Consultants & Culture: The Good, the Bad and the Ugly
Consultants & Culture: The Good, the Bad and the Ugly At Aerossurance we believe culture and leadership are critical to business performance. A 2016 Deloitte research report showed 86% and 89% of executives rate these as important priorities. Organisations are however often tempted by offers of ‘diagnoses’ from consultants promising to diagnose their culture or leadership and by implication, prescribe a ‘cure’. There is something soothing in the idea that your organisation’s problems can be cured as easily as visiting a doctor. However, General Practitioners often match symptoms to off-the-shelf remedies in consultations lasting minutes, then adjusting if the symptoms persist. Similarly, there is no equivalent of a hospital monitor to plug into an organisation. Internationally renowned social psychologist Professor Edgar Schein, author of the highly influential Organizational Culture and Leadership, has commented that in his view, “simple culture diagnoses and cultural change fixes rarely accomplish what the clients want” (see Humble Consultanting p25). That’s because Schein contends, “organisational problems are increasingly complex, messy and unstable” and over reliance on supposed diagnostic tools “will at minimum waste time and at a maximum do unanticipated harm” (p172). He believes that while culture can be described and understood, it can’t be quantified. Supporting this thinking, in a Health and Safety Executive (HSE) report from 2000 that proposed a safety culture maturity model, the authors cautioned their model was “provided to illustrate the concept and it is not intended to be used as a diagnostic instrument”. Large consultancies like structured diagnostic tools because not only because they can be marketed as unique trade marked Intellectual Property but also because they can be applied by less skilled junior staff, matching symptoms to a limited number of existing off-the-self solutions. Some of these so-called tools are merely audit check lists re-branded to fool the gullible into premium fees. While some consultants promise neat solutions using proprietary tools: …the most important work by the consultant is to help the client understand the messiness of the problem…[p179] …and apply focused solutions that match the client’s real needs. As said elsewhere: There are few management skills more powerful than the discipline of clearly articulating the problem you seek to solve before jumping into action. However, a 2013 survey of 42 FTSE CEOs, 56 other CEOs and 62 C-level exeutives (chairman, presidents, principles, and board members in the UK found that 52% of them believed consultants fail to deliver on culture change programmes. Faux-consultancies that are really a front for training providers for example will jump to make training the preferred action irrespective of the true client need or the most effective and efficient possible solutions. Liza Taylor comments that: Culture Change is Not About Navel Gazing: …addressing culture is extremely important for business success however organizations need to be informed about whether they will actually get measurable performance results from the approach that is being suggested. Don’t be fooled…an approach that sounds like an interesting behavioral experiment or a snazzy tech solution is not usually a good one. Sociologist Prof Diane Vaughan, whose seminal work The Challenger Launch Decision lead to her involvement in the Columbia Accident Investigation Board (CAIB), conducted under Admiral Hal Gehman, does make the point that “cultural blind spot” can exist where “insiders are unable to identify the characteristics of their own workplace structure and culture that might be causing problems”. Rather than surveys and focus groups, as a counter-measure she recommends immersing ethnographically trained researchers into organisations. This is the antithesis of using simplistic off the...
