2009

NEWS

NON GOVERNMENTAL ORGANISATION

How are you solving the puzzle of implementing SMS around your exist-ing systems?

EDITORS:

John SaullExecutive Director

Linda HareSecretary

Andrew McClymontIFA Trustee

PUBLISHED BY:

The International Federation of AirworthinessIFA Secretariat14 Railway ApproachEast GrinsteadWest Sussex RH19 1BPUNITED KINGDOM

Tel: +44 (0) 1342 301788Fax: +44 (0) 1342 317808E-mail: sec@ifairworthy.comWeb: www.ifairworthy.com

UK registered Charity No. 296354

VAT No. GB5052673 63

IFA News is published free of charge to members and to other interested parties to keep them informed of the activities of the Federation and to disseminate worldwide news from aerospace industry.

Reproduction of material contained in IFA News is not permitted with-out written permission of the editor.

Except where stated none of the articles or other items in this newsletter are to be taken as expressing the opinion of the Federation.

IFA News is published annually.

3

ContentsIFA News 4-6 President Focus ‘Expectations’

Fatigue in Maintenance Issues

Membership Focus - EVAS

Regulatory News 7-11 EASA Updates

AircraftCertificationforBirdStrikeRisk

Composite Materials

Foreword

Airworthiness 12-20 SMS Implementation - How is it progressing?

The Role of Safety Culture in Aircraft Accidents

PMA Parts

Flight Safety in Icing Conditions

Human Factors 21-24

HF Presentation User Tips

International commercial aviation is being pressed to further improve its safety standards with an increasing pace of regulatory change, driven by ICAO. There is the Global Aviation Safety Road Map, changes to Annex SARPs to include Safety Management Systems (SMS) and a State Safety Programme(SSP).Introductionof thesecomplexinitiativeswillrequireflexibilityintheapproachtoregulatory approval. and timescales.

SMS or Integrated SMS (ISMS) has been in the forefront of deliberations for a few years, but has by nomeansmetthecompliancedate.IndeedmanyStatesarestillatthestageof defininganddevelopingtheirbasicregulationsand industry implementation guidance plans, including the use of the ICAO Safety Management Manual which is being updated.Clearly.someStateswilllooktomirrormajorregulatoryauthorityschemesoncedeveloped

Undoubtedly,progressisbeingmadeandbasicSMStrainingisbeingconductedincludingriskanalysistechniques.However,there are several controversial aspects yet to be resolved at an industry level, for example, what are the standards required for the appointment of the Safety Manager, how will existing approved Quality Systems be matched into an SMS, what are theriskanalysisscenariostobeassessedforeachcategoryof approvaland,howdoesthewholeprocessfitinwithnationalindustrial health and safety (HSE) legislation and requirements?

A further important question arises; how will the regulators standardise their acceptance (Approval) level. It will be dependent ontheapprovalcategory,sizeandcomplexityof theorganisation.Theuseof BestPracticesisoftencitedindocumentsandpresentations,butwherearetheydefined,itappearstobeamatterof interpretationi.e.subjective.Officialtechnicalprocedural documents should be listed as SMS guidance material.

Itisobviousthatimplementationof SMSisatleastamediumterm,ongoingdevelopmentalprojectwithhumanfactorsintegration (understandingandcommunication)at itsverycoreandonwhichoverall successwill largelybe judged.Wealreadyknowthatcommercialaircraftfatalaccidentsarerareeventsandappearinarandomfashion.Moreoftenthannotit is the simple human element related to the causal factors acting in a combination or sequence of basic errors. Human factors considerations represent the biggest challenge for the satisfactory implementation of SMS, overarching the whole structure.

There is no short term fix to safety initiatives- gains are a slow, laborious and dedicated process. Concentration onimplementing SMS and all its changes must not be allowed to divert the day to day management of basic well established fundamental safety control.

Safety culture has been associated with technological industries such as aviation and nuclear for a long time, albeit it with shortcomings. Introducing SMS gives the impression that we are creating a safety culture. I suggest we should be trying to create a Learning Environment within the safety culture to ensure long term success

www.ifairworthy.com

4

IFA News

Dear Members

You are all aware that last year I wrote to all of our corporate members with respect to

theneedforongoingsupportforIFAtocon

tinueitssignificantcontributiontoaviation

safety. However, despite the onset of recession which has further accelerated due to

thecollapseof debtmarketsweweresucces

sfulinsecuringsponsorshipof Emirates

and Aero Inventory for one year with possible future sponsorship if we met their and

expectations of our other corporate members.

Firstlyitwastoprepareabudgetwhichreq

uiredbreakevenonourfundingwithout

recourse to our trust fund, which we did, whilst at the same time developing our

portfolio of activities and offerings to meet the expectations of our membership.

Secondly tofindoutwhatourcorporatem

embers requiredandsatisfy thisneedwitho

utviolating this

budget.Inordertomeetthislatterobjective

GrahamMitchellQualityManagerAeroInv

entoryhasjoined

the Technical Committee and Abdel Kader Tazerout Executive VP Emirates Airline has agreed to become

Chairman of the Executive Committee. This brings new blood and considerable experience to bear, but

itwillonlyworkif weareclearwhatourco

rporateandassociatemembersexpectof IF

Aastheystrive

to deliver continued improvements in airworthiness and safety in a world that is becoming more and

moretechnologically,environmentallyandec

onomicallydifficult.Thisisparticularlysow

iththeentryinto

serviceof theA380andthedelayedB787.

OnceagainthereforeIamaskingeachof our

CorporateandAssociatememberstotellus

whattheyexpect

of IFAtomeetthischallengingobjectiveand

wouldlikeeachmembertofloodtheExecuti

veandTechnical

Committees with ideas by submitting at least one per member.

FrankTurnerPresidentIFA

EXPECTATIONS-Whatdoyouexpectof IFA?

Sadly, we have to advise of the passing of Harry Payne. Harry was Secretry General of IFATE from itsconceptionin1963uptoitre-organisationintotheIFAweknowtodayin1975.Hewasakeymemberandsupporterof IFATEhelpingtoorganisethefirstconferenceinLondonin1964.Hisworkinthoseearlydaysestablishedtheneedforsuchanorganisation.

Harry Payne, FRAeS, Freeman of the City of London and of the Guild of Air Pilots and Navigators, was born on25thMay,1910.HemarriedKit(JessieKate)Goveronthe1stJune,1935.Theyhadthreechildren,Brian,JillandGeraldine. In1935Harrybecameamemberof theRoyalAuxillaryAirForce.Hewascommissionedin1944asaFighterControlOfficer,withpostingstoInverness,BigginHillandeventuallytotheDesertAirForceinItaly.AfterthewarhereturnedtocivilianlifebutrejoinedtheRoyalAirForceasaregularofficerin1950.HeserveduntilMarch1962whenhetookvoluntaryretirement,beinghead-huntedbytheRAFAssociationtojointheCentralHeadquartersstaff. In1963hebecameSecretary-Generalof theSocietyof LicensedAircraftEngineersandTechnologists.WhilewithSLAEThewasSecretaryof theStandingConferenceforNationalQualificationsandTitle,thatledtotheestablishmentof CharteredEngineersandEngineering Technicians. He became Chairman of the Kingston & Richmond Area Health Authority in 1973 until 1977. InhisretirementheeditedAircraftEngineeringfor4yearsandtheJournalof theGuildof AirPilotsandAirNavigatorsuntil1993.Healsotookoverthefinancesof theRAFEscapingSociety.

Harry Payne1910 - 2009

5

The IFA focus on fatigue within maintenance personnel has over the past year gained in momentum. Early in 2008 we published and widely distributed the second of our white papers on fatigue management, this paper gave guidance information for the establishment of Duty Time Limitations and Rest Periods. The paper was well received with many copies being requested via the IFA website.

IFAmembersMrPhilHosey,andMrFrankJaureguiweregiventheopportunitytopresentapaperonthesubjectatthe2008InternationalAirSafetySeminarheldinHonolulu.Theynotonlytooktheissueof workerfatigue,butalsohighlightedthelackof availablemaintenanceerrordata.Itisshownthatanalysisof dataforflightcrewrelatedaccidentshasproducednew measures and regulations that after implementation has produced reductions of accidents so why is no data provided for maintenance personnel?

Theresultingfeedbackfromthepresentationhasbeenexcellent.Withindaysitwashighlightedinaviationpublications,onseveral news websites and we received an offer for co-operation from the FAA. Further credence was given when the editor of FlightSafetyFoundationmagazinewrotetheJanuary2009issueeditorialonthesubject.

Theissueof HumanFatigueasacontributoryfactorinincidentsisgatheringmomentumworldwide.TheUSNTSBhavepublishedtheir‘MostWantedList’for2009andinthreecatagories,Aviation,MarineandPipeline(Hazardousmaterials)there is the same item ‘Reduce Accidents and Incidents Caused by Human Fatigue’. Under Aviation there are two actions required by the FAA:

- setworkinghourlimitsforflightcrews,aviationmechnanicsandairtrafficcontrollersbasedonfatigueresearch,circadian rhythms, and sleep and rest requirements.

- Developafatigueawarenessandcountermeasuresprogramforairtrafficcontrollers.

Itwillbeinterestingoverthenext12monthstoseehowmuchprogressismadeontheseissues,notjustintheUS,butthroughout the world.

GatheringdataonMaintenanceerrorstoprovideeffectiveanalysiswillbealongtermproject,butwithcompaniesracingtoimplement SMS systems in order to meet ICAO deadlines, reporting and data collection may begin to increase rapidly over thenextfewyears.Aspartof SMSmuchworkisbeingdonebycompaniestoeducatetheirpersonnelabouttheneccessityof reportingandapplyinga‘JustCulture’approachtohumanfactorsinvestigationsassociatedwithincidents/errors.

