Transcript IRM-TEM-BOW-TIE-Presentation-Template

Incident Review Meeting
[insert title of event]
Incident Review Meeting
1
Latent Conditions
 [insert conditions present in the system before the
accident, made evident by triggering factors]
Incident Review Meeting
2
Threats
 [List the Threats that were realized in the triggering event
or events]
Incident Review Meeting
3
Preventive Defenses
 What are the specific mechanisms that should have helped prevent
the undesired aircraft state?
 Which of these defenses/barriers failed?
 Why? What caused the these defenses/barriers to fail?
Incident Review Meeting
4
Undesired Aircraft States (UAS)
 [Describe the Undesired Aircraft State]
Incident Review Meeting
5
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?
Incident Review Meeting
6
End States
 [insert End States]
Incident Review Meeting
7
Safety Enhancements
 What was learned from this occurrence?
 What changes have been or should be made at your
airline and in industry?
Incident Review Meeting
8
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?
Incident Review Meeting
9
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?
Incident Review Meeting
10
Incident Review Meeting
11