TRAINING FOR
SAFETY
World Aviation Training Symposium
Orlando
27th April 2010
John Bent
Director Training Strategy
proposed Pegasus Flight Academy - China
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The latest threat to crew training resources
USD
1.7billion
has just been lost to international airlines in one week
Source IATA
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SAFETY - THE GOOD NEWS - 2009
IATA SAFETY REPORT 2009:
2009 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 billion people on 35 million flights
(27 million jet, 8 million turboprop)
LESS ACCIDENTS WESTERN BUILT TYPES: 19 vv 22 in 2008
LESS ACCIDENTS (all types) 90 vv 109 in 2008
LESS FATAL ACCIDENTS (all types): 18 vv 23 in 2008
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SAFETY - THE BAD NEWS - 2009
IATA SAFETY REPORT 2009:
 MORE FATALITIES: 685 vv 502 in 2008 1.36 times worse
 REGIONAL RATES WHICH ROSE:
• ASIA PACIFIC:
0.86 vv 0.58 in 2008 1.48 times worse
• M/E:
3.32 vv 1.89 in 2008 1.75 times worse
• AFRICA:
9.94 vv 2.12 in 2008 4.68 times worse
Runway excursions and ground damage were main categories
Pilot handling was a contributing factor in 30% of all accidents.
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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
an industry safety system failure
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CREW TRAINING - UK CAA 2008:
Training is the best investment against catastrophic risk
The top catastrophic accident risks identified were:
1. LOC (loss of control)
2. CFIT (controlled flight into terrain)
3. Post-crash fire
4. 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
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FLIGHT SAFETY FOUNDATION:
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”
BUFFALO NEWS – DEC 2009:
Are today's airline pilots churned out by "pilot mills" that train
to minimum standards?
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AN INDUSTRY WITH REMARKABLE CHALLENGES
Hardware growth has outstripped human-ware available
911 and SARS discouraged steady expansion of training capacity
2007-2008: aircraft were grounded without crews
Crew training rates inadequate; training trended to minimums
2009 - 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
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THE LONG TERM ACCIDENT RATE MAY EXCEED
THAT COMMENSURATE WITH EXPANSION ALONE
IF SO, WHY?
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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
As many as 35 of this sample (88%) may be concluded to
have contained crew training as possible mitigants
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2 Aug 2005
Air France A340 Toronto
RUNWAY DEPARTURE: Could more effective training have mitigated?
Undesired aircraft state- unstable approach in bad weather
1
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14 Aug 2005
Helios B737 Greece
CREW INCAPACITATION: Could more effective training have mitigated?
Tech and procedures?
2
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16 Aug 2005
W Caribbean MD82 Venezuala
LOSS OF CONTROL: Could more effective training have mitigated?
loss of control in cruise; a/c overload, stall?
“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
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23 Oct 2005
Bellview B737 Lagos
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
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29 Sep 2006
GOL B737-800 Brasil
COLLISION: Could more effective training have mitigated?
Procedures, situational awareness, TCAS?
5
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29 Nov 2007
AtlasJet MD83 at Isparta
IMPACT WITH TERRAIN: Could more effective training have mitigated?
- heading, situational awareness = controlled flight into terrain (CFIT)?
6
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7 Mar 2007
Garuda B737 Yogyakarta
OVERRAN RUNWAY: Could more effective training have mitigated?
Crew resource management (authority gradient)
7
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4 May 2007
Kenya Airways B737 Douala
CRASHED AFTER TAKE-OFF: Could more effective training have
mitigated? - took-off into heavy TS
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 737-800 suddenly disappeared from
radar screens two minutes after take-off from the Douala
International Airport during a heavy thunderstorm.
8
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17 Jul 2007
TAM A320 Sao Paolo
RUNWAY EXCURSION: Could more effective training have mitigated?
Undesired aircraft state - reverser inoperative procedures
9
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17 Jan 2008
BA B777 Heathrow
LOSS OF POWER: Could more effective training have mitigated?
