1 Incident Review Meeting

1 Incident Review Meeting 1 Incident Review Meeting - Start

2015-09-28 271K 271 0 0

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Guidance Material & Presentation Template . Introduction to the Template. This template allows Safety Managers to . analyze. events using the TEM framework in conjunction with the Bow Tie Model. ID: 143827 Download Presentation

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1 Incident Review Meeting




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Presentations text content in 1 Incident Review Meeting

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Incident Review Meeting

Guidance Material & Presentation Template

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Introduction to the Template

This template allows Safety Managers to analyze events using the TEM framework in conjunction with the Bow Tie ModelThe TEM framework helps to underline the classification system used by IATA to determine contributing factors, in incidents and accidentsThese factors can be viewed as Threats, failed Preventive Defenses (including Error Management) resulting in Undesired Aircraft StatesThe Undesired Aircraft States is then managed through Recovery Defenses (including Undesired Aircraft State Management) to prevent or not prevent the Accident or IncidentAn example is provided to illustrate the steps that can be followed to analyze events in this mannerIRM speakers are reminded that: this is not intended to be a complete Bow Tie Analysisthis format is optional

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IRM presenters are asked to ensure they clearly define: Safety enhancementsWhat was learned? What was changed?Lessons learned for IRM attendeesWhat should attendees consider checking and/or changing at their own operation?Key messages for Safety Group What should the Safety Group act on?

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The IRM presentations are an integral part of IATA’s and the Safety Group’s

hazard identification processAll presentations are welcome, even short onesPresentations must have take aways for IRM attendees and Safety Group

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Latent Conditions

Conditions present in the system before the accident, made evident by triggering factors

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Latent Conditions: Examples

Deficiencies in:Design factorsSafety managementTrainingStandard Operating ProceduresSelection systemsEtc.

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Threats

Factors external to the flight deck that increase the complexity of flight operations and which are realized through a triggering event

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Threats: Examples

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Weather

Maintenance

errors

Ground crew

errors

Flight/Cabin Crew errors

Passenger

events

ATC errors

Terrain

Similar call signs

Time pressures

Heavy traffic

Unfamiliar airports

Automation events

Missed approaches

Flight diversions

System

malfunctions

Distractions

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Bow Tie Model

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ASR, GHR, Ext…

Preventive DEFENSES

RECOVERY DEFENSES

END STATES

ACCIDENT/INCIDENT

Altitude Deviation

Unstabilized Approach

Runway Incursion, Unsecured Loading

ATC Comm. Loss, etc

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Threats

List the Threats that were realized in the triggering event or events

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Preventive Defenses

What are the specific mechanisms that should have helped prevent the undesired aircraft state?Examples: policies, procedures, trainingWhich of these defenses/barriers failed?Why? What caused the these defenses/barriers to fail?

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UAS: Examples

Aircraft Handling:Lateral, vertical or speed deviationOperation Outside Aircraft LimitationsUnstable approachGround Navigation:Runway / taxiway incursionProceeding towards wrong taxiway / runwayWrong hold spotIncorrect aircraft configurationsSystemsLanding gearFlight controls

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Undesired Aircraft States (UAS)

Describe the Undesired Aircraft State

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Recovery Defenses

List the Recovery Defenses that either prevented or failed to prevent the Accident or Incident from occurringExplain the specific mechanisms which should have helped recover from the unsafe event?Which of these failed?Why? What caused these to fail?

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End States

End States are reportable events:IncidentsAccidentsTailstrikeUndershootHard LandingEtc…

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Safety Enhancements

What was learned from this occurrence?What changes have been or should be made at your airline and in industry?Procedures, PoliciesTraining Equipment ATC AirportWeather Information etc….

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Lessons Learned for IRM(Note: this slide will be shared with all IRM attendees)

What should attendees at IRM learn from this occurrence?What should attendees at IRM consider changing at their own airline?

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Key Messages for Safety Group(Note: this slide will be shared with all IRM attendees)

What are the key messages that Safety Group should act on?

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Usage Notes for IRM Template

When discussing crew actions management, describe only observable facts, and avoid judgments. Value statements such as “minor”, ”poor” or “very” attached to the description of crew actions should be avoided.When discussing undesired states management, describe only observable facts, and avoid judgments. Value statements such as “minor”, ”poor” or “very” attached to the description of crew actions related to undesired states management should be avoided.

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