SAFETYWIRE IN THIS EDITION PAGE 1

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1 SAFETYWIRE YOUR MONTHLY SOURCE FOR SAFETY INFORMATION MAY 2018 VOLUME XVIII ISSUE V IN THIS EDITION PAGE 1 The Risks of Circling Approaches PAGE 3 Managing Change Safely PAGE 8 Safety Manager s Corner PAGE 9 Quote of the Month On Short Final... The Risks of Circling Approaches BY: Steve Witowski, PRISM Sources: AIM; FSF Discussion Paper Comparing a circling instrument approach to a straight in approach falls into the apples to oranges comparison metaphor. Circling to land around an airport at a low level brings multiple unusual risk factors into play. It is inconsistent from airport to airport because of variables such as runway layout, final approach track and obstacles in the airport vicinity or transient variables such as prevailing wind and other meteorological conditions. Therefore, no single designed circling procedure will apply to a circling approach in every situation. The Airman s Information Manual describes circling approaches as follows: Published circling minimums provide obstacle clearance when pilots remain within the appropriate area of protection. Pilots should remain at or above the circling altitude until the aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers. Circling may require maneuvers at low altitude, at low airspeed, and in marginal weather conditions. Pilots must use sound judgment, have an in-depth knowledge of their capabilities, and fully understand the aircraft performance to determine the exact circling maneuver since weather, unique airport design, and the aircraft position, altitude, and airspeed must all be considered. 1

2 The Flight Safety Foundation conducted a survey of pilots, asking for their understanding of the requirements to commence descent from MDA on a circling approach. The response sample shown below clearly indicates a variety of interpretations, indicating there is no common understanding of when to commence descent to landing from MDA. Question: When to descend? Responses: Only when visual contact can be maintained and on the middle of the base leg, never earlier. Within 30 degrees from the final approach track This depends on whether visual or have achieved circling criteria. This is interpreted that you cannot descend below Circling Minima until you intercept the nominal approach angle, or you declare visual in the latter case the crew become fully responsible for terrain avoidance. If the Circling minima are high (above 1500ft AAL - normal basic training circuit altitude) some operators ask crews to ensure that the aircraft remain within the protected area at all times. To achieve this it may mean descending before the base turn is commenced to ensure a normal descent angle to landing. Before leaving MDA certain criteria must be met. Ideally the RWY environment should be visual at every stage of the descent but practically this may not always be the case, particularly if the MDA is high or there is a prescribed track associated with the circling maneuver. The really important point is that we must assure ourselves that the predicted flight path of the aircraft will remain in a clear area at all times with regard to both weather and obstacles before a descent is commenced. The crew must maintain the MDA until the runway threshold has been positively identified by the PF and that a normal FPA can be achieved to land in the TDZ, a steep or a flat descent should not be attempted, if at any stage the visual cues of the runway are lost, a missed approach should be initiated Generally, crew should stay at circling MDA/ H until necessary for approach and landing; this is often on base leg. This is based on the height of MDA and the interception of a normal glide path. Fly at circling minima (AP and AT engaged) all the way to the end of the downwind leg and commence descent when turning bas. Landing threshold acquired by PF and the aircraft is in a position to carry out a landing. 2

3 It is important that the descent is to be made in a way to allow for a stabilized approach. Some operators require that the MDA be maintained until the aircraft has maneuvered to within a 300-degree angle of the extended runway centerline. Is there consistent understanding among all the pilots in your flight operation? A discussion might reveal some interesting perceptions. A careful examination of SOPs for circling approaches during this discussion would also provide benefit. Managing Change Safely BY: Susan Cadwallader, PRISM Source: Various Imagine a company that realized it had a lot of leftover oil from an aircraft that it had recently sold to another company. Furthermore they did not have any of the correct oil they needed for their current aircraft. They were afraid somebody would try to use the incorrect oil in their current aircraft. While this is certainly an immediate concern, there is a larger overarching concern that needed attention too change management. In other words, what other things did they have left over from the sold aircraft and how could those items (parts, manuals, support equipment, etc) affect them now? What risks should they be assessing as a result of selling an aircraft? There has been a lot of focus (and findings) on the management of change during SMS audits over the last couple years. This article will provide the ICAO and FAA references on the topic as well as some suggested techniques for your organization s process to do change management. The most important takeaway from this article should be: Change Management in SMS is concerned about managing the risks associated with change and that you have a process to discover and manage those risks. Aviation service providers experience change due to a number of factors including, but not limited to: a) Organizational expansion or contraction. Examples include acquiring or selling major equipment, building or moving to a new facility, and hiring or laying off employees. b) Changes to internal systems, processes or procedures that support delivery of the products and services. For example the use of new flight management software may require changing procedures and training in order to use it. 3

4 c) Changes to the organization s operating environment, which may be thought of as external changes. For example, an increase in fuel prices may cause the organization to change their scheduling, routes and/or aircraft utilization. Other examples might include a change in regulatory requirements or a change in the security situation nationally or locally. Change may affect the appropriateness or effectiveness of existing safety risk mitigation strategies. In addition, new hazards, and related safety risks may be inadvertently introduced into an operation whenever change occurs. Such hazards should be identified so as to enable the assessment and control of any related safety risks. So What Does SMS Require for Change Management? The ICAO Safety Management Manual (SMM) summarizes the goal of change management in SMS Element 3.2 (under the Safety Assurance Component) as follows: The service provider shall develop and maintain a formal process to identify changes which may affect the level of safety risk associated with its aviation products or services and to identify and manage the safety risks that may arise from these changes. Now contrast that with the FAA view in the Safety Assurance Component section of Advisory Circular B SMS for Aviation Service Providers : 5.71 Safety performance monitoring and measurement. (a) The certificate holder must develop and maintain processes and systems to acquire data with respect to its operations, products, and services to monitor the safety performance of the organization. These processes and systems must include, at a minimum, the following: (2) Monitoring of the operational environment to detect changes. 4

