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1 ASC-TRM

2 70 (02) (02) / AIRS FOM FOQA ICAO LOAS FOQA ICAO , ,000 FOM LOAS AIRS ASC-TRM

3 ASC-TRM : : / / : / / / / : , : (1) (2) (3) (4) (5) 8. : ( ), : ( ) :

4 Airbus ASC-TRM

5 Flight Operation Quality Assurance(FOQA) Line Operation Monitoring System(LOMS) Aviation Safety Reporting System(ASRS) Aviation Safety Reporting System(AIRS) Flight Operation Monitoring(FOM) Global Aviation Information Network(GAIN). NASA LEIDIN UNIVERSITY ASC-TRM

6 (AIRBUS) (CATHAY PACIFIC AIRWAYS) 200 CATHAY CITY ASC-TRM

7 ASC-TRM

8 ASC-TRM

9 Flight Operations Quality Assurance FOQA ICAO , , A View of Accident Prevention from an Accident Investigator Perspective Kwok Chan Airbus Kwok Proactive Safety Systems Latent threats and Active failures ASR MOR LOSA FOQA FDR QAR Lessons Learned report (De-identified) 2 ASC-TRM

10 Event Kwok Chan Airbus Prevention is better than Reaction 1 4 ASC-TRM

11 Accident Scenario Crisis Situation Unplanned Hits you when least expect Launch of Crisis Plan Media attention Your world is suddenly turned Upside Down Operations Monitoring Scenario Routine review Trend analysis Incoming reports Special study or Survey Regular operation work 1. On-Scene or Initial tasks Get to the scene Familiar environment Formation of Working Groups led by Activate safety committee meeting IIC Set objectives for review Health and Safety awareness On- Gather all available and relevant data Site On-Site data gathering Preservation of Evidence 2. Data Retrieval / Recovery Search and rescue takes priority Ready access to recorders Recovery of recorders responsibility Routine downloading of State of Occurrence may not have resources Condition Unknown 3. Analysis of Data State of Occurrence may not have processing capability Use of another State s facilities and resources Time Pressure Travel Internal Analysis A few key people Confidential Own equipment and resources Use of manufacturer s resources Set / Agree time scales 4. Crew Statements Crew Interview (if Available) Crew Reports Immediately after incident / Confidential, protected accident (Agreement) Under the auspices of the IIC Identifiable by Flight Safety Pilot Union Rep. present Manager (FSM) only Under stress, tension on both Crew Interview (if required) sides To obtain clarification Language differences One-to-One, between FSM and Fear of Incrimination Crew Member ASC-TRM

12 Sometimes non co-operative, confrontational Between persons of trust, cooperative spirit Non-punitive Clear objectives; seeks to enhance safety 5. Final Report Factual Report Analysis Topics Probable Cause Safety Recommendations Lessons Learned Corrective actions launched No punishment Confidential Enhancement of safety A300 ASC-TRM

13 A320 ASC-TRM

14 A A330 CVR FDR ASC-TRM

15 3.2 Airbus Anne FABRESSE Line Assistance Director Flight Operation Monitoring FOM 5 Airbus FOM Line Operations Monitoring System LOMS 6 7 deviation flight profile AIRBUS 8 LOMS dots dots 50 3 Line Operations Assessment System LOAS Airbus LOAS LOSA Aircraft Incident Reporting System AIRS AIRS Airbus Teledyne DFDAU LOMS QAR/FDR Teledyne Flight Data Replay and Analysis System FLIDRAS ASC-TRM

16 5 Airbus Proactive Vs. Reaction 6 LOMS I ASC-TRM

17 7 LOMS II 8 LOMS dots dots 50 ASC-TRM

18 3.3 Neil Campbell BASI Neil QAR 1992 L1011 B QAR B : 23 B F: 4 B :7 B : 5 A A Cooperated Safety Department CSD QAR B F A320 B A A B QAR ,321 FDC FDC Spirent GRAF VAX PC Airbus LOMS Spirent Vision QAR OQAR GPWS / TCAS Warnings Limit Speeds (VMO, MMO, Flap & Gear) Take-off/Landing Speeds Pitch/Roll Limits Rushed Approaches (Late Landing Flap, High ROD s) XX.3 HK AOA QAR 9 LOMS A340 3 ASC-TRM

