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ATS INCIDENT REPORTING AND INVESTIGATIONS
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Reporting Aviation Occurrences
NAV CANADA RESPONSIBILITES NAV CANADA has a requirement under CARs to report certain aviation incidents to Transport Canada. NAV CANADA Management has a need to be aware of incidents as they occur. .
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Aviation Occurrence Reporting System
Shift Manager in each ACC is focal point. Receives information and inputs to the AOR data base.
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Aviation Occurrence Reporting System
Information is automatically forwarded to Transport Canada. NAV CANADA managers receive the information. ATS Operating irregularities are followed up.
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Operations Safety Investigation INITIAL NOTIFICATION
Initial notification to Head Office of an aviation occurrence will usually be through the Aviation Occurrence Report database.
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Operations Safety Investigation PRELIMINARY INVESTIGATION
Involves an immediate examination of the basic facts to determine the necessity for further action.
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Operations Safety Investigation
Investigators (Chairperson)come from the Operations Group around the country. They are not dedicated to investigations. Training is provided for designated investigators by S&SD
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Operations Safety Investigation Three levels of investigation
Service the entire Operations Group Manager in System Safety and Service design decides what type of investigation will be conducted.
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Operations Safety Investigation Three levels of investigation
Level one (OSI -1 ): -To collect factual information, but without interviewing operational employees directly involved. -Investigation would be comprised only of the Chairperson. .
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Operations Safety Investigation Three levels of investigation
Level two (OSI -2 ): -To collect factual information, including interviewing operational employees directly involved. S
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Operations Safety Investigation Three levels of investigation
Composition of the Board- OSI -2 a chairperson. a non-supervisory controller/specialist from the area or Operations Group division under review Person is selected by the Unit Manager. a NAV CANADA manager from a similar specialty area as that under review.
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Operations Safety Investigation Three levels of investigation
Level three (OSI -3 ): - Complete Operational Review. - Conducted when similar events reoccur.
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Operations Safety Investigation Criteria for Investigation Type
Level two (OSI -2 ): operating irregularity staffing, equipment or procedures a factor, or on the Job Training may be a factor, or trends are apparent, or occurrence is high profile, or recommended by OPS Group Manager .
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Operations Safety Investigation Criteria for Investigation Type
Level one (OSI -1 ): Operating Irregularity -less than OSI 2 defined criteria -may be upgraded on site by S&SD appointed investigator
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Operations Safety Investigation Criteria for Investigation Type
Level three (OSI -3 ): Operating Irregularity???? -less than OSI 2 defined criteria -may be upgraded on site by S&SD appointed investigator
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Operations Safety Investigation Human Factors
Identify unsafe acts. Identify latent unsafe conditions. Identify last successful defense barrier. ,
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Operations Safety Investigation Follow-up
Unit Management is briefed by Chairperson. Corrective action taken as required. Report is published and widely distributed. Head Office Monitoring and Evaluations will review and follow-up if required. ,
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