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WATS 10 ‘Training for Safety’ John Bent 1 TRAINING FOR SAFETY John Bent Director Training Strategy proposed Pegasus Flight Academy - China World Aviation.

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Presentation on theme: "WATS 10 ‘Training for Safety’ John Bent 1 TRAINING FOR SAFETY John Bent Director Training Strategy proposed Pegasus Flight Academy - China World Aviation."— Presentation transcript:

1 WATS 10 ‘Training for Safety’ John Bent 1 TRAINING FOR SAFETY John Bent Director Training Strategy proposed Pegasus Flight Academy - China World Aviation Training Symposium Orlando 27th April 2010

2 WATS 10 ‘Training for Safety’ John Bent 2 The latest threat to crew training resources USD 1.7 billion has just been lost to international airlines in one week Source IATA

3 WATS 10 ‘Training for Safety’ John Bent 3 IATA SAFETY REPORT 2009: 2009 ACCIDENT RATE REDUCED ACCIDENT RATE REDUCED: 0.71 versus 0.81 in 2008 [hull losses per million flights of Western-built jet aircraft] = one per 1.4 million flights SAFELY FLOWN: 2.3 SAFELY FLOWN: 2.3 billion people on 35 million flights (27 million jet, 8 million turboprop) 1922 LESS ACCIDENTS WESTERN BUILT TYPES: 19 vv 22 in LESS ACCIDENTS (all types) 90 vv 109 in LESS FATAL ACCIDENTS (all types): 18 vv 23 in 2008 SAFETY - THE GOOD NEWS ✔

4 WATS 10 ‘Training for Safety’ John Bent 4 IATA SAFETY REPORT 2009:  times worse  MORE FATALITIES: 685 vv 502 in times worse   REGIONAL RATES WHICH ROSE: times worse ASIA PACIFIC: 0.86 vv 0.58 in times worse times worse M/E: 3.32 vv 1.89 in times worse times worse AFRICA: 9.94 vv 2.12 in times worse Runway excursions Runway excursions and ground damage were main categories Pilot handling 30% Pilot handling was a contributing factor in 30% of all accidents. SAFETY - THE BAD NEWS ×

5 WATS 10 ‘Training for Safety’ John Bent 5 ANY SENSE THAT 2009 RESULTS WERE BETTER COULD GENERATE COMPLACENCY   Longer term trends by type and regions remain disturbing   Complete elimination of accidents is unrealistic, but:   Any serious accident which could have been reasonably AVOIDED or MITIGATED was industry safety system failure an industry safety system failure

6 WATS 10 ‘Training for Safety’ John Bent 6 Training is the best investment against catastrophic risk The top catastrophic accident risks identified were: LOC (loss of control) CFIT (controlled flight into terrain) Post-crash fire Runway excursions and overruns Crew judgment and actions are the most consistent causal factor in global catastrophic accidents This situation will remain true for the foreseeable future Crew-related issues dominate accident causal factors, featuring in 75% of fatal accidents CREW TRAINING - UK CAA 2008:

7 WATS 10 ‘Training for Safety’ John Bent 7 Major accident totals threaten levels not seen since 1990s Totals threaten levels not seen since 1990s ‘Last five-year’ accidents exceed previous five-year periods “at this pace, we'll be turning the clock back 10 years in safety” FLIGHT SAFETY FOUNDATION: Are today's airline pilots churned out by "pilot mills" that train to minimum standards? BUFFALO NEWS – DEC 2009:

8 WATS 10 ‘Training for Safety’ John Bent Hardware growth has outstripped human-ware available 911 and SARS discouraged steady expansion of training capacity : aircraft were grounded without crews Crew training rates inadequate; training trended to minimums global recession; reversal to surplus crews Pilot layoffs and unpaid leave Less pressure on training delivery, yet increased pilot mobility Accidents on the rise; no surprise Now volcanic ash AN INDUSTRY WITH REMARKABLE CHALLENGES 8 Accidents & Incidents

9 WATS 10 ‘Training for Safety’ John Bent 9 THE LONG TERM ACCIDENT RATE MAY EXCEED THAT COMMENSURATE WITH EXPANSION ALONE IF SO, WHY?

10 WATS 10 ‘Training for Safety’ John Bent 10 TRAINING & SAFETY The following slides depict a sample of just 40 airline accidents since 2005 (not exhaustive) Detailed analysis is not intended These tragic slides will be shown rapidly, aimed at the bigger picture, and to stay within my presentation time 88% As many as 35 of this sample ( 88% ) may be concluded to have contained crew training as possible mitigants

11 WATS 10 ‘Training for Safety’ John Bent 11 Air France A340 Toronto2 Aug 2005 RUNWAY DEPARTURE: Could more effective training have mitigated? Undesired aircraft state- unstable approach in bad weather 1

12 WATS 10 ‘Training for Safety’ John Bent 12 Helios B737 Greece14 Aug 2005 CREW INCAPACITATION: Could more effective training have mitigated? Tech and procedures? 2

