Presentation on theme: "Incident Review Meeting Guidance Material & Presentation Template"— Presentation transcript:
1Incident Review Meeting Guidance Material & Presentation Template
2Introduction to the Template This template allows Safety Managers to analyze events using the TEM framework in conjunction with the Bow Tie ModelThe TEM framework helps to underline the classification system used by IATA to determine contributing factors, in incidents and accidentsThese factors can be viewed as Threats, failed Preventive Defenses (including Error Management) resulting in Undesired Aircraft StatesThe Undesired Aircraft States is then managed through Recovery Defenses (including Undesired Aircraft State Management) to prevent or not prevent the Accident or IncidentAn example is provided to illustrate the steps that can be followed to analyze events in this mannerIRM speakers are reminded that:this is not intended to be a complete Bow Tie Analysisthis format is optional
3IRM presenters are asked to ensure they clearly define: Safety enhancementsWhat was learned? What was changed?Lessons learned for IRM attendeesWhat should attendees consider checking and/or changing at their own operation?Key messages for Safety GroupWhat should the Safety Group act on?
4The IRM presentations are an integral part of IATA’s and the Safety Group’s hazard identification processAll presentations are welcome, even short onesPresentations must have take aways for IRM attendees and Safety Group
10Bow Tie Model U.E. Unwanted Events Undesired Aircraft State CFIT ThreatUndesired Aircraft StateLOCCFITRunway CollisionMid-Air CollisionRunway ExcursionOther Damages (Flight)Other Damages (Ground)ASR, GHR, Ext…Preventive DEFENSESRECOVERY DEFENSESEND STATESACCIDENT/INCIDENTAltitude DeviationUnstabilized ApproachRunway Incursion, Unsecured LoadingATC Comm. Loss, etc.
11ThreatsList the Threats that were realized in the triggering event or events
12Preventive DefensesWhat are the specific mechanisms that should have helped prevent the undesired aircraft state?Examples: policies, procedures, trainingWhich of these defenses/barriers failed?Why? What caused the these defenses/barriers to fail?
13UAS: Examples Aircraft Handling: Ground Navigation: Lateral, vertical or speed deviationOperation Outside Aircraft LimitationsUnstable approachGround Navigation:Runway / taxiway incursionProceeding towards wrong taxiway / runwayWrong hold spotIncorrect aircraft configurationsSystemsLanding gearFlight controls
14Undesired Aircraft States (UAS) Describe the Undesired Aircraft State
15Recovery DefensesList the Recovery Defenses that either prevented or failed to prevent the Accident or Incident from occurringExplain the specific mechanisms which should have helped recover from the unsafe event?Which of these failed?Why? What caused these to fail?
16End States End States are reportable events: Incidents Accidents TailstrikeUndershootHard LandingEtc…
17Safety Enhancements What was learned from this occurrence? What changes have been or should be made at your airline and in industry?Procedures, PoliciesTrainingEquipmentATCAirportWeather Information etc….
18Lessons Learned for IRM (Note: this slide will be shared with all IRM attendees) What should attendees at IRM learn from this occurrence?What should attendees at IRM consider changing at their own airline?
19Key Messages for Safety Group (Note: this slide will be shared with all IRM attendees) What are the key messages that Safety Group should act on?
20Usage Notes for IRM Template When discussing crew actions management, describe only observable facts, and avoid judgments. Value statements such as “minor”, ”poor” or “very” attached to the description of crew actions should be avoided.When discussing undesired states management, describe only observable facts, and avoid judgments. Value statements such as “minor”, ”poor” or “very” attached to the description of crew actions related to undesired states management should be avoided.