Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 For a better use of incident analysis and safety data International Air Safety Summit Flight Safety Foundation Capt. Bertrand de Courville Washington 31st October 2013

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Worlwide Air Transport Safety Records (up to date) Fatal accidents Multi-engine commercial aircraft Certified for more than 13 passengers Source: ASN - FSF ProductionProtection Risk exposureSafety barriers Production/Protection “balance management” Environmental changes are continuously affecting both sides Corrections, adjustments and adaptations are permanently needed Major improvements need imagination and joint innovations

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Less catastrophic accidents Challenges and opportunities  Less fatal accidents potentially leads to Unclear trends and correlation between accident scenarios Focus on the most recent catastrophic accident and consequently less resources to address other accident risks A significant risk awareness and safety commitment erosion at all level  More than ever, learning from accidents is not sufficient. Further safety improvement suppose to introduce innovations in the way we monitor, check and maintain critical safety barriers we analyze worldwide serious incidents we disseminate the most significant outcomes

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Managing Safety Defenses Monitoring, checking and maintaining  Three significant safety case studies related to three different risks and corrective actions A risk of loss of control (1994) A risk of runway collision (1998) A risk of mid air collision (2002)

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013  Three significant safety case studies related to three different risks and corrective actions A risk of loss of control (1995) A risk of runway collision (1999) A risk of mid air collision (2002) Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Managing Safety Defenses Monitoring, checking and maintaining  Three significant safety case studies related to three different risks and corrective actions A risk of loss of control (1995) A risk of runway collision (1999) A risk of mid air collision (2002)

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 San Diego B727 – 2600 ft - Approach Los Angeles – 1986 DC9 – 6000ft - Approach Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 In 2002 … F/O safety report related to a non consequence event He reported having initially reacted the opposite way to a RA TCAS. A simple risk assessment rates this scenario as a high risk one This event was published in our monthly safety bulletin The publication triggered two other reports relating similar events A FDA algorithm was implemented to monitor opposite response This issue was shared and published in Eurocontrol ACAS bulletin Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 FDA (FOQA) algorithm Detecting and sharing opposite response to TCAS 3 sec pitch order opposite to RA RA t sec 7 Consecutive sec Sharing at a European level (Eurocontrol) Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Airbus Safety Conference in Barcelona (2003) TCAS opposite response case presented FDA algoritm offered to be shared One airline used it and found the same results This became an industry issue and led to the TCAS 7.1 TCAS 7.0 TCAS 7.1 ‘’Level Off’’ Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Accidents Operations  Loss of control  CFIT  Mid air collision  Runway collision  Runway excursion  Other damages/injuries (Flight)  Other damages/injuries (Ground) Managing Safety Defenses Monitoring, checking and maintaining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013  Whenever a critical aircraft system failure affecting airworthiness aspects is identified through an incident, manufacturers and/or authorities may decide a check of an aircraft type fleet worldwide because there is a significant probability that the same failure already have or could occur somewhere else. AD could be published.  Similarly, serious incident related to pure operational issues may reveal critical operational failures that could reflect a much wider industry problem. But there is no process to check further the existence of the same weaknesses, in other airlines/organisations. Managing Safety Defenses Dissemination of lessons learnt

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Arcraft systems related incident Very efficient and structured dissemination process of lessons learnt whenever an incident reveals key airworthiness aspects of aircraft systems or technical issues. A fleet could be inspected and measures taken within a few week with immediate measures Flight operations related incident No formal and structured processe to encourage further « inspection » worldwide of specific operational issue discovered in operational incident Predictive aspects of key operational (non airworthiness) related failures Not used to prevent accident worldwide. Accidents still needed to consider repetitive incidents and trends The most significant safety failures found in every single high risk operational incidents, should inspire further check across the industry and, when needed, safety actions. Dissemination of lessons learnt Comparing Technical and Operational Events

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Worlwide harmonization bring opportunities More standardized policies, procedures, practices and training makes more « predictable » operational failures Most of safety issues detected and addressed in a single airline are also a concern in other airlines. Do we take enough advantage of this ? Dissemination of lessons learnt Taking advantage of standardization

