Incident Review Meeting Guidance Material & Presentation Template

1. Incident Review Meeting Guidance Material & Presentation Template

2. Introduction to the Template • This template allows Safety Managers to analyze events using the TEM framework in conjunction with the Bow Tie Model • The TEM framework helps to underline the classification system used by IATA to determine contributing factors, in incidents and accidents • These factors can be viewed as Threats, failed Preventive Defenses (including Error Management) resulting in Undesired Aircraft States • The Undesired Aircraft States is then managed through Recovery Defenses (including Undesired Aircraft State Management) to prevent or not prevent the Accident or Incident • An example is provided to illustrate the steps that can be followed to analyze events in this manner • IRM speakers are reminded that: • this is not intended to be a complete Bow Tie Analysis • this format is optional

3. IRM presenters are asked to ensure they clearly define: • Safety enhancements • What was learned? What was changed? • Lessons learned for IRM attendees • What should attendees consider checking and/or changing at their own operation? • Key messages for Safety Group • What should the Safety Group act on?

4. The IRM presentations are an integral part of IATA’s and the Safety Group’s hazard identification process • All presentations are welcome, even short ones • Presentations must have take aways for IRM attendees and Safety Group

6. Latent Conditions • Conditions present in the system before the accident, made evident by triggering factors

7. Latent Conditions: Examples • Deficiencies in: • Design factors • Safety management • Training • Standard Operating Procedures • Selection systems • Etc.

8. Threats • Factors external to the flight deck that increase the complexity of flight operations and which are realized through a triggering event

9. Passengerevents Distractions ATC errors Flight/Cabin Crew errors Terrain Weather Similar call signs Maintenance errors Time pressures Ground crew errors Flight diversions System malfunctions Heavy traffic Unfamiliar airports Missed approaches Automation events Threats: Examples

10. Bow Tie Model END STATES ACCIDENT/INCIDENT Preventive DEFENSES RECOVERY DEFENSES ASR, GHR, Ext… Altitude Deviation Unstabilized Approach Runway Incursion, Unsecured Loading ATC Comm. Loss, etc.

11. Threats • List the Threats that were realized in the triggering event or events

12. Preventive Defenses • What are the specific mechanisms that should have helped prevent the undesired aircraft state? • Examples: policies, procedures, training • Which of these defenses/barriers failed? • Why? What caused the these defenses/barriers to fail?

13. UAS: Examples • Aircraft Handling: • Lateral, vertical or speed deviation • Operation Outside Aircraft Limitations • Unstable approach • Ground Navigation: • Runway / taxiway incursion • Proceeding towards wrong taxiway / runway • Wrong hold spot • Incorrect aircraft configurations • Systems • Landing gear • Flight controls

14. Undesired Aircraft States (UAS) • Describe the Undesired Aircraft State

15. Recovery Defenses • List the Recovery Defenses that either prevented or failed to prevent the Accident or Incident from occurring • Explain the specific mechanisms which should have helped recover from the unsafe event? • Which of these failed? • Why? What caused these to fail?

16. End States • End States are reportable events: • Incidents • Accidents • Tailstrike • Undershoot • Hard Landing • Etc…

17. Safety Enhancements • What was learned from this occurrence? • What changes have been or should be made at your airline and in industry? • Procedures, Policies • Training • Equipment • ATC • Airport • Weather Information etc….

18. Lessons Learned for IRM(Note: this slide will be shared with all IRM attendees) • What should attendees at IRM learn from this occurrence? • What should attendees at IRM consider changing at their own airline?

19. Key Messages for Safety Group(Note: this slide will be shared with all IRM attendees) • What are the key messages that Safety Group should act on?

20. Usage Notes for IRM Template • When discussing crew actions management, describe only observable facts, and avoid judgments. Value statements such as “minor”, ”poor” or “very” attached to the description of crew actions should be avoided. • When discussing undesired states management, describe only observable facts, and avoid judgments. Value statements such as “minor”, ”poor” or “very” attached to the description of crew actions related to undesired states management should be avoided.