Documented Information 17 Occurrence Reporting and Analysis
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Publication History
Version No. Details of Changes Made Date Approver Initials
01 New format with introduction of Aerodrome Management Policies (AMP)
29/09/2016 JMC
02 Section 5.2.1-Define timeframe for reporting occurrences to CA Section 5.3-clarify reporting timelines for occurrence investigation reports to be sent to the CA.
28/06/2017 JMC
03 Insert Appendix 2— Updated list of Abbreviations Update section 5.2.1 on timeline of reporting MOR Update section 5.3 on investigation and timeline for closure of report
12/12/2017 JMC
04 Section 2—add reference to IR 2015/2018 Section 5.2.2-Addition of Voluntary reporting scheme for ATM and update to existing voluntary reporting via website Section 5.2.1 (g) Addition of quality checking program for MOR and VOR Section 5.2.1 (r) & (s) Update to confidentiality requirements Update to abbreviations table Section 3 Add definition of Incident as per EU Reg 996/2010 Section 5.2.1 (m) update to reporting headline requirements Appendix 3-Align with ESARR 2 Update Reference Documents and definitions Section 5.2.1.1—outline completing SOTS form (ATM 003) Section 5.2.1.2—outline how to complete MOR via the ECCAIRS system Section 4.1 update to Aerodrome reporting
21/12/2018 JMC
05 Section 5.2.1-add reference to regulation 996/2010 and reporting of volcanic ash clouds and destination of reports Section 5.2.2.3—Update to Voluntary reporting process to include the use of the ECCAIRS system Update Document reference section
27/02/2020 JMC
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KEY TO ABBREVIATIONS:
IAA Irish Aviation Authority
ATC Air Traffic Control ISO International Standard Organisation
ASP Airport Security Programme
AIS Aeronautical Information Services
SATCO Senior Air Traffic Control Officer
SRD Safety Regulatory Department
AIP Aeronautical Information Publication
SOP Standard Operating
Procedures
AAIU Air Accident Investigation Unit
ANSRD Air Navigation Safety Regulation
Department
MOR Mandatory Occurrence Report
SI Statutory Instruments DI Documented Information
MTOW Maximum Take Off Weight
RSI Remote Status Indicator
SMS Safety Management System
LOA Letter of Agreements UTP Unit Training Plan
ACMS Advanced Control Monitoring System
DATCO Duty Air Traffic Control Officer
ICAO International Civil Aviation Organisation
SLA Service Level Agreements
AOI Airport Operational Instructions
TORA Take Off Run Available
ATM Air Traffic Management
SOTS Safety Occurrence Tracking System
GP Glide Path AMP Airport Management
Policy
TODA Take Off Distance Available
ANSRD Air Navigation Safety Regulation
Department
CAR Corrective Action Requests
VOR VHF Omnidirectional Range
CBT Computer Based Training
ASDA Accelerate Stop Distance available
O+M Operate and Maintenance Plan
EASA European Aviation Safety Agency
SUA Small Unmanned Aircraft
UCS Unit Competency
Scheme
GPU Ground Power Unit
FSDO Fire and Security Duty Officer
IWAK Ireland West Airport Knock
MATS Manual of Air Traffic Services
DME Distance Measuring Equipment
APU Auxiliary Power Unit
ADI Aerodrome Instrument Rating
RAD Radar LVP Low Visibility Procedures
NATS National Air Traffic Services
(UK)
DA Decision Altitude
APP Approach Procedural Rating
VFR Visual Flight Rules RAVP Reduced Aerodrome Visibility Procedures
FIR Flight Information
Region
DH Decision Height
PBN Performance Based Navigation
IFR Instrument Flight Rules
NDB Non-Directional Beacon ILS Instrument Landing System
GA General Aviation
RFFS Rescue and Fire Fighting Service
NOTAM Notice to Air Men GNSS Global Navigation Satellite System
GPS Global Positioning
System
RA Resolution Advisory
ALM Aerodrome Licensing Manual
OJT On the Job Training SIS Signal in Space WTMD Walk Through Metal Detector
TA Traffic advisory
AIC Airport Identification Cards
VIC Vehicle Identification Cards
HHMD Hand Held Metal Detector
LAGS Liquids, Aerosols and Gels
TAF Terminal Aerodrome Forecast
PRM Person with Reduced Mobility
CCTV Closed Circuit Television Scanning
CFSO Chief Fire and Security Officer
CPSRA Critical Part Security
Restricted Area
FAP Final Approach Point
NCR Non-Conformance Report
ADR Aerodrome (EASA) QMS Quality Management System
IATA International Air Transport
Association
AFIDS Airport Flight Information Display
System
DG Dangerous Goods AFTN Aeronautical Fixed Telecommunications
Network
CFMU Central Flow Management Unit
ACOP Approved Codes of Practice
ALARP As Low As Reasonably Practicable
DSE Display Screen Equipment
EAP Employee Assistance Programme
GP General Practitioner HSA Health and Safety Authority
HSE Health Service Executive
MEWP Mobile Elevated Work Platform
OHS Occupational Health and Safety
PAT Portable Appliance Testing
PPE Personal Protective Equipment
PRA Primary Response Agency
PRM Persons with Reduced Mobility
PTW Permit to Work QMS Quality Management System
RAMS Risk Assessment and
Method Statement
RPE Respiratory Protective Equipment
RSA Road Safety Authority SDS Safety Data Sheet SHQ Safety, Health and Quality
FSEU Field Site Electronics Unit
TMS Time Management System
ATS Air Traffic Services VHF Very High Frequency UHF Ultra-High Frequency OK Oscar Kilo (NDB)
TCAP ATSEP Training & Competency Assessment
Program
VCR Visual Control Room RMM Remote Maintenance & Monitoring
LED Light Emitting Diode LLZ Localiser KNK Kilo November Kilo (NDB)
AGL Aeronautical Ground Lighting
CCR Constant Current Regulator
ACMS AGL Control & Monitoring System
PAPI Precision Approach Path
Indicator
NM Nautical Mile
SMGCS Surface Movement Guidance & Control
UPS Uninterruptible Power Supply
CWP Controller Working Position
VCCS Voice Control & Communication
LCSU Local Control Status Unit
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System System
IRVR Instrument Runway Visual Range
CRU Control & Recording Unit
BLM Background Luminance Monitor
PIT Pilot’s Illuminance Threshold
AMS Airport Management System
ACN Aircraft Classification Number
PCN Pavement Classification Number
GDPR General Data Protection Regulations
PIGs Passenger integrated
guidance system
EOBT Estimated Off-Blocks Time
ETOT Estimate Take-Off Time MEWP Mobile Elevated Work Platforms
PSDP Project Supervisor Design Phase
PSCS Project Supervisor
Construction Phase
PTW Permits to Work