13 WATS 10 ‘Training for Safety’ John Bent Aug 2005 LOSS OF CONTROL: Could more effective training have mitigated? loss of control in cruise; a/c overload, stall? W Caribbean MD82 Venezuala “The pilots may have lacked basic instrument flying skills due to continuous over reliance on automated flight. Did they monitor their instruments? Indications should have alerted them of subtle airspeed decay as the aircraft was overloaded and at too high a FL...” 3

14 WATS 10 ‘Training for Safety’ John Bent 14 Bellview B737 Lagos23 Oct 2005 LOSS OF CONTROL: Could more effective training have mitigated? - Unknown as yet The airplane impacted ground at a speed of around 400 knots in a near wings level attitude with both engines at takeoff thrust. All 111 passengers and 6 crew perished in the crash. Nigerian Authorities promised a final report in 2007, but has not come to light so far. 4

15 WATS 10 ‘Training for Safety’ John Bent Sep 2006 COLLISION: Could more effective training have mitigated? Procedures, situational awareness, TCAS? GOL B Brasil 5

16 WATS 10 ‘Training for Safety’ John Bent Nov 2007 IMPACT WITH TERRAIN: Could more effective training have mitigated? - heading, situational awareness = controlled flight into terrain (CFIT)? AtlasJet MD83 at Isparta 6

17 WATS 10 ‘Training for Safety’ John Bent 17 7 Mar 2007 OVERRAN RUNWAY: Could more effective training have mitigated? Crew resource management (authority gradient) Garuda B737 Yogyakarta 7

18 WATS 10 ‘Training for Safety’ John Bent 18 4 May 2007 CRASHED AFTER TAKE-OFF: Could more effective training have mitigated? - took-off into heavy TS Kenya Airways B737 Douala According to the former minister, “the Camerounian State is not to be blamed as the pilot was asked not to fly due bad weather”. The Kenya Airways Boeing suddenly disappeared from radar screens two minutes after take-off from the Douala International Airport during a heavy thunderstorm. 8

19 WATS 10 ‘Training for Safety’ John Bent Jul 2007 RUNWAY EXCURSION: Could more effective training have mitigated? Undesired aircraft state - reverser inoperative procedures TAM A320 Sao Paolo 9

20 WATS 10 ‘Training for Safety’ John Bent 20 BA B777 Heathrow17 Jan 2008 LOSS OF POWER: Could more effective training have mitigated? NO: Sound airmanship displayed - AAIB report 10

21 WATS 10 ‘Training for Safety’ John Bent 21 Belgavia CRJ100 Yerevan 14 Feb 2008 DE-ICING PROCEDURES: Could more effective training have mitigated? Loss of control -refused advice to de-ice for take off 11

22 WATS 10 ‘Training for Safety’ John Bent Feb 2008 FLEW INTO TERRAIN: Could more effective training have mitigated? - failed to align NAV pre-take off = Situational Awareness + CFIT ATR42 nr Merida12

23 WATS 10 ‘Training for Safety’ John Bent Apr 2008 RUNWAY OVERRUN: Could more effective training have mitigated? Overrun - tyre burst after V1; tried to stop Hewa Bora DC95 Goma13

24 WATS 10 ‘Training for Safety’ John Bent May 2008 RUNWAY OVERRUN: Could more effective training have mitigated? Procedures; slow rejected take off? Kalitta B747 Brussels 14

25 WATS 10 ‘Training for Safety’ John Bent May 2008 RUNWAY DEPARTURE: Could more effective training have mitigated? Undesired aircraft state - landing performance? TACA A320 Tegucigalpa 15

26 WATS 10 ‘Training for Safety’ John Bent Jun 2008 RUNWAY DEPARTURE: Could more effective training have mitigated? Undesired aircraft state - landing performance? Sudan Airways A310 Khartoum 16

27 WATS 10 ‘Training for Safety’ John Bent 27 6 Jul 2008 GO AROUND FAILED: Could more effective training have mitigated? Undesired aircraft state-approach to wrong runway USA Jet DC91 Saltillo 17

28 WATS 10 ‘Training for Safety’ John Bent Aug 2008 DEPARTED RUNWAY: Could more effective training have mitigated? Flaps not set for take-off -undesired aircraft state - procedures Spanair MD82 Madrid 18

29 WATS 10 ‘Training for Safety’ John Bent 29 Itek Air B732 Bishkek 24 Aug 2008 LOST CONTROL ON APPROACH: Could more effective training have mitigated? Undesired aircraft state – visual awareness? 19

30 WATS 10 ‘Training for Safety’ John Bent Aug 2008 FLEW INTO TERRAIN: Could more effective training have mitigated? crew resource management, situational awareness Conviasa B737 Latacunga 20

31 WATS 10 ‘Training for Safety’ John Bent 31 Aeroflot-Nord B735 Perm 14 Sep 2008 LOST CONTROL ON APPROACH: Could more effective training have mitigated? Recent formal ruling that pilot was drunk, CRM? Since this accident Russia's transport ministry signed an agreement with Boeing aimed at improving air transport safety in the country. The memorandum, identifies provision of training for flight crew and technical personnel and the development of training infrastructure as crucial areas 21

