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

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Incident Review Meeting

Incident Review Meeting Presentation Template with Example

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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.

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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

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Latent Conditions

 Conditions present in the system before the accident, made evident by triggering factors  Fatigue Incident Review Meeting

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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

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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

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Undesired Aircraft States (UAS)

     Unstable approach Off track Below profile Below Vref Low altitude Incident Review Meeting

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

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

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End States

 The aircraft stalled and crashed killing all but one of the 36 passengers and crew onboard Incident Review Meeting

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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

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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

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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

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Incident Review Meeting

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