1. FDM, Risk and Protecting your Assets
Sonya Tietjen
Principal, Safety Management Systems
April 2013, Montreal, Canada

2. Agenda The Problem The Solution The Benefits Risk Management
Flight Data Monitoring
Protecting Your Assets
Today I will speak about Risk Management, Flight Data Monitoring and Protecting your assets.
I have a passion for Safety in aviation, so my presentation is to highlight the value and cost benefit of implementing an FDM programme.
To put this all in context, I’m going to start with a couple of quotes…
And probably a couple of familiar graphics

3. NTSB Report
The flight crew made numerous procedural errors and deviations during the final approach segment of the VOR/DME approach.
The crew demonstrated poor crew coordination during the accident flight.
The flight crew was under pressure to land.
Unfortunately, it doesn’t always work out that way.
Excerpt from an NTSB report – it doesn’t matter which accident
This is not a-typical
The big question is: Do you think that this is the first time any of these situations has arisen with this particular crew?
But Oh.. You say… we have a great safety reporting culture. The crew would tell us if they have problems….
March 29, 2001, about 1901:57 mountain standard time
Gulfstream III, N303GA,
owned by Airbourne Charter, Inc., and
operated by Avjet Corporation of Burbank, California,
crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, Colorado.

4. Causal Factors - Primary
BizAv, UK CAA, CAP 776
Helicopters IHST 2006 (JHSAT)
So where’s the problem…
In fact - Two-thirds of all fatal accidents involved a flight crew related primary causal factor
and 7% involved an aircraft related primary causal factor.
Three-quarters of all fatal accidents involved at least one flight crew related causal factor
and 42% involved at least one aircraft related causal factor.
So what’s going on up there?
UK CAA, CAP 776
Flight Crew

5. The Problem?
OK… maybe not always, and maybe not as complete a picture as we would like
Patrick Hudson, Professor at Delft University, estimated some years ago that 75% of “events” go unreported
And that’s just the reactive stuff.
We’re pretty good at reporting things that others noticed, or definitely will notice,
But not so good where we either don’t think it’s important, or maybe when we don’t think we’ll get caught messing up.
And of course there are the issues that the pilots did not detect.
An example: One RW pilot flying offshore did not know he was close to Vortex Ring until the Flight Data Analyst asked him to review the flight. He turned white as a ghost.

6. How accidents [or do not?] happen
Threats
Organization
Technology
Humans
That interaction between the flight crew and the technology is what this is all about
You only have 3 main levels.
Most of those holes we talk about are at the top end of the model.
This is closer to the truth as it is the organisation that has the resources to make or block these holes.
If the organisation does it’s job, and the technology is appropriate and cared for
The people have many fewer holes to block.
Much more effective in preventing an accident than having all the holes being blocked by the people
The heros… the ones that work against all odds to prevent an accident or recover from one that could have been much worse
We can’t leave it to the last resort – we have to get proactive.
Modified from J. Reason 1997

7. BowTieXP: Loss of Separation
Aircraft in motion represents the greatest hazard faced by an operation.
And each of the threats firing arrows at your swiss cheese
In between the “unwanted event” – in this case Loss of Separation – are the controls – the holes in the swiss cheese.
If these controls fail, and you get to the unwanted event, you require recovery procedures to avoid catastrophe
The yellow – a baaaad situation, such as: inadvertent IMC
Or the worst - The red: Airborne contact with opposing traffic
CLICK: Here I’ve circled all those threats and controls that are dependant on the flight crew having the resources (tools, training, equipment, wide awake, etc.) and the ability to do their job well
Source: CGE Risk

8. Two tools for Flight Ops data
Safety Reporting
Flight Data Monitoring
There are 2 tools for gathering operational flight data:
Safety Reporting
Flight Data Monitoring
Of these two tools, only FDM is comprehensive and quantifiable.
You get everything that the aircraft is capable of recording

9. Air Safety Report Safety Reporting Safety Reporting is important..
You get real and valuable information, not to mention the 2-way communication you get with staff.
Extremely important and I could do an entire presentation on its merits and the benefit to the SMS
But this presentation is about FDM… although we’ll see later how the 2 are related
Now the real question – is do we get all the information we need this way?