32 WATS 10 ‘Training for Safety’ John Bent Nov 2008 LOST CONTROL: Could more effective training have mitigated? test flight procedures training (BEA)? ANZ A320 nr Perpignan 22

33 WATS 10 ‘Training for Safety’ John Bent Dec 2008 RUNWAY OVERRUN: Could more effective training have mitigated? Undesired aircraft state -failed take-off & runway overrun? Continental B737 Denver 23

34 WATS 10 ‘Training for Safety’ John Bent 34 US Air A320 Hudson River 15 Jan 2009 TRAINING & EXPERIENCE SAVED THE DAY! An example to study 24

35 WATS 10 ‘Training for Safety’ John Bent 35 Colgan Air DH8D Buffalo12 Feb 2009 LOST CONTROL: Could more effective training have mitigated? - procedures, icing and stall recovery training? 25 A change trigger

36 WATS 10 ‘Training for Safety’ John Bent Feb 2009 Turkish B737 Amsterdam LOST CONTROL ON APPROACH: Could more effective training have mitigated? Automation reliance & monitoring? 26 An automation threat?

37 WATS 10 ‘Training for Safety’ John Bent Mar 2009 FLIPPED ON LANDING: Could more effective training have mitigated? Undesired aircraft state -known handling issues in strong gusts? Fedex MD11 Tokyo 27

38 WATS 10 ‘Training for Safety’ John Bent 38 9 Apr 2009 IMPACT WITH TERRAIN: Could more effective training have mitigated? Undesired aircraft state-loss of control; circling in low cloud base? Aviastar BAe 146 Wamena 28

39 WATS 10 ‘Training for Safety’ John Bent Apr 2009 CRASHED AFTER TAKE-OFF: Could more effective training have mitigated? As yet unknown but aircraft stored for 1 year? Bako Air B737 Massamba 29

40 WATS 10 ‘Training for Safety’ John Bent 40 1 June 2009 Air France A330 Atlantic LOST CONTROL: Could more effective training have mitigated? - inadequate evidence as yet 30

41 WATS 10 ‘Training for Safety’ John Bent 41 Yemenia A310 East Africa 30 Jun 2009 LOST CONTROL: Could more effective training have mitigated? Undesired aircraft state - missed approach in big twin; as yet unknown 31

42 WATS 10 ‘Training for Safety’ John Bent 42 Caspian Tu 154 nr Tehran 14 Jul 2009 IMPACTED TERRAIN: Could more effective training have mitigated? -as yet unknown 32

43 WATS 10 ‘Training for Safety’ John Bent 43 Aryan Airlines IL62 Mashhad (Iran) 24 Jul 2009 OVERRAN RUNWAY: Could more effective training have mitigated? -Technical (gear?), late landing, but as yet unknown 33

44 WATS 10 ‘Training for Safety’ John Bent 44 Bangkok Awys ATR72 Koh Samui 4 Aug 2009 RUNWAY EXCURSION: Could more effective training have mitigated? Departed runway in strong winds and rain - as yet unknown 34

45 WATS 10 ‘Training for Safety’ John Bent 45 Sudan Awys B707F Sharjah 21 Oct 2009 LOST CONTROL: Could more effective training have mitigated? Lost control during initial climb and crashed – as yet unknown 35

46 WATS 10 ‘Training for Safety’ John Bent 46 Cpgn African Avn MD82 Goma 19 Nov 2009 OVERRAN RUNWAY: Could more effective training have mitigated? Overran runway in ‘rainy conditions’ - as yet unknown 36

47 WATS 10 ‘Training for Safety’ John Bent 47 American Airlines 738 Kingston 22 Dec 2009 OVERRAN RUNWAY: Could more effective training have mitigated? Overran runway in heavy rain - as yet unknown 37

48 WATS 10 ‘Training for Safety’ John Bent 48 Compagnie B Kinshasa 2 Jan 2010 RUNWAY EXCURSION: Could more effective training have mitigated? Veered off runway on landing - heavy rain 38

49 WATS 10 ‘Training for Safety’ John Bent 49 Taban Air TU 154 Mashad Iran 24 Jan 2010 RUNWAY EXCURSION: Could more effective training have mitigated? Landing in fog with medical emergency Flight International 39

50 WATS 10 ‘Training for Safety’ John Bent 50 Ethiopian 738 Nr Beirut 25 Jan 2010 CRASHED IN DEPARTURE: Could more effective training have mitigated? Lost height and impacted Mediterranean (WX?) - as yet unknown 40

51 WATS 10 ‘Training for Safety’ John Bent 51 LESSONS FROM THIS SAMPLE? 1. That most accident risks realised could be foreseen in training! 2. That reactive is easier then proactive! 3.88% probable human factors and training [ 3. That 35 of the 40 accidents sampled (88%) may count as probable human factors and training [LOSS OF CONTROL / undesired aircraft state (irrecoverable departure from normal operational parameters) & controlled flight into terrain] That today we still DO NOT focus a commensurate amount of pilot training on human factors! (it’s more like 10%?) TRAINING 5. We must mitigate accidents with TRAINING

52 WATS 10 ‘Training for Safety’ John Bent 52 Back to the 2009 IATA REPORT  Runway excursions  Runway excursions and ground damage were main categories  Pilot handling 30%  Pilot handling was a contributing factor in 30% of all accidents 2010 So what’s happening in 2010 ?

