ch 1-6 Aviation Safety Management System

• State Safety Program (SSP) – State safety policy and objective – State safety risk management – State safety assurance – State safety promotionInstitute of Aviation Technology, RMUTTO Boonyawat Aksornkitti, lecturer 51

• Safety Management System (SMS) – The SMS approved training organization, in accordance with Annex 1 – The SMS certified operator of aeroplanes or helicopters authorized to conduct international commercial air transport, in accordance with Annex 6Institute of Aviation Technology, RMUTTO Boonyawat Aksornkitti, lecturer 52

– The SMS of an organization responsible for the type design of aircraft/ manufacture, in accordance with Annex 8,– The SMS of an ATS provider, in accordance with Annex 11– The SMS of an operator of a certified aerodrome, in accordance with Annex 14*** All SMS must be accepted by State’s responsibilityorganizationInstitute of Aviation Technology, RMUTTO Boonyawat Aksornkitti, lecturer 53

Institute of Aviation Technology, RMUTTO Boonyawat Aksornkitti, lecturer 54

Assignment• Parried assignment – Which Annex is the most important (in your opinion) and why?Institute of Aviation Technology, RMUTTO Boonyawat Aksornkitti, lecturer 55

Chapter 3 :Threat and Error Management (TEM)Institute of Aviation Boonyawat Aksornkitti, lecturer 56Technology, RMUTTO

3.1 Introduction• Threat and error management (TEM) is safety concept in aviation operations and human performance• TEM is developed from experience in avition, such as human performance, interaction between people and organizational, regulatory and environmental factorsInstitute of Aviation Boonyawat Aksornkitti, lecturer 57Technology, RMUTTO

• Worldwide statistics indicate that about 75% of aircraft accidents are caused by Human Factors (HF) deficiencies.• Threat and Error Management (TEM) practices requires the competent use of HF skills.Institute of Aviation Boonyawat Aksornkitti, lecturer 58Technology, RMUTTO

3.2 Components of the TEM• Threats– Environmental Threats : I. Weather e.g. Thunderstorm II. ATC/Airport e.g. communication, short runway III. Terrain e.g. slop, high groundInstitute of Aviation Boonyawat Aksornkitti, lecturer 59Technology, RMUTTO

– Organizational Threats I. Operational pressure II. Eqiupment design III. Trainning IV. Organizational cultureInstitute of Aviation Boonyawat Aksornkitti, lecturer 60Technology, RMUTTO

• Error– factor effect error I. Fatigue (increase reaction time, moody) II. Situation awareness III. WorkloadInstitute of Aviation Boonyawat Aksornkitti, lecturer 61Technology, RMUTTO

IV. Lack of experienceV. MemoryVI. CommunicationInstitute of Aviation Boonyawat Aksornkitti, lecturer 62Technology, RMUTTO

• Undesired States – Undesired states that result from ineffective threat and/or error management may lead to situations and reduce margins of safety in flight operationsInstitute of Aviation Boonyawat Aksornkitti, lecturer 63Technology, RMUTTO

3.3 TEM training• Use Standard Operating Procedures (SOP)– Checklist, Briefings• Cognitive skills– Information management, monitoring and evaluationInstitute of Aviation Boonyawat Aksornkitti, lecturer 64Technology, RMUTTO

• Interpersonal skills– Communication• Personal skills– Scenario based learningInstitute of Aviation Boonyawat Aksornkitti, lecturer 65Technology, RMUTTO

3.4 TEM Strategies and Countermeasures• Hard Resources (systemic based ) – Legislative controls (ICAO, CAA, FAA) – Aircraft Systems Design: Collision Avoidance SystemsInstitute of Aviation Boonyawat Aksornkitti, lecturer 66Technology, RMUTTO

– Operating procedures and practices (SOP's, checklists, briefings)– Training (maintain and develop expertise, improve crew coordination)Institute of Aviation Boonyawat Aksornkitti, lecturer 67Technology, RMUTTO

• Soft Resources (personal and team strategies or tactics) – Planning countermeasures I. SOP briefing : briefing that meets SOP requirements II. Plan started : adequately discussed to provide the crew with a shared understandingInstitute of Aviation Boonyawat Aksornkitti, lecturer 68Technology, RMUTTO

