1.

Executive summary

The human element is the most flexible and adaptable part of the aviation
system, but it is also the most susceptible to influences that can unfavourably
affect its performance. Aviation accidents are rarely caused by a single event or
action, but rather by a chain of factors or events. Though this makes it complex
to analyse, it also infers that, the accident could be averted if one event in the
chain is broken. The fast changing operating environment is posing new types of
challenges to safety. As old risks are conquered, new risks and corresponding
counter measures are emerging. The human element and it’s interaction with
technology still remains at the heart of the solution for improved safety systems.
This paper will attempt to compare the flight data monitoring programme and
safety reporting as sources of safety data sources. This will involve examining the
type of operational issues they are able to detect as well as their
advantages/advantages.

2. Definitions

Safety reporting.

These involves the various mandatory, voluntary and confidential systems put in
place to enable all personnel and stakeholders involved directly or indirectly with
aviation systems provide safety related information. The aim is to have a just
culture in operation to foster a reporting culture that will both expose the root
causes of accidents and incidents as well as prevent re-occurrence of such.
These includes but not restricted to the following: Air safety reports (ASR),Cabin
safety report (CSR),Maintenance safety reports (MSR), Service difficulty reporting
system(SDRS) only applicable to the FAA, Ground safety reports (GSR) and
Human factors reporting, e.g. (CHIRP).

Modern aviation Safety reporting has it’s origins during the enactment hearings of
1958 in the USA. Finally became operational with NASA administering the system
from 15th April 1976.(*2)

Flight data monitoring programme (FDMP).

This is “A systematic, proactive and non-punitive programme for gathering and

analysing data recorded during routine flights to improve flight crew performance,
operating procedures, flight training, air traffic control procedures, air navigation
services, or aircraft maintenance and design.”

It is the recording, collating, analysing and logical presentation of the interaction

of the flight crew and the aeroplane usually from the time it is powered up at pre-
flight to when the engines are shut down post-flight.
Known as flight operations quality assurance (FOQA) to operators regulated by
the FAA. ICAO’s 26th amendment to annex6 3.6.3, requires member states who
have adopted this recommendation into national legislation to mandate operators
of all aeroplanes with MTOM >27000kg to have non-punitive FDMP in place by 1st
Jan, 2005.

3. Comparative analysis

• Proactive vs reactive

Both methods of data acquisition have elements of reactive and proactive

processes. However, most personnel will hesitate to report observations that
have not resulted in an incident unless they have proof/evidence that it is
potentially unsafe and is a re-occurring event. As a result most ASR comprise
mostly of events or near misses that have already occurred. Human error is
inevitable and according to Helmreich and Merritt, how we learn manage it is the
key to improving aviation safety; mitigate, trap or avoid (*3). To further
complement the NASA led ASRS, the FAA initiated another confidential and non
jeopardy reporting aimed at pilots; Aviation safety action programme (ASAP) in
1997.

The FDM is designed to be more of a proactive accident prevention tool. This is

achieved in the detection, analyses and logical depiction of routine operational
trends and exceedances such as:
 Exceedences or Events deviation data; e.g. engine, speeds, flaps,
gears, unstabilised approach criteria.
 Routine data measurements. Monitoring subtle trends and
tendencies before they result in incidents or accidents; e.g. take off
weight, Flap settings, temperature, rotations rates, speeds, pitch.

• Ease of investigation.

The FDMP makes it much easier to conclusively investigate a great number of

mandatory occurrence reportable incidences as well as prescribe the best
remedial action or cost effective training. Such events include; go arounds,
altitude deviations, Stalls, engine failures, high speed RTO’s, tail strikes, Heavy
landings, wake/severe turbulence and flight control difficulties accompanied by
excessive control deflections, e.t.c.

Of course ASR will provide useful contextual information, though it relies on the
ability of the human element to recall complex events during periods of high
stress. The FDMP is definitely a more versatile tool in this regards.

• Reported vs unreported events

The number and quality of safety reports in an organisation is largely dependent

on the safety culture prevailing within the organisation. Bearing in mind, that
evidence from research indicates inadvertent human error is complicit in 75% of
accidents. Line observations show flight crew were unaware of about 50% of the
errors noticed by observers. Most of these errors were inconsequential, not
reported and therefore not investigated. Resulting in lost opportunities to learn
from such events. The logic is simple; people cannot report what they fail to
notice.
An FDMP on the other hand has a valid data capture rate of 96% of all man-
machine onboard interaction. With the development of high data capacity disks,
there’s no reason why the voice element cannot be included in the overall data
capture. Most airlines that run a FDMP also observe a corresponding increase in
ASR. This is more evident for events like unstabilised approaches and go-
arounds.

• Objective vs. subjective

Data from the FDMP is able to provide realistic, accurate and objective and
description of the pilot-aircraft (livewire-hardware) interaction. Thus providing the
vital “When” and “How” it happened. With data validity of at least 98%, the
system is robust. However, there are many scenarios that this data alone does
not provide a clear and comprehensive understanding of the event without input
from the operating crew. The knowing of “Why” it happened.

