International Civil Aviation Organization ADREP/ECCAIRS End-user course Module N° 7 Analysis and Codification Mexico City November, 2010

Safety Culture SOPs ECCAIRS 4 ADREP 2000 Same database TRAINING Common taxonomy Sharing concepts Encoding procedures? Harmonized training Production of consistent data Exchanging data ICAO BFU Striving for more consistency 2ADREP/ECCAIRS End-user Course (Rev. #3)

Explanatory factor Descriptive factor Event / phase of flight Analyses on occurrence categories (CFIT, RI, etc.) Analyses on symptoms Statistics n Occurrence Who, where, when ? What ? How ? WHY ? Analyses on causes (HF) Investigating, encoding and analyzing in ADREP 3ADREP/ECCAIRS End-user Course (Rev. #3)

Explanatory factor Descriptive factor Event / phase of flight Analyses on occurrence categories (CFIT, RI, etc.) Analyses on symptoms Statistics n Occurrence (1) Who, where, when ? (2) What ? (3) How ? (4) WHY ? Analyses on causes (HF) Four levels of data quality 4ADREP/ECCAIRS End-user Course (Rev. #3)

Who, where, when ? Complete initial factual information with data entry procedures and electronic tools. What ? How ? Why ? Content of a database Scale of Data Quality Inc1 Inc2 Inc3 … Inc n Acc1 Acc2... S-Inc1 Inc n+1 … Complete analyzed information with encoding methodology Statistics, trends Safety studies on occurrence categories Analyses on Symptoms Initial data Analyses on causes (HF) Summary: What tool and what type of data? 5ADREP/ECCAIRS End-user Course (Rev. #3)

Based on current general way of writing investigation reports (nothing revolutionary) Most of the analysis reflect a sequence of events associated with phase of flight (ICAO causal approach)  The codification should reflect the report analysis where causal factors are discussed Accident Latent failures Active failure(s) * cf. Application of ADREP 2000 taxonomy for the analysis and the encoding of aviation accidents and incidents: a human factors approach, Human Factors and Aerospace Safety 4(1), 19-48, 2004, Ashgate Publishing Proposed methodology* for encoding events and factors 6ADREP/ECCAIRS End-user Course (Rev. #3)

1) Sequence of events 2) Encoding version “0” Events/phase of flight descriptive factors 3) Explanatory factors (SHELL) 4) Table linking factors to factual elements 5) Drafting Analysis in line with codification Process of Analysis/Encoding 7ADREP/ECCAIRS End-user Course (Rev. #3)

Application of the methodology Example: loss of control accident on 6 March 2003 at Tamanrasset Report released in September ADREP/ECCAIRS End-user Course (Rev. #3)

Accident at Tamanrasset on 6 March ADREP/ECCAIRS End-user Course (Rev. #3)

Date and timeAircraft Thursday 6 March 2003 at 14 h 15 UTC Boeing registered 7T-VEZ Site of accident Owner Tamanrasset Aguenar aerodrome Type of flight Operator Public transport of passengers Scheduled domestic flight DAH6289 Tamanrasset - Ghardaïa - Algiers Air Algérie Persons on board 97 passengers 2 Flight crew 4 Cabin crew Air AlgérieSynopsis 10ADREP/ECCAIRS End-user Course (Rev. #3)

CVRFDRwreckage radiocoms witness statements Radar/GPS… Events Accident 1) Sequence of events 11ADREP/ECCAIRS End-user Course (Rev. #3)

Events, phases of flight Descriptive factors, modifiers Example: 2) Encoding version « 0 » 12ADREP/ECCAIRS End-user Course (Rev. #3)

3) Explanatory factors Identification of explanatory factors using SHELL SHELL, modified by Hawkins 1987 Human / machine Human / human Human / environment Human / system support Environment Hardware SoftwareLiveware Machines, ergonomics, calculators... Manuals, procedures, documentation Physical, psychological, workload... Social, operational factors, ATC... Communication, CRM… 13ADREP/ECCAIRS End-user Course (Rev. #3)

SHELL model

Event, phase of flight Descriptive factors Explanatory factors Factual elements justifying the codification Flight preparation related event during standing The chosen modifiers describe the absence of pre-flight checks and the fact that the Captain was not in the cockpit at that time (CVR data) Pre-flight preparation: missing, not monitored Flight crew : Psychological distraction (L) Copilot prepares the flight alone; discussions and interruptions in the cockpit Flight crew : pre-flight planning : underestimated (L) It seems to them that it was a normal (routine) situation (result of deviations) Flight crew related event during taxiing to runway Flight crew’s interpretation of SOPs not observed … Elements from the CVR 4) Table linking chosen factors to factual elements of the investigation 15ADREP/ECCAIRS End-user Course (Rev. #3)

Complete codification : Scenario : failures in action Second part : systemic issues 5) Drafting the report analysis based on the codification 16ADREP/ECCAIRS End-user Course (Rev. #3)

1) Sequence of events 2) Encoding version “0” Events/phase of flight descriptive factors 3) Explanatory factors (SHELL) 4) Table linking factors to factual elements 5) Drafting Analysis in line with codification – Iterative – Based on teamwork – Illustrates the depth of the investigation Process of Analysis/Encoding 17ADREP/ECCAIRS End-user Course (Rev. #3)

B737 Engine Failure After Take-off […] « Among the lessons learnt from this report are the importance of pre-flight briefings and formalised hand-over/takeover procedures. The report is of particular relevance given our recent formalisation of the Engine Fire, Failure, Malfunction Procedures. » […] Qantas Safety, Flight Ops Newsletter, Vol 4. No 6 December 2004 Feedback for training 18ADREP/ECCAIRS End-user Course (Rev. #3)

ICAO standard (aggregation of results and know-how of worldwide investigations) – From 88 causes (ADREP 76) to 552 (ADREP 2000) – Standardized and structured support Convincing and tangible analysis tool for multi-national investigation teams – Taxonomy = same safety concepts, keywords i.e. language – Clear breakdown between events and explanatory factors Facilitates deeper and more systemic investigations Provides human factors data for future safety analysis Pros of using a method based on ADREP ADREP/ECCAIRS End-user Course (Rev. #3)

20 Module N° 7 Analysis and Codification