# Presentation: 266163

## British Airways’ Flight DataAnalysis Programme 1969 - 1999Captain Mike HoltomSenior Manager Safety ServicesBritish Airways

## “Yard cars will have ‘black box’ recorders”- THE TIMES 11 March 1999

- speedbrakingcar signalsuse of sirens & blue lights

- “...better able to reconstruct crashes using the boxes”

## A View of Safety Management

- Safety Dept, Safety
- Committees, BASIS,
- FDR, etc

- Loss control,
- Legislation

- Policy, Plan,
- Procedures,
- Standards,
- Culture, etc

- Risk Assessments,
- Audits, FOQA,
- Safety Mgmt Trng,
- COSHH, etc

- Incidents,
- Accidents,
- Dangerous
- Occurrences

*DRIVERS:-*

***PROACTIVE***
***= CONTROL***

***REACTIVE***
***= LOSS***

*MANAGEMENT:-*

*MONITORING:-*

## Brief History

- 1958	Analogue accident-protected recorders		photographic & scribing		FAA mandate - 4 parameters on foil
- 1962	BA Research		first commercial flights
- 1966	Digital accident-protected recorders		UK CAA mandate - 5 parameters on wire
- 1966	Cassette-loaded QAR developed 				Autoland development
- 1968	Computer-based playback  and analysis 		fully operational

## BA Hull Losses 1952 - 1998

- 30 losses in
- 26 years

- 2 losses in
- 21 years

## BA’s FDR Programme

- Flight operations monitoring (SESMA / FOQA)
- Engine health monitoring
- Airplane performance monitoring
- Autoland analysis
- Incident investigation

## BA’s FDR Programme

- Management	Culture, Personnel, Confidentiality, “Key person”
- Union	Co-operation, Feedback, Commitment
- The Authority	Legislative framework, Facilitation
- Hardware / software	Recorder, Replay/analysis system, Networks

- The Old FOQA Process

**SESMA**

- Event
- Database

**Notes:**
Flight data is recorded on the aircraft on cassette or optical disc, or in solid state memory. The medium is then replayed at high speed through the SESMA computer, which is programmed to search for "events" or "exceedances", i.e.. occasions when the aircraft has gone outside pre-determined limits.

Whenever an "event" is discovered, a trace is printed out covering 4 minutes of flight time around the event. This can then be studied in detail.

Brief details of the event are also entered into SESBASE: a database of SESMA events that can sort by date, aircraft type, event type, airfield, flight phase and so on.

## Event Detection

**Event Detection**

- High Pitch on Landing

- Triggered
- an Event

## Flight Ops Monitoring(Exceedences)

- Operating boundaries
- Pilot induced  e.g. flap selection, touchdown pt
- Environmental  e.g. turbulence, windshear, r/ws
- Design  e.g. GPWS, EGPWS, TCAS, structures
- Performance  e.g. engine out, GPWS, TCASgo-arounds, difficult approaches
- Auto-severity indexing
- Uses actual parameter values
- Combined with expert knowledge-base

## Engineering Data

- Engine performance monitoring 	Overspeed / overheat / vibration / blade balancing
- Aircraft performance monitoring 	cf manufacturer’s spec, e.g. fuel burn, flap life
- Fuel consumption	Aerodynamic and engine efficiency, rigging
- ETOPS	Certification and on-going validation
- Ad hoc data 	Hard landings, autoland, false/nuisance GPWS

## Other Benefits

- Detail for incident investigation, e.g. 737 yaw, DHA
- Data to support cases for improvement,e.g. 747 loss of elevator control, r/w surfaces
- Individual playback on crew request
- Simulator validation against aircraft
- Research, e.g. fuel ToD to T/D, noise procedures

## FDR in BA Today

- 5 Gigabytes analysed daily
- Around 65 flight parameters
- Approx 6,000 events per year
- 94% playback rate
- Fully funded by savings
- Union / Management contract

## QAR Parameters by Fleet 

- QAR Parameters by Fleet** **

- B777-200
- B747-400
- B767-300
- A320
- B757-200
- L1011
- Concorde
- B747-200
- B737-200
- DC10
- BAC1-11

- B777 data:
- 60,000 available
-   2,000 to QAR
-      700 to crash
-             recorder

- The New FOQA Process

- Primary
- analysis

- MaxVals

- PC Trace

- Simulation/Animation

- Procedure validation

- Auto severity calc

- Flight path

- Trends & Links

- 5 Gb daily

## BASIS 1999

**ACCIDENTS**
**& DANGEROUS**
**OCCURRENCES**

**EVENTS**

**HUMAN**
**FACTORS**

**RAMP**
**INCIDENTS**

**H&S**
**AUDITS**

**SIMULATION**

**Hazardous**
**Substances**

**Personnel**

**Payroll**

**Flight Crew**
**Database**

**SAFETY**
**INFORMATION**
**EXCHANGE**

**REPLAY &**
**ANALYSIS**

**RAMP**
**AUDITS**

**MAXVALS**

**AIRS**

**Job Risk**
**Assessments**

**Properties**
**Databases**

**PATH**

**HELIBASIS &**
**AIRFORCE**

**CABIN **
**INCIDENTS**

**TRACE**

**AIR**
**SAFETY**
**INCIDENTS**

**SECURITY **
**INCIDENTS**

**Quick Access Recorder**

**FDR**

## BASIS Flight Data Trace

## Sample FOQA Events

- 1A		Vmo Exceedence
- 1B		Vmo Exceedence (Birdstrike)
- 2		Mmo Exceedence
- 3A		Flap Placard Speed Exceedence
- 4		Exceedence of Flap/Slat Altitude
- 5		Exceedence of Max Operating Altitude
- 6A		Approach Speed High within 90 Secs of T/D
- 6B		Approach Speed High below 500ft AAL
- 6C		Approach Speed High below 25ft AGL
- 7A		Approach Speed Low within 2 mins of T/D
- 8C		Climb Out Speed Low 35ft AGL to 400ft AAL
- 8D		Climb Out Speed Low 400ft to 1500ft AAL

