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© Dédale & EUROCONTROL Systemic Occurrence Analysis Methodology Tony LICU EUROCONTROL Glasgow – Aug 2005.

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Presentation on theme: "© Dédale & EUROCONTROL Systemic Occurrence Analysis Methodology Tony LICU EUROCONTROL Glasgow – Aug 2005."— Presentation transcript:

1 © Dédale & EUROCONTROL Systemic Occurrence Analysis Methodology Tony LICU EUROCONTROL Glasgow – Aug 2005

2 SOAM A Reason-Based Organisational Methodology A tool for the analysis of safety occurrences (accidents & Incidents)

3 EUROCONTROL SOAM SOAM Antecedents l The Reason Model ~ circa 1990 è Developed from Professor James Reasons work on human error and organisational accidents l Tripod Delta ~ circa 1994 è Developed for Shell Petroleum, based on Reason Model l ICAM ~ circa 2000 è Developed for BHP Billiton, based on Reason Model and Tripod Delta

4 EUROCONTROL SOAM Recent fatal accidents in Europe with ATM contribution Überlingen, 1 July 2002 Linate, 8 October 2001

5 EUROCONTROL SOAM Call for Action l Aviation Safety is still at a good level l Traffic however is increasing l Two major accidents involving Air Traffic Management in 2001 and 2002 ….. l In well developed countries in the heart of Europe … l From which many lessons can be learnt Wake up call for action

6 EUROCONTROL SOAM AGAS/ SSAP Priority Areas 1.Safety related human resources in ATM 2.Incident reporting and data sharing 3.ACAS/TCAS 4.Ground-based safety nets 5.Runway safety 6.Enforcement of ESARRs and implementation monitoring 7.Awareness of safety matters 8.Safety and human factors research & development An Action Group of European aviation safety experts identified the following areas as needing immediate focus: An Action Group of European aviation safety experts identified the following areas as needing immediate focus: 1.Safety related human resources in ATM 2.Incident reporting and data sharing 3.ACAS/TCAS 4.Ground-based safety nets 5.Runway safety 6.Enforcement of ESARRs and implementation monitoring 7.Awareness of safety matters 8.Safety and human factors research & development

7 EUROCONTROL SOAM Why another investigation tool? l Support ESARR 2 implementation and Strategic Safety Action Plan l Higher quality reports and AST returns ~ a need to: è clearly identify causes and report them concisely è go beyond the human errors, to find systemic causes è use a simple, consistent approach for events of all severity levels è ensure recommendations are relevant and effective

8 EUROCONTROL SOAM Current investigation methods What can we improve about the way we conduct safety occurrence investigations?

9 EUROCONTROL SOAM How SOAM can help l A methodology that includes structured processes to: è identify and classify a range of contributing factors è sort out irrelevant, non-contributing facts è move from a focus on human error/s to identify systemic causes ~ support for Just Culture è analyse simple events through to high severity incidents and accidents è clearly link recommendations to the facts of the analysis

10 EUROCONTROL SOAM Elements of Organisational Occurrences l Organisational Factors: è Latent system failures that produce or allow conditions under which accidents are possible l Contextual Conditions: è Situational factors involving characteristics of the task, the environment or human limitations l Human Involvement: è Errors and/or violations which have an immediate adverse affect (active failures) l Inadequate or absent barriers/defences: è Failure to identify and protect the system against human errors or violations, local conditions

11 EUROCONTROL SOAM The Reason Model Organisational Error Chain Organisational and System Factors Unsafe Acts Latent Conditions (adapted from Reason, 1990) Active Failures Contextual Conditions Human Involvement Limited window/s of opportunity Absent or Failed Barriers ACCIDENT People, Task, Environment

12 Human Involvement Contextual Conditions Organisational & System Factors Causes Investigation process Latent condition pathways Stages in development & investigation of an organisational accident (Adapted from Reason, 1997) Barriers Losses DANGER Hazards DANGER

13 EUROCONTROL SOAM Accident Causes l A man has a bad argument with his wife. l He storms out of the house to the nearest bar and drinks four whiskies. l He then decides to go for a drive. l It is night-time, there is a skim of snow on the ground, and the tyres on our victims car are smooth. l In rounding a poorly banked curve at excessive speed, the right front tyre blows out, the car leaves the road and is demolished. What is the cause of the accident? (Johnston, 1996)

14 EUROCONTROL SOAM SOAM Worked Example Runway Overrun, Bangkok September 1999

15 EUROCONTROL SOAM Accident Summary On 23 September 1999, at about 2247 local time, a Boeing aircraft overran runway 21 Left (21L) while landing at Bangkok International Airport, Thailand.

