AV11: Operations Safety Investigations Flashcards
Occurence
Any event which is irregular, unplanned, or nonroutine in nature, including and accident, incident, or other occurence which involves aircraft, NAV CANADA employees or facilities, or any FSS system deficiency.
What are the five types of occurences?
Accident Aircraft incident Aircraft occurence Operating irregularity Other qualifying events
Accident
An occurence associated with the operation of an aircraft, manned or unmanned, in which a person is fatally or seriously injured, the aircraft sustains damage or structural failure, or the aircraft is missing or completely inaccessible
Aircraft incident
An event or sequence of events that may endanger human lives or compromise the safety of the AC
Aircraft occurence
Any deviation from the CARs associated with the operation of an AC
ATS Operating Irregularity
A situation that occurs when ATS are being provided and when a preliminary investigation indicates that a hazardous situation or a loss of separation may have occured.
Non-ATS Operating Irregularity
A situation that occurs when ATS are being provided and when a preliminary investigation indicates that a hazardous situation or loss of separation may have occurred where it was determined that ATS had not contributed to the outcome.
Other reportable occurences
Any other event outlined in the CADORS manual or that otherwise qualifies as irregular or non-routine.
Runway incursion
Any occurrence at an airport involving the unauthorized or unplanned presence or an aircraft, vehicle, or person on the protected area of a surface designated for aircraft landings and departures.
AOR
Aviation Occurrence Report: A form to be filled out when any occurrence takes place.
Once an AOR has been completed, what must be done?
It must be recorded in the unit log that ACC or NOC has been informed of the occurence.
For FSS units, which occurrences must be submitted to the ACC (vs all others, which are submitted to NOC)
ELT reports
ATS OIs
Non ATS OIs
What must be completed when wake turbulence has been encountered?
Both an AOR and a Wake Vortex Encounter Report.
ATS-OI Report Form
A report that is completed after an AOR has been filed. is used to supplement the information in the AOR. Cannot be used in cases of discipline; is solely used to support the safety investigation.
What are the two sections of the ATS-OI Report Form?
Section A-Data
Section B-Sleep/awake form
OCR
Operational Condition Report: Used to report on any item or subject that, in your judgement, impedes the achievement of operational effectiveness.
Which specific items are OCRs not to be used to report?
Grievances
Ideas that have already been given full consideration
Replace Unsatisfactory condition report for reporting automated system deficiencies
EMI Report
Electromagnetic Interference Report: Used to report EMI ground based electronics equipment or pilot reports of interference with airborne electronic equipment. Must be kept in the unit operational record for a year.
EMI
The impairment of the reception of a wanted electromagnetic signal caused by an unwanted electromagnetic signal.
ARGUS
NAV CANADA’s confidential reporting program that allows employees to report concerns about latent safety hazards.
SECURITAS
The Transportation Safety Board’s confidential reporting program which allows anyone to report potentially unsafe acts or conditions relating to the Canadian transportation system that would not normally be reported through other channels.
OSI
Operational Safety Investigation: conducted solely for the purpose of advancing safety. OSIs are essential to ensure the integrity of the air navigation system and reduce the possibility of occurrences being repeated. There are two levels: OSI 1 and OSI 2.
Preliminary investigation
To find out if an OI has occured.
What are the manager’s responsibilities when an OSI occurs?
Te remove personnel from position(if necessary) and notify them in writing
Conduct a preliminary investigation
If OI: collect, retain, and secure all pertinent date and initiate the appropriate reporting process.
CISM
Critical Incident Stress Management: Learning to deal with and talking with peers about any incident that has sufficient emotional power to cause an employee a strong and overwhelming reaction.
What are the two types of investigations?
Operational Safety Investigation
Safety Investigation
OSI process
- Gather, preserve, and examine all of the facts
- Document all pertinent findings
- Identify the errors
- Determine and describe the outcome
- Publish a report to assist in preventing reoccurrence.
Post OSI procedures
ATS evaluations and investigations will:
- Prepare the final report
- Prepare correspondence for manager’s signature
- Dispatch the report
- Prepare and retain a ‘working file’ for all typed and hand written correspondence
- File and maintain all OSI records
How long does the manager have after receiving an OSI report to complete the OSI follow up form?
21 days
PETE factors
Factors which negatively contributed to the performance of employees directly involved in an occurrence.
Right of review
An employee is allowed to read the final report from an OSI and request, in writing, a right of review within two weeks of the opportunity to read. After review, this may result in a revised OSI report.
Human factors trend analysis
Published twice a year, this document includes conclusions from OSIs. Documents what factors make people behave in a certain manner.
The GEMS Model
Generic Error Modeling System. The point of an investigation is not to find out where people went wrong, it is to understand why their assessments and decisions made sense at the time.
Skill based performance
Characterized by routine, highly practiced tasks that are carried out fairly automatically with the occasional conscious check on progress.
Slip
An unintentional action where the failure involves attention.
Lapse
An unintentional action where the failure involves memory.
Perceptual slip/lapse
Where a person misrecognizes an object, sound, or situation, in large part because of expectation or habit.
Rule-based performance
Characterized by situations that are familiar and which require some conscious evaluation. Occur when attempting to solve a familiar or trained-for problem.
What are the two types of rule-based performance mistakes?
Misidentifying the situation and misidentifying the solution.
Misidentifying the situation
When the person does not recognize the counter-indications and misapplies otherwise good rules.
Misidentifying the solution
When the person correctly identifies the situation, but does not apply the correct solution. Commonly occurs when a general rule does not work for a specific situation
Knowledge-based performance
Characterized by novel or atypical problem situations for which people have no ready-made solutions.
Adaptations
Deliberate deviations from established rules and procedures not intended to commit a malevolent act.
Short-cuts
Adaptations that people make because they follow the path of least resistance.
Workarounds
Adaptations that people make to get the job done because if they actually followed the rules they would not be able to do their jobs efficiently.
The PETE model
Person Equipment Task Environment. The main source of human factors information, considering all elements and how they would influence the specialist.
What are the key attributes of the PETE model?
- Systems approach
- User-centered design philosophy
- Task based
Defence barriers
Procedures or actions that limited or mitigates the effect of the occurrence
