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FEDERAL AVIATION ADMINISTRATION

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4th ANNUAL INTERNATIONAL AVIATION SAFETY FORUM

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BREAKOUT PANEL C

Safety Assurance - Monitoring the System:

Safety Data Sharing and Metrics

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THURSDAY, NOVEMBER 29, 2007

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The Panel met in Grand Dominion Room

V in the Westfield Marriott Hotel, 14750

Conference Center Drive, Chantilly, Virginia, at

3:22 p.m., Jay Shilling, Moderator, presiding.

PANEL MEMBERS:

JAY SCHILLING, Chief Engineer, GE-Aviation

KENNETH J. HYLANDER, Senior Vice President,

Safety & Engineering Chief Safety Officer,

Northwest Airlines

J. RANDOLPH BABBITT, Director, Oliver Wyman

DR. HAROLD O. DEMUREN, Director General, Nigeria

DR. NORBERT LOHD, Director, Oliver Wyman

LIU YAJUN, Director General, Aviation Safety

Office General Administration of Civil Aviation

of China

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TABLE OF CONTENTS

INTRODUCTION

Jan Schilling, Moderator. . . . . . . . . . . . . .3

OPENING REMARKS

Jay Schilling . . . . . . . . . . . . . . . . . . .4

PANEL DISCUSSION. . . . . . . . . . . . . . . . . 13

AUDIENCE PARTICIPATION. . . . . . . . . . . . . . 41

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1 P-R-O-C-E-E-D-I-N-G-S

2 3:22 p.m.

3 MODERATOR SCHILLING: Thanks, Jay, for

4 that great introduction.

5 I would like to start \-- you know, the

6 team\'s topic today is safety data-sharing and

7 metrics and monitoring. So, I would really like

8 to introduce the panel and move right into the

9 questions, and then if there\'s anything we

10 missed, the panel can fill in at the end, and

11 then we\'ll open it up to your questions.

12 So the first person here is Randy

13 Babbitt. Randy is the director of Oliver Wyman.

14 The next person is Dr. Harold Demuren.

15 Harold is the director general, Nigerian Civil

16 Aviation Authority.

17 Next to him is Dr. Norbert Lohl,

18 director, Certification, European Aviation Safety

19 Agenda.

20 Next to him is Ken Hylander, senior

21 vice president, Safety and Engineering and chief

22 safety officer.

23 And last but not least, Mr. Yajun Liu,

24 who is the director general, Aviation Safety

25 Office, general administration of Civil Aviation

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1 of China.

2 So, it\'s great to be a moderator of

3 such an august group of individuals here to talk

4 just like we\'re all here to talk about safety.

5 You know, today, when we do an

6 accident or incident or incident investigation,

7 sometimes we find data that, if we had looked at

8 it earlier, we might have mitigated the outcome

9 of that accident or incident.

10 So what we\'re trying to do here in

11 terms of minimizing any future accidents is to

12 look at data on more of a proactive basis. And

13 that gets a little tough. We want to look at

14 that data as leading indicators to future

15 accident prevention.

16 But, there are barriers to that.

17 Barriers to data-sharing, assessment \-- proper

18 assessment of the risk and taking the appropriate

19 action.

20 Certainly, most all of us, if we do

21 find that there is a true safety need, there is

22 generally never a problem with taking appropriate

23 action. It\'s making that proper risk assessment

24 without adding a lot of entropy to the system.

25 So, what I\'d like to start with is the

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1 first question that was given to this panel,

2 which is: \"What are the barriers to information-

3 sharing?\" And I\'d like to prime the panel with

4 \-- since I\'m from kind of the corporate side of

5 things, the TC holder, the maker and producer of

6 products, with possibly one barrier that side,

7 and that\'s corporate liability.

8 You know, the corporation is looked at

9 as knowing everything. We have all the data.

10 We\'ve made the assessment. We\'ve worked with the

11 regulators. We monitor the data continually, and

12 when there\'s an incident we\'re looked at as \"Why

13 haven\'t \-- Why didn\'t you discover that earlier?\"

14 So, when we start putting more data

15 out, if there is an inaccurate assessment of that

16 data, that could be used against us in terms of

17 our liability.

18 So, what it boils down to is just what

19 we\'ve been talking about from eight o\'clock this

20 morning on, an appropriate safety management

21 system where you understand the data, you

22 categorize the data, you make an assessment of

23 the risk, and then you take appropriate action.

24 So, there is liability associated with

25 the corporate entity, but you have to follow that

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1 up with the proper system so that that barrier

2 turns into a perceived barrier, than a real

3 barrier.

4 So, with that primer I\'d like to ask

5 maybe the regulators, maybe Dr. Demuren, to

6 comment on what he sees from a regulator\'s

7 perspective of barriers with data-sharing.

8 Dr. Demuren.

9 DR. DEMUREN: Thank you so much,

10 Moderator.

11 Since I come from the region that has

12 the highest rate of accidents, and we also share

13 these with you in this area. The biggest barrier

14 to sharing safety information is the fear of the

15 unknown, whether they are pilots or engineers,

16 whether they are the airlines\' executives,

17 service providers, the fear is that they may lose

18 their job if they report that accident \-- that

19 incident.

20 There\'s a fear that after a big

21 accident and we are bitter, the fear of coming up

22 is, \"Are we going to \-- will that bring me

23 criminal investigation if this information are

24 known?\" So, people have fear to come forward.

25 And these, as grievously in that the

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1 level of information that we have and, in fact,

2 the action we take. And it\'s also as to that, as

3 readily said, even manufacture, you know,

4 corporate litigation.

5 Regulatory authorities also are not

6 immune from this. You know, is it not part of

7 the world, a regulatory authority that ground the

8 aircraft a political class for civil pressure,

9 get fired, lose their job.

10 Well, the accidental cause, instead of

11 looking for the cause of the accident, we are

12 looking for scapegoats. And this has really

13 affected quality safety information that we get.

14 And I think we should work to remove this. The

15 solution is one. You discuss it, it\'s non-

16 punitive reporting system.

17 I think the most entrenched phase

18 analysis, that would be non-punitive so people

19 can come freely. We\'ve done that in our part of

20 the world now. Addressing our woeful city

21 records that have to come with these so people

22 can come out. You don\'t have to let us \-- we

23 don\'t need to know who gives that information.

