https://ntrs.nasa.gov/search.jsp?R=20140011315 2018-04-10T05:51:25+00:00Z On Time Performance Pressure InfoShare – Fall, 2013 Atlanta, GA David Wichner Linda Connell Program Manager, Booz Allen Hamilton Program Director, NASA ASRS Abegael Jakey Quality Assurance Manager, Booz Allen Hamilton September 2013
Agenda � ASRS Reporting � On-time Performance Events Aviation Safety Reporting System September 2013
System-Wide Event Occurrences � ASRS is complementary to other systems of reporting and focuses on precursors to the most severe events Fatal Accidents FAA & NTSB Injury Accidents Precursors Incidents ASRS Normal Operations Aviation Safety Reporting System September 2013
ASRS Report Volume Profile Monthly Intake 37 years of confidential � January 1981 – December 2012 safety reporting Over 1,100,000 reports � 7,000 Smoothed Intake received 6,000 Over 5,550 alert � 5,000 messages issued 4,000 Over 6,700 reports per � 3,000 month, or 322 per working day 2,000 Total report intake for � 1,000 2012 was 71,540 0 '81'82'83'84'85'86'87'88'89'90'91'92'93'94'95'96'97'98'99'00'01'02'03'04'05'06'07'08'09'10'11'12 Current rate estimate � for 2013 is over 80,000 Aviation Safety Reporting System September 2013
Incident Reporter Distribution � Percentage of Total Intake 100% 80% 60% 40% 20% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 34,043 38,116 40,657 39,694 45,603 50,405 48,986 58,683 61,018 71,540 � Controller � Air Carrier � General Aviation � Cabin Crew � Maintenance � Other Other Maintenance Cabin Crew Gen Av Air Carrier Controller January 2003 – December 2012 Aviation Safety Reporting System September 2013
ASRS Internal Screening Data Set (100%) � Top 20 Events Reported 2008 – 2012 A TC Issue 42,302 Track / Heading Deviation 33,723 A ircraft Equipment P roblem Less Severe 30,1 97 Overshoot 1 9,1 89 Airspace Violation 1 6,838 Crossing Restriction Not M et 1 6,092 Excursion From Assigned A ltitude 1 4,740 A irbo rne Conflict 1 4,600 M aintenance Issue 1 4,1 53 Inflight Weather / Turbulence Encounter 1 3,272 Speed Deviation 1 1 ,749 Critical A ircraft Equipment Problem 1 1 ,325 Runway Incursio n 8,059 Taxiway Incursio n 7,396 M EL Issue 5,546 Ilness Issue 4,692 n = 290,632 Weight and B alance 3,346 Landing Without Clearance 3,243 Ground Conflict Less Severe 3,1 36 Unstabilized A pproach 2,843 - 1 0,000 20,000 30,000 40,000 *Categories are not mutually exclusive. Therefore, a single incident may be coded by ASRS analysts as involving more than one anomaly. Note: 100% of Dark Green Bars are given detailed analysis Aviation Safety Reporting System September 2013
ASRS Web Site � Launch Oct. 2007 • Over 9 million sessions in 2012 � File ASRS Report • Electronic • Print and Mail � Database Online � ASRS Publications � Program Information � Immunity Policies http://asrs.arc.nasa.gov Aviation Safety Reporting System September 2013
ASRS Database Online (DBOL) � DBOL launched 2006 • Over 125,000 total online queries completed to date • Over 19,600 queries completed in 2012 � Fixed field and text search capability � Data formats (export) • MS Word, Excel, CSV HTML � Experts version is being proposed for the future http://asrs.arc.nasa.gov Aviation Safety Reporting System September 2013
Industry Integration with ASRS � Report Intake ASRS is a national repository of aviation ~75,000 safety data reports / year from across industry � Company ’ s safety processes can use ASRS to obtain a systemic view of emerging issues � Companies can review reports for similarities to their operations to help identify issues not yet encountered � ASRS can help companies recognize important issues within their own processes Company #2 Aviation Safety Reporting System September 2013
Agenda � ASRS Reporting � On-time Performance Events Aviation Safety Reporting System September 2013
System Context for On-time Performance � ASRS reports provide detailed explanation and insight into on-time performance challenges � System contextual factors for on-time performance include human oversight tasks � But how does “ Safety ” fit into on-time performance expectations? Aviation Safety Reporting System September 2013
James Reason - Performance Levels Control Modes Situations Conscious Mixed Automatic Skill- Routine Based Rule- Trained-for Problems Based Knowledge Novel Based Problems Source: Reason, J. (1997). Managing the risks of organizational accidents. Ashgate Press. Hants, England Aviation Safety Reporting System September 2013
