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

2. 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)

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)

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

5. 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)

6. 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)

7. 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

8. 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)

9. 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

10. 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)

11. 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)

12. 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)

13. 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)

14. 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)

15. 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)

16. SHELL model

17. 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)

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

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

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

21. 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)

22. 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)

23. 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)

24. 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)

25. 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)

26. 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)

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