16 EUROCONTROL SOAM Accident Summary The aircraft sustained substantial damage during the overrun. None of the three flight crew, 16 cabin crew or 391 passengers reported any serious injuries. The overrun occurred after the aircraft landed long and aquaplaned on a runway which was affected by water following very heavy rain.

17 EUROCONTROL SOAM SOAM analysis key steps Review the Facts Identify the Organisational Factors Identify the Contextual Conditions Identify the Human Involvement Identify the Absent or Failed Barriers Validate the OFs against the Occurrence CHECK QUESTIONS HELP TO SORT AND CLASSIFY FACTS

18 EUROCONTROL SOAM The SHEL Model (after Edwards, 1972) LIVEWARE Operators L HARDWARE Equipment, vehicles, tools, controls, switches, levers, workplace design, seating etc H L LIVEWARE/LIVEWARE Interface between people. Operators, controllers, managers, etc E ENVIRONMENT Site, terrain, weather, roads, traffic, remoteness etc S SOFTWARE Procedures, checklists, manuals, training materials, charts etc

19 First Officer Other pilots Captain PEOPLE Crew employed flaps 25/ idle reverse landing configuration Very heavy rainfall, runway surface affected by water Captain awake 21 hours at time of accident Importance of reverse thrust as stopping force on water-affected runways not known Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways FO awake for 19 hours at the time of the accident Confusion after thrust levers retarded, in high workload situation Most pilots not fully aware about 'aquaplaning' Crew did not use an adequate risk mgt strategy for approach and landing No formal risk assessment conducted when changed landing procedure researched Landing on Slippery Runways (Boeing doc) not distributed in Qantas since 1977 Captain & FO quite low levels of flying prior 30 days No policies or procedures for maintenance of recency for management pilots Normal practice to use flaps 25/idle reverse Documents unclear (eg., key terms not well defined) FO did not fly the aircraft accurately during final approach No formal review of new procedures after 'trial' period Absence of reverse thrust during landing roll not noticed, not used Captain cancelled go- around decision by retarding thrust levers SOFTWAREHARDWAREENVIRONMENTORGANISATION Raw Data Collection AC1 overruns runway at Bangkok after landing long, recent heavy rainfall, and water on runway. Captain did not order a go-around earlier Recent crew experience using full reverse thrust lacking No appropriately documented info, procedures regarding operations on water- affected runways No policies, procedures on duty or work limits for pilots with flying & non-flying duties Reduced visibility & distraction: rain and windscreen wipers High workload situation, distraction or inexperience Contaminated runway issues not covered in recent years during crew endorsement, promotional or recurrent training Cost-benefit analysis of new landing procedure was biased Gather data relevant to the occurrence Partial loss of external visual reference due to heavy rain Revised approach/ landing procedure introduced in 1996: flaps 25, idle reverse thrust Boeing advised that if idle reverse technique is adopted, it should be the exception rather than the rule Most pilots disagreed they had adequate training on landing on contaminated runways Introduction of new landing procedure poor Bangkok runway was resurfaced in 1991

20 First Officer Other pilots Captain PEOPLE Crew employed flaps 25/ idle reverse landing configuration Very heavy rainfall, runway surface affected by water Captain awake 21 hours at time of accident Importance of reverse thrust as stopping force on water-affected runways not known Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways FO awake for 19 hours at the time of the accident Confusion after thrust levers retarded, in high workload situation Most pilots not fully aware about 'aquaplaning' Crew did not use an adequate risk mgt strategy for approach and landing No formal risk assessment conducted when changed landing procedure researched Landing on Slippery Runways (Boeing doc) not distributed in Qantas since 1977 Captain & FO quite low levels of flying prior 30 days No policies or procedures for maintenance of recency for management pilots Normal practice to use flaps 25/idle reverse Documents unclear (eg., key terms not well defined) FO did not fly the aircraft accurately during final approach No formal review of new procedures after 'trial' period Absence of reverse thrust during landing roll not noticed, not used Captain cancelled go- around decision by retarding thrust levers SOFTWAREHARDWAREENVIRONMENT Raw Data Refinement Captain did not order a go-around earlier Recent crew experience using full reverse thrust lacking No appropriately documented info, procedures regarding operations on water- affected runways No policies, procedures on duty or work limits for pilots with flying & non-flying duties Reduced visibility & distraction: rain and windscreen wipers High workload situation, distraction or inexperience Contaminated runway issues not covered in recent years during crew endorsement, promotional or recurrent training Cost-benefit analysis of new landing procedure was biased Partial loss of external visual reference due to heavy rain Revised approach/ landing procedure introduced in 1996: flaps 25, idle reverse thrust Boeing advised that if idle reverse technique is adopted, it should be the exception rather than the rule Most pilots disagreed they had adequate training on landing on contaminated runways Introduction of new landing procedure poor Bangkok runway was resurfaced in 1991 Sort out the non-contributing facts of the investigation Boeing advised that if idle reverse technique is adopted, it should be the exception rather than the rule Bangkok runway was resurfaced in 1991 ORGANISATION AC1 overruns runway at Bangkok after landing long, recent heavy rainfall, and water on runway.

