Module 1 Occurrence Reporting Concept · PDF file · 2015-12-16Module 1...
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Module 1 – Occurrence Reporting Concept Introduction Martin Bernandersson EASA Safety Analysis Officer 7 December 2015 TE.GEN.00409-001
Transcript of Module 1 Occurrence Reporting Concept · PDF file · 2015-12-16Module 1...
Module 1 – Occurrence Reporting Concept Introduction
Martin BernanderssonEASA Safety Analysis Officer7 December 2015
TE.GEN.00409-001
What we don’t want…
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What we don’t want…
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What we don’t want…
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Aviation safety
Aviation is one of the safest means of travel in the world
Standardised international regulations – ICAO, Chicago Convention
Just Culture
Accident Investigation
Occurrence reporting
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The Safety Pyramid
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•Fatal Accidents
•Reportable Occurrences
•Serious Incidents
•Accidents
•Incidents
EUROPEAN CENTRAL REPOSITORY 2014
Fatal Accidents 111
Non-Fatal Accidents
608
Serious Incidents 322
Incidents and other reported occurrences
77 599
Prevention through knowledge –Occurrence reporting
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•Fatal Accidents
•Reportable Occurrences
•Serious Incidents
•Accidents
•Incidents
…the more we can do to prevent these.
The more we know about these…
Information vs Knowledge
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Data-driven approach to improvement
No safety improvement without understandingcauses
Collection of accident and incident data.
Analysis turns data into knowledge
Knowledge leads to mitigating actions
Actions analysed by collecting data
Data
AnalysisKnowledge
Actions
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SAFETY CONCEPTS
•SOPs
ECCAIRS
ADREP
Same software / database
•TRAINING
Common taxonomy
Sharing concepts
Coding procedures
Harmonised training
Production of consistent data
TRAINING
SOPs
Consistency and standardisation
Exchanging dataExchanging knowledge
Facilitation
Legal framework for information gathering on occurrences is vital
For Accidents and serious incidents – ICAO Annex 13, implemented into national law
What about the incidents and other occurrences?
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•Fatal Accidents
•Reportable Occurrences
•Serious Incidents
•Accidents
•Incidents
Facilitation
In Europe: Regulation (EU) 376/2014 on the reporting, analysis and follow-up of occurrences in civil aviation
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•Fatal Accidents
•Reportable Occurrences
•Serious Incidents
•Accidents
•Incidents
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Regulation (EU) 376/2014 facilitates
Reporting – Gathering the information
Analysis/ Follow Up – Getting more information - doing something with it
Data Quality – Getting the best data
Exchange – Sharing the information
Confidentiality – Using it only for safety
Just Culture – Setting the right environment to get even more reports
SMS and Risk based approach to safety
Reporting flows
Individual
Organisation
Competent Authority
Individual
Competent Authority
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Direct Reporting by Individuals
Who can report directly to Competent Authorities?
Persons not employed or contracted by an organisation (e.g. General Aviation Pilot)
Persons who do not want to report to their organisations (e.g. whistle blowers)
EU Reporting portal created –http://www.aviationreporting.eu
Who reports what?
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Pilots-in-command
Occurrences related to the operation of
aircraft
Occurrences for light aviation
Maintenance, manufacturing or design
organisation (Part 21) staff members
Airworthiness certification officials
Occurrences related to technical
conditions, maintenance and repair of the aircraft
Air Traffic controllers
Air Navigational Facilities safety managers
Occurrences related to air
navigation services and
facilities
Airport safety managers
Ground Handlers
Occurrences related to
aerodromes and ground
services
Analysis and Follow up
Each organisation, Member States and EASA must analyseoccurrences directly submitted, identify necessary safety actionand monitor effectiveness
Organisations shall report within 30 days first result of analysis(investigation) to the Competent Authority which shall monitoraction taken by organisations and request additional actionwhere necessary
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Knowledge and Intelligence
Feedback gives us Knowledge
Analysis turns this into Intelligence
