icao adrep 2007

ICAO ADREP2007

ICAO ADREP2007

Focus on Incident reporting

Jarmo Korhonen

AIG Section

Air Navigation Bureau

Focus on Incident reporting

Jarmo Korhonen

AIG Section

Air Navigation Bureau

ADREP ECCAIRS 2007, slide 2

Overview

Vision ADREP SMS ICAO Annex 13 Reporting ECCAIRS Benefits of using an ADREP compatible

system Road Map


Related Performance Indicators

ICAO – Performance Review

Accident Rate Level of mandatory reporting of the States

– Official Annex 13 reporting of contracting States vs. Media and other sources


Data Analysis

AIG Divisional Meeting (1999) Recommendation 2/1 – ADREP Data Analysis

– That ICAO develop a data analysis programme that will allow the effective analysis of ADREP data. The programme should enable the categorization of accidents, the development of appropriate safety indicators and the systematic and rapid identification and dissemination of safety issues. . . . .


Vision

To provide access to safety data and information required to meet and monitor levels of safety


How to Achieve This

Integrated Systems Compatible Taxonomies

ADREP ECCAIRS safety management tool


ADREP

A System for Providing Feedback of Safety Lessons Learned:

From States to ICAO

and

From ICAO back to States


ADREP Taxonomy

Effective analysis of ADREP data Definitions, Taxonomies, etc. ECCAIRS common frame work

Safety indicators Categorisation of accidents Identification and dissemination of safety

issues


ICAO – ADREP

ADREP – Accident Incident Data Reporting System A database of accidents and serious incidents

reported to ICAO by States Maintained in the AIG Section Contains occurrences from 1970 to today 35 892 Occurrences (07 NOV 07)


Safety Programme (States)

- An integrated set of regulations and activities aimed at improving safety

Safety Management System

- A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures


States shall require, as part of their safety programme, that an [operator, maintenance organization, ATS provider, certified aerodrome operator] implements a safety management system accepted by the State that, as a minimum:

Identifies safety hazards Ensures that remedial action necessary to maintain an

acceptable level of safety is implemented Provides for continuous monitoring and regular assessment of

the safety level achieved Aims to make continuous improvement to the overall level of

safety

ICAO Annexesas of 23 November 2006


New Approach & Future Focus

Must be guided by hazards identified through Safety Information shared and problems addressed by cooperative approach (Includes routine collection)

Effectiveness metrics System monitoring for emerging risks Combined Data sources (beyond current scope) and

sharing (Safety issues) Analysis


ACCIDENTS

SERIOUS INCIDENTS

OTHER SAFETY RELATED OCCURRENCES / HAZARDS

Investigatio

nPrevention

Aviation Safety Pyramid

3000

300

1

15

INCIDENTS


ADREP Reporting RequirementsAnnex 13 – Chapter 7

States investigate and report to ICAO: Accidents to aircraft over 2 250 kg (para.7.1, 7.5) Investigated incidents to aircraft over 5 700 kg (para.

7.7) Means of reporting:

Reporting forms, Electronic reporting

Guidance: Accident Incident Reporting Manual


ICAO Reporting standard for StatesAnnex 13 - Chapter 7, Attachment B

Initial Notification Preliminary Report Data Report Final Report

ADREP REPORTING


Accident/Incident Reporting to ICAO

Occurrence

Investigation

Data

Analysis

Data entry

Initial Notification

Prelim

report

Data

report

Final

report


Global Reporting CulturePercentage of Open Files

0%

10%

20%

30%

40%

50%

60%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

10%

~30%


Global Reporting Culture

58 States notify ICAO between 25 and 75% of the time

58 States notify ICAO less than 25% of the time

51 States notify ICAO more than 75% of the time


Accident Prevention Measures Annex 13 - Chapter 8

Incident reporting system A State shall establish an accident and

incident reporting systems (8.1 & 8.2)


Database systems Recommendation - A State should

establish a database to facilitate effective analysis of information obtained from incident reporting systems (8.4)

Recommendation – The database systems should use standardized formats (8.5)



