The ADF Aviation Safety Occurrence Reporting System Occurrence Reporting.pdf– RAAF Document •...

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The ADF Aviation Safety Occurrence Reporting System The ADF Aviation Safety Occurrence Reporting System WGCDR PETER WOOD Deputy Director of Flying Safety Australian Defence Force WGCDR PETER WOOD WGCDR PETER WOOD Deputy Director of Flying Safety Deputy Director of Flying Safety Australian Defence Force Australian Defence Force

Transcript of The ADF Aviation Safety Occurrence Reporting System Occurrence Reporting.pdf– RAAF Document •...

The ADF Aviation Safety Occurrence Reporting System

The ADF Aviation Safety Occurrence Reporting System

WGCDR PETER WOODDeputy Director of Flying Safety

Australian Defence Force

WGCDR PETER WOODWGCDR PETER WOODDeputy Director of Flying SafetyDeputy Director of Flying Safety

Australian Defence ForceAustralian Defence Force

INTRODUCTION

INTRODUCTIONADF Aviation Safety Program

INTRODUCTIONADF Aviation Safety Program

History and Status of ADF Reporting System

INTRODUCTIONADF Aviation Safety Program

History and Status of ADF Reporting System

The ADF ASOR Project

INTRODUCTIONADF Aviation Safety Program

History and Status of ADF Reporting System

The ADF ASOR Project

Safety Culture

THE ADF AVIATIONSAFETY PROGRAM

ADF Aviation Safety Program ElementsADF Aviation Safety Program Elements

• Total Management Commitment and resources• Sound Aviation Safety Culture and Awareness• Safety Organisation/Structure• Documentation• Training and Education• Hazard identification and Risk Management• Reporting and Evaluation• Investigation• Emergency response

•• Total Management Commitment and resourcesTotal Management Commitment and resources•• Sound Aviation Safety Culture and AwarenessSound Aviation Safety Culture and Awareness•• Safety Organisation/StructureSafety Organisation/Structure•• DocumentationDocumentation•• Training and EducationTraining and Education•• Hazard identification and Risk ManagementHazard identification and Risk Management•• Reporting and EvaluationReporting and Evaluation•• InvestigationInvestigation•• Emergency responseEmergency response

ADF Aviation Safety Program Elements:ADF ASOR Review ProjectADF Aviation Safety Program Elements:ADF ASOR Review Project

• Total Management Commitment and resources• Sound Aviation Safety Culture and Awareness• Safety Organisation/Structure• Documentation• Training and Education• Hazard identification and Risk Management• Reporting and Evaluation• Investigation• Emergency response

•• Total Management Commitment and resourcesTotal Management Commitment and resources•• Sound Aviation Safety Culture and AwarenessSound Aviation Safety Culture and Awareness•• Safety Organisation/StructureSafety Organisation/Structure•• DocumentationDocumentation•• Training and EducationTraining and Education•• Hazard identification and Risk ManagementHazard identification and Risk Management•• Reporting and EvaluationReporting and Evaluation•• InvestigationInvestigation•• Emergency responseEmergency response

Training and Education Hazard identification and Risk ManagementReporting and EvaluationInvestigation

Training and Education Hazard identification and Risk ManagementReporting and EvaluationInvestigation

• Reporting Hazards• Reporting Incidents• Investigation and analysis of both• Process to produce recommendations• Processes to ensure actions are completed

•• Reporting HazardsReporting Hazards•• Reporting IncidentsReporting Incidents•• Investigation and analysis of bothInvestigation and analysis of both•• Process to produce recommendationsProcess to produce recommendations•• Processes to ensure actions are completedProcesses to ensure actions are completed

History of the ADF Aviation Occurrence Reporting SystemHistory of the ADF Aviation Occurrence Reporting System

• The AIM (Aircraft Incident Message)• Change to ASOR

– Not Closed Loop• Brooks Winching Accident

– 1995– Failure to act to address known problems

• Effect of Blackhawk

•• The AIM (Aircraft Incident Message)The AIM (Aircraft Incident Message)•• Change to ASORChange to ASOR

–– Not Closed LoopNot Closed Loop•• Brooks Winching AccidentBrooks Winching Accident

–– 19951995–– Failure to act to address known problemsFailure to act to address known problems

•• Effect of BlackhawkEffect of Blackhawk

Current Status of the ADF Aviation Occurrence reporting SystemCurrent Status of the ADF Aviation Occurrence reporting System

• Closed Loop in Army, Navy not RAAF• Lack of established follow-up in RAAF• Lack of education and training• Database Problems

– 20 databases– Little corporate knowledge– Support Difficulties– User problems

•• Closed Loop in Army, Navy not RAAFClosed Loop in Army, Navy not RAAF•• Lack of established followLack of established follow--up in RAAFup in RAAF•• Lack of education and trainingLack of education and training•• Database ProblemsDatabase Problems

–– 20 databases20 databases–– Little corporate knowledgeLittle corporate knowledge–– Support DifficultiesSupport Difficulties–– User problemsUser problems

The ADF ASOR ProjectThe ADF ASOR Project

• Began in 1999•• Began in 1999Began in 1999

The ADF ASOR ProjectThe ADF ASOR Project

• Began in 1999• Put on hold as a result of:•• Began in 1999Began in 1999•• Put on hold as a result of:Put on hold as a result of:

The ADF ASOR ProjectThe ADF ASOR Project

• Began in 1999• Put on hold as a result of:• Re-vitalised 2001

•• Began in 1999Began in 1999•• Put on hold as a result of:Put on hold as a result of:•• ReRe--vitalised 2001vitalised 2001

