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

Questions?

Martin BernanderssonEASA Safety Analysis Officermartin.bernandersson@easa.europa.eu