# Presentation: 266180

## Flight Operations Quality Assurance (FOQA)

**Captain Jeff Bayless**
*Director - Flight Safety*
- United Airlines

*International Symposium on Transportation Recorders*

## FOQA Objectives & Philosophy

**Promote the free-flow of safety related information**
**Identify and correct unsafe practices**
**Provide feedback**
**Provide information**

**Notes:**
Promote the free-flow of safety related information

Identify and correct operating practices that may lead to an incident
Provide feedback regarding compliance with standard operating procedures

Provide information in the areas of air transport operating efficiency, air traffic control, and airport design

In general terms, it is of critical importance to ensure the flow of safety related information to flight operations, engineering, and back to the pilot group.

Detailed analysis of FOQA data will be of immense value in identifying “Soft Spots” in our daily operation that may lead to an incident if uncorrected.  

FOQA data will also be an additional feedback tool regarding compliance with established operating procedures such as stabilized approaches, taxi speeds, and Ground Proximity Warning System activation.  On the engineering side, we will receive valuable information regarding aircraft systems and performance.

Further, detailed analysis of arrival speeds, descent rates, and aircraft configuration will permit analysis of air traffic control efficiency.  As an example, the information would permit documentation of the impact of “Slam Dunks” on stabilized approaches and descent rates during arrival.

## Established a Steering Committee

Reviewed other carriers’ Letters of Agreement

(SAS, British Airways, and ALPA proposed agreement)

**Reviewed other carriers’ Letters of Agreement**
**(SAS, British Airways, and ALPA proposed agreement)**

**Notes:**
Established a Steering Committee of ALPA and United representatives to define initial program guidelines and milestones 

Reviewed the contents of other carriers’ Letters of Agreement

(SAS, British Airways, and ALPA proposed agreement)

Flight Operations Quality Assurance was an industry initiative through the Flight Safety Foundation.

United established a Steering Committee of ALPA and Company representatives to develop the framework and timetable for program elements.

This core group reviewed the language written into other carriers’ Letters of Agreement.  Of particular interest were LOA’s of mature programs such as British Airways.

Following a thorough review of existing programs, the Steering Committee drafted a hybrid document that met United’s specific program objectives.

The draft Letter of Agreement was approved and signed in (date).

The FAA must promulgate a rule to protect information gathered through the FOQA Program from use in any certificate or disciplinary action and to guarantee immunity for those participating.  At present, we have secured FAA immunity through a letter signed by the FAA Administrator,  Mr. Henson.  

**Drafted objectives**
**Signed UAL/ALPA Letter of Agreement**
**Received FAA guarantee of immunity**

**Notes:**
Drafted hybrid document to meet United’s specific program objectives

Signed UAL/ALPA Letter of Agreement

Received FAA guarantee of immunity

## Developed trust between pilots and the Company

Steering Committee established a Technical Team and Exceedence Guidance Team

**Steering Committee established a Technical Team and Exceedence Guidance Team**

**Notes:**
Each step of the initial planning process was carefully implemented to ensure the development of trust between pilots and the Company

Steering Committee established a Technical Team and Exceedence Guidance Team

Of extreme importance was the development of a trusting relationship between the pilot group and the Company.  This was primarily achieved through joint development of the Letter of Agreement and program elements--a true team effort in every sense of the word.

The Letter of Agreement established a provision for a Technical Team and Exceedence Guidance Team, each with specific responsibilities.  These Teams are responsible for developing the day-to-day procedures used in managing the program.  The Steering Committee subsequently initiated action to fill ALPA and Company positions on these Teams. 

**Technical Team **
**Steering Committee **

**Notes:**
Technical Team defined specific procedures to manage data, ensure confidentiality, and define exceedence parameters

Members include pilots who are qualified as instructors/evaluators and noted engineering experts
The Steering Committee reviews significant safety issues identified during data analysis

Members are several ALPA captains respected for their experience and expertise
The Technical Team’s first initiative was to define specific procedures to manage data and to define exceedence parameters.

Since these exceedence parameters include events applicable to both Flight Operations and Engineering, the Team included experienced pilots and recognized engineering experts.

The Exceedence Guidance Team’s primary responsibility is to review significant safety issues identified during routine data analysis.

This Team is composed of several ALPA captains respected for both their extensive experience and superb flying skills.  In essence, they are respected and trusted by their peers.