read moreFlying Control FOD: Screwdriver Found in C208 Controls
Flying Control FOD: Screwdriver Found in C208 Controls An Australian Cessna 208B Caravan pilot detected a control restriction during a flight control rigging check according to a Service Difficult Report (SDR) submitted to the Civil Aviation Safety Authority (CASA). The report described how the pilot: …checked full and free movement of all flight controls. Very slight friction or binding of the elevator control was identified. The issue was discussed with the LAME [Licenced Aircraft Maintenance Engineer] who investigated further and discovered an object wedged between the control column shroud and the control column attaching cables. The shroud was removed and a screw driver was found. CASA do not report any investigation results that explain the lost tool. Even when such information is available, it is very easy to fall for the fundamental attribution error that the personnel in a particular incident were ‘stupid’ or ‘unprofessional’ without considering the organisational environment and the circumstances they found themselves in. We have previously discussed these FOD events: Tool Control and a Rotor Blade FOD Incident Micro FOD: Cessna 208B Grand Caravan Engine Failure & Forced Landing Misrigged Flying Controls: Fatal Maintenance Check Flight Accident FOD Damages 737 Flying Controls Crew Bag FOD Shatters Hawk Canopy C-130J Control Restriction Accident, Jalalabad The UK AAIB report on the loss of Yak-52 G-YAKW, considered a fatal accident where a tool, seemingly borrowed from an unlocked tool box, jammed flying controls. Damages of £270,000 were awarded to the pilot’s family in a subsequent court case. UPDATE 26 March 2017: Cessna 208 Forced Landing: Engine Failure Due To Re-Assembly Error UPDATE 14 April 2017: The NTSB preliminary report on an incident on SA227 N158WA on 20 March 2017 in Boise, ID, where a lost tool appears to have come loose at rotation and caused the loss of a propeller blade tip and for debris to enter the cabin. …about the time the airplane was rotating from Runway 10L, the pilot experienced a light vibration; he subsequently returned to BOI and landed uneventfully. During a post-landing examination of the airplane, it was revealed that a portion of the outboard section of a left propeller blade, which had fragmented into 2 pieces, was missing. Additionally, about a 4 inch by 4 inch puncture hole was observed to have gone through the left forward side of the fuselage just aft of the main air stair door; a piece of the propeller blade was found in the cabin. It was further noted during a runway sweep for foreign objects shortly after the occurrence, that a screw driver which had been used during maintenance on the airplane earlier, and the second piece of the propeller blade tip, were both recovered from the departure runway in the same approximate location from where the airplane would have rotated. UPDATE 12 November 2018: We analyse the outcome of this SA226 investigation: Lost Tool FODs Propeller Blade, Penetrating Turboprop’s Fuselage Plus we have discussed maintenance human factors and error management more generally here: Professor James Reason’s 12 Principles of Error Management Back to the Future: Error Management Maintenance Human Factors: The Next Generation Aircraft Maintenance: Going for Gold? Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements: Aerossurance can provide practice guidance and specialist support to successfully implement...
read moreFatal H500 / 369D Low Altitude Hover Power Loss: Power Line Maintenance Project
Fatal H500 / 369D Low Altitude Hover Power Loss: Power Line Maintenance Project The Transportation Safety Board of Canada (TSB) has released their investigation report into a fatal power loss while hovering alongside a power line near Paynton, Saskatchewan on 22 October 2015. The Accident SaskPower had contracted Forbes Bros…to construct and erect hydro towers and to string power lines. Oceanview Helicopters was contracted by Forbes Bros to carry out aerial work and install marker balls on power lines strung over the North Saskatchewan River. Because SaskPower had no control over the aerial work being conducted, Forbes Bros. Ltd. and Oceanview were expected to provide the necessary oversight. Hughes (later MD) 369D helicopter C-FOHE, was: …conducting aerial work installing marker balls…with a pilot and an external platform worker [from Forbes Bros] on board. During the marker ball installation, the single-engine helicopter was hovering at 325 feet above ground level when it experienced an engine failure. The helicopter began to descend and collided with terrain. The rate of descent, calculated by analysis of the video, would have resulted in a g force of 139 to 208 on impact. Possible attempts by the pilot to arrest the rate of descent before impact may have reduced impact forces; however, they remained above the threshold for survivability. The g forces sustained on impact were also well outside the structural limitations of the helicopter and resulted in the rupture of the fuel cell and a post-impact fire. It was determined that the accident was not survivable. Both the pilot and the platform worker sustained fatal injuries, and the helicopter was destroyed… The ELT activated on impact, and the signal was received by the Joint Rescue Coordination Centre in Trenton, Ontario. The ELT signal was lost soon after the impact owing to the post-impact fire. The Joint Rescue Coordination Centre did not dispatch any equipment. The Investigation The engine was badly damaged in the post-crash fire. The investigation however was able to determine that an engine compressor failure resulted in the loss of power. It was determined that the lead event was likely the failure of a stage 2 compressor blade; therefore, it is likely that the failed compressor blade was subject to fatigue and eventual overload failure before the prescribed overhaul period had elapsed; research suggests that this sort of failure is rare. The TSB were not able to pinpoint a specific cause of the blade failure. The investigation also concluded that, while not contributory in this occurrence, the reduced-interval erosion/corrosion inspection and daily fresh-water rinses of the compressor were not completed as recommended by the engine manufacturer. If operators do not follow manufacturer-recommended procedures when operating in an erosive/corrosive environment, there is an increased risk of an undetected and premature failure of the compressor. We have previously discussed failures to follow these recommendations: Ignoring Corrosive Environment Brings Down Helicopter involving a power line washing operation in Taiwan. As the loss of power: …occurred while the helicopter was in a hover, and there was insufficient altitude to conduct an autorotation landing (a manoeuvre to land without engine power), which led to the helicopter impacting the terrain. The TSB observed that: …the helicopter was hovering at an approximate altitude of 325 feet with very little wind. In this occurrence, the pilot had to avoid power lines and could not immediately transition into forward flight. A significant amount of rotor...
