Agenda

Flight Operations Workshop

Tuesday, October 18, 2011

08:00 – 09:30 Powerplant (GE presentation)

09:30 – 10:00 Coffee Break
10:00 – 11:00 Volcanic Ash – Overview and
Recent Initiatives
11:00 – 12:00 New Generation FMS
12:00 – 13:00 Lunch
13:00 – 14:00 Air Safety Reports and Risk
Management
14:00 – 14:30 Performance Issues
14:30 – 15:00 Flight Profile Optimization
Program

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Agenda

Air Safety Reports and Risk Management

Air Safety Reports and Risk Management

Communication
Summary

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Agenda

Air Safety Reports and Risk Management

Air Safety Reports and Risk Management

Communication
Summary

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Objectives
• What happens when I send a Safety Report to Embraer?
• I’ve just received this OB… is it important?
• How do I know what Embraer is doing about a potential safety issue?

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

TECHNICAL RISK
SOLUTION IDENTIFICATION

PSC
RISK ANALYSIS

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Case: Receiving the Report

• “Shortly after landing flight crew reported ENG 2 NO DISPATCH and ENG 2 REV
PROT FAULT Caution EICAS messages”

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

What do I need to report?

• SNL 170-00-0022 / SNL 190-00-0018: “SIGNIFICANT TECHNICAL/OPERATIONAL
OCCURRENCE REPORTING POLICY”

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Fires caused by a system or equipment failure, malfunction, or defect. An engine exhaust

system failure, malfunction, or defect which causes damage to the engine, adjacent aircraft
structure, equipment, or components. The accumulation or circulation of toxic or noxious
gases in the crew compartment or passenger cabin. A blade structural failure. Flammable fluid
leakage in areas where an ignition source normally exists. A brake system failure caused by
structural or material failure during operation. A significant aircraft primary structural
defect or failure caused by any autogenous condition (fatigue, understrength, corrosion,
etc.). Any abnormal vibration or buffeting caused by a structural or system malfunction,
defect, or failure. An engine failure. Any structural or flight control system malfunction,
defect, or failure which causes an interference with normal control of the aircraft or which
derogates the flying qualities. A complete loss of more than one electrical power generating
system or hydraulic power system during a given operation of the aircraft. A failure or
malfunction of more than one attitude, airspeed, or altitude instrument during a given
operation of the aircraft. Rejected takeoff related to aircraft technical issues. Landing in
other than the intended destination airport (air turn backs, unscheduled landings,
diversions) due to emergency conditions related to the aircraft. In-flight control
difficulty. Hard landing resulting in aircraft inspection. GPWS improper activation. Use of
landing gear free fall system. Bird strike resulting in aircraft damage. Lightning strike
resulting in aircraft damage. Wake turbulence (vortex) encounter resulting in aircraft damage
or injury to persons or aircraft attitude outside the operational envelope. Turbulence
resulting in aircraft damage or injury to persons. Rapid depressurization and/or
pressurization difficulties. Tire burst or tire thread separation resulting in aircraft
damage. Presence of foreign object in the aircraft that could affect its operation.
Captain/First Officer seat slide / failed to lock during aircraft operation. Anomalous, not
annunciated behavior of the guidance or navigation system which significantly changes the
aircraft path entered by the crew. Anomalous behavior or loss of critical systems not
annunciated. Ground operations resulting in aircraft damage or injury to persons. Runway
incursion / excursion. Burning and/or Oil odor in the cockpit and cabin.

