International Civil Aviation Organization (ICAO)
Regional Aviation Safety Group
(Asia & Pacific Regions)
Asia Pacific Regional Aviation Safety Team
FLIGHT CREW PROFICIENCY
developed by
DCA Malaysia, Malaysia Airlines and AAPA
Executive Summary
ICAO has identified loss of control in flight (LOC-I) as one of three high-risk accident
occurrence categories. The utilization of Flight Data Analysis (FDA) as part of the Safety
Management System (SMS) allows for a predictive approach to identification of
potential risks of events leading to LOC-I. This is achieved through trend analysis of the
data captured from safety reports and flight data monitoring. The outcome of this analysis
would necessarily be incorporated in the specific flight crew training program to enhance
crew proficiency in managing the related threat.
The purpose of this guidance material as the combined outputs of SEI LOC/2 and SEI
LOC/4 is to provide air operators guidance on the integration of SMS processes for
hazard identification and risk management with operational decision making in utilizing
safety trend information to address LOC-I events through performance based training,
and guidance for regulators in assessing air operators’ utilization of safety trend
information in the development and implementation of performance based flight crew
training.
Version 1 dated May 2017
Preamble
Background on Regional Aviation Safety Group – Asia & Pacific (RASG – APAC)
The Regional Aviation Safety Group Asia-Pacific (RASG-APAC) was established in 2011 by
the Council of ICAO. The RASG-APAC is tasked with improving aviation safety in the Asia
& Pacific regions by developing and implementing a work programme, in line with the ICAO
Global Aviation Safety Plan, aimed at identifying and implementing safety initiatives to address
known safety hazards and deficiencies in the region.
The Asia Pacific Regional Aviation Safety Team (APRAST), a sub-group of the RASG-APAC,
assists the RASG-APAC in its work by recommending safety interventions which will reduce
aviation safety risks.
The full commitment and active participation of APAC States/Administrations and the industry
partners is fundamental to the success of the RASG-APAC in reducing aviation safety risks
and accident rates in the Asia and Pacific regions.
Disclaimer
This report makes use of information, including air transport and safety related data and
statistics, which is furnished to the RASG/APRAST by third parties. All third party content
was obtained from sources believed to be reliable and was accurately reproduced in the report
at the time of printing.
However, RASG/APRAST specifically does not make any warrants or representations as to the
accuracy, completeness of timeliness of such information and accepts no liability or
responsibility arising from reliance upon or use of the same. The views expressed in this report
do not necessarily reflect individual or collective opinions or official positions of
RASG/APRAST Members. It is the responsibility of each RASG/APRAST member to
determine the applicability of the contents of this report. If there should be any conflict between
the contents of this report and ICAO Standards, then the ICAO Standards will take precedence
over that contained in this report.
Feedback/Enquiries
Should there be any feedback or queries with regard to this report, please address them to:
Jacob Kurien
Malaysia Airlines
Email: jacob.kurien@malaysiaairlines.com
Mobile: +6012 3162236
or
RASG/APRAST Secretariat
ICAO Asia and Pacific Office
Email: APAC@icao.int
FLIGHT CREW PROFICIENCY
INTRODUCTION
The purpose of this guidance material as the combined outputs of SEI LOC/2 and SEI LOC/4
is to provide air operators guidance on the integration of SMS processes for hazard
identification and risk management with operational decision making in utilizing safety trend
information to address LOC-I events through performance based training, and guidance for
regulators in assessing air operators’ utilization of safety trend information in the
development and implementation of performance based flight crew training.
BACKGROUND OF SAFETY ENHANCEMENT INITIATIVE (SEI)
Loss of control in flight is the leading cause of jet fatalities worldwide. Aside from their
frequency of occurrence, accidents resulting from loss of aircraft control seize the public’s
attention by yielding a large number of fatalities in a single event. International Civil Aviation
Organization (ICAO) has identified LOC-I as one of three high-risk accident occurrence
categories. LOC-I accidents represents only 3 percent of all accidents in 2015, but 33 percent
of fatal accidents, according ICAO statistics. In response to the rising threat to aviation safety,
Aviation Safety Programs are regulated for implementation.
IATA LOC-I accident investigation and analysis conducted between 2010 and 2014 concluded
that the trigger that very often initiates LOC-I accidents sequence is an external factor,
predominantly meteorological or potentially traffic related in the form of wake turbulence.
Human performance deficiencies, including improper, inadequate or absent training,
automation and flight mode confusion, distraction, the ‘startle’ factor and loss of situational
awareness frequently compounded the initial upset and precluded an effective recovery until it
was too late.
Causal factors that contribute to loss of control are segregated into three categories:
a) Pilot or human induced;
b) Environmentally induced; and
c) Systems induced.
(refer to Appendix 2 for expanded list of causal and contributory factors to LOC-I event)
The analysis found that pilots often missed or ignored readily available indications that could
have alerted them to an impending upset or LOC-I event. These included icing conditions,
flight control system malfunctions and turbulence. Ultimately, the failure to recognize these
precursors to loss of control led to inadvertent or in some cases even deliberate pilot-induced
upsets and LOC-I accidents.
Hence, there is a clear need to enhance flight crew proficiency in preventing LOC-I events by
incorporating into their training program any identifiable gaps or deficiencies, based on trend
monitoring of aggregate information available from FDA and other SMS parameters.
Since the establishment of Flight Data Analysis Program (FDAP) as part of SMS from
1 January 2005, various initiatives were undertaken to leverage on the potential capabilities of
this program. This includes creating a safety database generated from FDA reports and
performing appropriate trend analysis to identify any potential or emerging risks to the safety
of flight operations in general. Apart from FDAP, other safety reports from hazard reporting
program, air, ground incident reports, audits and reports from other safety related function can
be used for the same purpose.
A survey was conducted among Asia Pacific air operators and regulators in 2014 to gauge the
extent of implementation and effectiveness of the flight data analysis among the individual air
operators. Survey response from 38 participants were collated and presented during the
APRAST/4 meeting held in Manila in 2014. The result from the survey draws attention to the
need to further expand the scope of implementation among the air operators and regulators
within this region.
This guidance material is aimed at utilizing trend information from SMS, such as FDAP, Safety
Reports, Audits, and other non-punitive safety reporting program in enhancing the flight crew
training curriculum (recurrent and type-rating training), aimed at mitigating safety risks,
incidents or accidents related to LOC-I. This is also aligned with the current shift in regulatory
oversight across the globe, from a prescriptive to performance based approach. Customized
flight crew training and qualification program based on the air operator’s individual
performance, with appropriate level of regulatory oversight, are essential in mitigating LOC-I
related risks.