19 3 10B Unstick Speed Low V2-8:1sec V2-8:1sec V2-8:1sec V2-8:1sec V2-8:1sec 10C Tyre limit Speed Vtyre-5:1sec Vtyre-5:1sec Vtyre:1sec Vtyre-5:1sec Vtyre:1sec 20A Pitch attitude high takeoff 10deg:1sec 10deg:1sec 12deg:1sec 11deg:1sec 12deg:1sec 20B Pitch attitude high landing 10deg:1sec 10deg:1sec 12deg:1sec 11deg:1sec 12deg:1sec 20C Pitch attitude low landing -1deg:1sec -1deg:1sec 0deg:1sec 0deg:1sec 0deg:1sec 21A Bank angle (20-100ft) 10deg:1sec 10deg:1sec 10deg:1sec 10deg:1sec 10deg:1sec 21B Bank angle ( ft) 30deg:1sec 30deg:1sec 30deg:1sec 30deg:1sec 30deg:1sec 21C Bank angle (>500ft) 35deg:1sec 35deg:1sec 35deg:1sec 35deg:1sec 35deg:1sec 21D Bank angle (<20ft) 12.8deg:1sec 14deg:1sec 8deg:1sec 8deg:1sec 8deg:1sec 22A ROD (<400ft) 1200fpm:1sec 1200fpm:1sec 1200fpm:1sec 1200fpm:1sec 1200fpm:1sec 22B ROD (1000 to 400ft) 1200fpm:1sec 1200fpm:1sec 1200fpm:1sec 1200fpm:1sec 1200fpm:1sec 22C ROD (2000 to 1000 ft) 1700fpm:1sec 1700fpm:1sec 1700fpm:1sec 1700fpm:1sec 1700fpm:1sec 22D Height Loss - Initial Climb 100ft:1sec 100ft:1sec 100ft:1sec 100ft:1sec 100ft:1sec 22F Slow Climb to 1000 ft 60secs 60secs 60secs 60secs 60secs 22H Descent Rate ft 5000fpm:1sec 5000fpm:1sec 5000fpm:1sec 5000fpm:1sec 5000fpm:1sec 23A Normal Accel - Ground <.6g or >1.4g <.6g or >1.4g <.6g or >1.4g <.6g or >1.4g <.6g or >1.4g 23B Normal Accel - Airborne <-1g or >2.5g <-1g or >2.5g <-1g or >2.5g <-1g or >2.5g <-1g or >2.5g 23C Normal Accel - Landing >1.5g >1.5g >1.5g >1.5g >1.5g 23D Hard Bounced Landing >1.5g then >1.4g >1.5g then >1.4g >1.5g then >1.4g >1.5g then >1.4g >1.5g then >1.4g 24 Go-Around <200ft <200ft <200ft <200ft <200ft 26 Abandoned Takeoff >90knots >90knots >90knots >90knots >90knots 40B Flap Slow or Stationary (not in gated position) 45secs 45secs 45secs 45secs 45secs 40C Speed Brake with Flap Nil Nil >7deg:2secs Nil >11deg:2secs Gross Power Change within 41 2mins TD >85%:3secs >85%:3secs >1.4EPR:3secs >1.3EPR:3secs >1.4EPR:3secs 42 Low on Approach (3mins to 2mins before TD) 800ft:2secs 800ft:2secs 800ft:2secs 800ft:2secs 800ft:2secs 44 GPWS Any mode:2secs Any mode:2secs Any mode:2secs Any mode:2secs Any mode:2secs Reduced Lift Margin 45A (CL/CLmax) >0.826:2secs >0.826:2secs >0.826:2secs >0.826:2secs >0.826:2secs 45B Reduced Lift Margin Climbout >0.876:2secs >0.876:2secs >0.876:2secs >0.876:2secs >0.865:2secs 46A Stick Shaker Nil Nil 1sec 1sec Nil 47 Early Configuration Change 1500ft:1sec 1500ft:1sec 1500ft:1sec 1500ft:1sec 1500ft:1sec 48A Late Land Flap <1000ft:1sec <1000ft:1sec <1000ft:1sec <1000ft:1sec <1000ft:1sec 48B Incorrect Land Flap <21deg:1sec <25deg:1sec <25deg:1sec <25deg:1sec <25deg:1sec 49 TCAS RA RA:1sec RA:1sec Nil RA:1sec Nil 50C Deep Landing >3000ft:1sec >3000ft:1sec >3000ft:1sec >3000ft:1sec >3000ft:1sec 56A Below Glide Slope 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 56B Above Glide Slope 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 56C Left of Centre Line (below 600ft) 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 56D Right of Centre Line (below 600ft) 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs 1dot:2secs ASC-TRM

20 61 Low Buffet Margin >20,000ft (CLb/CL1g) <1.2:2secs <1.2:2secs <1.3:2secs <1.3:2secs <1.3:2secs 70A Alternate Law (Airbus) 1sec 1sec Nil Nil Nil 70B Alternate Law 2 (Airbus) 1sec 1sec Nil Nil Nil 71 Alpha Floor (Airbus) 1sec 1sec Nil Nil Nil 72 Windshear (Airbus & 777) 1sec 1sec Nil 1sec Nil Code Description A330 A340 B744 B777 B747F 9 LOMS 3.4 CAAC CAAC % 23% FOQA FOQA CAAC FOQA FSD 1997 No Provisional technical requirements for QAR and its ground supporting system IB FS Requirements for using airborne QAR to realize flight technique monitoring and quality analysis ASC-TRM

21 QAR % QAR 75% QAR FOQA FOQA ASC-TRM

22 3.5 [ ] G. Defer FOQA parameters operational baseline LOMS unsafe trend / 1 4 LOC G/S A/D 10 Flight Parameter Visualisation Tool FPVT PFD 11 what lies behind the words I.E. rotation speed low/hi changed to early/late rotation the interpretation can sometimes be wrong if not correlated with the actual context (weather, type of approach, ATC constraints, etc.) ASC-TRM

