SOPs 2015
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Transcript of SOPs 2015
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DEPARTAMENTO DE ESTANDARIZACIONFebrero 2015STANDARD OPERATING PROCEDURES (SOPs)
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Procedimientos y SOPsPara asegurar el cumplimiento efectivo con los procedimientos y SOPs publicados, es importante entender porque los pilotos se desvan de ellos en forma intencional o inadvertida.
En la mayora de los casos de desviacin, los procedimientos que se siguen en vez de los correctos, parecen ser los apropiados, considerando la informacin disponible.Constituyen la referencia para estandarizacin de tripulaciones y proporcionan el ambiente requerido para mejorar una comunicacin y coordinacion de tripulacin eficiente.
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Objetivos de los Procedimientos y SOPsEstablecer un proyecto de accin comnReducir las ambigedades y riesgos de errorGarantizar un mejor reparto de tareasReducir la carga de trabajo de la tripulacinFacilitar el dominio de las acciones y erroresContribuir al conocimiento de la situacinReducir los riesgos de conflictos ICAO Operacion de Aeronaves IATA HFWG en Adherencia a los SOP
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Esquema y Objetivos de la PresentacinEn pocas anteriores:Los incidentes y accidentes estaban relacionados con catstrofes estructurales, de motor oFallas de los sistemas o por el mal tiempoLas evoluciones tcnicas han llevado a una disminucin de fallas catastrficas
Actualmente:Las causas primarias y contributivas son en su mayora relacionados con la tripulacin (dos de cada tres)
La no adherencia a los procedimientos y SOPs como una amenaza:Las fuentes de error humano abundan: ADREP de la OACI, FSF ALARLas Auditoras de Seguridad en Lnea de las operaciones de ruta (LOSA) y la presentacin de informes confirman el aumento de errores de procedimientos
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No Adherencia a los ProcedimientosFactores en accidentes de Aviacin 1970-2007ICAO ADREP
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Auditorias de Seguridad en Operaciones de Lnea (IOSA)Frecuencia de los ErroresCuales son las consecuencias?
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El Aumento del No Cumplimiento de los ProcedimientosLos procedimientos se estn haciendo cada vez ms para promover la conducta de la tripulacin hacia lo que se considera seguroUn diseo Duro" combinado con defensas procesales "suaves" animan las desviacionesLa sobreabundancia de procedimientos de trabajo standard se deriva principalmente en:la necesidad de adaptarse a los constantes cambios de hbitos y polticasla necesidad de aumentar la capacidad y eficiencia de las operacionesla necesidad de gestionar un entorno cada vez ms complejo? La comprensin del incumplimiento se puede hacer desde una variedad de ngulos: Cognitivo, de Comportamiento, Ergonmico, Gestin de la Seguridad y Anlisis de Datos.
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23 Tipos de No Adherencia a los ProcedimientosNo percepcin de la informacin relevante (entrada)Percepcin errnea de la informacin (bsqueda de patrones)Diseo de Procedimiento (entrada, interpretacin)Experiencia Procesal / formacin (memoria a largo plazo)Los aspectos culturales (los factores que influyen)Personalidad aspectos / actitudes (factores influyentes)Los factores situacionales (factores influyentes)Heurstica de toma de decisiones (toma de decisiones)CRM (el conocimiento y manejo de atencin)Reducido a nueve subcategoras de medidas correctivas:ENTRENAMIENTOOPERACIONESDISEO
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Ocho Tipos de No Adherencia de ProcedimientosCuatro tipos de violaciones basado en niveles de rendimiento:Violaciones de rutina: practicas comunes que se convierten en normas de grupoViolaciones de optimizacin: un desafo a las reglas que son muy restrictivasViolaciones situacionales: dictadas por el entorno inmediatoViolaciones excepcionales: circunstancias inusuales o no familiaresCuatro tipos de error basados en la taxonoma operacional:Errores de Procedimiento: intencin correcta/ ejecucin incorrectaErrores de Comunicacin: Trasmisin/interpretacion incorrectaErrores de desempeno: conocimientoand/or skill operational decision errors: unnecessary increase in risk
Violaciones Intencionales y No Cumplimiento No Intencional (errores)
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Absence of Recognition Leading to Nonadherence to ProceduresWhat is absence of recognition other than a trap into lack of rigor?
