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Executive summary
The human element is the most flexible and adaptable part of the aviation
system, but it is also the most susceptible to influences that can unfavourably
affect its performance. Aviation accidents are rarely caused by a single event or
action, but rather by a chain of factors or events. Though this makes it complex
to analyse, it also infers that, the accident could be averted if one event in the
chain is broken. The fast changing operating environment is posing new types of
challenges to safety. As old risks are conquered, new risks and corresponding
counter measures are emerging. The human element and it’s interaction with
technology still remains at the heart of the solution for improved safety systems.
This paper will attempt to compare the flight data monitoring programme and
safety reporting as sources of safety data sources. This will involve examining the
type of operational issues they are able to detect as well as their
advantages/advantages.
2. Definitions
Safety reporting.
These involves the various mandatory, voluntary and confidential systems put in
place to enable all personnel and stakeholders involved directly or indirectly with
aviation systems provide safety related information. The aim is to have a just
culture in operation to foster a reporting culture that will both expose the root
causes of accidents and incidents as well as prevent re-occurrence of such.
These includes but not restricted to the following: Air safety reports (ASR),Cabin
safety report (CSR),Maintenance safety reports (MSR), Service difficulty reporting
system(SDRS) only applicable to the FAA, Ground safety reports (GSR) and
Human factors reporting, e.g. (CHIRP).
Modern aviation Safety reporting has it’s origins during the enactment hearings of
1958 in the USA. Finally became operational with NASA administering the system
from 15th April 1976.(*2)
3. Comparative analysis
• Proactive vs reactive
• Ease of investigation.
Of course ASR will provide useful contextual information, though it relies on the
ability of the human element to recall complex events during periods of high
stress. The FDMP is definitely a more versatile tool in this regards.
Data from the FDMP is able to provide realistic, accurate and objective and
description of the pilot-aircraft (livewire-hardware) interaction. Thus providing the
vital “When” and “How” it happened. With data validity of at least 98%, the
system is robust. However, there are many scenarios that this data alone does
not provide a clear and comprehensive understanding of the event without input
from the operating crew. The knowing of “Why” it happened.
Irrespective of the honesty and best intentions, the quality of an ASR’s is usually
unwittingly subjective to a plethora of reporter biases. Including but not restricted
to frequency, selectivity, familiarity, conformity, group conformity and
overconfidence biases. This is more evident when it comes to describing the
events in the light of Liveware-Hardware interactions. The inaccuracies range
from subtle to glaring depending on the impact these and other human factors.
Though subject to cognitive lapses, the human reporter is still the preferred tool
of choice that gives contextual and valuable insight to what influenced the
decision making process of the frontline operators. This is the “why” element. It
constitutes a milestone in unravelling the root cause during an investigation.
Conversely, though the FDMP is able to provide a realistic, accurate and objective
information it’ s major drawback is, it still only quantitative in nature.
Analysis can accurately depict how and when an event occurred but leaves out an
important part of the Jigsaw; the why it happened. Why certain decision/ actions
were made/not made.
• Aircraft operational data only vs. Carte blanche broad based data
ASR have a rather “carte blanche” option when it comes to scope of reporting.
Reference to ICAO doc 9859 highlights this fact. “ASR has the mandate to
include….unsatisfactory behaviour or procedure which did not immediately
endanger the aircraft but which, if allowed to continue uncorrected, or if repeated
in different, but likely, circumstances, would create a hazard.(CAP 382, 5.4.3).
This could be anything at all that in the judgement of the reporter is likely to
affect safety.”
All said and done, it is obvious that the FDMP is well ahead of ASR. This can be
seen from the testimonials below:
All safety initiatives have an element of cost attached to it. Given that the flight
safety office usually manages the reporting systems in place, the implementation
of a FDMP will require additional cost. Approximately £300,000 start-up cost for a
small operator with 10 aircraft. These are modest investments compared to the
added safety and operational benefits the FDMP will impart to the core business
function.
Conclusion
The author is of the opinion that the industry is currently neglecting an important
capability of the flight data management programme in improving the current flat
stagnant accident rate. The major weakness of the FDMP is its inability to detect
human factors issues that can be gleaned by analysing inter-cockpit, cockpit-
cabin and pilot-controller communications. The major obstacle restricting this is
possibly the pilot unions and to some extent the airlines. The industry has
accepted that taxi, take-off and initial climb to 10000ft are critical flight phases.
It is therefore reasonable to expect the crew to restrict their communications to
that which is pertinent to the safe operation of the flight. All this requires is some
level of discipline from the operating crew. Of course, the same pilots initially
kicked against the FDM programme, but have now realised the safety benefits. If
this change is implemented, the pilot community will eventually realise that the
safety benefits far outweigh any disadvantages. Knowledge of risks is the key to
flight safety.
References.
1. Cliff Edwards and Jari Nisula;Active safety management (May 2009) City
University London.
2. (2)http://asrs.arc.nasa.gov/overview/summary.html
3. Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of
Crew Resource Management training in commercial aviation.
4. http://www.ukfsc.co.uk.
(2)http://asrs.arc.nasa.gov/overview/summary.html
5. Wells & Rodrigues; Commercial aviation safety 2003
6. ICAO DOC 9859 Safety management manual
7. Reason, J (2006) Managing the risks of organisational accidents.
8. CAP 739, flight data monitoring.
9. CAP 382 The mandatory occurrence reporting scheme
10. S. Dekker (2002), The Field Guide to Human Error Investigations.
11. Heinrich HW (1959). Industrial accident prevention: a scientific approach
(4th ed.). McGraw-Hill.
12. (23) http://www.flightsafety.org/cfit5.html