1 Incident Review Meeting
Presentations text content in 1 Incident Review Meeting
Incident Review Meeting
Guidance Material & Presentation TemplateSlide2
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
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?
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
Conditions present in the system before the accident, made evident by triggering factors
Latent Conditions: Examples
Deficiencies in:Design factorsSafety managementTrainingStandard Operating ProceduresSelection systemsEtc.
Factors external to the flight deck that increase the complexity of flight operations and which are realized through a triggering event
Flight/Cabin Crew errors
Similar call signs
Bow Tie Model
ASR, GHR, Ext…
Runway Incursion, Unsecured Loading
ATC Comm. Loss, etc
List the Threats that were realized in the triggering event or events
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?
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
Undesired Aircraft States (UAS)
Describe the Undesired Aircraft State
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?
End States are reportable events:IncidentsAccidentsTailstrikeUndershootHard LandingEtc…
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….
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?
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?
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.