AUTP ATSEP Unit Training Plan
ROTC Record of Training & Competency
AIS Airport Information System (Rick)
ARR Arrival DEP Departure
DLY Delay CNL Cancellation DIV Diversion SCH Schedule Flight SCHP Scheduled Positioning flight
CH Charter STA Scheduled Time of Arrival
SCD Scheduled Time of Departure
POS Positioning Flight OOH Out of Hours operation
SITA Société Internationale de Télécommunications
Aéronautiques
SGHA IATA Standard Ground Handling
Agreement
AHM IATA Airport Handling Manual
IGOM IATA Ground Operations
Manual
MTBO Mean Time Between Outages
MTBF Mean Time Between Failures
MM Middle Marker OM Outer Marker ARP Aerodrome Reference Point
TDZ Touchdown Zone
THR Threshold ECCAIRS European Co-ordination centre for
Accident and Incident Reporting Systems
CA Competent Authority EATMP European Air Traffic
Management Programme
SAM Safety Assessment Methodology
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TABLE OF CONTENTS
Document Title 1
Document Distribution Record 1
Reference Documents 1
Publication History 2
Key Abbreviations 3/4
Table of Contents 5
Introduction 6
Objective and Purpose 6
Definitions 7
Scope 7/8
Aerodrome Reporting Procedures 8-15
At the time of the Incident 8
Recording the information 8/9
Mandatory Occurrence Reporting 9-13
Voluntary reporting 14-16
Investigation 16-18
Reporting to External Regulatory Authorities 18
Confidentiality 19
Lesson Dissemination 19
Appendix 1—Guidance on Occurrences to be reported 20-24
Appendix 2—Investigation of ATM Safety Related Occurrences 25-28
Appendix 3—Severity Classification Scheme for Safety Occurrences in ATM 29-31
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1. Occurrence Reporting and Analysis Policy for Airport Management System at Ireland West Airport:
1. Introduction All employees are required to report verbally initially if necessary but also in writing without delay any incident that has or may have a safety, security, quality or health implication to person/s and/or property including injuries, ill health, near misses and non-conformities and to co-operate in any subsequent investigation. Ireland West Airport operates a Just Culture. "Just Culture" is a culture in which frontline operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated (AMP 39 outlines IWA’s Just Culture Policy). Although overall responsibility for ensuring safety at Ireland West Airport lies with management, all staff are individually responsible to ensure safety through their actions. It is not the intention of this procedure to apportion blame or liability. 2. Objective and Purpose The objective of this procedure is to ensure that all accidents, occurrences or incidences with safety, security, quality or health significance at Ireland West Airport are reported and investigated sensibly, fairly and effectively in accordance with the objectives and requirements of:
• Safety, Health and Welfare at Work Act, 2005
• Safety, Health and Welfare at Work (General Application) Regulations, 2007
• Safety, Health and Welfare at Work (General Application) (Amendment) (No. 3) Regulations 2016 (SI 370 of 2016)
• European Communities (Occurrence Reporting in Civil Aviation) Regulations, 2007 - SI 285/2007
• ESARR 2 Reporting and Assessment of Safety Occurrences in ATM
• Provision of air navigation services and Regulation (EU) No 1035/2011
• Common rules in the field of civil aviation and Regulation (EU) No 216/2008
• Requirements and administrative procedures related to aerodromes and Regulation (EU) No 139/2014
• The NCASP structured in line with EC Regulation 300/2008, EC Regulation 185/2010 and EC Decision 2010/774.
• EU Regulation Nr. 376/2014 on the reporting, analysis and follow-up off occurrence in civil aviation.
• ISO 9001:2015
• ISO 45001:2018
• IR 2015/1018
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3. Definitions
Accident: An unforeseen or unplanned event or circumstance resulting undesired consequences eg. serious injury, major damage or loss of property/equipment, environmental and/or operational control
Incident: An unplanned, undesired occurrence, other than an accident, that adversely affected the completion of a task/s or operational process or affected the safe operation of an aircraft. These could be General Operational, Safety, Environmental or Security related.
Near miss: safety or security observation in which the potential for injury or ill health to person/s (staff, passengers, contractors, visitors) or damage to property, plant, materials or equipment at the workplace or as a result of workplace activities/operations is identified
Place of work includes any, or any part of any, place (whether or not within or forming part of a building or structure), land or other location at, in, upon or near which, work is carried on whether occasionally or otherwise. Person/s: staff, passengers, crew, ancillary staff, contractors, visitors, members of the public affected or involved in activities at the place of work 4. Scope Ireland West Airport operates three formal reporting schemes as part of managing and improving safety levels: 4.1. Aerodrome Reporting
• Incidents: o Operational: affected normal operations e.g. equipment breakdown, load sheet
errors, FOD o Damage: to property/equipment e.g. vehicles, baggage, equipment, surfaces etc o Minor Injury: harm to person/s at place of work which required minor first aid
attention (e.g. cuts, grazes, swelling, scalds etc) o Serious Injury: harm to person/s at place of work which required
ambulance/GP/hospital attention (e.g. fractures, burns etc) o Ill health: as a result of work tasks e.g. strains/aches, stress, chemical exposure
etc o Medical incident: person/s suffering ill health unrelated to workplace/operations,
where first aiders may have attended/assisted o Environmental: unintended or uncontrolled spills, leaks etc o Security: e.g. loss, theft, unauthorised access, unruly pax, threats etc
• Observations/Concerns: non-compliances (e.g. not wearing PPE), opportunities for safety/security improvement etc
• Near Misses: As per definition above
• Operator Safety Reports (ASR/CSR)
• Other: Anything not covered by above list
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NOTE: A full list of ATM & Aerodrome occurrences to be reported are contained in Appendix 1 of this document.