## A320 recording capabilities

Placement and routing structure

Data Bus Mapping

**Placement and routing structure**
**Data Bus Mapping**

**Notes:**
A320’s are equipped with Quick Access Recorders (QAR’s) providing tremendous flexibility in identifying and recording a broad array of operational and maintenance parameters.  All 31 of United’s A320’s are equipped with Optical QAR’s.

A320 aircraft are based on the West Coast, the East Coast, and centrally located in Chicago, thus providing information regarding operations into most domestic airports.  

The aircraft were delivered with a state-of-the-art flight data acquisition capability that permitted operator selection of the desired recorded parameters. 

## Minor deviations from SOPs

Trend analysis

Issues addressed through simulator training & general training materials

Flight Crew anonymity guaranteed

**Trend analysis**
**Issues addressed through simulator training & general training materials**
**Flight Crew anonymity guaranteed**

**Level I “Informational” Parameters**

**Notes:**
Technical Team members drafted a set of performance parameters that reflected United’s aircraft operating procedures.  Parameters may be relaxed to eliminate “nuisance” exceedences.

United established THREE levels of exceedences rather than two levels, i.e.., Level I, II, and III exceedences.

Level I “Informational”  exceedences is the primary indicator that performance is beginning to deteriorate from desired norms.

Operational issues surfaced during data analysis may be addressed in Transition Training or during annual Recurrent Training programs.  In many cases, the pilot group can be easily made aware of growing concerns through existing training materials.

Flight crew members are guaranteed anonymity, a critical element of an effective program.

## Significant deviations from SOPs

Enhanced trend analysis and detailed event analysis

Flight Crew anonymity guaranteed

**Enhanced trend analysis and detailed event analysis**
**Flight Crew anonymity guaranteed**

**Level II “Alert” Parameters**

**Developing Exceedence Parameters**

**Notes:**
Significant deviations from SOPs that require prompt attention

Enhanced trend analysis and detailed event analysis to ensure appropriate corrective measures

Flight Crew anonymity guaranteed

Level II “Alert” exceedences are significant deviations from SOPs that requires prompt  resolution.

Level II events are reviewed more carefully  to ensure understanding as to why the event occurred.  Corrective measures are jointly developed by individual Fleet and ALPA representatives.

Once again, flight crew anonymity is guaranteed.

## Major deviation from SOPs

Event could result in aircraft damage

Data is provided to Exceedence Guidance Team for review

**Event could result in aircraft damage**
**Data is provided to Exceedence Guidance Team for review**

**Level III “Safety” Parameters**

**Notes:**
Major deviation from SOPs

Event could result in aircraft damage

Diskette containing data is provided to Exceedence Guidance Team for review
Level III “Safety” exceedences are major deviations from expected operating procedures.  

Level III events are incidents that could result in aircraft damage such as a tail strike on takeoff or failure of an engine reverser to operate normally.  An engineering Level III, e.g.., may include information regarding an engine performance and component reliability.

Once a Level III event is identified during initial analysis, a diskette containing data is provided to the Exceedence Guidance Team for review.

Only the ALPA Exceedence Team has the ability to identify and contactcrew members.

The Exceedence Team has several options following event review:
 Decide to take no action.		       --Hard landings requires
Recommend voluntary de-identified training         immediate engineering
Recommend issuance of a Safety Bulletin	          analysis.
Recommend SOP or training syllabus changes

**Exceedence Team has ability to identify crew members**
**Team can recommend voluntary de-identified training, issue a *****Safety Bulletin*****, or SOP changes**

**Level III “Safety” Parameters**

**Notes:**
Exceedence Team has ability to identify crew members

Following event review, the team can recommend voluntary de-identified training, issuance of a Safety Bulletin, or SOP changes

## Program support - initial and future

Establish equipment specifications

Define confidentiality agreement

**Establish equipment specifications**
**Define confidentiality agreement**

**Notes:**
United selected two companies, Teledyne and The Flight Data Company (FDC), to provide FOQA hardware and software for UAL evaluation.  

Initial vendor support included system set-up in our San Francisco Flight Safety office and appropriate training on system operation.

We envision United’s FOQA Program to evolve continuously, thus requiring continuous vendor support to ensure system modification or enhancement to meet future needs.