APPLICABILITY TO STATES / INDUSTRY
This guidance material proposes guidance for regulators and air operators to ensure that their
policies, procedures and training reflect the methods and best practices described in this
guidance material. The guidance material is outlined as follows:
Appendix 1: Survey on policies and practices among the Asia Pacific air operators in
relation to establishment of “performance based” training curriculum
utilizing lessons learned and Flight Data Monitoring (FDM) analysis.
Appendix 2: The causal and contributory factors to loss of control events.
Attachment A: Model Regulations in relation to mitigating LOC-I events utilizing aggregate
and safety trend information.
Attachment B: Guidance for regulatory inspectors to utilize in assessing air operator
utilization of their own aggregate and safety trend information in the
development and utilization of performance based flight crew training.
Attachment C: Guidance for air operators in utilizing safety trend information to address
LOC-I events through performance based training.
Consideration of the guidance proposed in this guidance material will be a positive contribution
to flight safety.
SEI CONTENTS / PHASES
Broadly, the phases for this SEI project are as follows:
Output 1
Conduct a survey of Asia Pacific air operators on the policies and practices to establish and
maintain “performance based” training curriculum utilizing lessons learned and FDM analysis.
Output 2
Based on results of Output 1, draft model regulations, guidance and checklists focusing on
mitigating LOC-I events that utilize aggregate and safety trend information.
Output 3
Develop guidance materials for regulatory inspectors to utilize in assessing air operator
utilization of their own aggregate and safety trend information in the development and
utilization of performance-based flight crew training.
Output 4
Develop and provide guidance material to the region’s air operators on performance based
training in order to encourage movement toward recurrent training curricula that utilize each
carriers aggregate and safety trend information from FDM, non-punitive reporting programs,
or other sources within a company, as well as regionally produced safety information.
ACTION / COMMENTS BY RASG
The meeting is invited to approve the proposed guidance material as the combined outputs of
both SEI LOC/2 and SEI LOC/4 on Flight Crew Proficiency.
APPENDIX 1
Survey on policies and practices among the Asia Pacific air operators in relation to
establishment of “performance based” training curriculum utilizing lessons learned and
FDM analysis.
Based on the survey conducted on 38 air operators in the Asia Pacific region, it was concluded
that:
1. 100% of the respondents have an established flight data monitoring and analysis
program in the form of Flight Operations Quality Assurance (FOQA), Air Safety
Reports (ASR), or less frequently collected data such as Line Operations Safety Audit
(LOSA), and other internal or external audits.
2. 64% of the respondents perform data analysis specific to LOC-I events.
3. From the 64% of respondents, approximately 70% incorporated the outcome from their
data analysis into their flight crew training programs.
4. 79% have the training program documented in Part D of their Operations Manual
(Training Manual).
77% of the respondents indicated that their respective regulators have not promulgated
regulations requiring emphasis on LOC-I performance based training, while 85% noted that no
guidance materials were issued by the State with regards to the same.
Conclusion
From the survey results, it is evident that 36% of respondents do not perform data analysis
specific to LOC-I events, despite having established respective Flight Data Monitoring
program. It is also found that 7 out of 38 air operators that were surveyed indicated that they
do not have a performance based training program incorporated in Part D of their Operations
Manual. A large number of operators surveyed indicated that their regulator’s participation in
promoting this safety enhancement initiative had been relatively low.
This number is estimated to rise further in the coming years with air traffic projected to double
in the next 15 years. (ICAO Global Aviation Safety Plan 2014-2016).
Hence, there is a need to address the current and emerging safety risks proactively to ensure
that this significant capacity expansion is carefully managed and supported through strategic
regulatory and infrastructure development.
Whilst the major focus of ICAO and State Regulators remain on compliance monitoring, a
different approach in delivering continuous improvement in aviation safety is needed. This can
be achieved through a performance based approach to training and qualification, be it in the
oversight function of regulators, as well as compliance responsibility of operators, with the use
of safety trend monitoring and analysis devices such as Flight Data Analysis (FDA), Air Safety
Report, LOSA program, internal and external safety audit findings and other related means of
establishing a trend data.
The proposed LOC-I flight crew training implementation plan is illustrated below:
LOC - I
APPENDIX 2
The causal and contributory factors to loss of control events with reference to individaul
categories are illustrated in the following. The list is not in the order of risk priority.
1. Pilot or human-induced:
a. Improper training
b. Poor energy management
c. Changing pilot skill base
d. Spatial disorientation
e. Poor pilot awareness
f. Distraction
g. Automation confusion or mode confusion
h. Automation and human factors
i. Improper procedure
j. System integration issues (complexity, interdependencies and lack of standard
interfaces)
k. Pilot actions leading to destabilized approaches
l. Faulty loading or shifting of cargo
m. Incompetence
2. Environmentally-induced
a. Weather (turbulence, icing, adverse winds, wind shear)
b. Wake vortices
c. Hail leading to loss of control (engine performance)
d. Visibility degradation
e. Foreign object damage (hail, bird strike, volcanic ash)
3. Systems-induced
a. Poor design
b. Poor energy management (systems-induced)
c. Propulsion related (asymmetric thrust, energy management)
d. Erroneous sensor data
e. Air traffic operations leading to destabilized approaches
f. Loss of control power, authority, or effectiveness
g. Aircraft system failures (non-propulsion and propulsion)
h. Faults or failures or damage of or to any or all of the aircraft control effectors
i. Pilot-induced oscillation (PIO)
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Model Regulations in relation to mitigating LOC-I events utilizing
aggregate and safety trend information
1. REFERENCE
a) ICAO Annex 19, Safety Management, 1
st
Edition, June 2013
b) ICAO Doc 9859, Safety Management Manual, Third Edition, 2013
c) IOSA Standards Manual, Edition 10 Revision 1, September 2016
d) IATA Loss of Control In-Flight Accident Analysis Report, 2010-2014, 1
st
Edition
2. DEFINITION
Acceptable Level of Safety Performance (ALoSP). The minimum level of safety
performance of civil aviation in a State, as defined in its State safety program, or of a
service provider, as defined in its safety management system, expressed in terms of
safety performance targets and safety performance indicators.
Flight Data Analysis Program (FDAP). A process of analyzing recorded flight data in
order to improve safety of flight operations. (ICAO annex 6 – Operations of aircraft)
Loss of Control-Inflight (LOC-I). The definition of LOC-I as stated in the IATA Safety
Report is “Loss of Aircraft Control While In-Flight”. This includes events such as
aerodynamic stalls and upset following failures of aircraft systems.
Loss of control in-flight is an extreme manifestation of a deviation from intended flight
path.
LOC-I accidents often result from failure to prevent or recover from stall and upset.
(Refer Appendix 2 for causal factors to LOC-I)
Operator means a person, organization or enterprise engaged in or offering to engage in
an aircraft operation.
Risk Mitigation. The process of incorporating defenses or preventive controls to lower
the severity and/or likelihood or a hazard’s projected consequence.