See AMP 17 (Safety Statement) for list of H&S related incidents to be reported
4.2. Mandatory Occurrence Reporting (MOR—ATC) 4.3. Voluntary Reporting (HR): Additional information available in Voluntary Reporting
Policy and Employee Handbook. 5. Aerodrome Reporting Procedures 5.1. At time of incident: The Supervisor/Manager on duty must assist / attend the scene as soon as possible to try and contain the potential for further harm/disruption/damage. He/she may require the assistance of others, and must escalate the reporting of same to the Head of Airport Operations ASAP where deemed to be of a serious nature i.e. could adversely affect operations/safety/security.
• In the event of injury, ill health or medical incidents contact a first aider if required (names located on form HS 037 and in various frames around the airport).
• Cordon off the area and divert pedestrians/traffic where required and if possible. If equipment was involved, cease its operation until further investigation. If any other hazard poses an ongoing risk the operation should be ceased immediately pending investigation.
• The person involved in the occurrence/incident must complete report form (GEN 001) unless they are incapacitated. In this situation the supervisor/manager must agree who will record details of the incident on GEN 001 and submit to Head of Airport Operations and Commercial Services. Any individual involved / witness to the occurrence/incident may also submit a report or be asked to submit a report by the investigator to complement the information on the initial report. This should be done as soon as practicable after the event.
• Record as much detail as possible including the date, time and exact location of the incident, if the victim was wearing appropriate PPE/footwear, any general and/or weather conditions that may have had an impact, machinery involved etc.
• Take photographs of the scene if possible and attach to the report. 5.2. Recording the information
• Record as much information as possible by the person/s involved or by the head of the department or his/her deputy as soon as practical on the Aerodrome Report Form (Gen-001). This must be done on the day of the incident and before leaving work.
• Submit report with any additional attachments including witness statements and photos as soon as practicable to the Operations and Commercial Services Administrator (email [email protected] or by hand) and the Head of Airport Operations and Commercial Services(email [email protected] or by hand) for quality and tracking purposes.
• Records of all reports are held on the network under the control of the Operations and Commercial Services Administrator (see AMP 07 for detail on record retention).
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• A unique reference for quality and tracking purposes will be assigned to each report by the Operations and Commercial Services Administrator.
• A copy of the Aerodrome Report with tracking number will be forwarded to the Head of Airport Operations and Commercial Services who will decide on whether it requires investigation and by whom (this may be more than one individual).
• The SATCO will decide if the report should be upgraded to a Mandatory Occurrence Report (MOR) in line with Appendix 1 (Guidance on Occurrences to be Reported Extract from EU Regulation 2015/1018). This will require a SOTS form (ATM 003) to be completed and from 01st January 2019 a MOR report will be filed through the ECCAIRS (European Co-ordination Centre for Accident and Incident Reporting Systems). ECCAIRS can be used to file an ATM or an Aerodrome report.
5.2.1. Mandatory Occurrence Reporting (ATM)– SOTS form or online Portal
a) The SATCO and/or assigned deputy shall be informed in writing or verbally of all
Reportable Occurrences as soon as practical after occurrence.
b) All occurrences of a reportable nature as detailed in EU Reg 376/2014 and IR 2015/1018 and EU Regulation 996/2010 shall be reported by either Air Traffic Control, Technical Services or Aerodrome staff involved in the event.
c) In addition Ireland West Airport should report volcanic ash clouds, encountered by aircraft operators, for which it has become aware of.
d) Occurrences shall be reported to the organisation as soon as practical after the event or at the latest 72 hours after the event has occurred giving as much detail as possible unless . On receiving a report IWA will forward this report onto the competent authority as soon as practicable but at the latest 72 hours after receiving the report.
e) An Aerodrome report must also be competed for each MOR filed and forwarded to SATCO, Head of Airport Operations and Commercial Services and Operations and Commercial Services administrator.
f) Ireland West Airport shall, in addition to making a report to the competent authority shall also report if deemed necessary, to the organisation responsible for the design of system and constituents, if different from the service provider, any malfunction, technical defect, exceeding of technical limitations, occurrence, or other irregular circumstance that has or may have endangered the safety of services and that has not resulted in an accident or serious incident.
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6
Reporting Process
Individual
Organisation
ECR
Competent Authority
• ECCAIRS/ADREP Compatibility• Reporting means• Minimum Data Fields• Risk Classification• Data Quality checks
• Free format (C.A. Forms)
• ECCAIRS• Minimum Data Fields• EU Risk Classification• Data Quality checks
• Organisation Manual
5.2.1.1 Making a report using the SOTS form
• Complete the SOTS form (ATM 003) which can be found under Templates on the “G” drive (templates/forms/ATM & Tech Services / ATC).
• Assign a report number to the report (from tracking sheet as outlined above)
• When report completed send to [email protected] and copy in Head of Airport Operations and Commercial Services, SATCO and Ops and Commercial services Administrator and Head of Technical Services if the occurrence involved equipment or technical personnel.
• The SATCO will save the report in the SOTS file and assign an investigator. Only the SATCO has access to the MOR-VOR folder on the “F” drive.
• An Aerodrome report must also be competed for each MOR filed
5.2.1.2 Making a report using ECCAIRS (from 01st January 2019)
• Log onto EU Portal www.aviationreporting.eu/aviationreporting/
• Select “I report on behalf of my organisation”
• Select “Ireland Flag”
• Select either “off-line reporting” or “on-line reporting”
• For off-line reporting select “use the off-line reporting form”
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• For on-line reporting select either “Report a new occurrence” or Update a reported occurrence).
• For updating you will have to use the E5Y file that you received via e-mail when submitting the original report.