IFA continues to highlight Fatigue in Maintenance issues

Extracts from IFA presentation made at IASS 2008 - Errors and the Influence of working Patterns and Fatigue

Thepresentationlookedataspectsof accidentsandincidentswhoseoriginsarerootedinmaintenanceerrorsandin particular to establish if fatigue had any part to play.

They asked What part does maintenance error play in air accidents?

The only answer to this question is that we have no answer, neither is it clear if improvement is being made. Figures doexistthatshowthatmaintenanceerrorscauseaccidents–Boeingputhulllossesduetomaintenanceerrorat3%, the FAA say that 8% of US accidents for larger aircraft are maintenance caused and even worse 26% of global accidentsin2003forcommercialjetandturbopropplaneswerestartedbyamaintenanceevent.

In developing protection against these growing trends we need better data on which to act.

Theopenandfactualreportsfromtheworldsinvestigatorsareasignificantcontributiontoaccidentreductions.Everyaccidentandmostincidentreportsprovidedataontheoverallandrecentexperienceof theflightcrew,evenif the crew had no bearing on the accident. Few if any accident reports give similar data for the person or persons involved in the maintenance considered to be the causal factor, why not?

IFA News

Contd over ...

6

UN to propose new rules for pilot rest

The UN's International Civil Aviation Organisation is preparing to rewrite rules on pilot fatigue, abandoning standards based on flighttimeandreplacingthemwith"fatigueriskmanagementsystems."Pilotgroupsaregenerallysupportive of the new approach. "The aviationbusiness has pretty much outgrown the arbitrary flight time limits of the past (and) it is time totakeamorethoughtfulapproachthatuseswhatweknowaboutfatiguetomakethesystembetterfor everybody," saysWilliamVoss, president of the Flight Safety Foundation in Virginia.

Spanner and knife found in engine prior to flight - UK CAA Incident Report - November 2008

A spanner was found in the RH engine coldstream exhaust duct by amember of the pushback team after the flight crewwalkaround. Further inspection also revealed a utility knife.Afterfurtherchecks,theflightcontinuednormally.Thereporternotes that the aircraft had been in base maintenance during the previous night.

CAA Closure: This event was a maintenance error (tool control). Suitable action by the company has been taken against theindividual concerned. Operator has requested individual toolbox inventorycheckstobecarriedoutbyendDecember2008.Allservicecheckteamsbriefedontheincident

As can be seen from the two inserted items below maintenance errors occuring on night shifts are a continuing problem butnew proposals continue to concentrateonpilot fatigue, lets hope that IFA’s continueddrive to look at fatigueof maintenancepersonnelwillsoonseesimilarstandardsbeingputinplace.TocontinueoureffortsFrankJaureguihasbeenaskedtopresentthepaperattheHumanFactorsconferenceinDallasandPhilHoseyishopingtopresentattheCEASconference, Manchester later in the year.

Copies of all relevant papers are available for IFA members from the website – www.ifairworthy.com Non-IFA members can download the white papers from the FREE papers page of the website.

Membership FocusIFA’s membership continues to grow and we are pleased to welcome our new Associate member. Our members cover all aspects of Aviation and we are pleased to provide this focus on our newest member and to give them theopportunitytoshowhowtheyfitintotheIndustry.

IFA News

“Eden Valley Airworthiness Services is an aviation consultancy based in the north of England and commenced business inSeptember2008.Weprovide trainingandconsultancy related to–butnot limited to -EuropeanAviation Safety Agency (EASA) regulations, including Human Factors. Our experience covers aircraft maintenance, Quality,maintenancemanagement and training for awidevarietyof fixed and rotary-wing aircraftoperatedfor commercial air transport, State and private purposes in many parts of the world. Past experience also includes providing training on behalf of the business unit of a national regulator and long-established training organisation. Our staff are licensed aircraft engineers by profession who cut their teeth,fingersandheadseitherinaircraftmaintenanceforcharterorscheduledcarriersandsmallerGAorganisationscoveringlineand/orbase maintenance. All served recognised apprenticeships with AMOs or production organisations and several hold current foreign aircraft maintenancelicensesaswell.Themovefromhands-onmaintenancetoanofficeenvironmentprovedattractivewhenconsideringfew,if any,nightshiftsandsmellingof aftershaveratherthanhydraulicfluid,engineoilortoiletfluids.However, thebenefitof amaintenancebackground is anabsoluteboonand facilitatesareasof common understanding in those with whom we interact. EdenValleyAirworthiness Services is very pleased to join the IFA and to play a small part in contributingtowardsourcommongoal–safety–andenhancingawarenessof suchtotheindustryandthepublic.Welookforward to meeting many of IFA’s members in the near future.”

www.evaservices.co.uk

7

European Aviation Safety Agency Updates

Common European air operation rules in reach The European Aviation Safety Agency (EASA) has published on its website proposed implementing rules for air operations of community operators, including the corresponding acceptable means of compliance (AMC) and guidance material (GM)aswellascertificationspecifications (CS) forflight time limitations.Following theAgency’sprinciplesof broadconsultation and transparency, interested persons worldwide now have the possibility to comment on this Notice of Proposed Amendment (NPA 2009-02) by using the Agency’s web-based Comment Response Tool (CRT). The comment period ends on 30 May 2009.

ThedraftimplementingrulesaredevelopedfollowingtheAgency’sextensionof responsibilitiestorulemakinginthefieldsof airoperations,flightcrewlicensingandthirdcountryoperators(Regulation(EC)No216/2008).Withthepresentdraftrules,EASAestablisheshighlevelsafetyobjectivesbindingtoallEuropeanoperators.Theywillbethecommonbasisforthecertificationof commercialCommunityoperatorscreatingalevelplayingfield.Thedraftrulesfornon-commercialoperations on the other hand are tailored to the complexity of the aircraft used.

TheNPAwasdevelopedinarulemakinggroupwithseveralsubgroups.Toallowaseamlesstransitionandconsistency,thedraftrulesarelargelybasedonexistingmaterialsuchasEU-OPS,JointAviationRequirements(JAR-OPS1and3,draftJAR-OPS0,2and4),aswellasJAAJointImplementationProcedures.

TheAgency set-up a dedicatedwebsite (www.easa.europa.eu/flightstandards), to keep stakeholders up-to-date on thestatus of the extension of responsibilities.

Product SafetyEnd of October 2008, The European Commission has adopted the amendment to Part-M that introduces alleviations for general aviation. This is the result of extensive dialoguewith general aviation stakeholders andisonecomponentof theeffortsundertakenbyEASAtosimplify the regulations applicable to this activity.

Thecertificationspecificationsapplicabletolargeaeroplanes(CS-25)havebeenamendedtointroducenewspecificationsforElectricalWiringInterconnectionSystems. This isanimportant amendment that has been developed in close coordination with the US Federal Aviation Administration as a result of air accident investigation recommendations.

In2009,significantopinionswillbepublishedconcerningthe following topics: (i) certification of light aircraft, (ii)creation of a license for aircraft engineers for light aircraft and (iii) improvement of the operational suitability of aircraft. - EASA News - Feb 09 Issue 1

International CooperationEASArecentlysigned12WorkingArrangmeentswiththeChineseAuthoritiesonthevalidationof certificatesissuedbyEASAonseveralEuropeancivilaeronauticalproducts.Furthermore,EASAheldthefirstInternationalCooperationForuminColognelastNovember.Thiseventattractedaround100delegatesrepresentingmorethan50statesandorganisationsaroundtheworldthatareusingtheEuropeanAviationSafetyAgencyrulesastheirnationalorregionalframework.Currently,theAgency ispreparingWorkingArrangementswith13ECACcountries toensure thepan-Europeanco-operation foraviatonsafetyaftertheclosureof theJAA(June2009)-EASANews-Feb09issue1.

EASA ReorganisationAsof 1January2009,aneworganisationalstructureappliesto the Agency. The main change is that a new Finance andBusinessServicesDirectorate iscreatedwhiletheoldAdministrative Directorate ceases to exist. Within theFinanceandBusinessServicesDirectorateallapplicationsforthecertificationof productsororganisationsincludingflightpermitsareprocessed.

The Directorate also coordinates the Agency’s outsourcing activities to National Aviation Authorities and will be in charge of Financial Services and Procurements.

EASA NewsletterEASAinadditiontotheirweeklyemailbulletins,NewsSummaries and Industry Avaition News, will now also produce a traditional-style newsletter to complement their existing technical publications. The quarterly EASA News gives an overview of some of the “hot topics” at the Agency.

Regulatory News

8

Regulatory NewsAircraft Certification for Bird Strike Risk

Experienceof AccidentandIncidentshasledtoprogressivelytougherrequirementsalthough,aswithmostcertificationstandards, grandfather rights are applied so that new requirements are not retrospectively applied to in-service aircraft and engines. The Standards established by both the FAA and EASA are essentially similar but are not fully harmonised. However, new aircraft and engine types have to meet both so the most demanding of each applies in each instance.

Bird Impact Forces

What has been convincingly demonstrated from incident data analysis is that, although the number of recorded birdimpactsreducesrapidlywithaltitude,thegreaterthealtitude,thegreatertheproportionof birdstrikeswhichproducemajordamage.

Apartfromspeed,anumberof factorshavebeenidentifiedasinfluencingthedamageabirdimpactcancauseandareallconsidered during the design of both aircraft and engines in an attempt to understand the robustness of structures and enginestobirdimpactfromfirstprinciplesaswellastopreparetomeetcertificationstandards.Theyinclude,withthemostcommon simplifying assumptions shown:

BirdweightBirddensityBirdrigidity[deformationby50%of itsshape]Angleof impact[90degrees]Impactsurfaceshape[flat]Impactsurfacerigidity[nodeformity]

The important point to be aware of is the degree of force with which birds, especially the larger ones, hit a moving aircraft. A6.8kggooseimpactinganaircraftdoing200knotsexertsaforceof over16tonnes.Theeffectof proportionalitytothesquareof theairspeedisillustratedbythefactthatthesame6.8kgbirdhittinganaircraftdoing250knotsexertsof forceof nearly26tonnesandhittinganaircraftdoing280knotsexertsaforceof over32tonnes.Clearlythereislittleprospectof ‘hardening’anyenginetoresistsuchaforceandcertificationstandardsdonotaddresstheissue.