24 We want to get information, analyze it,

25 immediately take a public action to avert future

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1 accident.

2 And I think that\'s where we stand in

3 this. This barrier is because of fear, loss of

4 job security. And we need to eliminate these

5 from our safety system.

6 MODERATOR SCHILLING: Now, great

7 point. Not only in the regulatory world, but

8 also in the corporate world, too.

9 So, I\'ll get another regulator\'s

10 perspective, Mr. Liu.

11 MR. LIU: The director general of

12 Nigeria has just mentioned the barrier for safety

13 data-sharing, rather to add some point for the

14 safety data-sharing between the countries.

15 As we all know that ICAO is working

16 for that safety data transparency and the sharing

17 for long time and I do think that the barrier

18 between the states, between the country is

19 somehow the \-- some of the contractor not \--

20 well, the others know their shortcomings.

21 So, that is my concern. And my

22 personal view is that, for each of the country,

23 for the improving safety purposes, so we have to

24 encourage each of the states to report to ICAO as

25 well as the \-- to share that safety information

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1 to other countries. That is very important.

2 MODERATOR SCHILLING: Good. Thank

3 you. Do you have \-- is that ongoing, is that

4 something you\'re trying to push in a certain way?

5 MR. LIU: For our government, we are

6 working on the open data to other countries. We

7 have signed some agreements with other regulators

8 like, you know, Federal Aviation Administration,

9 and also Australia, so we signed the agreement

10 and we are working on the sharing of information

11 by \-- particularly.

12 MODERATOR SCHILLING: Thank you.

13 Good, great.

14 From maybe independent, Mr. Babbitt,

15 you have a different perspective or something

16 that would go along with these two gentlemen,

17 what they said?

18 MR. BABBITT: Sure. I think the

19 points made have been excellent and I think Dr.

20 Demuren has mentioned something that is really \--

21 has rested for a long time at the core of the

22 data collection, which has been the fear by

23 anyone who reports, of reprisal.

24 And it\'s interesting when we think

25 about a safety management system, and we think

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1 about how we are going to apply that, I was asked

2 recently by someone in my office to explain to me

3 what is this about in aviation? What is a safety

4 management system?

5 And I said, \"It\'s an evolution.\" If

6 we think back, go back 30 or 40 years ago, our

7 view of safety was to provide someone with

8 authority to be the safety inspector. And we

9 might have used the analogy of a factory. We

10 have a thousand people working in the factory and

11 we have two or three people that we charge with

12 the responsibility of making the factory safe.

13 Today, we\'ve gotten a lot smarter.

14 Why don\'t we let all one thousand people report

15 what\'s going on in the factory. They see

16 everything in the factory. We have a thousand

17 eyes looking at safety today, not three.

18 So, the hurdle to overcome was to

19 convince those thousand people that if they saw

20 an error, if they saw a mistake, if they made a

21 mistake \-- and part of that adoption of where we

22 are today is the adoption of a culture, a just

23 culture \-- we\'ve heard it mentioned before \--

24 where we acknowledge that very well-trained,

25 skilled, competent people can make mistakes, and

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1 aren\'t we better served by letting those people

2 submit that they have seen an error, they have

3 made an error, and the information they provide

4 will fix the error.

5 And I think that that\'s when we come

6 full circle. It\'s taken a long time to convince

7 pilots, mechanics, flight attendants, anybody

8 involved to say, you know what, it\'s okay. Go

9 ahead and put your hand up, there will not be

10 reprisal. We\'re going to fix the system.

11 Now, we certainly don\'t want to cover

12 people doing foolish things, unprofessional

13 things. That\'s not what it\'s about. The system,

14 though, is designed to get the proper feedback

15 and to allow the system to correct itself with

16 this thousand pair of eyes.

17 MODERATOR SCHILLING: I think that\'s

18 probably one of the most important points.

19 Does anybody else want to comment on

20 that before we move on here?

21 MR. HYLANDER: I\'d make one comment.

22 This morning, in one of the sessions, it was

23 mentioned, feedback. And I think, in my own

24 experience and in our own experience at

25 Northwest, that\'s really becoming an issue for us

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1 when people take the time to share \-- an employee

2 takes the time to share something with the

3 company.

4 We think we\'ve been very diligent

5 about taking all that information and making the

6 correction and building it back into our training

7 program or whatever. But, if we haven\'t fed back

8 something tangible and meaningful to the affected

9 employee or the employee that brought the issue

10 up, I think that we\'re finding out that they have

11 a lot of distrust in the system.

12 It just goes into the ether, into this

13 mysterious bucket of stuff that they don\'t really

14 recognize it. When it comes back in the form of

15 training or manual change, they may not recognize

16 that.

17 So, I really picked up on that this

18 morning, because that\'s something that we\'re

19 definitely feeling and I think it impacts the

20 amount of information you get, and therefore what

21 we\'re able to share among organizations or even

22 outside of our own company.

23 DR. LOHL: If I may, add here,

24 concerning feedback, I must say that I can

25 confirm what you just said not only with respect

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1 to individuals but also to organizations. They

2 want, for sure, to get feedback, what they submit

3 to us for the authorities, to the agencies. They

4 are then motivated to be better, to improve the

5 system.

6 One of the really generic questions we

7 always receive is: \"What are you doing with the

8 data we have provided to you? What is the

9 outcome? What is the result of our efforts?

10 I must clearly underline what you just

11 said. That\'s very, very important. It has

12 something to do with motivation, with the

13 establishment of the system. We can only

14 establish a system if this question of feedback

15 is resolved. I must confirm that.

16 MODERATOR SCHILLING: Right. You\'re

17 right-on in my book. That has to be a loop or

18 you don\'t have a system.

19 Yes.

20 MR. LIU: Okay. Taking about the

21 feedback of safety data, safety information, and

22 I\'d rather to give you some examples for one of

23 the airlines we have in China, and the \-- many

24 years ago, and the employee of the airline did

25 not have the confidence to provide safety

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1 information because of the \-- although they

2 provide information to the company, but not any

3 actions being taken.