• For new report select either “Aerodrome and Ground Handling” “ATM/ANS” or “Technical”
• There are 17 web pages in total-not all have to be completed
o Page 1: First some general questions
o Page 2: General information about the occurrence
o Page 3: Aircraft involved in the occurrence
o Page 4: Information about the main aircraft
o Page 5: The occurrence happened at or around the aerodrome
o Page 6: There was an ATM contribution
o Page 7: Damage sustained by an aircraft or other objects/structures
o Page 8: Injuries or incapacitation sustained in the occurrence (more than one aircraft involved)
o Page 9: The occurrence involved a runway incursion IE
o Page 10: The occurrence involved a bird strike or collision with wildlife
o Page 11: The occurrence involved dangerous goods IE
o Page 12: The weather was relevant to the occurrence
o Page 13: The classification of the occurrence
o Page 14: Analysis and follow-up actions
o Page 15: Reporting history and attachments
o Page 16: Review your occurrence
o Page 17: Contact Details
• Only complete the sections of the form which are relevant to your report
• Sections which are not relevant are to be left empty
• Sections where information is relevant to the report, but not known, should be filled with the entry “UNKNOWN” where applicable
NOTE: The use of “Empty” and “Unknown”:
Exceptions excluded, each data entry field allows giving no value or selecting the “empty” equivalent. No value or “empty” means that the information is either not available or not relevant for the report.
Some data entry fields include the element “unknown”. Use this value ONLY if an attempt to obtain the information was made but at the time of reporting it is not available and you want to
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indicate that to some extent you consider the missing information relevant for the occurrence. Do not use this to indicate “I don’t know” because this is expressed by no value or by “empty”
• Mandatory fields must be completed (shaded in pink)
• For reporting entity select Ireland/Other/ANSP or Aerodrome
• For ANSP report select IE.470 // EIKN (this is the ANSP Licence number followed by space // space and ICAO designator).
• For Aerodrome report select IE.511 // EIKN (this is the Aerodrome Licence number followed by space // space and ICAO designator)
• Follow the prompts to complete the form
• When submitted you will receive an e-mail with 2 attachments (PDF and a E5Y file).
• Save both and send a copy of both files to the SATCO who will save both files in the MOR-VOR reporting folder.
g) To ensure the accuracy, quality and consistency of reports being made initially and throughout the entire MOR process (investigation, analysis, closure etc), the following process applies:
• After receiving a copy of the MOR sent to AVREPS or via ECCAIRS the SATCO shall review the MOR to ensure the numbering of the MOR is correct, the information collected is accurate, all sections are completed correctly and honestly, mandatory fields are correctly completed, correct use of ADREP taxonomy is used and if necessary, re-submit the report after consultation with the individual who made the initial report.
• Save a copy of the MOR in the reporting folder and investigation folder of the MOR-VOR folder located on the “G” drive.
• Complete the MOR tracking sheet as per information received in the report and update this sheet as the investigation progresses including inserting recommendations, responsibilities and closure dates as appropriate.
• Review the investigation report from a data checking aspect ensuring conclusions and recommendations are presented correctly and ensuring the accuracy of information.
• Submit report to Head of Airport Operations and Commercial Services for review, de-identifying both the reporter and the investigator if necessary.
• MORs are reviewed by the SATCO on a monthly basis as to the status of closure of recommendations.
• Update number of MORs on the monthly Ops report.
• Contribute to the 2 monthly board report regarding MORs and other ATS issues.
• Update the Runway Safety Committee meetings on the number of MORs filed and the status of the MORs and recommendations.
• Update the quarterly SMS Committee meetings on the number of MORs filed and the status of the MORs and recommendations.
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• A 6 monthly report as outlined in (r) below is carried out by the SATCO.
• A statistical analysis is carried out at year end on root cause etc of MORs.
• A safety report is presented to the airport board of management which includes MOR data.
• All MOR reports are de-identified to ensure confidentiality of the individual filing the report.
h) All activities and information relevant to reported occurrences, especially follow-up investigation, shall be recorded in a traceable manner in the SOTS file (investigation folder).
i) Corrections can be made to online reports by selecting the “update existing occurrence”.
j) The SATCO or assigned deputy shall liaise with Technical Services if appropriate to determine the cause of the occurrence.
k) In the case of an occurrence being reported by a member of the public, or which is likely to become public knowledge, the Head of Airport Operations and Commercial Services or assigned deputy, Ireland West Airport shall determine the level of information to be released.
l) Where an occurrence may be defined under more than one category, it shall be reported under all mandatory categories ensuring it meets the requirements of EU REG 376/2014, Annex 1 and Implementing Regulation (EU) 2015/1018.
m) In the event of an Aircraft Proximity all operating companies involved shall be notified by the Head of Airport Operations and Commercial Services or nominated deputy.
n) As soon as practical the SATCO and/or Head of Technical Services or their assigned deputies shall determine the severity of each occurrence, classify the risk incurred and decide what further action is necessary. The severity shall be defined as is contained in EAM 2/GUI 1.
o) Recorded material to be impounded shall be placed in separate locked and fire-proof storage under the control of the SATCO (see MATS for location of secure storage). This shall include but not limited to the following:
- Occurrence report
- Flight Strips;
- Copies of flight plans;
- Meteorological Information;
- Recordings of all transmissions/telephone calls pertinent to the occurrence
p) The Head of Airport Operations & Commercial Services and SATCO shall carry out a review of SOTS at six monthly intervals (ATM 005) so that patterns or trends are identified. This review shall consist of checking all of the SOTS to ensure that they are closed or otherwise update their status. The review shall also ensure that all safety recommendations and corrective actions have been implemented or update the progress of implementation.
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5.2.2 Voluntary Reporting EU Regulation No 376/2014 on the Reporting, Analysis, and follow-up of Occurrences in Civil Aviation places an obligation on Ireland West Airport to establish a Voluntary Occurrence Reporting System for (VORS). Any member of staff or anyone working at the airport in any capacity may submit a Voluntary Report highlighting any Safety Issues or concerns through either of the avenues outlined below. 5.2.2.1 Objective The process and related arrangements for collecting information about, 1. Safety concerns, issues and hazards, which otherwise would not be revealed by the mandatory
reporting system as detailed in 5.2.1 above; 2. Other safety related information which is perceived by the reporter as an actual or potential
hazard to aviation safety or general safety.
