Example The next slides are an example of how to complete the template and identify latent conditions, threats, errors, UAS and crew.
Download ReportTranscript Example The next slides are an example of how to complete the template and identify latent conditions, threats, errors, UAS and crew.
Example
The next slides are an example of how to complete the template and identify latent conditions, threats, errors, UAS and crew actions from a typical narrative Latent Conditions are in
green
Threats are in
orange
Errors are in
red
UAS are in
purple
Extra slides or content (e.g. Jepp charts, animations, airport diagrams, etc…) can be added
1
Incident Review Meeting
Incident Review Meeting Presentation Template with Example
2
Incident Review Meeting
Narrative
XYZ Airways Flight 000 (AAA to BBB) took off from AAA at 19:00 in fair weather. Approximately 10 minutes after takeoff,
the No.2 engine lost oil pressure and failed
, and the crew decided to return to AAA immediately. The aircraft also experienced minor
problems with the compass and pressurization
. The crew were distracted by these problems and by an
incorrectly set radio
. This rushed approach resulted in the aircraft being
low on the instrument approach
and
off-course on the ILS
. The crew decided to perform a go-around. The aircraft was
below Vref and at a low altitude
. One minute later, the aircraft crashed killing all but one of the 36 passengers and crew onboard. The accident happened in
darkness
. This was the
5 th sector for the crew that day.
3
Incident Review Meeting
Supporting Information
Please add whatever additional supporting information or materials (charts, animations, pictures, etc…) that would help explain the event.
Incident Review Meeting
4
Latent Conditions
Conditions present in the system before the accident, made evident by triggering factors Fatigue Incident Review Meeting
5
Threats
Factors external to the flight deck that increase the complexity of flight operations and which are realised through a triggering event Technical Engine Failure Compass Pressurisation problems Darkness
6
Incident Review Meeting
Preventive Defenses
What are the specific mechanisms that should have helped
prevent
the undesired aircraft state?
Which of these defenses/barriers failed?
Flight Crew mis-selection of the radio Stable Approach Criteria Horizontal and Vertical Approach path management Energy/Speed management Late decision to go around Why? What caused the these defenses/barriers to fail? Training not applied Standard & Non-normal Operating Procedures non-adherence Poor CRM Incident Review Meeting
7
Undesired Aircraft States (UAS)
Unstable approach Off track Below profile Below Vref Low altitude Incident Review Meeting
8
Recovery Defenses
List the Recovery Defenses that either prevented or failed to prevent the Accident or Incident from occurring The crew (PF & PM) recognition of unstable criteria as well as lateral and vertical parameter deviation - an early go-around Response to EGPWS Manual handling Which of these failed? – ALL Why? What caused these to fail?
A desire to complete the approach due to non-normal configuration Possible expectation bias from simulator training De-skilling due to automation Incident Review Meeting
9
End States
The aircraft stalled and crashed killing all but one of the 36 passengers and crew onboard Incident Review Meeting
10
Safety Enhancements
What was learned from this occurrence?
There is an enhanced degree of get-home-itis in a failure state The major failure was complicated by lesser failures and distractions Simulator training focuses on system failures rather than distraction management and CRM Manual aircraft handling in non-normal configuration inadequate What changes have been or should be made at your airline and in industry?
More complex failure scenarios including CRM in simulator Additional simulator training to maintain manual flying skills
11
Incident Review Meeting
Lessons Learned for IRM
(Note: this slide will be shared with all IRM attendees)
What should attendees at IRM learn from this occurrence ?
The breakdown in CRM and SOP under intense workload and with multiple distractions The latent loss of manual flying skills not evident under normal circumstances What should attendees at IRM consider changing at their own airline?
Adapt training to address the above points Introduction of FRMS
12
Incident Review Meeting
Key Message for Safety Group
(Note: this slide will be shared with all IRM attendees)
What are the key messages that Safety Group should act on?
The loss of manual flying skills may now be an industry wide latent failure The need for the highest standards of CRM in workload and distraction management in simulator training The importance of FRMS in identifying latent fatigue risk Incident Review Meeting
13
Incident Review Meeting
14