read moreUnexpected Load: AS350B3 USL / External Cargo Accident in Norway
Unexpected Load: AS350B3 Under Slung Load (USL) / HESLO Accident in Norway The Accident Investigation Board Norway (AIBN – the Statens Havarikommisjon for Transport [SHT] in Norwegian) has issued its final report on a helicopter accident that occurred in Troms, Norway on 20 July 2016. It involved Airbus Helicopters AS350B3 LN-OSN of HeliScan that was supporting powerline construction by Consorzio Italia 2000 for power utility Statnett with Helicopter External Sling Load Operations (HESLO). The AIBN report that: During a landing to load off [three] personnel, an external load was attached to the helicopter by longline without the commander being aware of it. At lift off, the long line tightened, and the commander experienced a jerk in the helicopter that made him decide to make an emergency landing in terrain with birch trees. The rotor blades and the landing gear sustained damage. The pilot, the sole occupant, was uninjured. It emerged during the investigation that it was given an unclear message from the [construction company] principal who gave room for the commander and task specialist to have different understanding of the task to be performed. The commander had the notion that it should be transport of [all] personnel from a mast point along the power line [as he had just move three of the five personnel from that site]. [The] task specialist, who believed that stringing of pilot lines was the next task [and that only the key personnel needed to be moved], attached longline to the load hook. This caused the helicopter to take off in such a way that [4 seconds into the flight] there was a strong pull due to the weight that hung in longline when it was tightened. The report [only available in Norwegian] focuses on cooperation and communication between the commander and task specialist, and the equipment used for communication. The AIBN note that: EASA OPS Annex VIII Part-SPO (Special Operations) Subpart E HESLO (Helicopter Sling Load Operations) which was introduced in Norway 1 January 2016 has in its AMC / GM (Acceptable Means of Compliance / Guidance Material) defined minimum standards for communication equipment to be used in this type of assignment: AMC 1 SPO.SPEC.HESLO.100 Standard operating procedures, Party C Equipment (4) Adequate radio communication equipment (eg VHF, UHF, VHF) should be installed and serviceable in the helicopter for co-ordination with the task specialists Involved in the operation. (5) Task specialists Involved in the operation should be equipped with hand-held communication equipment, protective helmets with integrated earphones and microphones. In this case the task specialist / loadmaster did not use his more basic hand-held VHF radio because of the noise. The helicopter was fitted with mirrors that would have given the pilot a view of the belly hook but as the pilot was not expecting a load to be added, the action of the task specialist went unnoticed. In 2009 the Norwegian Civil Aviation Authority (the NCAA or Luftfartstilsynet) established an air safety forum for operators of inland helicopters, which commissioned a safety study: The reason for this study was a concern for the development of aviation safety in this part of the Norwegian helicopter operations. In particular the accident rate for aerial work and passenger flights [is] unsettling. The study was released in December 2013 and included 41 recommendations. Two of these were linked to this accident by the AIBN: Recommendation T04 Training between pilot and load master....
