Airspace Incident Investigation - Incident Investigation... The Civil Aviation Authority of New...

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Transcript of Airspace Incident Investigation - Incident Investigation... The Civil Aviation Authority of New...

  • Civil Aviation Authority of New Zealand

    Airspace Incident Investigation

    Civil Aviation Authority of New Zealand

    Richard White

    Manager Safety Investigation

  • A New Zealand airspace incidents 1994-2002: A causal trend analysis Arnab Majumdar

    Washington Yotto Ochieng Centre for Transport Studies

    Dept. of Civil & Environmental Engineering Imperial College London

    London, SW7 2BU Ph: 44(0)20-7594-6037 Fx: 44(0)20-7594-6102

    Email: a.majumdar@imperial.ac.uk Email: w.ochieng@imperial.ac.uk

    Peter Nalder The Civil Aviation Authority of New Zealand

    Aviation House 1 Market Grove

    P. O. Box 31 441 Lower Hutt

    New Zealand Tel: +64–4–560 9424 Fax: +64–4–569 2024

    Email: nalderp@caa.govt.nz

  • CIVIL AVIATION AUTHORITYCIVIL AVIATION AUTHORITY POLYGON OF CERTAINTYPOLYGON OF CERTAINTY

  • CIVIL AVIATION AUTHORITYCIVIL AVIATION AUTHORITY POLYGON OF UNCERTAINTYPOLYGON OF UNCERTAINTY

    Poor Maintenance practices

    Risky operations

    Poor corporate cultureOK

    Accident

    Risky

    Bogus parts

    Lack of training

    Unfamiliar equipment

  • Just Culture � ��������� ��� ����� �� ������� ���

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  • NON- COMPLIANCE

    13

    CAUSAL FACTOR

    CORRECTIVE ACTION REQUEST

    OCCURRENCES

    TAIC OR EXTERNAL

    INVESTIGATION REPORTS

    CORRECTIVE ACTION

    RESPONSES

    A/DS EROPS

    CO STAT

    CAUSAL FACTORS ASSIGNED

    CATEGORISE RECORD

    RESPONSE ADDRESS

    C.A.R.

    CLOSE ACTION

    FOLLOW UP

    OPEN/CLOSE

    NO FURTHER ACTION

    CLOSE OCCURRENCE

    ASSIGN TASK NON- COMPLIANCE

    REVIEW

    CAUSAL FACTOR

    CORRECTIVE ACTION REQUEST

    IMPLEMENT CORRECTIVE

    ACTION INITIATE CORRECTIVE

    ACTION

    AUDITORS

    ASMS RULES SCOPE OBJECTIVE CALENDAR

    SCOPE OBJECTIVE

    A/D RULES ENFORCEMENT ENTRY CONDITIONS EDUCATION

    02

    04

    08

    07

    13

    0503

    14

    13

    06

    DETERMINE ASMS OCC REF.

    CLOSE

    OPEN

    YES

    NO

    YES

    NO

    CARRY OUT TASK

    YES

    NO

    FURTHER CORRECTIVE

    ACTION

    ������� ������� � ��� �������� � ��� ������

    INDIVIDUAL OCCURRENCESINDIVIDUAL OCCURRENCES

  • Organisational Factors

    For example:

    Communications

    Management

    Structure

    Goals

    Local Error or Violation Factors

    For example:

    Morale

    Fatigue

    Equipment

    Procedures

    Active Failures

    Eg Errors;

    Information

    Diagnostic

    Goal

    Strategy...

    AND /OR

    ComponentsComponents

    ORGANISATIONORGANISATION TASK/ENVIRONMENTTASK/ENVIRONMENT INDIVIDUALINDIVIDUAL DEFENCESDEFENCES

    Latent Failures

    For example Structural/Mechanical/Other

  • ORGANISATION ORGANISATION FAILURE ITEMSFAILURE ITEMS

    �� Inappropriate Goals or PoliciesInappropriate Goals or Policies �� Organisation Structural DeficienciesOrganisation Structural Deficiencies �� Inadequate CommunicationsInadequate Communications �� Poor PlanningPoor Planning �� Inadequate Control and MonitoringInadequate Control and Monitoring �� Design System DeficienciesDesign System Deficiencies �� Inadequate DefencesInadequate Defences �� Unsuitable MaterialsUnsuitable Materials �� Unsuitable EquipmentUnsuitable Equipment �� Poor ProceduresPoor Procedures �� Poor TrainingPoor Training �� Poor CoordinationPoor Coordination �� Inadequate RegulationInadequate Regulation �� Other Organisation FactorOther Organisation Factor

  • ERROR ITEMSERROR ITEMS

    � Task Unfamiliarity � Time Shortage � Poor Signal: Noise � Poor Human-System Interface � Designer User Mismatch � error Irreversibility � Information Overload � Negative Task Transfer (Habits) � Task Overload � Risk Misperception � Poor System Feedback � Inexperience (Not Lack of Training) � Lack of Knowledge � Task/Education Mismatch � Poor Instructions/Procedures

    � Inadequate Checking � Hostile Environment � Other Environmental Factor (e.g. Weather) � Interpretation difficulties � Disturbed Sleep Patterns � Fatigue - Other � Drugs/Alcohol � Visual Illusion � Disorientation/Vertigo � Physiological Other � Monotony/Boredom � Lack of Confidence � Poor Attention Span � Psychological Other � Other Error Enforcing Condition

  • VIOLATION ITEMSVIOLATION ITEMS

    �� Lack of Safety CultureLack of Safety Culture �� Management/Staff ConflictManagement/Staff Conflict �� Poor MoralePoor Morale �� Poor Supervision & CheckingPoor Supervision & Checking �� Group Violation Condoning AttitudeGroup Violation Condoning Attitude �� Hazard MisperceptionHazard Misperception �� Lack of Management Care/ConcernLack of Management Care/Concern �� Lack of Pride in WorkLack of Pride in Work �� Risk Taking Culture EncouragedRisk Taking Culture Encouraged �� Complacency (i.e.. It CanComplacency (i.e.. It Can’’t Happen)t Happen) �� Learned Helplessness (i.e... Who Cares)Learned Helplessness (i.e... Who Cares) �� Perceived License to Bend RulesPerceived License to Bend Rules �� Age/Sex FactorAge/Sex Factor �� Other Violation Enforcing ConditionOther Violation Enforcing Condition

  • Active Failure ClassificationActive Failure Classification Was there an opportunity for human intervention?

    Did the person detect cues arising from the change in the system state?

    On the basis of the information available, did the person diagnose accurately the state of the system?

    Did the person choose a goal which was reasonable in the circumstances?

    Did the person choose a strategy which would achieve the goal intended?

    Did the person execute procedures consistent with the strategy intended?

    Was the procedure executed as intended?

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Structural/Mechanical No

    No Information Error

    No Diagnostic Error

    No Goal Error

    No Strategy Error

    No Procedure Error

    No Action Error

    The values shown in the green boxes are the codes loaded into the AQS system for active failures.

  • Effective incident reporting Effective incident reporting programmeprogramme

    300

    30

    1

  • Ineffective incident reportingIneffective incident reporting

    1313

    ?

  • AccidentsAccidents

    Critical Critical IncidentsIncidents

    Major Major IncidentsIncidents

    Minor IncidentsMinor