A coursework for City University London, detailing a risk assessment carried out for Loss of Control -In Flight

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RohitTomar
rohithtomar@gmail.com
901, Nariman Tower, Nariman Road, Vile Parle (East), Mumbai
400057
ATM
RISK MANAGEMENT
22nd June 2013 21st June 2012
RohitTomar
2
2336

2. CITY UNIVERISTY
RISK MANAGEMENT MODULE
[RISK ASSESSMENT OF LOSS OF CONTROL IN FLIGHT]
Rohit Tomar
6/19/2013

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Table of Contents
List of Figures..................................................................................................................3
List of Table.....................................................................................................................3
1. Introduction ...............................................................................................................4
2. Define Risk................................................................................................................5
2.1 Risk Definition: Loss of Control in Flight (LOC-I) ................................................5
2.2 Hazard Definition:...............................................................................................5
2.3 Threats Definition: ..............................................................................................5
3. Identify Risk Involved ................................................................................................6
4. Assess Risk Factor ...................................................................................................7
4.1 Exposure ............................................................................................................9
4.2 Risk Factor .........................................................................................................9
4.3 Severity ..............................................................................................................9
4.4 Probability:..........................................................................................................9
4.4.1 System Control Failure ..............................................................................11
4.4.2 Loss of Power ............................................................................................11
4.4.3 Crew Incapacitation ...................................................................................11
4.4.4 Flight Management or Control Error...........................................................11
4.4.5 Environmental Factors ...............................................................................11
4.4.6 Aircraft Load ..............................................................................................11
4.4.7 Malicious Interference................................................................................12
4.4.8 Improper Procedures .................................................................................12
4.4.9 Risk Assessment for LOC – I for an Airline................................................12
4.4.10 Risk Acceptance ........................................................................................13
4.4.11 Conclusion .................................................................................................13

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5. Make control decisions............................................................................................13
6. References..............................................................................................................17

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List of Figures
Figure 1 ...........................................................................................................................4
Figure 2 ...........................................................................................................................6
Figure 3 ...........................................................................................................................8
Figure 4 ...........................................................................................................................8
Figure 5 .........................................................................................................................10
Figure 6 .........................................................................................................................10
List of Table
Table 1 ............................................................................................................................7
Table 2 Risk Assessment Matrix .....................................................................................9
Table 3 Risk Assessment Matrix for LOC –I..................................................................12
Table 4 Risk Acceptance Criteria ..................................................................................13
Table 5 ..........................................................................................................................16

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1. Introduction
This risk assessment is performed to define the risk of Loss of Control in Flight for
an Airline. Historical data from Boeing Statistical summary of commercial jet airplane
accidents worldwide operations 1959-2011 shows that Loss of Control in Flight
(LOC-I) has been attributed as the reason for highest number of accidents and
fatalities as compared to other causes. As per the statistical data from Boeing, a
total of 18 accidents caused by LOC-I resulted in more than 1400 fatalities and thus
an important area for study of Flight Safety.
Figure 1
This assessment would use secondary research data available to define the risk and
analyze the threats that an airline is exposed to during its operations which can
cause Loss of Control in Flight. This assessment would also aim to provide some

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decisions that would aim to eliminate the risks or mitigate the risks to a controllable
level for the Airline.
2. Define Risk
2.1 Risk Definition: Loss of Control in Flight (LOC-I)
As per ICAO Aviation Occurrence Categories Definition and Usage Notes – June 2004
(4.1) Loss of Control - In-flight (LOC-I) is referred to when aircraft control is lost during
the airborne phases. ‘Loss of Control In-flight is an extreme manifestation of a deviation
from intended flight path’ (Skybrary, 2010).
2.2 Hazard Definition:
The hazard in this risk assessment would be Loss of Control In Flight (LOC-I) as it’s an
unacceptable situation for an Airline and cause Harm, Injury, Loss of Life and
Inconvenience to the passengers.
2.3 Threats Definition:
NASA Aviation Safety Program conducted a study of the loss on control problems and
compiled a list of casual factors that contributed to loss of control. The factors were
segregated in to 3 categories
1) Pilot or Human Induced
2) Environmentally Induced
3) Systems Induced
For performing the risk analysis, we would use the factors categorized by Skybrary
which is in line with the categories defined in the NASA Report, however more specific
in terms of defining the causing effects of each of the threats and the situation which
can lead to release of these threats and cause a risk of LOC-I. The threats as per
Skybrary report which would be used for risk assessment in this study are
1) Systems control failure
2) Loss of power
3) Crew Incapacitation