## Sample FOQA Event Alert Levels

- 1A		Vmo Exceedence		Vmo + 10 kts for 3 secs
- 1B		Vmo Exceedence		Vmo + 20 kts for 5 secs
- 		(Birdstrike)
- 2		Mmo Exceedence		Mmo + 0.02 for 3 secs
- 3A		Flap Placard			Placard for 2 secs
- 		Speed Exceedence
- 4		Exceedence of 			Placard + 500ft for 2 secs
- 		Flap/Slat Altitude

## Event Processing - Part 1

## Monthly FOQA Meeting

- FDR Working Group Chairman
- Aircraft Performance Engineer
- FDR Analyst
- Fleet Training Manager
- Union Fleet Representative
- “Key person”
- Safety Services Manager
- Additional Specialists as required

## Event Processing - Part 2

**GPWS "Pull-up" Warnings**
- 1991-1992 Study

-  301 warnings in the study
-  60% of all warnings did not incur go-around
-  20% of genuine warnings received no action
-  Only 13% of "Pull-up" warnings were genuine
-  Highest go-around "g" increment was 0.1

**GPWS "Pull-up" Warnings**
- Study Following Policy Change
- and Simulator Training

- 121 warnings in this study
-  All incurred go-around action except 9
-  These 9 occurred in VMC in the climb

## Severity Factors

- A method of assigning a
- "degree of seriousness”
- to every SESMA/FOQA event.

**Notes:**
The next sequence of slides explains the concept of "Severity" of SESMA events. In risk management it is imperative to be able to distinguish between a great many relatively minor events which may present little risk, and just a few  major ones that could present a significant risk.

## Severity Auto-Indexing

**Notes:**
Optimal Decision Maker - developed for European Space Agency and also used in the nuclear power industry.
It is a hypothetical “expert” which best represents a synthesis of all the experts canvassed. A formula is calculated using the parameters for each SESMA event, each parameter having a range of values. The assessments of 40 experts of varying disciplines, were taken for each event.
The formula is derived from identifying two fixed points relating to the risk relevant to the event; e.g.. Vmo exceedence - severity factor of 0 below Vmo and at some point above there is a speed at which the experts consider the aircraft to be in immediate jeopardy - this is given a severity of 100. So indices greater than 100 are possible. In fact Vmo+28 kts was the value awarded a severity of 100.
When an event is entered into SESBASE, a severity index is automatically calculated. Analysis of the high risk areas of operation are then easier to identify.

## Severity Auto-Indexing

**Notes:**
Optimal Decision Maker - developed for European Space Agency and also used in the nuclear power industry.
It is a hypothetical “expert” which best represents a synthesis of all the experts canvassed. A formula is calculated using the parameters for each SESMA event, each parameter having a range of values. The assessments of 40 experts of varying disciplines, were taken for each event.
The formula is derived from identifying two fixed points relating to the risk relevant to the event; e.g.. Vmo exceedence - severity factor of 0 below Vmo and at some point above there is a speed at which the experts consider the aircraft to be in immediate jeopardy - this is given a severity of 100. So indices greater than 100 are possible. In fact Vmo+28 kts was the value awarded a severity of 100.
When an event is entered into SESBASE, a severity index is automatically calculated. Analysis of the high risk areas of operation are then easier to identify.

## Severity Auto-Indexing

- SI = [27.3 * abs(X) ^1.2] * (100/Y)^0.28

**Notes:**
Optimal Decision Maker - developed for European Space Agency and also used in the nuclear power industry.
It is a hypothetical “expert” which best represents a synthesis of all the experts canvassed. A formula is calculated using the parameters for each SESMA event, each parameter having a range of values. The assessments of 40 experts of varying disciplines, were taken for each event.
The formula is derived from identifying two fixed points relating to the risk relevant to the event; e.g.. Vmo exceedence - severity factor of 0 below Vmo and at some point above there is a speed at which the experts consider the aircraft to be in immediate jeopardy - this is given a severity of 100. So indices greater than 100 are possible. In fact Vmo+28 kts was the value awarded a severity of 100.
When an event is entered into SESBASE, a severity index is automatically calculated. Analysis of the high risk areas of operation are then easier to identify.

## Flight Ops Monitoring(MaxVals)

- Records dataset for every flight
- Fuller picture of every-day operation
- Monitors technique and efficiency
- Allows cross-fleet comparisons
- Standard Operating Procedures (SOPs)
- Adherence (individual and group)
- Appropriate and viable
- Training feedback, monitoring & validation

## MaxVals - Rates of Descent

**Measured below 2000 ft AAL**

## MaxVals - Rates of Descent at LAX

## MaxVals Rates of Descent

**B767-336                    B747-436**

## MaxVals - Normalised Comparison

## Flight Instrument Replay

## Flight Path

**Flight Path**

## British Airways’ Flight DataAnalysis Programme 1969 - 1999Captain Mike HoltomSenior Manager Safety ServicesBritish Airways