1. Incident Review Meeting Guidance Material & Presentation Template

2. Introduction to the Template
This template allows Safety Managers to analyze events using the TEM framework in conjunction with the Bow Tie Model
The TEM framework helps to underline the classification system used by IATA to determine contributing factors, in incidents and accidents
These factors can be viewed as Threats, failed Preventive Defenses (including Error Management) resulting in Undesired Aircraft States
The Undesired Aircraft States is then managed through Recovery Defenses (including Undesired Aircraft State Management) to prevent or not prevent the Accident or Incident
An example is provided to illustrate the steps that can be followed to analyze events in this manner
IRM speakers are reminded that:
this is not intended to be a complete Bow Tie Analysis
this format is optional

3. IRM presenters are asked to ensure they clearly define:
Safety enhancements
What was learned? What was changed?
Lessons learned for IRM attendees
What should attendees consider checking and/or changing at their own operation?
Key messages for Safety Group
What should the Safety Group act on?

4. The IRM presentations are an integral part of IATA’s and the Safety Group’s hazard identification process
All presentations are welcome, even short ones
Presentations must have take aways for IRM attendees and Safety Group

6. Latent Conditions
Conditions present in the system before the accident, made evident by triggering factors

7. Latent Conditions: Examples
Deficiencies in:
Design factors
Safety management
Training
Standard Operating Procedures
Selection systems
Etc.

8. Threats
Factors external to the flight deck that increase the complexity of flight operations and which are realized through a triggering event

9. Threats: Examples Weather Maintenance errors Ground crew
Flight/Cabin Crew errors
Passenger events
ATC errors
Terrain
Similar call signs
Time pressures
Heavy traffic
Unfamiliar airports
Automation events
Missed approaches
Flight diversions
System
malfunctions
Distractions

10. Bow Tie Model U.E. Unwanted Events Undesired Aircraft State CFIT
Threat
Undesired Aircraft State
LOC
CFIT
Runway Collision
Mid-Air Collision
Runway Excursion
Other Damages (Flight)
Other Damages (Ground)
ASR, GHR, Ext…
Preventive DEFENSES
RECOVERY DEFENSES
END STATES
ACCIDENT/INCIDENT
Altitude Deviation
Unstabilized Approach
Runway Incursion, Unsecured Loading
ATC Comm. Loss, etc.

11. Threats
List the Threats that were realized in the triggering event or events

12. Preventive Defenses
What are the specific mechanisms that should have helped prevent the undesired aircraft state?
Examples: policies, procedures, training
Which of these defenses/barriers failed?
Why? What caused the these defenses/barriers to fail?

13. UAS: Examples Aircraft Handling: Ground Navigation:
Lateral, vertical or speed deviation
Operation Outside Aircraft Limitations
Unstable approach
Ground Navigation:
Runway / taxiway incursion
Proceeding towards wrong taxiway / runway
Wrong hold spot
Incorrect aircraft configurations
Systems
Landing gear
Flight controls

14. Undesired Aircraft States (UAS)
Describe the Undesired Aircraft State

15. Recovery Defenses
List the Recovery Defenses that either prevented or failed to prevent the Accident or Incident from occurring
Explain the specific mechanisms which should have helped recover from the unsafe event?
Which of these failed?
Why? What caused these to fail?

16. End States End States are reportable events: Incidents Accidents
Tailstrike
Undershoot
Hard Landing
Etc…

17. Safety Enhancements What was learned from this occurrence?
What changes have been or should be made at your airline and in industry?
Procedures, Policies
Training
Equipment
ATC
Airport
Weather Information etc….

18. Lessons 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?

19. Key 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?

20. Usage 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.