NO: Sound airmanship displayed - AAIB report
10
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14 Feb 2008
Belgavia CRJ100 Yerevan
DE-ICING PROCEDURES: Could more effective training have mitigated?
Loss of control -refused advice to de-ice for take off
11
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ATR42 nr Merida
21 Feb 2008
FLEW INTO TERRAIN: Could more effective training have mitigated?
- failed to align NAV pre-take off = Situational Awareness + CFIT
12
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15 Apr 2008
Hewa Bora DC95 Goma
RUNWAY OVERRUN: Could more effective training have mitigated?
Overrun - tyre burst after V1; tried to stop
13
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25 May 2008
Kalitta B747 Brussels
RUNWAY OVERRUN: Could more effective training have mitigated?
Procedures; slow rejected take off?
14
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30 May 2008
TACA A320 Tegucigalpa
RUNWAY DEPARTURE: Could more effective training have mitigated?
Undesired aircraft state - landing performance?
15
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10 Jun 2008
Sudan Airways A310 Khartoum
RUNWAY DEPARTURE: Could more effective training have mitigated?
Undesired aircraft state - landing performance?
16
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6 Jul 2008
USA Jet DC91 Saltillo
GO AROUND FAILED: Could more effective training have mitigated?
Undesired aircraft state-approach to wrong runway
17
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20 Aug 2008
Spanair MD82 Madrid
DEPARTED RUNWAY: Could more effective training have mitigated?
Flaps not set for take-off -undesired aircraft state - procedures
18
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24 Aug 2008
Itek Air B732 Bishkek
LOST CONTROL ON APPROACH: Could more effective training have
mitigated? Undesired aircraft state – visual awareness?
19
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30 Aug 2008
Conviasa B737 Latacunga
FLEW INTO TERRAIN: Could more effective training have mitigated?
crew resource management, situational awareness
20
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14 Sep 2008
Aeroflot-Nord B735 Perm
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
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27 Nov 2008
ANZ A320 nr Perpignan
LOST CONTROL: Could more effective training have mitigated?
test flight procedures training (BEA)?
22
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20 Dec 2008
Continental B737 Denver
RUNWAY OVERRUN: Could more effective training have mitigated?
Undesired aircraft state -failed take-off & runway overrun?
23
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15 Jan 2009
US Air A320 Hudson River
TRAINING & EXPERIENCE SAVED THE DAY!
24
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12 Feb 2009
Colgan Air DH8D Buffalo
LOST CONTROL: Could more effective training have mitigated?
- procedures, icing and stall recovery training?
25
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25 Feb 2009
Turkish B737 Amsterdam
LOST CONTROL ON APPROACH: Could more effective training have
mitigated? Automation reliance & monitoring?
26
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23 Mar 2009
Fedex MD11 Tokyo
FLIPPED ON LANDING: Could more effective training have mitigated?
Undesired aircraft state -known handling issues in strong gusts?
27
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9 Apr 2009
Aviastar BAe 146 Wamena
IMPACT WITH TERRAIN: Could more effective training have mitigated?
Undesired aircraft state-loss of control; circling in low cloud base?
28
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29 Apr 2009
Bako Air B737 Massamba
CRASHED AFTER TAKE-OFF: Could more effective training have
mitigated? As yet unknown but aircraft stored for 1 year?
29
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1 June 2009
Air France A330 Atlantic
LOST CONTROL: Could more effective training have mitigated?
- inadequate evidence as yet
30
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30 Jun 2009
Yemenia A310 East Africa
LOST CONTROL: Could more effective training have mitigated?
Undesired aircraft state - missed approach in big twin; as yet unknown
31
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14 Jul 2009
Caspian Tu 154 nr Tehran
IMPACTED TERRAIN: Could more effective training have mitigated?
-as yet unknown
32
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24 Jul 2009 Aryan Airlines IL62 Mashhad (Iran)
OVERRAN RUNWAY: Could more effective training have mitigated?