Sheet1
EVENTRECOGNITIONPROCEDUREREMARKS
WARNINGEXECUTION
LOSS OF IRS DATA"ATT" FLAG IS NOTSOPs FOR NOT MOVING"ATT" WARNING WILL
AFTER TAKEOFFDISPLAYED ON PFD, WITHTHE AIRCRAFT DURING IRSBE DISPLAYED AS
A 300 - 600HONEYWELL IRU, IF A/C IS MOVEDALIGNMENTSOON AS EXCESSIVE
JUST AFTER PFD DISPLAYMOTION DETECTED
COMES ON
RETURN TO GATEFQI LESS THAN REQUIREDON PREVIOUS LEG, ARRIVAL FOB
ALT TO THR CLB /NOT CHECKED VERSUS DEPARTURE
OPEN CLB WITHFOB LESS TRIP FUEL PER SOP
AIRCRAFT DESCENDING
AT IDLE
A 320
BRUTAL DOORECAM DISPLAY RESOLUTION?SOP STATE "CHECK DIFFERENTIAL
OPENING AT GATEPRESSURE IS ZERO"
A 300 - 600
EVENTRECOGNITIONPROCEDUREREMARKS
CREW DIAGNOSISEXECUTION
NAVIGATIONNO F-PLN ABNORMALITYNO FOR F-PLN CROSSED
DEVIATION AFTERNOTED DURING COCKPITCHECK ?
GO AROUNDPREPARATION
NAV DEVIATION DETECTED BY ATCFOR NAV MONITORING
DURING SID ?
NAV LINE ANOMALY
OBSERVED ON PFD
RADAR VECTORS ISSUED TO
RECOVER F-PLN AT "TO WPT"
Sheet2
EVENTRECOGNITIONPROCEDURECREW ACTIONREMARKS
CREWCONTENTS
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIRPOSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYCRM AND WORKLOAD ISSUESMOKE WARNINGS
EVENTRECOGNITIONPROCEDURECREWREMARKS
WARNINGCONTENTSACTION
RTO DUE TOECAM WARNING TRIGGERED BY
ENGINEPREVIOUS CREW AWARENESS
THRUST LOSSMESSAGE A.ICE ENGNOTE TO BE ADDED IN FCOMLATE RTO ACTIONNEED TO AVOID SUCH
A330VALVE OPENTO ANTICIPATESITUATIONS IN ANY
INTERLINK BETWEEN CREWECAM AT 80 KT /FUTURE DESIGN
A. ICE ENG 1 VALVE OPEN CREWAWARENESS MESSAGE ANDRTO AT 180 KT
AWARENESS MESSAGEECAM WARNING
ACTIVATED AT HOLDING POINT
Sheet3
EVENTRECOGNITIONPROCEDUREPROCEDURECREW ACTIONREMARKS
CREWCONTENTSEXECUTION
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCFAILURE TO COMPLETEDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIR"CAB PRESS MAN CTL"POSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSPROC BEFORE CALLING EVACUATIONOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYAND DOING THECRM AND WORKLOAD ISSUESMOKE WARNINGS
"ON GROUND EMER / EVAC" PROC
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Recognition Issue Leading to NonadherenceHow can recognition issue lead to procedural adherence?
