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United Airlines Safety Culture

Document Series:
Publications
Author:
  • Captain Hank Krakowski
Subject:
Risk Reduction Program
Keywords:
C3RS
Document
closecalls_krakowski.pptx (523.1 KB)
Workshop: Improving Railroad Safety through Understanding Close Calls
Captain Hank Krakowski Presentation

 

Slide 1
[United Airlines logo] UNITED AIRLINES Safety Culture An evolution of learning & cooperation

 

Slide 2
[United Airlines logo] State of UNITED AIRLINES Chapter 11 - Update Airline is running well ?Excellent operational and safety performance #1 On-time in 2002 No significant Safety or Reliability issues Negotiated agreements with labor

 

Slide 3
[United Airlines logo] Mission: Find Truth ?Facilitate Change Mechanisms * Independent Safety Department * Self disclosure Employee > Company > Unions > FAA * Partnership between Management, Unions and Regulators * Evolution to systems auditing & continuous improvement

 

Slide 4
[United Airlines logo] Safety at United An engine of Continuous Improvement [flow chart of operations safety auditing, reports, and data] Mission: Find Truth ?Facilitate Change

 

Slide 5
[United Airlines logo] Safety Programs - Flight Safety Training Watershed Event ?1978 United alarmed by UAL DC-8 fuel starvation accident Portland, Ore Crew members aware of danger but silent due to human factors All crewmembers now trained to Inquire, Discuss and Advocate Captain authority is strengthened not undermined through CRM tools Pilot simulator checks equally evaluate CLR / CRM and flight skills (CRM Crew Resource Management)

 

Slide 6
[United Airlines logo] Safety Programs - Flight Safety Auditing FOQA ?Flight Operations Quality Assurance Data driven analysis 60% of UAL aircraft equipped with FOQA recorders Program has saved engines, aircraft and lives FAA / industry working to aggregate de-identified data Very labor sensitive

 

Slide 7
[United Airlines logo] Safety Programs - Flight Safety Auditing FOQA ?Flight Operations Quality Assurance * Aircraft FOQA Data downloaded * Data aggregated & deidentified Trend Data Identified Unstable approaches TCAS RA’s Flap / Speed exceedances * Flight management and ALPA analyze Changes to procedures/training

 

Slide 8
[United Airlines logo] Safety Programs - Flight Safety Auditing FOQA ?Flight Operations Quality Assurance ALPA Exceedence Guidance Team reviews IDENTIFIED data If significant ?Crew is Contacted Gross exceedances Significant over limits Discussion is between EGT / Crew Only Learning Environment

 

Slide 9
[United Airlines logo] Safety Programs - Flight Safety Auditing FOQA ?Flight Operations Quality Assurance Routine Trending Data Engines & systems Non Routine Event Download requested Engine surge Flap overspeed

 

Slide 10
[United Airlines logo] Safety Programs - Flight Safety Auditing Quality Assurance Auditing Shift in Philosophies Compliance police (Traditional) Systems & Processes (ISO 9000) (JQRT Joint Quality Review Team) Identifies: Non-compliance (direct violations) Non-conformance (written procedures different from practice) Significant concerns (oversight & systems weak)

 

Slide 11
[United Airlines logo] Safety Programs Safety Auditing Quality Assurance Auditing B747 near - accident Engine failure shortly after takeoff IFR conditions First Officer flying Crew late in recognizing engine failure First officer reacted improperly Came within 100?of hill top

 

Slide 12
[United Airlines logo] Safety Programs Safety Auditing Quality Assurance Auditing B747 near - accident Full FAA / UA compliance at takeoff People &##39;&##39;felt&##39;&##39; problems existed COO directs audit of training center 263 findings (all corrected) Proficiency Scheduling Long range relief pilots FAA joint experiment (JQRT) Ability to keep self interests at bay

 

Slide 13
[United Airlines logo] Safety Programs - Flight Safety Auditing FSAP ?Flight Safety Awareness Program Provides atmosphere for open and honest discussion - Management - Union - Crews - FAA Provides protections for Company & Crews (unless willful disregard or intentional) Requires solid agreements & understandings between unions / management / FAA

 

Slide 14
[United Airlines logo] Safety Programs - Flight Safety Auditing FSAP ?Flight Safety Awareness Program Pilots electronically submit reports Altitude deviations Missed communications Security issues Safety department collects reports Ranks risk Assigns taxonomies Weekly Event Review Committee meetings (QA Management, ALPA & FAA) Three options: Close issue outright or with recommendations Letter of No Action Notice of Violation

 

Slide 15
[United Airlines logo] Safety Programs - Flight Safety Auditing FSAP ?Flight Safety Awareness Program * DSAP (Dispatch Safety Awareness Program) Began program in October 2002 Already effective (deficient employee out of service) * MSAP (Maintenance Safety Awareness Program) Revisiting concept with new union leadership (IAM) VISION: FSAP + DSAP + MSAP will create a total safety analysis culture overall and traverse departmental barriers

 

Slide 16
[United Airlines logo] Recent FSAP/ASAP example DEN B737 ice damaged engines * Very unusual event * Probable cause atmospherics / procedures mismatch * Employee groups very different to work with * Serious immediate safety issue took too long to resolve

 

Slide 17
[United Airlines logo] Safety at United An engine of Continuous Improvement [flow chart of operations safety auditing, reports, and data] Mission: Find Truth ?Facilitate Change

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Last updated: Wednesday, April 23, 2003