read moreAirworthiness Matters: Next Generation Maintenance Human Factors
Airworthiness Matters: Next Generation Maintenance Human Factors Aerossurance’s Andy Evans wrote an article in the 2016 issue of the International Federation of Airworthiness (IFA) Airworthiness Matters magazine on: Next Generation Maintenance Human Factors (available here: IFA Airworthiness Matters 2016). The article starts by discussing a Royal Aeronautical Society (RAeS) conference: Maintenance Human Factors: The Next Generation. At that event Professor Dave King highlighted we needed to think “about a next generation approach to human factors in engineering”: Over the last 10-15 years, much attention has been focused on maintenance human factors training and reporting & investigating errors. While we could concentrate on simply doing more of these and certainly can find ways to do these things better, perhaps the next generation approach needs to include a much wider range of activities. At the conference the results of an on-line RAeS survey were discussed that indicated a need to: Share data better across the industry. Integrate HF more fully into Safety Management Systems. Get better at actually implementing improvements. In relation to improvements, the Airworthiness Matters article goes on to discuss topics first raised in our on-line article: Aircraft Maintenance: Going for Gold? This posed the question: Can aviation maintenance learn lessons from championship athletes? It advocated seeing aircraft maintenance engineers less as the generators of errors and more a needing to deliver peak performance every day, hence the need for: …a near obsessive attention to detail, to focus on every element that can affect human performance, seeking out opportunities to make small improvements, that collectively lead to noticeable performance improvement. This also means less time spent on determining if someone should be blamed after an error and more time on systemic improvement. Evans quotes management consultant Yves Morieux of BCG commented in a TED Talk on business generally: If you think about it, we pay more attention to knowing who to blame in case we fail, than to creating the conditions to succeed. We are creating organizations able to fail, but in a compliant way, with somebody clearly accountable when we fail. And we are quite effective at that: failing. Evans discusses the misapplication of bureaucratic Just Culture ‘decision aids’ to ‘judge’: …individuals not the system, with the potential to inadvertently reduce trust rather than enhance it. The circumstances that influenced an individual’s performance are seen as factors that mitigate culpability rather than systemic opportunities to improve. Inappropriate use of these mechanisms help normalise failure at the expense of collective improvement. The destructive misuse of such Just Culture tools, like a modern day ducking stool, has a negative cultural effect, completely the opposite of some misguided advocates, who without realising it are taking a ‘Just Culpability’ approach (sometimes this is semantically turned to judging ‘accountability’, but still focused exclusively on the front line individual(s) and their behaviour). Its well worth considering Trust vs Control and How do we find belonging at work?. A 2014 report published by the Royal Academy of Engineering identified six engineering habits of mind (EHoM) which, taken together, describe the ways engineers think and act, all of which should help manage human factors and enhance human performance: Systems thinking Adapting Problem-finding Creative problem-solving Visualising Improving That report looked at how the education system suppressed children’s natural tenancies to develop these habits. Are we doing the same in the maintenance sector by over-enthusiasm for compliance with the status quo? Amy Edmonson discusses psychological safety and openness, another function of good leadership that builds trust...
read moreDrone Goes Walkabout: Hemispherical Human Factors Hiccup
Drone Goes Walkabout: Hemispherical Human Factors Hiccup On 27 September 2016, a 55lb / 25kg Pulse Aerospace Vapor 55 Remotely Piloted Air System (RPAS) / Unmanned Air System (UAS) or ‘drone’ helicopter, suffered a Loss of Control (LOC) was operating a trial flight at Lighthouse Beach, Ballina, NSW. The RPAS helicopter had been operating in manual mode for about 7 minutes when the data link was lost. According to the Australian Transport Safety Bureau (ATSB) investigation report: Thirty seconds later, the RPA entered the ‘home’ flight mode, and commenced tracking to the programmed home position at an altitude of 154 ft. …the RPA did not respond to the control inputs made by the pilot, and the pilot subsequently lost sight of the RPA. The RPA was not found despite an extensive search. The Safety Investigation The cause of the lost signal was not determined. The operator suspected interference from a media outside broadcast unit located about 30 m from the GCS. However, this used a narrow satellite communications uplink. The subsequent disappearance of the RPA was due to errors in flight planning. The ATSB say: Prior to the flight, the pilot’s preparation for the planned mission involved using Google earth on a computer (not the [Ground Control Station] GCS), and selecting a north-western and a south-eastern reference point. These markers defined an outer rectangle, within which the flight was to take place. The pilot then transferred an image…onto the GCS using a USB stick…to create the ‘Lighthouse Beach’ mission. To georeference the image, the pilot then overlaid the markers in the image with a point icon on the controller, and entered the latitude and longitude of two positions into the dialogue box on the GCS. Once the image had been georeferenced, the pilot then used the graphical interface to place the start and home icons and any intervening waypoints for the planned mission. The remote pilot reported that both they and an observer checked each waypoint before the flight, verifying latitude, longitude, altitude and height. However, the GCS data shows that during the planning phase, while the north-western marker was correctly assigned, the south-eastern marker was incorrectly assigned to a georeference point with a latitude in the northern hemisphere. This resulted in all of the waypoints and home location being incorrect, as they were created by dragging icons on the georeferenced image. Waypoints 2, 3, 6 and 7 had latitudes in the northern hemisphere, and the home position was assigned to 17.222395° S and 153.591582° E. That location was in the Coral Sea Islands about 1,200 km north of the start position. The ATSB say: The GCS has a ‘flight plan’ tab, which shows the planned distance and time (among other items) for the mission, which could have alerted the pilot to the incorrect latitude references. However, a check of the flight plan tab had not been included in the operator’s pre-flight procedures. In addition, the flight plan tab includes a measure tool that can be used to check that the map size is correct. The manufacturer advised that the following steps are included in their pre-flight procedure specified in the aircraft flight manual: verify flight plans verify lost communication home waypoint. The operator stated that there was no further detail of the verification process in the manual. The default hemisphere was north (N) in the GCS...
