Guidance Documents for Aviation,
Space and Defence Organizations

Appendix-2- Flight Safety Training - April, 2014 Published- June, 2017 Revised(Added English translation for Examples)1

Table of contents
1. Objectives
2. Scope
3. Terms and abbreviations
4. Flight safety training
4.1 The objectives of the training
4.2 The commitment of top management
4.3 Training content
4.3.1 The flow and content of the training
4.3.2 Training method
4.3.3 Utilization of examples

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Table of contents (continued)
5. Example
5.1 Emergency landing - British Airways Flight 5390
5.2 China Airlines Flight 120 fire
5.3 Japan Self-Defence Forces jet crash into a riverbed
5.4 Handling of ultra-high tensile strength steel leading
to damage of parts
5.5 Engine stoppage during a flight caused by material
defects

6. Reference documents/related web sites
7. Editor’s Note3

1. Objectives
 Aviation and space hardware or instruments are comprised of many
parts, and each of them play an important role in flight safety.
However, in the respective work sites, there is always a possibility that
operator could not keep aware of “the fact that each of the daily worktasks/operations are directly connected to flight safety” is reduced,
and that tendency is particularly strong in manufacturing work sites
for materials, parts, etc. where it is difficult to imagine the completed
aircraft. For that reason, it is extremely important for organizations toactively provide training about flight safety to the personnel and getthem to understand its importance.
 The objective of this guidance material is to help organizations in theaviation, space and defence industries when they are implementing
flight safety training by providing guidelines regarding whatperspectives the organizations should take when planning andimplementing training, and several examples related to flight safety
training materials.
42. Scope■ This guidance is suitable for use as an training guide when providing
flight safety training for the following organizations, personnel,products, and processes.
(1) The organizations and personnel should be the organizations andpersonnel in the aviation, space and defence industries.
(2) The products should be for "flight" in the broad sense, and include
spacecraft and systems, as well as aircraft.

(3) The processes should be the processes from manufacturing ofmaterials and parts/components to final assembly/maintenance.
(4) The training that is covered here is not only promoting awareness offlight safety that leads to the prevention of harm to persons orproperty damage during operations, but can also be applied toachieving operational missions, etc.
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3. Terms and abbreviations(1) Flight safety
The state in which the risk of harm to persons or property damage
caused by a flight is reduced to, and maintained at an acceptablelevel(2) Approved Organizations
Organizations that have received approval based on the Civil
Aeronautics Act, Article 20 to engage in the design, manufacturing ormaintenance, etc. of aircraft or components(3) 2.5 person perspective
This is a perspective for handling the operations which combines the“3rd person perspective" thinking as an expert and the "1st personand 2nd person perspective" thinking what if oneself or one’s family
member is a victim of an accident.
(4) Failure Mode and Effects Analysis (FMEA)This is a method of analyzing the failure modes of constituent
elements and their effects of top-ranked items in order to discoverimperfections and latent defects in design(5) Risk map (R-Map)
Map showing the risk tolerance in the figure obtained by multiplying
the extent of the damage and the occurrence frequency

64. Flight safety training
It is important for each organization to repeatedly andregularly provide training in accordance with theguidelines in Section 4.1 and subsequent sections of thisguidance material to ensure that the personnel
understand the importance of flight safety and the factthat their respective daily work tasks/ operations aredirectly connected to flight safety.
Note that under the revision* to the Ordinance for Enforcement of the Civil Aeronautics Act,the introduction of a Safety Management System (SMS) is required for Approved
Organizations. “Flight safety training“ is included as a part of the introductionof the SMS.
* In relation to the Ordinance for Enforcement of the Civil Aeronautics Act, Article 35, theintroduction of a safety management system was added as an approval criterion for theseorganizations. (Promulgated on November 5, 2010)7

4. Flight safety training
4.1 The objectives of the training
Objective of the training is to ensure that all of thepersonnel involved in the aviation, space and defence
industries understand :■ The importance and scariness of flight safety as a problemof their own facing a close-at-hand problem.
■ The risk that the level of performance of their work by eachand every person" has an effect on flight safety.
■ The truth that Flight safety is realized by ensuring that “thequality expected in subsequent processes” frommanufacturing of materials and parts/components to aircraft
body assembly/ maintenance is "inherited without anyinterruption."84. Flight safety training
4.2 The commitment of top management■ It is necessary for the top management tocommunicate a clear message to personnel involved in
the aviation, space and defence industries that flightsafety is important.

