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Flybe SMS and Flight Data Analysis. 21/05/2009. Captain Neil Woollacott. The Flybe Fleets. E 195. Q400. Flybe Today. Flybe is Europe’s largest and most successful regional airline. Serving 13 countries; Over 190 routes flown; Operating from 36 UK and 30 European airports; - PowerPoint PPT Presentation
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Flybe SMS and Flight Data Analysis
21/05/2009
Captain Neil Woollacott
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The Flybe Fleets
Q400
E 195
3
Flybe Today
Serving 13 countries;
Over 190 routes flown;
Operating from 36 UK and 30 European
airports;
Largest airline at 9 UK airports by flights;
7.5m passengers 2008.
Revenues of £536m in 2007/08, record
profits of £35.4 million.
Fourth most spontaneously recalled
aviation brand in the UK;
Operating 73 Aircraft;
Over 500 flights a day.
Flybe is Europe’s largest and most successful regional airline
4
The Company encourages all personnel to report any event which is considered to
be in the interests of Flight Safety
SafetyNet is a tool that enables pilots to submit safety reports which come through to the flight safety department where we can quickly access the details and begin
investigations.
THE COMPANY FOLLOWS A
A JUST CULTURE
How Flybe’s Safety Reporting System work’s
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The Safety Coordinator will o Cross reference will the CAP382o Determine the descriptor & Risk
Crew will submit ASRs on SafetyNet
Safety & Quality will submit EORs on SafetyNet
Safety & Quality will submit GORs on SafetyNet
Require additional information
MORs Closures
Closure Report is submitted onto the Public Summary
No additional information required
Investigation findings are submitted to the Safety/ Quality Department who reviews and completes a compliance check
Fleet Managers
CAA
Aviation ServicesCabin Safety Ground Safety EngineeringFlight Safety
Flight Safety
25/11/08
MORs
ASRsEORsGORs
Ground Safety Engineering
The investigation is allocated an owner
Safety Report Process
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Crew Complete an ASR
Central Safety will determine which department the ASR will go to and then cross reference it with the CAP 382 to establish whether it is reportable under the MOR scheme
MOR reports are emailed to the CAA
Incidents are sent through SafetyNet as an e-mail in a PDF format to the relevant external investigator e.g. ATC .
Providing that we have all the details a full investigation is carried out. Notes and action responses are entered into SafetyNet
When flight safety is satisfied that an investigation is complete, it is closed
Air Safety Reporting Process
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SafetyNet
Full electronic reporting system
Fully transportable
Easy to use
Full audit trail
Full trend facilities
Use at remote locations
Direct link with Flight Data System
Many default form types e.g Airprox,Birdstrike.
Approved Use by the CAA.
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Ensure that everyone understands safety responsibilities. Develop and maintain a culture of safety Equip people to carry out their tasks safely Identify and minimise risks to safety and health Develop safe systems of work The Company promotes safety with others Plans to mitigate the consequences of Accidents & other emergencies Monitor safety performance
Objectives and Goals of the Safety Management System
Operational Safety Meeting (monthly)
Chair : Director Safety, Quality & Training
Vice Chair : Head of Safety & Quality
Director Aircraft OperationsDirector Aviation Services
Post HoldersSafety Coordinators
HS&E DirectorSMS Admin
Chief Officer (as required)
Postholder Safety Meetings (monthly)
Flight OpsMaintenanceGround Ops
Health and Safety
Postholders,Safety Coordinators
Department Managers (as required)
Production MeetingOperating Board
(monthly)Chief Operating Officer
Flybe Group Board
Flybe Safety Committee
(Quarterly Oversight)Non-Exec Director
Central Safety Management System
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The Flybe Top 5 Safety Concerns
FLYBESAFETY PLAN
Loading Errors
Q400 Landing Gear
Altitude Deviations
Human Factors/DisciplineGround De-Icing
Effectiveness
On analysing the safety statistics the Operational Safety Meeting have complied five key areas that pose the highest safety risk to the company.
Flybe intends to focus on these key areas during 2009/10 within the Safety Plan
Medium & High RiskThe probability that the company will have a high risk event
is remote in 2009/10
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HAZARD IDENTIFICATION
EVALUATION OF SCENARIOS AND CONSEQUENCES
QUANTIFY RISK
DECISION MAKING
IMPLEMENTATION AND MONITORING
RISK ANALYSIS & ASSESSMENT
DATA COLLECTION
The core of the Product Safety The core of the Product Safety Monitoring Process is the RISK Monitoring Process is the RISK ANALYSIS & ASSESSMENT.ANALYSIS & ASSESSMENT.
Risk Analysis & Product Safety Monitoring
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P r
i o
r i t
y
No Safety Relevance
Potential for Primary cause for an accident
Causing Operational disturbance
Eventual Reduction on Safety Margin
Potential contributing factor of an Accident
Safety Concern
No Safety Concern
The traditional approach divided the issues into Safety Concern and No Safety Concern categories. This approach is very subjective and does not establish priorities for safety related issues.
Establishing Safety Priorities
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Severity ClassificationProbability
Levelx = RIRI+ Level of control
Reflects the uncertainty regarding assumptions made and the knowledge and control of the related technology.