53 WATS 10 ‘Training for Safety’ John Bent 53 DURING THE FIRST 120 DAYS OF 2010, NOT MUCH HAS CHANGED

54 WATS 10 ‘Training for Safety’ John Bent 54 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page1) Veered off runway on landing 2 JanCompagnie Africaine Aviation B , Kinshasa (Congo) Veered off runway on landing Rejected takeoff - runway overrun 3 JanAir Berlin B , Dortmund (Germany) Rejected takeoff - runway overrun Veered off runway on take off 8 JanAir Berlin B , Nuremberg (Germany) Veered off runway on take off Runway excursion on landing 9 JanYas Air IL76, Kiev (Ukraine) Runway excursion on landing Nose gear collapse on landing 15 JanIran Air F100, Isfahan (Iran) Nose gear collapse on landing Went off runway on line up for take off 16 JanIran Air A , Stockholm (Sweden) Went off runway on line up for take off Overran runway on take off 19 JanPSA Airlines CRJ2, Charleston (USA) Overran runway on take off Source: Aviation Herald 7

55 WATS 10 ‘Training for Safety’ John Bent 55 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page2) Runway excursion on landing 19 JanLion Air B , Padang (Indonesia) Runway excursion on landing Went off runway on landing 21 JanAeromexico Connect E145, Tijuana (Mexico) Went off runway on landing Overran runway on landing 22 JanSkywest CRJ7, Winnipeg (Canada) Overran runway on landing Veered off runway on landing 25 JanWest Air CRJ2 Longyearbyen (Norway) Veered off runway on landing ) Veered off runway on landing 27 JanCimber AT72, Bornholm (Denmark) Veered off runway on landing Overran runway on landing 28 JanBulog AN26, Wamena (Indonesia) Overran runway on landing Overran runway on landing 30 JanDonavia B , Rostov (Russia) Overran runway on landing Source: Aviation Herald 14

56 WATS 10 ‘Training for Safety’ John Bent 56 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page3) 31 Jan Skyservice A320, Varadero (Cuba) Hard landing – three tyres blown 4 FebYakutia AN24, Yakutsk (Russia) Rejected take-off but airborne / gear up 8 FebShasheen B , Peshawar (Pakistan) Departed runway on landing 10 Feb KLM B , Schiphol (Netherlands) Took off on taxiway 13 Feb Batavia B , Surabaya (Indonesia) Nose gear skidded on line up – tyres blew 18 Feb Shuttle America Embraer ERJ-170, Cleveland (USA) Overran the runway on landing 22 Feb Spring Airlines A , Shenyang (China) Landed tail first – structural damage Source: Aviation Herald 21

57 WATS 10 ‘Training for Safety’ John Bent 57 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page4) 24 Feb Ethiopian Airlines B , Lubumbashi (Congo) Departed taxiway after landing 24 Feb Air Canada Airbus A , Toronto (Canada) Landed without ATC clearance 25 Feb Lion Air B 737, Padang (Indonesia) Main gear departed paved surface 26 Feb Garuda Indonesia B , Perth (Australia) Entered RWY 06 after landing - no clearance 26 Feb Aeroflot A , Oslo Gardermoen (Norway) Took off on taxiway Veered off the departure runway 30 1 MarAir Tanzania B , Mwanza (Tanzania) Veered off the departure runway 30 Overran the runway on landing 17 MarShaheen Air International B , Peshawar (Pakistan) Overran the runway on landing Source: Aviation Herald 28

58 WATS 10 ‘Training for Safety’ John Bent 58 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page5) Landed about 1000 meters short of rwy 14R 22 MarAviastar TU , Moscow Domodedovo (Russia Landed about 1000 meters short of rwy 14R Struck its tail onto the departure runway 23 Mar China Airlines B F, Anchorage, (USA) Struck its tail onto the departure runway Overran runway 06 while landing 24 Mar Cargojet B , Moncton, (Canada) Overran runway 06 while landing Overran runway 21L by about 30 meters 24 Mar Asiana A , Omitama (Japan) Overran runway 21L by about 30 meters Tail strike during takeoff 25 Mar Westjet B , Cancun (Mexico) Tail strike during takeoff Main gear off the paved surface after landing 25 Mar Air Madagascar B , Nossi-be (Madagascar) Main gear off the paved surface after landing Wrong taxiway - impacted two light poles 5 AprEgypt Air A , Cairo (Egypt) Wrong taxiway - impacted two light poles ( wrong park position entered into FMS – wing damage) Source: Aviation Herald 35

