Envelopes (ICATEE) to report next year]

ATC simulation – maturing in Type VII FSTD (Flight Simulation Training Device)

Instructor qualifications & training – higher standards

98

UPSET RECOVERY

TRAINING (URT): Actual flight in

training aircraft +

Simulator training


Advanced training equipment + ineffective

instruction = learning barrier

Poor training equipment + effective

instruction = learning catalyst

MPL requires more appropriate (1)

instructor training and (2) training devices

More relevant instructor entry criteria +

improved instructor training = essential for MPL,

however challenging!

HONE THE INSTRUCTOR’S ART – THAT HUGELY FERTILE VARIABLE!

99


Lost Hydraulics - Sioux City United 232 July 89 >

IMBIBE GOOD AIRMANSHIP (the consistent use of good judgment

& well-developed skills (Kern 96) – STUDY EVENTS

100

> Power loss & ditching - US Airways Flt 1549 Jan 09

> Volcanic ash All Engines out - BA 9 - June 82

Cathay A330 – both engines fluctuated - thrust stuck @ 70% N1

asymmetric - landed at 230kts - April 10

(subject to inquiry underway) >

SOMETIMES PROCEDURES & CHECKLISTS MAY NOT BE ENOUGH:


Enhanced Instructor training and oversight

More LOFT (LINE ORIENTED FLIGHT TRAINING) training

More task-focussed, competency-based, quality embedded programmes (as in MPL)

Programmes designed for continuous improvement

Driven by performance & SMS feedback

Training devices designed to training task and learning phase (as in MPL, APT)

Embedded human factors / threat & error management (TEM) (as in MPL)

Mandated uniforms in simulator training – raising crew fidelity

TRAINING ENHANCEMENT SUMMARY:

101


UNIFORMS IN SIMULATION (an easy option; what’s the problem here?)

Zero cost - all crews have uniforms!

Matching crew fidelity with simulator fidelity

Creating a more professional atmosphere in simulator training

102

SO WHY THIS?Let’s just fix it!



Long term the industry is highly exposed to ineffective training

Airlines need to offer comfortable and safe air travel as a long term profitable business plan

Resource flow must be maintained to the vital organs of a positive safety culture

Effective crew training is an investment which protects safety margins for years to come

Training must deliver efficient best practice, with relevance and continuous improvement

104

THE BOTTOM LINE


From the 2009 FAA safety call to action speech (Randy Babbitt): “That day is today”

We must know more about pilot performance over a pilot’s entire career

Good, effective training has to be at the top of our list

We need to ensure we’re meeting and exceeding the standards

The fundamentals of quality training are clear and direct

One of the quickest ways to spread excellence is to cross-pollinate

We need to share so that we’re all at the highest level possible

We have some great opportunities to look at best practices …..

ONE LIGHT SWITCH FOUND!


Are airline COOs & CFOs AWARE of Training as the critical safety priority to address today?

Will budgetary maximums be ‘regulatory training minimums’ next financial year?

Two Parting questions


TRAINING & SAFETY ‘TAKE-AWAYS’

OPTIMISE BEST PRACTICE - minimise additional cost

MEASURE to continuously improve

EMBED MEASUREMENT into the

training process, and instructor’s task

EMBED TEM into all training thinking

If QUANTITY shrinks, QUALITY must grow

107

SAFETY GROWS FROM EFFECTIVE TRAINING


Thank You!


Best practice safety-driven training founded on MPL in one location

Aimed at higher training standards

+ expanded safety margins

ENTER THE PROPOSED

Pegasus Flight Academy


Documents

WATS 10 ‘Training for Safety’ John Bent 1 TRAINING FOR SAFETY John Bent Director Training Strategy proposed Pegasus Flight Academy - China World Aviation