James Reason - Types of Error Attentional Slips of Action Skill-based slips Basic Human Factors and lapses Lapses of Memory Errors Misapplication of “ Good ” Rule • Rule-based Application of “ Bad ” Rule • Failure to apply a “ “ “ “ Good ” ” ” rule ” Mistakes • a.k.a. (erroneous violation) Complex Human and Organizational Factors Mistakes Knowledge- • Inadequate rules and problem solving based Mistakes (highly error-prone) Source: Reason, J. (1997). Managing the risks of organizational accidents. Ashgate Press. Hants, England Aviation Safety Reporting System September 2013
On Time Performance Pressures � ASRS reports reflect how on-time performance pressures may result in • Incomplete work • Skipping process steps to get back on time • Incomplete problem solving / Troubleshooting • Impaired attention to detail � These can lead to increases in downstream mistakes and associated costs Aviation Safety Reporting System September 2013
On Time Performance Pressures (con’t) � Work environment is characterized by • Pressure to perform, survival mode • Lack of priority for compliance norms • “ We have always done it this way ” • Tendency to underestimate complex issues • Employment termination threats Aviation Safety Reporting System September 2013
Maintenance “ …we have had two instances where the Thrust Reverser � A Maintenance Supervisor describes Air Carrier Line Hydraulic Control Unit (HCU) lockout pin was left in the aircraft Maintenance environment that pushes mechanics to causing the thrust reverser not to deploy on landing. Mr. X came in during the first instance, (I was there), and rushed Aircraft "rush" their work resulting in errors. Reporter also Maintenance Technician X, (AMT) to hurry and finish the work he stated there is a constant feeling of fear for their jobs. was performing on a Job Card; and in hurrying AMT X forgot the lockout pin. All…are fearful for their jobs, making a less than desirable place to work as well as asking for an accident or mistake to be made. We are constantly being rushed to HURRY and work on aircraft; problem is sometimes we are given unrealistic time frames. I understand the need for aircraft to fly as quickly as possible, but not to the point of rushing people beyond their means.… ” (ACN 993708 Excerpt) Aviation Safety Reporting System Aviation Safety Reporting System September 2013
Gate / Ramp Operations “ … I was working with the Narita agents. We were at crunch � Ground Personnel report describes a jetbridge being time already for an on-time departure and we were ready to pulled without the help of a guide. Hurry to make the pull the jetbridge and so I rang the bell several times and no On Time Departure was cited. ramp guide. I had 2 agents telling me I was cleared to back the jetbridge not knowing that the air-conditioning was attached to the aircraft. I only saw that the GPU was detached and when I was told…okay to go, I went ahead and pulled the bridge. I don ’ t ever pull the jetbridge without a guide but today we were so close to departure time…. ” (ACN 1096099 Excerpt) Aviation Safety Reporting System Aviation Safety Reporting System September 2013
Maintenance � B757 Captain reported that a landing gear hydraulic “ …6) Maintenance removed the aircraft from service and replaced the left main landing gear tilt actuator line, leak reported prior to departure was not repaired which has nothing to do with the #2 brake line leaking 3 even though the maintenance release indicated that drops per minutes. 7) The plane was cleared at the it was. This air carrier management's push for on departure airport of the hydraulic leak, however it was time departures is forcing flight crews and mechanics clearly “pencil whipped” to achieve an on time departure, thus completely sacrificing safety. There is a huge push to not report defects or fake defect repairs. at this carrier from the top down for on time departures. This pressure on our pilots, mechanics, gate agents and ramp personnel is clearly creating a chain of events that is severely compromising safety at any cost. ” (ACN 927510 Excerpt) Aviation Safety Reporting System Aviation Safety Reporting System September 2013
Recommend
More recommend