59 WATS 10 ‘Training for Safety’ John Bent 59 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page6) PSA Airlines CRJ-200, Charleston, WV (USA) Overran runway - rejected takeoff at high speed 8 Apr PSA Airlines CRJ-200, Charleston, WV (USA) Overran runway - rejected takeoff at high speed 13 Apr Overran runway while landing 13 Apr Merpati Nusantara B , Manokwari (Indonesia) Overran runway while landing 21 Apr Overran runway 06 while landing 21 Apr Cargojet B , Moncton (Canada) Overran runway 06 while landing Source: Aviation Herald 38 (Since 1 st Jan 2010)

60 WATS 10 ‘Training for Safety’ John Bent 60 Is our collective industry eye still off the SAFETY ball?

61 WATS 10 ‘Training for Safety’ John Bent 61 THE BIG QUESTION SHOULD INDUSTRY ACCEPT THAT ACCIDENT & INCIDENT RATES: (1) ARE AS LOW AS ECONOMICALLY VIABLE? (1) ARE AS LOW AS ECONOMICALLY VIABLE?OR (2) MUST BE FURTHER REDUCED? THE BIG QUESTION SHOULD INDUSTRY ACCEPT THAT ACCIDENT & INCIDENT RATES: (1) ARE AS LOW AS ECONOMICALLY VIABLE? (1) ARE AS LOW AS ECONOMICALLY VIABLE?OR (2) MUST BE FURTHER REDUCED?

62 WATS 10 ‘Training for Safety’ John Bent AS GROWTH RESUMES, IF THE ACCIDENT RATE REMAINS UNCHANGED Expansion of the global fleet will increase the number of accidents The accident RATE must be DRIVEN DOWN further 62

63 WATS 10 ‘Training for Safety’ John Bent 63 ALTHOUGH THE RATE IS LOW RELATIVE TO ACTIVITY: A doubling of the fleet next 20 years at same rate could result in 10,000 10,000 fatalities or more; tragedies with commercial consequences for passenger growth SO WE MUST ACT 150 HALVE the accident rate NOW To hold accidents down to 150 and a possible 5,000 fatalities, we must HALVE the accident rate NOW

64 WATS 10 ‘Training for Safety’ John Bent THE BRIC COUNTRIES (Brazil, Russia, India, & China) ARE MOST EXPOSED – NEXT 20 YEARS Source: ACI Sept 08 THE BRICS WILL EXCEED USA BY 2027

65 WATS 10 ‘Training for Safety’ John Bent IN CHINA ALONE: 20 YEAR PROJECTIONS FOR NEW AIRCRAFT: 65 Pre-recession projection: 3,800 airframes 2,800 Post recession-REVISED projection: 2,800 airframes 41,600 New airline pilots required (including 8,000 retirements): 41,600 Source: manufacturers and IATA

66 WATS 10 ‘Training for Safety’ John Bent 66 THE VERDICT: ‘RATES MUST BE FURTHER REDUCED’! This month in Montreal, ICAO announced an action plan to: Lead a safety information exchange Coordinate efforts to establisha global safety information exchange to enable analysis of key safety indicators Work with IATA and the FAA, to "facilitate the collection, analysis and dissemination of safety information provided by states and industry partners throughout the international aviation community” But these actions will take a LONG TIME. Improved training is an obvious action which can be taken NOW

67 WATS 10 ‘Training for Safety’ John Bent 67 ACTION - THE CHALLENGES:

68 WATS 10 ‘Training for Safety’ John Bent 68 DOEPS DOEPS [DEFENCE OF ESTABLISHED PROCESS SYNDROME]? Change is not easy; defense of ‘status quo’ is A long established process is understood Prejudice ( conclusions without the facts ) is a great time saver New processes are more acceptable once widely adopted NAAs and Training Organisations prefer not to be ‘first’ THE CHANGE CHALLENGE

69 WATS 10 ‘Training for Safety’ John Bent 69 BUT: Hundreds of thousands of safe flights are not news Airline accidents are immediate media drama Public perceptions form with the first media bite THE SAFETY CHALLENGE ANOMALY (AREN’T WE SAFE ENOUGH?) Approx 18,000 airliners are continuously in operation; that’s approx 2,700,000 passengers in flight Safe enough to relax? NO, that’s complacency

70 WATS 10 ‘Training for Safety’ John Bent 70 THE SKILL & EXPERIENCE LOSS CHALLENGE (UNCOMFORTABLE SYSTEMIC MIX): THE SKILL & EXPERIENCE LOSS CHALLENGE (UNCOMFORTABLE SYSTEMIC MIX):

71 WATS 10 ‘Training for Safety’ John Bent 71 Washington Post, 29 June 2009 Washington Post, 29 June 2009 “Automated systems are often designed to relieve humans of tasks that are repetitive. “When such algorithms become sophisticated, however, humans start to relate to them as if they were “The autopilot on a plane, the cruise control on a car, automated speed control systems in mass transit, are all conveniences but fellow human beings” fellow human beings” “ The more reliable the system, the more likely it is that humans in charge will ‘switch off’ and lose their concentration, and the greater the likelihood can become crutches” that a confluence of unexpected factors that stymie the algorithm will produce catastrophe” THE AUTOMATION CHALLENGE

