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Preventing Level- bust Operator’s strategies

Preventing Level- bust Operator’s strategies. Capt . Stephen Eggenschwiler Flight Safety Officer Swiss International Air Lines Ltd. 2014 Safety Forum: Airborne Conflict Brussels June 10 th. Data Collection. Since 2006 we received 57 reports of unintended level deviation

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Preventing Level- bust Operator’s strategies

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  1. Preventing Level-bustOperator’sstrategies Capt. Stephen Eggenschwiler Flight Safety Officer Swiss International Air Lines Ltd. 2014 Safety Forum: Airborne Conflict BrusselsJune 10th

  2. Data Collection 2014 Safety Forum Brussels June 10th Since 2006 wereceived 57 reportsofunintendedleveldeviation Onlyreportswith an actualaltitudedeviationwereconsidered

  3. Weather 2014 Safety Forum Brussels June 10th …flying in moderate turbulencewewerepassedby an aircraft 1’000 ftbelow. Weencountered a downdraftand at the same time theotheraircraftencountered an updraftresulting in an immediate TCAS RA. Weclimbed 400 ftwhereastheotherflightmaintainedaltitude…

  4. Technical 2014 Safety Forum Brussels June 10th • …duringlevelflightwithautomatics on the AP suddenlydisconnected due to an out oftrimsituation. Aircraftpitchedupand A/T increased power. Immediate manualtakeoverofaircraft but still a levelbustof 500 ftoccurred… • …flight was clearedtoaltitude 8’000 ft. This was setandconfirmedbybothpilots. Whenapproaching 8’000 ft CMD realizedthataltitudepreselectshowed 7’000 ft. 8’000 ft was confirmedwith ATC. Aircraft was levelled off but undershootof 200 ftcould not beavoided… • …asthe rate ofclimb was 2’500 ft/min verticalspeed was selectedwith a rate of 1’000ft/min about 1’400 ftbeforeclearedaltitude. FGS capturedthealtitude but due totheslowreactionofthe AP theaircraftovershootby 300 ft…

  5. ATC 2014 Safety Forum Brussels June 10th • …at FL 159 receivedreclearancetolevel off at FL 160. Undershootof 500 ft… • …at FL 310 clearedtodescendto FL 200 tobelevelwithin 3 minutes. Passing FL 240 with a rate ofdescentof 4’000 ft/min ATC ordered «turn left HDG 120°, level off FL 230». Even with AP disengagement an undershootof 300 ftcould not beavoided…

  6. Misunderstanding 2014 Safety Forum Brussels June 10th • Handovertonextsector • Similarcallsigns • Readbackhearbackissues • Atmosphericaldisturbances • Language proficiency • Callsign versus flightlevel e.g. LX1100 – FL110 • Unclearorcomplex SID description

  7. Crew

  8. Just Culture 2014 Safety Forum Brussels June 10th • Human natureremainstheweakest link • Today’s SOPs areusuallywelldevelopedandsound • Tobeabletocorrecttheflawswithinitis imperative thatthesystemknowswhatisgoing on • Tounderstand an errorweneedthecrewstoreporteventsandthis will onlyworkwithtrust in thesystem • Thereforeto manage human error a just cultureenvironmentis a MUST

  9. RiskmitigationWhatarewedoing? Just Culture 2014 Safety Forum Brussels June 10th

  10. RiskMitigationWhatarewedoing? 2014 Safety Forum Brussels June 10th • Awarenessmeasures • Altimeter settingerrors • Wherearetheautomation traps • Foster awarenessforenvironmentandtraffic • Publishowncases on a regular i.e. monthlybasis • Joint ATCO-Pilot CRM courses • Importanceofdiscipline • Encouragereporting • Operator • Review of SOPs • Encouragetheuseofintercoms • Useofmode S • Lobby for SID/STAR redesign

  11. Thankyouforyourattention 2014 Safety Forum Brussels June 10th

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