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

E-Mail the reports to:

• airsafety@embraer.com.br

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Embraer Safety Offices around the world

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

RISK
IDENTIFICATION

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Case: Investigating the Report

• Analysis and tests demonstrated that when

the Thrust Lever is moved below IDLE on
ground, the Thrust Reverser is commanded
to deploy and it takes a short time to reach
“unstowed” condition

• During this short interval, if the pilot performs

hesitant Thrust Lever movements between
IDLE and MIN REV, the Hydraulic Isolation
Control Unit may be de-energized, stopping
the movement of the Thrust Reverser

• In this situation the FADEC may consider

Thrust Reversers as stowed, even though
they are not fully closed

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

The Pyramid (or Iceberg) Theory

1 serious accident
29 minor accidents /
incidents
300 recorded risk
situations
600 observed
risk situations

Bird/Heinrich Theory

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Embraer receives 2,500 air safety reports annually

Whenever a report is received:
• Event is logged into Embraer Database
• A “Communication Form” may be
issued according to a preliminary filter
• CFs are distributed electronically
to all related areas at Embraer

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Database management
• The database is continuously monitored to support the identification and risk mitigation
• Identified the risk, an analysis is started to quantify and determine the response plan

Engineering

Flight Air Safety

Operations Department
Support

Technical
Support

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

RISK
IDENTIFICATION

RISK ANALYSIS

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Risk
• Questions that usually appear:
• What is the risk of the described scenario?
• What can happen that can increase the risk?

• Risk is often classified into 5 categories. How to

Potential primary
identify in which category the reported scenario is? cause for an accident

Potential contributing
factor of an accident

R I S K
Eventual reduction on
safety margin

Causing operational
disturbance

No safety relevance

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

RISK INDEX

LEVEL OF
SEVERITY PROBABILITY
CONTROL

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

LEVEL OF
SEVERITY X PROBABILITY + CONTROL

4 Results in multiple fatalities and/or loss of the aircraft

Large reduction of safety margins

Crew excessive workload such that cannot be relied upon to perform required tasks
3 accurately or completely
Serious or fatal injury to small number of occupants
Significant increase in crew workload
2 Conditions impairing operator efficiency or creating significant discomfort
Physical distress to occupants of aircraft
Slight reduction in safety margin or functional capabilities
1
Slight increase in workload such as routine flight plan changes

Probability(p) s.p
Reported Condition: Severity (s)

“ENG NO DISPATCH” and “ENG REV PROT FAULT” 1

messages displayed on EICAS after landing .

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

LEVEL OF
SEVERITY X PROBABILITY + CONTROL

5 Frequent
Likelihood of occurrence, can be:
4 Probable • Qualitative, and/or
• Quantitative (using statistical tools or system
3 Remote safety assessment reports)

2 Extremely Remote

1 Extremely Improbable

Probability(p) s.p
Reported Condition: Severity (s)

“ENG NO DISPATCH” and “ENG REV PROT FAULT” 1 4 4

messages displayed on EICAS after landing .

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

LEVEL OF
SEVERITY X PROBABILITY + CONTROL

2 Low Reflects the uncertainty regarding

assumptions made, and;
1 Medium
Knowledge and control of the related
0 High
technology.

Reported Condition: Severity (s) Probability(p) s.p

“ENG NO DISPATCH” and “ENG REV PROT FAULT” 1 4 4

messages displayed on EICAS after landing .

Level of Control
(High =0, Med =1, Low =2) 0

Preliminary Risk Index

RI = 4
THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

What if…?
• Sometimes the reported condition has a very low risk, but other things can happen and
increase the risk
• This analysis is also part of the RI process

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Reported Condition: Severity (s) Probability(p) s.p

“ENG NO DISPATCH” and “ENG REV PROT FAULT” 1 4 4

messages displayed on EICAS after landing .
Severity (s) Probability(p) s.p
Conditions that may increase severity:
Throttle lever is moved back out of the reverse range immediately
(within less than 0.2 seconds) after the thrust reverser has been
commanded and the pilot subsequently chooses to perform a take-off. 4 2 8

Worst Case
Highest value of (s x p)→
8
+
Level of Control
(High =0, Med =1, Low =2) 0

