Transcript AVIATION SAFETY ENABLERS - COSCAP-NA

ICAO ADREP
2007
Focus on Incident reporting
Jarmo Korhonen
AIG Section
Air Navigation Bureau
Overview
Vision
 ADREP
 SMS
 ICAO Annex 13 Reporting
 ECCAIRS
 Benefits of using an ADREP compatible
system
 Road Map

ADREP ECCAIRS 2007, slide 2
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
ADREP ECCAIRS 2007, slide 3
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. . . . .
ADREP ECCAIRS 2007, slide 4
Vision

To provide access to safety data and
information required to meet and monitor
levels of safety
ADREP ECCAIRS 2007, slide 5
How to Achieve This
Integrated Systems
 Compatible Taxonomies

ADREP ECCAIRS safety management tool
ADREP ECCAIRS 2007, slide 6
ADREP
A System for Providing Feedback of Safety
Lessons Learned:
From States to ICAO
and
From ICAO back to States
ADREP ECCAIRS 2007, slide 7
ADREP Taxonomy

Effective analysis of ADREP data



Definitions, Taxonomies, etc.
ECCAIRS common frame work
Safety indicators


Categorisation of accidents
Identification and dissemination of safety
issues
ADREP ECCAIRS 2007, slide 8
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

35 892 Occurrences (07 NOV 07)
ADREP ECCAIRS 2007, slide 9
Safety Programme (States)
- An integrated set of regulations and
activities aimed at improving safety
Safety Management System
- A systematic approach to managing s
afety, including the necessary organizat
ional structures, accountabilities, polici
es and procedures
ADREP ECCAIRS 2007, slide 10
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
ADREP ECCAIRS 2007, slide 11
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
ADREP ECCAIRS 2007, slide 12
Aviation Safety Pyramid
ACCIDENTS
SERIOUS INCIDENTS
1
15
INCIDENTS
300
OTHER SAFETY RELATED
OCCURRENCES / HAZARDS
3000
ADREP ECCAIRS 2007, slide 13
ADREP ECCAIRS 2007, slide 14
ADREP Reporting Requirements
Annex 13 – Chapter 7



States investigate and report to ICAO:

Accidents to aircraft over 2 250 kg (para.7.1, 7.5)

Investigated incidents to aircraft over 5 700 kg (para.
7.7)
Means of reporting:

Reporting forms,

Electronic reporting
Guidance: Accident Incident Reporting Manual
ADREP ECCAIRS 2007, slide 15
ICAO Reporting standard for States
Annex 13 - Chapter 7, Attachment B
Initial Notification
 Preliminary Report
 Data Report
 Final Report

ADREP ECCAIRS 2007, slide 16
ADREP REPORTING
Accident/Incident Reporting to
ICAO
Initial
Notification
Occurrence
Data
entry
Prelim
Data
Final
report
report
report
Investigation
Data
ADREP ECCAIRS 2007, slide 17
Analysis
Global Reporting Culture
Percentage of Open Files
60%
50%
40%
30%
~30%
20%
10%
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
0%
10%
ADREP ECCAIRS 2007, slide 18
Global Reporting Culture
58 States
notify ICAO
between 25
and 75% of
the time
51 States notify
ICAO more than
75% of the time
ADREP ECCAIRS 2007, slide 19
58 States
notify
ICAO less
than 25%
of the time
Accident Prevention Measures
Annex 13 - Chapter 8
Incident reporting system
 A State shall establish an accident and
incident reporting systems (8.1 & 8.2)
ADREP ECCAIRS 2007, slide 20
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)
ADREP ECCAIRS 2007, slide 21
Reporting flow
AIB
State
Data Base
ICAO
ADREP using ECCAIRS
database software
CAA
State
ADREP ECCAIRS 2007, slide 22
Regional Body
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)
ADREP ECCAIRS 2007, slide 23
Example
AVIATION
SAFETY
OFFICER
Queries and Reports
ECCAIRS
DATABASE
DATAFORMAT
FILE
EDF
BROWSER
ADREP ECCAIRS 2007, slide 24
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)
ADREP ECCAIRS 2007, slide 25
Service Providers
ATNS, Aerodromes,
Air Operators
Contracting States
RO
ICAO
Reporting to ICAO as per Annex 13 provisions
ADREP ECCAIRS 2007, slide 26
ECCAIRS view
Not reported to ICAO = Media Source
ADREP ECCAIRS 2007, slide 27
Level of practical usage
Hazard
NEW
ADREP ECCAIRS 2007, slide 28
Occurrence = sequence of events
ADREP ECCAIRS 2007, slide 29
Example of Output
ADREP ECCAIRS 2007, slide 30
Distribution of Type of
Occurrence
2002-2006
Accidents
Serious Incidents
Incidents
1997-2001
0
500
ADREP ECCAIRS 2007, slide 31
1000
1500
2000 2500
3000
Distribution of Type of
Occurrence
400
350
300
250
SI
200
ACC
150
100
50
ADREP ECCAIRS 2007, slide 32
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
0
Regional Distribution (% to total Fatal
Accidents) by
major Occurrence Categories for 2002-2006
12.3%
10.4%
17.0%
9.1%
9.1%
18.2%
3.8%
7.6%
WORLD
18.2%
18.2%
5.9%
9.1%
5.6%
LA
11.8%
16.7%
27.3%
9.1%
11.8%
11.1%
5.6%
15.0%
5.0%
30.0%
17.2%
13.8%
5.0%
3.4%
6.9%
3.4%
6.9%
3.4%
SCF-PP
ADREP ECCAIRS 2007, slide 33
CFIT
EUR
AP
22.2%
5.0%
LOC-I
NA
ME
5.9%
20.7%
7.6%
9.1%
9.1%
29.4%
10.0%
2.8%
9.1%
5.9%
16.7%
12.3%
F-POST
ADRM
RE
EVAC
SCF-NP
AFR
Probability (%) of Accident rate exceeding
twice the mean accident rate
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
-10.0%
Probability
(%) Accident
rate
Departure
share
AF
AP
ADREP ECCAIRS 2007, slide 34
EU
LA
ME
NA
Reactive versus Proactive Safety
ADREP ECCAIRS 2007, slide 35
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

ADREP ECCAIRS 2007, slide 36
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
ADREP ECCAIRS 2007, slide 37
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
ADREP ECCAIRS 2007, slide 38
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
ADREP ECCAIRS 2007, slide 39
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
ADREP ECCAIRS 2007, slide 40
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)
ADREP ECCAIRS 2007, slide 41
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)
ADREP ECCAIRS 2007, slide 42
Aviation Safety System
Safety Policy
 Safety Information and Reporting



mandatory & voluntary reporting
ADREP
Accident Prevention Programme
 Investigation of incidents and accidents
 Education and training

ADREP ECCAIRS 2007, slide 43
ADREP ECCAIRS 2007, slide 44
Questions?
ADREP ECCAIRS 2007, slide 45
THANK YOU
ADREP ECCAIRS 2007, slide 46