john dutcher president - webs...2009 international seminar on aviation human factors civil aviation...

::: Tianjin, China – 14 August 2009 :::

John DutcherPresident

Dutcher Safety & Meteorology ServicesHalifax, Nova Scotia, Canada

Presented by: Mike Doiron

Dutcher SMS & Cirrus Aviation Safety ServicesHalifax, Nova Scotia, Canada

2009 International Seminar on Aviation Human FactorsCivil Aviation University of China

Presentation Outline

• Weather Decisions in the Cockpit – Different than on the ground

• Cost of Weather

• Aviation Weather Hazards and Concerns

• Weather Risk Management (Wx-RM)

• Way forward

Visual Weather Charts Conceptual Model What is everyone else doing? TCAS and ATC

Use Aircraft Weather Radar to scan the sky at different angles to “size up” the storm.

How big is this thing?

8 miles a min

Operational Pressures Dispatch ServiceFatigue

Team EnvironmentNew TechnologyNew Route

Fuel

SOPs?

(Klein, 1998; Flin, 2003)

Characteristics of the Environment

• Ill structured problems• Uncertain dynamic conditions• Shifting, ill defined goals• Time pressure• High risk• Multiple players / Teams• Organisational norms• Experienced decision makers• Ambiguous, Missing and Questionable data

The goalThe goal……

• Use systems theory and principles of good safety management to manage the risk of weather to reduce incident and accident rates.

• Enable organisations to develop a more robust system (i.e., Weather Risk Management System) to make their operations more “weather tolerant” and enhance operational efficiencies.

Costs of WeatherCosts of Weather

The Cost of an Accident ?The Cost of an Accident ?

(Adapted from Flight Safety Foundation, 2002)

Damaged reputationDamaged reputation11 Killed11 Killed11 Killed

Aircraft written offAircraft written off

Airline ceased operations

Airline ceased Airline ceased operationsoperations

Repairs bring new configurations resulting in higher fuel consummation, etc

Repairs bring new configurations resulting in higher fuel consummation, etc

Direct CostEquipment, injuries, and fatalities

Indirect CostRestoring Order

Loss of equipment and personnel

Cost of Recovery

Delay in Doing Business

Corporate Reputation

Investigation Costs

LitigationSource: U.S. Naval Safety Center

COST OF ACCIDENTSCOST OF ACCIDENTS

Aviation Weather Hazards and ConcernsAviation Weather Hazards and Concerns

• Winds and Temperatures (Terminal and Enroute) • Wind shear• Thunderstorms (e.g., lightning, hail, etc)• Precipitation• Icing• Density Height / Altitude• Turbulence• Visibility / Ceiling

Summary of the Summary of the ““Weather ProblemWeather Problem””

• Weather has a major impact on the safety, efficiency, and capacity for aviation operations.

• Accidents and incidents continue to be caused by adverse weather.

• Passengers are inconvenienced by:

– Delays, – Flight cancellations or diversions due to weather, – Uncomfortable or may even be injured when turbulence is

encountered during a flight.

Weather: Weather: ““Cost of Doing BusinessCost of Doing Business””

• Weather for the longest time has been a “cost of doing business”

• Need to start thinking “outside the box”

• Weather for the longest time has been a “cost of doing business”

• Need to start thinking “outside the box”

Weather Management System (WMS) Weather Management System (WMS)

• ‘Holistic’ approach to managing the impact of weather

• Comprised of a series of Weather Risk Control Systems (Wx-RCSs) designed to manage the impact of weather hazards (e.g., thunderstorms, turbulence, reduced visibility, LLWS) on safety and operations.

(International Labour Office, 2001)(Dutcher, 2005; Dutcher and Doiron, 2008)

A Basic Safety Management SystemA Basic Safety Management System

Some hazards identified.

Risk controls are described in procedures.

Risk controls are linked by a common method.

Safety activity is planned.

Controls are monitored and reviewed regularly.

Responsibilities are defined for everyone.

Company policy communicated.

Public and others’ risks are managed in a planned way.

Some hazards identified.

Risk controls are described in procedures.

Risk controls are linked by a common method.

Safety activity is planned.

Controls are monitored and reviewed regularly.

Responsibilities are defined for everyone.

Company policy communicated.

Public and others’ risks are managed in a planned way.

