Predicting the fatal flaws: can we do things differently in aviation safety?

A Conference presented by

Royal Aeronautical Society Human Factors Group,
NATS – National Air Traffic Services
Chartered Institute of Ergonomics and Human Factors

and hosted by

Virgin Atlantic Airways
Virgin Atlantic Airways, The Base, Manor Royal, Crawley, Gatwick

Thursday and Friday, 26/27 November, 2015

Programme Summary and Presentation Materials

N.B. All documents and files published here are copyright (c) by their author(s) and reproduced with consent solely for aviation safety research use. Links to information are published when provided by authors.

Time	Topic	Speaker	Notes
Day 1
0830	Registration	Tea and coffee sponsored by HeliOffshore:
	Introduction
0915	Welcome and housekeeping	Nicole Svatek Chair, RAeS Human Factors Group
	Day 1 Keynote: Is there a Problem?
0930	New forms of Regulation for the Human Factors of Aviation Safety	Prof. Chris Johnson, Head of Computing Science, Glasgow University	Existing forms of regulation have provided strong support for human factors in aviation safety. However, the public-private relationships that have grown up over previous decades are arguably insufficient to protect us in future.
	Accidents and What they Tell Us
1015	Issues Arising from the Helios Disaster	Lieutenant Colonel Panagiotis Stathopoulos, Hellenic Air Force	Account and factors arising from the Helios accident including hypoxia, human factors in aircraft design and Alerting, automation and other issues from a military perspective – see Abstract.
1100	Tea and coffee break sponsored by LMQ Ltd
1120	Safety nets for Airborne Conflict	Stanislaw Drozdowski, Senior ACAS Expert, Eurocontrol	The presentation introduces the existing safety nets against midair collisions and their interactions with human operators (pilots, controllers). These interactions will be further illustrated by a description of a recent incident. As the world of safety nets is evolving, the speaker describes forthcoming changes to them and how these changes may introduce additional challenges.
	What Has to Change?
1150	Developing a Just Culture to achieve an effective safety-focused Management System	Nick Clutton, Former B767, 757 and 737 pilot with BA, Astraeus and Ethiopian Airlines, multi-crew training, CRM developer and author	The speaker describes a development of the Just Culture that adopts a holistic systems approach with supporting toolkits to enable a Management System (MS or SMS) to function as intended. (See the HCAP discussion paper “Culture and Safety Management“.)
1220	Question Time	Morning Panelists, Moderator: Maj. Mike Baker MAA MOD
1300	Conference Lunch sponsored by BooHoo.com:
1410	Helen Muir Award Presentation		Sponsored by Ashgate Publishing
1420	CIEHF: Designing for People	Jon Berman, Director, Greenstreet Berman Ltd and Past President of the Chartered Institute of Ergonomics and Human Factors (CIEHF)	‘The Chartered Institute of Ergonomics & Human Factors has been promoting ‘designing for people’ to good effect since 1949. By taking into account the capabilities and situation of the person at the centre of an interaction with other people, technologies, equipment or any kind of live environment, ergonomists (also termed human factors specialists) aim to contribute to the design of safe, productive spaces, equipment and procedures’.
1430	The Art of Measuring Nothing	Eric Arne Lofquist, Associate Professor, Department of Leadership and Organizational Behaviour, BI Norwegian Business School – Campus Bergen. www.twitter.com/BI_BizSchool	Prof. Lofquist discusses a safety model that shifts the focus from traditional safety monitoring mechanisms (risk analysis and trial and error learning) to the natural interactivity within socio-technical systems found in high reliability organizations. The presentation includes empirical results of an alternate methodology for measuring perceived changes in safety at the operational level.
1505	Tea and coffee break		Sponsored by Ashgate Publishing
1525	Through a Glass Darkly: Safety at the pilot-controller interface	Dr. Anne Isaac, Head of Human Performance in External Safety, NATS	Concentrating on past occurrences gives us a one dimensional view of system safety, and typically one which is negative. Developing ways of assessing system safety on a day to day basis and observing good practice has proven to give a more accurate picture of ‘work as done’. This practical approach has increased the understanding of both the ATC system, the flight-deck and the risk prone interface between the two professions.
1600	Question Time	Afternoon Panelists, Moderator: Mariann Hintz, Senior ATM Expert, Eurocontrol	Panelists and Safety II practitioner from Flybe
1645	Day 1 Close
1710	Conference Reception		Sponsored by NATS See Sponsors and Supporters page