III. Workload assignment : Roles and responsibilities defined and understood for normal and non-normal situations.IV. Contingency management : Development of effective strategies to manage threats including anticipating their nature and consequences as well as allocation of resources to manage themInstitute of Aviation Boonyawat Aksornkitti, lecturer 69Technology, RMUTTO

– Executing countermeasuresI. Monitor and cross checkingII. Workload management : operational tasks are given correct priority to ensure primary flight duties are adequately managedIII. Automation Management : Adequate use of automation is applied to balance workload and situational requirements.Institute of Aviation Boonyawat Aksornkitti, lecturer 70Technology, RMUTTO

– Review countermeasuresI. Evaluation and Modification of Plans : crew decisions are collectively analyzed to verify the existing plan is the best optionII. Inquiry : Crew openly question and clarify current plans adoptingIII. Assertiveness : Critical information and solutions are posited with assertively and without hesitation.Institute of Aviation Boonyawat Aksornkitti, lecturer 71Technology, RMUTTO

3.5 TEM in Flight Operations• Threats – Anticipated Threats : flight crews can anticipate the consequences of a thunderstorm by briefing their response in advance, or prepare for a congested airportInstitute of Aviation Boonyawat Aksornkitti, lecturer 72Technology, RMUTTO

– Unexpected Threats : in-flight aircraft malfunction that happens suddenly and without warning– Latent Threats : equipment design issues, optical illusions, or shortened turn-around schedulesInstitute of Aviation Boonyawat Aksornkitti, lecturer 73Technology, RMUTTO

• Error – Errors would include the inability to maintain stabilized approach parameters, executing a wrong automation mode, or misinterpreting an ATC clearanceInstitute of Aviation Boonyawat Aksornkitti, lecturer 74Technology, RMUTTO

• Undesired Aircraft States – incorrect runway during approach to landing, exceeding ATC speed restrictions during an approach, or landing long on a short runway requiring maximum brakingInstitute of Aviation Boonyawat Aksornkitti, lecturer 75Technology, RMUTTO

3.6 TEM in ATC• Threats– Anticipated Threats : air traffic controller can use information from the weather forecast to anticipate runway changes– Unexpected Threats : call sign confusionInstitute of Aviation Boonyawat Aksornkitti, lecturer 76Technology, RMUTTO

• Error – Equipment handling errors– Procedural errors– Communication errorsInstitute of Aviation Boonyawat Aksornkitti, lecturer 77Technology, RMUTTO

• Undesired state – aircraft climbing or descending to another flight level/altitude than it should; – or an aircraft turning in a direction other than flight planned or directed.Institute of Aviation Boonyawat Aksornkitti, lecturer 78Technology, RMUTTO

– Loss of separation I. Aircraft may be a consequence of a “Level Bust” (unauthorized vertical deviation of more than 300 feet from an ATC flight clearance)Institute of Aviation Boonyawat Aksornkitti, lecturer 79Technology, RMUTTO

II. Aircraft may encounters with “Wake Vortex Turbulence”III. Notified airspace is dealt with under “Airspace Infringement” (enters notified airspace without previously requesting and obtaining clearance)Institute of Aviation Boonyawat Aksornkitti, lecturer 80Technology, RMUTTO

IV. The ground is dealt with under CFIT or Control Flight into Terrain (aircraft under the complete control of the pilot is inadvertently flown into terrain, water, or an obstacle)Institute of Aviation Boonyawat Aksornkitti, lecturer 81Technology, RMUTTO

Assignment• Paired assignment, due after class– Analyze Threat and Error in flight operation and If you were a Flight Operation Officer (FOO), how would you prevent threat and error to the aircraft– Analyze Threat and Error in ATC and If you were an Air Traffic Controller (ATC), how would you prevent threat and error to the aircraftInstitute of Aviation Boonyawat Aksornkitti, lecturer 82Technology, RMUTTO

Chapter 4 :Risk managementInstitute of Aviation Boonyawat Aksornkitti, lecturer 83Technology, RMUTTO

4.1 Introduction• Risk management is The identification, analysis and elimination (and/or mitigation to an acceptable or tolerable level) of those hazards that threaten in an organization.• The complete elimination of risk in aviation is an unachievable goal as not all risks can be removed and not all possible risk mitigation measures are economically practical.Institute of Aviation Boonyawat Aksornkitti, lecturer 84Technology, RMUTTO

