ATS INCIDENT REPORTING AND INVESTIGATIONS

Reporting Aviation Occurrences NAV CANADA RESPONSIBILITES NAV CANADA has a requirement under CARs to report certain aviation incidents to Transport Canada. NAV CANADA Management has a need to be aware of incidents as they occur. .

Aviation Occurrence Reporting System Shift Manager in each ACC is focal point. Receives information and inputs to the AOR data base.

Aviation Occurrence Reporting System Information is automatically forwarded to Transport Canada. NAV CANADA managers receive the information. ATS Operating irregularities are followed up.

Operations Safety Investigation INITIAL NOTIFICATION Initial notification to Head Office of an aviation occurrence will usually be through the Aviation Occurrence Report database.

Operations Safety Investigation PRELIMINARY INVESTIGATION Involves an immediate examination of the basic facts to determine the necessity for further action.

Operations Safety Investigation Investigators (Chairperson)come from the Operations Group around the country. They are not dedicated to investigations. Training is provided for designated investigators by S&SD

Operations Safety Investigation Three levels of investigation Service the entire Operations Group Manager in System Safety and Service design decides what type of investigation will be conducted.

Operations Safety Investigation Three levels of investigation Level one (OSI -1 ): -To collect factual information, but without interviewing operational employees directly involved. -Investigation would be comprised only of the Chairperson. .

Operations Safety Investigation Three levels of investigation Level two (OSI -2 ): -To collect factual information, including interviewing operational employees directly involved. S

Operations Safety Investigation Three levels of investigation Composition of the Board- OSI -2 a chairperson. a non-supervisory controller/specialist from the area or Operations Group division under review Person is selected by the Unit Manager. a NAV CANADA manager from a similar specialty area as that under review.

Operations Safety Investigation Three levels of investigation Level three (OSI -3 ): - Complete Operational Review. - Conducted when similar events reoccur.

Operations Safety Investigation Criteria for Investigation Type Level two (OSI -2 ): operating irregularity staffing, equipment or procedures a factor, or on the Job Training may be a factor, or trends are apparent, or occurrence is high profile, or recommended by OPS Group Manager .

Operations Safety Investigation Criteria for Investigation Type Level one (OSI -1 ): Operating Irregularity -less than OSI 2 defined criteria -may be upgraded on site by S&SD appointed investigator

Operations Safety Investigation Criteria for Investigation Type Level three (OSI -3 ): Operating Irregularity???? -less than OSI 2 defined criteria -may be upgraded on site by S&SD appointed investigator

Operations Safety Investigation Human Factors Identify unsafe acts. Identify latent unsafe conditions. Identify last successful defense barrier. ,

Operations Safety Investigation Follow-up Unit Management is briefed by Chairperson. Corrective action taken as required. Report is published and widely distributed. Head Office Monitoring and Evaluations will review and follow-up if required. ,