Presentation on theme: "WATS 10 Training for Safety John Bent 1 TRAINING

FOR SAFETY John Bent Director Training Strategy proposed Pegasus

Flight Academy - China World Aviation." Presentation transcript:

Slide 1

WATS 10 Training for Safety John Bent 1 TRAINING FOR SAFETY John Bent Director Training Strategy
proposed Pegasus Flight Academy - China World Aviation Training Symposium Orlando 27th April 2010

Slide 2

WATS 10 Training for Safety John Bent 2 The latest threat to crew training resources USD 1.7 billion
has just been lost to international airlines in one week Source IATA

Slide 3

WATS 10 Training for Safety John Bent 3 IATA SAFETY REPORT 2009: 2009 ACCIDENT RATE REDUCED
0.71 0.81 2009 ACCIDENT RATE REDUCED: 0.71 versus 0.81 in 2008 [hull losses per million flights of
Western-built jet aircraft] = one per 1.4 million flights SAFELY FLOWN: 2.3 SAFELY FLOWN: 2.3 billion
people on 35 million flights (27 million jet, 8 million turboprop) 1922 LESS ACCIDENTS WESTERN BUILT
TYPES: 19 vv 22 in 2008 90109 LESS ACCIDENTS (all types) 90 vv 109 in 2008 1823 LESS FATAL
ACCIDENTS (all types): 18 vv 23 in 2008 SAFETY - THE GOOD NEWS - 2009

Slide 4

REGIONAL RATES WHICH ROSE: 0.86 1.48 times worse ASIA PACIFIC: 0.86 vv 0.58 in 2008 1.48 times
worse 3.32 1.75 times worse M/E: 3.32 vv 1.89 in 2008 1.75 times worse 9.94 4.68 times worse
AFRICA: 9.94 vv 2.12 in 2008 4.68 times worse Runway excursions Runway excursions and ground
damage were main categories Pilot handling 30% Pilot handling was a contributing factor in 30% of all
accidents. SAFETY - THE BAD NEWS - 2009 MORE FATALITIES: 685 vv 502 in 2008 1.36 times
worse 685 5021.36 times worse WATS 10 Training for Safety John Bent 4 IATA SAFETY REPORT
2009:

Slide 5

Any serious accident which could have been reasonably AVOIDED or MITIGATED was industry safety
system failure an industry safety system failure Complete elimination of accidents is unrealistic, but:
Longer term trends by type and regions remain disturbing WATS 10 Training for Safety John
Bent 5 ANY SENSE THAT 2009 RESULTS WERE BETTER COULD GENERATE COMPLACENCY

Slide 6

WATS 10 Training for Safety John Bent 6 Training is the best investment against catastrophic risk The
top catastrophic accident risks identified were: 1. 1. LOC (loss of control) 2. 2. CFIT (controlled flight
into terrain) 3. 3. Post-crash fire 4. 4. Runway excursions and overruns Crew judgment and actions are
the most consistent causal factor in global catastrophic accidents This situation will remain true for the
foreseeable future Crew-related issues dominate accident causal factors, featuring in 75% of fatal
accidents CREW TRAINING - UK CAA 2008:

Slide 7

WATS 10 Training for Safety John Bent 7 Major accident totals threaten levels not seen since 1990s
Totals threaten levels not seen since 1990s Last five-year accidents exceed previous five-year periods
at this pace, we'll be turning the clock back 10 years in safety FLIGHT SAFETY FOUNDATION: Are
today's airline pilots churned out by "pilot mills" that train to minimum standards? BUFFALO NEWS
DEC 2009:

Slide 8

WATS 10 Training for Safety John Bent Hardware growth has outstripped human-ware available 911
and SARS discouraged steady expansion of training capacity 2007-2008: aircraft were grounded
without crews Crew training rates inadequate; training trended to minimums 2009 - global recession;
reversal to surplus crews Pilot layoffs and unpaid leave Less pressure on training delivery, yet increased
pilot mobility Accidents on the rise; no surprise Now volcanic ash AN INDUSTRY WITH REMARKABLE
CHALLENGES 8 Accidents & Incidents

Slide 9

WATS 10 Training for Safety John Bent 9 THE LONG TERM ACCIDENT RATE MAY EXCEED THAT
COMMENSURATE WITH EXPANSION ALONE IF SO, WHY?

Slide 10

WATS 10 Training for Safety John Bent 10 TRAINING & SAFETY The following slides depict a sample of
just 40 airline accidents since 2005 (not exhaustive) Detailed analysis is not intended These tragic
slides will be shown rapidly, aimed at the bigger picture, and to stay within my presentation time 88%
As many as 35 of this sample ( 88% ) may be concluded to have contained crew training as possible
mitigants

Slide 11

WATS 10 Training for Safety John Bent 11 Air France A340 Toronto2 Aug 2005 RUNWAY DEPARTURE:
Could more effective training have mitigated? Undesired aircraft state- unstable approach in bad
weather 1

Slide 12

WATS 10 Training for Safety John Bent 12 Helios B737 Greece14 Aug 2005 CREW INCAPACITATION:
Could more effective training have mitigated? Tech and procedures? 2

