240411-Aura_QA-Loss_of_Control_In-flight_(LoCI)

• Site conducted

• Conducted on

  Date

• Prepared by

T - Inadequate Performance and/or Mismanagement of Automation

• Flight Crew Selection, Qualification and Training

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• Flight Data Monitoring (FDM)

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• Observed Flight Evaluation (LOSA) (Chained BowTie)

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• Flight Crew adhere to automation policy that minimizes manual handling at an inappropriate time

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• Managing and Monitoring Flight Path

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E - Degraded Flt Crew monitoring due to complancey, distraction or fatigue

• Monitoring and Communications Skills included in CRM

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• Flight & Duty Time Limitations

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• Fatigue Risk Management System (FRMS)

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• Adherence to SOPs that define monitoring roles and callouts

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• Flight Crew adherence to sterile cockpit SOPs

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E - Inappropriate manual handling of aircraft

• FCOM or OEM based automation policy for appropriate use of manual handling

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• Aircraft Systems - Design highlights errors/differences

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• Flight Crew detect and recognise mismanagement of automation via monitoring

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• Flight Crew detect and recognise mismanagement of automation via automated alerts or warnings

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T - Malfunction of flight safety critical; component, instrumentation or automation

• After every flight all known or suspected defects are reported

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• HUMS turnround procedures identify problems or exceedances

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• MPM Maintenance activity iaw OEM program and dispatch iaw MEL requirement

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• Flight Crew detect and recognise problems via pre-flight systems checks

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• Flight Crew detect and recognise the malfunction via automated alerts/warnings or monitoring

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T - Loss of power due fuel; fault, loss, contamination or exhaustion

• MPM Maintenance activity iaw OEM program and dispatch iaw MEL requirement

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• Flight Crew plan fuel upload iaw with OM and Flight Plan

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E - Inadequate Planning IT

• Effective Flight Planning Software

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• Aircraft Fuelling - approved suppliers and daily fuel QC checks

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• Fuel upload correctly recorded in Aircraft Tech Log

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• Flight Crew Pre-flight check for correct volume of fuel

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• Flight Crew monitor fuel status in-flight and respond to abnormal conditions

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• Ensure that alternate airfields are identified as part of pre-flight planning

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T - Severe Meteorological Conditions / Unintended IMC

• Operator does not fly below NCAA Weather Minima

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• Avoidance via reference to forecasts and appropriate pre-flight planning

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• Ensure that alternate airfields are identified as part of pre-flight planning

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• Avoidance via observation of airborne weather radar indication

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• Avoidance via ATC/ HLO reporting

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• Avoidance via visual lookout

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• Aura QA tbc - UIMC Recovery Procedures / Protocols

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T - Birdstrike resulting in Cockpit incursion

• Aircraft type certification tolerance to birdstrike

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• Ops Manual Part A - Bird avoidance policy

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E - Ops Manual - Policy not followed

• Use of FDM to verify compliance with prevention policy

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• Avoidance via ATC/ HLO reporting

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• Avoidance through RT/SA

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• Avoidance via visual lookout

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T - Unsafe actions by passengers

• Passenger Screening by Security for drugs and alcohol

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• Pre-flight Safety Briefing

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• Passengers are not permitted to occupy co-pilot or jump seat

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• No smoking in aircraft

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• Flight Crew trained in DG and Security Procedures

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T - Incorrectly loaded cargo

• See - Support Operations BowTie

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T - Release of an Unairworthy Aircraft to Service

• See - Continuing Airworthiness / MCM - Release of an Unairworthy Aircraft to Service BowTie

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• See - Maintenance / AMO PM - Release of an Unairworthy Aircraft to Service BowTie

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Section Break - Top Event - Loss of Control In-flight (LoCI)

C - Ineffective BowTie / HRM

• QA Mgnt System - Threat Line Audit

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C - Unrecovered LoCI; leading to uncontrolled collision with terrain or in-flight structural failure

• Automated systems that assist in aircraft recovery

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• Flight Crew performs Undesired Aircraft State (UAS) recovery procedures

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• Aircraft protection systems limit certain manoeuvres (e.g.TQ_limiter)

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• Aircraft Type Certification (TC) margin between envelope and structural failure

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• Emergency Response Plan (ERP) (See ERCM Manual)

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C - Aircraft Ditching

• Flight Crew responds appropriately to LoCI (above)

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• Aircraft meet requirements for over water operations

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• Flight Crew and pax provided with life jacket and PPE

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• Flight Crew and pax HUET and survival training

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C - Abrupt avoidance manoeuvre resulting in injuries

• Flight Crew responds appropriately to LoCI (above)

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• Aircraft protection systems limit certain manoeuvres (e.g.TQ_limiter)

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• Cabin secured for flight by SOPs

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• Cabin design features to minimise injuries (e.g FAK strapped down)

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