International Civil Aviation Organization
ADREP/ECCAIRS End-user course
Module N° 7
Analysis and Codification
Mexico City- 22-26 November, 2010
Striving for more consistency
Production of consistent data
BFU
Exchanging
data
TRAINING
SOPs
ECCAIRS 4
ICAO
ADREP 2000
Safety Culture
ADREP/ECCAIRS End-user Course (Rev. #3)
Harmonized training
Encoding procedures?
Same database
Common taxonomy
Sharing concepts
2
Investigating, encoding and analyzing in
ADREP
Who, where, when ?
Occurrence
Statistics
n
What ?
Event / phase
of flight
Event / phase
of flight
Analyses on occurrence
categories (CFIT, RI, etc.)
How ?
Descriptive
factor
Descriptive
factor
Analyses on
symptoms
WHY ?
Explanatory
factor
Explanatory
factor
ADREP/ECCAIRS End-user Course (Rev. #3)
Analyses on
causes (HF)
3
Four levels of data quality
(1) Who, where, when ?
Occurrence
Statistics
n
(2) What ?
Event / phase
of flight
Event / phase
of flight
Analyses on occurrence
categories (CFIT, RI, etc.)
(3) How ?
Descriptive
factor
Descriptive
factor
Analyses on
symptoms
(4) WHY ?
Explanatory
factor
Explanatory
factor
ADREP/ECCAIRS End-user Course (Rev. #3)
Analyses on
causes (HF)
4
Summary: What tool and what type of
data?
Scale of
Data Quality
Complete initial factual information with
data entry procedures and electronic
tools.
Complete analyzed
information with encoding
methodology
Why ?
4
Analyses on
causes (HF)
How ?
3
Analyses on
Symptoms
What ?
2
Safety studies
on occurrence
categories
Who, where,
when ? 1
Statistics,
trends
Inc1 Inc2 Inc3 … Inc n Acc1 Acc2 ... S-Inc1 Inc n+1 …
Content of a database
Initial data
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Proposed methodology* for encoding
events and factors
• Based on current general way of writing investigation reports (nothing
revolutionary)
• Most of the analysis reflect a sequence of events associated with phase of
flight (ICAO causal approach)
Accident
Latent failures
Active failure(s)
 The codification should reflect the report analysis where causal factors are
discussed
* cf. Application of ADREP 2000 taxonomy for the analysis and the encoding of aviation
accidents and incidents: a human factors approach, Human Factors and Aerospace Safety
4(1), 19-48, 2004, Ashgate Publishing
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Process of Analysis/Encoding
1) Sequence of events
2) Encoding version “0”
Events/phase of flight
descriptive factors
3) Explanatory factors
(SHELL)
4) Table linking factors
to factual elements
5) Drafting Analysis in line
with codification
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Application of the methodology
Example: loss of control accident
on 6 March 2003 at Tamanrasset
Report released in September 2004
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Accident at Tamanrasset on 6
March 2003
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Synopsis
Date and time
Aircraft
Thursday 6 March 2003
at 14 h 15 UTC
Boeing 737-200
registered 7T-VEZ
Site of accident
Owner
Tamanrasset Aguenar
aerodrome
Air Algérie
Operator
Type of flight
Air Algérie
Public transport of passengers
Scheduled domestic flight
DAH6289
Tamanrasset - Ghardaïa Algiers
Persons on board
• 97 passengers
• 2 Flight crew
• 4 Cabin crew
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1) Sequence of events
wreckage radiocoms witness statements
Events
CVR
FDR
Radar/GPS…
Accident
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2) Encoding version « 0 »
• Events, phases of flight
• Descriptive factors, modifiers
Example:
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3) Explanatory factors
Human / machine
Identification of explanatory
factors using SHELL
Hardware
Machines,
ergonomics,
calculators...
Human / system support
Software
Manuals,
procedures,
documentation
Human / human
Liveware
Physical,
psychological,
workload...
Liveware
Communication,
CRM…
Environment
Social,
operational factors,
ATC...
SHELL, modified by Hawkins 1987
Human / environment
ADREP/ECCAIRS End-user Course (Rev. #3)
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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
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
LIVEWARE (HUMAN)
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
PRIORITIZATION
TASK SCHEDULING
EXPERIENCE
AND QUALIFICATIONS
TIMING
RECENCY
TASK SHEDDING
SITUATIONAL
AWARENESS
ATTENTION
PERCEPTION
MONITORING
PERSONALITY
AND ATTITUDES
SKILL
TECHNIQUE
ABILITY
MENTAL
EMOTIONAL STATE
LIVEWARE (HUMAN)
LIVEWARE (HUMAN)
INTERFACE
EXPERIENCE
QUALIFICATIONS
RECENCY
AND KNOWLEDGE
COMMUNICATIONS
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
DOMESTIC ISSUES
OTHER
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
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
4) Table linking chosen factors to
factual elements of the investigation
Event, phase of flight
Descriptive factors
Explanatory factors
Flight preparation related
event during standing
Pre-flight preparation:
missing, not monitored
Factual elements justifying the
codification
The chosen modifiers describe the absence of
pre-flight checks and the fact that the Captain
was not in the cockpit at that time (CVR data)
Flight crew : Psychological
distraction (L)
Copilot prepares the flight alone; discussions
and interruptions in the cockpit
Flight crew : pre-flight planning
: underestimated (L)
It seems to them that it was a normal (routine)
situation (result of deviations)
Flight crew related event
during taxiing to runway
Flight crew’s interpretation of
SOPs not observed
Elements from the CVR
…
ADREP/ECCAIRS End-user Course (Rev. #3)
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5) Drafting the report analysis based on the
codification
• Complete codification :
•
•
Scenario : failures in action
Second part : systemic issues
ADREP/ECCAIRS End-user Course (Rev. #3)
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Process of Analysis/Encoding
1) Sequence of events
2) Encoding version “0”
Events/phase of flight
descriptive factors
– Iterative
– Based on
teamwork
– Illustrates the
depth of the
investigation
3) Explanatory factors
(SHELL)
4) Table linking factors
to factual elements
5) Drafting Analysis in line
with codification
ADREP/ECCAIRS End-user Course (Rev. #3)
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Feedback for training
B737 Engine Failure After Take-off
[…]
« Among the lessons learnt from this report are the importance of
pre-flight briefings and formalised hand-over/takeover procedures.
The report is of particular relevance given our recent formalisation
of the Engine Fire, Failure, Malfunction Procedures. »
[…]
Qantas Safety , Flight Ops Newsletter, Vol 4. No 6 December 2004
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Pros of using a method based on
ADREP 2000
•
ICAO standard (aggregation of results and know-how of
worldwide investigations)
– From 88 causes (ADREP 76) to 552 (ADREP 2000)
– Standardized and structured support
•
Convincing and tangible analysis tool for multi-national
investigation teams
– Taxonomy = same safety concepts, keywords i.e. language
– Clear breakdown between events and explanatory factors
•
Facilitates deeper and more systemic investigations
•
Provides human factors data for future safety analysis
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Module N° 7
Analysis and Codification
ADREP/ECCAIRS End-user Course (Rev. #3)
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