Slide 13

WATS 10 Training for Safety John Bent 13 16 Aug 2005 LOSS OF CONTROL: Could more effective
training have mitigated? loss of control in cruise; a/c overload, stall? W Caribbean MD82 Venezuala
The pilots may have lacked basic instrument flying skills due to continuous over reliance on
automated flight. Did they monitor their instruments? Indications should have alerted them of subtle
airspeed decay as the aircraft was overloaded and at too high a FL... 3

Slide 14

WATS 10 Training for Safety John Bent 14 Bellview B737 Lagos23 Oct 2005 LOSS OF CONTROL: Could
more effective training have mitigated? - Unknown as yet The airplane impacted ground at a speed of
around 400 knots in a near wings level attitude with both engines at takeoff thrust. All 111 passengers
and 6 crew perished in the crash. Nigerian Authorities promised a final report in 2007, but has not
come to light so far. 4

Slide 15

WATS 10 Training for Safety John Bent 15 29 Sep 2006 COLLISION: Could more effective training have
mitigated? Procedures, situational awareness, TCAS? GOL B737-800 Brasil 5

Slide 16

WATS 10 Training for Safety John Bent 16 29 Nov 2007 IMPACT WITH TERRAIN: Could more effective
training have mitigated? - heading, situational awareness = controlled flight into terrain (CFIT)? AtlasJet
MD83 at Isparta 6

Slide 17

WATS 10 Training for Safety John Bent 17 7 Mar 2007 OVERRAN RUNWAY: Could more effective training
have mitigated? Crew resource management (authority gradient) Garuda B737 Yogyakarta 7

Slide 18

WATS 10 Training for Safety John Bent 18 4 May 2007 CRASHED AFTER TAKE-OFF: Could more effective
training have mitigated? - took-off into heavy TS Kenya Airways B737 Douala According to the former
minister, the Camerounian State is not to be blamed as the pilot was asked not to fly due bad
weather. The Kenya Airways Boeing 737-800 suddenly disappeared from radar screens two minutes
after take-off from the Douala International Airport during a heavy thunderstorm. 8

Slide 19

WATS 10 Training for Safety John Bent 19 17 Jul 2007 RUNWAY EXCURSION: Could more effective
training have mitigated? Undesired aircraft state - reverser inoperative procedures TAM A320 Sao Paolo
9

Slide 20

WATS 10 Training for Safety John Bent 20 BA B777 Heathrow17 Jan 2008 LOSS OF POWER: Could more
effective training have mitigated? NO: Sound airmanship displayed - AAIB report 10

Slide 21

WATS 10 Training for Safety John Bent 21 Belgavia CRJ100 Yerevan 14 Feb 2008 DE-ICING
PROCEDURES: Could more effective training have mitigated? Loss of control -refused advice to de-ice
for take off 11

Slide 22

WATS 10 Training for Safety John Bent 22 21 Feb 2008 FLEW INTO TERRAIN: Could more effective
training have mitigated? - failed to align NAV pre-take off = Situational Awareness + CFIT ATR42 nr
Merida12

Slide 23

WATS 10 Training for Safety John Bent 23 15 Apr 2008 RUNWAY OVERRUN: Could more effective
training have mitigated? Overrun - tyre burst after V1; tried to stop Hewa Bora DC95 Goma13

Slide 24

WATS 10 Training for Safety John Bent 24 25 May 2008 RUNWAY OVERRUN: Could more effective

training have mitigated? Procedures; slow rejected take off? Kalitta B747 Brussels 14

Slide 25

WATS 10 Training for Safety John Bent 25 30 May 2008 RUNWAY DEPARTURE: Could more effective
training have mitigated? Undesired aircraft state - landing performance? TACA A320 Tegucigalpa 15

Slide 26

WATS 10 Training for Safety John Bent 26 10 Jun 2008 RUNWAY DEPARTURE: Could more effective
training have mitigated? Undesired aircraft state - landing performance? Sudan Airways A310
Khartoum 16

Slide 27

WATS 10 Training for Safety John Bent 27 6 Jul 2008 GO AROUND FAILED: Could more effective training
have mitigated? Undesired aircraft state-approach to wrong runway USA Jet DC91 Saltillo 17

Slide 28

WATS 10 Training for Safety John Bent 28 20 Aug 2008 DEPARTED RUNWAY: Could more effective
training have mitigated? Flaps not set for take-off -undesired aircraft state - procedures Spanair MD82
Madrid 18

Slide 29

WATS 10 Training for Safety John Bent 29 Itek Air B732 Bishkek 24 Aug 2008 LOST CONTROL ON
APPROACH: Could more effective training have mitigated? Undesired aircraft state visual awareness?
19

Slide 30

WATS 10 Training for Safety John Bent 30 30 Aug 2008 FLEW INTO TERRAIN: Could more effective
training have mitigated? crew resource management, situational awareness Conviasa B737 Latacunga
20

Slide 31

WATS 10 Training for Safety John Bent 31 Aeroflot-Nord B735 Perm 14 Sep 2008 LOST CONTROL ON
APPROACH: Could more effective training have mitigated? Recent formal ruling that pilot was drunk,
CRM? Since this accident Russia's transport ministry signed an agreement with Boeing aimed at
improving air transport safety in the country. The memorandum, identifies provision of training for flight
crew and technical personnel and the development of training infrastructure as crucial areas 21