-Technical (gear?), late landing, but as yet unknown
33
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4 Aug 2009 Bangkok Awys ATR72 Koh Samui
RUNWAY EXCURSION: Could more effective training have mitigated?
Departed runway in strong winds and rain - as yet unknown
34
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21 Oct 2009
Sudan Awys B707F Sharjah
LOST CONTROL: Could more effective training have mitigated?
Lost control during initial climb and crashed – as yet unknown
35
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19 Nov 2009 Cpgn African Avn MD82 Goma
OVERRAN RUNWAY: Could more effective training have mitigated?
Overran runway in ‘rainy conditions’ - as yet unknown
36
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22 Dec 2009 American Airlines 738 Kingston
OVERRAN RUNWAY: Could more effective training have mitigated?
Overran runway in heavy rain - as yet unknown
37
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2 Jan 2010
Compagnie B727-200 Kinshasa
RUNWAY EXCURSION: Could more effective training have mitigated?
Veered off runway on landing - heavy rain
38
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24 Jan 2010
Taban Air TU 154 Mashad Iran
RUNWAY EXCURSION: Could more effective training have mitigated?
Landing in fog with medical emergency
Flight International
39
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25 Jan 2010
Ethiopian 738 Nr Beirut
CRASHED IN DEPARTURE: Could more effective training have mitigated?
Lost height and impacted Mediterranean (WX?) - as yet unknown
40
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LESSONS FROM THIS SAMPLE?
1.
That most accident risks realised could be foreseen in training!
2.
That reactive is easier then proactive!
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) &
4.
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%?)
5.
We must mitigate accidents with TRAINING
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Back to the 2009 IATA REPORT

Runway excursions and ground damage
were main categories

Pilot handling was a contributing factor in
30% of all accidents
So what’s happening in
2010 ?
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DURING THE FIRST 120 DAYS OF 2010,
NOT MUCH HAS CHANGED
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RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page1)
2 Jan
Compagnie Africaine Aviation B727-200, Kinshasa (Congo)
Veered off runway on landing
3 Jan Air Berlin B737-800, Dortmund (Germany)
Rejected takeoff - runway overrun
8 Jan Air Berlin B737-800, Nuremberg (Germany)
Veered off runway on take off
9 Jan Yas Air IL76, Kiev (Ukraine)
Runway excursion on landing
15 Jan Iran Air F100, Isfahan (Iran)
Nose gear collapse on landing
16 Jan Iran Air A300-600, Stockholm (Sweden)
Went off runway on line up for take off
19 Jan PSA Airlines CRJ2, Charleston (USA)
Overran runway on take off
7
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Source: Aviation Herald
54
RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page2)
19 Jan
21 Jan
22 Jan
25 Jan
27 Jan
28 Jan
30 Jan
Lion Air B737-900, Padang (Indonesia)
Runway excursion on landing
Aeromexico Connect E145, Tijuana (Mexico)
Went off runway on landing
Skywest CRJ7, Winnipeg (Canada)
Overran runway on landing
West Air CRJ2 Longyearbyen (Norway)
Veered off runway on landing
Cimber AT72, Bornholm (Denmark)
Veered off runway on landing
Bulog AN26, Wamena (Indonesia)
Overran runway on landing
Donavia B737-400, Rostov (Russia)
Overran runway on landing
14
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Source: Aviation Herald
55
RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page3)
31 Jan
4 Feb
8 Feb
10 Feb
13 Feb
18 Feb
22 Feb
Skyservice A320, Varadero (Cuba)
Hard landing – three tyres blown
Yakutia AN24, Yakutsk (Russia)
Rejected take-off but airborne / gear up
Shasheen B737-200, Peshawar (Pakistan)
Departed runway on landing
KLM B737-300, Schiphol (Netherlands)