read moreMitsubishi MRJ (now SpaceJet) Schedule Slips Further
Mitsubishi MRJ (now SpaceJet) Schedule Slips Further In a press conference update on progress with the MRJ regional jet, Mitsubishi Heavy Industries (MHI) has confirmed, as anticipated, a two-year delay to the programme. The first MRJ90, the 90 seat version, is now expected to be delivered to launch customer All Nippon Airways (ANA) in mid-2020. https://youtu.be/OOun1gBmuUw This is not the first delay in the programme. So far there have been 5 slips in the delivery schedule, totalling 5 years. The prototype first flew on 11 November 2015, but a year later there was a major reorganisation in the programme to try to restore order. The Mitsubishi Aircraft Corp is 64% owned by MHI. Toyota Motor Corporation and Mitsubishi Corporation each own 10%. Other shareholders include Sumitomo Corporation and Mitsui & Co. In a joint statement MHI and MAC said: The change is due to revisions of certain systems and electrical configurations on the aircraft to meet the latest requirements for certification. We will continue with [the] ongoing flight test programme with current test aircraft configuration and obtain certification flight test data of performance, flight characteristics for type certification. They say that the revisions will not affect the aircraft’s structure, its performance, or system functionality. Flight tests are currently under way in the US at Moses Lake, WA. The MRJ90 is now expected to obtain type certification in mid-2019. https://youtu.be/w0Mrg3xG41c Mitsubishi has commitments for 427 aircraft, comprised of 233 firm orders, 170 options and 24 purchase rights. The MRJ will be the first airliner designed and produced in Japan since the NAMC YS-11 in the 1960s. UPDATE 30 January 2017: In an editorial, Flight International comment: Although the MRJ’s customers in the USA may express their frustration, the fresh delay does not significantly inconvenience them, as pilot scope clauses will prevent its deployment there until 2019 at the earliest. However, the real worry for the fledgling airframer is the competitive advantage it is ceding to rival Embraer. The MRJ should have had a seven-year head-start over the E175-E2, but assuming current schedules hold, that has now been whittled down to just 12 months. UPDATE 31 January 2017: The company plans to boost the number of engineers at its Seattle facility from 150 to 200. Additionally: ANA, Japan’s biggest airline, said last week it was “disappointed” at this latest delay, but will continue to support the development of the jet as its launch customer. The carrier will maintain its order of 25 planes, including options, it said. St. George, Utah-based SkyWest Inc., which has placed an order for 200 planes including options, said last week that its firm orders for the MRJ aircraft “remain unchanged” and are dependent on flying contracts and scope availability. Bridgeton, Mo.-based Trans States Airlines Inc., which has 100 MRJs on order, said in an e-mail that it was “disappointed” by the additional delay. UPDATE 3 April 2017: The fourth MRJ, FTA-3, has arrived at Moses Lake after a 19 day ferry flight, delayed by hydraulic problems en route. UPDATE 26 April 2017: Production line photographs. UPDATE 21 August 2017: The second prototype suffered an engine failure during flight test in the US which resulted in a temporary pause in flight test. UPDATE 27 December 2017: Mitsubishi Aircraft Details Latest Organizational Changes Mitsubishi Aircraft plans to undergo organizational changes that will see MRJ program director Alex Bellamy run what the company calls its new program management division…. Established...