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4) Flight Management or control error
5) Environmental factors
6) Aircraft Load
7) Malicious interference
This report would in additional to the 7 factors consider an 8th
Factor of Improper
procedure as same is not clearly reflected in the skybrary report.
3. Identify Risk Involved
In order to identify the risks involved based on the threats; secondary data from NASA
Aviation Safety Program has been used for an initial risk assessment study.
A statistical summary developed in NASA Aviation Safety Program report supports to
categorize the risk of the occurrence of In-Flight loss of control based on the
contributing factors, see Figure 2.
Figure 2
Leading this risk identification based on the report from NASA Figure 2, the threats to
be analyzed can be categorized as below
Identified Threats as per
Skybrary
Categorized as per
NASA Figure 2
Comments
Systems Control Failure Systems Induced
Loss of Power Systems Induced Loss of power can also occur due to

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incorrect operation of the a/c,
however we will consider that in
Procedure deviation in this analysis
Crew Incapacitation Systems Induced An unfit pilot or unfit pilot operating
an aircraft would be considered in
Improper Procedures
Flight Management or
Control Error
Systems Induced
Environmental Factors Environmentally
Induced
Aircraft Load Pilot or Human
Induced
Malicious Interference Pilot or Human
Induced
Improper Procedures Pilot or Human
Induced
Table 1
4. Assess Risk Factor
Secondary data from NASA Report will be used to perform the risk assessment of the
contributing factors or threats identified which can cause the risk of loss of control in
flight. The NASA report records data from various operators and produced important
benchmarks like Figure 3 and Figure 4 crucial towards this risk assessment.

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Figure 3
Figure 4
The figures 3 & 4 highlights that the probability of an LOC –I occurrence is higher in the
Asia Region except China and the lowest in China, and improper procedures have a
higher probability of becoming the cause of such an occurrence as compared to other
factors.

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This report would use the risk assessment matrix as used in City University London by
Prof. Morten Kjellesvig in his Risk Management Course as in Table 2
PROBABILITY
SEVERITY
Low (1) Low (2) Medium (3) High (4) High (5)
High (5) 5 10 15 20 25
High (4) 4 8 12 16 20
Medium (3) 3 6 9 12 15
Low (2) 2 4 6 8 10
Low (1) 1 2 3 4 5
Table 2 Risk Assessment Matrix
4.1 Exposure
Using table 2 for carrying out the risk assessment, it is taken into account that the
Exposure rate will remain the same. The reason for the exposure remaining the same
being that the aircraft is exposed to the risk of loss of control every time it takes flight
and during every flight the threats exist and can cause the occurrence of LOC-I. For
calculation purpose the Exposure rate is taken as 3 and is kept constant.
4.2 Risk Factor
The risk factor for the risk assessment is calculated as Risk Factor = Probability x
Severity + Exposure
4.3 Severity
The severity of this case is kept at 5 i.e. very high, this is to indicate that if any of the
threats get released and cause a Loss of Control In Flight it can lead to a maximum
damage of fatalities and loss of lives and aircraft as depicted in Figure 1 by Boeing.
4.4 Probability:
At the outset, data based approach would be used to determine the highest level of
probability of the risk of LOC – I occurring for an Airline. Figure 6, the percentage of
accidents has reduced to nearly 1 or less than 1 accident per million departures and the
downward trend in the graph indicates the improvements in Aircrafts and operations that
has taken place over the years, hence it would be wise to set the maximum probability

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for an occurrence of an accident due to LOC-I as 4 instead of 5. This can be further
justified by Figure 5 which shows that LOC-I accidents are 0.10 accident per million
flight hours.
Figure 5
Figure 6