Took off on taxiway
Batavia B737-200, Surabaya (Indonesia)
Nose gear skidded on line up – tyres blew
Shuttle America Embraer ERJ-170, Cleveland (USA)
Overran the runway on landing
Spring Airlines A320-200, Shenyang (China)
Landed tail first – structural damage
21
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Source: Aviation Herald
56
RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page4)
24 Feb Ethiopian Airlines B737-700, Lubumbashi (Congo)
Departed taxiway after landing
24 Feb Air Canada Airbus A321-200, Toronto (Canada)
Landed without ATC clearance
25 Feb Lion Air B 737, Padang (Indonesia)
Main gear departed paved surface
26 Feb Garuda Indonesia B 737-800, Perth (Australia)
Entered RWY 06 after landing - no clearance
26 Feb Aeroflot A320-200, Oslo Gardermoen (Norway)
Took off on taxiway
1 Mar Air Tanzania B737-200, Mwanza (Tanzania)
Veered off the departure runway 30
17 Mar Shaheen Air International B737-200, Peshawar (Pakistan)
Overran the runway on landing
28
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Source: Aviation Herald
57
RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page5)
22 Mar Aviastar TU-204-100, Moscow Domodedovo (Russia
Landed about 1000 meters short of rwy 14R
23 Mar China Airlines B747-400F, Anchorage, (USA)
Struck its tail onto the departure runway
24 Mar Cargojet B727-200, Moncton, (Canada)
Overran runway 06 while landing
24 Mar Asiana A321-200, Omitama (Japan)
Overran runway 21L by about 30 meters
25 Mar Westjet B737-800, Cancun (Mexico)
Tail strike during takeoff
25 Mar Air Madagascar B737-300, Nossi-be (Madagascar)
Main gear off the paved surface after landing
5 Apr Egypt Air A330-200, Cairo (Egypt)
Wrong taxiway - impacted two light poles
(wrong park position entered into FMS – wing damage)
35
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Source: Aviation Herald
58
RUNWAY EXCURSIONS & GROUND DAMAGE 2010 (page6)
8 Apr PSA Airlines CRJ-200, Charleston, WV (USA)
Overran runway - rejected takeoff at high speed
13 Apr Merpati Nusantara B737-300, Manokwari (Indonesia)
Overran runway while landing
21 Apr Cargojet B727-200, Moncton (Canada)
Overran runway 06 while landing
38
(Since 1st Jan 2010)
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Source: Aviation Herald
59
Is our collective industry eye still
off the SAFETY ball?
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THE BIG QUESTION
SHOULD INDUSTRY ACCEPT THAT
ACCIDENT & INCIDENT RATES:
(1) ARE AS LOW AS ECONOMICALLY VIABLE?
OR
(2) MUST BE FURTHER REDUCED?
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AS GROWTH RESUMES, IF THE ACCIDENT RATE
REMAINS UNCHANGED
Expansion of
The accident
the global fleet
will increase
RATE must be
DRIVEN DOWN
the number of
further
accidents
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ALTHOUGH THE RATE IS LOW RELATIVE TO ACTIVITY:
A doubling of the fleet next 20 years at same rate could result in
10,000 fatalities or more; tragedies with commercial
consequences for passenger growth
SO WE MUST ACT
To hold accidents down to 150 and a possible 5,000 fatalities,
we must HALVE the accident rate NOW
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THE BRIC COUNTRIES (Brazil, Russia, India, & China)
ARE MOST EXPOSED – NEXT 20 YEARS
Source: ACI Sept 08
THE BRICS WILL EXCEED USA BY 2027
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IN CHINA ALONE: 20 YEAR PROJECTIONS FOR
NEW AIRCRAFT:
Pre-recession projection: 3,800 airframes
Post recession-REVISED projection:
2,800 airframes
New airline pilots required (including 8,000
retirements):
41,600
Source: manufacturers and IATA
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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
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ACTION - THE CHALLENGES:
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THE CHANGE CHALLENGE
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’
DOEPS [DEFENCE OF ESTABLISHED PROCESS SYNDROME]?