Safety Management System (SMS). A systematic approach to managing safety,
including necessary organizational structures, accountabilities, policies, and procedures.
Safety Performance. A State’s or service provider’s safety achievement as defined by
its safety performance target and safety performance indicators.
Safety Performance Indicator (SPI). A data-based safety parameter used for
monitoring and assessing safety performance.
Safety Performance Target (SPT). Define the required level of safety performance of a
system.
Safety Risk. The predicted probability and severity of the consequence or outcome of a
hazard.
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The following Model Regulations are intended to provide reference to the
implementation of performance based oversight in addressing LOC-I events using
FDAP and other safety trend data information.
(i) Operators should ensure that their training and qualification processes utilize trend
information from Flight Data Analysis (FDA), Safety Reports, LOSA, internal audits,
and other safety performance monitoring tools prescribed under SMS, to mitigate the
risk of a LOC-I incident.
(ii) The Operator should have processes for setting performance measurement as a
means to monitor the operational safety performance of the organization and to
validate the effectiveness of safety risk controls.
(iii) The operator should establish a program to identify and monitor events leading to
LOC-I with the aim of developing specific Safety Performance Indicator (SPI) and its
corresponding Safety Performance Target (SPT). These elements should be used in
the development of a performance based training program to address LOC-I.
(iv) The operator should establish a safety performance working group to provide an on-
going monitoring and periodic review of the LOC-I Safety Performance Indicator (SPI)
and Safety Performance Target (SPT).
(v) The selection and effectiveness of the LOC-I Safety Performance Indicator (SPI) and
its corresponding Safety Performance Target (SPT) remain the responsibility of the
operator, with concurrence from the regulatory authority.
(vi) The effectiveness of the flight crew proficiency training using data derived from FDAP
and other safety performance monitoring tools related to SMS should be periodically
reviewed by the operator, and subjected to periodic regulatory oversight.
ATTACHMENT B
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Guidance for regulatory inspectors to utilize in assessing
air operator utilization of their own aggregate and safety trend information
in the development and utilization of performance based flight crew training
CONTENTS Page
1. Introduction 1
2. Background 1
3. Scope 1
4. Reference 2
5. Definition 2
6. Applicable Regulation (Model Regulations) 3
7. Implementation 3
STEP 1 – Development of policy and regulatory framework relating 3
to enforcement of performance based oversight.
STEP 2 - Provide appropriate training to the inspectors in relation to 4
requirements for performance based training in addressing LOC-I
and conduct of oversight function.
STEP 3 - Encourage consistent engagement and collaboration with 4
operators to develop and enforce an effective performance
based training.
STEP 4 – Monitor and assist in the development of SPI and setting 4
of SPT by air operator.
STEP 5 - Develop audit program to specifically monitor the 5
implementation of performance based training in addressing LOC-I.
STEP 6 - Monitor and assess the effectiveness of the data gathering, 5
analysis and overall efficiency of the performance based training program.
STEP 7 - Verify that the safety performance achieved by the 6
operator meets the agreed level of safety performance (ALoSP) as
intended, with regard to flight crew proficiency in managing LOC-I.
STEP 8 – Ensure periodic review of ALoSP is conducted by the Operators. 6
Appendix A – Causal and Contributory factors to LOC-I 7
Appendix B - Data Integration and Safety Performance Enhancement 8
Process flow chart
Appendix C - Checklist for Implementation of Performance Based 9
Methodology for Flight Crew Training Enhancement
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1. INTRODUCTION
This document was written to provide background information and guidance material for
Regulatory Inspector that intends to develop and establish an assessment program to
enable oversight on Air Operators in relation to managing their own aggregate and safety
trend information in the context of implementing a performance-based flight crew training,
aimed at mitigating LOC-I events. This assessment program must be applied consistently
across the Air Operators.
2. BACKGROUND
Performance based oversight.
Performance based oversight has gained significant momentum with the worldwide
implementation of State Safety Program and Safety Management System. This in turn
encouraged Regulator and Air Operators alike to move towards complementing the
existing prescriptive approach to safety with performance based oversight using data as
a basis of achieving safety assurance.
In a conventional compliance-based regulatory environment, approach to safety
management is relatively rigid and prescriptive, where safety regulations are used as
administrative control. Within this context, the regulatory framework is supported by
inspections and audits to assure regulatory compliance. Compliance based safety
oversight was the predominant characteristics of safety regulation from the early days of
aviation and it is still valid, particularly for small organization, or when the regulatory
environment is not fully matured. However, in large organizations or regulatory
environment that has reached the level of maturity, further safety improvements cannot
be achieved by following a purely compliance-based approach. Hence, a shift from a
reactive compliance based approach to a proactive and performance based oversight is
necessary to ensure an adequate level of safety across the highly regulated industry.
In a performance based environment, certain performance-based elements are
introduced within a prescriptive framework. In addition to being fully compliant with the
applicable regulations and safety requirements, this new proactive model of performance
based oversight ensures that specific lead indicators or precursor to incidents or
accidents are continuously monitored, measured and managed to an acceptable level of
safety performance. Consequently, the Air Operator would benefit not only from the
having a good safety record, and but also have the opportunity to possibly earn “credit
points” from their own Authority. This enables “compliance” aspect of a regulation to be
more flexible, risk–based and dynamic, while providing greater visibility in the
achievement of the required safety performance.
3. SCOPE
The scope of this document is to provide guiding principal to Regulators in providing
effective oversight on Air Operators of aeroplanes of a maximum certified take-off mass
in excess of 27,000 kg, in the development, implementation and management of an
effective performance based training utilizing safety trend information to address LOC-I
events.
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4. REFERENCE
a) ICAO Annex 19, Safety Management, 1
st
Edition, June 2013
b) ICAO Doc 9859, Safety Management Manual, Third Edition, 2013
c) IOSA Standards Manual, Edition 10 Revision 1, September 2016
d) IATA Loss of Control In-Flight Accident Analysis Report, 2010-2014, 1
st
Edition
5. DEFINITION
Acceptable Level of Safety Performance (ALoSP). The minimum level of safety
performance of civil aviation in a State, as defined in its State safety program, or of a
service provider, as defined in its safety management system, expressed in terms of
safety performance targets and safety performance indicators.
Flight Data Analysis Program (FDAP). A process of analyzing recorded flight data in
order to improve safety of flight operations. (ICAO annex 6 – Operations of aircraft)
Loss of Control-Inflight (LOC-I). The definition of LOC-I as stated in the IATA Safety
Report is “Loss of Aircraft Control While In-Flight”. This includes events such as
aerodynamic stalls and upset following failures of aircraft systems.
Loss of control in-flight is an extreme manifestation of a deviation from intended flight
path.
LOC-I accidents often result from failure to prevent or recover from stall and upset.