Sheet1
EVENTRECOGNITIONPROCEDURECREWREMARKS
CREWEXECUTIONACTION
ENG FAILED TOLOW POWERENG SET AT IDLE ONLYFOT AND FCOMFOT AND FCOM
REACH TAKE OFFHIGH FUEL LOWENG NOT SHUTDOWNREVISIONREVISION
POWER DUE TOVISIBLE FUEL LEAKPLANNEDPLANNED
FUEL LEAKFROM ENGINE
A 320
Sheet2
EVENTRECOGNITIONRECOGNITIONPROCEDUREREMARKS
WARNINGCREW DIAGNOSISEXECUTION
ENG TAIL PIPE FIRENO ENG FIRE WARNINGENG TAIL PIPE FIREENG FIRE DRILL APPLIED
A 310TRIGGEREDREPORTED BY ATCENG TAIL PIPE FIRE NOT APPLIED
ENG FLAMEOUT DUEUNDETECTEDFUEL OUTR TANKQRH PROCEDURE NOTFUEL FEED
TO FUEL STARVATIONAUTOFEED FAULTLOW LEVELFOLLOWEDFROM OUTR TANK
A 300 - 600DISREGARDED AS SUSPECTEDFOLLOWING FAULT
SPURIOUS
THROTTLE LEVERTHROTTLE LEVER NOT AT IDLEAIRCRAFT PUSHED TRACTORNON COMPLIANCE WITH6 EVENTS SO FAR
NOT AT IDLENOT SET AT IDLEABOUT 10 FEET BACKSOPs FOR SETTING THR
DURING MESMESSAGE CREATEDLVR TO IDLE BEFORE MES
A 320
UNWARRANTED IFSDDECREASING OIL PRESSUREMISUNDERSTANDINGUNWARRANTED ENGINETYPICAL CASE OF
BASED ON DECREASINGBUT NO LOW OIL PRESSUREOF OIL PRESSURE AND LOPSHUTDOWNHURRIED REACTION
OIL PRESSUREWARNINGINDICATIONSCLIMB PHASE
A 320
Sheet3
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Procedural Subtlety Leading to NonadherenceHow can procedural subtlety lead to correct adherence?
Sheet1
EVENTRECOGNITIONPROCEDUREPROCEDURECREW ACTIONREMARKS
CREW DIAGNOSISCONTENTSEXECUTION
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCFAILURE TO COMPLETEDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIR"CAB PRESS MAN CTL"POSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSPROC BEFORE CALLING EVACUATIONOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYAND DOING THECRM AND WORKLOAD ISSUESMOKE WARNINGS
"ON GROUND EMER / EVAC" PROC
EVENTRECOGNITIONPROCEDURECREWREMARKS
CREW DIAGNOSISEXECUTIONACTION
ENG FAILED TOLOW POWERFOT AND FCOM
REACH TAKE OFFHIGH FUEL LOWENG NOT SHUTDOWNENG SET AT IDLE ONLYREVISION
POWER DUE TOVISIBLE FUEL LEAKPLANNED
FUEL LEAKFROM ENGINE
A 320
EVENTRECOGNITIONPROCEDURECREWREMARKS
WARNINGCONTENTSACTION
RTO DUE TOECAM WARNING TRIGGERED BY
ENGINEPREVIOUS CREW AWARENESS
THRUST LOSSMESSAGE A.ICE ENGNOTE TO BE ADDED IN FCOMLATE RTO ACTIONNEED TO AVOID SUCH
A330VALVE OPENTO ANTICIPATESITUATIONS IN ANY
INTERLINK BETWEEN CREWECAM AT 80 KT /FUTURE DESIGN
A. ICE ENG 1 VALVE OPEN CREWAWARENESS MESSAGE ANDRTO AT 130 KT
AWARENESS MESSAGEECAM WARNING
ACTIVATED AT HOLDING POINT
Sheet2
EVENTRECOGNITIONPROCEDURECREW ACTIONREMARKS
CREWCONTENTS
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIRPOSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYCRM AND WORKLOAD ISSUESMOKE WARNINGS
EVENTRECOGNITIONPROCEDURECREWREMARKS
WARNINGCONTENTSACTION
RTO DUE TOECAM WARNING TRIGGERED BY
ENGINEPREVIOUS CREW AWARENESS
THRUST LOSSMESSAGE A.ICE ENGNOTE TO BE ADDED IN FCOMLATE RTO ACTIONNEED TO AVOID SUCH
A330VALVE OPENTO ANTICIPATESITUATIONS IN ANY
INTERLINK BETWEEN CREWECAM AT 80 KT /FUTURE DESIGN
A. ICE ENG 1 VALVE OPEN CREWAWARENESS MESSAGE ANDRTO AT 180 KT
AWARENESS MESSAGEECAM WARNING
ACTIVATED AT HOLDING POINT
Sheet3
EVENTRECOGNITIONPROCEDUREPROCEDURECREW ACTIONREMARKS
CREWCONTENTSEXECUTION
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCFAILURE TO COMPLETEDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIR"CAB PRESS MAN CTL"POSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSPROC BEFORE CALLING EVACUATIONOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYAND DOING THECRM AND WORKLOAD ISSUESMOKE WARNINGS
"ON GROUND EMER / EVAC" PROC
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Rushed Action Leading to NonadherenceWhat is rushed action other than premature decision making?
