Title: ATS INCIDENT REPORTING AND INVESTIGATIONS
1ATS 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.
3Aviation Occurrence Reporting System
- Shift Manager in each ACC is focal point.
- Receives information and inputs to the AOR data
base.
4Aviation Occurrence Reporting System
- Information is automatically forwarded to
Transport Canada. - NAV CANADA managers receive the information.
- ATS Operating irregularities are followed up.
5Operations Safety Investigation INITIAL
NOTIFICATION
- Initial notification to Head Office of an
aviation occurrence will usually be through the
Aviation Occurrence Report database.
6Operations Safety Investigation PRELIMINARY
INVESTIGATION
- Involves an immediate examination of the basic
facts to determine the necessity for further
action.
7Operations 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
8Operations 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.
9Operations 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.
10Operations Safety Investigation Three levels of
investigation
- Level two (OSI -2 )
- -To collect factual information, including
interviewing operational employees directly
involved. -
11Operations 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. -
12Operations Safety Investigation Three levels
of investigation
- Level three (OSI -3 )
- - Complete Operational Review.
- - Conducted when similar events reoccur.
13Operations 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
-
14Operations 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
-
15Operations 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
-
16Operations Safety Investigation Human Factors
- Identify unsafe acts.
- Identify latent unsafe conditions.
- Identify last successful defense barrier.
-
17Operations 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. -