Incident Review Meeting

Example The next slides are an example of how to complete the

template and identify latent conditions, threats, errors, UAS and crew actions from a typical narrative Latent Conditions are in green Threats are in orange Errors are in red UAS are in purple

Extra slides or content (e.g. Jepp charts, animations, airport diagrams, etc…) can be added

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Incident Review MeetingPresentation Template with Example

Incident Review Meeting

Narrative

XYZ Airways Flight 000 (AAA to BBB) took off from AAA at 19:00 in fair weather. Approximately 10 minutes after takeoff, the No.2 engine lost oil pressure and failed, and the crew decided to return to AAA immediately. The aircraft also experienced minor problems with the compass and pressurization. The crew were distracted by these problems and by an incorrectly set radio. This rushed approach resulted in the aircraft being low on the instrument approach and off-course on the ILS. The crew decided to perform a go-around. The aircraft was below Vref and at a low altitude. One minute later, the aircraft crashed killing all but one of the 36 passengers and crew onboard. The accident happened in darkness. This was the 5th sector for the crew that day.

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Supporting Information

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Please add whatever additional supporting information or materials (charts, animations, pictures, etc…) that would help explain the event.

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Latent Conditions

Conditions present in the system before the accident, made evident by triggering factors Fatigue

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Threats

Factors external to the flight deck that increase the complexity of flight operations and which are realised through a triggering event Technical

Engine Failure Compass Pressurisation problems

Darkness

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Preventive Defenses What are the specific mechanisms that should have helped prevent

the undesired aircraft state? Which of these defenses/barriers failed?

Flight Crew mis-selection of the radio Stable Approach Criteria Horizontal and Vertical Approach path management Energy/Speed management Late decision to go around

Why? What caused the these defenses/barriers to fail? Training not applied Standard & Non-normal Operating Procedures non-adherence Poor CRM

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Undesired Aircraft States (UAS)

Unstable approach Off track Below profile Below Vref Low altitude

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Recovery Defenses List the Recovery Defenses that either prevented or failed to prevent

the Accident or Incident from occurring The crew (PF & PM) recognition of unstable criteria as well as lateral and vertical

parameter deviation - an early go-around Response to EGPWS Manual handling

Which of these failed? – ALL

Why? What caused these to fail? A desire to complete the approach due to non-normal configuration Possible expectation bias from simulator training De-skilling due to automation

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End States

The aircraft stalled and crashed killing all but one of the 36 passengers and crew onboard

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Safety Enhancements What was learned from this occurrence?

There is an enhanced degree of get-home-itis in a failure state The major failure was complicated by lesser failures and distractions Simulator training focuses on system failures rather than distraction management

and CRM Manual aircraft handling in non-normal configuration inadequate

What changes have been or should be made at your airline and in industry? More complex failure scenarios including CRM in simulator Additional simulator training to maintain manual flying skills

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Incident Review Meeting

Lessons Learned for IRM(Note: this slide will be shared with all IRM attendees)

What should attendees at IRM learn from this occurrence? The breakdown in CRM and SOP under intense workload and with multiple

distractions The latent loss of manual flying skills not evident under normal circumstances

What should attendees at IRM consider changing at their own airline? Adapt training to address the above points Introduction of FRMS

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Key Message for Safety Group(Note: this slide will be shared with all IRM attendees)

What are the key messages that Safety Group should act on? The loss of manual flying skills may now be an industry wide latent failure The need for the highest standards of CRM in workload and distraction

management in simulator training The importance of FRMS in identifying latent fatigue risk

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