1. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Data standardisation Reinhard Menzel Safety Analysis Manager Safety Analysis EASA

2. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ What should be standardised  Background data  Accuracy  Do not guess, enter what has been reported –Check back with reporter if required  Read definitions –Do not think that meaning is obvious  Contents  Provide all required background data –Differs by occurrence type »Ditching »Fire »Etc…

3. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Required background data  Time and space: Date, time, location (State, name, airport, airspace)  Aircraft: type, mass group, propulsion, make model, operator (for commercial operations), operation type  Severity: injury level, damage  Could be preset for occurrence reports  If at hand: number of persons involved  ATM contribution and effect on ATM  Headline / narrative  Admin: report status, report source, reporting organisation  Meteorological: weather relevant, light condition, general weather

4. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Essential data (1)

5. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Essential data (2) To support the occurrence class selection General statistics

6. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ What should be standardised (2)  Analysis data  Occurrence categories  Read the definitions  Event types  Read the definitions  Sequencing of events  Time sequence  Events and factors  Identification of failed system / involved issue  Causal/contributory versus consequential

7. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ n n n Occurrence categories Event / phase of flight Descriptive factor Explanatory factor Numbers, statistics, Safety Indicators Safety studies on accident types (i.e. CFIT, RI..) precursors, consequences Analysis of patterns and causal factors (technical) Analysis of recurrent causal factors (human factors) Which categories ? What ? How ? Why ? Analysis data

8. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Occurrence categories  The overall classification  To monitor industry trends  To monitor results of safety initiatives

9. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Assignment of occurrence categories  Read definitions  Including usage notes  Special care  GCOL – collisions on the ground  EVAC: Evacuation: –only if the “evacuation” is relevant –Only if evacuation using related procedures was carried out  F-POST: Post-impact fire: –Only when contributory to damage/injury level  Note: more than one category may be assigned

10. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ n n n Occurrence Categories Event / phase of flight Descriptive factor Explanatory factor Numbers, statistics, Safety Indicators Safety studies on accident types precursors, consequences Analysis of patterns and causal factors (technical) Analysis of recurrent causal factors (human factors) Which categories ? What ? How ? Why ? Sequence of events

11. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Events  Events tell the story of the occurrence in bullet form  Events describe what happened, not meant to state causes  “tyre related event”, not “event caused by tyre”  Sequence order is important, e.g.  Tyre failure leading to runway excursion  Runway excursion leading to tyre failure

12. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Use of events  Events provide information on:  What initiated the occurrence  Frequency of systems involved  Operational versus technical issues  What are the consequences, if any  E.g. what happens after an engine failure?  E.g. how often is loss of control preceded by an engine failure?

13. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Requirement for analysis  Use definitions  They are available on screen!  Enter what went wrong  Leave out what worked fine  Order events in time sequence  With exception of the “consequential events” (incl. diversion)  Do not enter consequential damage  Do not enter correct use of systems  Do not enter correct functioning of system  Do not enter proper remedial actions  Do concentrate on essentials  Differentiate between systems failures and indication failures

14. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Observe difference aircraft collision – aircraft struck  Use “aircraft struck” if the aircraft is stationary  Use “aircraft collided” if the aircraft is moving

15. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Identify the failed system  False fire warning  Fire warning – fire in engine

16. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example – wrong event type+ incomplete sequence  Narrative  Wrong  Right

17. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example – wrong system identified  Narrative  Wrong  Right

18. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example of Aerodrome event  Note : unrelated to a specific aeroplane operation

19. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ n n n Occurrence categories Event / phase of flight Descriptive factor Explanatory factor Numbers, statistics, Safety Indicators Safety studies on accident types (i.e. CFIT, RI..) precursors, consequences Analysis of patterns and causal factors (technical) Analysis of recurrent causal factors (human factors) Which categories ? What ? How ? Why ? Descriptive Factors

20. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Descriptive Factors  Explain how it happened  Adding detail to the events  Giving information on causal/contributory aspects  Example: The valve of reciprocating engine failed

21. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example factors: Narrative Event sequence

22. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example: Sequencing of factors  Environmental factors first  Then action related factors in time sequence  “general” factors at the end

23. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Hint  Think about retrieval / analysis !  Which events are relevant ?  Which factors are relevant ?  If you were to look for this occurrence  What events would you use to find it?  What factors would you use to find it?

24. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Remember!  ECCAIRS is used to detect weaknesses / shortcomings / areas of improvement  Therefore  Code what went wrong, what did not work as required, what failed; but  Do not code what worked properly  And do not code consequential damage/failures  Except if they are causal/contributing to subsequent events

25. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example – wrong event, factors not supported by narrative  Narrative  Wrong  Right

26. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Factors: be as direct/specific as possible Narrative: Wrong: Right:

27. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Example: Incorrect events, SHEL model not followed Narrative Wrong Right

28. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Summary : Do’s  Do identify the system / aspect involved  Note difference between initiating (causal, contributing) and consequential events  Note difference between system problem and the incorrect use of a system  Only code what is supported by the facts/conclusions in the report

29. European Aviation Safety Agency Standardisation Workshop 2006 11 30 – Cologne – Germany – EASA HQ Summary: Don’t s  Do not  Do not enter factors for systems that worked  Do not code correct actions taken  Do not enter non-relevant details  Do not guess  Do not invent stories