Operational Performance Monitoring -...

Flight Path Management

Simon Harlow

Head of Flight Standards / Test Pilot

Bond Offshore Helicopters

Operational Performance

Monitoring

Simon Stewart

Safety Director / Head of Training

Babcock Mission Critical Services

Safety Through Collaboration

Flight Path Management


The Hot Topics

Issue Causes Barriers

Uncontrolled

flight into

terrain

• Handling Error

• System malfunction • Helicopter

Design

• Systems

• Skill /

Training

• Procedures

Controlled flight

into terrain

• Handling Error

• Disorientation

• System malfunction

Wrong Deck

Landing

• Navigation Error

• Disorientation



Accident

“Swiss Cheese” Accident Model

Event

Barrier

Weakness in Barrier

(like holes in Swiss

Cheese)


Accident


Event


Accident


Design Systems Training Procedures

Latent

Failures

Event


The Hot Topics

Issue Causes Barriers

Uncontrolled

flight into

terrain

• Handling Error

• System malfunction • Helicopter

Design

• Systems

• Skill /

Training

• Procedures

Controlled flight

into terrain

• Handling Error

• Disorientation


Wrong Deck

Landing

• Navigation Error

• Disorientation



What we are doing '..

• Sharing best practise

• Stabilised Approach

• Investigating the problem and solutions

• Wrong Deck Landing Working Group

• 80 reported WDL in last 5 years (suspect there are more

unreported)

• Helicopter –Terrain Awareness Warning System


Wrong Deck Landing Working Group

• Commenced under EHOC (nearing completion)

• To be presented to IOGP Aviation Safety

Committee in October 2015

• Aim to include prevention checklist in next IOGP

Aircraft Management Guidelines (AMG).

• Key Event Findings

• 90% Good day VMC, low workload, multi-stop (2nd or later),

rarely shuttling

• 10% IFR


Wrong Deck Landing Working Group

• Key Recommendation Area

• Multiple recommendations for operator,

logistics and helideck personnel

• Improvements to future installation

signage and lighting

• Review global naming conventions

• Level and quality of reporting needs to

improve!

• Remove the opportunities for human error!


Accident Current Proposed Improvement

Warning

TimeMode(s)

Warning

TimeMode(s)

G-BEON 15.0 6 24.0 4 +9.0

G-TIGH 4.0 6 17.0 3 +13.0

G-BLUN 7.0 1, 2, 4 & 6 8.0 1 & 2 +1.0

G-REDU 4.5 6 16.0 1 & 2 +11.5

HTAWS – New Warnings


Human Error

• Human Performance is the single greatest

contributor to both accidents and the prevention

of accidents.

• We rely on the human not to make errors

• We rely on the human to provide safety barriers

• Do we know how reliable we are?


What is the chance of

Cognitive Failure

AA

BB

CC

DD

EE

FF

1 in 100 0001 in 100 000

1 in 10 0001 in 10 000

1 in 10001 in 1000

1 in 1001 in 100

1 in 101 in 10

1 in 11 in 1


Supervision Error

• We rely on the human to monitor other humans

• Do we know how reliable our supervisors are?


What is the chance of

Supervision Error?

AA

BB

CC

DD

EE

FF

1 in 100 0001 in 100 000

1 in 10 0001 in 10 000

1 in 10001 in 1000

1 in 1001 in 100

1 in 101 in 10

1 in 11 in 1


• Cognitive Failure

• Low Stress 1 in 1000

• High Stress 1 in 10

• Supervision Error

• 1 in 10

Human Error

Source: WASH-1400 (NUREG-75/014)

NUREG/CR-1278


Accident

Take Human Factors into account

everywhere!

Design Systems Training Procedures

Event


Complexity

Can we understand the sources of error better?

How do we build resilience?

Different generations

in service

Aircraft Systems

Operating Environment

Human Performance (Limitations)

Errors have more

complex consequences


Operational Performance Monitoring

Threat and Error Management



links to other workstreams

Automation Monitoring Flight Path

Management

Information

Exchange

We need to understand what people are really doing in the

day to day operation so we can use that information to

continuously improve and create error tolerant cockpits

That improvement supports crew in doing their jobs even

better (design, training, leadership/culture, standards, and

performance management)


Key issues:• Automation feedback can be inadequate

• Differences between types and manufacturer philosophies

• A pilot can have an incomplete and/or inaccurate mental picture

of the aircraft state or flight path

Fatigue

Abnormal event

Knowledge Error

Complexity

Training

Understand

the issues


Pilot Error Accidents (Offshore)


Human Error

“Human error is a symptom of trouble deeper in the

system.” 1

“Underneath every simple, obvious story is a deeper,

more complex story.”1

1 Prof. Sidney Dekker

“The key question in any organizational accident is not

who blundered but how and why did the defences fail?”2

2 Prof. James Reason


Crew Resource Management (CRM)

• CRM was originally developed to address crew errors &

error avoidance

• Threat and Error Management (TEM) is the 6th

Generation of this program with a focus on error

management and the concept of threat identification

and management

• Find ways to get crews to report on Threat and Error

Management of operational issues.


Supporting resilience:

Threat & Error Management training

• To enable crew to

identify threats

proactively and

manage them

• To train crews to

understand the nature

of human error and to

work more effectively

as a team to improve

operational safety

each flight

Adapted from FAA/Industry TEM/LOSA training


Are pilots doing what we expect?pilot interaction with automation

• Pilot monitoring has been shown to be a

causal factor in several accidents

• To better understand how people really

monitor information in the cockpit, we can

find ways to better support build best

practice

Methods

• Pilot Survey

• Eye-tracking PF & PM concurrent

• Compound performance measures (Situational Awareness, subjective, etc.)

• Controls (workload, etc.)

Pictures are from the BA / Thomson monitoring project (parallel fixed wing research)

Fundamental research which can improve training across our industry


Understanding risk leads to better barriers and

controls for pilots

Adapted from FAA/Industry TEM/LOSA training



Change Management

Act & learn

Performance Management

Detection & notification

There are specific initiatives drawn from

the safety strategy such as;

• Safety Leadership (values,

attitudes, behaviours)

• Performance measurement

driving data driven risk

management and evidenced

based training

• Evolution of crew behaviours

through training, information

and support

• Working with regulators and

industry partners to drive safety

standards Risk Assessment

Inquiry & recommendation

Data from daily operations helps us better support effective human performance


What we know''

• Aircraft Systems are getting more complex

• The consequences of errors are getting more

complex

• Humans are NOT getting more complex

• Error rates are not decreasing

• Different Generations of Helicopter pose

different problems

• There is not a single silver bullet


Where next?

• What we cannot do:

Tell crews not to make mistakes….

Rely on procedural barriers…..

• We must understand human performance issues.

• So''''''

• How do we deal with differing levels of technology?

• How can we design an error tolerant cockpit?

• Where should we concentrate our efforts?

Date post:	26-Apr-2018
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Operational Performance Monitoring -...

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