Slide 32

WATS 10 Training for Safety John Bent 32 27 Nov 2008 LOST CONTROL: Could more effective training
have mitigated? test flight procedures training (BEA)? ANZ A320 nr Perpignan 22

Slide 33

WATS 10 Training for Safety John Bent 33 20 Dec 2008 RUNWAY OVERRUN: Could more effective
training have mitigated? Undesired aircraft state -failed take-off & runway overrun? Continental B737
Denver 23

Slide 34

WATS 10 Training for Safety John Bent 34 US Air A320 Hudson River 15 Jan 2009 TRAINING &
EXPERIENCE SAVED THE DAY! An example to study 24

Slide 35

WATS 10 Training for Safety John Bent 35 Colgan Air DH8D Buffalo12 Feb 2009 LOST CONTROL: Could
more effective training have mitigated? - procedures, icing and stall recovery training? 25 A change
trigger

Slide 36

WATS 10 Training for Safety John Bent 36 25 Feb 2009 Turkish B737 Amsterdam LOST CONTROL ON
APPROACH: Could more effective training have mitigated? Automation reliance & monitoring? 26 An
automation threat?

Slide 37

WATS 10 Training for Safety John Bent 37 23 Mar 2009 FLIPPED ON LANDING: Could more effective

training have mitigated? Undesired aircraft state -known handling issues in strong gusts? Fedex MD11
Tokyo 27

Slide 38

WATS 10 Training for Safety John Bent 38 9 Apr 2009 IMPACT WITH TERRAIN: Could more effective
training have mitigated? Undesired aircraft state-loss of control; circling in low cloud base? Aviastar BAe
146 Wamena 28

Slide 39

WATS 10 Training for Safety John Bent 39 29 Apr 2009 CRASHED AFTER TAKE-OFF: Could more
effective training have mitigated? As yet unknown but aircraft stored for 1 year? Bako Air B737
Massamba 29

Slide 40

WATS 10 Training for Safety John Bent 40 1 June 2009 Air France A330 Atlantic LOST CONTROL: Could
more effective training have mitigated? - inadequate evidence as yet 30

Slide 41

WATS 10 Training for Safety John Bent 41 Yemenia A310 East Africa 30 Jun 2009 LOST CONTROL: Could
more effective training have mitigated? Undesired aircraft state - missed approach in big twin; as yet
unknown 31

Slide 42

WATS 10 Training for Safety John Bent 42 Caspian Tu 154 nr Tehran 14 Jul 2009 IMPACTED TERRAIN:
Could more effective training have mitigated? -as yet unknown 32

Slide 43

WATS 10 Training for Safety John Bent 43 Aryan Airlines IL62 Mashhad (Iran) 24 Jul 2009 OVERRAN
RUNWAY: Could more effective training have mitigated? -Technical (gear?), late landing, but as yet
unknown 33

Slide 44

WATS 10 Training for Safety John Bent 44 Bangkok Awys ATR72 Koh Samui 4 Aug 2009 RUNWAY
EXCURSION: Could more effective training have mitigated? Departed runway in strong winds and rain as yet unknown 34

Slide 45

WATS 10 Training for Safety John Bent 45 Sudan Awys B707F Sharjah 21 Oct 2009 LOST CONTROL:
Could more effective training have mitigated? Lost control during initial climb and crashed as yet
unknown 35

Slide 46

WATS 10 Training for Safety John Bent 46 Cpgn African Avn MD82 Goma 19 Nov 2009 OVERRAN
RUNWAY: Could more effective training have mitigated? Overran runway in rainy conditions - as yet
unknown 36

Slide 47

WATS 10 Training for Safety John Bent 47 American Airlines 738 Kingston 22 Dec 2009 OVERRAN
RUNWAY: Could more effective training have mitigated? Overran runway in heavy rain - as yet unknown
37

Slide 48

WATS 10 Training for Safety John Bent 48 Compagnie B727-200 Kinshasa 2 Jan 2010 RUNWAY
EXCURSION: Could more effective training have mitigated? Veered off runway on landing - heavy rain
38

Slide 49

WATS 10 Training for Safety John Bent 49 Taban Air TU 154 Mashad Iran 24 Jan 2010 RUNWAY
EXCURSION: Could more effective training have mitigated? Landing in fog with medical emergency
Flight International 39

Slide 50

WATS 10 Training for Safety John Bent 50 Ethiopian 738 Nr Beirut 25 Jan 2010 CRASHED IN
DEPARTURE: Could more effective training have mitigated? Lost height and impacted Mediterranean
(WX?) - as yet unknown 40

Slide 51

WATS 10 Training for Safety John Bent 51 LESSONS FROM THIS SAMPLE? 1. That most accident risks
realised could be foreseen in training! 2. That reactive is easier then proactive! 3.88% probable human
factors and training [ 3. That 35 of the 40 accidents sampled (88%) may count as probable human
factors and training [LOSS OF CONTROL / undesired aircraft state (irrecoverable departure from normal
operational parameters) & controlled flight into terrain] 4. 4. That today we still DO NOT focus a
commensurate amount of pilot training on human factors! (its more like 10%?) TRAINING 5. We must
mitigate accidents with TRAINING