5.2.2.2 Scope Reports can be made using either of Ireland West Airports voluntary reporting schemes as outlined in 5.2.2.3 and 5.2.2.4 below. 5.2.2.3 Procedure (ATM and Aerodrome)
a. The VORS is used to facilitate the collection of details of occurrences and safety related information not subject to mandatory reporting and reported by persons who are not listed in Article 4(6) of EU Regulation 376/2014.
b. The reporting person has the option of submitting a voluntary incident report, using the VORS
Form (GEN 015) or via the ECCAIRS system under the EU Aviation Safety Reporting Portal.
c. The EU Aviation Safety Reporting Portal can be accessed as outlined in section 5.2.1.2 above www.aviationreporting.eu/aviationreporting/ . The person making the voluntary report under this option should select “I report on my personal behalf” and fill in the appropriate sections when prompted. When completed the person making the report has the option of providing their contact details which allows contacting them if deemed necessary. The individual can also specify a valid e-mail address for obtaining a PDF copy of the submitted report or they can select an e-mail address of a member of the management team at IWA if appropriate. If the person does not want to be contacted or receive a PDF copy of the report and remain anonymous them leave the credentials and e-mail empty. If a person is aware that the occurrence being reported could be a serious incident or accident then, in addition to reporting via this site, they are also legally obliged to notify the Safety Investigation Authority in the State of Occurrence. Regulation (EU)996/2010 refers.
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d. The VORS Form (GEN 015) is available on the “G” drive under “Templates” / “Forms” / “General”.
e. The VOR shall be submitted to the ANS Safety Manager and the Head of Operations and Commercial Services Manager, within 72 hours of becoming aware of the occurrence, unless exceptional circumstances prevent this.
f. The ANS Safety Manager will submit the VOR to the Competent Authority as soon as possible
and in any event no later than 72 hours of becoming aware of the occurrence.
g. The information reported in the VOR will be collated, evaluated, processed, analysed and stored in a similar way SOTS information is handled.
h. If the ANS Safety Manager or the Head of Airport Operations and Commercial Services decide that further investigation is warranted, an investigator will be assigned and an investigation will be carried out in accordance with section 5.3 below and Appendix B of this procedure.
i. As Part of the investigation, the investigator may recommend appropriate corrective or
preventative action required to improve safety.
j. The ANS Safety Manager will implement any appropriate corrective or preventative action as recommended by the investigator and will monitor the effectiveness of the action.
k. Timeframes for transmitting identified actual or potential aviation safety risks and action taken as a result of the analysis of a VOR and the issuing of a preliminary and final report will be the same as outlined for SOTS in 5.3 below.
l. The data quality checking process to improve data consistency between the information
collected initially, and the report stored in the ECCAIRS database as outlined in the MOR procedure, section 5.2.1 (h) above will be complied with.
m. The VORS file will be held in the MOR/VOR folder where there is restricted access as outlined section 7 below.
n. Confidentiality is also assured as outlined in section 7 below.
5.2.2.4 Voluntary Reporting (Safety issues / concerns not relating to Aviation Safety) Ireland West airport is committed to maintaining an open culture with the highest standard of honesty and integrity and encourages employees to report any concerns to a manager for resolution. The online voluntary reporting system is available to employees who wish to report a serious wrongdoing / breach in health and safety or the Code of Ethics policy (AMP 28) (e.g. fraud). This can be done anonymously. Protection of the identity of the individual making the report and any individual referred to in the report is a primary element of the scheme. The Voluntary reporting system is not for grievances relating to one’s terms and conditions of employment or to be used by employees/personnel for their own personal circumstances, such as the way they have been treated at work. In those cases, employees should use the Grievances
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Procedure. The Voluntary Reporting scheme is not a forum for personal agendas or grudges. False/malicious reports or those made for personal gain will not be tolerated and may result in disciplinary action up to and including dismissal (see AMP 47-Grievance and Disciplinary Policy). 5.2.2.5 Procedure
a) Log onto www.irelandwestairport.com
b) At the bottom of the page click on “Voluntary Reporting”
c) Enter Password: IWA2018 (upper case) and click continue
d) An explanation of the Voluntary Reporting scheme will appear. Click Continue.
e) Voluntary reporting form will automatically come up
f) Complete the form ensuring all data is captured (name is optional).
g) Click submit.
Once submitted the report automatically goes to the HR department. 5.3. Investigation
• All occurrences shall be investigated whether they be MORs’ or Aerodrome Reports or Voluntary Reports. The SATCO shall assign an investigator to all MOR reports. Aerodrome Reports that have not been upgraded to an MOR shall be reviewed by the Head of Airport Operations and Commercial Services and an investigator assigned if required.
• The HR Manager will initiate an investigation into all Voluntary Reports after de-identifying the report. The investigation may be conducted by the HR manager or another appropriate manager.
• Medical incidents unrelated to Airport operations/activities are not investigated, but merely recorded to demonstrate first aider assistance/involvement.
• Health and safety related incidents are investigated in line with AMP 17 - Safety Statement Section 4.5.1 and 4.5.2.
• Depending on the seriousness of the incident an initial internal report shall be produced within 5 working days of occurrence and any immediate corrective actions identified.
• Irrespective of whether the MOR is closed a report on the occurrence analysis shall be forwarded onto the competent authority within 30 days of the occurrence.
• When investigations are completed and all recommendations identified, an Investigation and Closure Report (GEN 002 for Aerodrome reports, ATM 004 for MOR’s and GEN 016 for VORS) must be completed within 90 days of the occurrence and forwarded to the Head of Airport Operations and Commercial Services, documenting a summary of the incident, investigation conclusions and safety recommendations and corrective actions. MOR closure reports (ATM 004) must be forwarded to the competent authority within this timeframe also.
• The investigator and/or Head of Airport Operations and Commercial Services shall assign actions and target implementation dates arising out of the report to the appropriate manager / person.