Sheet1
EVENTRECOGNITIONPROCEDURECREWREMARKS
CREWEXECUTIONACTION
ENG FAILED TOLOW POWERENG SET AT IDLE ONLYFOT AND FCOMFOT AND FCOM
REACH TAKE OFFHIGH FUEL LOWENG NOT SHUTDOWNREVISIONREVISION
POWER DUE TOVISIBLE FUEL LEAKPLANNEDPLANNED
FUEL LEAKFROM ENGINE
A 320
Sheet2
ENGINE FIREBECAUSE PARAMETERS WASECAM DISREGARDEDSPURIOUS WARNINGSPURIOUS WARNING
WARNING AND IFSDNORMAL, EXCEPT OQ "XX"SHOULD BE CORRECTEDSHOULD BE CORRECTED
PERFORMED 54CREW CONCLUDED TO SPURIOUSEFFECTIVELY ANDEFFECTIVELY AND
MINUTES LATERWARNING DESPITE 2 VISUALQUICKLY TO PREVENTQUICKLY TO PREVENT
A 330INSPECTIONSCREW DISREGARDINGCREW DISREGARDING
WARNING ACTIVATIONWARNING ACTIVATION
IFSD WHEN OP "XX"
AFTER 54 MINUTES
Sheet3
EVENTRECOGNITIONPROCEDURECREWREMARKS
CREW DIAGNOSISEXECUTIONACTION
ALT DEV IN TURBULENCETURBULENCE READINESSIF TURB WAS FORECAST SP/ALT HLDCREW DISCONNECTED AUTOPILOT
WITH PROFILE MODEFROM FORECASTSHOULD HAVE BEEN PREFERRED TORATHER THAN LEAVING PROFILE
A 300 - 600PROFILE MODE(REVERSION TO SPD/ALT HLD)
AP + A/THR + PITCH TRIMNONESOPs NOT COMPLIED WITHAP DISCONNECTION BY STICK
DISCONNECTION +FOR PREVENTION AND RECOVERYFORCE SUSPECTED
ALT DEV IN TURBULENCEMANUEL RECOVERY AND
A 310AUTOPILOT REENGAGEMENT
TURB ENCOUNTERPOSITIVEQRH NOT APPLIED FOR OVERSPEEDSPEED BRAKES EXTENSIONTRAINING ISSUE ?
AND STALLPREVENTION AND RECOVERYAS SPEED UP TO MMO
A 310CREW RESISTED THE AUTOPILOTA-THR REDUCING TRUST
AT FL 350
SPEED DECREASING TO
STALL WARNING
OUT OF TRIM
CONDITION CORRECTED
BY F/O PNF
AP REENGAGED
RECOVERY AT FL330
COLLISION WITHBREAK PRESSURECREW FAILURE TO CONFIRM PARKING
JETWAY ON ARRIVALNOT VERIFIEDBRAKE PRESSURE BEFORE
A 320RELEASING PEDALS AND SHUTTINGRELEASING PEDALS AND SHUTTING
ENGINES DOWN, PER SOPENGINES DOWN PEMATURILY
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Undue Interpretation Leading to NonadherenceWhat is undue interpretation other than biased decision making?
