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Aviation Safety > June 2018 Exam > Flashcards

June 2018 Exam Flashcards

1
Q

What are the 5Es?

A
  1. Economic
  2. Engineering
  3. Education
  4. Enforcement
  5. Engagement
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2
Q

% Causal Factors of Aviation Accidents

A 
53% Pilot Error
21% Mechanical Failure
11% Weather Conditions
8% Other Human Error (ATCOs, maintenance)
6% Sabotage
1% Other
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3
Q

Outline / draw the evolution of safety thinking

A

1950s onwards - technical factors (nav. systems, radar, auto-pilot)
1960 onwards - human factors (flight simulators)
1970s onwards - organisational factors (SMS)

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4
Q

How does ICAO Annex 13 define an accident, incident, and a precursor?

A

ACCIDENT

  1. Where a person is fatally or seriously injured, requiring hospital treatment, as a result of being onboard an aircraft, or being in direct contact with the aircraft (including parts which have been detached or direct exposure to jet blast)
  2. The aircraft sustains damage or structural failure
  3. The aircraft is completely inaccessible or missing.

INCIDENT
1. An occurrence where an accident is about to happen but due to an intervention does not occur.

PRECURSOR
1. Conditions or events which lead up to accidents and incidents.

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5
Q

Outline the shift in accident prevention strategies

A

Past - Reactive (F-C-F-F)
Present - Proactive (SMS)
Future - Predictive

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6
Q

What are the three accident causation models?

A
  1. Simple linear (sequential)
  2. Complex linear (epidemiological)
  3. Complex non-linear (systemic)
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7
Q

Tell me 3 things about the Simple Linear Causation Model (and an example)

A
  1. The simple linear model groups together accidents that result in a series of events or circumstances which occur sequentially.
  2. It is the most simple form of accident modelling.
  3. The goal is to eliminate broken links; identifying which precursor is responsible.

EXAMPLE: Heinrich (1931) domino theory

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8
Q

Give me two pros and cons of the Simple Linear Causation Model.

A

PROS:

  1. It’s simplistic
  2. It identifies and eliminates broken links

CONS

  1. It may be too simplistic as it only identifies one cause
  2. Arguably not suitable for aviation as it’s such a complex system
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9
Q

What is the Complex Linear Causation Model?

Give an example.

A
  1. The complex linear model considers that accidents are a result of a combination of unsafe acts, and that latent hazard conditions within the system follow a linear path

EXAMPLE: Swiss Cheese Model (Reason, 1997) and the 2002 Überlingen Air Disaster

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10
Q

Give me one pro and two cons about the Complex Linear Causation Model?

A

PROS:
1. It recognises latent hazards, which is advantageous in the analysis of complex systems that may present multi-failture situations

CONS:

  1. It still follows the principle of a sequential model so it can only consider one initial event.
  2. Latent factors are not always necessarily identifiable within the model.
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11
Q

What is a complex non-linear model? (2 points)

A
  1. The complex non-linear model considers accidents which result from complex non-linear interactions of unanticipated or unexpected sequences.
  2. These things (cheese slices) may occur concurrently and may interact with each other in complicated and unexpected ways in which designers could not foresee.
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12
Q

Give an example of a complex non-linear causation model.

A

STAMP, developed by Nancy Levison @ MIT. It’s an analysis model which treats accidents as a result of flawed processes involving interactions among human, social and organisation structures; and physical and software components.

It views accidents as a control problem and events are the results of inadequate control.

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13
Q

A pro and con about complex non-linear models.

A

PRO:
1. It’s capable of handling mutually interacting variables

CON:
1. Interactions are not predictable unless air industry gathers enough data from normal flight operations.

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14
Q

What is an airprox?

A

When the distance between aircraft and their relative positions and speed have been compromised such that the safety of the aircraft was or may have been compromised.

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15
Q

What is the process for investigating airproxes?

A

The UK Airprox Board reports on and investigates all airprox occurrences.

  1. The Board sends an acknowledgement to the pilots / reporter that an investigation has been launched.
  2. The Board determines what happened and analyses the main causal factors. Radar recordings are inspected and radio transcripts are analysed. Pilots and ATCOs involved provide reports.
  3. The Board assesses the level of collision risk and grades it A - E.
  4. The Board makes safety recommendations where appropriate to reduce the risk of incident recurrence.
  5. The Board publishes and distributes full reports so that lessons can be identified and shared.

