Safety Management System: Occurrence Reporting and Classification

Transcription

1 Lecture Notes: Operations Research and Aviation Safety Safety Management System: Occurrence Reporting and Classification Page 1

2 BASIC CONCEPTS Safety Management System I. SMS proactive approach II. III. ICAO and EASA strategic plan SMS integrated system for managing all safety aspects: Coordinated set of processes All levels of the organisation involved (top management and egineers) Living system Safety Management System is the most complete and integrated approach to safety that an organisation must put into operation for the prevention, recovery and containment of the negative outcome of occurrences, incidents and non-conformity events that may occur during the life and active processes of an organisation. Page 2

3 ORGANISATION STRUCTURE ICAO DOC 9859 Page 3

4 ORGANISATION STRUCTURE Page 4

5 Operational approaches of SMS 1. Prospective safety analysis; 2. Retrospective safety analysis; 3. Safety Audit; 4. Emergency management. Prospective safety analysis; A precise methodology that allows to evaluate the risk of certain initiators and possible boundary conditions, giving rise to precise values to be inserted into the Risk Matrix, typical of an organisation Retrospective safety analysis; Requires the implementation of retrospective analysis methods relating to the content resulting from the collected data of occurrences and events, which required a report to the authorities, and voluntary reports submitted to the attention of an organization. Page 5

6 Retrospective Analysis for SMS Data collection and Classification of an Occurrence 1. Identification of Events; 2. Event Time Line; 3. Classification of each Event Occurrence: an interruption of operations, defect, failure, or other circumstances that has or can have influence on flight safety, which does not necessarily have resulted in a severe accident, which meets the need to archive the events according to a standard mode on a system of data collection. Event: a measureable change of state of a system Human Factor Event: a performance (or non performance) of an action that has an effect on the system state Page 6

7 Event Time Line (ETL) E 1 E 2 E 3 E 4 E 5 t Taxonomies ADREP ( Accident/Incident Data Reporting ) - ICAO (1993, ) Cognitive Reliability and Error Analysis Method (Hollnagel, 1998) Fallible Machine Model (Reason, 1990) Page 7

8 ADREP Page 8

9 ADREP Model & Taxonomy : ADREP ADREP ( Accident/Incident Data Reporting ) - ICAO (1993, ) SHELL Model E L L H S H E L Software Hardware Environment Liveware S Page 9

10 ADREP ATM Rating and endorsement Aviation operations S Reporting forms Recommendations Aircraft ATM by Designator Organisation and person Aircraft make/model Operators Pilot licence type L L H Engines Fuels Propellers Air navigation services Location by state Event phase E State Location by indicator Aircraft ATM by Manufacturer OTHER TABLES Attributes Entities Descriptive factors Explanatory factors Modifiers Occurrence classes Events ICAO-Taxonomy-ADREP: Page 10

11 Root Cause Analysis (RCA): ADREP How severe? Occurrence Severity Type of investigation Which categories? Occurrence Category Statistics, Safety Indicators What? Event and Event phase Event and Event phase Safety studies on event types and on positive and negative events How? Descriptive Factor Descriptive Factor Descriptive Factor Analysis of patterns and causal factors (technical) Why? Explanatory Factor Organisations and Persons Explanatory Factor Organisations and Persons Analysis of recurrent causal factors (human factors) Page 11

12 Root Cause Analysis (RCA): ADREP Page 12

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15 ADREP Page 15

16 An example of classification Occurrence Severity: 100 Accident Occurrence Category: CFIT (Controlled Flight into Terrain) ETL: 1. Wrong selection of NAV 2. Wrong management of approach: Crew actions ATC actions 3. Go-Around interrupted. Page 16

17 ADREP Page 17

18 ADREP Page 18

19 ADREP Page 19

20 Thank you for your attention Page 20