Engine Certification Standards

Current standards for bothmultiple and single bird engine ingestions into a single fixed wing aircraft engine exist inequivalentforminFAA14CFRPart33-77andinEASAAirworthinessCodeCS-E800’BirdStrikeandIngestion’.Thebasicrequirementsforengineingestionwererevisedin2000totakeaccountof bothevidenceof anincreaseinthesizeof birds impacting aircraft and issues raised by the development of very large inlet, high by pass ratio, engines.

Airframe Certification Standards

Currentstandardsfortheimpactof asinglebirdwithalargeaircraftairframeexistinbothFAA14CFRPart25-571andinEASACS-25.631asdesignrequirementsforwhichmeansof complianceareprovided.Thisisthatanaeroplanemustbecapableof continuedsafeflightandlandingafterhittinga4lbbirdatthemorecriticalof:

Vc (cruise speed) at mean sea level or85%of Vcat8000feetaltitude.

Future Directions

Anumberof concernshavebeenquitewidelyvoicedaboutthecontributionof certificationtothemitigationof theriskof hazardousbirdstrikes:

The case of bird ingestion into more than one engine at the same time is not addressed directly and it is clearly extremely difficulttomeaningfullyestimatetheprobabilityof suchanoccurrence.However,ithasbeenobservedthat,sincesomeof the current standards only require that a damaged engine can be safely shut down, this circumstance should be more fully considered when determining the acceptable outcome of ingestion into single engines, especially for the twin engine case.

Ithasbeennoted that thepotential effectsof bird strikesonmodern electronicflight control systems andflightdeck

9

Peggy Gilligan, the new FAA Associate Administrator for Aviation Safety, outlined FAA efforts to reduce the probability of birdstrikes.HerremarksweremadeatacongressionalhearingfollowingtheUSAirwaysFlight1549emergencylandingintheHudsonRiverinJanuary,believedtobecausedbyamultiplebirdingestion.AbirdstrikedatabasemaintainedbytheWildlifeServicesProgramof theU.S.Departmentof Agriculture(USDA)hascollectedover100,000voluntarywildlifestrikereportssince1990andisavailabletooperatorsandsafetyanalystsfordeterminingwhichspeciesaremostfrequentlyinvolvedinstrikes,seasonalpatternsandextentandtypeof damagefromstrikes.FAA,withUSDA,workstoeducateandincreaseawarenesswithindustry,conferencesandparticipationonthenationalBirdStrikeCommittee.FAAairworthinesscertifications require thataircraftbeable tosurvivesituations includingflight intoaflockof birds,emergency landingson land, loss of engine power and emergency landings in water. The Airbus A320 involved in the Hudson River landing waspoweredbytwoCFM56-5B4/Pengines,whichwerecertifiedtobeabletoingestbirdsandshutdownsafely.InothertestimonyattheHouseTransportationAviationSubcommitteehearing,NTSBMemberRobertSumwaltsaid,“Thefactthattheaccidentenginesexceededeventoday’sstandardandstillfailedisof greatinterestandconcern.”NTSBisconsideringwhethertorecommendtougherfederalstandardsforjetenginesinresponsetotheincident.TheBoardhasnotedenginesshould be able to withstand birds as large as the Canada goose, which can weigh up to 24 pounds, thereby representing a more realistic threat to airplanes, Sumwalt said.

ExtractsfromKirstein&YoungPLLC/AttorneysatLawMarch2009

FAA Work on Bird Strikes

instrument displays have not yet been fully assessed.

BothEASAandtheFAAhaveindicatedthatthesemattersremainunderreviewatvaryinglevelsof priority.

Theotherissuewhichhasbeenraisedinrelationtocertificationtoprotectagainstunacceptableoutcomesof aircraftbirdimpactistheapparentabsenceof aco-ordinatedapproachfromthestandpointsof aircraftcertification,aircraftoperationalmatters (like speed andvertical profile) and themanagementof birdprevalence (thedichotomybetween the strongestriskmanagement optionswithin airport perimeters and arguably the greatest risks to aircraft safety beyond the airportperimeter)

ExtractstakenfromarticleAircraftCertificationforBirdStrikeRiskavailablefromSKYbrarywebsite:www.skybrary.aero/index.php/Aircraft_Certification_for_Bird_Strike_Risk

Regulatory News

Mitigationof thebirdstrikeriskrequiresacombinedandconcertedactionbyairports, landowners, localauthoritiesandplanners.InthepasttheCAA’sSafetyRegulationGrouphasoverseenseveralinitiativestotackletheproblem.TheCAAsets out guidance in CAP772,BirdstrikeRiskManagementforAerodromes and the Airport Operators Association has published Safeguarding Advice Notes,compiledjointlywiththeCAA,toprovidebirdstrikeandothersafeguardingadvice.

InDecember2003theAirNavigationOrderwasamendedtomandatethereportingof allbirdstrikes,regardlessof whetherdamagewascausedtotheaircraft.Thisrequirementwasintroducedtogathermoreinformationonbirdstrikes,sothatnewstrategiescouldbedevelopedtobringtheincidentratedownandalsobecauseof theperceivedunderreportingof birdstrikeevents.

During2008approximately1477birdstrikeoccurrenceswerereportedtotheCAA,representinganincreaseof 40%onthenumberof strikesreportedtotheCAAin2003(theyearimmediatelypriortomandatoryreporting).During2004-2008,theperiodsincemandatoryreportingwasintroduced,thenumberof strikesreportedtotheCAAannually,hasaveraged1537.

CAA UK Work on Bird Strikes

10

Mostbirdstrikestoaircraftresultinnodamage.However,seriousbirdstrikescanleadtoanaircrafthavingtoaborttake-off,returntotheairportitdepartedfrom,ortodiverttomakeanemergencylanding.During2008therewere62birdstrikeoc-currences reported to the CAA under the auspices of the MOR scheme, however, this number has been relatively constant year-on-yearforthepast10years,withanaverageof 58eventsannually.

Aerodrome bird control

Modernaircraftenginesaredesignedandbuilttoberesistanttomultiplebirdstrikesfrombirdsof upto4.5lbsinweight.TheCAAhasplayedaleadingroleindevelopingenhancedenginecertificationrequirementsandtheNTSBandAAIBrec-ommendationshaveservedfurthertoemphasisetheneedforsuchactivity.Thisworkhasbeenconductedinco-operationwithothersafetyregulators(theUSFederalAviationAdministration,TransportCanadaandotherEuropeanJointAviationAuthorities) and the aero engine industry. However, these requirements are only the last line of defence; it is far better to reducethechancesof birdstrikeshappeninginthefirstplace.Birdscaringandcontrolmeasurespractisedbyairportsareinthe main an effective tool in the airports armoury. UK licensed airports have developed, together with the CAA, a series of programmesaimedatreducingtheriskposedbybirdswithintheairfieldboundary.

Off airport bird control

ItiswidelyrecognisedbyIndustryexpertsthatthebiggestriskfrombirds(particularlygullsandwaterfowl),lieintheim-mediatevicinityof anairport.Althoughmuchworkhasbeendoneinrecentyearstofocusonincreasingtheeffectivenessof off-airport bird awareness, this is still an area of particular concern to the CAA and one that needs the co-operation of many interested parties. Although within the airport boundary the management of birds is now managed well, control of birdsoutsidetheairportislesseffective.Consequently,theCAA,togetherwithindustrystakeholders,government,wildlifeandconservationgroupsagreethatmoreworkneedstobedoneonhabitat-management,whichwouldyieldbetterlong-term results in reducing the hazard and improving safety.

Toreducetheriskposedbybirdstrikesinthevicinityof anairport,itisimportantto‘manage’thelocalhabitattodiscour-agebirds.Thiscanmeanthenettingof nearbyponds,lakesandlandfillsites.TheCAA,ascanairportsthemselves,adviseagainstthegrantingof planningpermissionfordevelopmentsinthevicinity(upto13kmfromtheairport)thatarelikelytoincreasethebirdhazardsuchaslandfillsitesordevelopmentswithwaterfeatures.Additionally,guidanceisofferedonthetypesof habitatlikelytoattractbirds,includingtheplantingof fruit/berrybearingtreesandshrubs.

TheCAAalsoregularlypublishesinformationforairportoperatorsandothersabouttherisksof birdstrike-forexample,thisleafletcomprehensivelydetailstheissues:http://www.caa.co.uk/docs/1437/srg_acp_00018-01-030303.pdf All the CAAinformationonbirdstrikescanbefoundonthispermanentpageontheirwebsite:http://www.caa.co.uk/birdstrikes

Regulatory News

UKCAA-AirworthinessCommunication2009/03

Ensuring Satisfactory Co-ordination Between Operators and Maintenance Organisations for Maintenance Check Flights

This AIRCOM is intended to remind all Operators and Maintenance organsiations of their responsibilities, and to offer additional general advice andguidanceinrespectof maintenancecheckflights,anyflightsconductedforinvestigativepurposes,ortestflying,customeracceptanceflights,orlease‘handback’flights. The importanceof formalandaccuraterecordingof defects isalso highlighted.

This follows a recent incident involving aB737-700 aircraft. Control of theaircraftwas lost during a post-maintenance checkflight. Whilst the incidentitself wasspecifictotheBoeing737aircrafttype,manyof theissuesidentifiedcan be read across to other aircraft types.

ToviewtheAIRCOMvisitwww.caa.co.ukandsearchforAIRCOM2009/03.