4 But now since we have taken the SMS,

5 so the airline has direct policy. They have

6 mechanism. What information received from the

7 employee, there are certain departments being \--

8 dealing with those information and there after

9 analysis, they make their decision and then they

10 take the action.

11 Those actions, as witnessed by the

12 employee and making them more confident. So

13 that\'s why a lot of safety information comes to

14 the company. That is our practice. Thank you.

15 MODERATOR SCHILLING: That\'s great.

16 Great input.

17 Shall we move on to the next question.

18 The question posed to the panel was: \"How can we

19 prevent the next accident using data-sharing,

20 metrics or monitoring?\"

21 Certainly, matrices gets into thinking

22 about checking boxes, and we certainly don\'t want

23 to do that. We want metrics that really we can

24 understand. That\'s why \-- I like to refer to

25 that more as monitoring.

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1 I want to relate just a very \-- what

2 I think is a very proactive item that has been

3 going on for years, and that\'s the CAST committee.

4 You know, their work on rotor integrity of

5 turbine engines is just fantastic.

6 You know, here you have a diverse set

7 of competitors who have come together, shared

8 data while they still keep their company\'s

9 proprietary information protected and have raised

10 the bar with respect to rotor integrity in

11 turbine engines.

12 They\'ve devised a database under FAA

13 leadership where it\'s a receptacle for future

14 items in rotating parts where, hopefully, we can

15 look at that as a community and find the next

16 leading indicator before we have a hole in an

17 aircraft.

18 So, here\'s a very proactive look.

19 Even though it started around an incident, it

20 still is proactive. Now we have to take that to

21 the next level.

22 I\'d like Dr. Lohl to comment on what

23 he may see as raising the bar in terms of

24 proactive monitoring of systems.

25 DR. DEMUREN: Yes. For sure. Thanks

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1 for the expression. If you allow just maybe one

2 short remark you have presented me as

3 representative of the European Aviation Safety

4 Agenda.

5 MODERATOR SCHILLING: I know.

6 DR. LOHL: And I just wanted to say we

7 are not only on the agenda now anymore, we are in

8 reality, and we are representing, if I may say

9 this following some comments we heard this

10 morning, the responsible Europeans.

11 Coming back to your question, I would

12 say that\'s, of course, a huge subject, and I must

13 admit, one of my favorite subjects, how to deal

14 with data, safety data, how to have, I would say,

15 intelligent analysis available in order to have a

16 preventive tool, because all what we are doing

17 is, of course, looking basically back at

18 accidents, incidents, realizing, trying to

19 identify why these incidents or accidents

20 happened, knowing then, months, years later why

21 exactly these events happened.

22 And, of course, this is a very

23 important element for sure, and we must continue

24 that. But in addition, I think we should come to

25 a system where we come really to a certain kind

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1 of prospective analysis of identification of

2 risks, of challenges, of actions to be done, and

3 I would like to say that, for instance, in

4 Europe, but I know worldwide we have already a

5 lot of systems in place.

6 One of the problems I see personally

7 is that the different systems should mesh

8 together. For instance, we have a very well-

9 functioning system in Europe, and I\'m sure here

10 in the United States as well.

11 The responsibility of a TC holder, a

12 TC holder has to establish a system, a system of

13 receiving incident/accident data, of reviewing

14 that.

15 I know a very well-established

16 aggressive monitoring system, reviewing each and

17 every case, making statistics, finding out the

18 situation.

19 But there\'s an addition, then,

20 incident reporting systems or current reporting

21 systems for operators, for maintenance

22 organizations in Europe, in Asia, in Africa, in

23 the United States.

24 Too many individual elements, I would

25 say, but what for sure is needed is to combine

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1 all of these different elements together to a

2 really worldwide system because we are living in

3 the aviation world, exchanging products

4 worldwide.

5 I think we have not only to exchange

6 products worldwide, but also information, safety

7 information worldwide, and I think that\'s one of

8 the generic subjects of this safety conference

9 here, and I only can support that.

10 In addition, I would like to mention

11 that I personally think that maybe that\'s an idea

12 or a discussion item, a little bit exceeding the

13 agenda here and the discussion here.

14 But I wanted to mention that I

15 personally think that we should do much more and

16 we have already first steps done in this

17 direction regarding the monitoring of the

18 systems, for instance, in airplanes.

19 As an example \--

20 MODERATOR SCHILLING: Excuse me. Do

21 you have your mic on?

22 DR. LOHL: I think, yes.

23 (Discussion off the record.)

24 DR. LOHL: Yes, coming back to the

25 monitoring of data, of safety data, and that

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1 additional element I wanted to mention is that we

2 have already a few examples where I think this

3 proactive monitoring is already in place.

4 For instance, Jan, if I may mention

5 this specifically here, the trend monitoring for

6 engines, but also for instance another example,

7 the health and usage monitoring systems for rotor

8 craft, for helicopters.

9 Very interesting elements, observing,

10 monitoring, for instance, for the helicopter

11 case, vibrations, identifying the frequencies and

12 being able to identify in advance certain kinds

13 of changes, of things which should be monitored

14 and maybe should be cancelled or should be

15 removed before a certain threshold has been

16 reached.

17 I think these elements are very valid.

18 I would wish, personally, that we would invent

19 much more of that in all kind of areas of

20 airplanes, of systems. I only wanted to bring

21 this up into the discussion, we should not only

22 concentrate on operational data, but really on

23 technical data.

24 I know that\'s in the future, but we

25 should maybe start with the invention of those

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1 systems, think about, maybe encourage research on

2 that. I think that\'s a very, very important

3 element of that, what I would dream of a

4 systematic approach and a systematic monitoring

5 really of the health, of the behavior, of the

6 performance of an aircraft. Thank you.

7 MODERATOR SCHILLING: And I\'ll agree

8 with you. Certainly we heard today at lunch, and

9 we think about how little time ago when our

10 speaker landed on the moon and what he \-- what he

11 cited as the state of the business of the science

12 then, versus where the science is now.

13 So, I fully agree that we ought to

14 push that front as we can monitor, pick up \$30

15 phones and talk around the world, we ought to

16 have aircraft and engines talking to each other

17 all the time. So, I agree with that.

