Application of Risk Management in SOP Implementation

Dai Fuliang Air Safety Dept

Safety Information Manager

FOREWORD

Standard Operating Procedures (SOP) is developed in

accordance with long time operational practices, in combination

with characteristics of specific aircraft type. SOP is applied under

applicable conditions as the optimized, commonly recognized

and standardized operating procedures.

Why do the pilots deviate from SOP? What we can do？

FOREWORD

Applying ideas and methods of SMS risk management, we collect vast amount of daily operational data, systematically identify and analyze the factors of SOP deviations, and conduct corrective actions targeting on the root causes, so as to ensure hazard prevention.

Contents Page

目录页

02 Corrective Measures to SOP Deviations

03 Applying Risk Management in SOP Implementation

01 Analysis of Root Causes of SOP Deviations 01 Analysis of Root Causes of SOP Deviations

As operations deviation control theory indicates, the efficient implementation of SOP depends first and foremost on efficient pilot training.

I. Root Causes of SOP Deviations

I. Root Causes of SOP Deviations

Individual Differences

Comprehension Differences

Habitual Behavior

Serious Consequences

Pre-event Management

After-event Management

Flight quality monitoring

data

Air crew reporting

information

Flight deviation

occurrences

Case 1: Long Touchdown Distance

Analysis

of causes

Retard

throttle at

flare

High speed

in approach

Control stick

move

rapidly due

to large

pitch at flare

SOP Description of Touchdown Zone: Touchdown zone is the shorter of the first 3,000ft, or the first 1/3 length of the runway where the aircraft lands.

In the beginning of 2014, the topic of “Touchdown distance longer than 3000 ft” became a monitoring item of Xiamen Airlines’ safety performance. Correspondent corrective actions are taken, and the occurrence rate declines significantly.

Case 1: Long Touchdown Distance

SOP

Requirements and

Procedures for Go-around

“Conduct go-around when it is necessary.”

In IFR operations and airport

elevation lower than 1,000ft,

or in VFR operations and

airport elevation lower than

500ft, when steady approach

cannot be achieved 。

Case 2: Conduct Go-Around at Low Altitude

“Conduct go-around whenever steady approach

cannot be achieved.”

Press any TO/GA button, call

out “go-around flap”, ensure

go-around thrust setting for

normal climbing rate. When

altimeter indicates positive

climbing rate, retract landing

gear.

n conducting go-around at low altitude, other risks may derived from

improper control of aircraft.

Overall analysis on the go-around cases are made in conjunction with PIC

Reports and QAR data monitoring.

Case 2: Conduct Go-Around at Low Altitude

4

35

67

ATC Reasons

Technical Reasons

Weather Reasons

6

7

6

16

Go-around upon touchdown

Improper control of flare

Warning of “Sink Rate”

Higher than glideslope

Co-pilot

New PIC

Not well prepared for go-around due

to stereotype thinking pattern, being

hesitated in making decision

Not familiar with go-around

procedures, inadequate judgment

and reaction upon environmental

change

Inadequate knowledge on post

responsibility, inadequate

cross-checking, standard

callout and reminding

Senior PIC

Case 2: Conduct Go-Around at Low Altitude

1 Stereotype thinking pattern

2 Inadequate respects to SOP

3 Lack of CRM in the flight deck

4 Individual differences of pilots

5 Lack of risk management in accordance with priority

Factors

influencing pilots

in SOP

implementation

I. Root Causes of SOP Deviations

Contents Page

目录页

02 Corrective Measures to SOP Deviations

03 Applying Risk Management in SOP Implementation

01 Analysis of Root Causes of SOP Deviations

02 Corrective Measures to SOP Deviations

Establish Concept of “Strict Implementation of SOP”

Conduct Training on “Strict Implementation of SOP”

Cultivate habits of “Strict Implementation of SOP”

II Measures for SOP Deviation Corrections

Safety Education

To integrate SMS training into real cases

To demonstrate SOP’s advantage in performance optimization, easy operation and high safety margin. To show SOP’s nature as a basic risk control, which is carried out through the whole flight process via SOP implementation.

