Incident

Report
Incident Review Meeting
Guidance Material & Presentation Template
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Introduction to the Template
 This template allows Safety Managers to analyze events using the TEM
framework in conjunction with the Bow Tie Model
 The TEM framework helps to underline the classification system used by IATA
to determine contributing factors, in incidents and accidents
 These factors can be viewed as Threats, failed Preventive Defenses
(including Error Management) resulting in Undesired Aircraft States
 The Undesired Aircraft States is then managed through Recovery
Defenses (including Undesired Aircraft State Management) to prevent or
not prevent the Accident or Incident
 An example is provided to illustrate the steps that can be followed to analyze
events in this manner
 IRM speakers are reminded that:
 this is not intended to be a complete Bow Tie Analysis
 this format is optional
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 IRM presenters are asked to ensure they clearly
define:
 Safety enhancements
 What was learned? What was changed?
 Lessons learned for IRM attendees
 What should attendees consider checking and/or changing at
their own operation?
 Key messages for Safety Group
 What should the Safety Group act on?
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 The IRM presentations are an integral part of
IATA’s and the Safety Group’s hazard
identification process
 All presentations are welcome, even short ones
 Presentations must have take aways for IRM
attendees and Safety Group
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Latent Conditions
 Conditions present in the system before the accident,
made evident by triggering factors
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Latent Conditions: Examples
 Deficiencies in:
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Design factors
Safety management
Training
Standard Operating Procedures
Selection systems
Etc.
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Threats
 Factors external to the flight deck that increase the
complexity of flight operations and which are realized
through a triggering event
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Threats: Examples
Flight/Cabin
Crew errors
Distractions Passenger events
ATC errors
Terrain
Weather
Similar call signs
Maintenance
errors
Time pressures
Ground crew
errors
Flight diversions
System
malfunctions
Heavy traffic
Unfamiliar airports
Automation events Missed approaches
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Bow Tie Model
END STATES
ACCIDENT/INCIDENT
Preventive
DEFENSES
Threat
RECOVERY
DEFENSES
ASR, GHR, Ext…
Threat
Threat
Threat
Threat
Threat
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CFIT
Runway
Collision
U.E.
Undesired
Unwanted
Aircraft
State
Events
Altitude Deviation
Unstabilized Approach
Runway Incursion, Unsecured Loading
ATC Comm. Loss, etc.
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Mid-Air
Collision
Runway
Excursion
Other Damages
(Flight)
Other Damages
(Ground)
Threats
 List the Threats that were realized in the triggering event
or events
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Preventive Defenses
 What are the specific mechanisms that should have helped prevent
the undesired aircraft state?
 Examples: policies, procedures, training
 Which of these defenses/barriers failed?
 Why? What caused the these defenses/barriers to fail?
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UAS: Examples
 Aircraft Handling:
 Lateral, vertical or speed deviation
 Operation Outside Aircraft Limitations
 Unstable approach
 Ground Navigation:
 Runway / taxiway incursion
 Proceeding towards wrong taxiway / runway
 Wrong hold spot
 Incorrect aircraft configurations
 Systems
 Landing gear
 Flight controls
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Undesired Aircraft States (UAS)
 Describe the Undesired Aircraft State
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Recovery Defenses
 List the Recovery Defenses that either prevented or failed
to prevent the Accident or Incident from occurring
 Explain the specific mechanisms which should have
helped recover from the unsafe event?
 Which of these failed?
 Why? What caused these to fail?
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End States
 End States are reportable events:
 Incidents
 Accidents
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Tailstrike
Undershoot
Hard Landing
Etc…
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Safety Enhancements
 What was learned from this occurrence?
 What changes have been or should be made at your
airline and in industry?
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Procedures, Policies
Training
Equipment
ATC
Airport
Weather Information etc….
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Lessons Learned for IRM
(Note: this slide will be shared with all IRM attendees)
 What should attendees at IRM learn from this occurrence?
 What should attendees at IRM consider changing at their
own airline?
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Key Messages for Safety Group
(Note: this slide will be shared with all IRM attendees)
 What are the key messages that Safety Group should act
on?
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Usage Notes for IRM Template
 When discussing crew actions management, describe only
observable facts, and avoid judgments. Value statements
such as “minor”, ”poor” or “very” attached to the
description of crew actions should be avoided.
 When discussing undesired states management, describe
only observable facts, and avoid judgments. Value
statements such as “minor”, ”poor” or “very” attached to
the description of crew actions related to undesired states
management should be avoided.
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