18 Would anybody else like to add to Dr.

19 Lohl\'s \--

20 MR. BABBITT: I would make an

21 observation, that to rise to the next level for

22 this data that we\'re collecting to be universally

23 useful, that we probably should spend some time

24 making certain that the data collection is

25 consistent. We\'ll call it the same data language

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1 so that we\'re on the same platform.

2 It\'s one thing \-- an earlier speaker

3 today, they spoke of having conquered, if you

4 would, the data collection on a local basis.

5 We\'re now migrating to a national basis. I think

6 we will have achieved a huge final step when that

7 data collection can be shared on a global basis,

8 and in order for that to happen, it has to happen

9 on a common language.

10 Every pilot in this room knows how to

11 key in in Morse Code, SOS. Everybody knows what

12 \"mayday\" means. We need to know what all this

13 data means.

14 MODERATOR SCHILLING: Excellent

15 example. Anyone else before we move on? Yes.

16 DR. DEMUREN: You know, I have

17 listened very carefully to these contributions

18 and I totally agree with you. I don\'t want to

19 repeat these. I just want to change it a little

20 bit and see another dimension based on what you

21 have just said.

22 Again, I\'m looking at the background

23 from where I come from in our region with the

24 highest accident rate. Half of those accidents

25 occur usually in war-torn areas where we have

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1 illegal operations, flag of convenience.

2 All of us first know who are these

3 people. We know where the aircraft come from.

4 We know the owners. We know the operators. They

5 are not spirit, they are human beings, and the

6 worst is, when you look at some of them, they are

7 relief agencies, they work for agencies coming

8 from the United Nations. And ICAO is an

9 organization of the United Nations. How could we

10 stop this?

11 If we remove all these, fifty percent

12 of the accident rates in Africa would be out. I

13 feel when we talk about using data to prevent

14 accident, we have there, again, we need to take

15 some bold step to make sure we meet this.

16 It\'s a dangerous operation where

17 you\'re talking about, when you come to look at

18 it, flag of convenience. Aircraft that are not

19 fit to fly, crew is not competent, operating

20 illegally in cited areas. And you can\'t see any

21 justification for these, because it\'s war-torn

22 and because of the relief agency this is

23 flourishing.

24 I think we should work together as a

25 team to make sure we eliminate all these

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1 dangerous operations. And that\'s how we promote

2 public safety.

3 MODERATOR SCHILLING: Great point

4 there. Really good.

5 Okay. Let\'s go onto the third

6 question. This might spawn a few others. How

7 can we distill the large amounts of data that are

8 collected to identify safety risks?

9 Certainly in today\'s world of modern

10 computations, we amass mountains of data and some

11 of that data is just amassed. It\'s not looked

12 at. So, how do we sort through that? How do we

13 come up with a system that helps us really look

14 at the critical items of data that we really need

15 to look at, because we probably can\'t look at it

16 all.

17 I\'d like to have Mr. Hylander kick

18 this off, since Northwest Airlines has been very

19 active on the safety management front, as posing

20 him this question.

21 MR. HYLANDER: Thank you, Jan.

22 This is a subject that is sort of near

23 and dear to my heart and maybe I\'d start by just

24 saying a little bit about how I ended up in this

25 job as the chief safety officer at Northwest.

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1 I used to be the head of the

2 engineering department and maintenance quality at

3 Northwest, and about six years ago one day I got

4 a call to go into the CEO\'s office and he said,

5 \"Congratulations, you\'re now the chief safety

6 officer.\" And I said, \"But that really should be

7 a pilot and I\'m not a pilot.\"

8 And he was very clear at the time and

9 he said, \"What I want to see happen is the same

10 diligence that is applied to our engineering and

11 reliability data and our continuous analysis and

12 surveillance programs that we have in

13 maintenance. I want to see that applied across

14 the company.

15 So, that was a charter that I took on

16 in this role, and have been working on it for a

17 lot of years.

18 My team and I, we\'ve decided that the

19 way to approach that is, first-off, focus on our

20 airline and focus on, you know, Northwest, or we

21 call it the \"Red Tail,\" and we\'ve obviously gone

22 out and we have a lot of different programs and a

23 lot of different safety programs.

24 And just for instance, for one example

25 with our FOQA program, we really made a conscious

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1 decision that before we spent a lot of time

2 worrying about sharing at the industry level, we

3 were going to make sure we had gleaned every bit

4 of information we could from our own data first,

5 and that it was feeding back into the training

6 programs.

7 Then we said, \"Gee, we have three

8 airlines that fly red tail\'s and they are AirLink

9 partners and they are a regional airlines and we

10 want to work with them to make sure they are

11 doing the same thing.

12 And we made sure we had similar safety

13 metrics and we had \-- when we say we\'re doing a

14 FOQA program we found out it can mean very

15 different things to very different people, and so

16 we worked through that.

17 Then, Northwest, is a member of, in

18 our case, the Sky Team Alliance. Eleven airlines

19 now around the world, and we have a safety group

20 and we\'re sharing safety data within that

21 alliance, and we\'re trying to figure out what

22 does it mean.

23 And all of these things, in our view,

24 these impact our passengers immediately. And so

25 we\'ve really put the effort on that.

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1 Then we layer it up, and the fourth

2 layer is, okay, now the national and the

3 international information-sharing and the data-

4 sharing approach. And I\'d say we\'re really

5 getting into that now and wanting to do more,

6 because we\'re comfortable that we understand our

7 data.

8 So, I wanted to give that little

9 background as to sort of our strategic approach

10 at Northwest.

11 To the specific question about how do

12 we use the data to manage our business, I think

13 there\'s two things that we\'ve really looked at.

14 First is, we have all the different tools. We

15 have maintenance data. We have quality assurance

16 data. We have ASAP. We have FOQA. You have a

17 lot of different data throughout the operation.

18 And we\'ve really decided that we need

19 to look at all of these individual data streams

20 and we not only want to look and bore into each

21 one specifically, but we also want to step back

22 and take a high look, and what are they saying

23 about each other, and we\'re finding out \-- and

24 it\'s probably not a surprise to many people \--

25 that information that information you\'re getting

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1 from one data source might actually be telling

2 you something about another part of the company.

