Presentation on theme: "Focus on Incident reporting"— Presentation transcript:
1 Focus on Incident reporting ICAO ADREP 2007Focus on Incident reportingJarmo KorhonenAIG SectionAir Navigation Bureau
2 Overview Vision ADREP SMS ICAO Annex 13 Reporting ECCAIRS Benefits of using an ADREP compatible systemRoad Map
3 Related Performance Indicators ICAO – Performance ReviewAccident RateLevel of mandatory reporting of the StatesOfficial Annex 13 reporting of contracting States vs. Media and other sourcesThere is proposal to the Council of ICAO that in order to monitor the performance of the effectiveness of its safety programmes it will use these two measures.The accident rate is the traditional long term measure that is part of the best practices used in field of safety indicators.The second one is new and aims to reflect two essential components to managing safety.1) It acts as a measures of the global level of reporting culture;2) It reflects the willingness to share safety data.But while these indicators define the minimum data set necessary for ICAO; States will be drvien by other requirements.Amongst these is the need to be more proactive which requires incident data traditionally not collected by ICAO.
4 Data Analysis AIG Divisional Meeting (1999) Recommendation 2/1 – ADREP Data AnalysisThat ICAO develop a data analysis programme that will allow the effective analysis of ADREP data. The programme should enable the categorization of accidents, the development of appropriate safety indicators and the systematic and rapid identification and dissemination of safety issues
5 VisionTo provide access to safety data and information required to meet and monitor levels of safetyFirst off let me start with the requirement for all this. Why is ICAO pushing for this and why are we building a programme around this?The traditional answer would have been something along the lines of the requirement in Annex13 and the protocols used by ICAO to audit a States’ safety oversight capabilities.While these remain primary reasons, in the current budgetary environment we need to look beyond these texts towards a performance driven reason.Data collected and never used, especially when duplication of effort is almost unavoidable, is not what we seek.The ultimate performance objective is what you see on the slide.Data is a service, which has a customer that has a greater requirement.That requirement is to meet and monitor levels of safety.To that end ICAO has a dual roleIt provides data to States to enable them to perform more accurate analysis; andIt analyses the data at a high level to calculate high level performance indicators for the Assembly and Council.
6 How to Achieve This Integrated Systems Compatible Taxonomies ADREP ECCAIRS safety management toolIn order to minimize duplication of effort only two things are requiredAn Integrated system that will automate agreed to procedures with the necessary safeguards.And the use of compatible taxonomies.
7 ADREP A System for Providing Feedback of Safety Lessons Learned: From States to ICAOandFrom ICAO back to States
8 ADREP Taxonomy Effective analysis of ADREP data Safety indicators Definitions, Taxonomies, etc.ECCAIRS common frame workSafety indicatorsCategorisation of accidentsIdentification and dissemination of safety issues
9 ICAO – ADREP ADREP – Accident Incident Data Reporting System A database of accidents and serious incidents reported to ICAO by StatesMaintained in the AIG SectionContains occurrences from 1970 to todayOccurrences (07 NOV 07)
10 SMM Safety Programme (States) - An integrated set of regulations and activities aimed at improving safetySafety Management System- A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures
11 ICAO Annexes as of 23 November 2006 States shall require, as part of their safety programme, that an [operator, maintenance organization, ATS provider, certified aerodrome operator] implements a safety management system accepted by the State that, as a minimum:Identifies safety hazardsEnsures that remedial action necessary to maintain an acceptable level of safety is implementedProvides for continuous monitoring and regular assessment of the safety level achievedAims to make continuous improvement to the overall level of safety
12 New Approach & Future Focus Must be guided by hazards identified through Safety Information shared and problems addressed by cooperative approach (Includes routine collection)Effectiveness metricsSystem monitoring for emerging risksCombined Data sources (beyond current scope) and sharing (Safety issues)Analysis
15 ADREP Reporting Requirements Annex 13 – Chapter 7 States investigate and report to ICAO:Accidents to aircraft over kg (para.7.1, 7.5)Investigated incidents to aircraft over kg (para. 7.7)Means of reporting:Reporting forms,Electronic reportingGuidance: Accident Incident Reporting Manual
16 ICAO Reporting standard for States Annex 13 - Chapter 7, Attachment B Initial NotificationPreliminary ReportData ReportFinal ReportADREP REPORTING
17 Accident/Incident Reporting to ICAO Initial NotificationDatareportPrelimreportFinalreportData entryOccurrenceInvestigationDataAnalysis
18 Global Reporting Culture Percentage of Open Files ~30%This graph depicts the level ofFiles in ADREP onAccidents and Serious incidentsInvolving Aircraft with MTOM Greater than kgThat are ‘open’Since States may notify ICAO even after the year of the occurrence this graph does not show improvement with time, but rather that the older a file the less likely ICAO will be notified.[click]The good news is that we are now at around 30% of the occurrences going unreported.Once this level reaches below 10% ICAO may consider the use of all accidents, and not just the ones involving passenger fatalities when calculating the relevant rates.10%
19 Global Reporting Culture 58 States notify ICAO between 25 and 75% of the time58 States notify ICAO less than 25% of the time51 States notify ICAO more than 75% of the time
20 Accident Prevention Measures Annex 13 - Chapter 8 Incident reporting systemA State shall establish an accident and incident reporting systems (8.1 & 8.2)
