19 Jun 24_Theme of Command Safety Week (I) 1450-2025.pptx

Command safety week

1. COMD SAFETY WEEK - 1 2025 1

2. 2 Lesson from past experience, shape the future. ALOHA AIRLINES-243 2

3. 3 Lesson from past experience, shape the future. ALOHA AIRLINES-243 3

4. 4 BRITISH AIRWAYS BAC-111

5. The negligence by the Engineering officer during pre-flight check Low quality designing by manufacturer OUTCOME 5 “NO LESSON TAKEN FROM PAST EXPERIENCE”

6. 6 Lesson from past experience, shape the future. LION AIR-610 6

7. 7 Lesson from past experience, shape the future. ETHIOPIAN AIRLINES-302 7

8. Faulty program of MCAS software Pilots were not trained and oriented with this new system Measures MCAS software upgradation Pilots' simulator training OUTCOME Investigation 8 “LESSON TAKEN FROM PAST EXPERIENCE ENSURED SAFE FUTURE”

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10. 10   LESSON FROM PAST EXPERIENCE, SHAPE THE FUTURE THEME

11. 11 To apprise about the importance of Learning from past experience to shape our future with an effective Safety Management System AIM

12. SEQUENCE 12 04 03 01 08 06 05 02 07 Learning in Aviation Importance of Learning Statistics Safety Management System Conclusion Human Factors Case studies Recommendation 12 FL REDWAN SL KAFSAT

13. 13 Learning involves gaining new information and the ability to perform tasks or activities WHAT IS LEARNING Learning is often characterized by a modification in how an individual acts or reacts, either consciously or unconsciously

14. LEARNING IN AVIATION 14 LEARNING SHAPING THE FUTURE S M S

15. LEARNING IN AVIATION 15 LEARNING CULTURE A literature A part of safety culture Commitment to learn No compromise “SAFETY IS IN OUR HANDS”

16. LEARNING IN AVIATION 16 ACTIVE LEARNING CYCLE

17. Prevents repetition of mistakes Shapes Standard Operating Procedures (SOP) Supports Safety Management System (SMS) Improves flight safety Protects human lives and financial resources IMPORTANCE OF LEARNING 17

18. AVIATION INCIDENTS 1 Understanding the Nuances 2 Incorporating Diverse Perspectives 3 Utilizing a Numbered List LEARNING FROM INCIDENTS 18

19. 19 STATISTICS 19

20. AIRPLANE SAFETY 1 Human Factor 2 Aircraft Modification 3 Airport Upgradation MODIFICATIONS 20

21. 21 PT-6 INCIDENT Incident Mid-air collision during pitchout Resulting death of both pilots Recommendations Formulation of Flying order on fly-past New SOP on pitchout & rejoin

22. 22 STATISTICS Reduction of technical causes Incretion of human causes

23. SAFETY CULTURE 1 Informed Culture 2 Learning Culture 4 Flexible Culture 3 Just Culture SAFETY MANAGEMENT SYSTEM SAFETY CULTURE ELEMENTS 23

24. Learn from its mistakes Understands safety rules Adaptation Changing demands Punitive & non punitive action Errors and Violations Collects and analyses data Disseminates safety info Knowledge on the safety factors 1 Informed Culture 2 Learning Culture 4 Flexible Culture 3 Just Culture Safety Culture SAFETY CULTURE ELEMENTS 24

25. 25   LESSON FROM PAST EXPERIENCE, SHAPE THE FUTURE THEME

26. 29 Apr 1991 Destroyed 40 jets and 8 heli (50% of BAF fleet) Operational capabilities reduced BAF infrastructure critically damaged CYCLONE 1991 THE TRAGEDY THAT TAUGHT US 26

27. Evacuation plan of ac/ heli for natural disaster was formulated Raised platform were constructed for ac for protection from flood Evacuation according to Danger Alarm No 3 danger alarm - All efforts must be taken to make all unsvc ac/ hel airworthy ASP for evacuation No 5 danger alarm - evacuation of all ac/ hel AFTERMATH 27

28. No single damage to ac and eqpt was caused by natural disaster in last 34 years OUTCOME 28 “When we choose to act on experience, we shape a future that is stronger, safer and more disciplined”

29. 29 Nov 22: Ferry msn from Bogura to Jashore Engine seizing tendency followed by sudden shut down Force landed at paddy field PT-6 CRASH AT BOGURA 29

30. FACTOR 30 Malfunction/incorrect mixture ratio setting in carburator Malfunction of magneto & Spark plugs Error of Omission and lapse by Maint Crew

31. EARLY INDICATIONS IGNORED 31 Engine vibration Higher CHT Under power Mixture ratio known to drift early Schedule check every 3 Months

32. Engine shutdown mid air Schedule revised: mixture ratio check now every 15 days OUTCOME 32 “If we wait for a checklist to authorize common sense, we wait too long.”

33. Cyclone case : Human Factor used positively after the loss PT-6 case : Human Factors ignored despite early warnings One led to long-term safety, other to avoidable loss HUMAN FACTORS 33 “How we respond to human factors determines whether we repeat the past or shape the future.”

34. HUMAN FACTORS 34

35. HUMAN FACTORS HUMAN FACTOR CYCLONE 91 PT-6 CRASH Lack of awareness Ack and adds Early signs were ignored Communication Improved through SOPs Weak between pilots and techs Teamwork Strengthened after review Poor cross-trade communication Complacency Eliminated via new system Continued due to routine habit Decision making Swift, informed act taken Differed to ‘due date’ 35

36. CHALLENGES 36 Early Indications often undocumented or unaddressed SOPs Exist but Judgment is rarely encouraged Communication gap between aircrew and grd crew Maintenance schedule sometimes override operational reality Safety actions are often reactive not proactive

37. RECAP 37 Learning in aviation How to shape the future by taking lesson from past experience Practicing Safety culture through effective SMS for better future Cyclone 1991: Massive loss but led to structured preparedness PT-6 crash: Early signs ignored, action came too late Same Human Factors, different choices, different outcome

38. WHAT WE MUST CARRY FORWARD 1 Act When Even Procedures don’t demand it 2 Review Routine schedule when data indicates otherwise 4 After every incident, document and follow up with actual change 3 Encouraging Reporting From all Ranks Without Fear RECOMMENDATION 38

39. 39 “PAST EXPERIENCES DO NOT SHAPE THE FUTURE ON THEIR OWN . IT IS THE LESSONS WE CARRY FORWARD AND THE ACTIONS WE TAKE THAT TRULY SHAPE WHAT COMES NEXT” “LESSON FROM PAST EXPERIENCES, SHAPE THE FUTURE ”

40. 6/20/2025 40

41. 6/20/2025 41