3 So, I mean, a classic example is

4 you\'re getting ASAP reports that might be

5 pointing to some issues in clearing MELs and

6 maintenance, for instance, so you can begin to

7 cross-utilize the data streams if you begin to

8 think about things that way.

9 We also said, instead of what might be

10 traditional safety data, we should go look at our

11 just overall, what I\'ll call production data, how

12 many log pages are we getting, what are they

13 about, what \-- you know, what is the volume of

14 those doing, for instance.

15 So, for an example, in our maintenance

16 department, we recently ran a study because our

17 airline has gone through significant

18 restructuring. We have, you know, out-sourced to

19 third-party MROs and in some cases, line

20 maintenance.

21 Our maintenance organization two years

22 ago. We\'ve out-sourced 69 ground handling

23 stations and, you know, our safety and quality

24 team has had to be on its toes to stay on top of

25 the operation as that\'s been going on.

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1 And we started to use just normal

2 production data that we would have that our

3 operating groups are using on a day-to-day basis,

4 and we started to look at it from a safety

5 perspective, and we began to say \"This might be

6 telling us something about training,\" or \"It

7 might be telling us something about

8 communication,\" or \"It might be telling us

9 something about a vendor\'s internal policies for

10 how they manage employees.\"

11 We just ran a study in our maintenance

12 area where we decided there were 20 metrics that

13 our maintenance department used to manage their

14 business. Number of deferred\'s, how fast we

15 clear deferred\'s, things like that.

16 And we took a very high-level look at

17 that. It turned out we went back over three

18 years and there were 33 million data points that

19 we were massaging, to get to your point about

20 doing this internally and having a lot of data.

21 And we plotted this out, and what was

22 it like before we went through our restructuring,

23 what is it doing now, how has it changed, how

24 does this relate to what the pilots are telling

25 us from what they\'re seeing in maintenance.

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1 And it\'s been a fascinating effort and

2 a fascinating study. And I think the thing we\'re

3 learning is, as we went through all of this and

4 we\'ve looked at all of this, we did our best to

5 be proactive and to think about what should we be

6 looking at.

7 But, as we start to see all this data,

8 we begin to understand you can\'t be \-- have 100

9 percent foresight. You never quite know what\'s

10 going to happen, and you have to have robust

11 enough systems, and be flexible enough that you

12 can start to see things and you can react and you

13 can go get that data and you can start to act on

14 it.

15 So, I guess what I\'m saying is, one

16 key thing through managing data, in our view, is

17 to, number one, be on top of it. It\'s really

18 hard work. You spend a lot of time dealing with

19 it.

20 And then, as you\'re looking at it, be

21 ready to react to it, be ready to change what

22 you\'re doing, be ready to communicate to

23 different people, and be ready to use data that

24 you never thought you would use before.

25 So, that\'s sort of my high-level story

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1 on \-- it\'s really hard work. I\'m convinced, and

2 this may be a little bit biased from my position,

3 but I\'m convinced that many people aren\'t doing

4 enough with their own data and they\'re worried a

5 lot about everybody else\'s data.

6 And I\'m worried \-- if I have 33

7 million data points just in my maintenance world

8 that I\'m looking at over the last couple of

9 years, I\'m not sure I need another 30 million

10 right now from somebody else.

11 But I do understand, and there\'s

12 absolutely value to the information-sharing

13 that\'s happening in certain key areas, but I

14 really feel there\'s a lot of value to really bore

15 into what you\'re doing in your own operation.

16 MODERATOR SCHILLING: I couldn\'t agree

17 with you more. You\'ve got to start with, you

18 know, the house of cards that\'s in your own shop

19 first and understand that before you can even

20 offer up other data to other individuals.

21 I ran across \-- the other day we had

22 an incident with arc-out on a rotor disk, and we

23 burst the disk. So, what we did is \-- or what my

24 office did, I personally sent letters to all of

25 our RSP\'s, all of our partners to alert them of

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1 this problem and then agreed to share any of the

2 technical data they wanted, because it\'s a safety

3 issue.

4 So when you find that carrot you\'ve

5 got to share it, but you can\'t share everything

6 or you\'ll go nuts probably.

7 What would the regulators like to see

8 in terms of, you know, this vast quantity of

9 data? Is there any one area that could be

10 focused in to try \-- you know, what we talked

11 about all the day long was \-- was data-sharing,

12 safety management systems, but we\'ve got to start

13 somewhere. We can\'t just start with doing it all

14 at once.

15 So, do the regulators see an area

16 where maybe industry could do a little better job

17 as a first step, pushing a given item or items?

18 Anybody?

19 DR. LOHL: Maybe before criticizing

20 the industry, I would like to summarize what is

21 already existing, and maybe a few elements. It\'s

22 not complete, but maybe just from my point of

23 view they are the main elements, which are there.

24 For us the backbone of the data

25 analysis system is the design organization. We

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1 have the concept of approved design organizations

2 responsible for TCs, for type certificates.

3 That\'s, for us, the mainstream, I would say.

4 They have the obligation. According

5 to our regulations they have to produce based on

6 data received from operators, for instance. They

7 have to produce, as I said before, based on a

8 monitoring system, results. They distill to take

9 the word we are using here.

10 The data are distilled. They are

11 coming to conclusions. They are actions to be

12 issued by us, by the agencies or any other means

13 in order to control the situation. That\'s, for

14 us, the most important element.

15 Another element I want to mention here

16 is maybe just for us for EASA. We have a group,

17 safety analysis group established in our agency,

18 from my point of view, a very important group,

19 small group yet, but hopefully bigger in the near

20 future.

21 They review the available data. They

22 have to produce safety analysis data they are

23 feeding us, the certification people, and others,

24 and maybe also rule-making people, by the way,

25 because sometimes an output of a certain kind of

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1 deficiencies, of occurrences, have to lead in or

2 have to produce rule-making changes. Can be

3 another option, of course, of reactions.

4 That\'s very important, a monitoring

5 system inside our agency, available reviewing the

6 data from wherever they come, and providing data.

7 For instance, we are issuing now,

8 since this year the first time, and we will do

9 this annually in the future, a safety analysis

10 report of safety \-- annual safety report of the

11 EASA. Very important, from my point of view,

12 where we can \-- where we identify trends, risks

13 and the actual situation.

