Safety Management: Maintaining the safety margins – an integrated approach

1. Safety Management:Maintaining the safety margins – an integrated approach Georges Rebender, JAA

2. Operations = a highly interactive activity process National Aviation Authority Flight Safety Organisations Operator Training Organisations Manufacturers Maintenance Organisations Air Traffic Management Safety Achievements = Combination of mastering internal processes and interface management

3. The need for Safety Margins • human performance variability • environment variability • interactions complexity Example - Landing Distance Regulatory landing distance = Actual Distance x 1.67

4. Piloting technique (Long Flare) • Wind variability force and direction • Cross wind landing on slippery runway Safety Margin

5. Pre-entry into Service Certification/Operations Process Aircraft Certification Safety Margin Design limits awareness Operating procedures Training requirements expansion Aircraft Operation

6. Understanding Safety Margins • Operation of modern complex aircraft requires full safety margin understanding - how they are derived - application in normal operations - some accidents suggest lack of understanding of safety margins may be the cause Example = Rudder Operational Directive

7. JAA Operations Director’s recommendation to National Aviation Authorities to consider the issuing of an Operational Directive (OD) in respect of the use of the rudder Our reference number: 05/00-1/ 02-L051Your reference number: 16 October 2002 To: All JAAC Members Subject: JAA Operations Director’s recommendation to National Aviation Authorities to consider the issuing of an Operational Directive (OD) in respect of the use of the rudder Dear sirs, Your attention is drawn to a recent aircraft accident, involving the structural failure of the vertical stabiliser and its subsequent separation from the fuselage, causing loss of control, resulting in the destruction of the aircraft by ground impact, and the complete loss of life of the persons on board. Arising from the subsequent investigation into the accident, it has been determined that an immediate programme of training for pilots is warranted in order to establish a deeper understanding of the aerodynamic loads and forces acting on the vertical stabiliser, the design and certification criteria and also to emphasise the correct techniques when using rudder. The proposal to issue a recommendation for an OD in this matter has been made at the request of OST, and who have also approved the content. Attached is the background/substantive material, together with the recommendation itself. Kind regards, Georges Rebender Operations Director

8. Operations Internal Process External Process Pro-active Occurrence Incidents Safety Margin Information Sharing Operations Standards Safety Culture Communication Risk Management Occ Deep Treatment Reporting Systems Internal analysis External analysis (continued Airworthiness) NAA / Manufactures / Organisations

9. Occurrence / Incident “deep treatment” concept Occurrence, incident analysis “Good fortune” factor Virtual accident i.e. full investigation process Safety margin Short term Mid term