read moreConfusion of Compelling, But Erroneous, PC-12 Synthetic Vision Display
Confusion of Compelling, But Erroneous, PC-12 Synthetic Vision Display Synthetic Vision Systems (SVS) are an increasingly common tool to enhance flight crew situational awareness. The crew of an Australian Pilatus PC-12/47E (PC-12NG) however were momentarily misled during a night-time medevac take-off by their Honeywell SVS on 18 June 2016. The PC-12 Synthetic Vision System The Honeywell Primus Apex SmartView SVS display is shown below. It depicts a ‘3-D’ style-view of surrounding terrain, obstacles and runways, overlayed with attitude, altitude and airspeed data. The SVS is not to be used for ‘primary input or navigation’, and a warning can be found in the Honeywell avionics system Pilot’s Guide. The Incident Flight The Australian Transport Safety Bureau (ATSB) report that 18 seconds after take-off, as PC-12/47 VH-OWA of the Royal Flying Doctor Service (RFDS): …climbed through about 250 ft above ground level, the pilots observed the radio altimeter (radalt) wind down to zero. The radalt low altitude awareness display rose to meet the altitude readout. The synthetic vision image on both pilots’ primary flight displays (PFDs) then showed the runway move rapidly left and off the screen, and the ground representation on the PFD appeared to rise rapidly up to meet the zero pitch reference line. The pilot flying reported that the synthetic vision image created the impression that the aircraft was sinking rapidly towards the ground, and they responded by instinctively pulling back on the control column. The flight path indicator moved up to about 15°. No warnings or cautions were displayed and the crew did not receive any oral alerts from the Terrain Awareness and Warning System (TAWS). The check pilot [the pilot monitoring] immediately looked outside and was able to discern a visible horizon due to the moonlight. The check pilot cautioned the pilot flying that the aircraft had a nose-high attitude, which prompted the pilot flying to switch their focus to the electronic standby instrument system [EFIS – which the check pilot could not readily see as it was to the left side of the left hand seat, occupied by the pilot flying] and closely monitor the attitude and the airspeed tape. The pilot flying lowered the aircraft nose to regain an 8° pitch attitude and the airspeed, which had reduced to 101 kt, increased back to the target airspeed of 110 kt. The aircraft had continued to climb throughout the event and passing 850 ft all indications returned to normal. The aircraft subsequently landed…without further incident. The Technical Investigation Both radalt antennas (one for transmit and one for receive) had failed which would have resulted in the radalt reading dropping. As radalt data is used in conjunction with the runway (and obstacle) database information to provide the SVS display, the runway therefore appeared “to rise up towards the aircraft reference symbol on the PFD”. The movement of the runway to the left of the screen was probably associated with a small displacement of the aircraft to the right of the runway centreline. The wind at the time was from 094° at 9–11 kt, therefore largely a headwind component and the lateral displacement of the aircraft was unlikely to be a result of the wind. As the radalt senses that the aircraft is nearing the ground, smaller lateral deviations from the runway centreline generate significant movement of the synthetic vision runway image. An investigation by the synthetic vision system manufacturer, Honeywell, found that the radio altimeter sent incorrect radio altitude data to the synthetic vision system while still indicating that the data was valid. Therefore, the...
read moreEasyJet and Airbus Collaborate on ‘Big Data’ IVHM
EasyJet and Airbus Collaborate on ‘Big Data’ Integrated Vehicle Health Monitoring In a project, first revealed in mid 2015, EasyJet and Airbus are collaborating on ‘big data’ Integrated Vehicle Health Monitoring (IVHM) technology. At a SAE/RAeS/Cranfield University IVHM workshop Aerossurance participated in at the Farnborough International Airshow in July 2016, Ian Davies, EasyJet’s Head of Engineering & Technical Director commented how 20 years ago Health and Usage Monitoring Systems (HUMS) had become normal on offshore helicopters. The fixed wing sector is however he says still lagging behind (with the exception of engines were Engine Health Monitoring [EHM] has been routine for many years). Previously Davies had commented that EasyJet wants to carry out early prognostics “just like Formula One”, which uses telemetry to predict when maintenance is needed. At that time EasyJet, founded in 1995, had a fleet of 255 A319s and A320s across their UK and Swiss AOCs, which flew an average of 11.1 hours per day each in FY15, which is expected to expand to 350 in 3-5 years. Even with 99.3% technical dispatch reliability they currently 7 aircraft dedicated as spare aircraft, and when the fleet reached 350 they would need 10, worth $800 million. So although the fixed wing sector may be lagging behind in IVHM application, the potential prize is massive. EasyJet claim an engine In Flight Shut Down (IFSD) rate half of the average for the CFM56. However, although EHM has been in-use for years, they noted that they had 3 engines written off this year due to bearing failures, so their remain opportunities to improve EHM. Davies identified one typical problem being that of avionic cooling fans, which when they fail generate smoke and odour in the cockpit