The ADF ASOR ProjectThe ADF ASOR Project

• Began in 1999• Put on hold as a result of:• Re-vitalised 2001• Planned to roll-out Jan03

•• Began in 1999Began in 1999•• Put on hold as a result of:Put on hold as a result of:•• ReRe--vitalised 2001vitalised 2001•• Planned to rollPlanned to roll--out Jan03out Jan03

The ADF ASOR ProjectThe ADF ASOR Project

• Began in 1999• Put on hold as a result of:• Re-vitalised 2001• Planned to roll-out Jan03• Large, complex IT Support Project

•• Began in 1999Began in 1999•• Put on hold as a result of:Put on hold as a result of:•• ReRe--vitalised 2001vitalised 2001•• Planned to rollPlanned to roll--out Jan03out Jan03•• Large, complex IT Support ProjectLarge, complex IT Support Project

ADF Aviation Community Involvement

ADF Aviation Community Involvement

• Subject Matter experts from all Services• Database Managers from all Services• Command Comment• Updates in DFS Publications• Presentations to Units/bases• Training and Education Campaign

•• Subject Matter experts from all ServicesSubject Matter experts from all Services•• Database Managers from all ServicesDatabase Managers from all Services•• Command CommentCommand Comment•• Updates in DFS PublicationsUpdates in DFS Publications•• Presentations to Units/basesPresentations to Units/bases•• Training and Education CampaignTraining and Education Campaign

Part of Defence Aviation Safety Manual Re-write

Part of Defence Aviation Safety Manual Re-write

• Flying Safety Manual last revised 1996– RAAF Document

• Need ADF Manual• More emphasis on Aviation Safety Programs

– Elements– Responsibilities

• More emphasis on Human factors– HFACS, Reason Model, SHEL

• More emphasis on Safety Culture– Generative Safety Culture

•• Flying Safety Manual last revised 1996Flying Safety Manual last revised 1996–– RAAF DocumentRAAF Document

•• Need ADF ManualNeed ADF Manual•• More emphasis on Aviation Safety ProgramsMore emphasis on Aviation Safety Programs

–– ElementsElements–– ResponsibilitiesResponsibilities

•• More emphasis on Human factorsMore emphasis on Human factors–– HFACS, Reason Model, SHELHFACS, Reason Model, SHEL

•• More emphasis on Safety CultureMore emphasis on Safety Culture–– Generative Safety CultureGenerative Safety Culture

SAFETY CULTURE

GENERATIVESafety is how we do business around here

PROACTIVEWe work on the problems that we find

CALCULATIVEWe have systems in place to manage hazards

REACTIVESafety is important when we have an accident

PATHOLOGICALWho cares as long as we’re not caught

INCREASINGLY INFORMED

INCREASINGTRUST

Training and Education Sep-Dec02Training and Education Sep-Dec02

• Need to Have a simple system• Human Factors analysis• Organisational and Systemic Factors• Investigation process and procedures• Formulate recommendations• Report Completion

– Within five working days• Closed Loop System - Action Completion

•• Need to Have a simple systemNeed to Have a simple system•• Human Factors analysisHuman Factors analysis•• Organisational and Systemic FactorsOrganisational and Systemic Factors•• Investigation process and proceduresInvestigation process and procedures•• Formulate recommendationsFormulate recommendations•• Report CompletionReport Completion

–– Within five working daysWithin five working days•• Closed Loop System Closed Loop System -- Action CompletionAction Completion

INVESTIGATION PROCESSINVESTIGATION PROCESS

• Logical and simple• ‘Outside’ ideas

– REASON Model– BHP ICAM– ATSB– USN System– NTSB

•• Logical and simpleLogical and simple•• ‘Outside’ ideas‘Outside’ ideas

–– REASON ModelREASON Model–– BHP ICAMBHP ICAM–– ATSBATSB–– USN SystemUSN System–– NTSBNTSB

The New ADF ASOR System to be introduced in 2003

The New ADF ASOR System to be introduced in 2003

• One system for the three Services• One holistic database• Closed Loop Reporting• Trend and Statistical Analysis at all levels

– Common errors– Organisational factors– ADF-wide trends

• Data Sharing– ATSB, AsA, CASA, Foreign Services

•• One system for the three ServicesOne system for the three Services•• One holistic databaseOne holistic database•• Closed Loop ReportingClosed Loop Reporting•• Trend and Statistical Analysis at all levelsTrend and Statistical Analysis at all levels

–– Common errorsCommon errors–– Organisational factorsOrganisational factors–– ADFADF--wide trends wide trends

•• Data SharingData Sharing–– ATSB, AsA, CASA, Foreign ServicesATSB, AsA, CASA, Foreign Services

SummarySummary• ADF is totally reviewing the Aviation Occurrence

Reporting System• Part of the ADF Aviation Safety program

– Training and Education– Hazard identification and Risk Management– Reporting and Evaluation– Investigation

• Reason Model based, HFACS, ICAM• Closed-Loop• One system, holistic, powerful, commences

Jan 2003

•• ADF is totally reviewing the Aviation Occurrence ADF is totally reviewing the Aviation Occurrence Reporting SystemReporting System

•• Part of the ADF Aviation Safety programPart of the ADF Aviation Safety program–– Training and EducationTraining and Education–– Hazard identification and Risk ManagementHazard identification and Risk Management–– Reporting and EvaluationReporting and Evaluation–– InvestigationInvestigation

•• Reason Model based, HFACS, ICAMReason Model based, HFACS, ICAM•• ClosedClosed--LoopLoop•• One system, holistic, powerful, commences One system, holistic, powerful, commences

Jan 2003Jan 2003

QUESTIONS