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Etude de casRéaction aux alarmes TCAS « AVS »
Symposium DSAC
TCAS : Trafic Collision Avoidance System Détecte les trajectoires de collision potentielle Alerte l’équipage: Trafic Alert (‘’TA’’) Indique la maneuvre à effectuer pour garantir la
séparation verticale : Resolution Advisory (‘’RA’’)
Alarme vocale+
Indication d’assiette
Vitesse verticale demandée
San Diego - 1978 - B727Approche – 2600 ft
Los Angeles-1986- DC9Approche – 6000ft
1000 ft
10 20 30 40 50 600 sec
Réel
Idéal
Surveillance et prévention des
réactions excessives
Réactions inverses à RA TCAS ‘’AVS’’
Publication de l’événementRéception de deux autres rapports similairesMise en place d’une détection systématique
Alarme sur trajectoire et séparation initiale nominale
Premières actionsDétection et suivi des réactions inverses
Correct Reaction92.6%
Opposite Reaction7.4%
Réactions conformes93%
Réactions Inverses7%
Réactions pilote auxRA TCAS ‘’AVS’’
3 sec pitch order opposite to RA
RA
t sec7 Consecutive sec
Premières actionsPartage d’information, premières analyses
Bulletin TCASEurocontrol
Premières analysesPrincipaux facteurs contributifs ‘’Adjust’’ n’indique pas le sens de correction Aiguille de vitesse verticale rouge sur fond rouge Guidage en Vitesse verticale et non en Assiette Simulateurs non adaptés aux TCAS « AVS »
Présentation des événements et partage avec l’ensemble des compagnies de l’algorithme
d’analyse des vols pour la détection des cas de réaction inverse.
Safety Conference Airbus
Monitoring TCAS Crew Responses
Barcelona - October 2003
Evolution du TCAS
TCAS 7.0 TCAS 7.1
‘’Level Off’’
Reduction du risque
Procedures ATC Design Training Design
Reduction of Number of TCAS Ras ‘‘AVS‘‘
Reduction of Misinterpretation
Measures for Risk Reduction
A380, A350, etc …
Mais
Airbus
Boeing
+ FMGSAltitude capture software
Quelques leçonsSur le retour d’expérience Retour d’expérience actif Canaux de retour complémentaires Risques partagés >> Traitement partagé (collision en vol)
Sur la gestion de risque Gestion de la sécurité = > Surveillance et gestion des
défenses/barrière ou principe de sécurité Nécessité d’un modèle partagé
Having a well recognized safety model in mind, referring to a limited number of well identified accident families will :
tell us what and where we should look for
give sense to the safety data we collect
orient the design of new safety data software tool
clarify priorities and support prevention strategies
encourage a more systematic, proactive and efficient management of safety functions : “control”, “recovery” and “mitigation”
Airline Safety ManagementImportance of having a shared “safety model”
AccidentsOperations Loss of control CFIT Mid air collision Runway collision Runway excursion Other damages/injuries (Flight)
Other damages/injuries (Ground)
Accident and Defenses
Undesired EventControl
Recovery
Mitigation
Operations
Airline Safety ManagementImportance of having a shared “safety model”
Safety PrinciplesAny action contributing to prevent or recover a “loss of control” or minimizing damage
Safety ModelAccident = “loss of control”
Undesirable events (UE) Points where the “control of the situation is lost”
Three key safety functions Control Recovery Mitigation
Airline Safety ManagementInfluence of actors: Unsafe Conditions
Flight ops, ground ops, maintenance, cargo and other actorsare supporting or affecting the control, recovery or mitigation function separately, or collectively by interacting with each other
When the result of an action or inaction affects one of the « Safety Principles » , it is referred to an «Unsafe Condition» or ‘’UC’’
EXTERNAL (ATC, Reg Oversight, etc.)
FLIGHT OPS MAINTENANCE GROUND OPS
When the result of an action or inaction from stakholders affects one of the « Safety Principles » it is referred to an «Unsafe Condition»
FLIGHT OPS
Unsafe conditions related to flight ops
MAINTENANCE
Unsafe conditions related to aircraft maintenance release
EXTERNAL (ATC, Reg Oversight, etc.)
Unsafe conditions related to external actors
GROUND OPS
Unsafe conditions related to aircraft ground handling
Severity of accident
Corporate MatrixP
robability of accident scenario
1 2 53 4
1
2
3
4
5
Mitigation impact
2111132111432115432155432
Never
Unlikely
Often
Seldom
Alw
ays
Undesired event leads to accident
Frequent
Occasional
Remote
Improbable
Highly improbable
Probability of
Undesired event
Recovery Matrix
1
2
3
4
5
1 2 53 4
2111132111432115432155432
Never
Unlikely
Often
Seldom
Alw
ays
Unsafe Condition leads to Undesired event
Frequent
Occasional
Remote
Improbable
Highly improbable
Unsafe
Condition is
Control Matrix
1
2
3
4
5
1 2 53 4
Canaux de retour complémentaires
Surveys
FDM (FOQA)
Space of precursors
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Air Safety Reports