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geography. For example, noise sensitive airports may use higher than normal glide slopes on approach
paths over populated areas.
16.3.31 Events and measurements can be displayed on a ground computer screen in a variety of
formats. Recorded flight data are usually shown in the form of colour-coded traces and associated
engineering units, cockpit simulations or animations of the external view of the aircraft.
Chapter 16. Aircraft Operations 16-9
FDA in practice
FDA process
16.3.32 Typically, operators follow a closed-loop process in applying an FDA programme, for example:
a) Baseline established. Initially, operators establish a baseline of operational parameters against
which changes can be detected and measured.
Examples: Rate of unstable approaches, or hard landings.
b) Unusual or unsafe circumstances highlighted. The user determines when non-standard, unusual
or basically unsafe circumstances occur; by comparing them to the baseline margins of safety, the
changes can be quantified.
Example: Increases in unstable approaches (or other unsafe events) at particular locations.
c) Unsafe trends identified. Based on the frequency of occurrence, trends are identified. Combined
with an estimation of the level of severity, the risks are assessed to determine which may become
unacceptable if the trend continues.
Example: A new procedure has resulted in high rates of descent that are nearly triggering GPWS
warnings.
d) Risks mitigated. Once an unacceptable risk has been identified, appropriate risk mitigation actions
are decided and implemented.
Example: Having found high rates of descent, the SOPs are changed to improve aircraft control for
optimum/maximum rates of descent.
e) Effectiveness monitored. Once a remedial action has been put in place, its effectiveness is
monitored, confirming that it has reduced the identified risk and that the risk has not been
transferred elsewhere.
Example: Confirm that other safety measures at the airfield with high rates of descent do not
change for the worse after changes in approach procedures.
Analysis and follow-up
16.3.33 FDA data are usually compiled on a monthly basis. The data should then be reviewed by a
working group to identify specific exceedences and emerging undesirable trends and to disseminate the
information to flight crews.
16.3.34 If deficiencies in pilot handling technique are evident, the information is de-identified in order
to protect the identity of the flight crew. The information on specific exceedences is passed to an agreed
aircrew representative for confidential discussion with the pilot. The aircrew representative provides the
necessary contact with the pilot in order to clarify the circumstances, obtain feedback, and give advice and
recommendations for appropriate action, such as re-training for the pilot (carried out in a positive and nonpunitive
way); revisions to operating and flight manuals; changes to ATC and airport operating procedures;
etc.
16-10 Safety Management Manual (SMM)
16.3.35 As well as reviewing specific exceedences, all events are archived in a database. The
database is used to sort, validate and display the data in easy-to-understand management reports. Over
time, this archived data can provide a picture of emerging trends and hazards which would otherwise go
unnoticed. Where the development of an undesirable trend becomes evident (within a fleet, or at a particular
phase of flight, or airport location), the fleet’s training department can implement measures to reverse the
trend through modification of training exercises and/or operating procedures. Likewise with other areas of
the operation requiring action, the data can then be used to confirm the effectiveness of any action taken.
16.3.36 Lessons learned from the FDA programme may warrant inclusion in the company’s safety
promotion programmes. Care is required, however, to ensure that any information acquired through FDA is
studiously de-identified before using it in any training or promotional initiative.
16.3.37 As in any closed-loop process, follow-up monitoring is required to assess the effectiveness of
any corrective actions taken. Flight crew feedback is essential for the identification and resolution of safety
problems and could comprise answering the following questions, for example:
a) Are the desired results being achieved soon enough?
b) Have the problems really been corrected, or just relocated to another part of the system?
c) Have new problems been introduced?
16.3.38 All successes and failures should be recorded, comparing planned programme objectives with
expected results. This provides a basis for review of the FDA programme and the foundation for future
programme development.
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Safety Management Manual (SMM) 安全管理手册(113)