There is no blame culture; the Board just wants to raise awareness.

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16
Q

What are the top 5 causal factors of airproxes?

A
  1. Did not see traffic / late sighting
  2. Flew too close / failure to separate
  3. Did not obey instructions or procedures
  4. Conflict in flight information region.
  5. Misunderstood instructions
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17
Q

3 facts about RVSM

A

RVSM = Reduced Vertical Separation Minimia

Rolled out in Europe in 2002

Allows aircraft to fly within 1,000ft of each other between FL290 and FL410

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18
Q

3 pros and 3 cons about RVSM

A

PROS

  1. It enhanced Europe’s airspace capacity by 25%
  2. It allows flights to operate closer to their optimum flight levels (fuel efficiencies!)
  3. Provides operational flexibility for controllers as separation criteria is now the same across global airspace, thus reducing conflicts at crossing points

CONS

  1. Both pilots and controllers have reduced amount of time to react if something goes wrong
  2. There is a larger potential for wake turblence
  3. If one aircraft in the airspace is not RVSM compliant then all aircraft in the airspace must fly 2,000ft apart, which brings about an added complexity for controllers
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19
Q

What was the impact on safety with RVSM?

A

Airproxes in UK airspace reduced by 15%.

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20
Q

How do ICAO (2001) define Air Traffic Management?

A

As the aggregation of the airborne functions and grond-based functions (air traffic services, airspace management, and air traffic flow management) required to ensure safe and efficient movement of aircraft during all phases of operations.

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21
Q

What is the purpose of Air Traffic Management?

A

To enable aircraft operators to meet their planned times of departure and arrival and to adhere to their preferred flight profiles with the minimum constraints, without compromising agreed levels of safety.

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22
Q

What is the new ATM ConOps?

A

Air Traffic Management systems based upon trajectory-based operations versus traditional airspace-based approaches.

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23
Q

Define SESAR and give me five points about it

A

A new ConOps - Single European Sky ATM Research:

  1. £2.1bn project to modernise EU airspace systems to 4D trajectory-based approach
  2. Triples airspace capacity
  3. Enhances safety by a factor of 10
  4. Reduces environmental impacts by 10%
  5. Cuts Air Traffic Management costs by 10% as more automation replaces human
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24
Q

What are the four barriers in implementing new ATM systems?

A
  1. Institutional and political challenges
  2. Financial aspects, who pays for the system?
  3. Technological issues; compatibility
  4. The nature of the regulatory regime, what role will EASA play?
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25
Q

What is HERA-JANUS?

A

A model, methodology and technique to assist incident investigators in the accurate assessment of human error in ATM occurrences.

It attempt to increase the effectiveness of error recording, analysis, and hopefully prevention.

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26
Q

What are the three factors leading to a safety occurrence that HERA-JANUS attempts to identify?

A

Casual - the ultimate cause of the incident (directly responsible)
Contributing - errors that occurred in addition to the causal error (necessary but not sufficient to cause an accident)
Compounding - errors that made the situation worse

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27
Q

Why is it important to address runway safety?

A

Because 48% of accidents occur on landing and 13% of accidents occur on takeoff.

Runway occurrences are on the NTSB’s “most wanted” as so many accidents occur on runways.

As air traffic increases, runway occurrences are likely to increase without interventions.

3-4 runway overruns occur per month, with 10% of them resulting in fatalities.

28
Q

What four types of factors affect overruns and undershoots?

A
  1. Meterological conditions (arguably more important once in the air, so undershoots suffer more from this)
  2. Runway conditions (contamination, LDA)
  3. Aircraft performance (braking faults)
  4. Human error; incorrect procedures of crew:
    Landing long
    Delay in aborting LTO
    Incorrect configuration of aircraft
    Incorrect interpretation of reported conditions
    Selection of incorrect runway
29
Q

Runway safety is a shared responsibility which is reinforced by a system which includes what four things?

A
  1. Operational procedures (pilot readbacks of controller clearances)
  2. Airport infrastructure (airfield signage, pavement markings)
  3. Air Traffic Management (e.g., coordination between ground and local tower)
  4. Training and awareness
30
Q

Runway incursions are caused by what 3 main causal factors?

