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ATS INCIDENT REPORTING AND INVESTIGATIONS

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AND INVESTIGATIONS Reporting Aviation Occurrences NAV CANADA RESPONSIBILITES NAV CANADA has a requirement under CARs to report certain aviation incidents to Transport ... – PowerPoint PPT presentation

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Title: ATS INCIDENT REPORTING AND INVESTIGATIONS


1
ATS INCIDENT REPORTING AND INVESTIGATIONS
2
Reporting Aviation Occurrences
  • NAV CANADA RESPONSIBILITES
  • NAV CANADA has a requirement under CARs to report
    certain aviation incidents to Transport Canada.
  • NAV CANADA Management has a need to be aware of
    incidents as they occur.

3
Aviation Occurrence Reporting System
  • Shift Manager in each ACC is focal point.
  • Receives information and inputs to the AOR data
    base.

4
Aviation Occurrence Reporting System
  • Information is automatically forwarded to
    Transport Canada.
  • NAV CANADA managers receive the information.
  • ATS Operating irregularities are followed up.

5
Operations Safety Investigation INITIAL
NOTIFICATION
  • Initial notification to Head Office of an
    aviation occurrence will usually be through the
    Aviation Occurrence Report database.

6
Operations Safety Investigation PRELIMINARY
INVESTIGATION
  • Involves an immediate examination of the basic
    facts to determine the necessity for further
    action.

7
Operations Safety Investigation
  • Investigators (Chairperson)come from the
    Operations Group around the country.
  • They are not dedicated to investigations.
  • Training is provided for designated investigators
    by SSD

8
Operations Safety Investigation Three levels of
investigation
  • Service the entire Operations Group
  • Manager in System Safety and Service design
    decides what type of investigation will be
    conducted.

9
Operations Safety Investigation Three levels of
investigation
  • Level one (OSI -1 )
  • -To collect factual information, but without
    interviewing operational employees directly
    involved.
  • -Investigation would be comprised only of the
    Chairperson.

10
Operations Safety Investigation Three levels of
investigation
  • Level two (OSI -2 )
  • -To collect factual information, including
    interviewing operational employees directly
    involved.

11
Operations Safety Investigation Three levels of
investigation
  • Composition of the Board- OSI -2
  • a chairperson.
  • a non-supervisory controller/specialist from the
    area or Operations Group division under review
  • Person is selected by the Unit Manager.
  • a NAV CANADA manager from a similar specialty
    area as that under review.

12
Operations Safety Investigation Three levels
of investigation
  • Level three (OSI -3 )
  • - Complete Operational Review.
  • - Conducted when similar events reoccur.

13
Operations Safety Investigation Criteria for
Investigation Type
  • Level two (OSI -2 )
  • operating irregularity
  • staffing, equipment or procedures a factor, or
  • on the Job Training may be a factor, or trends
    are apparent, or
  • occurrence is high profile, or
  • recommended by OPS Group Manager

14
Operations Safety Investigation Criteria for
Investigation Type
  • Level one (OSI -1 )
  • Operating Irregularity
  • -less than OSI 2 defined criteria
  • -may be upgraded on site by
  • SSD appointed investigator

15
Operations Safety Investigation Criteria for
Investigation Type
  • Level three (OSI -3 )
  • Operating Irregularity????
  • -less than OSI 2 defined criteria
  • -may be upgraded on site by
  • SSD appointed investigator

16
Operations Safety Investigation Human Factors
  • Identify unsafe acts.
  • Identify latent unsafe conditions.
  • Identify last successful defense barrier.

17
Operations Safety Investigation Follow-up
  • Unit Management is briefed by Chairperson.
  • Corrective action taken as required.
  • Report is published and widely distributed.
  • Head Office Monitoring and Evaluations will
    review and follow-up if required.
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