Sheet1
EVENTRECOGNITIONPROCEDURECREWREMARKS
CREW DIAGNOSISEXECUTIONACTION
ENGINE FIREBECAUSE PARAMETERS WASECAM DISREGARDEDSPURIOUS WARNINGSPURIOUS WARNING
WARNING AND IFSDNORMAL, EXCEPT OQ "XX"SHOULD BE CORRECTEDSHOULD BE CORRECTED
PERFORMED 54CREW CONCLUDED TO SPURIOUSEFFECTIVELY ANDEFFECTIVELY AND
MINUTES LATERWARNING DESPITE 2 VISUALQUICKLY TO PREVENTQUICKLY TO PREVENT
A 330INSPECTIONSCREW DISREGARDINGCREW DISREGARDING
WARNING ACTIVATIONWARNING ACTIVATION
IFSD WHEN OP "XX"
AFTER 54 MINUTES
EVENTRECOGNITIONPROCEDURECREWREMARKS
WARNINGEXECUTIONACTION
IFSD BASED ONSTEP DECREASE OF ENGINEDECREASING OIL QTY OR OIL QTYPRECAUTIONARY IFSDNO OIL LEAK
DECREASING1 OIL QTYADVISORY CALL ONLY FOR+FOUND BUT
OIL QTYMONITORING OF OIL PRESSDIVERSION14 QTS ADDED !
A 321AND OIL TEMP
Sheet2
EVENTRECOGNITIONPROCEDURECREW ACTIONREMARKS
CREWCONTENTS
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIRPOSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYCRM AND WORKLOAD ISSUESMOKE WARNINGS
EVENTRECOGNITIONPROCEDURECREWREMARKS
WARNINGCONTENTSACTION
RTO DUE TOECAM WARNING TRIGGERED BY
ENGINEPREVIOUS CREW AWARENESS
THRUST LOSSMESSAGE A.ICE ENGNOTE TO BE ADDED IN FCOMLATE RTO ACTIONNEED TO AVOID SUCH
A330VALVE OPENTO ANTICIPATESITUATIONS IN ANY
INTERLINK BETWEEN CREWECAM AT 80 KT /FUTURE DESIGN
A. ICE ENG 1 VALVE OPEN CREWAWARENESS MESSAGE ANDRTO AT 180 KT
AWARENESS MESSAGEECAM WARNING
ACTIVATED AT HOLDING POINT
Sheet3
EVENTRECOGNITIONPROCEDUREPROCEDURECREW ACTIONREMARKS
CREWCONTENTSEXECUTION
VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCFAILURE TO COMPLETEDOOR OPENING WITHOUTCAB PRESS
ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIR"CAB PRESS MAN CTL"POSITIVE CONFIRMATIONDIFFICULTIES +
A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSPROC BEFORE CALLING EVACUATIONOF DEPRESSURIZATIONLAV / CARGO
IN AUTO ONLYAND DOING THECRM AND WORKLOAD ISSUESMOKE WARNINGS
"ON GROUND EMER / EVAC" PROC
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From Recognition and Execution toEVALUATION of ConstraintsINTERPRETATION of ConsequencesIDENTIFICATION of the State of a SystemSEARCH for InformationDETECTION of Abnormal ConditionsAdapted from Rasmussen (1986)DEFINITION of a TaskFORMULATION of a ProcedureEXECUTION of ActionsSkillsRules RulesKnowledgeKnowledgeKnowledge
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From Machine Minding to Decision MakingFrom a two-stage to a three-stage process
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Causal Factors in Approach and Landing AccidentsInadequate decision making 74%Omission of action or inappropriate action 72%Nonadherence to criteria for stabilized approach 66%Inadequate CRM practice (coordination, cross-check, backup) 63%Insufficient horizontal or vertical situational awareness 52%Inadequate or insufficient understanding of prevailing conditions 48%Slow or delayed action 45%Flight handling difficulties 45%Deliberate non-adherence to procedures 40%Incorrect or incomplete pilot/controller communication 33%Interaction with automation 20% No go-around when required 17%
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ConclusionsPilots use recognitive processes in the deployment of procedures, which may be accompanied by errorsEffective crews apply judgment to direct decision making Pilots natural risk-evaluation strategies help them to distinguish consequential errors from benign onesThis hinges on knowing how to trade off a variety of human factors Applying procedures can be repetitive, rather than sequential, even under heavy time pressureEffective crews avoid rushed overreactions, if at all possible
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Conclusions (continue)The challenge of the future is to develop decision aids, cockpit and training systems that support rather than hinder the way good decision makers make decisions Experienced crews tap a vast reservoir of alternatives These procedures and SOPs should enable pilots to exercise discernment and good decision makingThey should be simple and accurate and with easy-to-assess consequences There is an enlarged role for pilots to be trained indecision making while using relevant procedures
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Thanks you!!
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