Reporting flow

AIB ICAOADREP using ECCAIRS

database software

CAA

StateData Base

StateRegional Body


Analysis of data – Preventive actions A State shall analyse the information

contained in its database to determine any preventive actions required (8.6)

Recommendation. – If a State identifies safety matters considered to be of interest to other States, that State should forward such safety information to them as soon as possible (8.7)



Example

DATAFORMAT FILE

AVIATION SAFETY OFFICER

BROWSER

ECCAIRS DATABASE

EDF

Queries and Reports


Exchange of safety information Recommendation. – States should

promote the establishment of safety information sharing networks and should facilitate the free exchange of information on potential safety deficiencies (8.9)



Service Providers

ATNS, Aerodromes, Air Operators

Contracting States

ICAO

RO

Reporting to ICAO as per Annex 13 provisions


ECCAIRS view

Not reported to ICAO = Media Source


Level of practical usage

NEWHazard


Occurrence = sequence of events


Example of Output


Distribution of Type of Occurrence

0 500 1000 1500 2000 2500 3000

1997-2001

2002-2006

Accidents

Serious Incidents

Incidents


Distribution of Type of Occurrence

0

50

100

150

200

250

300

350

400

1990

1992

1994

1996

1998

2000

2002

2004

2006

SI

ACC


Regional Distribution (% to total Fatal Accidents) by

major Occurrence Categories for 2002-2006

20.7%

10.0%

16.7%

5.9%

9.1%

12.3%

17.2%

5.0%

5.6%

5.9%

9.1%

18.2%

10.4%

3.4%

30.0%

22.2%

29.4%

9.1%

9.1%

17.0%

13.8%

15.0%

16.7%

5.9%

9.1%

9.1%

12.3%

3.4%

11.8%

2.8%

6.9%

5.0%

5.6%

11.8%

18.2%

7.6%

3.4%

27.3%

3.8%

6.9%

5.0%

11.1%

9.1%

18.2%

7.6%

LOC-I SCF-PP CFIT F-POST ADRM RE EVAC SCF-NP

WORLD

NA

ME

LA

EUR

AP

AFR


Probability (%) of Accident rate exceeding twice the mean accident rate

-10.0%0.0%

10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

AF AP EU LA ME NA

Probability(%) - Accidentrate

Departureshare


Reactive versus Proactive Safety


Benefits using ADREP ECCAIRS

Implements comprehensive SMS principles

ICAO ADREP taxonomy compatible Designed for data sharing Family of tools and common framework

(multi modal) Free for all ICAO Contracting States Very stable system Available in English and French


Why not to choose ADREP ECCAIRS ?

Not a solution to solve all problems of aviation, only a data storage (should be seen as part of safety management systems)

No reasoning because ICAO needs or recommendation for ADREP compatible systems

No reasoning because of ICAO Audits No reasoning because of somebody’s request,

but rather because of commitment to safety and professionalism


Options

States with well established safety data systems: No need to convert to ICAO taxonomies Needs to map native system to ICAO

taxonomies to send data

States with a low level of aviation activity Evaluate the possibility of participating in a

sub-regional system


Options (cont.)

All other States ADREP ECCAIRS

Note – even if you do not implement ADREP ECCAIRS through-out your Civil Aviation system, you may still consider putting it on one work station so that you can share data with other who do use ADREP ECCAIRS


Next Steps

1) Define Focal Point of the State for the safety information and reporting systems (as part of the Safety Program of the State)

2) Define safety data and safety information system requirements

3) Select appropriate solution


For those who choose to implement ADREP ECCAIRS

Software will be provided by the EU through ICAO at no charge

Training is available on demand to ICAO HQ (not EU/JRC; participants and/or hosts to cover expenses)


Biggest Risk and Safety Culture

Biggest risk lay in the absence of reporting and standards

Safety culture must exist

Evaluation by safety performance (indicators & factors)


Aviation Safety System

Safety Policy Safety Information and Reporting

mandatory & voluntary reporting ADREP

Accident Prevention Programme Investigation of incidents and accidents Education and training


Questions?


THANK YOU

icao adrep 2007

Documents

safety data

safety programme

sourcesadrep eccairs

statesadrep eccairs

safety information

safety hazardsensures

safety management system

safety level achievedaims