FAA Confirms Gilligan in Top Safety Post

Peggy Gilligan is the new US Federal Aviation Administration, Associate Administrator for Aviation Safety, replacing Nicholas Sabatini, who retiredinJanuary.ShehasbeenDeputyAssistant Administrator for Aviation Safety since July 1995. JohnHickey,Director of theAircraft CertificationService since 2000, will replace Gilligan andHickey’sDeputy,DorendaBaker,will replace him.

11

Airworthiness

PMA Parts Thesubjectof “PMA”continuestoattractattention.The industry,be itregulator,operator,manufacturerorMROwillhave a view on the issues involved. Much media coverage has tended to the opinion that the debate is over and universal acceptance has arrived. This is not wholly the case. PMADefinition-Toremindmembersof thedefinition,therearetwoprimarydefinitionsof aPMApart;Identical(tooriginal) and Non Identical. In the case of non identical, the applicant must prove by test or other process that the part meets the requirements of the original part. IFA supported a paper presented in Paris at IASS 2006 entitled “Safety Considerations in the PMA Industry”. Many observers werekeentoseehow-particularlyinEurope-thelongstandingprocessof theApprovalof partsmanufacturebynonOEMparticipantsmetthesafetyneedsof users.Longbeforethisconferencehowevermanyof themajorairlineswerearguingfortheneedtoregulateaccesstowhatisuniversallyacceptedaslowercostparts.TheUSindustrythrough“FAA/PMA”haveledtheway.ASAIB(NE-08-40)relatingtoPowerplantswasissuedinAugust2008. Even before the formation of EASA some National regulators provided for PMA usage in controlled cases. Since EASA thedebatecontinuesforaEuropeanversionof PMA.Accordingtotherulemakingprogramme(task21.046)theEASAdecisionisduefordeliveryinJanuary2011. Much comment has ensued both from industry and the media, the latest of which was published in Flight Global on the 6th March 2009 under the headline “PMA prospers under egregious economy”. WhileEASAhasyettoprovideanequivalentruleto14CFR21.303and305,widespreadusecontinuesaroundtheworldof PMAparts,indeedPMApartsareissuedinsomecaseunderthecertificationof aircraftmanufacturers!

However,awordof caution.Whilemanyregulatorsapproveoraccepttheuseof PMAparts,someaircraftownersand/oroperatorsdonot.ThisineffectmeansthatwithinthestocksheldbyApprovedMaintenanceOrganisations(RepairStations),willbeparts,properlycertified,butacceptableonsomeaircraftyetnotonothers.Thiscannotbeacomfortablesituationforthefuture!

ExtractsfromFAASpecialAirworthinessInformationBulletinNo.NE-08049DateAugust8,2008

Powerplant - Original Type and Production Certificate Holder Parts and Aftermarket Modification and Replacement Parts.

Recommendations: The following information is provided to assist the aviation community with regard to the installation of FAA-approved replacement parts -

1) FAAapprovedTC/PCholder,PMA,andSTCpartsareinterchangeablewithinthecertificatedproductsincetheyareapprovedonly after a full demonstration of compliance to the applicable requirements of Title 14 of the Code of Federal Regulations (14 CFR).APMAorSTCpart,whenFAAapprovedforinstallationonacertificatedproduct,isavalidreplacementparttotheTC/PC holder part according to 14 CFR;

2) Unless stated otherwise as a limitation to an STC, the FAA has determined and the applicant has shown that FAA approved life limitsestablishedfortheTC/PCholderpartsremainunchangedforthoseTC/PCholderpartswhenPMAorSTCpartsareinstalledelsewherewithintheproduct.Forexample,thelifelimitforaTC/PCholderdiskisunchangedandremainsineffectwhenPMAbladesareinstalledinthatdisk;

3) The FAA approves the content of an ALS and ICA based upon its review of the substantiating data provided by an applicant. Applicants for PMA or STC parts are required to assess the ICA requirements. A PMA or STC applicant either shows and states that the product’s ICA are still valid with their part installed or provides a supplemental ICA for any differences; and

4) TC/PCholders,andSTCholderareresponsiblefortheCOSsupportinaccordancewiththeapplicablestandardsfortheirpartsand products which they have designed and produced.

Owners and operators are ultimately responsible for the safety and airworthiness of the product, which includes being responsible fortheconfigurationcontrolof theproduct.Ownersandoperatorsmustensurethatanyreplacementpartinstalledintheproductisapproved for that installation and further, they must also ensure that they follow any supplemental ICA that may have been developed for that part.

12

Safety Management Systems Implementation

Airworthiness

Many organisations and companies are busy preparing and implementing Safety Management Systems in order to comply withICAOandRegulatormandates.AlthoughthedateforAnnex8maybeextendeduntil2013,afullyworkingsystemtakes2-3yearstoestablishandtheinitialdateof November2010isamoreimportantdateforcompaniestoworkto.

WehaveaskedtwoIFAmembers,EmiratesAirlineandChinaAircraftServicesLimited(CASL)whorepresentdifferentsections of the airline industry to advise us as to how they are implementing and progressing with their individual SMS.

Firstly,weknowRegulatorsarepreparingrulesforSMSandweenquiredasto:

Which regulatory programme are they are complying with?

It was interesting to learn that the General Civil Aviation Authority (GCAA) the Regulatory Authority for the UAE, has not yetpublishedanyrules.AnNPAhasbeenissued(thedatefortheNPAwasextendedfrom1stJanuary2009to17thJanuary2009) and the industry in the UAE have participated to the debates. The rules are to be issued later this year.

Inlightof thisandthefactthatEmiratesareanapprovedEASAPart145company,theyaregoingtofollowtheEASArules.The UK CAA has given an introduction and guidelines which Emirates are actively pursuing to meet the EASA timeline.

CASL is developing their SMS in accordance with the CAD (Hong Kong) requirements. An SMS Steering Committee has been established for the purpose of developing the SMS, monitor its progress and resolve any problem which arise. The CEO of CASL is heading this Committee as Chairman.

SMS is not new and many companies have been implementing SMS for some time:

How are you now fitting your exisitng systems in the new regulations?

Emirates have had an Integrated Safety Management System (ISMS) for a few years. A gap analysis has been done which hasidentifiedsomeminorchangestomeetrequirements.

CASLfirstimplementedaQualityManagementSysteminaccordancewithHKAR-145in1998.In2003theyintroducedanindustrial SMS and then a year later a Maintenance Error Managmeent System. These three systems have provided the basic elementsandstructurerequiredfortheHKAR-145mandatedSMS.LikeEmiratesagapanalysisbetweenthethreesystemsand the HKCAD requirements has been carried out and CASL is now using the results to formulate their SMS.

Challenges faced with implementation and progressing of the SMS.

Kader Tazerout, VP-EQA has identified the areas of challenge withinEmirates“Thechallengewehaveasanorganizationandspecificallyinthefieldof engineeringisthetimelytrainingof allthestaff andsupervisorycommunityintheriskassessmentknowledgeandintroducingsuchnewprocesses in an already heavily regulated system in place at the present time. The change in organisational responsibilities is also a challenge at this time due to the current economical crisis, and having two similar organizations (quality and safety) seemingly doing the same jobwill behardtojustifyandIwouldexpectthattheSMSwillbeintegratedintothecurrent QA organization.”

Angus Cheung, CEO of CASL has noted the following areas as being challengingandgivesthesolutionstheyareworkingtowards.

a. SMS Training Toensurethefuturesuccessof ournewSMS,afteridentifingthatthe

training gaps existed, we have scheduled a two years initial SMS training program together with Safety Campaigns, quiz and poster / screensaverdesignstoprovidethenecessaryknowledgeaswellasarousetheinterests and safety awareness of all the staff.

ICAO Rules

New provisions are proposed by ICAO regarding the harmonisation of the existing safety management requirements. In a Letter to the States (AN 12/51-07/74, dated 7December 2007), ICAO presented its proposal for the amendment of Annex 1, Annex 6, Parts I and III, Annex 11, Annex 13 and Annex 14, Volume I, to harmonise and extend provisions relating to safety management. The applicability date envisioned for these provisions in Annex 6, Parts I and III, Annex 11, Annex 13 and Annex 14, Volume I is 19 November 2009. A separate applicability date for the proposed provisions in Annex 1 and Annex 8 is 18 November 2010. An optional applicability date of March 2013 is envisaged for Annex 8.

13

UK CAA State Safety Programme (CAP 784)

The UK has recently issued its State Safety Programme (SSP) in accordance with ICAO Standards. It notes `This is an ambitious undertakingandonethattheUKwelcomes.ForaStatetoproducean SSP, it requires the State to examine its own legislation, policies and processes in a new light. Although it may have assumed that all was in order, the SSP may reveal issues that should be resolved to improve the way in which aviation safety is managed in the State`

CAP 784 highlights the structure of aviation regulation in the UK whichconsistsof multipleauthorities(DfT,CAA,EASA)workingtogether to achieve aviation safety.

ThisdocumentwillbekeptupdatedontheDfT/CAAwebsite-www.caa.co.uk/docs

b. Setting up Safety Targets For effective continuous monitoring of the SMS performance, a set of safety targets has to be established. However, this

isnotaneasytasktogetallthedepartmentstoagreeonwhatarereasonabletargets(i.e.canbeachievedwithreasonableeffort).

c. Reportingof Potentialrisks IthastakenCASLmanagementalotof timeandefforttopromoteriskassessmentconceptstothefrontlinestaff and

encouragethemtoreportpotentialriskstotheirsupervisorsaftertheriskshavebeenidentified.

Conclusion

Ourgrateful thanksgotoEmirates,CASLandShellAviationforsharingtheirexperienceswith implemetingSMS. Wecandrawfromalltheircommentsthattheinitialstageof implementationisfittingtheregulationsaroundexistingsystems,throughusinggapanalysistheareasneedingimplementationoramendmentcanbeidentified.

AsweknowSMSisforthewholecompany/organisationsoitispositivetoseethatthetoplevelof companiesareheadingthe implmentation processes.