5 You may notice that the FAA s statement above in AC B is focused on specifying that the operational environment should be monitored for change but does not address what to do about identified changes. As it turns out though, this is simply a matter of presentation: Conducting Safety Risk Assessment (SRM) for items resulting from change is actually addressed quite a lot in AC B but it is found elsewhere in the Fundamentals section and in the Safety Risk Management Component section. Here are some excerpts: The risk analysis also needs to consider the basis for the estimates of severity and likelihood. What is it about the factors analyzed in [System Analysis and Hazard Identification], individually or in combination, which could result in an accident? Have you changed equipment that your employees must use, the procedures for using it, the layout of the facility, etc., in ways that could increase the likelihood of errors resulting in an accident?...the SRM process is triggered when proposed new systems or changes to systems are being considered....managers that have the authority to implement changes in systems and procedures must use the SMS processes in managing their area of operational responsibility. So assuming we accept that both ICAO and the FAA want the same thing aviation service providers shall manage the risks associated with change and have a process to discover and manage those risks., then what remains is how to do it in your organization. In order to address that we need to first think about your organization and its systems. The organization s management of change process should take into account the following three considerations: a) Criticality. Criticality assessments determine the systems, equipment or activities that are essential to the safe operation of aircraft. While criticality is normally assessed during the system design process, it is also relevant during a situation of change. Systems, equipment and activities that have higher safety criticality should be reviewed following change to make sure that corrective actions can be taken to control potentially emerging safety risks. b) Stability of systems and operational environments. Changes may be planned and under the direct control of the organization. Such changes include organizational growth or contraction, the expansion of products or services delivered, or the introduction of new technologies. Unplanned changes may include those related to economic cycles, labor unrest, as well as changes to the political, regulatory or operating environments. c) Past performance. Past performance of critical systems and trend analyses in the safety assurance process should be employed to anticipate and monitor safety performance under situations of change. The monitoring of past performance will also assure the effectiveness of corrective actions taken to address safety deficiencies identified as a result of audits, evaluations, investigations or reports. 5

6 As systems evolve, incremental changes can accumulate, requiring amendments to the initial system description. Therefore, change management necessitates periodic reviews of the system description and the baseline hazard analysis to determine their continued validity. With those considerations in mind, the next step is to map and document the change management process you are going to use. Start by using your existing operational processes as feeders to the change management process. Then lay out the milestone steps that would be needed to accomplish the change. For each milestone step, list any risks that may arise as result of that milestone. For each identified risk, take it through the formal risk assessment process as follows: a. Assess the risk based on your company s risk matrix b. Develop controls using the Hierarchy of Controls. c. Assess the residual risk with the same risk matrix this time with the controls in place. d. If the project is accepted, implement / communicate the controls. 6

7 In step #3 above, use separate forms to help brainstorm risk identification and the associated decisions that get made as a result. Be sure that however you build your change management process, it can directly trace the link between the proposed/actual change and the risks associated with it. In summary, this article has referenced important excerpts from both ICAO and the FAA on the management of change in SMS. Additionally it has offered some advice on how to build and document your change management process. The key take-away is that Change Management in SMS is concerned about managing the risks associated with change and that your organization has a process to discover and manage those risks. 7

8 Safety Policy The first element of SMS is Management commitment and responsibility in which a safety policy is required to be created in accordance with international and national requirements. Creating the safety policy statement is one of the first things that an organization does when it embarks on the implementation of SMS and it should be periodically reviewed to ensure it remains relevant and appropriate to the service provider. So how did your organization review its safety policy this year? Was it just a read-through and a vote or was there a discussion? It might first be useful to list the minimum requirements of the Safety Policy according to ICAO. The Safety Policy shall: a) reflect organizational commitment regarding safety; b) include a clear statement about the provision of the necessary resources for the implementation of the safety policy; c) include safety reporting procedures; d) clearly indicate which types of behaviors are unacceptable related to the service provider s aviation activities and include the circumstances under which disciplinary action would not apply; e) be signed by the accountable executive of the organization; f) be communicated, with visible endorsement, throughout the organization; and g) be periodically reviewed to ensure it remains relevant and appropriate to the service provider Here are some additional questions the organization may want to ask about it s safety policy: 1. Does the language sound oriented toward the front line operator / employee or is it in high level speak? In other words do employees feel when they read this that the organization is trying to talk to them or do they feel this language is intended for a lawyer? 2. What major people, process or physical changes have occurred in the organization in the last year that might warrant an adjustment in the Policy Statement? 3. Has the statement been vetted against the company s mission and vision statements if applicable? 8

9 Quote of the Month Change is inevitable, progress is optional BY: Tony Robbins The old saying about death and taxes being inevitable is missing one piece change. It happens all the time and there are two ways to deal with it: get ahead of it or ignore it. Those that get ahead of it take the time to evaluate the change and made logical decisions. Those that ignore change will eventually find themselves behind in some way that may come back to haunt them. On Short Final. 9