Slide 52

Pilot handling was a contributing factor in 30% of all accidents 2010 So whats happening in 2010 ?
Pilot handling 30% Runway excursions and ground damage were main categories Runway
excursions WATS 10 Training for Safety John Bent 52 Back to the 2009 IATA REPORT

Slide 53

WATS 10 Training for Safety John Bent 53 DURING THE FIRST 120 DAYS OF 2010, NOT MUCH
HAS CHANGED

Slide 54

WATS 10 Training for Safety John Bent 54 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY
EXCURSIONS & GROUND DAMAGE 2010 (page1) Veered off runway on landing 2 JanCompagnie
Africaine Aviation B727-200, Kinshasa (Congo) Veered off runway on landing Rejected takeoff - runway
overrun 3 JanAir Berlin B737-800, Dortmund (Germany) Rejected takeoff - runway overrun Veered off
runway on take off 8 JanAir Berlin B737-800, Nuremberg (Germany) Veered off runway on take off
Runway excursion on landing 9 JanYas Air IL76, Kiev (Ukraine) Runway excursion on landing Nose gear
collapse on landing 15 JanIran Air F100, Isfahan (Iran) Nose gear collapse on landing Went off runway
on line up for take off 16 JanIran Air A300-600, Stockholm (Sweden) Went off runway on line up for take
off Overran runway on take off 19 JanPSA Airlines CRJ2, Charleston (USA) Overran runway on take off
Source: Aviation Herald 7

Slide 55

WATS 10 Training for Safety John Bent 55 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY
EXCURSIONS & GROUND DAMAGE 2010 (page2) Runway excursion on landing 19 JanLion Air B737-900,

Padang (Indonesia) Runway excursion on landing Went off runway on landing 21 JanAeromexico
Connect E145, Tijuana (Mexico) Went off runway on landing Overran runway on landing 22 JanSkywest
CRJ7, Winnipeg (Canada) Overran runway on landing Veered off runway on landing 25 JanWest Air CRJ2
Longyearbyen (Norway) Veered off runway on landing ) Veered off runway on landing 27 JanCimber
AT72, Bornholm (Denmark) Veered off runway on landing Overran runway on landing 28 JanBulog
AN26, Wamena (Indonesia) Overran runway on landing Overran runway on landing 30 JanDonavia
B737-400, Rostov (Russia) Overran runway on landing Source: Aviation Herald 14

Slide 56

WATS 10 Training for Safety John Bent 56 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY
EXCURSIONS & GROUND DAMAGE 2010 (page3) 31 Jan Skyservice A320, Varadero (Cuba) Hard landing
three tyres blown 4 FebYakutia AN24, Yakutsk (Russia) Rejected take-off but airborne / gear up 8
FebShasheen B737-200, Peshawar (Pakistan) Departed runway on landing 10 Feb KLM B737-300,
Schiphol (Netherlands) Took off on taxiway 13 Feb Batavia B737-200, Surabaya (Indonesia) Nose gear
skidded on line up tyres blew 18 Feb Shuttle America Embraer ERJ-170, Cleveland (USA) Overran the
runway on landing 22 Feb Spring Airlines A320-200, Shenyang (China) Landed tail first structural
damage Source: Aviation Herald 21

Slide 57

WATS 10 Training for Safety John Bent 57 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY
EXCURSIONS & GROUND DAMAGE 2010 (page4) 24 Feb Ethiopian Airlines B737-700, Lubumbashi
(Congo) Departed taxiway after landing 24 Feb Air Canada Airbus A321-200, Toronto (Canada) Landed
without ATC clearance 25 Feb Lion Air B 737, Padang (Indonesia) Main gear departed paved surface 26
Feb Garuda Indonesia B 737-800, Perth (Australia) Entered RWY 06 after landing - no clearance 26 Feb
Aeroflot A320-200, Oslo Gardermoen (Norway) Took off on taxiway Veered off the departure runway 30
1 MarAir Tanzania B737-200, Mwanza (Tanzania) Veered off the departure runway 30 Overran the
runway on landing 17 MarShaheen Air International B737-200, Peshawar (Pakistan) Overran the runway
on landing Source: Aviation Herald 28

Slide 58

WATS 10 Training for Safety John Bent 58 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY
EXCURSIONS & GROUND DAMAGE 2010 (page5) Landed about 1000 meters short of rwy 14R 22
MarAviastar TU-204-100, Moscow Domodedovo (Russia Landed about 1000 meters short of rwy 14R
Struck its tail onto the departure runway 23 Mar China Airlines B747-400F, Anchorage, (USA) Struck its
tail onto the departure runway Overran runway 06 while landing 24 Mar Cargojet B727-200, Moncton,
(Canada) Overran runway 06 while landing Overran runway 21L by about 30 meters 24 Mar Asiana
A321-200, Omitama (Japan) Overran runway 21L by about 30 meters Tail strike during takeoff 25 Mar
Westjet B737-800, Cancun (Mexico) Tail strike during takeoff Main gear off the paved surface after
landing 25 Mar Air Madagascar B737-300, Nossi-be (Madagascar) Main gear off the paved surface after
landing Wrong taxiway - impacted two light poles 5 AprEgypt Air A330-200, Cairo (Egypt) Wrong
taxiway - impacted two light poles ( wrong park position entered into FMS wing damage) Source:
Aviation Herald 35

