ATS INCIDENT REPORTING AND INVESTIGATIONS Reporting Aviation Occurrences

ATS INCIDENT REPORTING AND INVESTIGATIONS

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.

Aviation Occurrence Reporting System • Shift Manager in each ACC is focal point. • Receives information and inputs to the AOR data base.

Aviation Occurrence Reporting System • Information is automatically forwarded to Transport Canada. • NAV CANADA managers receive the information. • ATS Operating irregularities are followed up.

Operations Safety Investigation INITIAL NOTIFICATION • Initial notification to Head Office of an aviation occurrence will usually be through the Aviation Occurrence Report database.

Operations Safety Investigation PRELIMINARY INVESTIGATION • Involves an immediate examination of the basic facts to determine the necessity for further action.

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 S&SD

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.

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.

Operations Safety Investigation Three levels of investigation • Level two (OSI -2 ): -To collect factual information, including interviewing operational employees directly involved.

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.

Operations Safety Investigation Three levels of investigation • Level three (OSI -3 ): - Complete Operational Review. - Conducted when similar events reoccur.

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

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 S&SD appointed investigator

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 S&SD appointed investigator

Operations Safety Investigation Human Factors • Identify unsafe acts. • Identify latent unsafe conditions. • Identify last successful defense barrier.

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.