Incident Review Meeting Example  The next slides are an example of how to complete the template and identify latent conditions, threats, errors, UAS and crew actions from a typical narrative  Latent Conditions are in green  Threats are in orange  Errors are in red  UAS are in purple  Extra slides or content (e.g. Jepp charts, animations, airport diagrams, etc…) can be added 1

Incident Review Meeting 2 Presentation Template with Example

Incident Review Meeting Narrative  XYZ Airways Flight 000 (AAA to BBB) took off from AAA at 19:00 in fair weather. Approximately 10 minutes after takeoff, the No.2 engine lost oil pressure and failed, and the crew decided to return to AAA immediately. The aircraft also experienced minor problems with the compass and pressurization. The crew were distracted by these problems and by an incorrectly set radio. This rushed approach resulted in the aircraft being low on the instrument approach and off-course on the ILS. The crew decided to perform a go-around. The aircraft was below Vref and at a low altitude. One minute later, the aircraft crashed killing all but one of the 36 passengers and crew onboard. The accident happened in darkness. This was the 5 th sector for the crew that day. 3

Incident Review Meeting Supporting Information 4 Please add whatever additional supporting information or materials (charts, animations, pictures, etc…) that would help explain the event.

Incident Review Meeting Latent Conditions  Conditions present in the system before the accident, made evident by triggering factors  Fatigue 5

Incident Review Meeting Threats  Factors external to the flight deck that increase the complexity of flight operations and which are realised through a triggering event  Technical  Engine Failure  Compass  Pressurisation problems  Darkness 6

Incident Review Meeting Preventive Defenses  What are the specific mechanisms that should have helped prevent the undesired aircraft state?  Which of these defenses/barriers failed?  Flight Crew mis-selection of the radio  Stable Approach Criteria  Horizontal and Vertical Approach path management  Energy/Speed management  Late decision to go around  Why? What caused the these defenses/barriers to fail?  Training not applied  Standard & Non-normal Operating Procedures non-adherence  Poor CRM 7

Incident Review Meeting Undesired Aircraft States (UAS)  Unstable approach  Off track  Below profile  Below Vref  Low altitude 8

Incident Review Meeting Recovery Defenses  List the Recovery Defenses that either prevented or failed to prevent the Accident or Incident from occurring  The crew (PF & PM) recognition of unstable criteria as well as lateral and vertical parameter deviation - an early go-around  Response to EGPWS  Manual handling  Which of these failed? – ALL  Why? What caused these to fail?  A desire to complete the approach due to non-normal configuration  Possible expectation bias from simulator training  De-skilling due to automation 9

Incident Review Meeting End States  The aircraft stalled and crashed killing all but one of the 36 passengers and crew onboard 10

Incident Review Meeting Safety Enhancements  What was learned from this occurrence?  There is an enhanced degree of get-home-itis in a failure state  The major failure was complicated by lesser failures and distractions  Simulator training focuses on system failures rather than distraction management and CRM  Manual aircraft handling in non-normal configuration inadequate  What changes have been or should be made at your airline and in industry?  More complex failure scenarios including CRM in simulator  Additional simulator training to maintain manual flying skills 11

Incident Review Meeting Lessons Learned for IRM (Note: this slide will be shared with all IRM attendees)  What should attendees at IRM learn from this occurrence ?  The breakdown in CRM and SOP under intense workload and with multiple distractions  The latent loss of manual flying skills not evident under normal circumstances  What should attendees at IRM consider changing at their own airline?  Adapt training to address the above points  Introduction of FRMS 12

Incident Review Meeting Key Message for Safety Group (Note: this slide will be shared with all IRM attendees)  What are the key messages that Safety Group should act on?  The loss of manual flying skills may now be an industry wide latent failure  The need for the highest standards of CRM in workload and distraction management in simulator training  The importance of FRMS in identifying latent fatigue risk 13

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