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4.4.1 System Control Failure
Probability is set at Low Level 2 which is based on the NASA Report as in Figure 3. As
depicted in Figure 3 the system failure caused 5 LOC-I occurrences as compared to
Improper procedures, which caused the highest number of LOC-I accidents and would
be graded as Probability Level 4 as explained in Point 4.4.
4.4.2 Loss of Power
Loss of power is analyses only with respect to System Failure and is thus given the
same probability level as System Control Failure, Level 2. An Event of Loss of Power
due to actions of the Pilots is taken into consideration under Improper Procedures.
4.4.3 Crew Incapacitation
Crew incapacitation can be a resultant effect of either System Failure like rapid
decompression or smoke or fire which can be caused either due to human factor or
systemic failure. In this analysis under Crew Incapacitation we would only consider
system failure and cover the human factor related failure under Improper Procedures.
The probability level for this is thus set at 2.
4.4.4 Flight Management or Control Error
A Flight Management or Control error can occur either due to system failure or due to
incorrect procedures followed by the Pilots. This can also be caused when Pilot is not
sufficiently trained on the Aircraft Systems and their actions cause a control error. In this
assessment, flight management or control error only encompasses systemic failure and
pilot induced errors are covered under Improper Procedures. The probability level for
this is thus set at 2.
4.4.5 Environmental Factors
Based on the NASA report as in Figure 3, Environmental factors accounted for a total of
5 Accidents of LOC – I, this is half of the number of accidents caused by improper
procedures and is thus set to a level of 2.
4.4.6 Aircraft Load
Incorrect loading on an aircraft can cause the aircraft to be out of trim, there are
procedures that are to be followed during the loading of the aircraft and since there is a

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human interface to this procedure, it is considered to be of equal probability as improper
procedures and set at highest level of 4.
4.4.7 Malicious Interference
After the September 9/11 attacks on USA, security at airports has been a prime focus
for all countries and airlines are equally more stringent in security procedures in areas
of high risk of malicious activities. It would still be incorrect to rule out this risk or term it
low as, airline by the nature of its business is always a target for malicious interference
and the probability of such a threat is being maintained at medium level of 3.
4.4.8 Improper Procedures
NASA’s report as shown in Figure 3 clearly attributes Improper procedures as the
highest contributing factor for the cause of LOC-I accidents. Improper procedures
encompass all the activities in which any personnel related with the aircraft is installed,
including but not limited to, Maintenance Engineers, Pilots, Quality Managers, Auditors
and also Stake Holders. With the involvement of all the personnel at all levels under the
improper procedures, the probability level for this threat is maintained at the highest
level of 4
4.4.9 Risk Assessment for LOC – I for an Airline.
Risks Probability Severity Exposure Risk Factor
System Control Failure 2 5 3 13
Loss of Power 2 5 3 13
Crew Incapacitation 2 5 3 13
Flight Management or
Control Error
2 5 3 13
Environmental Factors 2 5 3 13
Aircraft Load 4 5 3 23
Malicious Interference 3 5 3 18
Improper Procedures 4 5 3 23
Table 3 Risk Assessment Matrix for LOC –I

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4.4.10 Risk Acceptance
The Risk acceptance criteria for this analysis is based on City University Model and
shown in Table 4
Risk Factor Criteria of Acceptance
1-6 May be acceptable, however, review task
to see if risk can be reduced
7-14 Task should only proceed with appropriate
management authorization, where
possible the task should be redefined to
take account of the threats involved or the
risk should be reduced further prior to task
commencement
15-25 Task must not proceed. It should be
redefined or further control measures put
in place to reduce risk. The controls should
be reassessed for adequacy prior to task
commencement.
Table 4 Risk Acceptance Criteria
4.4.11 Conclusion
Based on the risk assessment performed, the risk of LOC – I in airline ranges from 13 to
23, under the Risk Acceptance Criteria, and hence all the threats are required to be
analyzed and control decision have to be implemented to lower the risk for the airline.
5. Make control decisions
Based on the risk assessment, this report proposes certain control decisions prioritizing
based on risk factor. The proposed control decisions are as below

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Risks Risk
Factor
Proposed Control Decision
Aircraft Load 23 a) Ensure Load and trim is handled by only
certified and trained personnel.
b) Ensure the training is of current
standards.
c) Ensure audits are performed to highlight
any non-compliance.
d) Promote reporting of incorrect load and
trim information effectively among the
ground employees.
e) Ensure the above control actions are in
place before performing the activities.
Improper
Procedures
23 a) All procedures to be documented in the
manuals and are communicated through
to all the employees.
b) Pilots to be fully trained on recovering
aircrafts from LOC-I.
c) Aircraft Unusual Attitude Recovery
Training in all Full Flight Simulator Type
Conversion and Recurrent Training
Programmes (Skybrary, 2013)
d) More time devoted to training multi crew
pilots for the monitoring role (Skybrary,
2013)
e) A dedicated Flight Safety Department for
constant monitoring of flight safety data
from FDM and Pilot reports and
corrective actions to be implemented.

