Download
1 / 8
80 likes | 104 Views
This seminar, held in Mexico City in March 2006, featured Jeremy Jackson from the Civil Aviation Authority of the Cayman Islands discussing Accident/Incident Occurrences Investigation System. The objective was to prevent accidents and incidents without assigning blame. Various elements like safety culture, reporting requirements for air traffic control services, navigation and communications equipment failures, and airfield incidents were covered. The notification and investigation occurrence flow control chart highlighted the process from notification to final report. The seminar also introduced TOKAI, a toolkit for air traffic management investigation, including forms, tools, manuals, and statistics templates available on the Eurocontrol website.
E N D
ICAO/ASPA Safety Management System Seminar Air Traffic Management Occurrence Reporting Mexico City, Mexico, 14 – 16 March 2006 Jeremy Jackson – Civil Aviation Authority of the Cayman Islands
Accident/Incident Occurrences Investigation System • Objective • What should be reported? • Notification and Investigation Occurrence Flow Control Chart • TOKAI and Manual • Eurocontrol Website
Objective • The sole objective of the investigation of an accident or incident is the prevention of accidents and incidents. • It is not the purpose of this activity to apportion blame or liability. • Safety Culture.
What Should Be Reported? Air Traffic Control Services - by Flight Crew/ATCOs/Ground Ops Support Staff. • Provision of significantly incorrect, inadequate or misleading information from any ground sources, e.g. ATC, ATIS, Meteorological Services, maps, charts, manuals, etc. • Provision of less than prescribed terrain clearance. • Provision of incorrect altimeter setting. • Misidentification of aircraft by an ATCO or radar operator. • Incorrect transmission, receipt or interpretation of significant messages. • Airprox and any occurrence in which separation between aircraft is less than that prescribed for the situation. • Non-compliance with prescribed letdown or departure procedures or any ATC/ATM instruction. • Declaration of an emergency (‘Mayday’ or ‘Pan’) by an aircraft. • Unauthorized infringement of any form of regulated airspace. • Unauthorized or illegal RTF transmissions. • ATC Overload reports • Declaration of an ACAS Resolution Advisory by an aircraft
What Should Be Reported? Navigation and Communications Equipment etc. – failures, malfunctions or defects - by Flight Crew/ATCO/ATS Maintenance Staff. • Total failure of navigation system or subsystem being used by an aircraft. • Total failure of communications system. • Total failure of radar system or subsystem. • Failure or unplanned shutdown of a major operational ATC computer system requiring reversion to manual back up and resulting in disruption to the normal flow of air traffic. • Significant malfunction or deterioration of Service. • Significant deficiency in maintenance. • Repetitive events of a specific type of occurrence, which in isolation may not be considered reportable (e.g. excessive monitor alarms). • Provision of erroneous information in the absence of any alarms.
What Should Be Reported? Airfields and Airfield Facilities - by Flight Crew/Airfield Staff/ATCOs. • Failure or significant malfunction of airfield lighting. • Major failure or significant deterioration of surfaces of runways or aircraft maneuvering areas. • Runways or aircraft maneuvering areas obstructed by aircraft, vehicles or foreign objects, resulting in a hazardous or potentially hazardous situation. • Runway incursions. • Errors or inadequacies in marking of obstructions or hazards on runway or aircraft maneuvering areas. • Collision between a moving aircraft and any other aircraft, vehicle or other ground object. • Aircraft departing from a paved surface which results in, or could have resulted in, a significant hazard. • Jet or prop blast incidents resulting in significant damage or serious injury. • Significant spillage of fuel on airfield ramps.
Notification and Investigation Occurrence Flow Control Chart Notification received from reporter Type of Occurrence? Need for investigation? Process form CYI 2000D Process form CYI 2000A No Yes ICAO Annex 13 ACCID/INCID Notify Accident/Serious Incident Other Incidents Internal Investigation Institute formal investigation Final Report Lesson Dissemination Remedial Action Close occurrence report
TOKAI: Tool Kit for Air Traffic Management Investigation • ATC Occurrence Report Form • Investigation Occurrence Report File 1. Background Information 2. Event Type 3. Descriptive Factors 4. Human Factors 5. Classification Scheme 6. Safety Recommendations • Occurrence Status • Risk Assessment Tools • Annual Summary Template and Statistics Tools • TOKAI Manual • www.eurocontrol.int/src