14 And I would also like to mention, if

15 you allow, just a third element which is there in

16 Europe and which is under, if I may say so, under

17 establishment construction, but the European

18 Union decided some years ago to establish an

19 occurrence data reporting system, if I may say

20 so.

21 A regulation provided to the European

22 Union member states, and the European Union

23 member states are feeding their occurrence data

24 into a system that\'s a European-wide data system,

25 eCare it\'s called, and eCare is nothing else than

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1 just an assembling, a collecting of data, and

2 providing on the other side data for analysis to

3 us, to others.

4 I think a very good point, a very good

5 system already established. And, of course, we

6 would like to establish this system in

7 cooperation with our member states and the

8 European Union to a system which is workable in

9 the near future and complete and I would say

10 quite an interesting model, maybe for other

11 regions as well. Thank you.

12 MODERATOR SCHILLING: Would you

13 recommend that sharing that with, you know, the

14 FAA, the CAAC \--

15 DR. LOHL: No problem. Yes. No

16 problem.

17 MODERATOR SCHILLING: Great. That\'s

18 a real proactive step.

19 Anyone else want to comment on that?

20 Yes.

21 MR. LIU: Okay. I think there are two

22 issues to be considered. One is how do you

23 distill the information from large amount of

24 safety data?

25 The other is, although you do not have

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1 much more information, but you can use the

2 limited information by improving your system.

3 And concerning the usage of the

4 information, I\'d rather provide to you a practice

5 we have. Many people talk about the use of the

6 FOQA, and QAR and FOQA system and the full CAAC

7 trainer almost more \-- more than 90 percent of

8 the data can be used by each of the airlines,

9 including the regulators.

10 And when we received the FOQA

11 information, when we found the problems with

12 regard to a certain airline, for example, hard

13 landings. I don\'t know if this word is correct

14 or not. Hard landing.

15 When we found some airline had a lot,

16 you know, many times of hard landing, we send a

17 group. We have the technical team to a certain

18 company, we do not want to give them a

19 punishment. We teach them. We have a discussion

20 with them to find the reason why they have such

21 kind, amount of the hard landing.

22 So, when we got the conclusion, those

23 hard landings occurred involving the 737, 800.

24 But during the same time the other airlines do

25 not have such kind of problems. So we teach

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1 them. We allow the airline to learn from the

2 other airline to be sure they are experienced.

3 And then they make some \-- they do

4 some more training, then they got a lot of

5 achievement, so the safety improvement. And the

6 numbers of hard landings has been reduced.

7 That\'s one of the usage of the FOQA.

8 And the other usage is that hard to

9 collect information from, you know, use

10 important, you know, information source. We can

11 use that information for case study. For

12 instance, we got information from the FOQA

13 website.

14 There is some concern about the runway

15 safety area. The concern about the EMARS, you

16 know, Engineered Materials Arresting System.

17 So when we receive those information

18 we had a meeting and then we talk about do we

19 have the such kind of problem, do we have the

20 same problems. So, after analysis that we made a

21 decision for some airport in the high terrain,

22 you know, very high terrain, the runway lands are

23 very limited.

24 So, by having this information we made

25 a decision to install the EMARS to improve the

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1 safety. So, the major \-- all copies, no matter

2 you have large amount of information or limited

3 information, you have to make any effort to use

4 that. That is, you know, from the point of the

5 regulators. Thank you.

6 MODERATOR SCHILLING: Yes. Those are

7 great examples of being proactive.

8 Any follow up? Yes.

9 DR. DEMUREN: I think regrettably,

10 though, we need to accept something, that we have

11 not learned enough lesson from accident. Tell me

12 why it is. We just have not learned enough

13 lesson. And I think when we start to look at

14 this batch of accumulated data we have from

15 incidents, we will learn from that.

16 Prompt and continuous \-- it has to be

17 prompt and continuous processing, analysis of

18 this data and take appropriate action to get

19 results. Very important.

20 And you would be surprised what you

21 can achieve in this. One lesson we learn from

22 our area is this. Regulatory authority, we have

23 to change our attitude. It\'s no longer this

24 police type of thing. That would be a

25 constructive engagement with the industry.

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1 But as the airline, the pilot, the

2 engineers, the service providers, it has to be

3 that, constructive. Then they can cover, because

4 they also have a large amount of this incident.

5 They have the data and they also have the license

6 and when they come up you can see the trend

7 easily and take appropriate action before major

8 accidents occur.

9 The information will have \-- whatever

10 incident, risk management can come easily and it

11 will follow this later, and I think it\'s very

12 important that, as we say, mostly we need some

13 more technology, advanced technology to assist in

14 processing this data. Very good. We have some.

15 We need to continue to work on these and we must

16 not forget that whatever we say, human beings

17 still have to take decision.

18 So, training, continuous training,

19 good training must be there to ensure that we can

20 meet the challenges of the future.

21 MODERATOR SCHILLING: Agreed.

22 Did you have something to add?

23 MR. BABBITT: I did. And I think \--

24 an excellent point was made by our colleague from

25 China. We\'ve done a marvelous job of collecting

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1 a lot of data and we digest it and we can

2 determine causes, we can project alternatives to

3 avoid the problems.

4 But, at the end of the day, the people

5 are at the end of the process, and the people who

6 are, you know, responsible in the operation have

7 to be able to identify with and utilize that

8 data. It has to be put into people-friendly and

9 people-understandable instructions, formats,

10 training in order for you to get a result.

11 It\'s wonderful to have all the data.

12 One of my first examples, as a fairly young pilot

13 I had to go in with another pilot who had had an

14 incident, an aircraft had taken off and had \--

15 when they went to retract the gear the nose wheel

16 didn\'t come up.

17 And there was a very good reason the

18 nose wheel didn\'t come. The gear pin was still

19 in the nose wheel, and they had to come back and

20 land.