Inall threeorganisationstraininghasbeenhighlightedasakey issue,makingemployeesawareandraisingtheir interestandmotivationintheseissuesisdifficultandduringthecurrenteconomicclimatewhenbonuses,reducedworkhoursandincentivesareveryfewandfarbetweenitwillbeevenmoredifficult.

EASA NPA 2008-22c :SMS

A further meeting of the European HF Advisory Group was held at EASA HQ, Cologne on 11th Feb. Items discussed included NPA 2008-22c concerning SMS proposed requirements for regulated organisations. The discussion focussed on pages 7&8 (OR.GEN.200) and 24- 34 (AMC to OR.GEN.200(a)) which relate to Management System requirements. It should be noted that this NPA has been written initially for OPS, FCL and Aeromedical centre codes - it will eventually cut acrossPart 145 andPartM.The closingdate forcomments has been extended to 14th April 2009.

Airworthiness

Modelled Risk Scenarios for an Aviation SMS System Paper

This paper covers thework carried out by ShellAircraft International (SAI) to develop its SMS requirements and inparticulartheriskscenariosthatwereidentifiedanddocumentedinthedevelopmentof itshazardanalysis.ThisoriginalworkhassubsequentlybeenfurtherdevelopedbytheSAIprojectleaderandauthorof thispaper,Cliff EdwardsthroughworkdonebyAviationHazaredManagementLtd(AHML)anaviationsafetyconsultancy.ForthepasttenyearsIFAhasplayed an active role in promoting and supporting aspects of SMS including having had input to the development of the riskscenarionsdiscussedinthispaper.Acopyof thepaperisavailableviatheIFAwebsite-www.ifairworthy.com

14

The Role of Safety Culture in Aircraft AccidentsbyProfessorGrahamBraithwaite

Head,Departmentof AirTransport,CranfieldUniversityUK

AbstractIn recent years, a great deal of emphasis has been placed on the role of safety culture in global aviation operations, particularly as part of an established safety management system. However, the way in which safety culture is both measured and managed is still the subject of much discussion. Furthermore, the investigation of safety culture following an accident adds further levels of complexity and potential bias to the task. This paper will discuss some of the issues and potential pitfalls surrounding the definition, measurement and investigation of safety culture and also examine the role of ‘Moments of Truth’ and the effect they have on both internal and external perceptions of safety culture.

Introduction

With thepublicationof theSafetyManagementManual in2006, the InternationalCivilAviationOrganization (ICAO)signaled its intent that member States should require operators to establish a formal safety management system (SMS) by 1 January2009.Asthedateapproaches,aflurryof activityisapparentacrosstheindustry.Whilstmanyof thecomponentsthatform an SMS are well established, it is their interaction within a well designed system that promises a tangible improvement in safety. Ultimately, the facilitation of an SMS depends on the shared beliefs and attitudes (culture) of the organisation if it istogobeyondthetheoreticalframework.

Althoughmuchhasbeenwritten aboutwhat safety culture should look like, understanding its role in the causationof incidentsandaccidentsishardertodefine.Thebiasesandtrapsthatmayaffectinvestigators,analystsorotherinterestedparties can give a distorted view of the role of safety culture and may be a factor in unwittingly shifting blame from individuals to their managers. If safety culture is to evolve positively, the industry needs to understand not only where it is aiming, but how it reacts to apparent failures of safety performance.

Safety Culture

The term safety culture first appeared after the catastrophic reactorfire atChernobyl nuclear power station located in the Soviet Union near Pripyat, Ukraine in 1986. Since then, the termhas beenwidely discussed by theindustry and academia alike, althoughasReason (1997)pointsout, “fewphrasesaresowidelyusedyetsohardtodefineassafety culture”.Whilstthetermitself isjustover20yearsold,theroleof anorganisation’sway of doing thingsasafactorinaccidentshasbeenknownforratherlonger.

The Royal Commission’s investigation into the 1979 Mount Erebus disaster provided a pivotal role in changing the way accident investigation involving complex socio-technical systems was conducted. Viewed in the context of modernsafetythinking,thefocusonorganisationalfactorsisunremarkable.However, at the time, the Commissioner went far deeper than the technical investigation did to examine the organisational and cultural factors within the operator and regulator. The Commissioner experienced a strong political backlashwhenhisfindingswerereleased,notleastbecauseof thedifficultconclusions he made about the honesty of the airline’s senior management, summarising the evidence he had heard from them as “…an orchestrated litany of lies” (Mahon, 1981).

Erebus was later cited in texts such as Beyond Aviation Human Factors (Maurino,Reason,JohnstonandLee,1995)andtheICAOHumanFactorsDigest No. 10 (ICAO, 1993) as an example of the way in which actions takenclosetothemomentof occurrencehadinmanycasesbeenseededorcompoundedbyevents,conditionsorthewayof workingmonthsoryearsbefore.Withtheworkof systemsafetyspecialistssuchasPerrow(1996),Rasmussen (1983 etc.) and Reason (1990, 1997b etc.), the appreciation of organisational failings has grown considerably.

ProfessorGrahamBraithwaiteHead, Department of Air Transport,

CranfieldUniversity,UK

ProfessorGrahamBraithwaiteisHeadof theDepartment of Air Transport and Director of the Safety and Accident Investigation Centre at Cranfield University, UK. AFellow of the Royal Aeronautical Society and Member of the International Society of AirSafetyInvestigators,Prof Braithwaitehas led the development and delivery of investigation, human factors and safety management courses for a range of external clients. He has also consulted extensively in safety and human factors matters. His research interests are in accident and incident investigation, human factors, safety managementandtheinfluenceof cultureonsafety.Prof BraithwaiteholdsaBachelorof Science (Hons) in Transport Management

Airworthiness

15

Thefataltake-off accidentatDryden,Ontario,Canadain1989furtherhighlightedtheinfluenceof thewidersafetysystem.TheCommissionof Inquiryexaminedfactorsfromactivefailuresonthedaythroughtodeficienciesintheairline’soperationand the wider regulatory environment. Concluding that the accident “...was a result of a failure in the air transport system”, Moshansky(1992)highlightedsystemicissuesinawaythatfewtechnicalinvestigationshadbeenabletodopreviously.AseriousincidentintheUKwherethepilotof aBAC1-11wasnearlysuckedoutof hisaircraftafterthewindscreenfailedallowedUKAirAccidentsInvestigationBranch(AAIB,1992)Inspectorstoconsidernotjusttheerrorsof anindividual(theshiftsupervisorwhomanagedtofitincorrectly-sizedboltstotheaircraft),butalsotheprocessesandpracticesthatshouldhave been in place to defend against the inevitability of human error.

These three accidents are well documented examples in which “the way of doing things” compounded individual failures, errors and violations. However, as the enthusiasm for SMS gathers pace, the question remains, how can we identify a failing safety culture prior to an accident, or indeed diagnose the role of safety culture in an incident or accident?

Measuring Safety CultureRodEddington,formerCEOof AnsettAustraliaandBritishAirways,oftenremindedhisstaff “…if youcan’tmeasureit,you can’t manage it”. In terms of safety culture, things are no different; the transition from one level of safety culture to the nextneedssomesortof measurement.Hudson(2001)buildsontheworkof RonWestrumindescribingtheevolutionof safety culture from “pathological organisations” (who cares as long as we’re not caught?) to the ideal “generative culture” (safety is how we do business around here).Suchstagesof evolutionareusefulmarkers,butidentifyingwhereanorganisationfindsitself onthescaleisalittleharder.TheAmericanInstituteof ChemicalEngineers’(2005)definitionhighlightswhymeasurementisdifficult:“Safetycultureishowtheorganisationbehaveswhennooneiswatching”.Itisalsoconceivablethatthe‘observereffect’ will modify the very thing being measured.

Anumberof researchershaveinvestigatedthemeasurementof safetyculturewithseminalworkpublishedbybothZohar(1980) and Reason (1997b). The methods that were generally employed included questionnaire-based techniques to score theorganisationinanumberof safetydimensionsaccordingtothemodelbeingemployedwithZoharcorrelatingthesedimensions against the effectiveness of safety programmes within industrial organisations. However, questions exist as to howwellthisindustrialmodelrelatestotheaviationindustry,althoughworkhasalsobeencarriedoutintospecificsafetyculturesurveysforaviationoperations(Gibbons,vonThadenandWiegmann2004).

Theproblemiscompoundedbyalackof dataintheaviationindustryandthe,albeitdesirable,lackof accidentsfromwhichto obtain it. Recent investigation trends in the aviation industry have seen the increased use of incidents as safety indicators andpre-emptorsinanattempttoaddressthelackof dataandthishasobviousparallelswithZohar’slaterwork(2003)toenhance both modeling and measurement through the use of “micro accidents”.

One failure of the questionnaire-based approach is that it lacks any measure of observable behaviours. Whilst someresearchers highlight the relative accuracy of this approach and its ability to capture change within an organisation, this presents a different challenge in accident or incident investigations where pre-existing data may not be available and where the effect of the accident on perceptions within the organisation may preclude any meaningful post-accident measurements. The advantage of measuring observable behaviours is that awareness of the measurement criteria will tend to improve those aspects; the disadvantage is that the same awareness will tend to improve only those aspects.

Whenanincidentoraccidentoccurs,aquestionnaireapproachisunlikelytobeappropriate,notleastbecausetheeventitself may have changed the perception of culture, or at least people’s recollection of it prior to the event. This is part of what Reason refers to as outcome knowledge.Justasallotheraspectsof investigationneedmultipleevidencesourcesandinductivereasoning to corroborate any conclusions, so evidence of the effect of culture needs to be collected. One way to achieve this is to test the organisation against established ideals for a safety culture (see Reason, 1997b).