Severity Classification 1 – Minor (Slight reduction of safety margins) (Routine changes of flight plan)
2 – Major (Significant reduction of safety margins) (Reduction of crew ability to cope with situation) (Phisical effects / injuries to occupants)
3 – Hazardous (Large reduction of safety margins) (Crew cannot be relied upon to implement defenses) (Injuries / death of small proportion of occupants)
4 – Catastrophic (possible loss of airplane with multiple fatalities)
Probability Level
5 – Frequent ( P 10-3 )
4 – Probable ( 10-3 to 10-5 ) May occur one or more times during the operational life of each airplane of the fleet
3 – Remote ( 10-5 to 10-7 )Unlikely to occur to each airplane, but may occur several times during the operational life of the fleet
2 – Extremely remote ( 10-7 to 10-9 ) Not expected to occur to each airplane, but may occur a few times during the operational life of the fleet
1 – Extremely improbable (P 10-9 )Not expected to occur
PRELIMINARY RISK INDEX CALCULATION
Establishing Safety Priorities – Risk Index
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P r
i o
r i t
y
No Safety Relevance
Potential for Primary cause for an accident
Causing Operational disturbance
Eventual Reduction on Safety Margin
Potential contributing factor of an Accident
I n
d e
x
14
13
12
11
10
9
8
7
6
5
4
3
2
Immediate Action Required
Action for Risk Reduction
Improve System Reliability
Monitor
Using the Risk Analysis Tool, each issue receives an index number, indicating the related priority.
Establishing Safety Priorities
A
B
C
D
E
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Immediate Risk Reduction
Risk Reduction System Review
RI 14 13 12 11 10 9 8
Define Action 12 hours
2 days
3 days
1 Months
2 Months
3 Months
6 Months
Action Availability
24 hours
4 days
1 week 2 Months
3 Months
6 Months
18 Months
Time for Action Accomplishment
Next Flight
50 FH
100FH
A*- 5A*
5A*- C*
1 C*
2 C*
* Consider the equivalent to the “A” or ”C” check flight hour interval for the applicable fleet
Time-Reference Table for Action Planning
Using the RIUsing the RI, the safety priority of each issue can be directly perceived by all , the safety priority of each issue can be directly perceived by all involved areas of the company using a involved areas of the company using a Time-ReferenceTime-Reference chart: chart:
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FDM
Flight Data Monitoring
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What Is FDM ?
Definition“A systematic method of accessing, analysing
and acting upon information obtained from digital
flight data records of routine operations
to improve safety”
FDM involves the pro-active use of flight data to identify and address operational risks before
they can lead to incidents and accidents
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Why use FDM ?
The Heinrich Pyramid
Accidents
UnreportedOccurrences
Incidents
Accidents
UnreportedOccurrences
Incidents
FDM Incidents
For every major accident there are several less significant
accidents, hundreds of reportable incidents and thousands of unreported
Occurrences
FDM gives more detail on the incidents, encourages more
consistent reporting and fills in the void that
we know very little about
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Important Ingredients
Important ingredientsA non-punitive company policy/open safety culture
The Flight Safety Manager must be
Trusted by crews to be impartial and maintain confidentiality
Supported and trusted by management
The system and its technology will be worthless
(or destructive) if the human factors are wrong
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Typical Management Process
Flight Data
Flight Safety ManagerData Replay, Analysis
and Verification Cross check BASIS
Review Meetings:FSM, Fleet Training Mgr (all data de-identified)
Changes to Procedures,
Manuals, Training and Flight Safety Investigations
BesafeMag
TelephoneCrew
REMOTE BASES
Download To PC
MAIN BASES
Replay & Analysis System
Back-up System
WLAN
The Ground-Based System
WAN data
transfer
Maintenance &
Development
Program development
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Analysis System
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Flight Data Analysis
Event analysisDetects exceedences of pre-defined operational
envelopes and provides information on the extremes of the operation.
Measurement analysisTakes a set of measurements on every flight
and provides information on the whole operation – quantifies normality
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Benefits
Pilot knowledge & skill
Gaps in the training system
Operating procedures
Environmental operating limitations
CRM
Culture at remote operating bases
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Feed Back - Training
Another deep landing
FDM lessons can be fed back into the training process
Information can identify areas for improvements in training
Events can be used to highlight key safety-related points
Data can be used to improve pilot techniques
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Feed Back - Engineering
Enables continuous checking of FDR parameters
Data can be used to troubleshoot pilot reported problems (e.g. event created to trap intermittent engine fault)
Data can be used to assess structuralimpact of events (e.g. hard landing)
Data can be used to detect misuse which could impact reliability
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Summary
FDM provides valuable information on the
risks associated with new areas of operation
Events can identify hazards which otherwise
may not come to light
The Company can take appropriate corrective
and preventative measures
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Summary
The measurements will build a useful picture
of everyday operations which has not previously
been available
The FDM programme gives us a pro-active
use of flight data which significantly enhances
the safety of our operation.
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Q400 Trend
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Long Flare – Location
THANK YOU