10. Breaching Defenses Human beings, the technology they operate, and the
organisation they work within,
are the three sets of factors
likely to be “implicated in
breaching defenses put in place
to avoid accidents.”
J. Reason 1997
Human beings, the technology they operate, and the organisation they work within,
are the three sets of factors likely to be “implicated in breaching defenses put in place
to avoid accidents
And how do accidents happen?

11. Risk Management
“Hazard and risk management must be data-driven and involve constant monitoring to either eliminate or reduce the risk to as low as reasonably practicable.”
ICAO 2009, Doc 9859
And to manage risk, ICAO says:
“it must be data-driven and involve constant monitoring to either eliminate or reduce the risk to as low as reasonably practicable

12. Data The data collected must be systematic, cover all areas of the
operation, and have the ability to
measure the results of controls put
in place […to control risk].
Finally,
the focus must first be
on the area of highest risk.
ICAO 2009, Doc 9859
ICAO further requires that the data collected is systematic, cover all areas of the operation and have the ability measure the results of the controls put in place to control that risk.
And finally… the focus must first be on the highest risk.
And what is that?

13. Flight Operations
Flight Operations

14. Bottom Line: Flight Operations
Human Factors are the primary cause of incidents and accidents
Flight is the highest area of risk in operations
Flight is the operation of which we have the least amount of information
And how much information do we have?
Ah yes. But we get flight safety reports. Pilots put an ASR in whenever something goes wrong
We know of all the mistakes, errors, technical faults, whenever they don’t quite stick to SOPs…
Right?
So it makes sense to ensure we have data that is:
Systematic
Cover all areas
Have the ability to measure the results
And most importantly – be able to focus on the area of highest risk
And what is that?

15. Two tools for Flight Ops data
Safety Reporting
Flight Data Monitoring
Only FDM is
comprehensive and quantifiable
There are 2 tools for gathering operational flight data:
Safety Reporting
Flight Data Monitoring
Of these two tools, only FDM is comprehensive and quantifiable.
You get everything that the aircraft is capable of recording

16. The Solution: FDM Records interaction between: Analyses interaction
the technology (aircraft)
and the people (pilots)
Analyses interaction
for specific events (reactive)
undesirable trends (proactive)
So the organisation can do something about it…

17. Safety Reporting + FDM = W6s”
Who*
What
Where
When
Safety Reporting – adds W5
Why
Together: W6
How
Photo: Brad Jorgenson
The data collected on the Super Puma tells you a lot
How the aircraft reacted and interacted with the controls
How the PIC reacted
The resulting ASR and investigation will add to the quantifiable data with
how the crew (no pax) got out, with only one minor injury
investigation and report would tell you the about the Ground run after maintenance
Now the problem with this one, is that FDM was installed, but as it was a maintenance run, there was not PCMCI card in the Quick Access Recorder, so no operational data could be collected.
The bottom picture has an FDR, and in this situation you would pull the data for the investigation
Now neither of these situations are unique, and as both are “accidents”, they are investigated
But what if it was a close call - landing late, unstable approach, malfunction, or in the case of the SuperPuma – a gust of wind on a top heavy helicopter just makes the one wheel lift up a bit…
Incidentally – a large investigation quite a number of years ago using recorded flight data CLICK: (due to “this event”) determined how to avoid a roll over in the super puma. It’s unfortunate that history continues to repeat itself in various ways
One: in business ops you may not know it ever happened – that wonderful “what happens in Vegas stays in Vegas”
Second, you cannot routinely analyse the precursers. One commercial airline Safety Manager told me rather cynically that “we never had an unstable approach until we put FDM in place”.
So you want robust information
Yes – to hold individuals accountable for their actions
But also to give them the tools to improve their performance
As well as the overall performance of the operation through training, procedures, and awareness.
Photo: Dave Mills//airliners.net

18. Modified from J. Reason 1997 Threats Organization Technology Humans
That interaction between the flight crew and the technology is what this is all about
You only have 3 main levels.
Most of those holes we talk about are at the top end of the model.
This is closer to the truth as it is the organisation that has the resources to make or block these holes.
If the organisation does it’s job, and the technology is appropriate and cared for
The people have many fewer holes to block.
Much more effective in preventing an accident than having all the holes being blocked by the people
The heros… the ones that work against all odds to prevent an accident or recover from one that could have been much worse
We can’t leave it to the last resort – we have to get proactive.
Modified from J. Reason 1997

