bad flight plans, fat fingers, and the iso trap four... · bad flight plans, fat fingers, and the...

Bad Flight Plans,Fat Fingers,and the ISO Trap

PRESENTED BY:John HarpoolMitch Launius

International Operators Conference | Tampa, FL | March 17 – 20, 2014

Monday, 17 March 2014 | 3:30 p.m. – 5:00 p.m.

1

Monday, March 17, 14

2Air Training International

• Threats• Errors• Undesired States

Threat and Error Management



• Threats are defined as events that:

– occur outside the influence of the flight crew (i.e., not caused by the crew themselves);

– increase the operational complexity of the flight;

– require crew attention and management if safety margins are to be maintained



• Errors are defined as flight crew action or inaction that:

– lead to a deviation from crew or organizational intentions or expectations;

– reduce safety margins;

– increase the probability of adverse operational events on the ground or during flight



• Undesired States are defined as a position, speed, attitude, or configuration of an aircraft that:

– result from flight crew error, actions, or inactions;

– clearly reduce safety margins


RESOURCES


• FAA Advisory Circular 91-70A

• North Atlantic Document 007

• ICAO Document 9868 PANS-TRG

• FAA International Notices (NOTAMs)

• Oceanic Errors Safety Bulletins


http://www.paris.icao.int/documents_open/files.php?subcategory_id=124






It is important that operators have a continuous analysis process to evaluate oceanic errors in order to

meet the ICAO Safety Management System (SMS) Standards

This OESB is intended for distribution to industry and training centers



• Conditional Clearances• Deviating Without a Request• Weather Deviation Procedures• Revised Clearances



Failure to comply with ATC clearances is a major risk in oceanic airspace

Operators must stress in pilot training and operations manuals the necessity

to fully comply with ATC clearances


Lateral Deviation Classifications

Lateral Deviation is any actual deviation from the cleared track other than those covered by the Strategic Lateral Offset Procedures ( SLOP);




Gross Navigation Error (GNE) is a lateral deviation from a cleared track by 10NM or more;

NAT CMA initiate GNE-related follow up actions in regard to GNEs of 25 NM or more




ATC Intervention is an event where the Air Traffic Controller (ATCO) caught and corrected a lateral deviation before it developed into a GNE; and




ATC Prevention is an event where the ATCO intervention prevented a lateral deviation;



0" 20" 40" 60" 80" 100" 120" 140" 160"

Separa-on"Erosion"

Lateral"Errors"

Ver-cal"Large"Height"Devia-ons"

Total North Atlantic Region Error Reporting for 2013

North Atlantic Central Monitoring Agency

UNDESIRED STATES

17

173475

69

Vertical Large Height Deviations

Lateral Errors

Separation Erosion

45

124


0" 2" 4" 6" 8" 10" 12" 14" 16" 18"

Interven.ons"

Lateral"Errors"

Aircra8"Performance"

UNDESIRED STATESIGA North Atlantic Region Error Reporting for 2013


2410Lateral Errors

Performance

62

5


THREAT IDENTIFICATION

• We can use this data as we strive to implement relevant and effective flight department Safety Management Strategies



THREAT IDENTIFICATION • These statistics are intended to assist us by

identifying data driven threats: –Aircraft performance–Waypoint insertion–Re-clearance execution



THREAT MANAGEMENT

• Is there a routing policy that may reduce the probability of a reroute being issued

• Is our aircraft capable of operating at speeds compatible with aircraft at that altitude and route

• Is our filed profile within the performance of our aircraft at ISA plus 15-18 degrees

• Are we equipped, filed, and approved for route specific requirements (ADS, CPDLC, RNP)

Can the threat be avoided



ERROR MANAGEMENT

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ERROR MANAGEMENT

• Errors avoidance tools –Downloading Flight Plans via ACARS –Briefings that establish expectations–Ensuring winds are utilized by the NAV Computer

to avoid longitudinal time errors



ERROR MANAGEMENT

• Error Trapping tools –Common phraseology, readbacks –Oceanic Operations Checklist–Plotting requirements–Verification of track after 10 minute–Position reporting–Standard Operating Procedures SOPs



ERROR MANAGEMENT

25


ERROR MANAGEMENT

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ERROR MANAGEMENT

• Failure to copy route or reroute correctly• Failure to insert the route correctly• Failure to activate a newly created route clearance

Also known asBad flight plans, fat fingers, and ISO traps

Oceanic errors we want to avoid



ERROR MANAGEMENT

• Validation procedures are intended to trap errors • It is not sufficient for one pilot to just observe the

other pilot or even assist the other pilot • By effectively putting SOPs into practice pilots can

trap errors by performing their task– Independently and, – In a prescribed sequence

Standard Operating Procedures



ERROR MANAGEMENT

• The PM downloads (or manually enters) the flight plan and circles each waypoint as he validates the coordinates matching the:–Flight Management System (MCDU) to;–The Master Document (reduces expectation bias)




ERROR MANAGEMENT

• The PM also validates and highlights the individual oceanic legs –Distance–Magnetic Course –Winds by leg




ERROR MANAGEMENT

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PM Validation of waypoint, course, and distance

Air Training International


ERROR MANAGEMENT

• The PF places a check by each waypoint as he validates the coordinates matching the:–Flight Management System (MCDU) to;–The Master Document




ERROR MANAGEMENT

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PF Validates MCDU to Master Document



ERROR MANAGEMENT

• Approaching each waypoint the PM validates the Next and Next +1 waypoints compares the:–Flight Management System to the;–Plotting Chart then the,–Master Document




ERROR MANAGEMENT

• Crossing the waypoint the PM verifies the sequencing occurs and the aircraft adopts a: –Magnetic Course (+/- 7 degrees)–Distance to the next waypoint (+/- 2NM)