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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
BUT:
Hundreds of thousands of safe flights are not news
Airline accidents are immediate media drama
Public perceptions form with the first media bite
Safe enough to relax? NO, that’s complacency
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THE SKILL & EXPERIENCE LOSS CHALLENGE
(UNCOMFORTABLE SYSTEMIC MIX):
As hardware and technology improved:
crew dependence on automation increased
raw piloting and monitoring skills regressed
technology was perceived to reduce training need
human factors became more exposed as common cause
In parallel, recent rapid growth:
reduced average experience on airliner flight decks
encouraged new entry criteria for pilots (generation ‘G’
and beyond may pose even more challenges)
placed increasing pressure on training systems
forced cost savings into crew training programmes
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THE AUTOMATION CHALLENGE
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 fellow human beings”
“The autopilot on a plane, the cruise control on a car, automated
speed control systems in mass transit, are all conveniences but
can become crutches”
“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
that a confluence of unexpected factors that stymie the
algorithm will produce catastrophe”
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THE PROCESS CHALLENGE
CUSTOMER NEED DEFINED
 COMPETENT SAFE PILOTS
 INPUTS TO SELECTION
FEEDBACK
ANALYSIS
Continuous improvement
COMPULSORY REPORTING:
 CUSTOMER & TRAINING ORG TO NAA
 NAA TO ICAO
VERIFICATION
AUDITS:
1)
2)
REGULATION
& FACILITATION
 INDUSTRY > ICAO
DEVELOP BEST PRACTICE
NEW SARPS TO NAA
 TRAINING ORGANISATION
APPLIES NAA REQUIREMENTS
PLUS LOCAL ENHANCEMENTS
TRAINING ORG BY CUSTOMER & NAA
NAA BY ICAO
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THE TIME & RESOURCE CHALLENGE
(THERE’S LIMITED TIME TO ACT)
Seeing through the recession
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
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THE MANAGEMENT PERCEPTION CHALLENGE
Training practitioners usually agree that
TRAINING IMPROVEMENTS ARE NEEDED,
but what about
CAPA Management survey 2009 >>
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TRAINING AS A PRIORITY: Current priorities are not training!
Short Term Challenges: What will be the 3 biggest challenges for your
business over the NEXT 12 MONTHS?
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Source: Centre for Asia Pacific Aviation Survey, Sept 09
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Quality of Training
Environmental Issues
Regulatory Issues
Technology
Implementation
Availability of Skilled
Resources
Operating Costs (nonfuel)
Oil Price Volatility
Funding & Capital Raising
Weak Demand
0.0%
TRAINING AS A CHALLENGE: A greater spread of opinions
on the key issues - medium term
Medium Term Challenges: What will be the 3 biggest challenges for your
business over the NEXT 1-3 YEARS?
50.0%
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
Source: Centre for Asia Pacific Aviation Survey, Sept 09
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Quality of Training
Technology
Implementation
Regulatory Issues
Availability of Skilled
Resources
Environmental Issues
Operating Costs (nonfuel)
Funding & Capital Raising
Weak Demand
Oil Price Volatility
0.0%
How can crew training be
enhanced if company executives
don’t see the need?
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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)
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FIND THE LOWEST HANGING FRUIT
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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
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RAISE TRAINING STANDARDS - EVERYWHERE
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RAISE QUALITY - EVERYWHERE
Cost reductions (‘more’ training
cannot easily be added)
Quality, and relevance
must rise
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TAKE A MORE GLOBAL HOLISTIC APPROACH
GENERAL
AVIATION
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
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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 >>
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USE INDUSTRY EXTERNAL DATA
Flight Operations
LINE OPERATIONAL SAFETY AUDIT
(LOSA)
Whole Airline:
IATA OPERATIONAL SAFETY AUDIT
(IOSA)
Whole Airline Industry:
GLOBAL SAFETY DATA
(ICAO, IATA, FSF..)
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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)
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LOSA DATA SHOWS WHAT CREWS DO RIGHT
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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: 1.
Cooperate to rigorously monitor and cross check to
make sure they pick up threats and errors early, and
2.
Actively engage in checking and verifying every
setting and action which can affect safety.”