(Refer Appendix A for causal factors to LOC-I)
Operator means a person, organization or enterprise engaged in or offering to engage
in an aircraft operation.
Risk Mitigation. The process of incorporating defenses or preventive controls to lower
the severity and/or likelihood or a hazard’s projected consequence.
Safety Management System (SMS). A systematic approach to managing safety,
including necessary organizational structures, accountabilities, policies, and procedures.
Safety Performance. A State’s or service provider’s safety achievement as defined by
its safety performance target and safety performance indicators.
Safety Performance Indicator (SPI). A data-based safety parameter used for
monitoring and assessing safety performance.
Safety Performance Target (SPT). Define the required level of safety performance of a
system.
Safety Risk. The predicted probability and severity of the consequence or outcome of a
hazard.
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6. APPLICABLE REGULATIONS (Model Regulations)
These regulations shall apply to all operators of aeroplanes of a maximum certified take-
off mass in excess of 27,000kg.
(i) Operators should ensure that their training and qualification processes utilize trend
information from Flight Data Analysis (FDA), Safety Reports, LOSA, internal audits,
and other safety performance monitoring tools prescribed under SMS, to mitigate the
risk of a LOC-I incident.
(ii) The Operator should have processes for setting performance measurement as a
means to monitor the operational safety performance of the organization and to
validate the effectiveness of safety risk controls.
(iii) The operator should establish a program to identify and monitor events leading to
LOC-I with the aim of developing specific Safety Performance Indicator (SPI) and its
corresponding Safety Performance Target (SPT). These elements should be used in
the development of a performance based training program to address LOC-I.
(iv) The operator should establish a safety performance working group to provide an on-
going monitoring and periodic review of the LOC-I Safety Performance Indicator (SPI)
and Safety Performance Target (SPT).
(v) The selection and effectiveness of the LOC-I Safety Performance Indicator (SPI) and
its corresponding Safety Performance Target (SPT) remain the responsibility of the
operator, with concurrence from the regulatory authority.
(vi) The effectiveness of the flight crew proficiency training using data derived from FDAP
and other safety performance monitoring tools related to SMS should be periodically
reviewed by the operator, and subjected to periodic regulatory oversight.
7. IMPLEMENTATION
7.1 STEP 1 – Development of policy and regulatory framework relating to
enforcement of performance based oversight.
The Civil Aviation Authority is responsible for safety regulation and oversight of the civil
aviation industry within the respective state. In achieving this, the state need to establish
a framework which is, wherever practicable, consistent and compliant with ICAO
Annexes. Model Regulation outlined in section 6 of this document prescribed the
requirement consistent with the policy and propose set forth to further enhance safety
management throughout the aviation system.
Define and establish the safety management responsibilities and accountabilities of the
respective regulatory organization, including a State aviation safety coordination platform
and the applicable documentation. This will ensure that the safety policy, safety
indicators, enforcement policy, safety data collection, analysis and exchange, safety
performance monitoring and oversight are carried out in an integrated and coordinated
manner.
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7.2 STEP 2 - Provide appropriate training to the inspectors in relation to
requirements for performance based training in addressing LOC-I and conduct of
oversight function.
One of the major challenges for regulators involve adapting to the shift from prescriptive
to performance based regulatory oversight. This would likely require new technical and
non-technical knowledge and skill set of the inspectors in order to effectively analyze and
determine the acceptability of the operator’s performance, based on the set targets.
Training should include elements of performance based training program, familiarization
with available FDA reports, identification of Safety Performance Indicators (SPI) which
are essentially precursors to LOC-I events, and the related Safety Performance Targets
(SPT) that are appropriate for the individual operators.
7.3 STEP 3 - Encourage consistent engagement and collaboration with
operators to develop and enforce an effective performance based training.
In this respect, the responsibility for overall aviation safety is shared between the
regulator and the operator to a certain degree. The regulator shall endeavor to reach an
agreement with the operators on SMS’s short, medium and long-term objectives on safety
performance. This includes evaluating and endorsing the outcome of the performance
based training employed by the individual operator, while providing the guidance
necessary to achieve the required target.
The performance based elements within an SSP/SMS framework include the process for
safety performance monitoring and measurement at the air operator and State level. This
element allows the organization to selects its own safety monitoring indicators and the
setting of relevant alerts and targets that are pertinent to its own context, performance,
history and expectations. There are no fixed (mandatory) prescribed safety indicators or
alerts levels or prescribed values under this SSP/SMS expectation.
While the goal is to ensure that such assessment is consistently applied across all air
operators, there are concerns regarding start-up operators which may not have any
historical data, expertise or experience for the initial setup, and effective participation in
the performance based training and flight crew proficiency. In such cases, the regulator
may provide the necessary framework and guidelines, including list of typical safety
indicators as well as industry or expected targets which commensurate with the type, size
and scope of operation, or any other parameters suitable for the purpose of capturing
safety lead indicators related LOC-I events.
7.4 STEP 4 – Monitor and assist in the development of SPI and setting of
SPT by air operator.
Performance based safety management is dependent on having safety indicators that
are monitored using basic quantitative data trending tools that can generate graphs and
charts that incorporate alerts/targets. The safety indicators consist of high (accidents and
serious incidents) and low consequence events as hazard reports, audits findings, FDA,
safety observations and others. Low consequence events are sometimes termed
‘proactive/predictive’ indicators that are used to monitor and assess safety performance
in relation to the high consequence (reactive) events. In this respect, the Safety
Performance Indicators (SPI) of LOC-I can be developed based on the contributory
factors to the LOC-I occurrence and their related safety risks.
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SPTs which define long term safety performance objectives, are expressed in numerical
terms (absolute or relative value) and must be concrete, measurable, acceptable,
reliable, relevant and contain timeline (milestone) for completion. When setting the
targets, consideration should be given into factors such as applicable level of safety risk,
the cost and benefits attached to the expected safety improvement, and achievability of
the set target, with reference to recent historical performance of that particular safety
indicator, industry standards, regulatory requirement and expert opinion.
A corresponding alert level is identified for each SPI, quantifying the acceptable and
unacceptable performance threshold during a specific monitoring period. The use of
objective data-based criteria for setting alert levels is essential to facilitate consistent
trending or benchmark analysis.
In general, the use of population standard deviation (STDEVP) provides a basic objective
method for setting alert criteria, the method derives the standard deviation (SD) value
based on the preceding historical data points of a given safety indicator. This SD value
plus the average (mean) value of the historical data set forms the basic alert value for the
next monitoring period. The SD principal (a basic MS Excel function) sets the alert level
criteria based on the actual historical performance of the given indicator, including its
volatility (data point fluctuations). Guidance on SPI, SPT and alert level setting using SD
criteria is provided in ICAO Doc 9859 Safety Management Manual.
