International Civil Aviation Organization
ADREP/ECCAIRS End-user course
Module N° 5
Encoding Occurrences (BEA)
Mexico City- 22-26 November, 2010
Overview
•
Objectives of encoding
– Structured analysis
– Thriving for more consistency
•
Coding structure
– Three levels of analysis
• Sequence of events
• Descriptive factors
• Explanatory factors
•
SHELL MODEL
– Human factors model
•
Encoding example
– Fuel starvation
•
Coding guidelines
– Coding standards for data consistency
– Common approach
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ADREP/ECCAIRS End-user Course (Rev. #3)
Objectives of encoding
• Memory of accidents
• Statistics, safety indicators
Safety Analysis (for the moment on similar accidents i.e. Mid-air
collisions, Fuel starvation, CFIT, Runway Incursions...)
Identify recurrent causal factors or patterns in accidents
Dissemination and exchange of safety data
Review of impact of safety initiatives
Support for structured analysis
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ADREP/ECCAIRS End-user Course (Rev. #3)
Analysis results
Top ten categories - accidents
1997-2005 - fixed wing, turbine powered ac/ over 5700 kg
RE: Runway excursion
ARC: Abnormal runway contact
SCF-NP: System/component failure
or malfunction [non-powerplant]
TURB: turbulence encounter
RAMP: Ground Handling
SCF-PP: powerplant failure or
malfunction
LOC-I: Loss of control - inflight
CFIT: Controlled flight into or
toward terrain
UNK: Unknown or undetermined
LOC-G: Loss of control - ground
0
50
100
150
200
250
300
350
400
Number of accidents
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ADREP/ECCAIRS End-user Course (Rev. #3)
Striving for more consistency
Production of consistent data
TRAINING
TRAINING
Exchanging
data
SOPs
SOPs
ECCAIRS 4
ADREP 2000
SAFETY CULTURE
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ADREP/ECCAIRS End-user Course (Rev. #3)
Harmonized training
Coding procedures
Same software / database
Common taxonomy
Sharing concepts
Coding structure
Event / phase
of flight
n
Descriptive factor
n
• Three levels structure
• Clear breakdown between the different elements
• Tree description for each element
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ADREP/ECCAIRS End-user Course (Rev. #3)
Explanatory
factor
Event types – level 1
Event types
Aircraft /
system / component
Aircraft operation
general
Consequential
events
Air Navigation Services
Aerodrome & ground aids
CAA
Unknown
Any other event
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Event Types – Level 2
Systems & components
Aircraft /
system / component
2100 Air cond & pressurization
2200 Autoflight sys
2300 Communication sys
2400 Electrical power sys
2500 Aircraft furnishing
2600 Fire protection sys
2700 Aircraft flight control
2800 Fuel sys
2900 Hydraulic sys
3000 Ice/rain protection sys
3100 Instruments
3200 Landing gear
3300 Aircraft lighting
Many more…….. (ATA 100)
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Event types – Level 3 & 4
3200 Landing gear
3210 Main landing gear
Partial collapse/retraction
Collapse or retraction
3220 Nose/tail landing gear)
Collapsed/retracted
3240 Wheels & brakes
3241 Tyres
3242 Brakes
Emergency brake
Parking brake
3244 Anti-skid sys
3250 Landing gear steering
3260 Gear position & warning
3270 Auxiliary landing gear
9
Sequence of events
•
Usually based on Findings
– Short reports: synopsis / history of flight
– Final report : plus analysis part
•
Events in time sequence (chronological order)
– Frequently used in analysis to determine Precursors, consequences
•
Each event is associated with a phase of flight
Event
Flight phase
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ADREP/ECCAIRS End-user Course (Rev. #3)
Descriptive factors
• Descriptive factor subject : add details to the events
• Sequence :
– Background information on weather, terrain, etc first
• These factors set the scene
– Other factors in time sequence (if that can be established)
– Otherwise use logical sequence
• Modifiers : one or several modifiers
Event
Descriptive factor
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ADREP/ECCAIRS End-user Course (Rev. #3)
Modifiers
Explanatory factors
• Organizations or persons
• SHELL model = explanatory factor subject
• One modifier
Modifier
Event
Descriptive factor
Organization /
person
Explanatory factor subject
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ADREP/ECCAIRS End-user Course (Rev. #3)
Different levels of data quality
Who, where,
when ?
What ?
n
Event / phase
of flight
Descriptive
factor
Explanatory
factor
13
Event / phase
of flight
n
How ?
Why ?
Numbers, statistics,
Safety Indicators
Occurrence
Descriptive factor
Safety studies on
accident types
(i.e. CFIT, RI..)