21 Accident Prevention Measures Annex 13 - Chapter 8 Database systemsRecommendation - A State should establish a database to facilitate effective analysis of information obtained from incident reporting systems (8.4)Recommendation – The database systems should use standardized formats (8.5)
22 Reporting flow AIB ICAO ADREP using ECCAIRS database software State CAARegional BodyState
23 Accident Prevention Measures Annex 13 - Chapter 8 Analysis of data – Preventive actionsA State shall analyse the information contained in its database to determine any preventive actions required (8.6)Recommendation. – If a State identifies safety matters considered to be of interest to other States, that State should forward such safety information to them as soon as possible (8.7)
24 Example AVIATION SAFETY OFFICER ECCAIRS DATABASE Queries and Reports DATAFORMAT FILEEDFBROWSER
25 Accident Prevention Measures Annex 13 - Chapter 8 Exchange of safety informationRecommendation. – States should promote the establishment of safety information sharing networks and should facilitate the free exchange of information on potential safety deficiencies (8.9)
26 Service ProvidersATNS, Aerodromes, Air OperatorsContracting StatesROICAOReporting to ICAO as per Annex 13 provisions
27 ECCAIRS viewNot reported to ICAO = Media Source
31 Distribution of Type of Occurrence This graph shows the ‘accident incident pyramid’ in ADREPThe ratio of accidents to incidents is around 1 to 2And while this falls far short of the 1 to 600 ratio used as a benchmark of safety management systems, ICAO, due to concerns of protecting sources and misuse of safety information is limited in the depth of its incident data set.As for the Serious incident, it can be seen here that ADREP still requires a significant increase in these numbers.[click]Just one more note on Serious incidents : it was noticed during the last meeting of the Safety Indicators Study Group, that States are using a wide variety of disparate thresholds when determining whether an occurrence was an incident or serious incident.
32 Distribution of Type of Occurrence This graph shows the number of accidents and serious incidents in ADREP over the last 17 yearsAs you can see the overall data set has almost doubledWhile the number of accidents has remained some what the same the number of serious incidents has exponentially increased since the AIG divisional meeting in 1999
33 Regional Distribution (% to total Fatal Accidents) by major Occurrence Categories for 2002-2006 This is a holistic view of the categories distributed by region.Each column represents a category while each colour a regionAs you can see not all regions have the same safety priorities, since the graph shows a multitude of colours and sizesLater on during the presentation we will show the categories by region individually.
36 Benefits using ADREP ECCAIRS Implements comprehensive SMS principlesICAO ADREP taxonomy compatibleDesigned for data sharingFamily of tools and common framework (multi modal)Free for all ICAO Contracting StatesVery stable systemAvailable in English and FrenchIn the 1990s the EU identified a requirement to share safety data across Europe.In order to get this done the EU commissioned the development of a software that would enable such an environment.The developers, however, were mindful of the ICAO taxonomies, and decided to implement them.Since ICAO does not develop software to implement its Taxonomies. And to date this is the only system that does.The advantages of the system are described on this slide. But in short ECCAIRS is:A system operation for over 10 years in Europe where it is used to seamlessly share data while implementing protocols that protect the identification of operators and other sensitive material, does all this in both English and French (with a Spanish translation in the works) and which is being evlauated or used by over 20 non European ICA Contracting States.
37 Why not to choose ADREP ECCAIRS ? Not a solution to solve all problems of aviation, only a data storage (should be seen as part of safety management systems)No reasoning because ICAO needs or recommendation for ADREP compatible systemsNo reasoning because of ICAO AuditsNo reasoning because of somebody’s request, but rather because of commitment to safety and professionalism
38 Options States with well established safety data systems: No need to convert to ICAO taxonomiesNeeds to map native system to ICAO taxonomies to send dataStates with a low level of aviation activityEvaluate the possibility of participating in a sub-regional systemAll States, groups of States and other Stakeholders who wish to participate in the future system have several options to prepare themselvesStates who have well established safety data systems should:Perform a needs analysis for participation in the global network;Evaluate the costs of implementing an interface between their system and the global system; andExecute a timeline for implementation suited to their needs
39 Options (cont.) All other States ADREP ECCAIRSNote – even if you do not implement ADREP ECCAIRS through-out your Civil Aviation system, you may still consider putting it on one work station so that you can share data with other who do use ADREP ECCAIRSAll other States should evaluate using the ECCARIS software
40 Next Steps1) Define Focal Point of the State for the safety information and reporting systems (as part of the Safety Program of the State)2) Define safety data and safety information system requirements3) Select appropriate solution
41 For those who choose to implement ADREP ECCAIRS Software will be provided by the EU through ICAO at no chargeTraining is available on demand to ICAO HQ (not EU/JRC; participants and/or hosts to cover expenses)
42 Biggest Risk and Safety Culture Biggest risk lay in the absence of reporting and standardsSafety culture must existEvaluation by safety performance (indicators & factors)
43 Aviation Safety System Safety PolicySafety Information and Reportingmandatory & voluntary reportingADREPAccident Prevention ProgrammeInvestigation of incidents and accidentsEducation and training