FOQA support equipment must be reliable, process data expeditiously, operate with minimal manpower, and be easily reprogrammed should exceedence parameters be revised.

The vendor must have access to data base information to ensure proper system operation.  Should a system fault occur, vendor participation will likely be required for problem resolution.  Agreements exist with both companies that prohibit sharing United data base information.

## Trial period/system verification - July to December 1995

Over 3656 flights (9467 hours) were accumulated

QAR diskettes were removed every 2-3 days

**Over 3656 flights (9467 hours) were accumulated**
**QAR diskettes were removed every 2-3 days**

**Notes:**
Vendors programmed the ground systems with UAL developed parameters.

Parameters and system operation was validated from July - December 1995.  Over 3,656 flights (9,467 hours) were accumulated during the 6 month test program.  Typically, the QAR diskette is removed by maintenance every 2-3 days and provided to Flight Safety for analysis.

UAL conducted a Steering Committee Trial Review of data collected during the test period in January, 1996.

UAL and ALPA jointly provided the pilot group with details about the gathering and handling of information gleaned from QAR data analysis.  In general, acceptance has been favorable.

Although FOQA has been an established program since July, 1995, the first FOQA quarterly report will cover the period of January through March, 1996.

**Steering Committee trial review - January 1996**
**Pilot education/notification**
**First formal report was published in April 1996**

## Potential problem of using the FOQA program for incident discovery rather than trend analysis

Technical Team needed stronger Engineering representation.  Flight Operations is making greater use of FOQA data than Engineering

**Technical Team needed stronger Engineering representation.  Flight Operations is making greater use of FOQA data than Engineering**

**Notes:**
Potential problem of using the FOQA program for incident discovery rather than trend analysis
Technical Team needed stronger Engineering representation.  Flight Operations is making greater use of FOQA data than Engineering
Early in the development process, we recognized the possibility of using the FOQA program only for incident discovery rather than as a useful tool for performance and trend analysis.  Level 1 and 2 events are useful indicators of areas that require additional training emphasis.  It is easy to get trapped into focusing only on Level 3 events as an the sole indicator of our operational integrity.
In retrospect, the Technical Team needed stronger Engineering representation to develop more parameters that would meet engineering’s need for information regarding fleet health.  At present, Flight Operations is making greater use of FOQA data than our Engineering counterparts.
Initial parameter definitions reflected the high standards of our pilot group but  were perhaps a bit too “idealistic” in some respects.  Several parameters have been relaxed to avoid “nuisance” exceedences.

Vendor selection required much more time than originally expected.  It takes several months to learn how to operate two different data management systems and to test them in an operational environment.  This problem is further exacerbated by vendor reluctance to spend great sums of money prior to signing a contract.

We discovered that we needed to assign a full-time person to manage development of the program, particularly during the first six months.

## Initial parameter definitions were too restrictive and generated “nuisance” exceedences

Vendor selection required more time than originally estimated

Assign full-time person to develop program

**Vendor selection required more time than originally estimated**
**Assign full-time person to develop program**

**Notes:**
Initial parameter definitions were slightly too restrictive and generated “nuisance” exceedences

Vendor selection required more time than originally estimated

Assign full-time person to develop program

## Universal Tech. Resource Services, Inc. Study

Demonstrate benefits of FOQA

Identify critical success factors

Develop roadmap and start-up checklist
Participation:

Fleet Engineering (B737-522 and B777 )

Other Air Carriers

Integrate Video Simulation Replay

**Demonstrate benefits of FOQA**
**Identify critical success factors**
**Develop roadmap and start-up checklist**
**Participation:**
**Fleet Engineering (B737-522 and B777 )**
**Other Air Carriers**
**Integrate Video Simulation Replay**

**Notes:**
UTRS has been selected by the FAA to conduct a study to:
-  Demonstrate safety/operational benefits of FOQA programs to airlines.
-  Determine critical success factors for implementation of FOQA programs.
-  Provide detailed information on resource (cost, time, & personnel) requirements.
-  Partnerships established with four other U.S. Carriers.
-  Developing a roadmap and checklist for initial start-up of FOQA programs.

United will select and purchase a video simulation replay unit to prepare visual presentations of significant events.  These videos may be used for event analysis and flight crew training.

## Questions & Comments

**Questions & Comments**