ICAO/ASPA ICAO/ASPA Safety Management System Safety Management System

SeminarSeminar

Air Traffic ManagementAir Traffic ManagementOccurrence ReportingOccurrence Reporting

Mexico City, Mexico, 14 – 16 March 2006Mexico City, Mexico, 14 – 16 March 2006Jeremy Jackson – Civil Aviation Authority of the Cayman IslandsJeremy Jackson – Civil Aviation Authority of the Cayman Islands

Accident/Incident Accident/Incident Occurrences Occurrences Investigation SystemInvestigation System

ObjectiveObjective What should be reported? What should be reported? Notification and Investigation Notification and Investigation

Occurrence Flow Control ChartOccurrence Flow Control Chart TOKAI and ManualTOKAI and Manual Eurocontrol WebsiteEurocontrol Website

ObjectiveObjective

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?What Should Be Reported?

Air Traffic Control Services Air Traffic Control Services - by Flight Crew/ATCOs/Ground Ops Support - by Flight Crew/ATCOs/Ground Ops Support Staff.Staff.

Provision of significantly incorrect, inadequate or misleading information Provision of significantly incorrect, inadequate or misleading information from any ground sources, e.g. ATC, ATIS, Meteorological Services, maps, from any ground sources, e.g. ATC, ATIS, Meteorological Services, maps, charts, manuals, etc.charts, manuals, etc.

Provision of less than prescribed terrain clearance.Provision of less than prescribed terrain clearance. Provision of incorrect altimeter setting.Provision of incorrect altimeter setting. Misidentification of aircraft by an ATCO or radar operator.Misidentification of aircraft by an ATCO or radar operator. Incorrect transmission, receipt or interpretation of significant messages.Incorrect transmission, receipt or interpretation of significant messages. Airprox and any occurrence in which separation between aircraft is less Airprox and any occurrence in which separation between aircraft is less

than that prescribed for the situation.than that prescribed for the situation. Non-compliance with prescribed letdown or departure procedures or any Non-compliance with prescribed letdown or departure procedures or any

ATC/ATM instruction.ATC/ATM instruction. Declaration of an emergency (‘Mayday’ or ‘Pan’) by an aircraft.Declaration of an emergency (‘Mayday’ or ‘Pan’) by an aircraft. Unauthorized infringement of any form of regulated airspace.Unauthorized infringement of any form of regulated airspace. Unauthorized or illegal RTF transmissions.Unauthorized or illegal RTF transmissions. ATC Overload reportsATC Overload reports Declaration of an ACAS Resolution Advisory by an aircraftDeclaration of an ACAS Resolution Advisory by an aircraft

What Should Be Reported?What Should Be Reported?

Navigation and Communications Equipment etc. – failures, Navigation and Communications Equipment etc. – failures, malfunctions ormalfunctions or

defects defects - by Flight Crew/ATCO/ATS Maintenance Staff.- by Flight Crew/ATCO/ATS Maintenance Staff.

Total failure of navigation system or subsystem being used by an aircraft.Total failure of navigation system or subsystem being used by an aircraft. Total failure of communications system.Total failure of communications system. Total failure of radar system or subsystem.Total failure of radar system or subsystem. Failure or unplanned shutdown of a major operational ATC computer Failure or unplanned shutdown of a major operational ATC computer

system requiring reversion to manual back up and resulting in disruption to system requiring reversion to manual back up and resulting in disruption to the normal flow of air traffic.the normal flow of air traffic.

Significant malfunction or deterioration of Service.Significant malfunction or deterioration of Service. Significant deficiency in maintenance.Significant deficiency in maintenance. Repetitive events of a specific type of occurrence, which in isolation may Repetitive events of a specific type of occurrence, which in isolation may

not be considered reportable (e.g. excessive monitor alarms).not be considered reportable (e.g. excessive monitor alarms). Provision of erroneous information in the absence of any alarms.Provision of erroneous information in the absence of any alarms.

What Should Be Reported?What Should Be Reported?

Airfields and Airfield Facilities Airfields and Airfield Facilities - by Flight Crew/Airfield Staff/ATCOs.- by Flight Crew/Airfield Staff/ATCOs.

Failure or significant malfunction of airfield lighting.Failure or significant malfunction of airfield lighting. Major failure or significant deterioration of surfaces of runways or aircraftMajor failure or significant deterioration of surfaces of runways or aircraft

maneuvering areas.maneuvering areas. Runways or aircraft maneuvering areas obstructed by aircraft, vehicles or Runways or aircraft maneuvering areas obstructed by aircraft, vehicles or

foreign objects, resulting in a hazardous or potentially hazardous situation.foreign objects, resulting in a hazardous or potentially hazardous situation. Runway incursions.Runway incursions. Errors or inadequacies in marking of obstructions or hazards on runway or Errors or inadequacies in marking of obstructions or hazards on runway or

aircraft maneuvering areas.aircraft maneuvering areas. Collision between a moving aircraft and any other aircraft, vehicle or other Collision between a moving aircraft and any other aircraft, vehicle or other

ground object.ground object. Aircraft departing from a paved surface which results in, or could have Aircraft departing from a paved surface which results in, or could have

resulted in, a significant hazard.resulted in, a significant hazard. Jet or prop blast incidents resulting in significant damage or serious injury.Jet or prop blast incidents resulting in significant damage or serious injury. Significant spillage of fuel on airfield ramps.Significant spillage of fuel on airfield ramps.

Notification and Investigation Notification and Investigation Occurrence Flow Control ChartOccurrence Flow Control Chart

Notification receivedfrom reporter

Need for investigation?Process formCYI 2000D

Process formCYI 2000A

Type of Occurrence?No

Yes

Other Incidents

Internal Investigation

Close occurrence report

Final ReportLesson Dissemination

Remedial Action

Accident/Serious Incident NotifyICAO Annex 13ACCID/INCID

Institute formal investigation

TOKAI: TOKAI: Tool Kit for Air Traffic Tool Kit for Air Traffic

Management InvestigationManagement Investigation ATC Occurrence Report FormATC Occurrence Report Form Investigation Occurrence Report FileInvestigation Occurrence Report File

1. Background Information1. Background Information2. Event Type2. Event Type3. Descriptive Factors3. Descriptive Factors4. Human Factors4. Human Factors5. Classification Scheme5. Classification Scheme6. Safety Recommendations6. Safety Recommendations

Occurrence StatusOccurrence Status Risk Assessment ToolsRisk Assessment Tools Annual Summary Template and Statistics ToolsAnnual Summary Template and Statistics Tools TOKAI ManualTOKAI Manual www.eurocontrol.int/srcwww.eurocontrol.int/src