Sample of Safety Performance Indicator and Target:
7.5 STEP 5 - Develop audit program to specifically monitor the
implementation of performance based training in addressing LOC-I.
The audit program may be tailored to address individual operator’s specific risks and
priorities. The frequency of audits on performance based training with respect to LOC-I
may vary between air operators depending on the level of safety performance exhibited
by individual air operators.
7.6 STEP 6 - Monitor and assess the effectiveness of the data gathering,
analysis and overall efficiency of the performance based training program.
This is the monitoring and measurement of safety performance and related processes
through appropriate safety performance measures that continuously track system safety
performance as necessary to determine whether an operator's system is truly operating
in accordance with design expectations.
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Targeting regulatory oversight on areas of greater concern or need in training, based on
the data and performance report obtained. Focus must be on ensuring continuous
improvement. A yearly review is recommended, however this may be adjusted based on
the level of performance achieved by the Air Operators and the maturity of the program
within the system.
7.7 STEP 7 - Verify that the safety performance achieved by the operator
meets the agreed level of safety performance (ALoSP) as intended, with regard to
flight crew proficiency in managing LOC-I.
An oversight on the program should be applied consistently across all air operators.
Unlike auditing of prescriptive requirement which often ends with a pass/fail decision, the
performance based process require the assessor to be aware of the context of the
process/element within its overall regulatory framework as within the complexity of the
audited organization. In this respect, it is crucial that an agreement is reached between
the regulator and operator on the selected SPIs and SPTs to ensure effective
implementation. Although this may vary considerably between different operators
depending on the type and scope of operations, the inspectors however, should ensure
that the outcome meets the acceptable level of safety performance (ALoSP) as
established by the operator and agreed by the regulator. The outcome of the safety
performance achieved by the operator in managing each of the SPI essentially reveals
the efficacy of the training program in improving flight crew proficiency in LOC-I.
7.8 STEP 8 – Ensure periodic review of ALoSP is conducted by the
Operators.
To ensure that the ALoSP safety indicators remain effective and appropriate over time,
they need to be reviewed periodically to determine if any modifications or additions to the
existing indicators, target or alerts are needed.
Refer Appendix B for the Data Integration and Safety Performance Enhancement
Process flow chart.
Refer Appendix C for the Checklist for Implementation of Performance Based
Methodology for Flight Crew Training Enhancement.
ATTACHMENT B
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Appendix A
The causal and contributory factors to loss of control events with reference to individual
categories are illustrated in the following. The list is not in the order of risk priority.
1. Pilot or human-induced
a. Improper training
b. Poor energy management
c. Changing pilot skill base
d. Spatial disorientation
e. Poor pilot awareness
f. Distraction
g. Automation confusion or mode confusion
h. Automation and human factors
i. Improper procedure
j. System integration issues (complexity, interdependencies and lack of standard
interfaces)
k. Pilot actions leading to destabilized approaches
l. Faulty loading or shifting of cargo
m. Incompetence
2. Environmentally-induced
a. Weather (turbulence, icing, adverse winds, wind shear)
b. Wake vortices
c. Hail leading to loss of control (engine performance)
d. Visibility degradation
e. Foreign object damage (hail, bird strike, volcanic ash)
3. Systems-induced
a. Poor design
b. Poor energy management (systems-induced)
c. Propulsion related (asymmetric thrust, energy management)
d. Erroneous sensor data
e. Air traffic operations leading to destabilized approaches
f. Loss of control power, authority, or effectiveness
g. Aircraft system failures (non-propulsion and propulsion)
h. Faults or failures or damage of or to any or all of the aircraft control effectors
i. Pilot-induced oscillation (PIO)
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Appendix B
Data Integration and Safety Performance Enhancement Process - SMS Working Group
(headed by Flight Safety Coordinator)
ATTACHMENT B
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Appendix C
Checklist for Implementation of Performance Based Methodology for Flight Crew
Training Enhancement
Item
Question
Response
Reference
Remarks
1.1
Are there regulations in place with regard
to establishment of performance based
training relating to LOC-I events for the
State?
1.2
Are there specific regulations which provides
a standardized operational procedures,
equipment, and infrastructures (including
safety management and training system), in
conformance with the Standard and
Recommended Practices (SAPRs) contained
in the Annexes to the Convention on
International Civil Aviation?
1.3
Has the operator established the
following safety programs:
a. Safety Management System
b. Flight Data Analysis
c. Open Reporting
d. Audit program
e. Flight Crew Training program
f. Flight Monitoring program
g. Engineering & Maintenance
program
h. Communication and coordination
program
i. Operating manual revision and
updating processes and procedure
j. Cargo packing loading, weight and
balance program/processes
k. Equipment reliability program
l. Weather monitoring and reporting
system
m. Security program
1.4
Does the organization have an integrated
safety database?
Alternate means of compliance include
obtaining data from individual operational
units.
1.5
Are the participants in the safety working
group:
a. Suitably qualified
b. Knowledgeable
c. Skilled
d. Experienced
e. Have attended the relevant training
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Item
Question
Response
Reference
Remarks
1.6
Does the organization have a process
for data analysis?
1.7
Is the safety working group independent
of any management influence?
1.8
Does the policy provide authority to the
working group to ensure that all
recommendations by the working group
shall be implemented?
1.9
Does the State have an oversight
program with regard to performance
based methodology?
2.0
Does the operator have an internal audit
or inspections program with regard to
performance based methodology to
ensure that the organization continues
to meet the established requirement
and functions at the level of competency
and safety required by the State?
2.1
Does the operator have an escalation
process to Board of Safety and Security
to address immediate high risk and long
standing issues?
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Guidance for air operators in utilizing safety trend information
to address LOC-I events through performance based training
CONTENTS Page
1. Introduction 1
2. Background 1
3. Objective and Scope 1
4. Reference 1
5. Definition 2
6. Applicable Regulation (Model Regulations) 3
7. Implementation 4
STEP 1: Develop policy and procedure in regard to effective 4
implementation of performance based training.
STEP 2: Ensure that the Safety practitioner responsible for the 4
management of aggregate data for the purpose of providing
performance based training information is adequately trained
and qualified.
STEP 3: Gather data from all safety programs and audits with 4
regard to LOC-I.
STEP 4: Develop flight safety analysis program focusing on 5
identification of hazards related to LOC-I events.
STEP 5: Development of Safety Performance Indicator (SPI) 7
and setting of Safety Performance Target (SPT) by air operator.
STEP 6: Establish and maintain a flight data analysis 8
program (FDAP) as part of its Safety Management System,
in addition to maintaining an effective open reporting system.
STEP 7: Analyze collected data to identify events leading to an LOC-I. 9
STEP 8: Develop and design LOC-I enhancement training specifically 10
in preventing LOC-I events, identification of impending LOC-I and recovery.
