Registration
Please use one of the following options to register:
1) Send a cheque (payable to the CRM Working Group) to:
Predicting the Fatal Flaws conference
c/o LOFTwork Ltd
29 Balcombe Road
Horley, Surrey, UK RH6 7JR
2) Pay by credit or debit card using the conference booking page hosted by the CRM Working Group:
http://crm-wg.co.uk/wg/products.php?cat=12
Predicting the Fatal Flaws
3) Pay by BACS or CHAPS: Please include your name in the payment reference:
a/c name: CRM Working Group
Sort code 20-24-00
a/c number 60120324
IBAN GB08 BARC 2024 0060 1203 24 SWIFTBIC BARCGB22
Can we do things differently in aviation safety?
Overview
Fees: The conference is strictly volunteer-run, non-commercial and not for profit. Registration fees are applied to
catering, speaker support and other direct expenses. Fees are £250.00 for two days including tea/coffee breaks,
lunch and a reception following the first day's programme. A 10% discount is available for RAeS and CIEHF members
on production of proof of membership. Single day attendance fees include the conference reception and cost
£150.00.
Location, Directions and Information
The conference is hosted by The Base, Virgin Atlantic Airway's Flight Training Centre in Crawley near Gatwick Airport:
Virgin Atlantic Airways Ltd, The Base, Fleming Way, Crawley, RH10 9LX, UK
By car: M25 to M23, exit at Gatwick
Airport, follow signs for
Reigate/A23. Take A23 to A281
roundabout and turn back South on
A23, follow to Fleming Way
roundabout (opposite County Oak
industrial estate), turn left on
Fleming Way, destination on left.
Parking behind Virgin Atlantic The
Base.
The shape of aviation is changing as it adapts to economic challenges, technology advances and emerging safety
threats. The key question is, when the unexpected happens how effective will our response be?
The ‘Fatal Flaws’ are caused by increasing complexity and decreasing transparency in complex systems. These
create more demanding patterns of teamwork and communication, both on and off the flight deck and including
ATM, Engineering, Cabin Crew and PAX as in the May 2013 BA A319 LHR incident, 2005 Helios flight 522 crash,
Germanwings Flight 9525 and the AF 447 ditching, among many others.
With the help of NATS and Eurocontrol the conference looks at threat trends including conflict zone overflight,
changing pilot/controller and other teamwork interactions, the effect of new organizational economic pressures;
and at the benefits and limitations of structured responses from SMS to safety audit tools, Safety II and Resilience
Engineering. We look at what has to change, and where those changes will take the industry.
Civil aviation safety performance itself poses a threat to flight safety by creating complacency about current safety
measures at a time of great change in technology and threat profiles; and because it tempts operators to look for
cost reductions.
Who Should Attend: The conference is recommended for all personnel and risk managers in flight operations, air
traffic control, safety systems design and implementation, CRMT/TEs, regulators, human factors specialists, distal
team working and related disciplines in training, ergonomics and applied psychology.
Human
Factors
Group
By air or train: On arrival at Gatwick
Airport, take taxi to The Base. The
cost should not exceed £10. A local
bus service is also available to
Fleming Way.
Hotels: We anticipate that most
delegates will probably use a
Gatwick hotel with which their
company has a booking
arrangement. However for those
who might like a more traditional
inn which is often recommended by
delegates, the London Gatwick Copthorne (http://www.millenniumhotels.co.uk/copthornegatwick/hotelspecials/advance-purchase.html) has a 20% advance booking discount.
Sponsored by:
Ashgate Publishing
Hosted by:
Virgin Atlantic Airways
The Base, Fleming Way, Crawley, RH10
9LX, UK
Dates:
Thursday and Friday,
26/27 November, 2015
National Air Traffic Services
Programme Summary
Time Topic
Speaker
Notes
Day 1 Registration
Tea and coffee
0830
sponsored by
HeliOffshore
Welcome and
0915
housekeeping
0830 Day 2 Registration
Tea and coffee
Welcome and
0915
housekeeping
Nicole Svatek, HFG Chair
0930
Nicole Svatek
Chair, RAeS Human Factors Group
Continuity & Reality
check
Capt. Mike Freeman, TRI/TRE,
RAeS Human Factors Group
Jon Berman, Past President
Management or Safety
CIEHF; Director, Greenstreet
0945
Management
Berman Ltd
Keynote: Is there a Problem?
0930
New forms of
Regulation for the
Human Factors of
Aviation Safety
Prof. Chris Johnson,
Head of Computing Science,
Glasgow University
Existing forms of regulation have provided strong support
for human factors in aviation safety. However, the publicprivate relationships that have grown up over previous
decades are arguably insufficient to protect us in future.
Part I: Accidents and What they tell us
1015
1100
1120
Issues Arising from the LTC Panagiotis Stathopoulos,
Hellenic Air Force
Helios Disaster
Account and factors arising from the Helios accident
including hypoxia, human factors in aircraft design,
alerting and automation from a military perspective.