No Surprise! But much more can be done
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USE AIRLINE INTERNAL DATA
Flight Operations
SELECTION CRITERIA & DATA
(& downstream performance: another presentation!)
Safety Dept
FOQA / QAR DATA & CONFIDENTIAL REPORTS
Flight Operations & Training Dept
CREW PERFORMANCE DATA
(training progress, PCs / route checks)
FUTURE INITIATIVE:
Flight Operations & Training Dept
SIMULATOR PERFORMANCE DATA
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OK SO WHAT’S NEW?
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
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CAPITALISE ON CURRENT INITIATIVES
ITQI (IATA Training & Qualification Initiative)
Active development of Type VII FSTD ATC Simulation
Active development of Upset Recovery Training (URT) standards
(RAeS International Committee - aviation training in extended envelopes– ICATEE)
Improved type training programmes;
eg. APT3 (Airbus Pilot Training) & B787 type training – all embedded with TEM
(Threat & Error Management)
ATSAS (Aircrew Training Standards & Safety - safety data driving training)
NGAP (ICAO Next Generation Aviation Professionals) Initiative – March 2010
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Recognise the new Airline Pilot License
MULTI-CREW PILOTS LICENCE (MPL)
after 60 years of almost no change
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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 >
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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)
MPL is now under development, trail, or use in:
Australia, China, Denmark, Germany, Philippines, Singapore,
Sweden, Switzerland, United Kingdom, Hong Kong… (10)
By operators:
Former Alteon-Boeing Flight Training-CAAC, CAAC-CAFUC, CAPASterling, 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)
Source: IATA
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MPL under TRIAL – some challenges
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:
80 - 130 hours
Simulator flight training spread:
155 - 292 hours
Course duration spread:
14 - 36 mths
But as the superior performance of MPL graduates is more
widely seen, operators will eventually demand MPL
Data Source IATA & Tng Orgs
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MPL STATUS MARCH 2010:
GRADUATED:
77
STUDENTS IN TRAINING:
800
Data Source: IATA & EASA MPL Advisory Board 16/17.3.10
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Training Comparison:
300
275
Multi-Crew Pilot License
(290 hrs- proposal)
250
210
201.5
JAR ATPL(A) Standard
Integrated Course incl.
T/R
Hours
200
150
90.5
100
111
120
65
56
50
0
Instruction Time
Flight A/C
FSTD
Instruction
FSTD type 1v &
V11 Instruction
Source: IATA
Kind of Training
MPL delivers more instructional hours than CPL
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MPL THROWS OUT SPECIAL CHALLENGES:
UPSET
RECOVERY
TRAINING (URT):
Actual flight in
training aircraft
+
Simulator
training
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
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HONE THE INSTRUCTOR’S ART – THAT
HUGELY FERTILE VARIABLE!
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!
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IMBIBE GOOD AIRMANSHIP (the consistent use of good judgment
& well-developed skills (Kern 96) – STUDY EVENTS
SOMETIMES PROCEDURES & CHECKLISTS MAY NOT BE ENOUGH:
> Volcanic ash All Engines out - BA 9 - June 82
Lost Hydraulics - Sioux City United 232 July 89 >
> Power loss & ditching - US Airways Flt 1549 Jan 09
Cathay A330 – both engines fluctuated - thrust stuck @ 70% N1
asymmetric - landed at 230kts - April 10
(subject to inquiry underway) >
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TRAINING ENHANCEMENT SUMMARY:
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
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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
SO WHY THIS?
Let’s just
fix it!
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THE BOTTOM LINE
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
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ONE LIGHT SWITCH FOUND!
From the 2009 FAA safety call to action speech (Randy Babbitt):
“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
 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
 We have some great opportunities to look at best practices …..
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Two Parting questions
 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?
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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
SAFETY GROWS FROM EFFECTIVE TRAINING
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Thank You!
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ENTER THE PROPOSED
Pegasus Flight Academy
Best practice safety-driven training
founded on MPL in one location
Aimed at higher training standards
+ expanded safety margins
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