Analysis of patterns and
causal factors (technical)
n
Explanatory
factor
Analysis of recurrent causal
factors (human factors)
ADREP/ECCAIRS End-user Course (Rev. #3)
Human Factors included in ADREP
2000
Occurrence
n
Event / phase
of flight
Event / phase
of flight
n
Descriptive factor
subject + modifier
Human
Factors
Descriptive factor
subject + modifier
H
n
Organization
/person +
EF subject
(SHELL) +
modifier
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Organization/
person +
EF subject
(SHELL) +
modifier
S
L
L
E
SHELL, modified by Hawkins 1987
ADREP/ECCAIRS End-user Course (Rev. #3)
Shell Model
Human / machine
Hardware
Risk inherent to
human activity
Human is at the center
of Safety
Risks lay in interactions
between Human
and its context
SHELL permits to
identify factors
that weaken the
system in direct
relation with
persons and
organisms
Machines,
ergonomics,
calculators...
Human / system support
Software
Manuals,
procedures,
documentation
Human / human
Liveware
Physical,
psychological,
workload...
Liveware
Communication,
CRM…
Environment
Social,
operational
factors, ATC...
Human / environment
ADREP/ECCAIRS End-user Course (Rev. #3)
SHELL, modified by
Hawkins 1987
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SHELL model
LIVEWARE (HUMAN)HARDWARE/ SOFTWARE
INTERFACE
HARDWARE
INFORMATION
DATA SOURCES
AUTOMATION
AUTOMATIC SYSTEMS
SOFTWARE/
FIRMWARE
AUTOMATIC
PROTECTIONS/
ALARMES
COCKPIT EQUIPMENT
COCKPIT DESIGN
DATA SOURCES
FIRMWARE
AUTOMATION
DESIGN AND
FUNCTIONALITY
AIRCRAFT EQUIPMENT
OTHER THAN
COCKPIT DESIGN
COMMUNICATIONS
MEDIA
SOFTWARE
USE OF AUTOMATION
OTHER
OPERATIONAL
MATERIAL
COCKPIT WARNINGS
FLIGHT DECK MANUALS
CHECKLISTS
AND CHARTS
ATC ALARMS/ALERTS
ATC OPERATIONAL
MATERIAL
OTHER DEFENCES
WARNINGS
MAINTENANCE
ENGINEERING
MATERIAL
AIRCRAFT
MAINTENANCE
EQUIPMENT
SUITABILITY OF
DESIGN/ ERGONOMICS
FOR TRAINING
PURPOSES
OPERATIONAL
MATERIAL – OTHER
ATC EQUIPMENT
SUITABILITY OF
DESIGN FOR
MAINTENANCE
PURPOSES
LIVEWARE (HUMAN)
SYSTEM SUPPORT
INTERFACE
LIVEWARE (HUMAN)
LIVEWARE (HUMAN)
INTERFACE
LIVEWARE (HUMAN)
COMMUNICATIONS
PROCEDURES
SOPS
TRAINING
OTHER
PROCEDURES
BASIC/ INITIAL
TRAINING
EMERGENCY
AND ABNORMAL
PROCEDURES
SIMULATOR
TRAINING
ATC
PROCEDURES
ON-THE JOB
TRAINING
AERODROME
PROCEDURES
EMERGENCY
TRAINING
MAINTENANCE
PROCEDURES
CRM/ TRM
TRAINING
COMPANY
PROCEDURES
RECURRENT
TRAINING
OTHER
HUMAN - SYSTEM
SYSTEM SUPPORT
ISSUES
MISCELLANEOUS
TRAINING
ISSUES
PHYSICAL
PHYSICAL
CHARACTERISTICS
SENSORY
LIMITATIONS
OTHER
PHYSIOLOGICAL
PSYCHOLOGICAL
WORKLOAD
MANAGEMENT
HEALTH
FITNESS
LIFESTYLE
ACTION
ERROR
JUDGEMENT
ILLNESS
INCAPACITATION
PLANNING
KNOWLEDGE
ACQUISITION
LEARNING
ILLUSIONS
FATIGUE
ALERTNESS
OTHER
INFORMATION
PROCESSING
DECISION MAKING
SITUATIONAL
AWARENESS
ATTENTION
PERCEPTION
MONITORING
PERSONALITY
AND ATTITUDES
SKILL
TECHNIQUE
ABILITY
MENTAL
EMOTIONAL STATE
EXPERIENCE
QUALIFICATIONS
RECENCY
AND KNOWLEDGE
PRIORITIZATION
TASK SCHEDULING
EXPERIENCE
AND QUALIFICATIONS
TIMING
RECENCY
TASK SHEDDING
INTERACTIONS
TEAM SKILLS
CRM/TRM
SUPERVISION
ORAL
COMMUNICATIONS
TEAM SKILLS/ CRM
OPERATIONAL
SUPERVISION
WRITE
READ
COMMUNICATIONS
FORMAL
COORDINATION
SUPERVISION
DURING TRAINING
VISUAL SIGNALS
SHIFT/ WATCH
TEAM CHANGEOVER
QUALITY CONTROL
OTHER
INTERACTIONS
STANDARDS
REGULATORY ACTIVITIES
OTHER
HUMAN HUMAN
INTERFACE
REGULATORY
PROCEDURES
MONITORING
(REGULATION)
REGULATORY
STANDARDS
SURVEILLANCE
REGULATION
AUDIT
INSPECTIONS
CHECKS
KNOWLEDGE
TASK ALLOCATION
OTHER
WORKLOAD MANAGEMENT
LIVEWARE (HUMAN)
ENVIRONMENT INTERFACE
PHYSICAL ENVIRONMENT
PSYCHOSOCIAL
AERODROME
LANDING
TAKEOFF SITE
AIR TRAFFIC
SERVICE
JOB SATISFACTION
INFORMATION
WEATHER
VISUAL
CONDITIONS
MORALE/MOTIVATION
WORKSPACE
ENVIRONMENT
OTHER
HUMAN-ENVIRONMENT
INTERFACE
CULTURAL ISSUES
COMPANY
MANAGEMENT
MANNING
REGULATORY ISSUES
OPERATIONAL
TASK DEMANDS
PRESSURES
LABOUR RELATIONS
HIGH WORKLOAD
TIME PRESSURES
MANAGEMENT
PERSONNEL POLICIES
MANNING
OPERATIONAL
MENTAL PRESSURE
TRAINING
EXAMINATION
CHECK SITUATION
REGULATORY
AUTHORITY
POLICIES
AND PRACTICES
MISCELLANEOUS
OPERATIONAL
TASK DEMANDS
DOMESTIC ISSUES
OTHER
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Fuel starvation example 1/2
Occurrence class
Occurrence category = FUEL
Accident
Fuel starvation
/ cruise
Event
Descriptive factor
Explanatory factor
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Preflight check /
incomplete
Pilot / time
pressure