21 First Officer Other pilots Captain PEOPLE Crew employed flaps 25/ idle reverse landing configuration Very heavy rainfall, runway surface affected by water Captain awake 21 hours at time of accident Importance of reverse thrust as stopping force on water-affected runways not known Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways FO awake for 19 hours at the time of the accident Confusion after thrust levers retarded, in high workload situation Most pilots not fully aware about 'aquaplaning' Crew did not use an adequate risk mgt strategy for approach and landing No formal risk assessment conducted when changed landing procedure researched Landing on Slippery Runways (Boeing doc) not distributed in Qantas since 1977 Captain & FO quite low levels of flying prior 30 days No policies or procedures for maintenance of recency for management pilots Normal practice to use flaps 25/idle reverse Documents unclear (eg., key terms not well defined) FO did not fly the aircraft accurately during final approach No formal review of new procedures after 'trial' period Absence of reverse thrust during landing roll not noticed, not used Captain cancelled go- around decision by retarding thrust levers SOFTWAREHARDWAREENVIRONMENT Raw Data Refinement Captain did not order a go-around earlier Recent crew experience using full reverse thrust lacking No appropriately documented info, procedures regarding operations on water- affected runways No policies, procedures on duty or work limits for pilots with flying & non-flying duties Reduced visibility & distraction: rain and windscreen wipers High workload situation, distraction or inexperience Contaminated runway issues not covered in recent years during crew endorsement, promotional or recurrent training Cost-benefit analysis of new landing procedure was biased Partial loss of external visual reference due to heavy rain Revised approach/ landing procedure introduced in 1996: flaps 25, idle reverse thrust Most pilots disagreed they had adequate training on landing on contaminated runways Introduction of new landing procedure poor Use the remaining factors to build the Analysis chart ORGANISATION AC1 overruns runway at Bangkok after landing long, recent heavy rainfall, and water on runway.

22 ACCIDENT ABSENT OR FAILED BARRIERS HUMAN INVOLVEMENT CONTEXTUAL CONDITIONS ORGANISATIONAL FACTORS Very heavy rainfall, runway surface affected by water Building the Analysis Chart Very heavy rainfall, runway surface affected by water ? ?

23 EUROCONTROL SOAM Absent or Failed Barriers l Describe the last minute measures which failed or were missing, and therefore did not prevent the accident l Check Question: Does the item describe a work procedure, aspect of human awareness, physical obstacle, warning or control system, or protection measure designed to prevent an occurrence or lessen its consequences?

24 EUROCONTROL SOAM Human Involvement l Describe the errors or violations (actions or omissions) by operators at the scene which triggered the accident l Check Question: Does the item describe an action or non- action (error or violation) that immediately contributed to the occurrence?

25 ACCIDENT ABSENT OR FAILED BARRIERS HUMAN INVOLVEMENT CONTEXTUAL CONDITIONS ORGANISATIONAL FACTORS Building the Analysis Chart Crew employed flaps 25/ idle reverse landing configuration Very heavy rainfall, runway surface affected by water Crew employed flaps 25/ idle reverse landing configuration ?

26 EUROCONTROL SOAM Contextual Conditions l Describe the context of the event ~ the conditions existing immediately prior to, or at the time of the accident Check Question: Does the item describe an aspect of the workplace, local organisational climate, or a persons attitudes, personality, performance limitations, physiological or emotional state that helps explain their actions?

27 EUROCONTROL SOAM Organisational Factors l Describe the organisational and system factors (failures) which created, or allowed, the prevailing contextual conditions l Check Question: Does the item describe an aspect of an organisations culture, systems, processes or decision-making that existed before the occurrence and which resulted in the contextual conditions or allowed those conditions to continue?

