Every flight crew involved in an accident/incident is flying the aircraft due to the fact that they have undergone the necessary training and have demonstrated their proficiency/competency. Since the flight crew is the last line of defense and as Prof. Patrick Hudson puts it is the first person at the scene of the accident/incident. The question that naturally arises is, why did the crew not prevent the accident/incident if they were adequately trained and had demonstrated their ability to fly safely?
In his 1931 book “Industrial Accident Prevention, A Scientific Approach”, Herbert W Heinrich put forward the following concept that became known as Heinrich’s Law:
in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries.
This is commonly depicted as a pyramid (in this case with the number of minor incidents shown as 30 for simplicity):
Heinrich’s law is based on probability and assumes that the number of accidents is inversely proportional to the severity of those accidents. It leads to the conclusion that minimising the number of minor incidents will lead to a reduction in major accidents, which is not necessarily the case.
There are two main points that emerge from the text above:
- There is a need to review the evaluation process in training due to which flight crew who are deficient in certain areas are allowed to pass through the gate.
- There are precursors to an accident/incident and the flight training data from devices like the FFS can be used to analyse and predict accidents/incidents.
There are approximately 1200 full flight simulators around the world, training airline crew at least biannually. This would translate to approximately 7,200,000 hrs of training annually. This gives the training and safety experts enough data to be able point out with reasonable assurance the common areas where the crew will commit errors leading to accidents/incidents and near misses.
Flight Crew Training
One important aspect of training where the recorded data is not so accurate is the trainers recording of evaluations and reasons thereof. There is a high probability of subjectivity and errors in recording grades during the evaluation. The reason could be due to the fact that the trainer is seated behind the trainees and has a very high dependency on visual detection of flight progress and error recording of both the pilots.
If the data from the FFS is used to assess the skill/handling of the flight maneuvers and accurately recording the flight parameters, then a lot of burden is reduced from the trainer. The trainer can then concentrate on the soft skills and human factor assessment of the trainees.
Since the flight maneuver tolerances are defined in detail, there is no doubt that a machine will give a much better report than a human observer who has limitations of the field of vision.
Flight safety experts can analyse the data to determine the common areas where the crew commit errors and the risk associated with them. The probability and severity will also vary with the type and area of operation. In the current state of training, safety has no idea about the errors committed during training and the severity of the errors. They may be recorded by the trainers but the handling of evaluations is purely a training issue. If for e.g. there are 10 Captains who are put down in evaluations for a common reason , then training will take their corrective action and when satisfies with the performance standard, they will put the crew back on line for flying. If safety looks at the same issue, they will find an alarmingly high rate of failures due to a serious error or lapse of the crew during training. Their analysis of the situation will be different and they would flag it as a potential threat to the system and monitor the line flying data to fins past or current similarities in data of the affected crew and all other crew. With this approach they can predict the possibility of an accident/incident t with reasonable assurance.
This data needs to be treated like any other line flying data and entered into the FDM and safety management system.
An integrated approach to the data analysis of the retrieved from the flight simulator will give a fore warning of the areas of concern. It will benefit the company from the safety point of view and at the same time improve the accuracy of evaluations and standards of training.