Slide 59

WATS 10 Training for Safety John Bent 59 RUNWAY EXCURSIONS & GROUND DAMAGE 2010 RUNWAY

EXCURSIONS & GROUND DAMAGE 2010 (page6) PSA Airlines CRJ-200, Charleston, WV (USA) Overran
runway - rejected takeoff at high speed 8 Apr PSA Airlines CRJ-200, Charleston, WV (USA) Overran
runway - rejected takeoff at high speed 13 Apr Overran runway while landing 13 Apr Merpati Nusantara
B737-300, Manokwari (Indonesia) Overran runway while landing 21 Apr Overran runway 06 while
landing 21 Apr Cargojet B727-200, Moncton (Canada) Overran runway 06 while landing Source:
Aviation Herald 38 (Since 1 st Jan 2010)

Slide 60

WATS 10 Training for Safety John Bent 60 Is our collective industry eye still off
the SAFETY ball?

Slide 61

WATS 10 Training for Safety John Bent 61 THE BIG QUESTION SHOULD INDUSTRY ACCEPT THAT
ACCIDENT & INCIDENT RATES: (1) ARE AS LOW AS ECONOMICALLY VIABLE? (1) ARE AS LOW AS
ECONOMICALLY VIABLE?OR (2) MUST BE FURTHER REDUCED? THE BIG QUESTION SHOULD INDUSTRY
ACCEPT THAT ACCIDENT & INCIDENT RATES: (1) ARE AS LOW AS ECONOMICALLY VIABLE? (1) ARE AS
LOW AS ECONOMICALLY VIABLE?OR (2) MUST BE FURTHER REDUCED?

Slide 62

WATS 10 Training for Safety John Bent AS GROWTH RESUMES, IF THE ACCIDENT RATE REMAINS
UNCHANGED Expansion of the global fleet will increase the number of accidents The accident RATE
must be DRIVEN DOWN further 62

Slide 63

WATS 10 Training for Safety John Bent 63 ALTHOUGH THE RATE IS LOW RELATIVE TO ACTIVITY: A
doubling of the fleet next 20 years at same rate could result in 10,000 10,000 fatalities or more;
tragedies with commercial consequences for passenger growth SO WE MUST ACT 150 HALVE the
accident rate NOW To hold accidents down to 150 and a possible 5,000 fatalities, we must HALVE the
accident rate NOW

Slide 64

WATS 10 Training for Safety John Bent THE BRIC COUNTRIES (Brazil, Russia, India, & China) ARE MOST
EXPOSED NEXT 20 YEARS Source: ACI Sept 08 THE BRICS WILL EXCEED USA BY 2027

Slide 65

WATS 10 Training for Safety John Bent IN CHINA ALONE: 20 YEAR PROJECTIONS FOR NEW AIRCRAFT: 65
Pre-recession projection: 3,800 airframes 2,800 Post recession-REVISED projection: 2,800 airframes
41,600 New airline pilots required (including 8,000 retirements): 41,600 Source: manufacturers and
IATA

Slide 66

WATS 10 Training for Safety John Bent 66 THE VERDICT: RATES MUST BE FURTHER REDUCED! This
month in Montreal, ICAO announced an action plan to: Lead a safety information exchange Coordinate
efforts to establisha global safety information exchange to enable analysis of key safety indicators
Work with IATA and the FAA, to "facilitate the collection, analysis and dissemination of safety
information provided by states and industry partners throughout the international aviation community
But these actions will take a LONG TIME. Improved training is an obvious action which can be taken
NOW

Slide 67

WATS 10 Training for Safety John Bent 67 ACTION - THE

CHALLENGES:

Slide 68

WATS 10 Training for Safety John Bent 68 DOEPS DOEPS [DEFENCE OF ESTABLISHED PROCESS
SYNDROME]? Change is not easy; defense of status quo is A long established process is understood
Prejudice ( conclusions without the facts ) is a great time saver New processes are more acceptable
once widely adopted NAAs and Training Organisations prefer not to be first THE CHANGE CHALLENGE

Slide 69

WATS 10 Training for Safety John Bent 69 BUT: Hundreds of thousands of safe flights are not news
Airline accidents are immediate media drama Public perceptions form with the first media bite THE
SAFETY CHALLENGE ANOMALY (ARENT WE SAFE ENOUGH?) Approx 18,000 airliners are continuously in
operation; thats approx 2,700,000 passengers in flight Safe enough to relax? NO, thats complacency

Slide 70

WATS 10 Training for Safety John Bent 70 THE SKILL & EXPERIENCE LOSS CHALLENGE
(UNCOMFORTABLE SYSTEMIC MIX): THE SKILL & EXPERIENCE LOSS CHALLENGE (UNCOMFORTABLE
SYSTEMIC MIX):

