Non Technical Skills Safety Systems Presentation

Belinda Warner - Leader NTS CC

Our NTS Program..

Approx 40 NTS instructors across the Virgin Group

Courses include:

• Recurrency

• FC/CC Initial

• FC/CC Leadership Upgrade

• Network Operations

• Ground Operations

– Post incident debriefs for FC and CC

– Integration with Safety Department (investigations,

recurrency, feedback, SMS training for NTS instructors)

– Development and Implementation of CC Behavioural

Markers (2013)

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Safety Reporting, Incidents

& Just Culture

Report Assessment

Classified by Risk

Rating

Investigation Trending

Report Submitted

Safety auto

acknowledgment

What's happening to my Safety Reports?

No blame culture?

The Just Culture explained…

A just culture balances the need to have a non-punitive learning

environment with the need to hold persons accountable for their actions.

No Blame Culture Punitive Culture

Just Culture

Safety Investigation Workshop

VAA Embraer 190 - Door Opened in Armed mode

– You’re the Safety Investigator…..

– In your Groups, review the incident and establish the contributing factors

– Please use worksheet to write down your answers.

Incident Causal Factors

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Was there more than one causal factor?

– Yes! When investigating an incident the safety team review ALL the

causes/influences

– This example demonstrates how teams and individuals will be

treated in line with the Just Culture Policy

We will now look at:

– How contributing factors in an occurrence are classified and

analysed

– Incident Examples for each category.

Organisational Influences

Risk Controls

Situational Factors

Participant

How are contributing factors classified in an event?

– Similarities to the ATSB investigation process

– Includes a review of Risk Controls

– Includes NTS elements.

Organisational Influences

Conditions within the organisation that maintain or influence

the effectiveness of an organisation’s Risk Controls

Organisational Influences

– Management processes

– Training

– Risk/Change management

– Communication & Learning

– Monitoring & Review.

– VAI – B777

– Engineer in KUL opened 5R & 2R doors

without stairs or truck attached

– These doors remained like this for 15mins

before caterers arrived

– After catering was complete CL had to

close 5R door as caterers were not willing

to do so before leaving

– This was a potentially dangerous situation

and was common in KUL.

Example Organisational Influences

This was not a ‘one off’ occurrence

–Situations were occurring where doors were being left open, opened by crew or closed

by crew in KUL which is in direct violation to our SOPs

–Misalignment of external door operating procedures between operational documentation

(Vol B7 and Vol A5)

–Inadequate wet lease port induction process to KUL. Leading to a deviation from SOP’s

in KUL and training not being conducted as would occur in a VAI port.

Organisational Influences

Risk

Controls

– Measures are put in place to facilitate and assure

safety of the operational system

– Risk Controls modify the Consequences and/or

Likelihood of event.

Risk Controls

Examples of how the risk is controlled:

–Procedures (SOPs)

–Training (NTS, FRMS)

–Equipment (warnings, alerts, safety barriers)

–Level of Supervision

–Rosters

Review of Risk Controls

are they ABSENT or FAILED?

Risk Controls

Example of Risk Controls

– A VAA A330 was being towed from the John Holland Aviation Services

(JHAS – engineering contractors) apron to the MEL terminal

– The tow was conducted by a Menzies Aviation Ramp Agent

(contractor) and 2 JHAS engineers.

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– The right wing of the VAA A330 passed the JQ aircraft and contacted

the fuselage above the flight deck

– Both aircraft were damaged.

Example of Risk Controls

Example of Risk Controls

– There were no wing walkers in place

– The headset engineer believed the tow operator could have gone wider but did

not communicate that at the time

– The clearance lines on the apron are unsuitable for a A330 to manoeuvre past a

parked aircraft of similar size in the NE corner

– Evidence suggests - Menzies Aviation tow vehicle operator did not intersect the

apron centre line correctly and made a decision error when they exited the bay at

an abnormal angle. It was concluded that his action likely resulted in the aircraft

traversing the centreline late

– Menzies aviation are only contracted to tow in or push back a/c

– They are not contracted for towing between other points.

Situational

Factors

Situational Factors

– Workspace Environment (ergonomics, OH&S)

– Physical Environment (lighting)

– Workload

– Weather Conditions

– External Influences (ATC, CASA).

Situational Factors Example

– FO was standing on stairs at the L2 door of a 737-800 at Brisbane International Airport

– The stairs were blown over by a jet blast from a passing Qantas Boeing 747. FO fell to the tarmac

(approx. 2.5m)

– FO suffered a broken arm and leg, and a ruptured ligament that at the time was assessed as

potentially requiring additional surgery

– As part of the investigation, discussion took place with Qantas and Boeing. It was generally

considered that the amount of thrust used was excessive under the circumstances.

Situational Factors Example

– There is no protection from jet blast at BNE Airport’s Charlie 9 - the gates directly behind that taxi

holding point

– Restrictions were placed on the amount of thrust all four-engined aircraft are able to use when

taxiing at that particular point at Brisbane Airport

– VA have stopped using stairs to the rear of the aircraft at that gate.

Participant Actions

Participation

Actions

– Action or Inaction performed by Operational personnel

– Actions that should not be reproduced in the future

The substitution test

Is it reasonable to think a different person could have made the same

error under similar circumstances?

Example of Participant Actions

– Empty half-cart fell from the platform of a High Lift Catering truck while the catering was

being replaced on turnaround (R2 door)

– Drivers first time attending to a VA aircraft, driving this type of truck

– The truck was positioned incorrectly – drivers ‘off sider’ was aware of this

– One of the carts on the truck platform did not have its brake on, or brake was faulty

– The unattended half-cart rolled off the truck platform, onto the tarmac (approx. 3.5m below).

Example of Participant Actions

– A “wedge-shaped” gap was left towards the

rear of the aircraft

– The fuselage tapers inward at the rear and the

truck and it’s platform must be positioned to

take this into account.

Example of Participant Actions

– High-lift truck positioning for Boeing 737 aircraft: Gate Gourmet Driver Manual

(Chapter 4 – B737 Aircraft Characteristics, page 2, August 2011)

– Gate Gourmet was asked to conduct their own investigation into this incident and found

a failure to follow procedure as the cause.

Participant Actions- HF classification

Human Factors have always been considered in investigations

Now, more focus on Non Technical Skills Core Elements

Just Culture does not minimise individual responsibility, or

accountability

It does consider Human Performance in a system context.

Summary

Organisational Influences

Risk Controls

Situational Factors

Participant

– Findings, recommendations, investigations statistics are presented to the

appropriate Division for actioning by the General Manager

– Safety incidents & data generated through reporting, are presented to the

appropriate people and divisions at the Safety Risk Review Committee

meetings

Your (de-identified) Virgin Safety Report may be

tabled in the next Virgin Group board meeting.

Your report- Safety learning for all

Questions?