Ideals for Safety Culture

An informed culturecomprehendsthehazardsthatitfacesandtheriskthateachof thempresents.Yet,organisationscannotanticipateallof thehazardsitislikelytofaceoraccuratelypredictthemagnitudeof allrisks.Farfrombeingafatalisticattitude,thisisanacknowledgementthatthewayinwhichconditionsandfailurescombinewithinacomplexsocio-technicalsystem cannot easily be mapped, even in mature organisations. Aircraft accidents are rare events and there are many examples where those with complex causality are the ones that slip through the safety net – the so-called “impossible accidents” (WagenaarandGroeneweg,1987).

Airworthiness

16

Whereano-blame approach was once advocated by many in the industry, there is now strong support for just culture to be at the heart of an SMS. It remains appropriate for accident investigations conducted through processes such as those found in the ICAO Annex (Aircraft Accident and Incident Investigation) to be no-blame in order to preserve the integrity and independenceof theprocess.However,modernthinkingonSMShighlightstheneedtomakeacleardistinctionbetweenwhatisacceptablebehaviourandwhatisnot.Whereresourcesandtrainingsupporttheemployeetomaketherightdecision,ajustculturewilltreatgenuinelyunintentionalerrorsquitedifferentlyfromwilfulviolations.Indeed,whenanincidentoraccidentoccurs,employeeswilllookforfairtreatmentof themselvesandtheircolleagues,orbehaviourswillstarttomodifyaccordingly.Misapplicationof eitherno-blameorjustculturewillunderminethecorevalueof amaturesafetyculture–trust.

A reporting culturewants toknowwhat ishappeningwithin theorganisation–bothgoodandbad.Negative feedback isproblematic, but a complete absence is arguably worse. In the airline environment where serious incidents are rare, there can be a natural reluctance to be the bearer of bad news. Following one incident, the accident investigation agency called the airline to say that they thought it was unusual that their safety manager had not attended the site. For the safety manager, thiswasthefirstnewsof anincidentthathadoccurredtwodayspreviouslythatnoonehadwantedto‘troublehim’with.Whenreviewingtheroleof reportingfollowinganoccurrence,theinvestigatormustconsiderwhetherthemessagewasabletogetthrough,whetheritwaswelcomed,orwhetheritspresencewasindicativethataproblemhadbeenidentified,butnotdealt with.

A learning or proactive culture is one that recognises that incidents, near-misses and voluntary reports can provide vital lessons before the onset of an accident. Indeed, there is a process in place to collate and do something with the information. All too often, the collection of data has become the focus and, with limited resources, there is little time to do anything with it other than present trend data. Several options exist for safety promotion, ranging from publications and presentations to training design and procedural changes. However, it should be borne in mind that no safety improvements can exist in isolationfromthefinancialhealthof anorganisation.Budgetsarenotlimitlessandchoicesneedtobemadeinordertoprioritise initiatives.

Whenanaccidentoccurs,itisalltooeasyfordigruntledemployees,orperhapsthosewhohavebeenaffected,topointtomissed opportunities for the organisation to learn. However, it is possible that the decision that was made at the time was the best one, based on available evidence. A learning culture tries to understand the context of failures. In other words, as Dekker(2002)remarks,“thepointof aninvestigationisnottofindwherepeoplewentwrong.Itistounderstandwhytheirassessments and actions made sense at the time”.

Finally, a flexible culture isadaptabletoevolvingthreatsandcrises.Itisthisaspectthatcanoftenbeoverlookedwhenreactiveinvestigationsfocusonwhatwentwrong,ratherthanlookingforthingsthatreducedthepotentialconsequencesof anevent.Whilstsafetypolicies,processesandresponsibilitiesneedtobedefinedclearlyaspartof anSMS,thewayinwhichan organisation responds to new situations is perhaps the greatest test of a safety culture. Encompassing all of the preceding elements, the ability to trap or mitigate against the impossible accident is the real test.

Interpreting Safety Culture

Mandating that organisations implement an SMS will not guarantee a sound safety culture. Regulators are faced with the unenviabletaskof attemptingtomeasureandassesscomplianceusingelementsof asystemthatarenoteasytomeasure,especiallyafteranevent.AlthoughICAOisclearthattheintentof SMSisnotsomethingthatcanbeachievedthrougha‘tickinthebox’solution,thechallengeof establishingwhattomeasureandhowtodoitremains.ICAO(2006)acknowledgesthat“safetycultureis…difficulttomeasure,especiallywhentheprincipalcriterionformeasuringsafetyistheabsenceof accidents and incidents”. Does this mean that the occurrence of an accident suggests a poor safety culture?

Cultureiseasilymisinterpreted,especiallyif itcrossesorganisational,professionalornationalboundaries.Spokenandbodylanguage,etiquetteandcustomsareallexamplesof thevariablesthatcanbereflectedacrossthecultureof anorganisation.Different combinations of cultural traits can be assembled to produce the same successful outcome – for example, a culture where questioning of authority does not come easily, can be balanced with strict adherence to standard operating procedures whichincludecross-checking.

The interpretation of data from certain elements of an SMS needs care to avoid false generalisations or false correlations. For example, an increase in incident reports may be symptomatic of either an increase in incidents or perhaps a greater willingness to report, or increased ease of reporting. Similarly, the operational requirements or conditions placed upon a certaingroupmayyieldresultswhichcanbemisinterpreted.Inthecaseof onemajorairline,theB737fleetappearedto

Airworthiness

17

yieldahigherproportionof unstableorrushedapproachesthantheotheraircrafttypes.Wasthissymptomaticof thewaythefleetwasbeingmanagedorthecrewtrained?Infact,oneof theinfluenceswasthetypeof flyingthattheB737fleetwas often being required to do, which involved short-notice replacement of aircraft types on sectors where the schedule neededmakingup–somethingthatbydefinitionwasplacingincreasedpressureoncrewsandevenencouragingthemtofly‘enthusiastically’. A blame-oriented view was to see the managers as failing whereas a more enlightened view might be that businessimperativeswerecreatingrisksthatneededmanaging.

Identifying and quantifying the role of safety culture in an occurrence is not easy. Although certain accident investigation agencies (notably theAustralianTransport SafetyBureau and theTransportationSafetyBoardof Canada) havepridedthemselves on their systemic approach to investigation and their willingness to examine organisational factors, this is far from thenorm.Few,if any,accidentinvestigationtextsexplainwhattolookfortoestablishwhethersafetyculturedeficiencieswere a latent condition leading to an event. Is this something that is perhaps best diagnosed in terms of how well the organisation practises the ideals of safety culture?

Moments of Truth

FormerScandanavianAirlinesSystem(SAS)GroupChief ExecutiveOffice,JanCarlzon(1989),spokeof “Momentsof Truth”whendescribingthe50milliontimesayearcompanyemployeescameintocontactwiththecustomer;theiractionsdefiningwhetherthecompanywouldsucceedorfail.WhilstCarlzonwaswritingfromabusinessmanagementperspective,such moments of truth are equally valid when determining both the internal reality and external perception of safety culture.

For example, a recent event within a Maintenance, Repair and Overhaul (MRO) organisation tested the commitment of senior management to its stated aim of developing a safety culture. The MRO organisation was very busy and a customer’s aircraftwasparkedoutsidethehangarformaintenance.Thecrewthatwasworkingonitwenttostartanair-poweredjackwhichwasplacedbeneaththewing.Despiteseveralattempts,thejackwouldnotstartandfitterswerecalledtorepairit.Afterinspectionandseveralattemptstofixit,itwasconcludedthatareplacementwouldbeneeded–(thisisalongdash)somethingwhichwouldtakeanhourtoarrange.Atthispointthemaintainersdecidedtotakelunchearlysothatthejackwouldbeavailableontheirreturnandtheycouldkeeptoschedule.Unfortunately,whilsttheywereaway,thejack(whichhadnowdriedoutfromthewatercontaminationthathadcauseditnottowork)startedtoworkandbegantoscrewitself upinto the wing of the aircraft, causing considerable damage.

Theinitialreactionwastoestablishwhowastoblame.Themaintainersagreedtheyhadtakenthedecisiontogotolunchearlyasagroupandassuchtheywouldtakeresponsibilityasagroup.Thetemptationformanagementwastostartdisciplinaryaction for the whole group – after all the repair bill was potentially several million dollars. However, there was also recognition thatthewayinwhichtheeventwasdealtwithwouldhaveaftershocksthroughtheorganisation.Althoughwithhindsight,amajorerrorhadbeenmadeinleavingthejackconnectedtotheairsupply,theintentof thegroupintakinganearlylunchwasapositiveone,relatedtotheircommitmenttomeettheworkschedule.Sackingthegroupwouldbeanexpensivemistake,notjustintermsof thelossof skillsandcapability,butalsoinsendingamessagetootherstaff thaterrorswouldbepunished.Eventhoughtheconsequencescarriedhighfinancialworth,theerrorsthatledtoitwerenomoresignificantthanformanyother inconsequential near-misses.

Anothermomentof truthoccurredasaresultof alandingaccidentinvolvingaB737cargoaircraftatBirmingham,UKin 2006. During landing approach at East Midlands airport, the pilot inadvertently disconnected the autopilot leading to a highrateof descent.Ago-aroundwascalled,butitwastoolatetoavoidcontactingtheground,breakingoff therightmainlandinggear.TheaircraftdivertedtoBirminghamwhereanemergencylandingwassubsequentlymadewithoutinjury.

TheresultingAircraftAccidentInvestigationBranch(AAIB)report(2008)highlightedanumberof causalandcontributoryfactors,includinginappropriatetransmissionof acompanymessageatalatestage(500feet)of aCategoryIIIautomaticapproach, and ineffective training of the co-pilot – the latter prompting a recommendation that the regulatory authority require the operator to review their standard operating procedures. As a result of the accident, approximately one month later, the operator sacked the pilot andwas quoted (MailReporter, 2006) as saying, “Although theAAIB investigationcontinues, it has been established that the automatic pilot was disengaged. That is down to human error. Although the pilots didmanagetorecoversuperblyandmadeatextbookemergencylandingatBirminghamairport,theyinstigatedtheincidentwith a momentary lapse and the company operates a zero accident tolerance level”.