Tea and coffee break
sponsored by LMQ Ltd
Stanislaw Drozdowski,
Safety nets for Airborne
Senior ACAS Expert,
Conflict
Eurocontrol
The presentation introduces existing safety nets against
midair collisions and their interactions with human
operators (pilots, controllers). These interactions are
illustrated by a description of a recent incident. The
speaker describes forthcoming changes to safety nets
and how these may introduce additional challenges.
Part II: What has to change?
Developing a Just
Nick Clutton, Former B767 pilot The speaker describes a development of the Just Culture
Culture to achieve an with BA, Astraeus and Ethiopian that adopts a holistic systems approach with supporting
1150
effective safety-focused Airlines, multi-crew training, CRM toolkits to enable a Management System (MS or SMS) to
function as intended.
Management System developer and author
1220 Question Time
1430
Changing the Flight
Deck
Increasing disjunction between individual state safety
oversight responsibility and EASA/EU authority, especially
in light of financial constraints, affects forward-looking
projects like NextGen and SESAR.
TBC: Prof. Guy Boy, Director, Florida Institute of Technology Human-centered Design,
Chair of IEA Technical Committee for HF
1500 Tea and coffee break
Developing ways of assessing system safety on a day to
Through a Glass Darkly: Dr. Anne Isaac, Head of Human day basis and observing good practice has proven to give
a more accurate picture of ‘work as done’. This practical
Performance in External Safety,
1520 safety at the pilotapproach has increased understanding of both the ATC
NATS
controller interface
system and the flight-deck, and the risk-prone interface
between the two professions.
1550 Question Time
Afternoon Panelists, Moderator: Mariann Hintz, Senior ATM Expert, Eurocontrol
Conference Reception
1730
sponsored by NATS
Captain Giancarlo Buono, IATA Conflict Zone overflight and security: how do we identify
1120 Conflict Zone overflight Regional Director Safety and
emerging risks including those coming from commercial
pressures?
Flight Operations, Europe
1150 Question Time
Morning Panelists, Moderator: Capt. Tim Rolfe, Bristow Group
1230 Lunch
1325
Helen Muir Award
Presentation
Sponsored by Ashgate
Publishing
Part III: Where are we going from here?
Dr. Jean Paries, CEO, Cabinet
The Challenge of the
1330
Dédale; President, Resilience
Unpredictable
Engineering Association
1400
Roderik D van Dam, President,
International Foundation for
Public Aviation (IFPA)
What can we expect from SMS? Can an SMS can ever be
an RMS (Risk Management System)? Do we need to be
clearer about what that means for behaviours throughout
the organisation?
What is likely to change (and what will not) over the
coming years: The paradoxes that this change dynamic
produces will largely have a human perspective. How the
human is integrated and equipped to manage the
sometimes conflicting pressures directly impacts
operating safety levels; how the industry as a whole faces
this future determines the eventual level of achievable
safety.
Tea and coffee break
1100 Sponsored by Elsevier
Publishing
Morning Panelists, Moderator: Maj. Mike Baker MAA MOD
Conference Lunch
1300 sponsored by
BooHoo.com
ATM Infrastructure:
1400 Responsibility and
Authority
“From Pyramids to
Pepsi”: A critical look at Capt. Harry Nelson,
Executive Operational Advisor
1015 the challenges our
industry is likely to face to Product Safety, Airbus
in the coming decades
What did we learn from Day 1? What do we need to do
now to anticipate and avoid the ‘Fatal Flaws’?
EASA Safety Risk
Management
Is there a role for the
1430 human controller in
future ATM?
John Franklin, Head Safety
Analysis and Research, EASA
Marc Baumgartner, IFATCA
SESAR / EASA coordinator
EASA’s new Safety Risk Management process will lead to
safety risk portfolios for different aviation sectors. The
presentation uses sample portfolios to show the
involvement of external stakeholders in the process
through the European Strategic Safety Initiative (ECAST/
EHEST/ EGAST) and the European HF Group.
Is our grasp of evolving teamwork and systemic
communication, particularly ATC/FD, adequate to cope
with emerging risks? How can SESAR help model the
impact of ‘big data’ on other flight operational areas?
Tea and coffee break
1500 Sponsored by CAA
International
1520 TBA
1620 Question Time
1700 Washup and Close
Dr. Kathy Abbott, FAA Chief
Scientific and Technical Advisor,
Flight Deck Human Factors
Afternoon Panelists, Moderator: Simon Roberts, SMS Programme Manager, CAA
Nicole Svatek, HFG Chair, and Can SMS and operational risk assessment as currently
Capt. Mike Freeman, TRI/TRE, implemented cope with extended teamwork
requirements? Is there a consensus for change?
RAeS Human Factors Group