Cases Study ICAO/Airbus Nairobi, 19-21 Sep. 2017 Agenda
T-VASIS
LOC Deviation
Incorrect Pitch at Takeoff
CRM Issue
Runway Excursion
Speed drop below VLS in GA
2 Sept 19-21, 2017 ICAO/Airbus FOSAS
Agenda
T-VASIS
LOC Deviation
Incorrect Pitch at Takeoff
CRM Issue
Runway Excursion
Speed drop below VLS in GA
3 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 1
T-VASIS
After a high severity short flare distance event a Safety
analyst opened the associated flight and replayed it. Case Study 1
T-VASIS Main facts: Unstabilized approach Night time ILS 16 Manual Flight Approach GPWS “GLIDE SLOPE” (5 sec) T-VASIS* 3° G/S
Low Approach slope
(MM at 100ft AAL)
* T-Visual Approach Slope Indicator System
Case Study 1
T-VASIS G/S
T-VASIS PAPI On Too Too G/S High Low path Case Study 1: T-VASIS Associated Risk Index Defense Elementary Hazards Consequences Actions Proposal (ICAO Matrix) Domains
? Case Study 1: T-VASIS Associated Risk Index Defense Elementary Hazards Consequences Actions Proposal (ICAO Matrix) Domains
Flight Path Deviation
Unstabilized Approach
Night Flight ? Inconsistency between two visual aids Case Study 1: T-VASIS Associated Risk Index Defense Elementary Hazards Consequences Actions Proposal (ICAO Matrix) Domains
Inconsistency between two visual - Misinterpretation aids Case Study 1: T-VASIS Associated Risk Index Defense Elementary Hazards Consequences Actions Proposal (ICAO Matrix) Domains
Inconsistency 4A between two visual - Misinterpretation (INTOLERABLE) aids Case Study 1: T-VASIS Associated Risk Index Defense Elementary Hazards Consequences Actions Proposal (ICAO Matrix) Domains
- GPWS - Crew Flight Path Controlled Flight Into Terrain 3A Redundancy Deviation (CFIT) (INTOLERABLE) - Visual Aids - ILS Signal
2B Night Flight - Crew Fatigue - Crew Rostering (TOLERABLE)
Inconsistency - Training 4A between two visual - Misinterpretation - Crew (INTOLERABLE) aids redundancy Case Study 1: T-VASIS Associated Risk Index Defense Elementary Hazards Consequences Actions Proposal (ICAO Matrix) Domains
- GPWS - SOP: Improved Approach - Crew Flight Path Controlled Flight Into Terrain 3A Briefing Redundancy Deviation (CFIT) (INTOLERABLE) - Communication on GPWS - Visual Aids reliability - ILS Signal
- Runway Excursion (RE) 2B
- Information on - Overshoot/ (TOLERABLE) - Go Around Unstabilized unstabilized approaches Undershoot (USOS) 3B - Stabilization Approach (Improved safety - Abnormal Runway Contact (TOLERABLE) Policy awareness) (ARC) 4C (TOLERABLE)
Inconsistency - Training - Visual Aids Info Reminder
4A between two visual - Misinterpretation - Crew (Urgent) (INTOLERABLE) aids redundancy - Info to Authorities Case Study 1
T-VASIS
As an Airline, what could be your contribution?
You could communicate on GPWS reliability to possibly
regain the pilot’s confidence in such a case You could provide a note on technical Visual Aids difference (PAPI vs T-VASIS). Agenda
T-VASIS
LOC Deviation
Incorrect Pitch at Takeoff
CRM Issue
Runway Excursion
Speed drop below VLS in GA
14 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 2
LOC Deviation
Let’s have a look at the following flight and try to
understand what happened…
15 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 2
LOC Deviation
What are your observations?
Could you explain what happened?
What will you do about it?
16 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 2
LOC Deviation
17 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 2
LOC Deviation
LOC ground signal disruption?
Aircraft safety has not been directly impacted Thus, Event 1803 (LOC deviation) can be disregarded and/or deleted from the database, nevertheless… Operational cleaning ensures that the retrieved events are valuable for analysis and statistics
Page 18 Sept 19-21, 2017 ICAO/Airbus FOSAS Case Study 2
LOC Deviation
As an Airline, what could be your contribution?
Agenda
T-VASIS
LOC Deviation
Incorrect Pitch at Takeoff
CRM Issue
Runway Excursion
Speed drop below VLS in GA
20 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 3
Incorrect Pitch at Takeoff
21 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 3
Incorrect Pitch at Takeoff
CONTEXT:
Mixed fleet A340-300/500 and A330.
Takeoff CONF3 on A340-500 and CONF2 on A340-300
Let’s look at FDA events list…
22 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 3
Incorrect Pitch at Takeoff
Event 1038: Speed Low in Climb
High Medium Low
23 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 3
Incorrect Pitch at Takeoff
It appears that the event 1038 is affecting more A340 fleet than A330 one.
A340 A330
24 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 3
Incorrect Pitch at Takeoff
Looking closer to statistics, A340-500 A/C type seems
more affected that A340-300 one A340-500 A340-300 A330
High Medium Low
25 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 3
Incorrect Pitch at Takeoff
FDA statistics show the following trends:
Event 1038 affects more the A340 fleet than the A330 fleet
Event 1038 concerns more the A340-500 type than A340-300 type.
Therefore, what could we do?
Transmission to AIRBUS for deeper analysis.
26 Sept 19-21, 2017 ICAO/Airbus FOSAS Case Study 3
FDA allowed the Airline to realize that some crews do not demonstrate the minimum required handling skills What will you do about it? level… • FDA analysis could also be completed by a flight crew report and/or a crew interview • Training concern?
36 Sept 19-21, 2017 ICAO/Airbus FOSAS
Agenda
T-VASIS
LOC Deviation
Incorrect Pitch at Takeoff
CRM Issue
Runway Excursion
Speed drop below VLS in GA
37 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 6
Speed Drop below VLS in GA
38 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 6
Speed Drop below VLS in GA
CONTEXT:
A/C type: A330
Flight phase: Approach
Configuration: CONF3, Speed brakes extended and L/G down
Let’s have a look at the following flight within FDA tool…
39 Sept 19-21, 2017 ICAO/Airbus FOSAS
Case Study 6
Speed Drop below VLS in GA
What are your observations? Go Around was performed without TOGA selection, not following Airbus SOP (Thrust levers still in CLB detent)
Could you explain what happened? FDA allows Airline to take into consideration that some pilots did not properly understood the Go Around philosophy and associated SOP.
What will you do about it?
Reminder of standard Go-Around Procedures must be considered (e.g. Briefing note, refresher training for Flight crew, …)
