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Air Traffic Management (ATM) is a continuously evolving

Increased cockpit automation on modern jet aircraft aim to reduce the risk of Undesired Aircraft State (UAS) instances such as Loss of Control in Flight (LOC-I). Although LOC-I globally accounts for only 9% of all analysed accidents IATA has reported that it was responsible for 58% of all accident fatalities in 2017. The focus of this paper is to answer whether Threat and Error Management and Crew Resources Management (CRM) techniques are an efficient risk management tool when facing a LOC-I threat. Three LOC-I final aircraft accident reports were analysed to understand the structure of Human Factors (HF) during these flights. Methods from the HF field such as the Generic Error Modelling System (GEMS) and Skill-, Rule-and Knowledge-based (SRK) error approach provided invaluable insights to identify potential findings. A holistic investigation of cognitive structures in flight path management helped to visualise latent conditions and cognitively demanding tasks during LOC-I in routine operations. Bearing in mind the limited number of cases considered in this paper it should be considered as an overview in LOC-I accident analysis. It shows that leadership and teamwork, as essential aspects of CRM training, can serve as key strategies to mitigate HF problems and LOC-I risks.

The paper introduces a conceptual framework that could improve the safety performance measurement process and ultimately the aviation system safety performance. The framework provides an implementation guide on how organisations could design and develop a proactive, measurement tool for assessing and measuring the Acceptable Level of Safety Performance (ALoSP) at sigma (σ) level, a statistical measurement unit. In fact, the methodology adapts and combines quality management tools, a leading indicators programme and Lean-Six Sigma methodology to formally measure and continuously improve a stable and in-control safety management process by reducing safety defects and variability from core organisational processes and objectives. The implementation guide was empirically tested and validated with data collected and analysed within a period of nine months by the safety department of a complex aviation organisation operating a large transport aircraft fleet.

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