predicting the fatal flaws

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: HeliOffshore-Logo-Tagline-PMS
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 Ltdlmqlogo
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
1410 Helen Muir Award Presentation Ashgatelogo 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.

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  Ashgatelogo 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 Logo_Black_HR 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  elsevier 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 Print 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?