21 And I went in with this pilot to the

22 chief pilot\'s office. The chief pilot was not

23 happy. He asked the first officer who had

24 inspected the airplane, he said, \"You did the

25 preflight?\" And he said, \"Yes, sir, I did.\"

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1 And he said, \"You\'re telling me that

2 you inspected the entire airplane, you inspected

3 the nose wheel and you didn\'t notice that four-

4 foot long, four-inch wide red tape hanging from

5 the nose wheel?\"

6 And he said, \"Notice it? Hell, I had

7 to move it out of the way to inspect the gear.\"

8 He was looking right past the obvious.

9 The change was that no longer did that

10 company, it was Eastern Airlines, they had a

11 process where they would put a nose gear pin when

12 they towed the airplane, and a mechanic had

13 inadvertently disconnected the tow bar, but

14 didn\'t take the pin out.

15 Pilots were quite used to seeing gear

16 pins. They see them all the time. So, you are

17 asking him to do two things at the same time.

18 They changed the process. Now the gear pin is

19 attached to the linkage, to the nose \-- tow bar.

20 It eliminated the process.

21 But the feedback mechanism, the bottom

22 line and the point being that the feedback

23 mechanism has to be people-understandable.

24 MODERATOR SCHILLING: All right.

25 We\'ve come full circle here. We originally

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1 talked about people as needing to inform people

2 that data, you know, data is great, but if you

3 don\'t execute, if you don\'t follow up then, you

4 know, it\'s all for naught. It\'s a problem you

5 think may be fixed, but it isn\'t.

6 So, I think the whole panel would

7 agree with that, that it boils down to educating

8 everyone around safety.

9 So, with that, if any of you have got

10 anything to add to our conversation, if not, I\'ll

11 open it up to questions from the floor.

12 Anyone have any questions that they\'d

13 like to ask this panel? It\'s hard to see with

14 the lights.

15 Yes. You might have to shout. Maybe

16 somebody will come with a mic.

17 UNKNOWN SPEAKER: I\'m the director of

18 safety for a very small airline and I have a

19 practical problem which I\'ll ask for some advice.

20 We have our metrics that we keep,

21 ground damage, rates, body injury rates, that

22 sort of thing, and we look at them and trend them

23 and look at them year-over-year, but sometimes

24 the CEO will turn to me and say, \"So, how are we

25 doing compared to the rest of the industry?\"

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1 And I don\'t have an answer for that

2 because I don\'t really have any way to get at

3 anybody else\'s damage numbers or injury numbers.

4 I get the feeling they\'re pretty close holds. We

5 don\'t belong to ATA. If we did, we\'d find them

6 on the internet, but again, we\'re too small for

7 that.

8 So, does anyone have any advice for me

9 on how to determine how my little airline is

10 doing with regard to the rest of the industry?

11 MODERATOR SCHILLING: Anyone want to

12 take that one?

13 DR. LOHL: Maybe generally, if I may

14 react on this because I\'m, of course, not

15 familiar with the little airline situation in the

16 United States, but little airlines in Europe, of

17 course, have to report this kind of incident or

18 this kind of things to the relevant authorities,

19 the operational approval authorities, and of

20 course the authorities have to exchange that kind

21 of data.

22 I think that\'s my answer to you. It

23 is, of course, not up to you to exchange with

24 your competition any kind of data, but it is the

25 agency, the authority responsible for your ALC,

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1 for instance, to receive that kind of data,

2 compare it, take actions out of it, inform maybe

3 in a more general way other small airlines, what

4 I personally see as one of the results of that

5 kind of activity that, if I am aware of a certain

6 kind of problem maybe related to a specific type

7 I would inform other airlines, but neutralized,

8 as I said and, of course, I would contact the TC

9 holder, the type certificate holder whether or

10 not there is something to do on the time.

11 Again, my general answer would be your

12 authority is the relevant body to whom you should

13 report and who should then react on that kind of

14 information.

15 DR. DEMUREN: I think I want to agree

16 with you on this. We have experience with a

17 small airline, one or two aircraft. I agree that

18 it is the responsibility of the stabilization

19 authority to digest all that information to

20 provide these.

21 And what you will find out is because

22 we want to encourage free reporting system. The

23 whole nation, the airline by name, it will come

24 out. The description will be very clear.

25 And you \-- so everybody can learn from

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1 it, because airlines are very \-- if you go out on

2 probably Airline A has this problem and this and

3 these, and it \-- the first thing is that it will

4 not come out.

5 They are afraid that the public will

6 see these, and they will see the airlines on it\'s

7 safe operation and therefore, this is the end.

8 So, the tendency is to bring that information and

9 lessons to be learned . Usually they\'re going to

10 bring this out, because that\'s the only way you

11 can \-- you have one or two aircraft, you cannot

12 measure \-- you are not going to have enough data

13 also to be able to see what is happening.

14 MODERATOR SCHILLING: Okay. Did that

15 help?

16 UNKNOWN SPEAKER: Yes.

17 MODERATOR SCHILLING: Any other

18 questions?

19 Yes.

20 MR. MEIJER: My name is Adriann

21 Meijer. I represent IATA safety. We have a

22 database, international database on incident-

23 sharing, and as a practical problem relating to a

24 remark Mr. Babbitt made, in the database if

25 people write incidents, they can write it in

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1 various ways regarding the language they use.

2 If you operate in China you will use

3 Chinese. If you are operate in France, or a

4 French-speaking country you will write in French.

5 If you operate in the States or English-speaking

6 countries, you will operate in English.

7 Now, if you start to share these data

8 in the same database you have a problem. What\'s

9 your view on this? How can we solve this?

10 MODERATOR SCHILLING: Anyone want to

11 take that one on?

12 Yes.

13 MR. BABBITT: I\'ve started \-- I

14 mentioned earlier, the common language, if you

15 would, meaning in data metrics, but I think, you

16 know, translating these types of incidents into

17 some common language, whatever the choice might

18 be, would be very helpful.

19 Overarching over that, I\'m somewhat

20 embarrassed to say that I think we set back the

21 reporting, the willingness to report incidents a

22 great deal just very recently. Some data came

23 out and reported very publicly incidents that

24 pilots had reported with the cover of immunity

25 years ago.

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1 Things like that set us back \-- we\'ll

2 be in the dark ages. People can cover up

3 mistakes like that, and that\'s the last thing we

4 want to do. We want to encourage this data to be

5 shared and we want that data to be provided with

6 complete immunity for the entire goal of making

7 the system safer.