94. Flight safety training
4.3 Training content

4.3.1 The flow and content of the training
It is preferable to implement training related to "flight safety" in accordance with the following flow. *)• Accident example information(event, background, cause, degreeof impact)• Potential incident• Customer operation information

Response after the training• Past non-compliant cases• Critical item information• Simple technicalgrounds• Tour of operational side(1)
Understandtheimportanceof flightsafety
Expected
effect• Understandscariness• Improve morale(2)
Understandthe functionsof our own
products,
and the way
they areused by theend users
Expected
effect• Increase
motivation(3)
Understandthe impact
our own
work has onflight safety
Expected
effect• Build
awareness ability(4)
Permanent
prevention(asnecessary)(5) Evaluate
residualrisks (asnecessary)

Expected
effectFor example….
• Add “warnings” to theprocedural manuals• Incorporate them intraining materials*) It is acceptable to implement these steps separately but it is necessary to implement them repeatedly and regularly. 104. Flight safety training
4.3.1 The flow and content of the training(1) Understand the importance of flight safety- Understand that deliberate corner-cutting, violations, near miss in our own
work lead to major accidents ■ It is desirable to include the following in the information that is necessaryfor the training(i) Present examples of accidents(ii) Explanations of the background and causes
Against what background and due to what action that was taken (or not taken) bywhat person did the incident or accident occur?
(iii) The resultant effects ― on the crew/passengers, their families, society, thecompany■ What if the victim was you or your family? Get the employee to think fromthe 2.5 person perspective.
■ Videos, books, movies, theater plays, etc. of the aircraft accident are alsoeffective■ Raise morale and quality awareness by understanding the scariness of thefact that deliberate corner-cutting, violations, and near miss can lead to aserious accident and prevent these behaviors by ourselves.

114. Flight safety training
4.3.1 The flow and content of the training(2) Understand the functions of our own products, and the way they are used by theend users■ It is desirable to include the following in the information that is necessary for thetraining(i) Operational information of end users and customers(ii) Critical item information■ Tours, etc. of the customers and end users are also effective■ The information of the customers and end users can beobtained from the following and other sources(i) Contract documents(ii) The training by the ordering party(iii) Appropriate handling by the ordering party with respect to the demands from the supplying party■ Normally the customers (the ordering party) have the responsibility of transmittingthese types of information, but it is also important for the people receiving the orders
to have the attitude of obtaining the information and getting their suppliers tounderstand it.
■ The employees can gain a strong sense of the aircraft body composition whichcannot be understood from individual parts, etc., which leads to improved motivation.
124. Flight safety training
4.3.1 The flow and content of the training(3) Understand the impact that our own work has on flight safety― Understand how the output of our own work is involved with flight safety ―■ It is desirable to include the following in the information that is necessary
for the training(i) Potential incident in the related industries(ii) Past potential incident of alarm and non-compliant cases that occurred inside the organization(iii) Explain the grounds for the technical requirements using simple words, diagrams, and videos
Why the narrow tolerance of precision bore holes is necessary, what would happen if the heat
treatment condition of the material changed, the scariness of improper material, stressconcentration with respect to damage, fastening with incorrect torque/contact pressure,preventing loosening, the direction in which bolts are inserted, film thickness requirements, etc.
■ Anticipate (identify) the risks that could have an impact on flight safety, and aim toimprove awareness ability■ It is important for each and every individual to participate in thinking asa group about the risks, rather than only relying on unilateral presentations
from superiors and the bureau of training, etc.
■ For the anticipation of risks use of techniques such as “Failure Modeand Effects Analysis" (FMEA)/"Risk Map" (R-Map), etc. is effective
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4. Flight safety training
4.3.1 The flow and content of the training(4) Permanent prevention― Transmit to the following successor in charge, etc., and visualize ―■ Examples of permanent prevention• Add "[Warnings]", etc. to operating procedure, work book etc.
• Add to training materials as “things which must not be done", etc.

