ADREP/ECCAIRS End-user course Module N° 5 Encoding Occurrences (BEA) Mexico City- 22-26 November, 2010

ADREP/ECCAIRS End-user Course (Rev. #3) Overview Objectives of encoding Structured analysis Thriving for more consistency Coding structure Three levels of analysis Sequence of events Descriptive factors Explanatory factors SHELL MODEL Human factors model Encoding example Fuel starvation Coding guidelines Coding standards for data consistency Common approach ADREP/ECCAIRS End-user Course (Rev. #3)

Objectives of encoding Memory of accidents Statistics, safety indicators Safety Analysis (for the moment on similar accidents i.e. Mid-air collisions, Fuel starvation, CFIT, Runway Incursions...) Identify recurrent causal factors or patterns in accidents Dissemination and exchange of safety data Review of impact of safety initiatives Support for structured analysis ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Analysis results ADREP/ECCAIRS End-user Course (Rev. #3)

Striving for more consistency Production of consistent data TRAINING SOPs Harmonized training TRAINING Exchanging data SOPs Coding procedures ECCAIRS 4 Same software / database ADREP 2000 Common taxonomy SAFETY CULTURE Sharing concepts ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Coding structure Event / phase of flight n Descriptive factor n Explanatory factor Three levels structure Clear breakdown between the different elements Tree description for each element ADREP/ECCAIRS End-user Course (Rev. #3)

Air Navigation Services Aerodrome & ground aids Event types – level 1 Event types Aircraft / system / component Aircraft operation general Consequential events Air Navigation Services Aerodrome & ground aids CAA Unknown Any other event

Event Types – Level 2 Systems & components Aircraft / system / component 2100 Air cond & pressurization 2200 Autoflight sys 2300 Communication sys 2400 Electrical power sys 2500 Aircraft furnishing 2600 Fire protection sys 2700 Aircraft flight control 2800 Fuel sys 2900 Hydraulic sys 3000 Ice/rain protection sys 3100 Instruments 3200 Landing gear 3300 Aircraft lighting Many more…….. (ATA 100)

Event types – Level 3 & 4 3200 Landing gear 3210 Main landing gear 3220 Nose/tail landing gear) 3240 Wheels & brakes 3241 Tyres 3242 Brakes 3244 Anti-skid sys 3250 Landing gear steering 3260 Gear position & warning 3270 Auxiliary landing gear Partial collapse/retraction Collapse or retraction Collapsed/retracted Parking brake Emergency brake

ADREP/ECCAIRS End-user Course (Rev. #3) Sequence of events Usually based on Findings Short reports: synopsis / history of flight Final report : plus analysis part Events in time sequence (chronological order) Frequently used in analysis to determine Precursors, consequences Each event is associated with a phase of flight Event Flight phase ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Descriptive factors Descriptive factor subject : add details to the events Sequence : Background information on weather, terrain, etc first These factors set the scene Other factors in time sequence (if that can be established) Otherwise use logical sequence Modifiers : one or several modifiers Event Modifiers Descriptive factor ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Explanatory factors Organizations or persons SHELL model = explanatory factor subject One modifier Modifier Event Descriptive factor Organization / person Explanatory factor subject ADREP/ECCAIRS End-user Course (Rev. #3)

Different levels of data quality Who, where, when ? Numbers, statistics, Safety Indicators Occurrence n What ? Safety studies on accident types (i.e. CFIT, RI..) Event / phase of flight Event / phase of flight How ? n Descriptive factor Descriptive factor Analysis of patterns and causal factors (technical) n Why ? Explanatory factor Explanatory factor Analysis of recurrent causal factors (human factors) ADREP/ECCAIRS End-user Course (Rev. #3)