STEP 9: Deliver the enhanced LOC-I training through both 10
simulator training and appropriate literature.
Step 10: Monitor the effectiveness of the training program through 10
quality assurance program.
Step 11: Review and modify the training program to meet overall 10
safety performance.
Appendix A – Causal and Contributory factors to LOC-I 11
Appendix B - Data Integration and Safety Performance Enhancement 12
Process flow chart
Appendix C - Checklist for Implementation of Performance Based 13
Methodology for Flight Crew Training Enhancement
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1. INTRODUCTION
This document was written to provide background information and guidance material for
Air Operators that intends to develop and establish performance based flight crew training
program using their own aggregate and safety trend information, specifically with regard
to mitigating LOC-I events.
2. BACKGROUND
Operators and Regulators alike are placing increased emphasis on performance-based
methods and performance-based compliance to regulation. Such mechanisms allow for
greater operational flexibility without degrading the safety performance of an operational
activity. This presumption is primarily dependent on the presence of specific
organizational and operational capabilities, the results of safety risk management
activities and the determination of acceptable standards of safety performance.
In order to establish an effective performance-based methodology and performance-
based compliance program to address risks, Operators must possess the requisite
knowledge, skills, experience, processes including: resources and technologies
necessary to implement and oversee the many systems and processes required to
support performance-based compliance.
a) The development of policy and procedure.
b) The staffing of positions with an appropriate number of qualified personnel.
c) Training to the operator's policy and procedure and to ensure personnel remain
competent and qualified.
d) Implementation or the demonstration of performance in accordance with policy
and procedure.
e) Data reporting, measurement and analysis for the purpose of monitoring the
effectiveness and efficiency of systems, processes, policies and/or procedures.
f) An adjustment component or subsystem to respond to any underperformance or
deviation and for the purpose of continuous improvement.
3. OBJECTIVE AND SCOPE
This document is intended to provide guiding principal to Air Operators of aeroplanes with
maximum certified take-off mass in excess of 27,000 kg, in the development,
implementation and management of an effective performance based training utilizing
safety trend information to address LOC-I events. The scope covers hazard identification
and risk management in relation to LOC-I events, determination of Safety Performance
Indicator and Targets, evaluation and monitoring of the training performance outcome.
4. REFERENCE
a) ICAO Annex 19, Safety Management, 1
st
Edition, June 2013
b) ICAO Doc 9859, Safety Management Manual, Third Edition, 2013
c) IOSA Standards Manual, Edition 10 Revision 1, September 2016
d) IATA Loss of Control In-Flight Accident Analysis Report, 2010-2014, 1
st
Edition
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5. DEFINITION
Acceptable Level of Safety Performance (ALoSP). The minimum level of safety
performance of civil aviation in a State, as defined in its State safety program, or of a
service provider, as defined in its safety management system, expressed in terms of
safety performance targets and safety performance indicators.
Flight Data Analysis Program (FDAP). A process of analyzing recorded flight data in
order to improve safety of flight operations. (ICAO annex 6 – Operations of aircraft)
Loss of Control-Inflight (LOC-I). The definition of LOC-I as stated in the IATA Safety
Report is “Loss of Aircraft Control While In-Flight”. This includes events such as
aerodynamic stalls and upset following failures of aircraft systems.
Loss of control in-flight is an extreme manifestation of a deviation from intended flight
path. LOC-I accidents often result from failure to prevent or recover from stall and
upset. (Refer Appendix A for causal factors to LOC-I)
Operator means a person, organization or enterprise engaged in or offering to engage
in an aircraft operation.
Risk Mitigation. The process of incorporating defenses or preventive controls to lower
the severity and/or likelihood or a hazard’s projected consequence.
Safety Management System (SMS). A systematic approach to managing safety,
including necessary organizational structures, accountabilities, policies, and procedures.
Safety Performance. A State’s or service provider’s safety achievement as defined by
its safety performance target and safety performance indicators.
Safety Performance Indicator (SPI). A data-based safety parameter used for
monitoring and assessing safety performance.
Safety Performance Target (SPT). Define the required level of safety performance of a
system.
Safety Risk. The predicted probability and severity of the consequence or outcome of a
hazard.
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6. APPLICABLE REGUALTION (Model Regulation)
These regulations shall apply to all operators of aeroplanes of a maximum certified take-
off mass in excess of 27,000kg.
(i) Operators should ensure that their training and qualification processes utilize trend
information from Flight Data Analysis (FDA), Safety Reports, LOSA, internal audits,
and other safety performance monitoring tools prescribed under SMS, to mitigate the
risk of a LOC-I incident.
(ii) The Operator should have processes for setting performance measurement as a
means to monitor the operational safety performance of the organization and to
validate the effectiveness of safety risk controls.
(iii) The operator should establish a program to identify and monitor events leading to
LOC-I with the aim of developing specific Safety Performance Indicator (SPI) and its
corresponding Safety Performance Target (SPT). These elements should be used in
the development of a performance based training program to address LOC-I.
(iv) The operator should establish a safety performance working group to provide an on-
going monitoring and periodic review of the LOC-I Safety Performance Indicator (SPI)
and Safety Performance Target (SPT).
(v) The selection and effectiveness of the LOC-I Safety Performance Indicator (SPI) and
its corresponding Safety Performance Target (SPT) remain the responsibility of the
operator, with concurrence from the regulatory authority.
(vi) The effectiveness of the flight crew proficiency training using data derived from FDAP
and other safety performance monitoring tools related to SMS should be periodically
reviewed by the operator, and subjected to periodic regulatory oversight.
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7. IMPLEMENTATION
7.1 STEP 1: Develop policy and procedure in regard to effective implementation of
performance based training.
Development of policy and procedures on the use of FDA and other non-punitive safety data
for the purpose of enhancing flight crew proficiency should be carried out appropriately.
7.2 STEP 2: Ensure that the Safety practitioner responsible for the management of
aggregate data for the purpose of providing performance based training information
is adequately trained and qualified.
The operator shall set the criteria for selection of the personnel required to lead and
manage the program.
The safety personnel should be trained with respect to analyzing data and providing
recommendation for the training department, based on the information gathered from
FDA and other aggregate safety reporting.
7.3 STEP 3: Gather data from all safety programs and audits with regard to LOC-I.
This can be achieved by having a systematic data acquisition and monitoring program
established through Flight Data Monitoring (FDM), Air Safety Reports, Audit reports and
other means of acquiring trend data, including the use of integrated safety database.
Integrated Safety Database
In addition to having a basic database to capture and archive safety information is
essential for the conduct of safety performance analysis on LOC-I events, greater benefit
can be realized by linking the existing safety database within the organization such as
database for air safety reports, FDA, audit reports, investigation findings, etc., in order to
provide integrated analysis of events or lead indicators to incidents or accidents.
