Malfunction clustering: managing the Black Swan

Malfunction clustering: managing the Black Swan

03 Jan 2017

Pilots don’t crash modern aircraft due to engine failures on take-off. They used to, but they don’t anymore. Advances in both aircraft technology and enhanced engine reliability and maintenance makes these events very rare and much easier to handle. So how do we crash aircraft nowadays? We crash aircraft because of Black Swan events.

A Black Swan event describes an event that is a surprise to the observer, has a major impact, and after the fact is often inappropriately rationalised with the benefit of hindsight. Accidents such as Air France Flight 447 and Indonesia AirAsia Flight 8501 are examples where the crew were faced with a sudden event which gave a significant startle factor, affected their instrumentation and degraded their aircraft controls. Both of these accidents resulted in loss of the aircraft and all life on board.

So if we could identify and list out the common characteristics of all Black Swan events and then make sure pilots have as much exposure to them as possible in the safety of the simulator environment that would be a good thing! Well that’s what will happen under Evidence-based training.


What is malfunction clustering?

Malfunction clustering is a move to utilise simulator time better to ensure pilots develop and maintain the high levels of competencies required to manage these significant Black Swan style events. The first step is for the airline to make a list of all the possible failures of aircraft systems, then bin all of the failures that don’t put a significant demand on a proficient crew member (e.g. single failures of redundant systems) Next we need to look at each of the remaining events and build a matrix to mark which characteristics they match:

Characteristics of Black Swan events:

  • Immediacy
  • Complexity
  • Degradation of aircraft controls
  • Loss of instruments
  • Management of consequences

Some events will display one of these characteristics and others will display multiple ones.

Once this analysis is complete, the operator should then ensure that at least one malfunction with each characteristic sis included in the EBT programme at the frequency indicated in ICAO Doc 9995.

For generation 4 aircraft, appendix 2 of Doc 9995 is applicable which states that at least one malfunction with each characteristic should be included every year. Combining characteristics should not reduce the number of malfunctions below 4 for each crewmember every year.

So the emphasis moves away from checking particular systems in the 3-year cycle and is now centred on these significant malfunctions that will test and develop flight crews overall competencies ready for if/when it were to happen to them on the line.

So you’re now thinking that pilots won’t ever get exposure to the less critical malfunctions? Not true - this is where Alternative Training Means will come in; a procedure is established to migrate these failures to other non-simulator devices such as computers, tablets and Virtual Reality.

Check out our blog on Alternative Training Means here to learn more about how our solutions free up simulator time for the Black Swan events under malfunction clustering.

About the author: Captain Andy Mitchell (BEng) is CEO & founder of Use Before Flight. He has over 10,000 hours on the Airbus A320 and works part-time as a training captain for a major European Airline. He is an expert in managing agile software teams and a leading expert in Evidence-based training, credited on the official EASA EBT checklist.