28 Aircraft overran runway after landing long No serious injuries (391 pax, 19 crew) Potential for more serious outcome Aircraft repair cost: $100,000,000 (?) Damage to company reputation Very heavy rainfall, runway surface affected by water Crew not aware of critical importance of reverse thrust as stopping force on water-affected runways FO awake for 19 hours at the time of the accident CM No formal review of new procedures after 'trial' period Most pilots not fully aware about 'aquaplaning' PP No appropriately documented info, procedures re operations on water-affected runways WM No policies, procedures on duty or work limits for pilots with flying & non-flying duties PP Regulations covering emergency procedures & EP training were deficient AC CASA surveillance of airline flight operations deficient Recent crew experience using full reverse thrust lacking RM No formal risk assessment conducted when changed landing procedure researched SOAM Chart Aircraft Accident Boeing Bangkok, Thailand September 1999 ACCIDENT ABSENT OR FAILED BARRIERS HUMAN INVOLVEMENT CONTEXTUAL CONDITIONS ORGANISATIONAL FACTORS OTHER SYSTEM FACTORS First Officer did not fly the aircraft accurately during the final approach Captain cancelled go-around decision by retarding the thrust levers New 1996 approach/ landing procedure inappropriate CO Documents unclear (eg., key terms not well defined) CO Landing on Slippery Runways (Boeing doc) not distributed in Qantas since 1977 Absence of reverse thrust during landing roll not noticed, reverse thrust not used Flight crew did not use an adequate risk management strategy for approach and landing Reduced visibility & distraction: rain and windscreen wipers Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways Captain awake 21 hours at time of accident High workload situation TR Contaminated runway issues not covered during crew endorsement, promotional or recurrent training in recent years Captain & FO quite low levels of flying prior 30 days WM No policies or procedures for maintenance of recency for management pilots Normal practice to use flaps 25/idle reverse CM Introduction of new landing procedure poor CG Cost-benefit analysis of new landing procedure was biased PP Regulations covering contaminated runway operations deficient Crew employed flaps 25/idle reverse landing configuration Captain did not order a go- around earlier Landing procedure inappropriate Crew Resource Management deficient OC Mgt decisions informal, intuitive, personality-driven

29 EUROCONTROL SOAM l Provide recommendations that will prevent recurrence of this scenario l Recommendations should be directed to the responsible position, and must address all identified: 1 Absent or Failed Barriers 2 Organisational Factors Recommendations

30 Aircraft overran runway after landing long No serious injuries (391 pax, 19 crew) Potential for more serious outcome Aircraft repair cost: $100,000,000 (?) Damage to company reputation Very heavy rainfall, runway surface affected by water Crew not aware of critical importance of reverse thrust as stopping force on water-affected runways FO awake for 19 hours at the time of the accident CM No formal review of new procedures after 'trial' period Most pilots not fully aware about 'aquaplaning' PP No appropriately documented info, procedures re operations on water-affected runways WM No policies, procedures on duty or work limits for pilots with flying & non-flying duties PP Regulations covering emergency procedures & EP training were deficient AC CASA surveillance of airline flight operations deficient Recent crew experience using full reverse thrust lacking RM No formal risk assessment conducted when changed landing procedure researched SOAM Chart Aircraft Accident Boeing Bangkok, Thailand September 1999 ACCIDENT ABSENT OR FAILED BARRIERS HUMAN INVOLVEMENT CONTEXTUAL CONDITIONS ORGANISATIONAL FACTORS OTHER SYSTEM FACTORS First Officer did not fly the aircraft accurately during the final approach Captain cancelled go-around decision by retarding the thrust levers New 1996 approach/ landing procedure inappropriate CO Documents unclear (eg., key terms not well defined) CO Landing on Slippery Runways (Boeing doc) not distributed in Qantas since 1977 Absence of reverse thrust during landing roll not noticed, reverse thrust not used Flight crew did not use an adequate risk management strategy for approach and landing Reduced visibility & distraction: rain and windscreen wipers Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways Captain awake 21 hours at time of accident High workload situation TR Contaminated runway issues not covered during crew endorsement, promotional or recurrent training in recent years Captain & FO quite low levels of flying prior 30 days WM No policies or procedures for maintenance of recency for management pilots Normal practice to use flaps 25/idle reverse CM Introduction of new landing procedure poor CG Cost-benefit analysis of new landing procedure was biased PP Regulations covering contaminated runway operations deficient Crew employed flaps 25/idle reverse landing configuration Captain did not order a go- around earlier Landing procedure inappropriate Crew Resource Management deficient OC Mgt decisions informal, intuitive, personality-driven CM No formal review of new procedures after 'trial' period PP No appropriately documented info, procedures re operations on water-affected runways WM No policies, procedures on duty or work limits for pilots with flying & non-flying duties PP Regulations covering emergency procedures & EP training were deficient AC CASA surveillance of airline flight operations deficient RM No formal risk assessment conducted when changed landing procedure researched CO Documents unclear (eg., key terms not well defined) CO Landing on Slippery Runways (Boeing doc) not distributed in Qantas since 1977 TR Contaminated runway issues not covered during crew endorsement, promotional or recurrent training in recent years WM No policies or procedures for maintenance of recency for management pilots CM Introduction of new landing procedure poor CG Cost-benefit analysis of new landing procedure was biased PP Regulations covering contaminated runway operations deficient OC Mgt decisions informal, intuitive, personality-driven Absence of reverse thrust during landing roll not noticed, reverse thrust not used Landing procedure inappropriate Crew Resource Management deficient

31 EUROCONTROL SOAM Questions?

32 EUROCONTROL SOAM


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