Preliminary Risk Index

RI = 8
THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

LEVEL OF
SEVERITY X PROBABILITY + CONTROL

Potential primary Immediate action

cause for an accident required

Potential contributing Action for risk

factor of an accident reduction

Eventual reduction on Improve system

safety margin reliability

Causing operational Monitor

disturbance

No safety relevance

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

RISK
IDENTIFICATION

PSC
RISK ANALYSIS

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Product Safety Committee

• High level meeting: vice presidents, directors
• Validates the Preliminary Risk Index analysis, defines actions and timelines
• Follow-up previous meeting action items and solutions

• Two types of meetings:

• Ordinary: once a month
• Extraordinary: whenever a RI analysis reaches a threshold

PSC

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

CHAIR: PRODUCT INTEGRITY

Product
Safety
Committee
PSC

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Timeframes
• For RI ≥ 8, the process define a timeframe of actions

Define Action Fleet

RI
Action Available Incorporation

≥ 14 12 Hours 24 Hours Next Flight

13 2 Days 4 Days 50 FH

12 3 Days 1 Week 100FH

11 1 Month 2 Months A

10 2 Months 3 Months 5A

9 3 Months 6 Months 1C

8 6 Months 18 Months 2C

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

SOLUTION RISK
IDENTIFICATION

PSC
RISK ANALYSIS

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Solution:
• Must meet the targets specified by Risk Index Analysis, validated by PSC
• Constant communication with Authorities
• Possible issuance of ADs
• Operational Bulletins, Alert Service Bulletins and other documentation may be issued
as an Interim Solution
• After Interim Solution available, fleet risk may be re-evaluated

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Case: Solution Availability

• Jan/2006: Operational Bulletin 170-001/06 issued
• Advising the crew to wait for the Amber REV icon before changing a deploy command to a
stow command.
• Apr/2006: Issued ANAC ADs 2006-03-02 and 2006-03-03
• Requires the inclusion of a temporary limitation to the AFM to prohibit a throttle movement into
the forward thrust range immediately following a thrust reverser application.

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Case: Solution Availability

• Aug/2006: Issued SBs 170-73-0003,
190-73-0005 and 190-73-0009
• New FADEC (Full-Authority Digital
Engine-Control) software upgrade.

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Example – Solution Availability

• Nov/2007: Issued ANAC ADs 2006-03-
02R1 and 2006-03-03R1
• Includes the new FADEC software as a
final action for the temporary AFM
limitation.
• May/2008: Issued FAA AD 2008-08-21
• Mandates the temporary limitation to the
Airplane Flight Manual (AFM) and including
the new FADEC software as a final action
for the USA Fleet.

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

TECHNICAL RISK
SOLUTION IDENTIFICATION

PSC
RISK ANALYSIS

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Service Bulletin Incorporation Report

• For the issues monitored, the SB incorporation is followed by the PSC and the item is
closed only after confirmation of 100% of fleet incorporation

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Agenda

Air Safety Reports and Risk Management

Air Safety Reports and Risk Management

Communication
Summary

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

How do I know what Embraer is doing about a “safety issue”?

download_center > Commercial Jets > Air Safety

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Embraer Release of Field Reports

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Relevant Actions

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Embraer Air Safety Reports Summary to Operators

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Field Reporting Form

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Agenda

Air Safety Reports and Risk Management

Air Safety Reports and Risk Management

Communication
Summary

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Air Safety Reports and Risk Management

Back to our questions…

• What happens when I send a Safety Report to Embraer?
• I’ve just received this OB… is it important?
• How do I know what Embraer is doing about a potential safety issue?

Summarizing
• Embraer Air Safety Strategy relies on reports:
• Report the relevant events that happens on your fleet (Follow SNL 170-00-0022 / SNL 190-00-
0018)
• Report the incorporation of technical solutions, refer to Service Bulletin for more information

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION
Agenda

Questions?

THIS INFORMATION IS EMBRAER PROPERTY AND CANNOT BE USED OR REPRODUCED WITHOUT WRITTEN AUTHORIZATION