Slide 71

WATS 10 Training for Safety John Bent 71 Washington Post, 29 June 2009 Washington Post, 29 June
2009 Automated systems are often designed to relieve humans of tasks that are repetitive. When
such algorithms become sophisticated, however, humans start to relate to them as if they were The
autopilot on a plane, the cruise control on a car, automated speed control systems in mass transit, are
all conveniences but fellow human beings fellow human beings The more reliable the system, the
more likely it is that humans in charge will switch off and lose their concentration, and the greater the
likelihood can become crutches that a confluence of unexpected factors that stymie the algorithm will
produce catastrophe THE AUTOMATION CHALLENGE

Slide 72

INDUSTRYWATS 10 Training for Safety John Bent 72 THE PROCESS CHALLENGE > TRAIICAO
DEVELOP BEST PRACTICE NEW SARPS TO NAA NING ORGANISATION APPLIES NAA APPLIES NAA
REQUIREMENTS PLUS LOCAL ENHANCEMENTS CUSTOMER NEED DEFINED REGULATION & INPUTS TO
SELECTION AUDITS: 1) 1)TRAINING ORG BY CUSTOMER COMPETENT SAFE PILOTS FACILITATION
VERIFICATION & CUSTOMER NAA 2) 2)NAA BY ICAO FEEDBACK ANALYSIS COMPULSORY REPORTING:
& NAA TO ICAO Continuous improvement IS THIS REALLY HAPPENNING? TRAINING ORG TO NAA

Slide 73

WATS 10 Training for Safety John Bent The training industry has had great difficulty preparing for the
next growth phase, as enterprise resources have been decimated Belt tightening prevented widespread
adoption of best practice; mostly more of the same prevailed The next growth surge can be seen on a
closer horizon Seeing through the recession 73 THE TIME & RESOURCE CHALLENGE (THERES LIMITED
TIME TO ACT)

Slide 74

WATS 10 Training for Safety John Bent 74 THE MANAGEMENT PERCEPTION CHALLENGE TRAINING
IMPROVEMENTS ARE NEEDED, but what about Training practitioners usually agree that TRAINING
IMPROVEMENTS ARE NEEDED, but what about CAPA Management survey 2009 >>

Slide 75

WATS 10 Training for Safety John Bent TRAINING AS A PRIORITY: Current priorities are not training!
Source: Centre for Asia Pacific Aviation Survey, Sept 09

Slide 76

WATS 10 Training for Safety John Bent TRAINING AS A CHALLENGE: A greater spread of opinions on the
key issues - medium term Source: Centre for Asia Pacific Aviation Survey, Sept 09

Slide 77

WATS 10 Training for Safety John Bent 77 How can crew training be enhanced if company
executives dont see the need?

Slide 78

WATS 10 Training for Safety John Bent 78 INDUSTRY ACTION? CONVINCE DECISION MAKERS THAT WE
HAVE A PROBLEM [ICAO, IATA, FAA ARE CLEARLY CONVINCED] ENHANCE CREW TRAINING; THE
CONTROLLABLE VARIABLE As hardware cannot be changed rapidly (we have what we have) Crew
Training (both airline & GA) must be driven rapidly towards: more relevance; proactive to risk & SMS
higher quality & continuous improvement more sustainability & topicality (recurrent)

Slide 79

WATS 10 Training for Safety John Bent FIND THE LOWEST HANGING
FRUIT 79

Slide 80

WATS 10 Training for Safety John Bent 80 Chairman of the Flight Training Department, EmbryRiddle
Aeronautical University: Our experience and research lead us to believe a successful airline pilot candidate preparation program
should embrace a methodology to weed out unsuccessful candidates prior to their employment by the
airlines TOO OBVIOUS? Yes but much more can be done USD 5,000 more invested in Selection could
reduce system risk, and save >USD 50,000 downstream

Slide 81

WATS 10 Training for Safety John Bent RAISE TRAINING STANDARDS EVERYWHERE 81

Slide 82

WATS 10 Training for Safety John Bent 82 Cost reductions (more training cannot easily be added)
Quality, and relevance must rise RAISE QUALITY - EVERYWHERE

Slide 83

WATS 10 Training for Safety John Bent 83 Much airspace is shared by GA & Airlines One airline supply
pipeline is GA Effective early training is vital throughout aviation Many best practices developed for
airline operations could be cross pollinated into GA training TAKE A MORE GLOBAL HOLISTIC APPROACH
GENERAL AVIATION Must wheels be re-invented?

Slide 84

WATS 10 Training for Safety John Bent 84 FIND THE QUALITY DRIVERS Without data, aviation safety is
at the mercy of opinion QA or SMS requires performance data to analyse This data comes from multiple
sources (in airlines): For example >>

Slide 85

WATS 10 Training for Safety John Bent Whole Airline: I ATA O PERATIONAL S AFETY A UDIT (IOSA)
Whole Airline: I ATA O PERATIONAL S AFETY A UDIT (IOSA) Flight Operations L INE O PERATIONAL S
AFETY A UDIT (LOSA) Flight Operations L INE O PERATIONAL S AFETY A UDIT (LOSA) USE INDUSTRY
EXTERNAL DATA 85 Whole Airline Industry: G LOBAL S AFETY D ATA (ICAO, IATA, FSF..)