To cultivate thinking pattern of “SOP implementation”

Preparing for rejected takeoff when taxiing; Preparing for returning back when taking off; Preparing for diversion when cruising; Preparing for go-around when approaching.

II Measures for SOP Deviation Corrections

Safety Performance Assessment

Conducting safety performance assessment on SOP implantation

SOP- standards to be followed SOP- procedures to be implemented one by one

Promoting SOP policy

Performance such as circumnavigation due to thunderstorm or go-around in accordance with SOP requirements would not be blamed; For violation of SOP, even if no negative effects occur, Xiamen Airlines would conduct investigation and punishment on such cases.

II Measures for SOP Deviation Corrections

Standardized cross teaching, e.g. special training in weak subjects/ special pairing of flight crew members, is applied in upgrade training of the co-pilots.

Other methods includes: setting up training groups, holding instructor seminar, inviting experts to give lecture on SOP discipline, compiling proper courseware to improve training quality.

Conduct analysis on deviation occurrence which is not flight

error, but violates SOP ;

Flight instructor and check airman target on technical deficiency

and carry out correction from both ground school and simulator

training.

Put Emphasis on SOP Training

Monitoring and Controlling of Quality Deviation Occurrence

II Measures for SOP Deviation Corrections

产品图

Example: Flight altitude and frequency being set incorrectly

Strict, precise, meticulous, steady and accurate

The pilots’ attitude influences directly SOP implementation in each flight.

Only when each of the pilots implement SOP strictly, can the SOP deviation be mitigated to the minimum.

Idea Technique Working principle

II Measures for SOP Deviation Corrections

Contents Page

目录页

02 Corrective Measures to SOP Deviations

03 Applying Risk Management in SOP Implementation

01 Analysis of Root Causes of SOP Deviations

03 Applying Risk Management in SOP Implementation

Risk M

anage

me

nt

Risk identification

Risk analysis

Risk control

Risk assessment

not acceptable

System and workflow analysis

Safety Assu

rance

信息获取

Data analysis

Continuous monitoring

Check Investigation Personnel reports and feedbacks

System assessment

Operational system

Not in conformance with

in conformance with

acceptable

Potential new risk or inefficient control

Preventive and corrective procedures

Figure： the relationship of Risk Management and Safety Assurance

III Applying Risk Management in SOP Implementation

Data Driven

The safety managers shall be good at risk management and risk prediction, and able to use data with aims.；

To prevent from reoccurrence, the initial root cause and its relevant factors shall be identified and mitigated.

III Applying Risk Management in SOP Implementation

CRM

Well established CRM will enhance situational awareness and risk management, and promote the application of:

SOP、

Standard callout、

Checklist、

Cross-checking、

Instruction recite、

Briefing

III Applying Risk Management in SOP Implementation

Constant improvement

Actions shall be taken, targeting on the root cause, to correct SOP deviations in real operations；

In accordance with risk management process, re-evaluate and revise SOP when relevant requirements are found to be neglected in SOP, or when new operations require so.

III Applying Risk Management in SOP Implementation

Co-operation of

various departments

Each unsafe event due to SOP deviations is a combined action resulting from a series of interrelated factors;

Operational Risk Control System is being established to call dynamically alert on risk grade, by assessing comprehensive factors of air crew, aircraft and operational environments.

III Applying Risk Management in SOP Implementation

SOP is the base of flight safety assurance. Constant review and

improvement of SOP shall be implemented to check its effectiveness and

applicability. Using SMS scientific methods, we make statistics of flight

operations data, carry out systematic analysis, and dynamically identify

hazards of SOP deviations and SOP deficiencies. A circle of self discovery,

self assessment and self improvement is hence completed. We set up

comprehensive assessment system of SOP to include evaluations in the

dimensions of safety philosophy, operational skill and working principle. We

also create favorable safety culture and environment through each

operational support process, so as to prevent inherent deviation acts of the

pilots, and to ensure strict implementation of SOP.

Summary

Thank you!