Human Factors included in ADREP 2000 Occurrence n Event / phase of flight Event / phase of flight n Human Factors Descriptive factor subject + modifier Descriptive factor subject + modifier n L H E S Organization /person + EF subject (SHELL) + modifier Organization/ person + EF subject (SHELL) + modifier SHELL, modified by Hawkins 1987 ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Shell Model Human / machine Human / human Human / environment Human / system support Environment Hardware Software Liveware Machines, ergonomics, calculators... Manuals, procedures, documentation Physical, psychological, workload... Social, operational factors, ATC... Communication, CRM… Risk inherent to human activity Human is at the center of Safety Risks lay in interactions between Human and its context SHELL permits to identify factors that weaken the system in direct relation with persons and organisms SHELL, modified by Hawkins 1987 ADREP/ECCAIRS End-user Course (Rev. #3)

SHELL model

Fuel starvation example 1/2 Occurrence class Occurrence category = FUEL Pilot / stress Preflight check / incomplete Fuel starvation / cruise Accident Emergency landing Fuel gauges / breakdown Pilot / time pressure Event Descriptive factor Explanatory factor ADREP/ECCAIRS End-user Course (Rev. #3)

Fuel starvation example 2/2 In ECCAIRS, use mouse right click to add, edit or remove items. ADREP/ECCAIRS End-user Course (Rev. #3)

In practice with ECCAIRS ADREP/ECCAIRS End-user Course (Rev. #3)

What about data consistency ? Investigator B Investigator A = ? ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Coding standards Permit analysis of data from different sources Different Investigators, States, Providers Comparability of data Use of common definitions Same term – same meaning Use of common collection standards Same occurrence category – same set of data • Ensure consistent data collection Adoption of harmonized procedures Define which differences are acceptable and which are not Think about the use of databases to issue safety indicators Mutual support and training (for instance, Human Factors) ADREP/ECCAIRS End-user Course (Rev. #3)

Common approach - general Only code what has been established or reported do not guess do not over-interpret Be as detailed as possible : if the nose gear collapsed, enter type “nose gear collapse” and not “landing gear related event” …but if desired detail not at hand or do not fit the circumstances, use data at higher level instead Fast way to navigate using filter but it may have insidious effects : always check items within the same level ADREP/ECCAIRS End-user Course (Rev. #3)

Common approach – events & phases Properly identify issues involved Example: If there was a spurious fire warning in an engine, enter fire warning system related event. If there was, however a fire, enter “fire” as event type as well as the related system Consequential events must not be the first event in the sequence. Enter that ”something” as first event Check the related phase of flight Example: After a “loss of control” the aircraft usually enters an “uncontrolled descent” flight phase. This would be the applicable phase for any collision with the terrain Aerodrome or ATC events have no corresponding flight phase except if they directly relate to the operation of an aircraft Link events to the entity to which they relate (aircraft for instance) ADREP/ECCAIRS End-user Course (Rev. #3)

Common approach – factors In terms of systems involved, only provide information on what went wrong, where there was a problem or an issue “Positive factors” will be included later Code the descriptive factors under the first event where they appear. Do not repeat them for subsequent events Do not code potential or non-contributory factors in the sequence of events. Use the appropriate section “Potential factors and safety issues” It can be found under Events or Recommendations topics ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Taxonomy enhancement Regular updates necessary ADREP 2000 revision 2008 More event details for aerodrome and maintenance occurrences Bird strike data Dangerous goods data Update aircraft categories and phases of flight Update safety recommendations section Standardisation of text and reduce number of abbreviations Update aircraft, operator and location indicator list Update of events and modifier lists … Will be available in next ECCAIRS release 5 ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Summary Advantages of tree description Clear breakdown between events, descriptive factors and explanatory factors Identification of interfaces where problems occurred (SHELL) ICAO standard Aggregation of results and know-how of worldwide investigations Based on agreed definitions Common safety concepts Language independent Avoid spelling errors Facilitate understanding Allow data exchange ADREP/ECCAIRS End-user Course (Rev. #3)

ADREP/ECCAIRS End-user Course (Rev. #3) Module N° 5 Encoding Occurrences (BEA) ADREP/ECCAIRS End-user Course (Rev. #3)