Slide 86

WATS 10 Training for Safety John Bent USE LOSA (LINE OPERATIONAL SAFETY AUDIT) DATA After 10
years, and more than 6,000 LOSA flights - over 90% of flights exhibited observable crew errors
Numerous events were precipitated by an error made by the captain, unchallenged by other crew
members (reluctance to challenge, expressed as authority gradient (G. Hofstede) 50% of LOSAobserved errors went undetected by the crew 32% of errors were intentional noncompliance
(Violations) 86

Slide 87

WATS 10 Training for Safety John Bent LOSA DATA SHOWS WHAT CREWS DO
RIGHT 87

Slide 88

WATS 10 Training for Safety John Bent Emeritus Professor Bob Helmreich (University of Texas),
champion of LOSA & TEM (Threat & Error Management), in October 2006: After 10 years of
examining how flight crews manage errors (LOSA data), it is clear that all successful crews do two
things: - No Surprise! But much more can be done 88 1. 1.Cooperate to rigorously monitor and cross
check to make sure they pick up threats and errors early, and 2. 2.Actively engage in checking and
verifying every setting and action which can affect safety. 1. 1.Cooperate to rigorously monitor and
cross check to make sure they pick up threats and errors early, and 2. 2.Actively engage in checking
and verifying every setting and action which can affect safety.

Slide 89

WATS 10 Training for Safety John Bent Safety Dept FOQA / QAR DATA & CONFIDENTIAL REPORTS
Safety Dept FOQA / QAR DATA & CONFIDENTIAL REPORTS Flight Operations SELECTION CRITERIA &
DATA (& downstream performance: another presentation!) Flight Operations SELECTION CRITERIA &
DATA (& downstream performance: another presentation!) USE AIRLINE INTERNAL DATA 89 Flight
Operations & Training Dept CREW PERFORMANCE DATA (training progress, PCs / route checks) FUTURE
INITIATIVE: Flight Operations & Training Dept SIMULATOR PERFORMANCE DATA

Slide 90

WATS 10 Training for Safety John Bent OK SO WHATS NEW? 90 Not much, most airlines collect these
data already But how many airlines analyse, organise, and collate this data into a REAL TIME system
health check? Airline training systems would benefit immediately; through more rapid response to
new threats

Slide 91

WATS 10 Training for Safety John Bent ITQI ITQI ( IATA Training & Qualification Initiative ) ATC
Simulation Active development of Type VII FSTD ATC Simulation Upset Recovery Training (URT)
International Committee - aviation training in extended envelopes ICATEE) Active development of
Upset Recovery Training (URT) standards (RAeS International Committee - aviation training in extended
envelopes ICATEE) type training programmes APT3 Improved type training programmes; eg. APT3
(Airbus Pilot Training) & B787 type training all embedded with TEM (Threat & Error Management)
ATSAS ATSAS (Aircrew Training Standards & Safety - safety data driving training) NGAP NGAP (ICAO
Next Generation Aviation Professionals) Initiative March 2010 91 CAPITALISE ON CURRENT INITIATIVES

Slide 92

WATS 10 Training for Safety John Bent Recognise the new Airline Pilot License MULTI-CREW PILOTS
LICENCE (MPL) after 60 years of almost no change 92

Slide 93

WATS 10 Training for Safety John Bent MPL concentrates best practice Despite controversy, MPL is: the result of 6 years of industry development to replace an outdated 60 year-old airline training process
initially very well received: after the Alteon Beta trial (small sample, but impressive base training
results) an ICAO approved programme and license a set of powerful airline pilot training tools,
demanding new standards in the airline pilot training process Just what the training industry needs:
relevance + focus + quality > 93

Slide 94

WATS 10 Training for Safety John Bent National MPL regulations are now in place in: Armenia,
Australia, Canada, Chile, China, Denmark, France, Germany, Ghana, Latvia, Maldives, Netherlands,
Pakistan, Philippines, Singapore, Sweden, Switzerland, Syrian Arab Republic, Thailand, UAE, United
Kingdom, Hong Kong (22) By operators: 94 MPL is now under development, trail, or use in: Australia,
China, Denmark, Germany, Philippines, Singapore, Sweden, Switzerland, United Kingdom, Hong Kong
(10) Source: IATA Former Alteon-Boeing Flight Training-CAAC, CAAC-CAFUC, CAPA- Sterling, Lufthansa,
Swiss, OAA-Flybe, FTE-Flybe, CAE-Air Asia, Kaufer-Air Berlin, SATA-Tiger Airways, L.U.S.A.-City Airline &
Skyways, Alpha Aviation, and proposed Pegasus Flight Academy China (13)

Slide 95

WATS 10 Training for Safety John Bent 95 Data Source IATA & Course duration spread: 14 - 36 mths
But as the superior performance of MPL graduates is more widely seen, operators will eventually
demand MPL MPL under TRIAL some challenges Simulator flight training spread: 155 - 292 hours
Aircraft flight training spread: 80 - 130 hours Some orgs conduct MPL in three separate global
locations Many orgs still apply old pre-ICAO 9625 FSTD categories Some orgs still apply twins
and jets to the MPL syllabus, distracting students with up to three non-airline types Tng Orgs Prior
to the next growth surge, self funded pilot applicants prefer the old CPL route to ensure a job on
graduation MPL beta syllabus: variations in structure and spread:-