• The report and recommendations will be tracked by the investigator and/or Operations and Commercial Services administrator. The ANS Safety Manager and HR Manager are also
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responsible for implementing all recommendations arising out of Voluntary reports relevant to them and to track all Voluntary reports to closure.
• If the incident is of a reportable nature to an external body (eg. HSA, airline, IAA etc) this shall be done by the relevant manager and the Head of Airport Operations and Commercial Services is notified. See 6.
• All reports shall be reviewed at the quarterly SMS Committee meetings until closed.
5.3.1. Standard practice for investigating incidents The causes (root and contributory) of incidents shall be identified and analyzed to the utmost degree of objectivity and recorded, in order to identify the extent to which the airport management system or otherwise helped, or could have helped, to reduce the risk incurred and prevent recurrence as far as possible. Form HS 024 can be used as guidance to analysis root cause.
Investigations may be carried out by more than one individual to ensure informal/formal internal investigations are impartial and unbiased and with the skills, knowledge and practical expertise of the processes involved and/or to provide adequate balance. This may also come in the form of external assistance where required.
Investigations should look at and analyze what was happening at the time, has this happened before, what was directly or indirectly involved in the lead up, were there controls in place (e.g. procedures, risk assessments, training, guards etc.) and were they adequate, were there non-compliances or errors, what did witnesses see/hear etc.
Information recorded should be FACTUAL and ACCURATE. Reports should not include hearsay, exaggeration or opinions and should NEVER try to cover up something that has happened. Reports should not be given to any other third parties without prior consent of the Head of Airport Operations and Commercial Services.
The conclusions arising from the investigation should avoid apportioning blame. They should allow management to create appropriate action plans for preventing recurrence by identifying the causes for which a solution can be found.
A Risk Classification shall be assigned to each MOR investigation (see appendix 3).
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11
Timeline
MandatoryReport
Reporting toOrganization
T0
72h
Reporting follow-up to Authority
1M
Reporting final report to Authority
Authority Reportingto ECR
Authority stores the reportin the National DB
1M
Authority updatesreport in ECR
2M
VoluntaryReport
T0
Reporting toOrganization
Reporting toAuthority
1M
72h2M
3M
Reporting toAuthority
72h
3M
Indi
vidua
lsIn
divid
uals
Reporting TimelinesFollow-up Reports
6. Reporting to External Regulatory Authorities Occurrences to be reported to the relevant authority by the relevant safety manager are outlined in the following documentation; 6.1 Health and Safety Authority:
Refer AMP 17 (Safety Statement) Section 4.5.2. Notifiable Accidents and Dangerous Occurrences.
6.2 Irish Aviation Authority
a. ATM and/or Aerodrome incidents as defined by Notice to Aerodrome Licence
Holders Nr T05, Issue 4,15/12/09, ESARR 2 Reportable Occurrences, Occurrence Reporting in Civil Aviation SI 285/2007 and 376/2014 and 2015/1018 list of classifying occurrences to be mandatory reported.
b. Breaches of or attempted breaches of security, deficiencies in security, security significant detections, cyber incidents and/or discovery of prohibited items or of unauthorised firearms and weapons as defined by the NCASP.
c. Occurrences involving Dangerous goods
6.3 Department of Transport, Tourism and Sport
d. Breaches of or attempted breaches of security, deficiencies in security, security significant detections, cyber incidents and/or discovery of prohibited items or of unauthorised firearms and weapons as defined by the NCASP.
6.4 An Garda Siochana: serious safety and/or security related incidents. Certain incidents may be reported to other external parties (eg. airlines, insurance companies etc) as required.
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7 Confidentiality To comply with EU Reg 376/2014 and Articles 1 (ensuring the continued availability of safety information by introducing rules on confidentiality), 15 (confidentiality and appropriate use of information) and 16 (protection of the information source) the following restrictions are in place:
(a) The SOTS file consists of the main folder (named MOR / VOR) on the “G” drive. Within this there are sub-folders (i) the year of the occurrence, (ii) a reporting folder where all reported and filed SOTS are saved by the SATCO after receiving copy of report sent to AVREPS. Only the SATCO and Head of Operations and Commercial Services has access to this folder, (iii) an investigation folder (where access is restricted to the SATCO and investigator of the occurrence).
(b) The Investigator of the occurrence will be assigned by the SATCO and access for the investigator to the investigation folder will be assigned by the SATCO on a case by case basis.
(c) The reporting folder will only have the SOTS report in it.
(d) The investigation folder for each occurrence will hold all of the information required to carry out an investigation and the restricted access is in place to ensure the confidentiality of the information reported in occurrences and to only use the information in occurrences for the purpose for which it was collected.
(e) The confidentiality of the reporters of occurrences is also assured and only dis-identified information shall be disseminated within the organisation as appropriate.
(f) Except in cases of willful misconduct or where there has been a manifest, severe and serious disregard of an obvious risk and profound failure of professional responsibility to take such care as is evidently required in the circumstances, causing foreseeable damage to a person or property, or which seriously compromises the level of aviation safety, employees and contracted personnel who report or are mentioned in occurrence reports shall not be subject to any prejudice by Ireland West Airport on the basis of the information supplied by the reporter.
(g) When an investigator continues to operate as a controller, he/she shall ensure absolute confidentiality regarding any occurrence they are investigating and shall not discuss any aspect of the investigation with ATS staff either during the investigation or after the investigation.
All Aerodrome reports and Investigations should be dealt with confidentially with the person/s involved de-identified during any discussion on the occurrence. 8 Lesson Dissemination The ANS Safety Manager, Head of Airport Operations and Commercial Services or any departmental manager shall ensure that safety lessons and the results of investigations are made available to all ATM and Aerodrome staff as is appropriate through Safety Bulletins, NOTOCS or Staff Notices. To ensure confidentiality only dis-identified information shall be disseminated within the organisation as appropriate.
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Appendix 1 to AMP 01
Guidance on Occurrences to be Reported Extract from EU Regulation 2015/1018
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Appendix 2 to AMP 01
INVESTIGATION OF ATM-RELATED SAFETY OCCURRENCES
This attachment describes the system in place at Ireland West Airport for investigating ATM - related occurrences. The process below is activated when required in accordance with AMP 01, “Occurrence Reporting and Analysis”. 1. Objectives
The purpose of investigations into occurrences in ATM is to determine:
• What happened
• The causes
• How similar events may be prevented.