72 WATS 10 ‘Training for Safety’ John Bent 72 THE PROCESS CHALLENGE  INDUSTRY > ICAO DEVELOP BEST PRACTICE NEW SARPS TO NAA  TRAINING ORGANISATION APPLIES NAA APPLIES NAA REQUIREMENTS PLUS LOCAL ENHANCEMENTS CUSTOMER NEED DEFINED REGULATION & FACILITATION VERIFICATION   COMPETENT SAFE PILOTS   INPUTS TO SELECTION AUDITS: 1) 1)TRAINING ORG BY CUSTOMER & NAA 2) 2)NAA BY ICAO FEEDBACK ANALYSIS COMPULSORY REPORTING:   CUSTOMER & TRAINING ORG TO NAA   NAA TO ICAO Continuous improvement IS THIS REALLY HAPPENNING?

73 WATS 10 ‘Training for Safety’ John Bent The training industry has had great difficulty preparing for the next growth phase, as enterprise resources have been decimated Belt tightening prevented widespread adoption of best practice; mostly ‘more of the same’ prevailed The next growth surge can be seen on a closer horizon Seeing through the recession 73 THE TIME & RESOURCE CHALLENGE (THERE’S LIMITED TIME TO ACT)

74 WATS 10 ‘Training for Safety’ John Bent 74 THE MANAGEMENT PERCEPTION CHALLENGE TRAINING IMPROVEMENTS ARE NEEDED, but what about Training practitioners usually agree that TRAINING IMPROVEMENTS ARE NEEDED, but what about CAPA Management survey 2009 >>

75 WATS 10 ‘Training for Safety’ John Bent TRAINING AS A PRIORITY: Current priorities are not training! Source: Centre for Asia Pacific Aviation Survey, Sept 09

76 WATS 10 ‘Training for Safety’ John Bent TRAINING AS A CHALLENGE: A greater spread of opinions on the key issues - medium term Source: Centre for Asia Pacific Aviation Survey, Sept 09

77 WATS 10 ‘Training for Safety’ John Bent 77 How can crew training be enhanced if company executives don’t see the need?

78 WATS 10 ‘Training for Safety’ John Bent 78 INDUSTRY ACTION? CONVINCE DECISION MAKERS THAT WE HAVE A PROBLEM [ICAO, IATA, FAA ARE CLEARLY CONVINCED] ENHANCE CREW TRAINING; THE CONTROLLABLE VARIABLE As hardware cannot be changed rapidly (we have what we have) Crew Training (both airline & GA) must be driven rapidly towards: more relevance; proactive to risk & SMS higher quality & continuous improvement more sustainability & topicality (recurrent)

79 WATS 10 ‘Training for Safety’ John Bent FIND THE LOWEST HANGING FRUIT 79

80 WATS 10 ‘Training for Safety’ John Bent 80 Chairman of the Flight Training Department, Embry‐Riddle Aeronautical University: “Our experience and research lead us to believe a successful airline pilot candidate preparation program should embrace a methodology to weed out unsuccessful candidates prior to their employment by the airlines” TOO OBVIOUS? Yes but much more can be done USD 5,000 more invested in Selection could reduce system risk, and save >USD 50,000 downstream

81 WATS 10 ‘Training for Safety’ John Bent RAISE TRAINING STANDARDS - EVERYWHERE 81

82 WATS 10 ‘Training for Safety’ John Bent 82 Cost reductions (‘more’ training cannot easily be added) Quality, and relevance must rise RAISE QUALITY - EVERYWHERE

83 WATS 10 ‘Training for Safety’ John Bent 83 Much airspace is shared by GA & Airlines One airline supply pipeline is GA Effective early training is vital throughout aviation Many best practices developed for airline operations could be cross pollinated into GA training TAKE A MORE GLOBAL HOLISTIC APPROACH GENERAL AVIATION Must wheels be re-invented?

84 WATS 10 ‘Training for Safety’ John Bent 84 FIND THE QUALITY DRIVERS Without data, aviation safety is at the mercy of opinion QA or SMS requires performance data to analyse This data comes from multiple sources (in airlines): For example >>

85 WATS 10 ‘Training for Safety’ John Bent Whole Airline: I ATA O PERATIONAL S AFETY A UDIT (IOSA) Whole Airline: I ATA O PERATIONAL S AFETY A UDIT (IOSA) Flight Operations L INE O PERATIONAL S AFETY A UDIT (LOSA) Flight Operations L INE O PERATIONAL S AFETY A UDIT (LOSA) USE INDUSTRY EXTERNAL DATA 85 Whole Airline Industry: G LOBAL S AFETY D ATA (ICAO, IATA, FSF..)