• The PM then places a line through the master document waypoint




ERROR MANAGEMENT

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PM Monitoring waypoint passage and sequencing


ERROR MANAGEMENT

• 10 minutes (or 2 degrees longitude) past the waypoint the PM records on the plotting chart;• the latitude and longitude from the master

navigation system and, • the time




ERROR MANAGEMENT

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PM Records the 10 minute position validating route



www.trainati.com


When comparing the plotted position to the course line on the plot should fall on the course

line.


http://www.trainati.com

http://www.trainati.com

WAYPOINT REPORTING

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ERROR MANAGEMENT

• When an aircraft is operating utilizing ADS-C, position reports may automatically provided directly to the controller

• The controller can validate that the Next and the Next +1 waypoint to match the clearance

ADS-C Event Reporting



ERROR MANAGEMENT

• The aircraft system sends a Waypoint Change Event (WCE) report anytime a change occurs to the:

• Next and/or; • Next + 1 waypoint in navigation system


42

MICKY PLUTONext

MINNYNext+1



ERROR MANAGEMENT

• If the controller observes an error at the Next +1 waypoints they will alert and challenge the crew

• This is referred to as an ATC “Intervention”




ERROR MANAGEMENT ADS-C Event Reporting

44

MICKY PLUTONext

MINNYATC

Clearance

FMSFlight Plan

DAFFYNext +1



ERROR MANAGEMENT

• Aircraft operating with CPDLC and ADS-C must still use standard operating procedures when operating in Class II airspace

• There were 75 ATC navigation interventions in the North Atlantic in 2013



There were 75 ATC navigation interventions in the North Atlantic in

2013


REVISED CLEARANCES

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ERROR MANAGEMENT

• Voice–Both pilots listen to the reclearance as it is read

–Whenever possible utilizing headsets–Independently writing what they hear

–Both pilots achieve consensus on the new clearance

–Read back and validate the reclearance with ATC

Revised Clearances



ERROR MANAGEMENT

• CPDLC–The PM reads the clearance message silently –The PF reads the clearance message silently–Both pilots achieve consensus on the clearance–PM accepts the revised clearance message

Avoid expectation bias

Revised Clearances



ERROR MANAGEMENT

• After receiving a revised route clearance the crew must update the master document–Create a new Navigation Log or;–Cross out and update the specific points on a

computer flight plan (overwriting increases error)

Revised Clearances



ERROR MANAGEMENT

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ERROR MANAGEMENT

• The crew must validate the new master document –Magnetic course –Leg distance

• Track and distance tables are available to assist –Leg times based on winds and groundspeed

Revised Clearances



ERROR MANAGEMENT

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FROM TO EAST WEST NM

53 64 296 414

52 72 288 396

51 81 279 386

50° 50 90 270 385

49 99 261 394

48 107 253 411

47 114 246 436Monday, March 17, 14

Revised ClearancesERROR MANAGEMENT

• Using SAT Voice call flight plan provider for revised route information or;

• Using internet connectivity have the revised route run and a new computerized flight plan created both reduce potential error

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ERROR MANAGEMENT

• The PM reprograms the master navigation system with the revised route and circles each waypoint as he validates that the coordinates match the–Flight Management System to the–NEW Master Document

• The PF places a check by each waypoint as he independently validates the coordinates match the–Flight Management System to the–NEW Master Document

Revised Clearances



ERROR MANAGEMENT

• The crew should must also create a new plotting chart to reflect the revised clearance or;

• Update the previous plotting chart to reflect the revised clearance (overwriting increases the probability of error)

• Both pilots must also independently validate the new plotting chart

Revised Clearances



Text

Te

A T C F P L R E V I E W 1 / 5

A T C C L E A R A N C E

A T C U P L I N K

Revised Clearances

O R I G I NK T E B

D I N I M

T A K A S

A L U T A

A C T I V A T E

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ERROR MANAGEMENT


Text

Te

A T C F P L R E V I E W 1 / 1

C O N F I R M R E P L A C I N GA C T I V E F L I G H T P L A N

N O

Revised Clearances

Y E S

57

ERROR MANAGEMENT


ERROR MANAGEMENT

• When activating a uploaded re-route the crew should brief a plan that addresses the possibility that the FMS could dump both the current and the revised flight plans–Heading mode set to the magnetic heading–A copy of the revised clearance available to

manually enter a from and to waypoint

Revised Clearances



ERROR MANAGEMENT

• There are documented Gross Navigational Errors where a crew receives a revised route clearance then:–The crew correctly responds to ATC

acknowledging the reroute –Correctly reprograms the master navigation

system with the revised route–Fails to select the aircraft to master navigation

system (Automation Mode Error)

Revised Clearances



ICAO Countermeasures

ICAO PANS TNG Doc 9868 Attachment C to Chapter 3

ERROR MANAGEMENT


EXECUTION COUNTERMEASURESEXECUTION COUNTERMEASURESEXECUTION COUNTERMEASURES

Monitoring and Crosschecking

Crew members ac+vely monitored and crosschecked systems and, other crew members

Aircra8 posi+on, se:ngs, and crew ac+ons were verified

Workload Management

Opera+onal task were priori+zed and properly managed to handle primary flight du+es

-‐Avoided task fixa+on-‐Did not allow work overload

Automation Management

Automa+on was properly managed to balance situa+onal and/or workload requirements

-‐Automa+on setup was briefed to crew-‐Effec+ve recovery techniques from automa+on anomalies


ERROR MANAGEMENT Proposed NAT Reductions in Separation

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Track W

Track X

Track Y

Track Z

RLAT SM Track (FL350-FL400)

50º 40º 30º 20º



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