Day 2
0830	Registration	Tea and coffee sponsored by Baines Simmons
0915	Welcome and housekeeping	Nicole Svatek, HFG Chair
0930	Continuity and Reality check	Capt. Mike Freeman, TRI/TRE, RAeS Human Factors Group	What did we learn from Day 1? What do we need to do now to anticipate and avoid the ‘Fatal Flaws’?
0945	Management or Safety Management	Jon Berman, Past President CIEHF; Director, Greenstreet Berman Ltd	What it is we can expect from SMS and whether an SMS can ever be an RMS (Risk Management System).The ‘Management System’ is actually the RMS – do we need to be clearer about what that means for behaviours throughout the organisation?
1015	“From Pyramids to Pepsi”: A critical look at the challenges our industry is likely to face in the coming decades	Capt. Harry Nelson, Executive Operational Advisor to Product Safety, Airbus	The talk looks at what is likely to change and what will probably not change so much in the aviation scene over the coming years. The paradoxes that this change dynamic produces will largely have a human perspective. How the human is integrated and equipped to manage the various and sometimes conflicting pressures will directly impact operating safety levels; how the industry as a whole faces this future will determine the eventual level of achievable safety.
1100	Tea and coffee break		Sponsored by Elsevier Publishing
1120	Conflict Zone overflight	Captain Giancarlo Buono, IATA Regional Director Safety and Flight Operations, Europe	Conflict Zone overflight and security issues’ effect on teamworking and safety – how do we identify emerging risks including those coming from commercial pressures?
1150	Question Time	Morning Panelists, Moderator: Capt. Tim Rolfe, Bristow Group
1230	Lunch
	Where Are We Going From Here?
1330	The Challenge of the Unpredictable	Dr. Jean Paries, Président-directeur général, Cabinet Dédale; president of the Resilience Engineering Association
1400	EASA Safety Risk Management	John Franklin, Head Safety Analysis and Research, EASA	EASA is finalising a new Safety Risk Management process for the governance and management of the European Aviation Safety Plan. This will lead to the establishment of safety risk portfolios for different aviation sectors. The presentation draws on example portfolios to show the active involvement of external stakeholders in the process through the European Strategic Safety Initiative (ECAST/ EHEST/ EGAST) and the European HF Group.
1430	Transforming the Flight Deck	Prof. Guy Boy, Director, Florida Institute of Technology Human-centered Design, Chair of IEA Technical Committee for Human Factors
1500	Tea and coffee break		Sponsored by CAA International – See Sponsors page.
1515	Is there a role for the human controller in future ATM?	Marc Baumgartner, IFATCA SESAR / EASA coordinator	Is our grasp of evolving teamwork and systemic communication, particularly ATC/FD, adequate to cope with emerging risks? How can SESAR help model the impact of ‘big data’ on other flight operational areas?
1545	Finding a Balance	Dr. Kathy Abbott, FAA Chief Scientific and Technical Advisor, Flight Deck Human Factors
1615	Question Time	Afternoon Panelists, Moderator: Simon Roberts, SMS Programme Manager, CAA
1640	Washup and Close	Nicole Svatek, HFG Chair, and Capt. Mike Freeman, TRI/TRE, RAeS Human Factors Group	Are SMS and operational risk assessment as currently understood and implemented still fit for purpose? Is there a consensus for change?