The Safety Analysis Methodology

1. The Safety Analysis Methodology EHEST Conference 13 October 2008 Cascais, Portugal

2. Contents • Introduction on Approach and Scope of the analysis • Analysis Methodology • Example

3. Develop Safety Action Plans Implement Safety Action Plans Review occurrences Monitors General Process

4. Develop Safety Action Plans Implement Safety Action Plans Review occurrences Safety Analysis Team (this presentation) Monitors General Process

5. Approach • Maintain international compatibility • Reviewing accidents using a standard method adapted by IHST from CAST (US Commercial Aviation Safety Team) • Format allows comparison with data from the US and other regions

6. Scope of analysis • Based on a data driven approach • Focus on: • Accidents (definition ICAO Annex 13) • Date of occurrence year 2000 - 2005 • State of occurrence located in Europe • For this purpose Europe is defined as the EASA Member States (27 EU + plus Iceland, Liechtenstein, Norway and Switzerland) • Only those accidents are being analysed where a final report from Accident Investigation Board is available

7. 1. Collect general occurrence information from accident report 2.Describe and analyse the accident Identify events (what happened) and factors (why it happened) in free text 3. Assign standard codes to factorsStandard Problem Statements (SPS) from IHST taxonomy and HFACS Analysis Methodology 4. Produce Intervention Recommendations (IR)

8. Process manual and tool

9. 1. Collect general occurrence information • From accident reports • Includes: • Occurrence Date and State of Occurrence • Aircraft Registration and Aircraft Type • Type of Operation • Aircraft Damage and Injury Level • Phase of Flight • Meteorological Conditions • Pilot and co-pilot flight experience • Etc.

10. 2. Describe and analyse the accident • Accidents are broken down into an event sequence • The method requires describing, in free text: • What happened (events and conditions) • Why these happened (factors) • The analysis uses the expertise and experience of the regional teams

11. 3. Assign standard codes to factors • Three models used to assign codes 1. Standard Problem Statements from IHST taxonomy And additionally, for a more thorough description of human factors 2. Human Factors Analysis and Classification System (HFACS) by Wiegmann and Shappell, US DoT, February 2001 3. HFACS Maintenance Extension by US Naval Aviation

12. 3. Assign standard codes to factors • Standard Problem Statements from IHST taxonomy • Over 400 codes in 14 different areas Ground duties Part/System Failure Safety Management Mission Risk Maintenance Post-crash survival Infrastructure Data issues Pilot judgment & actions Ground personnel Communications Regulatory Pilot Situation awareness Aircraft Design

13. 3. Assign standard codes to factors • Example Standard Problem Statements

14. Organisational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts 3. Assign standard codes to factors • HFACS by Wiegmann and Shappell • Over 170 codes in 4 main areas to code human factors in detail

15. Unsafe Acts Errors Violations Decision errors Skill-Based errors Perceptual errors Routine violations Exceptional violations 3. Assign standard codes to factors

16. Preconditions Environmental Factors Condition of Individuals Personnel Factors 3. Assign standard codes to factors

17. Supervision Inadequate Supervision Planned Inappropriate Operations Failure to Correct Known Problem Supervisory Violations 3. Assign standard codes to factors

18. Organisational Influences Organisational Process Organisational Climate Resource Management 3. Assign standard codes to factors

19. 3. Assign standard codes to factors • Example HFACS codes

20. 3. Assign standard codes to factors • HFACS Maintenance Extension (HFACS ME)

21. 1. Collect general occurrence information from accident report 2.Describe and analyse the accident Identify events (what happened) and factors (why it happened) in free text 3. Assign standard codes to factorsStandard Problem Statements (SPS) from IHST taxonomy and HFACS Analysis Methodology 4. Produce Intervention Recommendations (IR)

22. 4. Produce Intervention Recommendations • For every coded factor one or several Intervention Recommendations can be suggested • AIB recommendations are included • Will be used at a later stage by the implementation team to generate Safety Action Plans

23. Assessment of confidence in factors and recommendations • SPS/HFACS are scored between 0-4 on: • Validity: Quality and credibility of information (documented evidence versus expert judgment) • Importance: Contribution to the accident • IR are scored between 0-4 on: • Ability: Capability of an IR to mitigate an event • Usage: Confidence that an IR will be utilised and will perform as expected • Will be used at a later stage by EHSIT

24. Occurrence categories • Used to classify occurrences at a high level to permit analysis of the data in support of safety initiatives • Future developments based on existing internationally agreed taxonomy • Example:

25. Analysis Example

26. European Helicopter Safety Team EHEST Thank you for your attention Questions?

27. ANNEX EHSAT Analysis Tool

28. Process manual and tool

29. Process manual and tool • HFACS SPS taxonomy Human Factors Analysis and Classification System (HFACS) D.A. Wiegmann and S.A. Shappell