(5) Evaluate residual risks (as necessary)■ Conduct evaluations of the residual risks after implementation of
the measures and as necessary permanent prevention again
144. Flight safety training
4.3.2 Training Method(1) Instructors■ Select personnel who are appropriate as person who understand flightsafety and can evaluate the effectiveness of the implemented training.
(2) Training material■ It is necessary to use the following tools, etc. to implement the training
repeatedly and regularly.
• Classroom training (OFF-JT), e-learning, posting of teachingmaterials on LAN, provision of training within some meeting formats(tool box meeting is also possible) and in OJT(3) Effectiveness evaluations■ It is necessary to not only provide the training but also evaluate the levelof understanding of the students and provide the training again whenneeded.
• Evaluation tools: tests, oral questions by the instructors, questionnaires, ordinary
behavior, etc.
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4. Flight safety training
4.3.3 Utilization of examples
Utilize the following examples, the cited documents/related websites in Chapter 6, etc. to provide training materials suited to thebusiness format and needs of the organization.
(i) Understand the importance (scariness) of flight safety• Emergency landing - British Airways Flight #5390 (Section 5.1)
• China Airlines Flight 120 fire (Section 5.2)
• Japan Self-Defence Forces jet crash into a riverbed (Section 5.3)(ii) Understand the impact that our own work has on flight safety• Handling of ultra-high tensile strength steel leading to damage of parts(Section 5.4)-- Discussion based on F-111 crash caused by damage to the aircraft’swings -• Engine stoppage during a flight caused by material defect (Section5.5)
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5. Example
5.1 Emergency landing - British Airways Flight 5390

Reference:“Report ofthe Air Accidents
InvestigationBranch”(AAIB)
http://www.aaib.gov.uk/cms_resources.cfm?file=/1-1992%20GBJRT[2].pdf
http://www.aaib.gov.uk/cms_resources.cfm?file=/1-1992%20GBJRT%20Append.pdf

175. Example
5.2 China Airlines Flight 120 fire

Reference:“Report of the AirAccidents”(AA Jul.
2009)
Japan Transport
Safety Board
http://www.mlit.go.j
p/jtsb/aircraft/repacci/AA2009-7-2B18616.pdf

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5. Example
5.3 Japan Self-Defence Forces jet crash into a riverbedEducation to pass down the “Fear” for manufacturing / maintenance work of aircraft <Part 1>

Think about aircraft accident
Quoting from the text of ethical education of elementary school

A self-defense official who died on duty

This material quotes the ethical education of elementary school
which deals with a subject that the Japan Self-Defense Force jetcrashed into river bed but the pilot didn’t eject and continued to fly
the aircraft to avoid crashing on private houses.

A small mistake might become a threat to the safetyof aircraft used over many years. It should be realizedthat the quality level required by customer ismaintained. Moreover we shall realize a mistake
which occurs at the rate of the one of thousand, theone of ten thousand may lead to a serious accident.
Humankind that invented aircraft and can fly in thesky have learned a lot with numerous casualties bymany accidents. The most important thing is follow
rules and do our works perfectly. That is ourresponsibilities and pride. A person who does nothave the confidence with this, does not fit for theaircraft manufacturing work. Never forget that thereare persons who put their lives in our works.
Reference:
http://www.sanjo.nct9.ne.jp/yocchaki/kigai/junshoku/junshoku.html

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5. Example
5.4 Handling of ultra-high tensile strength steel leading to damage of parts

Reference:“Changes of designconcept of aircraftstructures” by Kouichi
Hiraoka
Journal of the Japan
Society of Aeronautical& Space Sciences:
Vol.55, No.63, 2007.1

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５．Example
５．５ Engine stoppage during a flight caused by material defectCommercial Airline Accident
Underlying Issue – Material DefectProblem – Engine gear failure due to raw material contamination
Impact – Engine failure, but because dual engine aircraft no loss of life or injury
Why – Contamination of raw stock not detected before gear manufacturing

Lessons Learned –••••

Ensure there is a robust inspection process to eliminate contamination of the raw material.
The importance of a heightened awareness and oversight of inspection processes required of raw material
suppliers.
It is impossible to find material defects in post-process (e.g. assy. line). Quality assurance of material isimportant (critical). Therefore, it is mandated to manage supplier quality.
Ensure that the raw stock supplier understands the importance of their material as it relates to the criticalityof the product usage.
Impurity[FOD] inmaterial (0.8mm length)

Causing the engine-shaft fractured
during take-off climb.