A
  1. Pilot deviation - actions of a pilot which violate any aviation regulation (crossing a taxiway hold-line, entering a runway without authorisation, taking-off from a taxiway, using a wrong runway)
  2. Operational errors / deviations (actions of ATCOs that result in: less than minimum separation between 2 aircraft of vehicles, or an aircraft landing on a departing runway that has been closed to aircraft)
  3. Vehicle / pedestrian deviation - movements of pedestrians / vehicles that have not been authorised by ATCOs
31
Q

5 measures to prevent runway incursions

A
  1. Signals (traffic lights) to prevent GSE incursions
  2. Infrared sensors
  3. Clearer lighting
  4. Training of pilots and ATCOs
  5. As human make so many errors, maybe automation is the answer… Autonomous taxiing / GSE vehicles
32
Q

Tell me about RESA improvements.

A

Between 2000-2012, £3bn has been spent on RESA improvements for over 1,000 runways.

33
Q

When is EMAS effective?

A

When an aircraft overruns at less than 70 knots.

Recommended by ICAO when the terrain does not allow for a compliant RESA.

34
Q

What is workload and what is taskload?

A

WORKLOAD
Is subjective. It’s how an individual controller perceives the task-load. It may be influenced by how much experience they have had, what their working environment is like, how they personally cope with stress.

TASKLOAD
Is what the controller has to do; how many tasks the controller is given (i.e., how many aircraft they have to control)

35
Q

What are the three main ways to measure controller workload?

A
  1. Performance measurements
  2. Psychological measurements
  3. Subjective measurements

No measure is suitable for all aspects.

36
Q

What are performance task measures?

A

How well is the controller dealing with the primary task? (e.g., how well is a car driver driving in a straight line?)

37
Q

What are psychological measures?

A 
Measurements based upon the assumption that workload strain induces quantifiable changes such as:
Blink rate
Blood Pressure
Heart rate
Pupil dilation
Saliva
38
Q

What issues are there with obtaining psychological measurements for controllers?

A

Data needs to be collected online and it’s often too disruptive to measure in an intense working environment, however, wearables such as FitBits or Apple Watches may be able to discretely send data.

39
Q

What are subjective measures?

A

It recognises that workload and stress is subjective and varies amongst individual controllers.

40
Q

What system attempts to measure controller workload subjectively?

A

NASA-TLX; it’s a multidimensional scale where the overall workload is a function of six dimensions on a continuum:

  1. Mental demand
  2. Physical demand
  3. Temporal demand
  4. Overall performance
  5. Frustration level
  6. Effort level

Each is rated and given a weighting by the user to establish their workload

41
Q

What is ICAO (2013)’s definition of SMS?

A

SMS = “A systematic approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures”

42
Q

Who do ICAO (2013) say have to implement an SMS?

A

“approved training organisations, aircraft operators, approved maintenance organisation, air traffic service providers and certified aerodromes”

43
Q

Does ICAO prescribe instructions for SMS?

A

No. It lies with the state regulator (e.g., CAA). This may lead to a lack of consistency but it may be good at addressing cultural variation.

44
Q

ICAO (2013)’s generic framework prescribes what four key components to SMS?

A

Safety Policy
Safety Assurance
Safety Risk Management
Safety Promotion

45
Q

What is Safety Policy? (SMS)

A

Establishes senior management’s commitment to continually improve safety.

It defines the methods, processes and organisational structure need to achieve safety goals.

46
Q

What is Safety Assurance? (SMS)

A

Evaluates the continued effectiveness of the implemented risk control strategies

Supports the identification of new hazards

47
Q

What is Safety Risk Management?

A

Determines the need for, and adequacy of, new or revised risk controls based on the assessment of acceptable risk.

48
Q

What is Safety Promotion?

A

Includes training, communication, and other actions to create a positive safety culture within all levels of the workforce.

49
Q

Draw the diagram for SMS

A

Draw the diagram for SMS

50
Q

How does CAP382 define a safety occurrence?

A

“Any incident which endangers or which, if not corrected, would endanger an aircraft, it’s occupants, or any other person” - CAA, CAP382

51
Q

What is the purpose of a safety occurrence reporting system?

A

To understand risk, monitor how risks may be changing, identify and mitigate hazards before they lead to accidents, and to provide more safety performance data that is not available from accident data alone.

(Feeds back to the 5E’s - engineering, economic, education, enforcement, engagement.)

52
Q

What are the best safety occurrence reporting systems?

A

Ones that are voluntary, non-punitive and protected (anonymous) although in the UK, most reporting is mandatory.

53
Q

What are the primary objectives of the CAA’s MOR?