19. The Good, the Bad, and the Ugly
Now the “bad” is a screenshot where one of these 2 fire-fighters posted themselves on Facebook
And another client sent it off to a gentleman named Paul Spring, owner of Phoenix HeliFlight and this aircraft.
Paul has graciously given me free license to use his material – and he uses it himself for presentations such as this
The pilot was a contractor who will no longer work for Phoenix Heliflight
As Paul says… The individuals on the skids were willing participants and maybe even instigators
so Phoenix uses these photos during training to educate Pilots and Firefighters of the consequences.
Phoenix’s HFDM equipment includes cockpit voice and video recorders, the presence of which may have discouraged any thought of such a reckless & stupid act
Now… incidentally, as you’re by now thinking I’m ignoring the “Good guys”
This is not true. Much can be learned about good SOPs from the guys that do things right in difficult situations.
But more about that in a minute.
Pilot: R.G. (full time employee)
• 2,099 PIC Single Engine R/W & F/W
• On July 22, 2007 our AS350 BA was returning to home base after a day of Initial Attack standby. The pilot with his crew of 4
woodland firefighters onboard had been in level cruise at 1000 feet AGL for 20 minutes when the helicopter descended
abruptly…….
1 person dead & his family devastated
• 4 persons injured
• 1 helicopter destroyed
• The company’s reputation threatened
• With the pilot’s testimony the Transportation Safety Board of Canada concluded that the helicopter was flown into
“servo transparency” following a “sudden high speed descent”.
The TSB final report stated “It was reported that the pilot had previously flown in a similar manner on other flights when
transiting between bases, with sudden climbs, descents, and pull-ups. Some of the passengers reportedly were discomforted
by the maneuvers; however, no complaints were submitted to the management at ASRD or Phoenix Heli-Flight”.
• The helicopter involved had no HFDM
recorder so if everyone had died, the cause
may have been ‘undetermined’.

20. Protecting Your Assets
Organisation
Technology
Humans

21. Humans (The Clients) Complaint Management Marketing Liability
Turbulence
Timing
Airmanship
Marketing
Liability
Risk Management
Professionalism

22. Humans (The Employees)
CEO
Peace of mind from actually knowing your aircraft are being operated in a professional manner.
False accusation
Airspace breaches
Low flying
Poor airmanship
Management Support
Non-SOP Flying Requests
Documents observations
Procedures
Equipment

23. Technology (The Aircraft)
Pre-purchase / Pre-funding:
Performance / Efficiency
Proper handling
Limits maintained
MRO:
Faulty Equipment
Limits maintained / exceeded
Warranty issues
FW: Exceedance of control limits – control surface or structural damage
Control surface and structural damage due to exceedance of control limits
Exceeding engine temperature ratio

24. Organisation (The Company)
Return on Investment
Protecting your Assets
Marketing
Promotion of SMS
Risk Management
Monitoring – Quality Assurance
Ferry Flights
Flight Operations
Human Resources
Continuous Improvement
Training Programs
Enhancement
Validation
Efficiencies
Fuel efficiency
Maintenance

25. FDM Resources
ECAST – European Operators FDM Forum (
UK Civil Aviation Authority - CAP 739 (
Global Helicopter Flight Data Monitoring Community (
International Helicopter Safety Team (
There is a lot of information out there on building a robust Flight Data Monitoring program
And there is a White Paper on the subject that has been is available ___________________________

26. FDM Programme Communicate Collect Analyse and Share
Flight Crew & Stakeholders
Collect
Different aircraft / hardware capacities
Analyse and Share
Verify
SOPs / Type
Set thresholds
Use the data fairly
Within a Just Culture
Trending - SPIs
Learning and improving

27. Wrap Up The highest risk to an operation is Flight
Without FDM, you really don’t have quality assurance on flight operations
Implement FDM

28. Protect your Assets

29. FDM, Risk and Protecting your Assets
Sonya Tietjen
Principal, Safety Management Systems