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A possible way to learn lessons?

A possible way to learn lessons?. ACCIDENT X YEARS LATER SAME CONDITIONS. The cause(s). ATCO lost situational awareness. Low/poor visibility. Disturbing environment. High workload. Other findings. Language issue. Use of ground system (e.g. surface movement radars).

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A possible way to learn lessons?

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  1. A possible way to learn lessons? SRC17 20-21 May 2003

  2. SRC17 20-21 May 2003

  3. ACCIDENT X YEARS LATER SAME CONDITIONS SRC17 20-21 May 2003

  4. The cause(s) SRC17 20-21 May 2003

  5. ATCO lost situational awareness • Low/poor visibility • Disturbing environment • High workload • Other findings • Language issue • Use of ground system (e.g. surface movement radars) • crossing stop bars when lit SRC17 20-21 May 2003

  6. What could we possibly do? SRC17 20-21 May 2003

  7. Recommendation  That SRC-SRU maintain a database of accident/incident summaries, that is accessible on internet (subject to the overall review of the SRC WP and budget !) SRC17 20-21 May 2003

  8. ICAO-AIG/99 Divisional Meeting Montreal 14th-24th September 1999 • Recommendation 1.4/1 and 14/2 States should have a database Data base systems 8.3 Recommendation.- A State should establish an accident and incident data base to facilitate the effective analysis of information obtained, including that from its incident reporting systems. 8.3.1 Recommendation.- The data base systems shoulduse standardized formats to facilitate data exchange. Note 2.- States are encouraged to foster regional arrangements, as appropriate, when implementing 8.3. Databases format standardised States should exchange safety data in a proactive manner Analysis of data-Preventive actions 8.5 Recommendation.- If a State in the analysis of the information contained in its data base, identifies safety matters considered to be of interest to other States, that State should forward information to them as soon as possible Exchange of safety information 8.7 Recommendation.- States should promote the establishment of safety information networks among all users of the aviation system and should facilitate the free exchange of information on actual and potential safety deficiencies. Note.- Standardized definitions, taxonomies and formats are needed to facilitate data exchange . Guidance material on the specifications for such information sharing networks will be provided by ICAO upon request. States should promote safety data exchange networks Need for a TAXONOMY Establishment and operation of a data base for safety recommendations. Subject to the provision of a suitable data base system and adequate resources being available to operate such a system, ICAO maintain a data base to record the following information: a) safety recommendations issued; and b) preventive actions taken or under consideration or the reasons why no such action will taken Establishment & operation of a centralised database SRC17 20-21 May 2003

  9. Recommendation  By End of August to provide comments if feasible to ask States (ANSPs, CAAs, AAIBs etc) to translate in English accidents and incidents reports summaries (including causes, recommendations and remedial actions) SRC17 20-21 May 2003

  10. Thank you for your attention. SRC17 20-21 May 2003

  11. Recommendation  That SRC-SRU maintain a database of accident/incident summaries, that is accessible on internet (subject to the overall review of the SRC WP and budget !) Recommendation  By End of August to provide comments if feasible to ask States (ANSPs, CAAs, AAIBs etc) to translate in English accidents and incidents reports summaries (including causes, recommendations and remedial actions) SRC17 20-21 May 2003

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