Weather

Maintenance

Ramp

(Adapted from Bottomley, 1999, p.5)

Fatigue

Fuel

Overall SMS

Flt Ops

Use Systems Models to put Operational Use Systems Models to put Operational Information into ContextInformation into Context

• Use of Non-Standard, Common, Operational Phrases– Picking their way through– Weather all around– Dark off to the north– Yeah, they are still getting in– Reported being a bit rough

• A need to incorporate all available Sig WX info – Equipment – Doppler, Windshear Alerts– Establish common Significant WX language

• Company Policy (How do you apply these items)– Do not operate in vicinity of TRW– Crews expected to display proper judgement– Crews paired with suitable experience

(Hawkins, 1987/ICAO, 2006)

The 4 Ps

(Degani and Wiener, 1994)

Philosophy

Policy

Procedures

Practices

Bow Tie Model

Event Tree

EventEvent

Escalation

DANGER

HAZARDS

DANGER

HAZARDSHarmHarm

Defences to eventPrevention

Defences to escalationResponse

(Dutcher and Doiron, 2008)

Weather Risk Controls

• Engineering defences. Physically prevent a hazard from causing harm (i.e. ‘engineering fixes’, equipment)

• System defences. Control hazards by specifying procedures to be followed, such as a company policy regarding operations near turbulence, recovery procedures.

• Human defences. Are the actions, competence and expertise required by individuals to prevent hazards from being realised in the first place.

(Dutcher and Doiron, 2008)

Loss of Separation with Adverse Weather – Deviation from Intended Flight Path Risk Assessment

Bow-Tie Risk Assessment

Build Defences In-depthBow-Tie Risk Assessment

Build Defences In-depth

See RecoveryBow Tie

Wake Turbulence

VOLASH

Thunderstorms,Wind Shear,

Mountain Wave Turbulence

Barriers/ Risk Controls

Support Decision MakingSupport Decision Making

• In addition to “Classical Decision Making” we need to look at Intuitive/Naturalistic Decision Making (NDM).

• Need to support decision making (enhanced SA); including “Weather Decision Making.”

– Decision Support Systems (DSS)• Decision Aids, e.g. checklist, flowcharts• Presentation e.g. how info is rcvd• Interface Technologies e.g. ATC, Weather Office, Airports

– Professional Development and Facilitated Learning (Knowledge and Skills)

– Policies

A WEATHER TRAINING MODELA WEATHER TRAINING MODEL

• Weather Theory

• Practical Weather Skills and Outcome Learning

• In-flight Recognition of Hazards

– Avoidance and Recovery (also in the simulator)

• How will the current weather impact the flight? (Judgment)

• Develop Decision Support Systems

• Use FOQA/FDM and LOSA data to help measure impact

WxWx--MS: Span of InfluenceMS: Span of Influence……

Wx-MS

Oversight Strategy

Management & Organisation

Workforce Skills

SOPs & Guidance

Information Technology

Decision Support Systems (DSS)

External Relationships

Business Processes

The way forwardThe way forward……

• Involve:

– Unions and Associations– Regulators– Investigation bodies– Pilots– Operational Controllers/Dispatchers– Airport operators– Air Traffic Services– Human Factors Specialists– Academia and the Research Community– Meteorologists– Flight Service Specialists– …

SummarySummary

• Weather has a major impact on the safety, efficiency, and capacity of aviation operations.

• Weather Events are NOT “just the cost of doing business”

• Just like Human Behaviour, weather hazards can be managed.

• Must take a systematic approach using WxMS

• Need to Support Decision Making

• Keep the discussion alive (Normalise the discussion of weather risk)!

(Dekker, 2002, p.119)

MURPHY'S LAW IS WRONG

WHAT CAN GO WRONG USUALLY GOESRIGHT, BUT THEN WE DRAW THE

WRONG CONCLUSION

ReferencesReferences• Bottomley, B. (1999). Occupational health and safety management

systems: Information paper. National Occupational Health and Safety Commission: Canberra, Australia.

• Dekker, S. (2002). The field guide to human error investigations. Cranfield, UK: Cranfield University Press, Ashgate.

• Dutcher, J.W. (2005, November-December). Heavy weather. Civil Aviation Safety Authority – Australia - Flight Safety Australia. 9 (6), 40-41.

• Dutcher, J.W. & Doiron, G.M. (2008). Weather risk management through a systematic approach to the investigation of weather events. Paper presented at the 39th International Society of Air Safety Investigators (ISASI) Seminar. Halifax, Canada, 8-11 September 2008. See www.johndutcher.com

• Hawkins, F.H. (1987). Human factors in flight. Aldershot, UK: Gower Technical Press.

• International Labour Office (2001). Guidelines on occupational health and safety and health management systems, ILO Geneva, Switzerland.

John DutcherDutcher Safety & Meteorology Services

Halifax, Nova Scotia, Canada

dutchersms@gmail.com

www.johndutcher.com

John DutcherDutcher Safety & Meteorology Services

Halifax, Nova Scotia, Canada

dutchersms@gmail.com

www.johndutcher.com

Mike DoironCirrus Aviation Safety ServicesHalifax, Nova Scotia, Canada

cirrussafety@yahoo.ca

Mike DoironCirrus Aviation Safety ServicesHalifax, Nova Scotia, Canada

cirrussafety@yahoo.ca