Thefullfactsareunlikelytobedisclosedinthepublicdomain,but if momentary lapsesaretobepunished(orat leastperceivedtobepunished)throughazerotoleranceculture,theeffectonthesafetycultureislikelytobenegative.Should

Airworthiness

18

the“superbrecovery”and“textbookemergencylanding”bythecrewbetakenintoaccountinlearningfromtheeventorwas the error unforgivable?

InAugust2007,anaircraftCaptainallowedaPremiershipfootballerontotheflightdeckof anA320privatecharterenroutefromFinlandtoManchester,UK,contraveningthestatedpolicyof theairline.Thepilotlateracknowledgedthathehadbrokenarulebutarguedthathedid“…interprettherulewasn’tquiteasstrictforaprivatecharter,whichthiswas.Everyoneonboard kneweachother”(BBC,2007).Hewasdismissedforgrossmisconductwithaspokesmanfortheoperatorquotedassaying“Wehaveazero tolerancepolicy towardsanyactionswhichcouldendanger thesafetyof ourpassengersandemployees”.

Inthiscase,theviolationrelatedtoasecurityprocedure;somethingwhichmaybetreateddifferentlytootherflightsafetyissues in the current climate. However, the operator had the added challenge of managing the dismissal of a ‘celebrity’ pilot and the involvement of a famous footballer. In these circumstances, should the matter be treated any differently and were external perceptions affected by those who were involved?

Analternativeformof occurrencetookplaceinJanuary2008whenthecaptainof aB777performedanunauthorisedfly-byof theBoeingairfieldduringthedeliveryflight,reportedlypassingwithin28feetof thegroundwiththeundercarriageraised. The Captain was subsequently dismissed as he had “…neither sought nor obtained the necessary company approval toundertakesuchafly-by”(Quinn2008)andtheco-pilotwassubjectedtodisciplinaryaction.

The event was complicated by the presence of a large number of airline executives including the Chairman, with the pilot allegedlyevenbeingpicturedintheoperator’snewslettertoastingthemaidenflightwithairlineexecutiveswhohadbeenonboard.Aseniorpilotfortheairlinewasreportedassaying“Maidenflightsaretreatedasabitof ajollyforexecutiveswithlotsof champagneflowingandthesefly-bysusedtobedoneforawheezeintheolddays.Buttheyaredangerous,becausehowevergoodthepilotthinksheis,heisn’ttrainedforitandtheplanesaren’tdesignedforit”(Batty,2008).

Whilstthefly-bywasaclearbreachof currentpolicy,itappearsthataculturehadexistedwherethiswasanacceptedpracticeand it is at least arguable that the presence and subsequent “celebration” of the event by executives amounted to tacit cultural approval. The apparent inaction of senior managers provides a strong case for the pilot to argue that he felt his actions to be culturally acceptable. Indeed, as safety leadership starts at the top, were the senior managers not equally culpable for the practice?

Itisinterestingtoreflectthatthesethreecasesarguablyrepresentthreelevelsof occurrencefromseriousviolationinthecaseof thefly-by,throughproceduralviolationbytheA320captaintomomentarylapseinthecaseof theB737.Despitethis,allthreeresultedinthesameoutcomeof dismissalof thepilot.However,itisdifficulttoimaginethatallthreeaffectedthesafety culture of the organisation in the same way, or that effect on the internal and external perceptions were the same.

Bad Accident: Bad Safety Culture?

Does the occurrence of an accident indicate the presence of a bad safety culture? Various hindsight biases encourage observerstoconsiderbadoutcomestobetheresultof badpeopleorhorrendousmistakes,somethingcompoundedbytheinstantnewscultureof lookingforsomeone,orsomething,toblame.Yettherealityisrarelysoclear-cut–someof themosthighlyregardedairlineshavebeeninvolvedinmajoraccidents,oftenafterlongperiodsof accident-freeoperation.Forexample,AmericanAirlineshadflownoverninemillionsectorswithoutlosspriortoaB757collidingwithterrainnearCali,Colombiain1995.InotheraccidentssuchasthoseinvolvingSASatMilanLinate,Italyin2001andDHLoverÜberlingen,Germany, in 2002, there was little more the operator could have done to prevent them. However, such events have an effect on the culture of the organisation and the perception of its customers.

Conclusion

The importance of safety culture has become widely accepted, but its measurement, particularly following an occurrence, remainsdifficult.Whilstthereisclearguidanceastowhereorganisationsshouldaimtobe,theresponseof anorganisationtoaneventwillprovideadefiningmomentof truthinestablishingthefuturedirectionforitssafetyculture.Understandinghowandwhyfailuresoccuriskeytoevenaproactiveapproachandguidanceonsafetycultureneedstobebasedonanaccurate understanding of how it contributes to accidents.

References - The full list of references are available on the IFA website - www.ifairworthy.com

Airworthiness

19

The US National Transportation Safety Board (NTSB) has again issued their Most Wanted List of SafetyImprovements and again on the list is ‘Reduce Dangers to Aircraft Flying in Icing Conditions: Actions need to be takentoimproveflightsafetyinicingconditions.’

More research is still needed into the problems of Icing. The Aircraft Icing Research Alliance (AIRA), formed from Canadian and US partners, aims to increase co-ordination in aircraft icing research. Presentations made at their annual seminargiveaninsightintothevariousresearchprojectsbeingundertaken,visitwww.icingalliance.orgtoview.

EASA have examined icing incidents to help identify changes in icing certification needs. Some operational changes havebeenproposedonacurrentNPA,butnocertificationchangeshave been suggested at present.

As reported in the Business Aviaton Magazine (Dec08/Jan09)“TheFAAhasyettocompleteeffortstorevise icingcertificationcriteria,testingrequirements,andrestrictionsonoperating in icing conditions. A recommendation added this year on deice boots addresses a widely held, but incorrect, belief that activation of deice boots be delayed rather than started immediatley upon entering icing conditions.”

Althoughdeicebootsandnewwing/enginetechnologyfornewaircraftwillhopefullyreducethedangersof icingconditionsitseemsalongtermproject.Ascanbeseenbythefollowingtwoincidentreports,bothhandandfluidde-icingtechniquesarecurrentlycausingtechnicaldifficulties,whetheritbefromtheiceorfromthecorrectiveactiontakenwiththeice.

Actions needed to improve flight safety in icing conditions

UKCAAIncidentReport-January2009

Sticky fluid found blocking static ports (A321 - 200 at Milan Linate)

During turnround,pilot found“stickyfluid’ (possiblydriedde-icingfluid)blockingRHP1andP2 staticports. Noabnormalindicationsinflight.Onremovalblockageappearedtobecrystallisedde-icingfluid.Almost80%of ports/holeswereobstructed.Thereportersuspectsthatthisabnormalconditionismostlikelytheresultof ade-icingbeingcarriedoutwithoutcarebeingtakentostopstaticportsbeingsprayedwithfluid.

Engine vibration due to ice(A319-100atBristolInternational)

During turnaround slight icing was noted on the leading edge of some fan blades, with slight frost at the front and rear of the blades. Maintenance were consulted regarding ice removal procedures but as no heaters were available the ice was removed by hand. After engine start NI was stable with nr1 engine vibration normal and nr2 slightly high at 4.6. During taxi, when thrust was increased to 30% NI, nr2 engine vibration reduced to normal parameters. On being cleared for take-off anenginerun-upwasperformed:at50%bothengineindicationswerenormalbutat70%nr2enginevibrationincreasedto9.6.Asecondrunupwasperformedwithsimilarresults(nr2enginevibration9.4).A/creturnedtostandwhereinspectionshowedsignificanticeonleadingedge,frontandbackof bladesandoninletguidevalves.

NTSB - Most Wanted List of Safety Improvements 2009

Reduce Dangers to Aircraft Flying in Icing Conditions

Use current research on freezing rain and large water droplets to revise the way aircraft are designed and approvedforflightinicingconditions.

Apply revised icing requirements to currently certificatedaircraft.

Require that airplanes with pneumatic deice boots activate boots as soon as the airplane enters icing conditions.

Airworthiness

20

FAA HF Presentation User Tips and Introduction to New ProjectsDr.BillJohnson

FAAChief ScientificandTechnicalAdvisor,HumanFactorsinAircraftMaintenanceSystemBill-dr.johnson@faa.gov

Summary

FAA’s Maintenance Human Factors Presentation System (See 2008 IFA News) has been widely circulated worldwide. The author offers MHFPS users a few tips to customize the tool to match it to the requirements of their organization as well as thoseof theirNationalAviationAuthority.CurrentFAA2009researchisalsobrieflydescribed.

Product Review and Distribution

The Maintenance Human Presentation System (MHFPS) is a multimedia support system to create human factors presentations and class lecture materials. It contains nearly 170 PowerPoint slides, 10 video snippets, and nearly 40 animations. The launch menu is shown in Figure 1. This article is most relevant if you are familiar with MHFPS. This articleshowsafewtipstomaketheMHFPSmostusefulforyour organization.

Over1,500E-mailsrequestedcopiesof theMHFPSDVDsduringthefirstyear.Inaddition,FAAinspectorshavegiventhe MHFPS to many of the airlines and repair stations in their regions. Over 10,000 copies of MHFPS were circulated in thefirst year. Since the systemwas designed tobe copied

therearelikelymanyadditionalcopiesincirculation.

A reliable cadre of voluntary partners responded to E-mails and distributed the product in a timely manner. The partners include the International Federation of Airworthiness for Europe; FAA’s Civil Aerospace Medical Institute for the Americas; Australia’s Civil Aviation Safety Authority; The Hong Kong Civil Aviation Authority for China; and the Singapore Institute of Aerospace Engineers and Air Transport Training College for South East Asia. The MHFPS is over 1 Gb. in size. Therefore, it is not conducive to web-based distribution. It can be viewed and downloaded from the FAA website, www.faa.gov, but the process is unacceptably slow. Therefore the DVD distribution seems to be the optimal distribution method for now. Obtain the DVD from one of the distribution channels in your region or send an e-mailrequest,withmailaddress,to:aam520-mmpi-2@faa.gov

How is MHFPS Being Used?

