Coursework - A

Active Safety Management

10 12 December 2009, Bahrain.

MSc Aircraft Maintenance Management

City University

Submitted by
Mr. Jijoo Jacob Varghese
Contact:
Tel: +971 6 5315896, Mob: +971 55 8178233
Email:

jijoov@gmail.com / Jijoo.Varghese@gulfair.com

Q1. Compare Flight Data Monitoring and Safety Reporting as safety data sources. Discuss
their ability to detect different types of operational safety issues, and highlight especially
areas where one of the tools has a clear advantage over the other.

Case Study:
This case study involves comparison between Flight Data Monitoring and Safety Reporting as safety data
sources and discussing their ability to detect different types of operational safety issues.
Introduction:
Although major air disasters are rare events, less catastrophic accidents and a whole range of
incidents occur more frequently. These lesser safety events may be harbingers of underlying safety
problems. Ignoring these underlying safety hazards could pave the way for an increase in the number of
more serious accidents.
Accidents (and incidents) cost money. Although purchasing insurance can spread the costs of
an accident over time, accidents make bad business sense. While insurance may cover specified risks,
there are many uninsured costs. In addition, there are less tangible (but no less important) costs such as
the loss of confidence of the travelling public. An understanding of the total costs of an accident is
fundamental to understanding the economics of safety.
The air transportation industrys future viability may well be predicated on its ability to sustain
the publics perceived safety while travelling. The management of safety is therefore a prerequisite for a
sustainable aviation business.
Safety has always been the overriding consideration in all aviation activities. This is reflected in
the aims and objectives of ICAO as stated in Article 44 of the Convention on International Civil
Aviation(Doc 7300), commonly known as the Chicago Convention, which charges ICAO with ensuring the
safe and orderly growth of international civil aviation throughout the world.
The human element and its interaction with technology still remains at the heart of the solution
for improved safety systems. This case study will attempt to compare the flight data monitoring
programme and safety reporting as safety data sources. This will involve examining the type of
operational issues they are able to detect as well as their advantages/disadvantages.
Argumentation/Discussion:
Flight Data Monitoring:
Flight Data Monitoring (FDM) is the systematic, pro-active and non-punitive use of digital flight data from
routine operations to improve aviation safety. Flight Data Monitoring (FDM) programs assist an operator
to identify, quantify, assess and address operational risks.
A FDM system allows an operator to compare their Standard Operating Procedures (SOPs) with those
actually achieved in everyday line flights. A feedback loop, preferably part of a Safety Management
System (SMS), will allow timely corrective action to be taken where safety may be compromised by
significant deviation from SOPs.
The FDM system should be constructed so as to:
Identify areas of operational risk and quantify current safety margins.
Identify and quantify changing operational risks by highlighting when non-standard, unusual or
unsafe circumstances occur.
To use the FDM information on the frequency of occurrence, combined with an estimation of the
level of severity, to assess the risks and to determine which may become unacceptable if the
discovered trend continues.
To put in place appropriate risk mitigation techniques to provide remedial action once an
unacceptable risk, either actually
present or predicted by trending, has been identified.
Confirm the effectiveness of any remedial action by continued monitoring.
Safety reporting:
These involve the various mandatory, voluntary and confidential systems put in place to enable all
personnel involved directly or indirectly with aviation systems, to 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 its origins during the enactment hearings of 1958 in the USA. Finally
became operational with NASA administering the system from 15th April 1976.
Comparative analysis
Proactive vs. reactive.
Both methods of data acquisition have elements of reactive and proactive processes. However, most
personnel will hesitate to report observations that have not resulted in an incident unless they have
proof/evidence that it is potentially unsafe and is a re-occurring event. As a result most ASR comprise
mostly of events or near misses that have already occurred. Human error is inevitable and how we learn

to manage it is the key to improving aviation safety. To further complement the NASA led ASRS, the FAA
initiated another confidential and no jeopardy reporting aimed at pilots; Aviation safety action program
(ASAP) in 1997.
The FDM is designed to be more of a proactive accident prevention tool. This is achieved in the detection,
analyses and logical depiction of routine operational trends and exceedances such as:
Exceedances or Events deviation data; e.g. engine, speeds, flaps, gears, unstabilised approach
criteria.
Routine data measurements. Monitoring subtle trends and tendencies before they result in
incidents or accidents; e.g. takeoff weight, Flap settings, temperature, rotations rates, speeds,
pitch.
Ease of investigation.
The FDMP makes it much easier to conclusively investigate a great number of mandatory occurrence
reportable incidences as well as prescribe the best remedial action or cost effective training. Such events
include; go arounds, altitude deviations, Stalls, engine failures, high speed RTOs, tail strikes, heavy
landings, wake/severe turbulence and flight control difficulties accompanied by excessive control
deflections, etc. 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.
Reported vs. unreported events
The number and quality of safety reports in an organization is largely dependent on the safety culture
prevailing within the organization. Bearing in mind, that evidence from research indicates inadvertent
human error is complicit in 75% of accidents. Line observations show flight crew were unaware of about
50% of the errors noticed by observers. Most of these errors were inconsequential, not reported and
therefore not investigated. Resulting in lost opportunities to learn from such events. The logic is simple;
people cannot report what they fail to notice.
An FDMP on the other hand has a valid data capture rate of 96% of all man-machine onboard interaction.
With the development of high data capacity disks, theres no reason why the voice element cannot be
included in the overall data capture. Most airlines that run a FDMP also observe a corresponding increase
in ASR. This is more evident for events like unstabilised approaches and go arounds.
Objective vs. subjective
Data from the FDMP is able to provide realistic, accurate and objective and description of the pilot-aircraft
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 ASRs is usually unwittingly
subjective to an excess of reporter biases. This is more evident when it comes to describing the events in
the light of pilot-aircraft interactions. The inaccuracies range from subtle to glaring depending on the
impact these and other human factors.
Quantitative vs. contextual information
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 finding out the root cause during an investigation.
Conversely, though the FDMP is able to provide realistic, accurate and objective information its major
drawback is, it is 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.
It is obvious that the FDMP has an edge over ASR. The following testimonials vouch for that.
UK CAA: "Such systems allow an airline to identify and address specific operational risks and are strongly
encouraged as part of a Safety Management System."
FAA: "Because of its capacity to provide early objective identification of safety shortcomings, the routine
analysis of digital flight data offers significant additional potential for accident avoidance. It is potentially
the best safety tool of the 21st century."
Conclusion
The aviation industry is currently neglecting an important capability of the flight data management
program 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 analyzing inter-cockpit, cockpit cabin and
pilot-controller communications. 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. The fact remains that the pilots initially objected to the FDM program, but have now
realized the safety benefits. If this change is implemented, the aviation community will eventually realize
that the safety benefits far outweigh any disadvantages. Knowledge of risks is the key to flight safety.
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References:
1. Cliff Edwards and Steve Bond; Active safety management (Dec 2009) City University, Bahrain Module.
2. ICAO DOC 9859 AN/460. Safety management manual
3. CAA CAP 739. Flight Data Monitoring.
4. CAA CAP 382. The mandatory occurrence reporting scheme
5. http://asrs.arc.nasa.gov/overview/summary.html
6. http://www.ukfsc.co.uk.