2. General
2.1 In the event of an accident or serious incident involving the ATM service
provided by Ireland West Airport, the SATCO will immediately initiate an investigation. 2.2 All reported occurrences other than those in 2.1 will be examined by the
SATCO / Head of Technical Services and/or Head of Airport Operations and Commercial Services to establish whether an investigation is necessary.
2.3 Whether or not an investigation is warranted, all reports will be retained by the SATCO/Head of Technical Services in the associated file to facilitate the
identification of trends. 3. Incident/Occurrence Investigation 3.1 The SATCO or his/her assigned deputy will be responsible for the
following actions to be carried out:
• Collate all the relevant information
• Evaluate all the relevant material
• Advise all staff concerned of the investigation
• Advise staff of operational status as necessary
• Co-operate with the AAIU as required
• Co-operate with the ANS Regulator as required
• Transcript of audio/radar tapes to be carried out and certified
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• Transcripts to be made available to staff involved (subject to agreement with AAIU if such permission required)
• Ensure that protocol for handling and transfer of recorded data is observed
• Interview staff involved
• Determine the degree of ATM contribution, including contributory factors
• Prepare final report containing recommendations, corrective actions and follow-up actions
• Ensure that all recommendations, corrective actions and follow-up actions are implemented
• See that the investigation is properly closed
• Maintain a traceable recording system for all investigation activities.
4. Accident/Serious Incident Investigation
4.1 The Head of Airport Operations and Commercial Services/SATCO or his/her assigned
deputy will ensure that 3.1 above is fully implemented and, in addition:
• Ensure that controllers involved in the accident/incident are removed from operational duties as soon as possible in order to write reports
• Ensure that Critical Incident Stress Management is available to staff if requested.
5. Handling and Transfer of Recorded Data for Investigation 5.1 When required for impounding, recorded material is removed from the recording device or storage area and retained in the secure fireproof safe provided, on the instructions of the SATCO. Technical services shall ensure that after removing the requested recording data from
the recorder that He/She ensures that the recorder is in full operation. 5.2 If copies of the original data are required they are numbered for tracking purposes. On closure of the investigation, these copies are retrieved and destroyed or stored. 5.3. Recordings impounded or released from impoundment are signed off by the SATCO or
his assigned deputy. 5.4 If custody of recorded or other original data is to be transferred, usually at the request of the AAIU, handover is carried out on a person-to-person basis and
signed for or is transferred by secure transport. 5.5 Recorded data for the purpose of investigation are retained until written
approval is obtained from the highest investigating authority involved that it is no longer required.
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5.5.1 Where an accident or serious incident is concerned a copy of recorded data is retained
by Ireland West Airport together with related documentation.
Requests for transcripts of recordings must be made in writing to the SATCO (ATM 039) and transcripts are prepared only on the instruction of the SATCO / Head of Airport Operations and Commercial Services or their assigned deputie’s.
Process Chart Incident Analysis
CORRECTIVE ACTION
DEFINITION
YES
INCIDENT ANALYSIS
Circumstances of the incident
Causal factors
Severity classification
INVESTIGATION
REPORTConclusions of the incident
investigation
If any, decided corrective action
Risk classification
FOLLOW-UP OF
CORRECTIVE ACTION
Verification that decided
corrective action are fully
implemented
INCIDENT
Return to safe operational conditions
Corrective
action needed ?
Subsequent
assessment
needed ?
LESSON
DISSEMINATION
System
Modification ?
Procedures/rules
amendement?
SAFETY
MONITORING
SYSTEM
SAFETY
ASSESSMENT
NO
1
2
3 4
Incident report
Incident report submitted to Safety Regulations Authority
YES
NO
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Appendix 3 to AMP 01
Severity Classification scheme for Safety Occurrences in ATM.
The following document outlines the severity classification scheme of ATM specific occurrences according to the severity of their effect on the ability to provide a safe ATM service. The proposed classification scheme consists of categories of severity and for the frequency of their occurrence. These are combined as a classification matrix whose columns correspond to the frequency categories and rows correspond to the severity categories. As a background into the severity classification scheme Table 1 lists the mapping between Eurocontrol and ICAO AIRPROX Classification.
SEVERITY Classification As
per ESARR 2
ICAO AIRPROX Classification
Accident ICAO Annex 13: - “Mid-air Collision between aircraft or between aircraft and other objects - Collision with the ground including Controlled Flight into Terrain or Collision on the ground, between aircraft or between aircraft and other objects”.
Serious Incident (A) AIRPROX CAT A: ICAO Doc 4444: AIRPROX - Risk of Collision: “The risk classification of an aircraft proximity in which serious risk of collision has existed”. Critical near collision between aircraft or between aircraft and obstacle(s). Separations lower than half the separation minima (e.g., 2NM). ICAO Annex 13/Attachment D: - “Near Collisions requiring an avoidance manoeuvre to avoid a collision or an unsafe situation or when an avoidance action would have been appropriate - Controlled Flight Into Terrain only marginally avoided - Aborted take-offs on a closed or engaged runway/Take-offs from a closed or engaged runway with marginal separation from obstacles/Landings or attempted landings on a closed or engaged runway/take-off or landing incidents, such as under-shootings, overrunning or running off the runway”.
Major Incident (B) AIRPROX CAT B: ICAO Doc 4444: AIRPROX - Safety Not Assured: “The risk classification of an aircraft proximity in which the safety of the aircraft may have been compromised”. Loss of separation (separation higher that half the separation minima/e.g., 4NM) which is not fully under ATC control. Safety margins not respected (higher than half the applicable safety margins) which is not fully under ATC control. A Crew avoidance manoeuvre and/or an ATC instruction allowed to reduce the risk, without eliminating it, as safety margins were still infringed.