• In other words, it is accepted that there will be some risk of harm to people, property or environment, but this is considered to be acceptable or tolerable by the responsible authority and the societyInstitute of Aviation Boonyawat Aksornkitti, lecturer 85Technology, RMUTTO

• Risk management tools– Procedural Event Analysis Tool (PEAT) is a structured, cognitively based analytic tool designed to help investigate flight crew procedural errors and develop strategies to prevent future similar errors.– Cabin Procedural Investigation Tool (CPIT) is a structured analytic tool developed to help operators understand the reasons underlying incidents caused by cabin crew procedural deviations. which are oriented toward flight and cabin crew activities.Institute of Aviation Boonyawat Aksornkitti, lecturer 86Technology, RMUTTO

– Maintenance Error Decision Aid (MEDA) is a structured investigation process used to determine the factors that contribute to errors committed by maintenance technicians and inspectors.– Ramp Error Decision Aid (REDA) is a structured investigation process used to determine the factors that contribute to errors committed by ramp and other ground operations personnel such as baggage handlers and individuals involved in aircraft servicing.Institute of Aviation Boonyawat Aksornkitti, lecturer 87Technology, RMUTTO

4.2 Type of Risk• Informed risk – A risk that has been correctly identified and assessed.• Uninformed risk – This is an unidentified risk as it has not been assessed, we don’t know that we are taking the risk and it’s incorrectly measured.Institute of Aviation Boonyawat Aksornkitti, lecturer 88Technology, RMUTTO

• Pointless risk – These are risks that are taken without any benefits attached to them. A pilot flying underneath the bridge instead of over it.• Benefit-driven risk – These are the risks taken because of the perceived benefits outweighing any risk.Institute of Aviation Boonyawat Aksornkitti, lecturer 89Technology, RMUTTO

4.3 Risk management processesInstitute of Aviation Boonyawat Aksornkitti, lecturer 90Technology, RMUTTO

4.4 Hazard identification• Hazard may involve any – Organization factor situation or condition, for – Work environment factor example – Communication – Regulatory oversight 91 factor – Personal factor – DefensesInstitute of AviationTechnology, RMUTTO Boonyawat Aksornkitti, lecturer

• Hazard Identification Methods– Reactive hazard identification methods - hazards are recognized through monitoring and investigation of safety occurrences.– Proactive hazard identification methods - hazards are identified analyzing systems’ performance and functions for threats and potential failures.Institute of Aviation Boonyawat Aksornkitti, lecturer 92Technology, RMUTTO

Institute of Aviation Boonyawat Aksornkitti, lecturer 93Technology, RMUTTO

4.5 Risk assessment• Assessment of the hazard involves – the “probability” of the hazard of an unsafe event – the “severity” of the outcome of an unsafe eventInstitute of Aviation Boonyawat Aksornkitti, lecturer 94Technology, RMUTTO

– Probability of consequences a) Unlikely to occur (systems fail) b) May occur (human performance) c) Probably to occur (operating conditions)Institute of Aviation Boonyawat Aksornkitti, lecturer 95Technology, RMUTTO

– Severity of occurrencea) Human livesb) property or financial damagec) environmental impactd) political implications and/or media interestInstitute of Aviation Boonyawat Aksornkitti, lecturer 96Technology, RMUTTO

4.6 Risk assessment matrix (FAA)Institute of Aviation Boonyawat Aksornkitti, lecturer 97Technology, RMUTTO

– Unacceptable (Red). the risk would be assessed as “unacceptable” and further work would be required to design an intervention to eliminate that associated hazard or to control the factors that lead to higher risk likelihood or severity.– Acceptable with Mitigation (Yellow) the risk may be accepted under “defined conditions of mitigation”. An example of this situation is the impact of a non- operational aircraftInstitute of Aviation Boonyawat Aksornkitti, lecturer 98Technology, RMUTTO

• Acceptable (Green). it may be “accepted” without further action. The objective in risk management should always be to reduce risk to as low as practicable regardless of whether or not the assessment shows that it can be accepted as is.Institute of Aviation Boonyawat Aksornkitti, lecturer 99Technology, RMUTTO

4.7 Risk mitigation• Defenses can be used to a) reduce the probability of unwanted events occurring b) reduce the severity of the unwanted eventsInstitute of Aviation Boonyawat Aksornkitti, lecturer 100Technology, RMUTTO