Irrespective of the honesty and best intentions, the quality of an ASR’s is usually
unwittingly subjective to a plethora of reporter biases. Including but not restricted
to frequency, selectivity, familiarity, conformity, group conformity and
overconfidence biases. This is more evident when it comes to describing the
events in the light of Liveware-Hardware interactions. The inaccuracies range
from subtle to glaring depending on the impact these and other human factors.

• Quantitative vs contextual information

Though subject to cognitive lapses, the human reporter is still the preferred tool
of choice that gives contextual and valuable insight to what influenced the
decision making process of the frontline operators. This is the “why” element. It
constitutes a milestone in unravelling the root cause during an investigation.

Conversely, though the FDMP is able to provide a realistic, accurate and objective
information it’ s major drawback is, it still only quantitative in nature.

Analysis can accurately depict how and when an event occurred but leaves out an
important part of the Jigsaw; the why it happened. Why certain decision/ actions
were made/not made.

• Aircraft operational data only vs. Carte blanche broad based data

Though the FDMP can continuously detect up to an impressive 60,000 aircraft

parameters with great precision, it is still restricted to detecting issues that can
be sensed by on-board systems only. These include environmental and surface
conditions. This seriously limits it’s ability to detect most latent conditions apart
from ergonomics.

ASR have a rather “carte blanche” option when it comes to scope of reporting.
Reference to ICAO doc 9859 highlights this fact. “ASR has the mandate to
include….unsatisfactory behaviour or procedure which did not immediately
endanger the aircraft but which, if allowed to continue uncorrected, or if repeated
in different, but likely, circumstances, would create a hazard.(CAP 382, 5.4.3).
This could be anything at all that in the judgement of the reporter is likely to
affect safety.”
All said and done, it is obvious that the FDMP is well ahead of ASR. This can be
seen from the testimonials below:

UK CAA: "Such systems allow an airline to identify and address specific

operational risks and are strongly encouraged as part of a Safety Management
System."
FAA: "Because of its capacity to provide early objective identification of safety
shortcomings, the routine analysis of digital flight data offers significant additional
potential for accident avoidance. It is potentially the best safety tool of the 21st
century."

• High vs. low start-up and running costs

All safety initiatives have an element of cost attached to it. Given that the flight
safety office usually manages the reporting systems in place, the implementation
of a FDMP will require additional cost. Approximately £300,000 start-up cost for a
small operator with 10 aircraft. These are modest investments compared to the
added safety and operational benefits the FDMP will impart to the core business
function.

A synthesis of additional operational benefits of FDMP that sets it further ahead of

the traditional ASR are given below

The FDMP is able to provide substantial evidence of:

• Adherence/ non adherence to company SOPs

• Compliance with published navigation and noise abatement procedures.
• Inadequate SOP’s or peculiar scenarios where the SOP needs official
variation.
• The effectiveness of remedial changes to SOP’s or training schemes.
• A vital part of the ATQP certification that provides efficient use training
resources.
• Ineffective training, briefing, handling or command skills
• Potential saving on fuel costs using Statistical analysis of route fuel and
taxi fuel leading to accurate flight planning.
• Airspace practices like early descents and long approaches that are
inefficient and environmentally unfriendly.
• Better engine and component (gears, brakes, reversers, flaps) life
utilisation.

Conclusion

The author is of the opinion that the industry is currently neglecting an important
capability of the flight data management programme in improving the current flat
stagnant accident rate. The major weakness of the FDMP is its inability to detect
human factors issues that can be gleaned by analysing inter-cockpit, cockpit-
cabin and pilot-controller communications. The major obstacle restricting this is
possibly the pilot unions and to some extent the airlines. The industry has
accepted that taxi, take-off and initial climb to 10000ft are critical flight phases.
It is therefore reasonable to expect the crew to restrict their communications to
that which is pertinent to the safe operation of the flight. All this requires is some
level of discipline from the operating crew. Of course, the same pilots initially
kicked against the FDM programme, but have now realised the safety benefits. If
this change is implemented, the pilot community will eventually realise that the
safety benefits far outweigh any disadvantages. Knowledge of risks is the key to
flight safety.

References.

1. Cliff Edwards and Jari Nisula;Active safety management (May 2009) City
University London.
2. (2)http://asrs.arc.nasa.gov/overview/summary.html
3. Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of
Crew Resource Management training in commercial aviation.
4. http://www.ukfsc.co.uk.
(2)http://asrs.arc.nasa.gov/overview/summary.html
5. Wells & Rodrigues; Commercial aviation safety 2003
6. ICAO DOC 9859 Safety management manual
7. Reason, J (2006) Managing the risks of organisational accidents.
8. CAP 739, flight data monitoring.
9. CAP 382 The mandatory occurrence reporting scheme
10. S. Dekker (2002), The Field Guide to Human Error Investigations.
11. Heinrich HW (1959). Industrial accident prevention: a scientific approach
(4th ed.). McGraw-Hill.
12. (23) http://www.flightsafety.org/cfit5.html