1. Focus on Incident reporting
ICAO ADREP 2007
Focus on Incident reporting
Jarmo Korhonen
AIG Section
Air Navigation Bureau

2. Overview Vision ADREP SMS ICAO Annex 13 Reporting ECCAIRS
Benefits of using an ADREP compatible system
Road Map

3. Related Performance Indicators
ICAO – Performance Review
Accident Rate
Level of mandatory reporting of the States
Official Annex 13 reporting of contracting States vs. Media and other sources
There 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 Analysis
That 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. Vision
To provide access to safety data and information required to meet and monitor levels of safety
First 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 role
It provides data to States to enable them to perform more accurate analysis; and
It 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 tool
In order to minimize duplication of effort only two things are required
An 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 ICAO
and
From ICAO back to States

8. ADREP Taxonomy Effective analysis of ADREP data Safety indicators
Definitions, Taxonomies, etc.
ECCAIRS common frame work
Safety indicators
Categorisation of accidents
Identification 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 States
Maintained in the AIG Section
Contains occurrences from 1970 to today
Occurrences (07 NOV 07)

10. SMM Safety Programme (States)
- An integrated set of regulations and activities aimed at improving safety
Safety 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 hazards
Ensures that remedial action necessary to maintain an acceptable level of safety is implemented
Provides for continuous monitoring and regular assessment of the safety level achieved
Aims 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 metrics
System monitoring for emerging risks
Combined Data sources (beyond current scope) and sharing (Safety issues)
Analysis

13. Aviation Safety Pyramid
ACCIDENTS 1
Investigation 15
SERIOUS INCIDENTS
INCIDENTS
Prevention
300
OTHER SAFETY RELATED OCCURRENCES / HAZARDS
3000

14. A N N E X 13

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 reporting
Guidance: Accident Incident Reporting Manual

16. ICAO Reporting standard for States Annex 13 - Chapter 7, Attachment B
Initial Notification
Preliminary Report
Data Report
Final Report
ADREP REPORTING

17. Accident/Incident Reporting to ICAO
Initial Notification
Data
report
Prelim
report
Final
report
Data entry
Occurrence
Investigation
Data
Analysis

18. Global Reporting Culture Percentage of Open Files
~30%
This graph depicts the level of
Files in ADREP on
Accidents and Serious incidents
Involving Aircraft with MTOM Greater than kg
That 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 time
58 States notify ICAO less than 25% of the time
51 States notify ICAO more than 75% of the time

20. Accident Prevention Measures Annex 13 - Chapter 8
Incident reporting system
A State shall establish an accident and incident reporting systems (8.1 & 8.2)

21. Accident Prevention Measures Annex 13 - Chapter 8
Database systems
Recommendation - 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
CAA
Regional Body
State

23. Accident Prevention Measures Annex 13 - Chapter 8
Analysis of data – Preventive actions
A 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 FILE
EDF
BROWSER

25. Accident Prevention Measures Annex 13 - Chapter 8
Exchange of safety information
Recommendation. – 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 Providers
ATNS, Aerodromes, Air Operators
Contracting States RO
ICAO
Reporting to ICAO as per Annex 13 provisions

27. ECCAIRS view
Not reported to ICAO = Media Source

28. Level of practical usage
Hazard
NEW

29. Occurrence = sequence of events

30. Example of Output

31. Distribution of Type of Occurrence
This graph shows the ‘accident incident pyramid’ in ADREP
The ratio of accidents to incidents is around 1 to 2
And 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 years
As you can see the overall data set has almost doubled
While 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 region
As you can see not all regions have the same safety priorities, since the graph shows a multitude of colours and sizes
Later on during the presentation we will show the categories by region individually.

35. Reactive versus Proactive Safety

36. Benefits using ADREP ECCAIRS
Implements comprehensive SMS principles
ICAO ADREP taxonomy compatible
Designed for data sharing
Family of tools and common framework (multi modal)
Free for all ICAO Contracting States
Very stable system
Available in English and French
In 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 systems
No reasoning because of ICAO Audits
No 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 taxonomies
Needs to map native system to ICAO taxonomies to send data
States with a low level of aviation activity
Evaluate the possibility of participating in a sub-regional system
All States, groups of States and other Stakeholders who wish to participate in the future system have several options to prepare themselves
States 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; and
Execute a timeline for implementation suited to their needs

39. Options (cont.) All other States
ADREP ECCAIRS
Note – 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 ECCAIRS
All other States should evaluate using the ECCARIS software

40. Next Steps
1) 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 requirements
3) Select appropriate solution

41. For those who choose to implement ADREP ECCAIRS
Software will be provided by the EU through ICAO at no charge
Training 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 standards
Safety culture must exist
Evaluation by safety performance (indicators & factors)

43. Aviation Safety System
Safety Policy
Safety Information and Reporting
mandatory & voluntary reporting
ADREP
Accident Prevention Programme
Investigation of incidents and accidents
Education and training

44. SAFETY CULTURE
KNOWLEDGE
LEARNING
ORGANIZATIONS

45. Questions?

46. THANK YOU