Fuel gauges /
breakdown
Pilot / stress
ADREP/ECCAIRS End-user Course (Rev. #3)
Emergency
landing
Fuel starvation example 2/2
In ECCAIRS, use mouse right click to add, edit or remove items.
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ADREP/ECCAIRS End-user Course (Rev. #3)
In practice with ECCAIRS
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ADREP/ECCAIRS End-user Course (Rev. #3)
What about data consistency ?
Investigator B
Investigator A
=
?
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ADREP/ECCAIRS End-user Course (Rev. #3)
Coding standards
• Permit analysis of data from different sources
– Different Investigators, States, Providers
• Comparability of data
– Use of common definitions
• Same term – same meaning
– Use of common collection standards
• Same occurrence category – same set of data
• Ensure consistent data collection
–
–
–
–
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Adoption of harmonized procedures
Define which differences are acceptable and which are not
Think about the use of databases to issue safety indicators
Mutual support and training (for instance, Human Factors)
ADREP/ECCAIRS End-user Course (Rev. #3)
Common approach - general
• Only code what has been established or reported
– do not guess
– do not over-interpret
• Be as detailed as possible : if the nose gear
collapsed, enter type “nose gear collapse” and not
“landing gear related event”
• …but if desired detail not at hand or do not fit the
circumstances, use data at higher level instead
• Fast way to navigate using filter
– but it may have insidious effects : always check items
within the same level
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ADREP/ECCAIRS End-user Course (Rev. #3)
Common approach – events & phases
• Properly identify issues involved
Example: If there was a spurious fire warning in an engine, enter fire warning system related event. If there was, however a fire,
enter “fire” as event type as well as the related system
• Consequential events must not be the first event in the
sequence. Enter that ”something” as first event
• Check the related phase of flight
Example: After a “loss of control” the aircraft usually enters an “uncontrolled descent” flight phase. This would be the applicable
phase for any collision with the terrain
• Aerodrome or ATC events have no corresponding flight
phase except if they directly relate to the operation of an
aircraft
• Link events to the entity to which they relate (aircraft for
instance)
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ADREP/ECCAIRS End-user Course (Rev. #3)
Common approach – factors
• In terms of systems involved, only provide
information on what went wrong, where there was
a problem or an issue
– “Positive factors” will be included later
• Code the descriptive factors under the first event
where they appear. Do not repeat them for
subsequent events
• Do not code potential or non-contributory factors
in the sequence of events. Use the appropriate
section “Potential factors and safety issues”
It can be found under Events
or Recommendations topics
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ADREP/ECCAIRS End-user Course (Rev. #3)
Taxonomy enhancement
• Regular updates necessary
– ADREP 2000 revision 2008
• More event details for aerodrome and maintenance occurrences
• Bird strike data
• Dangerous goods data
• Update aircraft categories and phases of flight
• Update safety recommendations section
• Standardisation of text and reduce number of abbreviations
• Update aircraft, operator and location indicator list
• Update of events and modifier lists
• …
– Will be available in next ECCAIRS release 5
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ADREP/ECCAIRS End-user Course (Rev. #3)
Summary
• Advantages of tree description
– Clear breakdown between events, descriptive factors and explanatory
factors
– Identification of interfaces where problems occurred (SHELL)
• ICAO standard
– Aggregation of results and know-how of worldwide investigations
– Based on agreed definitions
– Common safety concepts
• Language independent
– Avoid spelling errors
– Facilitate understanding
– Allow data exchange
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ADREP/ECCAIRS End-user Course (Rev. #3)
Module N° 5
Encoding Occurrences (BEA)
ADREP/ECCAIRS End-user Course (Rev. #3)
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