1. SOFIA Sequentially Outlining and Follow-up Integrated Analysis

2. 1 2 3 4 5 ESARR2 Compliance ESARR 2 terminology compliance; ESARR 2 concepts compliance - HEIDI-based tool; ESARR 2 Events types compliance; ESARR 2 Contributors types compliance; Applicability to aviation Accident/Incident/ATM specific Events;

3. 1 2 3 4 SOFIA supports: Factual Information Gathering; Event Reconstruction; Event Analysis; Safety Recommendations Elaboration;

4. Factual Information Gathering Phase

5. Time 10.23:39 10.25:12 10.25:45 10.25:49 Safety, separation Pilot ATCO Aircraft Local triggering conditions Latent conditions Actors

6. Existing Condition Hazard Event before Hazard Building Blocks Event at the moment Hazard

7. EXAMPLE Building Blocks Event happened at that moment Time 10.23:39 10.23:45 Applied heavy breaking Pilot Instructed aircraft to stop ATCO Actors

8. EXAMPLE Had cleared aircraft to climb Building Blocks Event happened before that moment Time 10.29:00 10.29:17 Climb to FL330 Pilot ATCO Actors

9. EXAMPLE Building Blocks Condition existing at that moment Time 10.23:39 10.23:45 Reduced vertical separation separation Inexperienced co-pilot Pilot Actors

10. EXAMPLE Building Blocks Event/condition happened/existed at/before that moment which is analysed that is increasing the likelihood for the final occurrence HAZARD Time 10.23:39 10.23:45 Reduced vertical separation separation Inexperienced co-pilot Pilot Actors

11. Event Reconstruction

12. ? How to link BB ? • Contributors: • direct • indirect • reductive • suspected • Safety Recommendation • Alternative hypothesis for the contributors • Link between contributors • System Symbols: OR

13. Case Example Engine failure “Clear to land” No braking action information Displaced touch-down RWY Excursion Object Poor braking action Collision

14. Time Inexperienced co-pilot No braking action information Bird Strike Poor braking action ? Object too close to the RWY Maintenance error 10.23:39 10.25:12 10.25:45 10.25:49 Safety, separation RWY Excursion Collision with object Displaced touch-down Pilot ATCO Engine failure Aircraft Local triggering conditions Latent conditions Actors

15. 1 2 3 4 5 6 Advantages Provide a mean for systematic, disciplined approach towards structuring the investigation process and organisation of data - summary of all; It is a rigorous approach suitable for investigation, performance monitoring, system and future hazard sequences assessment; It is visually-oriented tool which helps analysis, communication, focus team work and enhance lesson dissemination; It is open analysis system which allows more details to be acquired and added quickly at different phases; It enable analysis to focus quickly on data needed to complete the work; It provides worksheets which is a good mean of assurance documentation.

16. Thank You !