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Surveys FDM (FOQA) Space of precursors * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Air Safety Reports * * * * * * * * ? * * * * * * * * * SIB/SAFO Dissemination of lessons learnt Implementing safety watch as SMS component LOSA

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Dissemination of lessons Implementing safety watch as SMS component Internal monthly publication « safety watch » Safety Promotion (awareness) Monthly Safety Publication Hazard identification Most significant events are reviewed during Safety Action Groups Meeting Summary (per accident families)

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 UC Undesired events Runway Collision LOC Other Damages (Ground) CFIT Mid-Air collision Runway Excursion Other Damages (Flight) Control What we must manage Defenses Recovery What we must manage Altitude bust Runway Incursion, W&B error Aircraft system malfunction, Loss of separation, etc. Reporting channels What we collect Managing Safety Defenses About methodology

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 UC High Risk Operational Events Runway Collision LOC Other Damages (Ground) CFIT Mid-Air collision Runway Excursion Other Damages (Flight) Identified high risk operational event. Could it happen to us ? No. Can we prove it ? Yes. Do we monitor the risk? Can we prevent better ? Safety Watch Control barriersRecovery barriers Managing Safety Defenses About methodology

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Risk Assessment of Individual Safety Events ERC «Event Risk Classification» Idendify Safety Issue Reactive, preparing the proactive approach Risk Assessment of Safety Issues SIRA „Safety Issues Risk Assessement“ Proactive or Predictive Risk Assessment of operational changes (Management of Change) SIRA «Safety Issues Risk Assessement» Proactive or Predictive Managing Safety Defenses The ARMS methodology as an example

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Title, Subtitle & Text GA decision making is a barrier against landing accidents risk. Is this barrier robust? Are our crews performing well? What training? How do we know for these threats or unsafe conditions ? Wind above limits Severe turbulence Wake turbulence Windshear Instrument failures (in IMC) Runway occupied Runway/airport confusion Degraded visibility at low height Not stabilized at 1000/500 floor Destabilized at low height EGPWS “Sink rate” or “Pull Up” Tail wind and wet/contam. rwy Deep landing Bounced landing Managing Safety Defenses GA decision: a critical safety barrier

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Title, Subtitle & Text Degraded visibility at low height (rain showers, fog patches) When ground, approach lights and some runway lights are in sight, we may think they still sufficient visual cues to continue But we may not be aware that the horizontal visibility has reduced to a few hundreds of meters, below the minimum needed to detect and correct accurately deviations. Why ? More resources are needed to keep visual contact and control the flight path. Pilot corrections are delayed and become inaccurate. Vertical or lateral deviations may develop without being detected. PF alone have not any more resources to decide a go around. Again PM role is key ! Many runway overrun or landing short accidents are related to this type of situations which are not met during training Managing Safety Defenses GA decision: a critical safety barrier

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Degraded visibility at low height (rain showers) When a single good video equals hundreds of words A training opportunity through Youtube Managing Safety Defenses GA decision: a critical safety barrier Video 4 GA in Heavy Rain Video 4 GA in Heavy Rain

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Managing Safety Defenses High risk to high reliability era through innovation Weak transport system - Risk control based on individuals - Intensive training - Accident analysis Safe transport system - Technology (acft & simulators) - Procedures,regulation, HF - Incident analysis High reliability transport system - SMS: Beyond regulatory compliance - Evolution of training - Better use of safety data

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 High Risk Incident Review initative  Objective To identify the most significant safety barrier failures from individual high risk incidents, susceptible to inspire further check by safety professional throughout civil aviation.  Tasks (Extract) To agree on an review method and to document this method. To analyse High Risk Incidents using the agreed method To disseminate its findings to the wider aviation community Managing Safety Defenses A European (ECAST) Initative

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Conclusion Further safety improvements need innovation and … Better Safety board efforts around the world to comply with ICAO Annex 13 regarding investigation and communication about high risk incidents Formal and structured worldwide dissemination processes of key safety failure identified in high risk operational incidents still to be developed Adoption of a common barrier based model to be used both in high risk incident analysis and safety data mining

Capt. B. de Courville – Air France – Corporate Safety DepartmentFSF IASS– Washington – October 2013 Thank You