that can prompt a precautionary landing. The addition of a vibration sensor could give prior warning of a deteriorating bearing. At the SAE workshop it was said that two suppliers had been picked to demonstrate their solutions. Airbus have previously been working with IBM on Airbus Smarter Fleet Solutions (ASFS): …will integrate and also further develop Airbus’ current portfolio of software products (“e-solutions”). Presently, the latter comprise an extensive range of standalone applications… …will provide tailored fleet data management using an open, modular and flexible platform. This service will give customers visibility to plan ahead for smooth operations. It will also enable them to easily integrate existing and new services… “Today’s aircraft can generate up to a half terabyte of data per flight, an unprecedented volume and variety of data seen in few other industries,” said Timothy J. Wholey, Global Leader, Aerospace & Defense Industry, IBM Global Business Services. Airbus has recently disclosed work with Californian data specialist Palantir: Airbus taps Silicon Valley expertise to speed production of A350: Airbus began working with Palantir about 18 months ago, but has recently expanded the relationship…to eight projects across four countries… Palantir’s staff worked with Airbus to tie together data from several different countries and databases, so that engineers spread across the company are better able to learn from each others’ experiences when fixing quality issues. The secretive Palantir, which started out more than a decade ago working on national security projects, is valued at $20bn despite not yet delivering a profit. The multimillion-dollar [A350] deal with Airbus would help it reach its planned target of profitability this year, said Alex Karp, chief executive. We did very well last year,” he...
read morePerformance Based Oversight: Accountable Manager Meetings (CAP1508)
Performance Based Oversight (PBO): Accountable Manager Meetings The UK Civil Aviation Authority (UK CAA) has published a new leaflet on Accountable Manager Meetings (AMMs): CAP1508: Getting the most out of the Accountable Manager Meeting As the UK CAA focus more on Performance Based Regulation (PBR), and specifically Performance Based Oversight (PBO), AMMs are increasingly a key part of the UK CAA’s approach. Accountable Manager Meeting Guidance The aim is to ensure both the regulator and the Accountable Manager (AM) of an approved organisation or regulated entity have “a similar perspective on the major risks facing each entity”. They say: The key thing is that we have a constructive, two-way dialogue about the business context, safety risks and desired outcomes and importantly have a record of the discussions. The change from calling these ‘interviews’ to ‘meetings’ may be to encourage more dialogue. The AM will first be invited to give a short overview of their business and their operational context. The CAA say: A conversation should follow this around the entity’s performance on managing operational safety risks. This should be informed by our own analysis of their risks… …in other words what is discussed in the organisation’s own internal reviews. The CAA say they “want to ensure that Accountable Managers…have a consistent experience” whoever from the CAA meet them. They have therefore developed a set of core questions help guide the conversation: What are your top safety risks (current and future)?* How did you identify these safety risks? How do you assure yourself, as Accountable Manager, that these are your top safety risks? What outcomes do you want to see as a result of managing these safety risks? What actions are you taking to mitigate or remove the safety risks – and are relevant stakeholders involved? Are the outcomes achievable and measurable? How do you monitor and check that your actions are working (Plan, Do, Check, Review)? What do you do if your actions are not giving the desired outcome? How do you share knowledge and lessons learned in your organisation? * we note with relief that they are not insisting on a arbitrary set number of top risks (a now rather passé fad) The meeting should also cover: Progress against previously agreed actions Planned future oversight activity Sector risks and total risk trends and issues Where possible any other issues raised by the entity The CAA will produce a record of the meeting, including all agreed actions, outcomes, timeframes, owners and significant discussions. Other PBR Resources For more on the general topic of PBR see this 2002 paper from the Harvard John F Kennedy School of Government: Performance-Based Regulation Prospects and Limitations in Health, Safety and Environmental Protection See also our articles: Performance Based Regulation – EASA A-NPA & UK CAA Seminar Performance Based Regulation and Detecting the Pathogens UK CAA PBR Stakeholder Engagement (CAP1345) Safety Intelligence & Safety Wisdom High Reliability Organisations (HROs) and Safety Mindfulness UPDATE 1 March 2017: Safety Performance Listening and Learning – AEROSPACE March 2017 Organisations need to be confident that they are hearing all the safety concerns and observations of their workforce. They also need the assurance that their safety decisions are being actioned. The RAeS Human Factors Group: Engineering (HFG:E) set out to find out a way to check if organisations are truly listening and learning. The result was a self-reflective approach to find ways to stimulate improvement. UPDATE 22 March...
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