This integration of all available sources of safety data provides the organization viable
information on the overall safety health of the operation, including prevention of LOC-I
events.
For example, failure to extend landing flaps during an approach may be captured by:
a. Air safety report submitted by the flight crew
b. FDA event captured
c. Engineering report
In this instance, the crew report provides the context, the FDA event provides the
quantitative description, and the engineering report provides in depth technical
information of the defect and the rectification performed.
Alternatively, safety information can be obtained from individual department and
resources in the absence of an integrated safety database.
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7.4 STEP 4: Develop flight safety analysis program focusing on
identification of hazards related to LOC-I events.
A primary function of flight safety analysis program is hazard identification supported by
data analysis capability, which is an element of Safety Risk Management component of
SMS.
Hazard identification and risk management is a prerequisite to establishing a
performance based training. Information gathered from safety database is evaluated to
identify hazards and its associated risks related to LOC-I events, particularly those
hazards that are deemed to be contributors factors to LOC-I incidents or accidents.
Among the LOC-I indicators that are available from Flight Data Analysis Program (FDAP)
include: high pitch rate, dual input, thrust asymmetry, excessive bank angle, early
configuration change, flight control malfunction, windshear, and others.
Following identification of hazard, the next step is to perform a risk assessment for each
of the hazards using a risk matrix in relation to the likelihood and severity of the
consequence of the risk related. Typically, a 5 x 5 risk matrix is used (as shown below),
although there are several variations that are available such as 4 x 4 and 3 x 3 matrix.
The matrix selected will depend upon the size and complexity of the organization and the
risks being assessed.
Diagram 1: Risk Matrix
Note: Information on the method of performing risk assessment is covered extensively in
ICAO Document 9859.
Determination of the level of risk provides the air operator guidance with regard to the
allocation of resources and the priority accorded to eliminate or mitigate the risks
identified.
A mitigation is an action taken to reduce the risk of exposure to a hazard. Based on
System Safety Science, once a hazard is identified the priority for addressing the hazard
should be:
a. Hazard elimination (intrinsic safety)
b. Hazard reduction
c. Hazard control
d. Damage reduction
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Hazard and risk management will require a pragmatic approach and will require
conducting realistic or credible and plausible appraisals of the hazards and associated
risks faced by the air operator’s operational activities (See figure below). A common
approach may be applied but the hazards, risks and mitigation may vary due to the
operating equipment, type of operation, and operating environment including supporting
infrastructure.
Diagram 2: Risk Assessment Process
For aircraft loss of control, hazard elimination is a desirable but difficult-to-reach goal,
given the nature of performance demands in atmospheric flight. Thus, research should
focus on hazard reduction, hazard control, and damage reduction.
Prevention of loss of control events are more important strategies when compared to
recovery based mitigations, however, development of recovery-based mitigations are
also required in order to ensure complete coverage when “breaking the chain” of events
in a loss of control scenario.
Onboard systems that eliminate, or protect the aircraft from entering a loss of control
scenario are most effective. Avoidance and detection of loss of control events should not
be limited to real-time, onboard systems, but should include data mining of incident
reports, accidents reports, and flight operations quality assurance data to identify trends
and conditions that lead to loss of control so that the precursors may be eliminated or
minimized. Continued diligence by operational, research, and regulatory organizations is
required in order to improve aviation safety record.
ATTACHMENT C
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Another technique commonly employed by air operators in risk assessment is the Bowtie
methodology. It is described as a risk evaluation method that can be used to analyze and
demonstrate causal relationships in high risk scenarios. Taking its name after the shape
of diagram which looks like a man’s bowtie, the methodology serves to provide a visual
summary of all plausible accident scenarios that could exist around a certain hazard,
while it identifies the control measures that are put in place to mitigate the consequence
of the hazard. (See diagram below)
Diagram 3: Bow Tie Sample
The bowtie application may be integrated with organization’s management system
to provide an overview of the activities that keeps the control working and the
persons responsible over the controls.
Ultimately, the risk management system established within the organization must
be capable of identifying and addressing the current operational and systemic
issues, as well as detecting any emerging risks that would affect safety of
operations.
7.5 STEP 5: Development of Safety Performance Indicator (SPI) and setting
of Safety Performance Target (SPT) by air operator.
Performance based safety management is dependent on having safety indicators that
are monitored using basic quantitative data trending tools that can generate graphs and
charts that incorporate alerts/targets. The safety indicators consist of high (accidents and
serious incidents) and low consequence events as hazard reports, audits findings, FDA,
safety observations and others. Low consequence events are sometimes termed
‘proactive/predictive’ indicators.
SPTs which define long term safety performance objectives, are expressed in numerical
terms (absolute or relative value) and must be concrete, measurable, acceptable,
reliable, relevant and contain timeline (milestone) for completion. When setting the
targets, consideration should be given into factors such as applicable level of safety risk,
the cost and benefits attached to the expected safety improvement, and achievability of
the set target, with reference to recent historical performance of that particular safety
indicator, industry standards, regulatory requirement as well as expert opinion.
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A corresponding alert level is identified for each SPI, quantifying the acceptable and
unacceptable performance threshold during a specific monitoring period. The use of
objective data-based criteria for setting alert levels is essential to facilitate consistent
trending or benchmark analysis.
In general, the use of population standard deviation (STDEVP) provides a basic objective
method for setting alert criteria, the method derives the standard deviation (SD) value
based on the preceding historical data points of a given safety indicator. This SD value
plus the average (mean) value of the historical data set forms the basic alert value for the
next monitoring period. The SD principal (a basic MS Excel function) sets the alert level
criteria based on the actual historical performance of the given indicator, including its
volatility (data point fluctuations). Guidance on SPI, SPT and alert level setting using SD
criteria is provided in ICAO Doc 9859 Safety Management Manual.
Sample of Safety Performance Indicator and Target:
Diagram 4: Safety Performance Indicator and Target
7.6 STEP 6: Establish and maintain a flight data analysis program (FDAP) as
part of its Safety Management System, in addition to maintaining an effective open
reporting system.
A flight data analysis program shall be non-punitive and contain adequate safeguards to
protect the source(s) of the data. In addition, having an open reporting initiatives
supported by “Just Culture” principals, is aimed at identifying and managing potentials
hazards and risks associated with on-going aviation activities. They serve as a useful tool
to ensure sufficient information is available to make appropriate decisions and operational
controls with regard to managing emerging safety threats. This is achieved by offering
the ability to track and evaluate flight operations trends, identify risk precursors, and
taking appropriate remedial action.
The parameters analyzed on FDA framework should reflect elements that could
contribute towards of LOC-I event.