86 WATS 10 ‘Training for Safety’ John Bent USE LOSA (LINE OPERATIONAL SAFETY AUDIT) DATA After 10 years, and more than 6,000 LOSA flights… - over 90% of flights exhibited observable crew errors Numerous events were precipitated by an error made by the captain, unchallenged by other crew members (reluctance to challenge, expressed as ‘authority gradient’ (G. Hofstede) 50% of LOSA-observed errors went undetected by the crew 32% of errors were intentional noncompliance (Violations) 86

87 WATS 10 ‘Training for Safety’ John Bent LOSA DATA SHOWS WHAT CREWS DO RIGHT 87

88 WATS 10 ‘Training for Safety’ John Bent Emeritus Professor Bob Helmreich (University of Texas), champion of LOSA & TEM (Threat & Error Management), in October 2006: “ “ After 10 years of examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two things: - No Surprise! But much more can be done Cooperate to rigorously monitor and cross check to make sure they pick up threats and errors early, and 2. 2.Actively engage in checking and verifying every setting and action which can affect safety.” 1. 1.Cooperate to rigorously monitor and cross check to make sure they pick up threats and errors early, and 2. 2.Actively engage in checking and verifying every setting and action which can affect safety.”

89 WATS 10 ‘Training for Safety’ John Bent Safety Dept FOQA / QAR DATA & CONFIDENTIAL REPORTS Safety Dept FOQA / QAR DATA & CONFIDENTIAL REPORTS Flight Operations SELECTION CRITERIA & DATA (& downstream performance: another presentation!) Flight Operations SELECTION CRITERIA & DATA (& downstream performance: another presentation!) USE AIRLINE INTERNAL DATA 89 Flight Operations & Training Dept CREW PERFORMANCE DATA (training progress, PCs / route checks) FUTURE INITIATIVE: Flight Operations & Training Dept SIMULATOR PERFORMANCE DATA

90 WATS 10 ‘Training for Safety’ John Bent OK SO WHAT’S NEW? 90 Not much, most airlines collect these data already But how many airlines analyse, organise, and collate this data into a REAL TIME system ‘health check’? Airline training systems would benefit immediately; through more rapid response to new threats

91 WATS 10 ‘Training for Safety’ John Bent ITQI ITQI ( IATA Training & Qualification Initiative ) ATC Simulation Active development of Type VII FSTD ATC Simulation Upset Recovery Training (URT) International Committee - aviation training in extended envelopes– ICATEE) Active development of Upset Recovery Training (URT) standards (RAeS International Committee - aviation training in extended envelopes– ICATEE) type training programmes APT3 Improved type training programmes; eg. APT3 (Airbus Pilot Training) & B787 type training – all embedded with TEM (Threat & Error Management) ATSAS ATSAS (Aircrew Training Standards & Safety - safety data driving training) NGAP NGAP (ICAO Next Generation Aviation Professionals) Initiative – March CAPITALISE ON CURRENT INITIATIVES

92 WATS 10 ‘Training for Safety’ John Bent Recognise the new Airline Pilot License MULTI-CREW PILOTS LICENCE (MPL) after 60 years of almost no change 92

93 WATS 10 ‘Training for Safety’ John Bent MPL concentrates best practice Despite controversy, MPL is: - the result of 6 years of industry development to replace an outdated 60 year-old airline training process initially very well received: after the Alteon Beta trial (small sample, but impressive base training results) an ICAO approved programme and license a set of powerful airline pilot training tools, demanding new standards in the airline pilot training process Just what the training industry needs: relevance + focus + quality > 93

94 WATS 10 ‘Training for Safety’ John Bent National MPL regulations are now in place in: Armenia, Australia, Canada, Chile, China, Denmark, France, Germany, Ghana, Latvia, Maldives, Netherlands, Pakistan, Philippines, Singapore, Sweden, Switzerland, Syrian Arab Republic, Thailand, UAE, United Kingdom, Hong Kong (22) By operators: 94 MPL is now under development, trail, or use in: Australia, China, Denmark, Germany, Philippines, Singapore, Sweden, Switzerland, United Kingdom, Hong Kong… (10) Source: IATA Former Alteon-Boeing Flight Training-CAAC, CAAC-CAFUC, CAPA- Sterling, Lufthansa, Swiss, OAA-Flybe, FTE-Flybe, CAE-Air Asia, Kaufer-Air Berlin, SATA-Tiger Airways, L.U.S.A.-City Airline & Skyways, Alpha Aviation, and proposed Pegasus Flight Academy China (13)

95 WATS 10 ‘Training for Safety’ John Bent 95 Data Source IATA & Tng Orgs Prior to the next growth surge, self funded pilot applicants prefer the old CPL route to ensure a job on graduation MPL beta syllabus: variations in structure and spread:-   Some orgs still apply twins and jets to the MPL syllabus, distracting students with up to three non-airline types   Many orgs still apply old pre-ICAO 9625 FSTD categories   Some orgs conduct MPL in three separate global locations   Aircraft flight training spread: hours   Simulator flight training spread: hours   Course duration spread: mths But as the superior performance of MPL graduates is more widely seen, operators will eventually demand MPL MPL under TRIAL – some challenges

96 WATS 10 ‘Training for Safety’ John Bent MPL STATUS MARCH 2010: GRADUATED: 800 EASA MPL Advisory Board 16/ Data Source: IATA & EASA MPL Advisory Board 16/ STUDENTS IN TRAINING:

97 WATS 10 ‘Training for Safety’ John Bent Training Comparison: 97 MPL delivers more instructional hours than CPL Source: IATA

98 WATS 10 ‘Training for Safety’ John Bent MPL THROWS OUT SPECIAL CHALLENGES: Upset Recovery Training (URT) – still maturing [but WGs underway include the RAeS International Committee for Aviation Training in Extended Envelopes (ICATEE) to report next year] ATC simulation – maturing in Type VII FSTD (Flight Simulation Training Device) Instructor qualifications & training – higher standards 98 UPSET RECOVERY TRAINING (URT): Actual flight in training aircraft + Simulator training

99 WATS 10 ‘Training for Safety’ John Bent Advanced training equipment + ineffective instruction = learning barrier Poor training equipment + effective instruction = learning catalyst MPL requires more appropriate (1) instructor training and (2) training devices More relevant instructor entry criteria + improved instructor training = essential for MPL, however challenging! HONE THE INSTRUCTOR’S ART – THAT HUGELY FERTILE VARIABLE! 99

100 WATS 10 ‘Training for Safety’ John Bent Lost Hydraulics - Sioux City United 232 July 89 > IMBIBE GOOD AIRMANSHIP (the consistent use of good judgment & well-developed skills (Kern 96) – STUDY EVENTS 100 > Power loss & ditching - US Airways Flt 1549 Jan 09 > Volcanic ash All Engines out - BA 9 - June 82 Cathay A330 – both engines fluctuated - thrust 70% N1 asymmetric - landed at 230kts - April 10 (subject to inquiry underway) > Cathay A330 – both engines fluctuated - thrust 70% N1 asymmetric - landed at 230kts - April 10 (subject to inquiry underway) > SOMETIMES PROCEDURES & CHECKLISTS MAY NOT BE ENOUGH:

101 WATS 10 ‘Training for Safety’ John Bent Enhanced Instructor training and oversight More LOFT (LINE ORIENTED FLIGHT TRAINING) training More task-focussed, competency-based, quality embedded programmes (as in MPL) Programmes designed for continuous improvement Driven by performance & SMS feedback Training devices designed to training task and learning phase (as in MPL, APT) Embedded human factors / threat & error management (TEM) (as in MPL) Mandated uniforms in simulator training – raising crew fidelity TRAINING ENHANCEMENT SUMMARY : 101

102 WATS 10 ‘Training for Safety’ John Bent UNIFORMS IN SIMULATION (an easy option; what’s the problem here?) UNIFORMS IN SIMULATION (an easy option; what’s the problem here?) Zero cost - all crews have uniforms! Matching crew fidelity with simulator fidelity Creating a more professional atmosphere in simulator training 102 SO WHY THIS? Let’s just fix it!

103 WATS 10 ‘Training for Safety’ John Bent 103

104 WATS 10 ‘Training for Safety’ John Bent ineffective training Long term the industry is highly exposed to ineffective training Airlines need to offer comfortable and safe air travel as a long term profitable business plan Resource flow must be maintained to the vital organs of a positive safety culture Effective crew training is an investment which protects safety margins for years to come Training must deliver efficient best practice, with relevance and continuous improvement 104 THE BOTTOM LINE

105 WATS 10 ‘Training for Safety’ John Bent 105 From the 2009 FAA safety call to action speech (Randy Babbitt): That day is today “That day is today”   We must know more about pilot performance over a pilot’s entire career   Good, effective training has to be at the top of our list   We need to ensure we’re meeting and exceeding the standards  quality training  The fundamentals of quality training are clear and direct   One of the quickest ways to spread excellence is to cross-pollinate   We need to share so that we’re all at the highest level possible  best practices  We have some great opportunities to look at best practices ….. ONE LIGHT SWITCH FOUND!

106 WATS 10 ‘Training for Safety’ John Bent 106  AWARE  Are airline COOs & CFOs AWARE of Training as the critical safety priority to address today?   Will budgetary maximums be ‘regulatory training minimums’ next financial year? Two Parting questions

107 WATS 10 ‘Training for Safety’ John Bent TRAINING & SAFETY ‘TAKE-AWAYS’ OPTIMISE BEST PRACTICE - minimise additional cost MEASURE to continuously improve EMBED MEASUREMENT into the training process, and instructor’s task EMBED TEM into all training thinking If QUANTITY shrinks, QUALITY must grow 107 SAFETY GROWS FROM EFFECTIVE TRAINING

108 WATS 10 ‘Training for Safety’ John Bent 108 Thank You!

109 WATS 10 ‘Training for Safety’ John Bent 109 Best practice safety-driven training Best practice safety-driven training founded on MPL in one location Best practice safety-driven training Best practice safety-driven training founded on MPL in one location Aimed at higher training standards Aimed at higher training standards + expanded safety margins Aimed at higher training standards Aimed at higher training standards + expanded safety margins ENTER THE PROPOSED Pegasus Flight Academy ENTER THE PROPOSED Pegasus Flight Academy

110 WATS 10 ‘Training for Safety’ John Bent 110


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