Significant Incident
(C)
AIRPROX CAT C: ICAO Doc 4444: AIRPROX- No Risk of Collision: “The risk classification of an aircraft proximity in which no risk of Collision has existed”. After visual contact between two aircraft, no avoidance manoeuvre was seen as necessary or was carried out within safety margins. Aircraft deviation from ATC clearance (such as flight level, route, heading, runway), Unauthorised penetration of airspace, Runway incursion with no other traffic in the vicinity (hence, where no avoiding action was necessary).
Not determined (D) ICAO Doc 4444-Airprox- Risk Not determined- “The risk Classification of an aircraft proximity in which insufficient information was available to determine the risk involved or inconclusive or conflicting evidence precluded such determination”.
No safety effect (E)
Occurrences which have no safety significance. No direct mapping existing in ICAO “The risk Classification of an aircraft proximity in which insufficient information was available to determine the risk involved or inconclusive or conflicting evidence precluded such determination”.
Table AMP 01 C-1: Mapping between the EUROCONTROL Severity Classification Scheme &
ICAO AIRPROX Severity Scheme
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Severity as per
ESARR 2
A Serious incident A AIRPROX - Cat A SEVERITY As Per ICAO AIRPROX
B Major incident B AIRPROX - Cat B C Significant incident C AIRPROX - Cat C D Not determined D AIRPROX - Cat D E No safety effect - -
Table AMP 01 C-2: Continuation of mapping between the EUROCONTROL Severity
Classification Scheme & ICAO AIRPROX Severity Scheme
Risk Classification Scheme Tables
Seve
rity
Se
veri
ty
AA Total Inability to provide safe ATM services
AA1 AA2 AA3 AA4 AA5
A Serious inability to provide safe ATM services
A1 A2 A3 A4 A5
B Partial inability to provide safe ATM services
B1 B2 B3 B4 B5
C Ability to provide safe but degraded ATM services
C1 C2 C3 C4 C5
D Not Determined D1 D2 D3 D4 D5
E No effect on ATM services E1 E2 E3 E4 E5
1 2 3 4 5
Very Frequent Frequent Occasional Rare Extremely Rare
Table AMP 01 C-3: Severity Classification scheme of ATM specific occurrences according to the Severity of their effect on the ability to provide safe ATM service.
Table AMP 01 C-4: Definitions of ATM specific occurrences Frequency
Probability of Occurrence Definitions
5 Extremely Rare
4 Rare
3 Occasional
2 Frequent
1 Very Frequent
Qualitative definition
Has never occurred yet
throughout the total lifetime of
the system.
Only very few similar incidents on record when considering a large traffic
volume or no records on a small traffic
volume.
Several similar occurrences on record –
Has occurred more than once at the
same location.
A significant number of similar occurrences
already on record - Has occurred a significant number of times at the
same location.
A very high number of similar
occurrences already on record-
Has occurred a very high number
of times at the same location.
Quantitative numerical definition (Where
Ps = Frequency of an event per hour in the operational environment)
10-7 ≥ Ps 10-6 ≥ Ps > 10-7 10-5 ≥ Ps > 10-
6 10-4 ≥ Ps > 10-5 10-3 ≥ Ps > 10-4
Quantitative annual/daily equivalent (approx.)
Up to 1 in 1000 years
Up to 1 in 100 years
Up to 1 in 10 years
Up to 1 per year Up to 10 per year
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Definitions:
Severity Definition Total inability to provide safe ATM service. (AA)
Sudden inability to provide any degree of safe ATM Service within several airspace sectors without warning and for a significant period of time. No contingency Measure could be applied. ATCO losing totally his/her ability to control the situation. Situation has every chance to lead to many accidents/serious incidents An occurrence associated with the total inability to provide any degree of ATM services in compliance with applicable Safety Regulatory Requirements, where
• There is a sudden and non-managed loss of ATM service or situation awareness
• There is a totally corrupted ATM service or corrupted information provided to ATS personnel.
Serious inability to provide safe ATM service. (A)
Inability to maintain a safe ATM Service in one or more sectors for a significant period of time. High increase in workload for the ATCO- Provision of misleading information to the ATCO – ATCO losing seriously his/her ability to control the situation. Situation has every chance to lead to a limited number of accidents/serious incidents. An occurrence associated with almost a total and sudden inability to provide any degree of ATM services in compliance with applicable Safety Regulatory Requirements. It involves circumstances indicating that the ability to provide ATM services is severely compromised and has the potential to impact many aircraft safe operation over a significant period of time.
Partial inability to provide safe ATM service. (B)
Inability to maintain a safe ATM Service within one or more airspace sectors without warning and for a significant period of time. The ATCO’s workload increased significantly and he/she was provided with less information than required for normal operations. Limitations to ATM Services were imposed and/or contingency Separation Measures were applied to compensate for the loss or corrupted function(s) but the risk of infringing safe separation was high and multiple losses of separation did/could have occurred until traffic levels were reduced. An occurrence associated with the sudden and partial inability to provide ATM services in compliance with applicable Safety Regulatory Requirements.
Ability to provide safe but degraded ATM service. (C)
Inability to maintain a non-degraded ATM Service within one or more airspace sectors without warning and for a significant period of time. Safety Regulatory Requirements however respected. Contingency measures/ ATC procedures were not seen as necessary or, when taking place, they were able to compensate/mitigate for the loss/corruption of functionality, but the ATCO’s workload was high and/or the overall system capacity was affected. Back up ATM Service/systems were lost or were sending corrupted information. An occurrence involving circumstances indicating that a total, serious or partial inability to provide safe and non-degraded ATM services could have occurred, if the risk had not been managed/controlled by ATS personnel within Safety Regulatory Requirements, even if this implied limitation in the provision of ATM services.
Not Determined. (D)
Insufficient information was available to determine the risk involved or inconclusive/conflicting evidence precluded such determination. Insufficient information was available to determine the risk involved or inconclusive or conflicting evidence precluded such determination.
No effect on ATM service. (E)
Occurrences which do not impact the ability to provide ATM Services within Safety Regulatory Requirements. Occurrences which have no effect on the ability to provide safe and non-degraded ATM services.
Table AMP 01 C-5: Definitions of ATM specific occurrences Severity.