1. The Safety Analysis Methodology EHEST Conference 13 October 2008 Cascais, Portugal

2. The Safety Analysis Methodology 2 Contents Introduction on Approach and Scope of the analysis Analysis Methodology Example

3. The Safety Analysis Methodology 3 General Process Review occurrences Develop Safety Action Plans Implement Safety Action Plans Monitors

4. The Safety Analysis Methodology 4 General Process Review occurrences Develop Safety Action Plans Implement Safety Action Plans Monitors Safety Analysis Team (this presentation)

5. The Safety Analysis Methodology 5 Maintain international compatibility Reviewing accidents using a standard method adapted by IHST from CAST (US Commercial Aviation Safety Team) Format allows comparison with data from the US and other regions Approach

6. The Safety Analysis Methodology 6 Scope of analysis Based on a data driven approach Focus on: Accidents (definition ICAO Annex 13) Date of occurrence year 2000 - 2005 State of occurrence located in Europe For this purpose Europe is defined as the EASA Member States (27 EU + plus Iceland, Liechtenstein, Norway and Switzerland) Only those accidents are being analysed where a final report from Accident Investigation Board is available

7. The Safety Analysis Methodology 7 Analysis Methodology 1. Collect general occurrence information from accident report 4. Produce Intervention Recommendations (IR) 3. Assign standard codes to factors Standard Problem Statements (SPS) from IHST taxonomy and HFACS 2. Describe and analyse the accident Identify events (what happened) and factors (why it happened) in free text

8. The Safety Analysis Methodology 8 Process manual and tool

9. The Safety Analysis Methodology 9 1. Collect general occurrence information From accident reports Includes: Occurrence Date and State of Occurrence Aircraft Registration and Aircraft Type Type of Operation Aircraft Damage and Injury Level Phase of Flight Meteorological Conditions Pilot and co-pilot flight experience Etc.

10. The Safety Analysis Methodology 10 Accidents are broken down into an event sequence The method requires describing, in free text: What happened (events and conditions) Why these happened (factors) The analysis uses the expertise and experience of the regional teams 2. Describe and analyse the accident

11. The Safety Analysis Methodology 11 Three models used to assign codes 1. Standard Problem Statements from IHST taxonomy And additionally, for a more thorough description of human factors 2. Human Factors Analysis and Classification System (HFACS) by Wiegmann and Shappell, US DoT, February 2001 3. HFACS Maintenance Extension by US Naval Aviation 3. Assign standard codes to factors

12. The Safety Analysis Methodology 12 Standard Problem Statements from IHST taxonomy Over 400 codes in 14 different areas 3. Assign standard codes to factors Ground dutiesPart/System Failure Safety ManagementMission Risk MaintenancePost-crash survival InfrastructureData issues Pilot judgment & actionsGround personnel CommunicationsRegulatory Pilot Situation awarenessAircraft Design

13. The Safety Analysis Methodology 13 Example Standard Problem Statements 3. Assign standard codes to factors

14. The Safety Analysis Methodology 14 HFACS by Wiegmann and Shappell Over 170 codes in 4 main areas to code human factors in detail 3. Assign standard codes to factors Organisational Influences Unsafe Supervision Preconditions for Unsafe Acts

15. The Safety Analysis Methodology 15 3. Assign standard codes to factors Unsafe Acts ErrorsViolations Routine violations Exceptional violations Decision errors Skill-Based errors Perceptual errors

16. The Safety Analysis Methodology 16 3. Assign standard codes to factors Preconditions Environmental Factors Condition of Individuals Personnel Factors

17. The Safety Analysis Methodology 17 3. Assign standard codes to factors Supervision Failure to Correct Known Problem Planned Inappropriate Operations Inadequate Supervision Supervisory Violations

18. The Safety Analysis Methodology 18 3. Assign standard codes to factors Organisational Influences Resource Management Organisational Climate Organisational Process

19. The Safety Analysis Methodology 19 Example HFACS codes 3. Assign standard codes to factors

20. The Safety Analysis Methodology 20 3. Assign standard codes to factors HFACS Maintenance Extension (HFACS ME)

21. The Safety Analysis Methodology 21 Analysis Methodology 1. Collect general occurrence information from accident report 4. Produce Intervention Recommendations (IR) 3. Assign standard codes to factors Standard Problem Statements (SPS) from IHST taxonomy and HFACS 2. Describe and analyse the accident Identify events (what happened) and factors (why it happened) in free text

22. The Safety Analysis Methodology 22 For every coded factor one or several Intervention Recommendations can be suggested AIB recommendations are included Will be used at a later stage by the implementation team to generate Safety Action Plans 4. Produce Intervention Recommendations

23. The Safety Analysis Methodology 23 Assessment of confidence in factors and recommendations SPS/HFACS are scored between 0-4 on: Validity: Quality and credibility of information (documented evidence versus expert judgment) Importance: Contribution to the accident IR are scored between 0-4 on: Ability: Capability of an IR to mitigate an event Usage: Confidence that an IR will be utilised and will perform as expected Will be used at a later stage by EHSIT

24. The Safety Analysis Methodology 24 Occurrence categories Used to classify occurrences at a high level to permit analysis of the data in support of safety initiatives Future developments based on existing internationally agreed taxonomy Example:

25. The Safety Analysis Methodology 25 Analysis Example

26. The Safety Analysis Methodology 26 Thank you for your attention Questions? European Helicopter Safety Team EHEST

27. The Safety Analysis Methodology 27 ANNEX EHSAT Analysis Tool

28. The Safety Analysis Methodology 28 Process manual and tool

29. The Safety Analysis Methodology 29 HFACS SPS taxonomy Human Factors Analysis and Classification System (HFACS) D.A. Wiegmann and S.A. Shappell Process manual and tool