23 20 Raw data parameters LOMS visualisation Speed Pitch Sidestick input Time (s) FPVT looks alike, but it is not a PFD Raw data (recorded) : - CASC - RALT - GSC - ILS DME (4 s rate)... Computed parameters : - IVVC - Bird... LOC and GS show only if guidance mode engaged... Never shows FD bars 11 FPVT DME IVV LOC G/S ASC-TRM

24 flight profile deviation LOMS 13 Information : flags used to identify specific conditionselementary : Threshold overshoot from one directly recorded parameter or warning (raw data) i.e. Deviation GS... Elaborated : Threshold overshoot from a parameter elaborated with several raw data parameters i.e. Path High Composite : giving higher level monitoring capability by ANDing (logical conjunction) of other events i.e. Continuously High 12 ASC-TRM

25 3.6 Mike Harrison JAA Flight Data Monitoring FDM JAA 30 QANTAS FDM JAA JAA 70% JAA SOP FDM 13 JAA JAA ICAO FDM JAA JAR-OPS JAR-OPS IEM JAA Jet & Turboprop engine JAR-OPS An operator shall establish an accident prevention and flight safety programme, which may be integrated with the Quality System, including: Risk awareness programmes and; Evaluation and promulgation of relevant accident and incident information. 1. Guidance material for the establishment of a safety programme can be found in:a. ICAO Doc 9422 (Accident Prevention Manual); andb. ICAO Doc 9376 (Preparation of an Ops Manual). 2. Where available, use may be made of analysis of flight data recorder information (See also JAR-OPS 1.160(c).) JAA JAR-OPS JAA JAA JAA ICAO ASC-TRM

26 JAA ICAO Flight Recorder Panel FLIRECP ICAO 26 ANNEX6 Part1 Amendment , , Annex 6, Part 1, Amendment 26 Standard From 1 January 2002, operators of an aeroplanes of a MCTM in excess of kg should establish and maintain a flight data analysis programme as part of its accident prevention and flight safety programme. (3.6.3 From 1 January 2005, an operator of an aeroplane of a MCTM in excess of kg shall establish and maintain a a flight data analysis programme as part of its accident prevention and flight safety programme. ASC-TRM

27 4 27 Manufacturer Aircraft type Manufacturer Aircraft type Manufacturer Airbus A300 Boeing 707 British Industrie Aerospace Airbus Industrie (BAC) A310 Boeing 717 British Aerospace (BAC) Aircraft type One-Eleven VC10 Airbus Industrie A319 Boeing 727 Bombardier CRJ700 Regional Jet Airbus Industrie A320 Boeing 737 Bombardier Global Express Airbus A321 Boeing 747 Fokker 100 Industrie Airbus A330 Boeing 757 Fokker 70 Industrie Airbus A340 Boeing 767 Fokker F.28 Industrie Antonov An-124 Boeing 777 Gulfstream Gulfstream III Aerospace Antonov An-72 Boeing (McDonnell- DC-10 Gulfstream Gulfstream IV Douglas) Aerospace Antonov An-74 Boeing (McDonnell- Douglas) DC-8 Gulfstream Aerospace Gulfstream V BAE Systems RJ Avroliner Boeing (McDonnell- Douglas) DC-9 Ilyushin Il-76 BAE Systems RJX Boeing (McDonnell- MD-11 Lockheed L-1011 TriStar Avroliner Douglas) BAE Systems 146 Boeing (McDonnell- MD-80 Tupolev Tu-134 Douglas) Boeing (McDonnell- Douglas) MD-90 Tupolev Tu-154 Yakolev Yak Manufacturer Aircraft type Antonov Antonov An-12 An-32 Bombardier Dash Ilyushin Lockheed Lockheed Shorts IL-18 Hercules L-188 Electra SC.5 Belfast ASC-TRM

28 European Flight Data Conference IS FDM Operators NO S FIN EE JAA Full Members JAA Members RU IRL DK RU LV LT BY KZ UK NL PL P E F B D L CH MC IT CZ A SK HU SI HR BA YU MK AL EL RO BG MD UA TR GE AM AZ IR MA DZ TN MT SY Safety Regulation CY Group IQ 13 JAA ASC-TRM

29 ASC-TRM ICAO JAA FAA

30 Airbus ASC-TRM

31 ASC-TRM

32 LOMS Mr. Neil Campbell ASC-TRM

33 FDR QAR I FDR QAR II ASC-TRM

C09003825.doc

C09003825.doc 258 (02) 2547-5200ex.175 (02) 2547-5200 1 2 3 4 5 / CAAC ASC-TRM-01-08-001 2 ASC-TRM-01-08-001 3 : : : : 1. 2. 3. 4. 5. 6. 7., : (1) (2) (3) (4) (5) 8. : ( ), : ( ) : ASC-TRM-01-08-001 4 16:45 08:45 09:00