AVINOR

-

AFIS-Safety

Lars Kristensen

Safety Advisor/Head Investigator

Avinor AFIS

Geographical view of Avinors

operation

• Red: Local Airports With AFIS

• 46 Airports, incl OSL, Gardermoen

• 28 Airports with AFIS

• Appx 150 AFISO

What’s Avinor’s role?

Avinor is a certified ANSP with AFIS.

(Eu’s Common Requirements)

Certified school organisation for AFISO

(In collaboration with EPN) Basic course,

OJT, OJTI, OJTI refresh, and NEPTA

Requirements –

Norwegian Aviation

• The Law of Aviation gives CAA-N authority to

establish regulation.

International Civil

Aviation

Organization (ICAO)

• Established by UN

• ICAO controlling

authority within Aviation

Norwegian Law in compliance

with UNs regulations

Regulation

Distinctively

Norwegian

Requirements

EASA, EC

CAA-N

Regulation

• BSL A 1-3 Notification and reporting obligation

concerning incidents and accidents.

• BSL A 1-9 Use of Safety Management Systems

within ATM Service Providers and Ground Service Crew.

”Findings”

Through ”Continious” Safety monitoring

– Revisions

– Investigating incidents/accidents

– Risk Analysis

– Safety Review

– Suggestion’s of improvement, Reports of

concern

Investigations

• All reported incidents in Avinor are

being investigated by at least one

investigator leader

• Serious incidents are investigated with

a appointed group (3 members.)

• Reocurring incidents – are also being

investigated with a appointed group (3

members)

Investigating incidents/accidents AFIS

• All reported incident from AFIS units, are

being investigated by the AFIS investigation

group

• Investigation group AFIS is:

– 3 investigation leaders

– 2 ivestigators.

• The gruop is leaded by a «Head of

investigation»

MESYS

”Just culture”

Safety Culture

Safety Culture/Pro-active management

Numbers of reported incidents and

accidents (2007-2011)

WHY do we investigate?

What P

R

E

V

E

N

T

I

O

N

How

Why

Object of investigation

• Not to find out where people went wrong,

• But to find out how people’s assessment,

action and decisions could have made

sense to them at the time,

• And to determine how similar incident can

be prevented from reoccurring.

Investigatingprocess

Facts Analysis Conclusions Recommen-

dations

Le

ad

s to

Ge

ne

rate

s

Re

qu

ire

Brings up more

FREQUENCY

1 Very

Frequent

2 Frequent 3 Occasional 4 Rare 5 Extremely

rare

SEVERITY

A Serious incident A1 A2 A3 A4 A5

B Major incident B1 B2 B3 B4 B5

C Significant

incident C1 C2 C3 C4 C5

D Not determined D1 D2 D3 D4 D5

E No safety effect E1 E2 E3 E4 E5

According to BSL A 1- 3 Severity class A and B Major incident

Dissemination and info-Sharing

• Focus on recommendations - on Central and

Local level

• Safety Committee, Central and in each Division

• Safety Network (interface)

• Flight Safety Committee, Central and Local

• PRI 1

• Bakkenytt

• Safety Bulletins

Gives us -

Safety Improvements

&

Safety Awareness

Questions?

THANK YOU FOR YOUR ATTENTION!