A

To contribute to the improvement of air safety by ensuring that “relevant information on safety is reported, collected, stored, protected and disseminated”

54
Q

4 Facts about CAA’s MOR scheme.

A
  1. Launched in 1976
  2. Receives 16,200 reports each year.
  3. Reports are increasing, not sure if this is due to more incidents or an improved safety culture…
  4. Only investigates less than 100 ‘safety critical’ events each year.
55
Q

The CAA’s MOR scheme says it will do what…

A

The CAA will:

  1. Evaluate each occurrence report received
  2. Decide which occurrences require investigation by the CAA
  3. Make checks to ensure all involved parties are taking necessary remedial and preventative actions
  4. Involve foreign aviation authorities and organisations to take actions (if applicable)
  5. Assess and analyse the information to detect safety problems
  6. Make available the results of studies to those who will make use of them for the benefit of air safety
  7. Where appropriate, issue specific advice or take action in relation to legislation, requirements, and guidance
  8. Exchange data with other EC states
56
Q

What 7 issues must be reported under the CAA’s MOR scheme?

A
  1. Technical issues
  2. Operational issues
  3. Airspace + ATC issues
  4. Weather issues
  5. Wildlife issues
  6. 3rd party (e.g., drones)
  7. Ground service issues
57
Q

What is the ASRS

A

FAA’s version of the MOR Scheme but it’s voluntary

58
Q

What 4 issues are there with safety occurrence reporting systems?

A
  1. Particularly with mandatory reporting schemes, there may be a fear of blame for the event. People might not want to report things if they know they’re going to get blamed.
  2. People may be reluctant to report the failure of a co-worker
  3. Some people may not have enough time to complete reports
  4. Some events may be judged as trivial (near miss vs. Complete non-event)
59
Q

Define risk management.

A

“the systematic application of management policies, procedures and practices to the tasks of analysing, evaluating and controlling risks in aviation safety”

60
Q

What are the 6 steps of risk management?

A
  1. Objective setting (what are we trying to do?)
  2. Risk identification (what might affect me/us/the organisation)
  3. Risk assessment & evaluation (which of those things that might affect me are most important?)
  4. Risk-handling techniques, e.g., ARRT (policies, strategies, interventions, responses)
  5. Did we control the risk?
  6. Redesign - feedback loop (what changed?)

It’s a continuous process

61
Q

Given an example of a Risk Handling Technique

A

ARRT (Heinrich et al., 1980)

  1. Avoidance - A risk manager can influence the top management to persuade them not to enter a particular venture due to the risk involved. e.g., let’s not buy Russian aircraft!
  2. Reduction - Reducing the frequency and severity of loss
  3. Retention - Referred to as ‘self-insurance’; the amount of risk or a particular risk is retained for the organisation as opposed to the purchase of insurance. The threshold the company can afford for a loss/risk
  4. Transfer - Insurance is the most popular transfer device.
62
Q

Describe Event Tree Analysis

A
  1. Event tree analysis is a method of risk assessment. It is the most used method in aviation safety.
  2. It recognises that a single event could result in multiple consequences.
  3. It is an inductive procedure which shows all possible outcomes resulting from an accidental initiating event, taking into account whether safety barriers are functioning or not and additional events or factors.
  4. It allows people to see the chain of events which lead to an accident.
  5. Safety measures are shown (e.g., TCAS) in the order sequence that they’ll be activated.
63
Q

What are the 7 steps of an Event Tree Process?

A
  1. Identify and define a relevant accidental initial event that may give rise to unwanted consequences
  2. Identify the barriers that are designed to deal with the accidental event (e.g., TCAS)
  3. Construct an event tree
  4. Describe the potential resulting accident sequences
  5. Determine the frequency of the accidental event and the conditional probabilities of the branches in the event tree
  6. Calculate the probabilities/frequencies for the identified consequences/outcomes
  7. Compile and present the results from the analysis
64
Q

3 pros and 2 cons of event trees

A

PROS

  1. Able to visualise event chains following an accidental event
  2. Able to visualise barriers (e.g., TCAS) and their sequence of activation
  3. Provides a good basis for evaluating the need for new or improved procedures and barriers

CONS

  1. Only one initiating event can be studied in each analysis
  2. It can be easy to overlook inherent system dependencies
65
Q

Draw the CAA’s risk management strategic analysis pyramid

A

Draw the CAA’s risk management strategic analysis pyramid

Aviation Safety (1 decks)

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