Pilot stopped one of 2 engines, andlanded as emergency landing.

DamagedengineSource: Japanese Ministry of Land,Infrastructure, Transport & Tourism
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6. Reference documents/related websites
 AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT(AI2010-6) <JAPANESE ONLY>
http://jtsb.mlit.go.jp/jtsb/aircraft/download/pdf/AI10-6-1-JA847C.pdf

 Air Accident Information (Ministry of Land, Infrastructure, Transportand Tourism: Japan Transport Safety Board)
http://www.mlit.go.jp/jtsb/english.html

 Safety Management Manual (SMM) Doc 9859 International CivilAviation Organization (ICAO)

The concept of Safety (Section 2.1)
Safety Culture (Section 2.6)
http://www.icao.int/SAM/Documents/RST-SMSSSP-13/SMM_3rd_Ed_Advance.pdf

 The Human Contribution – Unsafe Acts, Accidents, and Heroic
Recoveries - James Reason (Author)

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6. Reference documents/related web sites(continued)
Implementation of the Construction of a Safety Culture in the JAL Groupand Future Issues <JAPANESE ONLY>
http://www.atec.or.jp/Forum__09__PNL_JAL.pdf

 Yotaro Hatamura: Failure Knowledge Database
http://www.sozogaku.com/fkd/en/index.html

 NTSB AVIATION ACCIDENT DATABASE
http://www.ntsb.gov/aviationquery/index.aspx

 National Diet Library AIRCRAFT ACCIDENTS IN JAPAN <JAPANESEONLY>
http://www.eonet.ne.jp/~accident/ Wikipedia: Aviation accidents and incidents by subcategory
http://en.wikipedia.org/wiki/Aviation_accidents_and_incidents

 On-Duty Deaths of Japan Self-Defence Force Officials by Yoshinori
Kobayashi <JAPANESE ONLY>
http://www.sanjo.nct9.ne.jp/yocchaki/kigai/junshoku/junshoku.html

 Play: Charlie Victor Romeo [CVR = Cockpit Voice Recorder].
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7. Editor’s Note
We commenced writing this guidance on the instruction of JAQG Strategy WG that keenly realized the necessity of ensuring that thepersonnel understand the importance of flight safety in order to prevent the recurrence of quality problems that have been occurring in theaviation, space and defence industries in recent years.
At the stage of making a draft form, the issue we directly encountered was people saying that “even if you talk about flight safety, the further
upstream you go, to materials manufacturers, etc. the more cases there are where individual workers are not even aware of whether or not
the materials are used in aircraft, etc., and they do not really know what you mean when you talk about flight safety training."
Of course the people working in the upstream sectors probably do not think about where the parts they have made themselves are used inaircrafts, what functions the parts have, or what would happen if the parts failed to fulfill their functions, etc.
However, it is a fact that due to parts processing mistakes, etc. human lives are directly threatened, and a significant number of accidents
related to flight safety has been occurring.
Near miss and errors in our own work affect the lives of people close to us; moreover once an accident has occurred, it does not only leadto misfortune for those people close to us; but also the company, etc. which caused the accident may have to pay compensation and be
held socially responsible, etc. for what happened, and as a result may not be able to continue existing as a company and could be pushed
out of business.
We think that there are a variety of ways of investing the time and effort and emphasizing points in each process, but in any case, it isnecessary at the least to ensure that workers understand that “manufacturing of aircraft is directly connected to the safety of human lives",
so we included as much of the content necessary for awareness of flight safety to penetrate in upstream sectors in this text as possible. We
hope that these materials will be used effectively for that purpose.
Furthermore, regarding the maintenance sector and assembly sector, we think there are probably already many cases of flight safety
training being implemented, but as the technologies come to mature awareness of doing “work that involves being responsible for lives”
tends to weaken because even when there are potential incidents or small instances of non-compliance, there is no experience of serious
accidents in which people die. For that reason, these materials can also be utilized in training aimed at continuing to reaffirm theimportance of flight safety.
Finally, we would like to emphasize that in order to provide flight safety training effectively, not only the supplier who provides the training
but also the people who orders the contracts have an important role. For example, the contractee should explain how the products areused, what is important, etc.

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