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The de-identified data is processed in accordance with the flow chart shown below:
Diagram 5: FDM Process Flow
7.7 STEP 7: Analyze collected data to identify events leading to an LOC-I.
Based on the analysis of data collected, lead indicators to LOC-I event could be identified
from the list of probable cause outlined (human, system and environmentally induced),
FDA outputs, safety/audit reports, investigation findings, and others, which may be
translated into Safety Performance Indicator (SPI). The corresponding Safety
Performance Target (SPT) value can be developed based on quantification of its potential
outcome, taking into consideration the risk factors identified for each of the elements.
These include applying various combinations of high/low probability against severity of
occurrence, as prescribed by the Safety Risk Assessment Matrix, to formulate the
appropriate target in relation to past performance, industry standards or regulatory
requirement. This provides the basis for the Operator to develop/design specific LOC-I
training enhancements.
An alert level can be set prior to reaching the target limit, in order to provide early
notification to Training Department of the imminent risks and to initiate enhancement
program to improve on related flight crew proficiency.
This analysis of LOC-I related safety data, identification of SPI and setting of SPT and
the corresponding alerts should be undertaken by the SMS Integrated Working Group
who will be the subject matter experts in the related field.
FDA Working
Group
Recommendations
FDA Working
Group Analysis
Monthly Meeting
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7.8 STEP 8: Develop and design LOC-I enhancement training specifically in
preventing LOC-I events, identification of impending LOC-I and recovery.
From the trend analysis and safety reports, areas of greater safety concern can be
identified and the training department will be notified to develop a safety action plan to
address the impending unsafe concerns identified. The training department will then
notify the working group of the action plans, and on agreement between both parties,
implement the training program which shall be accomplished within a period of 6 months
(proficiency check intervals).
Simultaneously, the training department shall incorporate such specific training curricula
in the training syllabus and the relevant operations manual in concurrence with the
manufacturer. Emphasis must also be given in developing training program in the
prevention of LOC-I incidents through a more effective flight path monitoring function.
7.9 STEP 9: Deliver the enhanced LOC-I training through both simulator
training and appropriate literature.
Once established, the training curricula will be incorporated in the Part D of the
Operations Manual approved by the regulator, which will then be referenced for the
proper conduct of the training and qualification. The delivery method shall include the use
of simulator, computer based training (CBT) or literatures highlighting the safety event
and the follow up action established. Appropriate revisions and syllabus enhancement
may be referenced from lessons learned both internally and from other operators around
the globe.
The simulator used in the conduct of LOC-I training must be suitably programmed and
capable of simulating possible scenarios or conditions that can lead to this specific event.
In this respect, consultation with the aircraft and simulator manufacturer is crucial in the
development of appropriate simulator training program, whilst ensuring that the flight
instructors are suitably trained and qualified to conduct the relevant training.
The operator may incorporate this into Evidence Based Training (EBT) Program.
7.10 STEP 10: Monitor the effectiveness of the training program through
quality assurance program.
Internal audits and Safety Assurance Program should be established to monitor the
effectiveness of the performance-based training in achieving the required safety
objective. Operators should develop or propose specific LOC-I training enhancement
performance indicator to facilitate effective assessment of the training program.
7.11 STEP 11: Review and modify the training program to meet overall safety
performance.
In the event that a short fall in training and safety performance in the areas relating to
LOC-I is evident, it is necessary to conduct an immediate review of the process involved
to ascertain whether the prescribed safety action plan is indeed effective and appropriate
to realize the desired outcome. If this cannot be accomplished, a new or updated follow
up plan must be executed and subsequently monitored for any deviation from the required
target.
Refer Appendix B for the Data Integration and Safety Performance Enhancement
Process flow chart.
Refer Appendix C for the Checklist for Implementation of Performance Based
Methodology for Flight Crew Training Enhancement.
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Appendix A
The causal and contributory factors to loss of control events with reference to individual
categories are illustrated in the following. The list is not in the order of risk priority.
1. Pilot or human-induced
a. Improper training
b. Poor energy management
c. Changing pilot skill base
d. Spatial disorientation
e. Poor pilot awareness
f. Distraction
g. Automation confusion or mode confusion
h. Automation and human factors
i. Improper procedure
j. System integration issues (complexity, interdependencies and lack of standard
interfaces)
k. Pilot actions leading to destabilized approaches
l. Faulty loading or shifting of cargo
m. Incompetence
2. Environmentally-induced
a. Weather (turbulence, icing, adverse winds, wind shear)
b. Wake vortices
c. Hail leading to loss of control (engine performance)
d. Visibility degradation
e. Foreign object damage (hail, bird strike, volcanic ash)
3. Systems-induced
a. Poor design
b. Poor energy management (systems-induced)
c. Propulsion related (asymmetric thrust, energy management)
d. Erroneous sensor data
e. Air traffic operations leading to destabilized approaches
f. Loss of control power, authority, or effectiveness
g. Aircraft system failures (non-propulsion and propulsion)
h. Faults or failures or damage of or to any or all of the aircraft control effectors
i. Pilot-induced oscillation (PIO)
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Appendix B
Data Integration and Safety Performance Enhancement Process - SMS Working Group
(headed by Flight Safety Coordinator)
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Appendix C
Checklist for Implementation of Performance Based Methodology for Flight Crew
Training Enhancement
Item
Question
Response
Reference
Remarks
1.1
Are there regulations in place with
regard to establishment of performance
based training relating to LOC-I events
for the State?
1.2
Are there specific regulations which
provides a standardized operational
procedures, equipment, and infrastructures
(including safety management and training
system), in conformance with the Standard
and Recommended Practices (SAPRs)
contained in the Annexes to the Convention
on International Civil Aviation?
1.3
Has the operator established the
following safety programs:
a. Safety Management System
b. Flight Data Analysis
c. Open Reporting
d. Audit program
e. Flight Crew Training program
f. Flight Monitoring program
g. Engineering & Maintenance
program
h. Communication and coordination
program
i. Operating manual revision and
updating processes and procedure
j. Cargo packing loading, weight and
balance program/processes
k. Equipment reliability program
l. Weather monitoring and reporting
system
m. Security program
1.4
Does the organization have an
integrated safety database?
Alternate means of compliance include
obtaining data from individual
operational units.
1.5
Are the participants in the safety
working group:
a. Suitably qualified
b. Knowledgeable
c. Skilled
d. Experienced
e. Have attended the relevant training
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Item
Question
Response
Reference
Remarks
1.6
Does the organization have a process
for data analysis?
1.7
Is the safety working group independent
of any management influence?
1.8
Does the policy provide authority to the
working group to ensure that all
recommendations by the working group
shall be implemented?
1.9
Does the State have an oversight
program with regard to performance
based methodology?
2.0
Does the operator have an internal audit
or inspections program with regard to
performance based methodology to
ensure that the organization continues
to meet the established requirement
and functions at the level of competency
and safety required by the State?
2.1
Does the operator have an escalation
process to Board of Safety and Security
to address immediate high risk and long
standing issues?
