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.