ThereisnotyetanorganizedMHFPSusers’blog.Suchablogwouldpermituserstoshowothershowtheyhavemodifiedthe system to meet local requirements. Keep an eye to the FAA website for information on such a users group.

FAAreceivesinformalfeedbackfromusers.MostusershaverecognizedthatMHFPSisnotaCBTasitispublished.Itisapresentationtool.SomesavvyusershaveintegratedtheFAAvideosintolocalCBTsystems.SomeusershavetappedintoLufthansa Technical Training to buy user rights for the 200 additional Flash animations not included with the 40 animations on the MHFPS.

Themajorityof usershavechosentooperatethesystemdirectlyfromtheDVDbyselectingfromtheshort,medium,orlongpresentation.Othersselectapresentationbasedonthetopicsuchasfatigue,error,orthePEARmodel.Withoutdoubt, theMHFPSworksbestwhen it is customized for theorganization. The following section show someways tocustomize the MHFPS

Figure 1. Main Menu of MHFPS

Human Factors

21

The Power Users Make MHFPS their Own

Most trainers have a reasonably high familiarity with PowerPoint.Theycanmodifythesystemfortheirspecificneeds. For example, they can substitute their corporate logo for the FAA logo. Or, preferably, they may add their logo nexttotheFAAbranding.Somemaylinkothervideostothe FAA videos or eliminate FAA media that is not suited to their requirements. The goal is to get the safety message across. Figure 2 is an example of a slide that has been modified,removingassociationwithFAAandcreatingatitleslide for IFA. Using the PowerPoint “Slide Master” tool this IFA theme can be integrated into all of the slides in the presentation.

TomakethechangesforFigure2itwasmerelyamatterof grabbing the IFA logo from the website and inserting it into

the slide. In this example the FAA logo was removed.

Some, including this author, have made the MHFPS a very important element of conference presentations. The system permits you to deliver prepared information, to add your ideas andexperience,andalsotoinjectanoccasionalvideoorFlashanimation. You can use the embedded FAA media or add your ownjustbyaddingahyperlinktothefile.

Figure 3 is an example of a minor, yet effective, change. Note that the conference logo is added to the lower left corner of the slide. Such logos are easily obtained from a conference sponsor or the website. Most sponsors are delighted to see their conference logo on your slides. In this example, the user retained the FAA logo and also added a slide counter. The unobtrusive counter permits the audience to have some idea of theprogressof thepresentation.Thistypeof modificationmakes the audience appreciate that the entire presentationappears to be customized for that conference. Further, it permits presenters to freshen and improve their speech anytime that it is repeated.

AnotherquickmodificationisshowninFigure4.AfterreviewingtheinformationintheMHFPStheuserdecidedtocreatea new summary slide about error. This is new information not included in the original MFHPS. Note that the author also added the conference logo in the lower left corner.

A Few Cautions for Power Users

This advice is for the true MHFPS power users.

ThereareafewminortrickswhenmakingmajormodificationstotheMHFPS. Forexample,eachof theanimationfiles iscontained in a hidden PowerPoint slide that follows the slide with the hyperlink. The hyperlinkmust be pointed to thespecificslidenumber.PowerPointisexcellentandpowerful.However sometimes it stumbles during extensive moving of slides and animations. PowerPoint may change the “properties” of thehiddenanimationfile.If thatoccursthenitismerelyamatterof rightclickingonthehiddenfile.The“Properties”“Playing” must be set to true. The “Properties” “Loop” must be set to false.

Figure3.ChangingtheLogoandkeepingtheVideoLink

Figure 4. Existing MHFPS Format with New Text and Logo

Figure 2. Title Slide Changed from FAA to IFA

Human Factors

22

BeforeyouusetheMHFPSwithanaudienceyoushouldgothrougheachslidethatcontainshyperlinks.Testthehyperlinks.MHFPSgivesyouanopportunitytomakeanexcellentpresentation.However,carelessrelianceontechnologycanleaveyouemptyhandedandembarrassed.Themoreyoupracticethebetteryouperform!

What is Next From FAA’s Applied Research Program?

Nowwetransitionfrompastdeliverables,liketheMHFPS,tocurrentactivityandexpectedappliedoutcomesfor2009andbeyond.

Thereare twonoteworthy2009projects todescribehere. Thefirstprojectaddresses fatigue issues inmaintenance. Asecond project addresses normal operations auditing inmaintenance and ramp environments. Both projects have theexpressed goal of capitalizing on good science to deliver applied solutions for government and the industry. Such products areexemplifiedbytheMHFPSandtheOperator’sManualsforHumanFactorsinMaintenanceandinAirportOperations(See IFA News 2008).

Fatigue

The first project, fatigue inmaintenance, startswith the known fact that fatigue is an important issue inmaintenanceworldwide. Theprojectwill not attempt to recreate experimental studiesor reinvent the known science about fatigue.Instead,theprojectwillcreatedeliverablestoeducatecompanies,workers,andgovernmentsaboutfatigue. Theprojectwillberealisticaboutfatigue.Itisrisky.Therearenomagicbulletstofixanexhaustedworker.Properrestisthebestsolution.

The fatigueprojecthas createdan activepanel comprisedof industry, academic, andgovernmentpersonnel. Thiswillensurethatthescienceof fatigueisproperlycommunicatedinamannerthatwillworkfortheairlines,MROs,andothermaintenance situations. The team plans to communicate and sell fatigue information as effectively as the private sector advertised their consumer products. Such promotional information will include print, video, and web-based media.

Thethreeyearprojectwillhavemanyappliedinterimdeliverables.Thedeliverableswillincludeadvicefornewregulationsbutthatisnottheprimaryobjectiveof theproject.WatchtheFAAwebsiteasthisprojectevolves.

Normal Operations Auditing Systems

Thesecondprojectcentersonnormaloperationsaudits.ForalongtimetheflightoperationscommunityhasbeenusingLineOrientedSafetyAudits(LOSA)andFlightOperationsQualityAssurance(FOQA).Thesesystemsmonitorflightcrewperformance during normal operations. Such systems are meant for post-event investigations. FOQA is automated with computer-basedmonitoringof flightpathandotherfactors.Ithasnoequivalentpracticalsystemformaintenance.LOSA,however, permits peers to monitor peers in an environment that is designed to be non-threatening. The proactive data collectedwithLOSAidentifiesstrengthsandweaknesseslongbeforetheymayleadtoevents.

ThenewmaintenanceandrampLOSAwillapplyrelevanttechniqueslearnedontheflightdeckandputthemtouseforgroundoperations.Therearemanychallengesonsuchaproject.Productsmustincludeaneffectivedatacollectionprocess,the analysis software, the education for observers, and a cultural shift that encourages such peer-to-peer oversight. These tools and processes must be generic and adaptable to organizational requirements. The research team believes that such proactive data collection is at the root of evolving safety management systems.

Like the fatigueproject this applied research is conducted inveryclosecooperationwith industry. In fact, theUSAirTransportAssociationGroundandMaintenanceSafetyCommitteehavetheleadroleontheproject. AirlineandMROlabor and management, along with US manufacturers, will help ensure that the research team scientists and engineers create useable end-products. Stay tuned by watching the FAA website.

Acknowledgement

TheauthorgratefullyacknowledgestheFAAFlightStandardsServiceandtheFAAChief ScientistProgramforfundingsupportfortheworkdescribedabove.Criticalmembersof theresearchteamarefromtheCivilAerospaceMedicalInstituteand Saint Lewis University.

Human Factors

23

Have you seen.....?

Engineering Solutions to Human Problems the IFA/TVC multimedia series that provides amanagement resource to address issues of human error in aircraft engineering.

Engineering Solutions to Human Problems is designed for easy use by the non-specialist in human factors. The series is presentedbyProfessorJamesReason,whoiswidelyregardedasoneof theworld’sleadingexpertsinmanaginghumanerror in hazardous circumstances.

Therearetwoformatsinthepackage:

- Programmes - The DVD programmes are designed tocomefirst.Theyareintendedtocapturetheimaginationand communicate an informed understanding of the issues. Their aim is to motivate the audience and begin the process of changing outcomes.

- Supporting Materials - These on CDs are intended to provide a set of tools to inform and guide decisions and action;fromlong-termmanagementissuestodailytasksbypeopledoinghands-onjobsonthehangarfloor

For a preview visit www.errormanagement.co.uk, for further information and pricing (discounts are available IFA members) please contact:

TVC,34GreatPulteneyStreet,LondonW1F9NPTel:+442077346840www.errormanagement.co.uk

ManagingRiskThe Human Element

RomneyDuffeyBSc,PhD,FASME,PrincipalScientist,AECLJohnSaullCEng,FRAeS,DAE,ExecutiveDirector,IFA

Managing Risk: the Human Element combines descriptive and explanatory text with theoretical and mathematical analysis, offering important new concepts that can beusedtoimprovethemanagementof risk,trendanalysisandprediction,andhence affect the accident rate in technological industries. It uses examples of majoraccidentstoidentifycommoncausalfactors,or“echoes”,andarguesthatthe use of specific experience parameters rather than the traditional calendarperiods for each particular industry is vital to achieving a minimum error rate as definedbymathematicalprediction.

Managing Risk: the Human Element is an essential read for professional safety experts, human reliability experts and engineers in all technological industries, aswellasriskanalysts,corporatemangersandstatisticalanalysts. It isalsoof interest to professors, researchers and postgraduate students of reliability and safety engineering, and to experts in human performance.

Hbk,576pages,October2008,ISBN13:978-0-470-69976-8£80,$160.00Forfurtherinformationvisit:www.interscience.wiley.com/onlinebooks

Human Factors

www.ifairworthy.com