Slide 96

WATS 10 Training for Safety John Bent MPL STATUS MARCH 2010: 77 96 GRADUATED: 800 EASA MPL
Advisory Board 16/17.3.10 Data Source: IATA & EASA MPL Advisory Board 16/17.3.10 STUDENTS IN
TRAINING:

Slide 97

WATS 10 Training for Safety John Bent Training Comparison: 97 MPL delivers more instructional hours
than CPL Source: IATA

Slide 98

WATS 10 Training for Safety John Bent MPL THROWS OUT SPECIAL CHALLENGES: Upset Recovery
Training (URT) still maturing [but WGs underway include the RAeS International Committee for
Aviation Training in Extended Envelopes (ICATEE) to report next year] ATC simulation maturing in Type
VII FSTD (Flight Simulation Training Device) Instructor qualifications & training higher standards 98
UPSET RECOVERY TRAINING (URT): Actual flight in training aircraft + Simulator training

Slide 99

WATS 10 Training for Safety John Bent Advanced training equipment + ineffective instruction =
learning barrier Poor training equipment + effective instruction = learning catalyst MPL requires more
appropriate (1) instructor training and (2) training devices More relevant instructor entry criteria +
improved instructor training = essential for MPL, however challenging! HONE THE INSTRUCTORS ART
THAT HUGELY FERTILE VARIABLE! 99

Slide 100

WATS 10 Training for Safety John Bent Lost Hydraulics - Sioux City United 232 July 89 > IMBIBE GOOD
AIRMANSHIP (the consistent use of good judgment & well-developed skills (Kern 96) STUDY EVENTS
100 > Power loss & ditching - US Airways Flt 1549 Jan 09 > Volcanic ash All Engines out - BA 9 - June 82
Cathay A330 both engines fluctuated - thrust stuck @ 70% N1 asymmetric - landed at 230kts - April
10 (subject to inquiry underway) > Cathay A330 both engines fluctuated - thrust stuck @ 70% N1
asymmetric - landed at 230kts - April 10 (subject to inquiry underway) > SOMETIMES PROCEDURES &
CHECKLISTS MAY NOT BE ENOUGH:

Slide 101

WATS 10 Training for Safety John Bent Enhanced Instructor training and oversight More LOFT (LINE
ORIENTED FLIGHT TRAINING) training More task-focussed, competency-based, quality embedded
programmes (as in MPL) Programmes designed for continuous improvement Driven by performance &
SMS feedback Training devices designed to training task and learning phase (as in MPL, APT) Embedded
human factors / threat & error management (TEM) (as in MPL) Mandated uniforms in simulator training
raising crew fidelity TRAINING ENHANCEMENT SUMMARY : 101

Slide 102

WATS 10 Training for Safety John Bent UNIFORMS IN SIMULATION (an easy option; whats the problem
here?) UNIFORMS IN SIMULATION (an easy option; whats the problem here?) Zero cost - all crews have
uniforms! Matching crew fidelity with simulator fidelity Creating a more professional atmosphere in
simulator training 102 SO WHY THIS? Lets just fix it!

Slide 103

WATS 10 Training for Safety John

Bent 103

Slide 104

WATS 10 Training for Safety John Bent ineffective training Long term the industry is highly exposed to
ineffective training Airlines need to offer comfortable and safe air travel as a long term profitable
business plan Resource flow must be maintained to the vital organs of a positive safety culture
Effective crew training is an investment which protects safety margins for years to come Training must
deliver efficient best practice, with relevance and continuous improvement 104 THE BOTTOM LINE

Slide 105

We have some great opportunities to look at best practices .. ONE LIGHT SWITCH FOUND! best
practices We need to share so that were all at the highest level possible One of the quickest ways
to spread excellence is to cross-pollinate The fundamentals of quality training are clear and direct
quality training We need to ensure were meeting and exceeding the standards Good, effective
training has to be at the top of our list We must know more about pilot performance over a pilots
entire career WATS 10 Training for Safety John Bent 105 From the 2009 FAA safety call to action
speech (Randy Babbitt): That day is today That day is today

Slide 106

Are airline COOs AWARE WATS 10 Training for Safety John Bent 106 & Will budgetary maximums
be regulatory training minimums next financial year? Two Parting questions CFOs AWARE of
Training as the critical safety priority to address today?

Slide 107

WATS 10 Training for Safety John Bent TRAINING & SAFETY TAKE-AWAYS OPTIMISE BEST PRACTICE minimise additional cost MEASURE to continuously improve EMBED MEASUREMENT into the training
process, and instructors task EMBED TEM into all training thinking If QUANTITY shrinks, QUALITY must
grow 107 SAFETY GROWS FROM EFFECTIVE TRAINING

Slide 108

WATS 10 Training for Safety John Bent 108

Thank You!

Slide 109

WATS 10 Training for Safety John Bent 109 Best practice safety-driven training Best practice safetydriven training founded on MPL in one location Best practice safety-driven training Best practice safetydriven training founded on MPL in one location Aimed at higher training standards Aimed at higher
training standards + expanded safety margins Aimed at higher training standards Aimed at higher
training standards + expanded safety margins ENTER THE PROPOSED Pegasus Flight Academy ENTER
THE PROPOSED Pegasus Flight Academy

Slide 110

WATS 10 Training for Safety John

Bent 110