8 You raise a good point, that in order

9 for that to be shared universally, that

10 information has to be distributed in a language

11 common to everyone. And I guess there is some

12 translation issues, but I think the effort should

13 be undertaken.

14 MODERATOR SCHILLING: Yes.

15 DR. DEMUREN: I think standardization

16 is important in this area, and I feel ICAO,

17 again, would take the initiative. I know IOTA

18 ask again, is the quality of work in this area.

19 I think it\'s very important because no

20 matter what you do, you can\'t always share this

21 information, then it\'s just useless. and it\'s

22 very important that we can have that. In fact,

23 similarly, the language to be used I think has to

24 be defined by ICAO and become a common practice

25 which everybody can benefit from. I think that\'s

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1 where it should go.

2 MODERATOR SCHILLING: Mr. Liu.

3 MR. LIU: Well, as far as I know,

4 there is a project between European Union and

5 China, which is the data-sharing by using the

6 same platform and \-- another name is eCare,

7 right? Yes, eCare.

8 I think those products have been

9 successful. We use the same category, we use the

10 same platform, and then, of course, for obtaining

11 the information, and therefore, Chinese flight,

12 we have to translate Chinese into English, then

13 we can share the information into that database.

14 So, of course, you know, translation

15 should be \-- could be needed, you know.

16 DR. LOHL. I would like to fully agree

17 with my colleagues, that must be, of course,

18 clarified, unified. Just a remark, you know, in

19 Europe, I\'m representing here 31 European member

20 states. 27 EU member states plus four voluntary

21 members.

22 You can imagine how many languages we

23 have to deal with in Europe. I would like to say

24 that\'s for sure world record. But we have solved

25 this problem. It is really not an issue in

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1 Europe, using the English language as the

2 standard language for submitting and exchanging

3 safety data.

4 MODERATOR SCHILLING: Okay. And so as

5 we get more global, we\'ve got to think about that

6 and what language or translators we have to put

7 in systems.

8 I think we also need, because we get

9 data shared around the world, we service around

10 the world, with respect to metrics, there needs

11 to be some kind of standardization of forms so

12 you know what you\'re looking for.

13 Everybody will write it down just a

14 little bit different, even though they may use

15 all English or all Spanish, they do write it down

16 a little different. So, maybe we can create more

17 of a standard form that becomes a standard that

18 clues you into, you know, the major events that

19 you might have to then go and translate to get

20 the details.

21 Anything else here? I don\'t see any

22 hands.

23 PARTICIPANT: I\'ll take this

24 opportunity to ask the next question. If you are

25 talking safety management systems terms, you

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1 infer you can close a certain loop which involves

2 action, taking responsibility for the outcomes of

3 the information that the system produces.

4 Now, we\'ve heard the word

5 \"standardization,\" and we also heard the word

6 \"global\" a lot. If I look at the it from a

7 global perspective on standardization, I don\'t

8 see a place where to go to to close the loop in

9 terms of action.

10 I see it on a company level, a CEO

11 ultimately. I see it on a national level. You

12 have the regulatory authority. But, on a global

13 level, I don\'t see it.

14 What\'s your view on this statement?

15 MODERATOR SCHILLING: Go ahead.

16 DR. LOHL: I don\'t know whether I got

17 really the core of your question, but I can \--

18 maybe I have to repeat that for us. The

19 responsibility of type certificate holders is

20 here, very prominent, and here there is a certain

21 kind of standardization of surveillance.

22 We, together with all our colleagues

23 worldwide, we review and survey design

24 organizations. The FAA here in the United States

25 here, we in Europe with our design organizations,

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1 and they have to comply with rules. There are

2 rules that they have to perform this data

3 assessment task and to present solutions to us,

4 to the agencies.

5 I think there is a certain kind of

6 standardization, at least with respect to TC

7 holders. If you mean for all kind of data, for

8 instance, operational data, airlines and so on,

9 then I agree with you, maybe there\'s an

10 additional initiative maybe on ICAO level

11 necessary, maybe as part of this universal

12 assessment program or whatever, I agree maybe

13 that must be reviewed.

14 MR. BABBITT: I might not answer your

15 question completely \-- not that that\'s stopped me

16 in the past. The idea, I think, that you were

17 trying to, if I understood, the idea of we don\'t

18 seem to have the feeling of global acceptance,

19 and I think if you really step back from any

20 system and take the human involvement, human

21 nature into the equation, this SMS system, on a

22 company basis, an individual basis, national,

23 global, we\'ll have achieved success when

24 everybody in that system says \"I want to do this.

25 There\'s something in this for me.\"

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1 Not, \"I\'m going to do this because

2 I\'ve been mandated to do this. I\'m going to do

3 this because I have to do this.\" We will have

4 achieved success, in my view, when we can say

5 \"We\'re all going to do this because there\'s a lot

6 in this for me. I\'m going to participate because

7 maybe I\'ll make somebody in Africa a safer

8 operation by reporting something we discovered.\"

9 That\'s when we will have achieved

10 that. And there is something, you know, why

11 should the CFO \-- I mean, some of these things

12 are going to cost money. This is not free. So,

13 why should the CFO of a corporation do anything

14 more than the regulators require them to do?

15 Well, I think eventually, maybe the

16 system says, \"You know what, if you are this

17 compliant and your system works so good, you\'ll

18 have a lower accident rate. Your insurance will

19 go down. You can actually safe money with this,\"

20 and I think we have to sort of sell this system

21 in to where people realize there is benefit for

22 all of us here, aside from a safer environment.

23 There\'s a lot of other components that go with

24 it.

25 And when everyone accepts that

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1 globally we will have achieved global success.

2 MODERATOR SCHILLING: Good. Anything

3 else?

4 It\'s late in the day, right?

5 Well, I want to really thank the

6 panel. They\'ve done a great job. This is a

7 tough, tough subject. Everybody is on kind of a

8 different plateau. We keep singing the same

9 song, though, which is good. We\'re just at

10 different levels. We need to continue to work

11 this and it\'s going to start with every

12 individual in the particular organization or

13 institution.

14 I couldn\'t agree more with that. So,

15 I want to thank you and please give them a round

16 of applause for their candor.

17 (Whereupon, the above matter was

18 concluded at 4:28 p.m.)

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