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f) Ensure actions are in place before
undertaking the activity.
Malicious
Interference
18 a) Security Procedures in place,
b) Promotion of safety among employees to
identify any malicious activities
c) Promotion of vigilance among all
employees.
d) Security Audit to be performed on regular
basis.
System Control
Failure
13 a) Monitoring and compliance with all AD’s
on the aircraft systems and controls.
b) Monitoring of Aircraft defects via a
reliability program.
c) Weekly Review of Aircraft incidents and
defects and invoked MEL’s
Loss of Power 13 a) Monitoring and compliance with all AD’s
on the aircraft systems and controls.
b) Monitoring of Aircraft defects via a
reliability program.
c) Weekly Review of Aircraft incidents and
defects and invoked MEL’s
Crew
Incapacitation
13 a) Monitoring and compliance with all AD’s
on the aircraft systems and controls.
b) Monitoring of Aircraft defects via a
reliability program.
c) Weekly Review of Aircraft incidents and
defects and invoked MEL’s
Flight
Management or
Control Error
13 a) Monitoring and compliance with all AD’s
on the aircraft systems and controls.
b) Monitoring of Aircraft defects via a
reliability program.

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c) Weekly Review of Aircraft incidents and
defects and invoked MEL’s
Environmental
Factors
13 a) Monitoring and compliance with all AD’s
on the aircraft systems and controls.
b) Monitoring of Aircraft defects via a
reliability program.
c) Weekly Review of Aircraft incidents and
defects and invoked MEL’s.
d) Ensuring all NOTAM’s are followed and
communicated to the required personnel.
e) Ensuring Flight reports are
communicated to other pilots for
environmental factors.
Table 5
The above control decisions that have been proposed within this report can now be
evaluated for a cost-benefit analysis and based on the decisions of the same, the risk
assessment of LOC-I will be recalculated post the decisions based on cost-benefit
analysis. The same would then again be presented to analyze if the actions have
resulted in achieving the desired effect of lowering the risk to the desired level or
acceptable level for the airline.

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6. References
Bateman, Don. ‘Some Thoughts on Reducing the Risk of Aircraft Loss of Control’.
Available at http://www.skybrary.aero/bookshelf/books/1372.pdf [Accessed 07 June
2013].
Boeing (2012). ‘Statistical summary of commercial jet airplane accidents worldwide
operations 1959-2011’. Available at
http://www.boeing.com/news/techissues/pdf/statsum.pdf [Accessed 07 June 2013].
Brooks, L Randall (2010). Loss of control in flight training foundations and solutions.
Istanbul: European Airline Training Symposium
Edwards, Christopher and Lombaerts, Thomas (2010), Fault Tolerant Flight Control
A Benchmark Challenge. Springer. Verlag Berlin
ICAO (2004). ‘Aviation Occurrence Categories Definition and Usage Notes’.
Available at http://www.cast-safety.org/pdf/cictt_occurrence-category0804.pdf
[Accessed 07 June 2013].
Jacobson, Steven R. (2010). ‘Aircraft Loss of Control Casual Factors and Mitigation
Challenges’. Available at
http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20100039467_2010042011.pdf
[Accessed 07 June 2013].
Learmount, David (2012). ‘Loss of control – training the wrong stuff?’ London: Flight
Global. Available at http://www.flightglobal.com/news/articles/in-focus-loss-of-
control-training-the-wrong-stuff-367220/ [Accessed 07 June 2013].
NTSB (2009). Review of U.S. Civil Aviation Accidents – Review of Aircraft Accident
Data 2007-2009. Available at http://www.ntsb.gov/doclib/reports/2011/ara1101.pdf
[Accessed 07 June 2013].
Reisinger, Dr. Ing Dieter (2011). Loss of control in flight – an accident type that
raises questions about today’s training. Available at http://www.uni-

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graz.at/isap11/ISAP11%20Loss%20of%20Control%20in%20Flight_Intro_Reisinger.
pdf [Accessed 20 June 2013].
Rogers, Daniel.E (2011). Loss of Control – In Flight: Upset Recovery Skills – Based
Training. Utah Valley University. Available at
http://flyacro.us/D.%20Rogers%2010486518%20Research%20Paper%20Final%20
Submission.pdf [Accessed 07 June 2013].
Skybrary (2013) http://www.skybrary.aero/index.php/Loss_of_Control [Accessed 20
June 2013].