ACCIDENT/INCIDENT INVESTIGATION IN ATM
Course aim The course is designed for operational air traffic controllers, flight safety officers, managers, union representatives, regulatory authorities, ATS management and others involved in operational aspects of flight safety within the ATM environment. The aim of the course is to provide participants with fundamental knowledge on both incident and accident investigation.
Course objectives After completing the course, the participants have:
- The skills necessary to carry out investigations into occurrences or act as advisors/coordinators or ATM operation specialists in official accident/incident investigation teams.
- Understanding of the depth of inquiry that is necessary in order for the investigation to conform to the legislation, regulations and other requirements of the state for which they are conducting the investigation.
- Familiarity with the accident/incident investigation techniques in ATM.
- A good understanding of the impact of human and latent organisational factors on an ATM related accident/incident.
- The ability to collect facts and preserve evidence.
- Knowledge on how to analyse facts in order to precisely determine causes and make safety recommendations.
- The knowledge to write a clear and unambiguous final report that meets the requirements of the accident investigation authority of the state conducting the investigation.
Course overview The course is divided into theoretical lessons and practical training.
Theory The course is intended to provide an introduction to investigative techniques and procedures in accordance with international requirements. The entire process of investigation is thoroughly explained - from initial actions, through collecting and analysing facts, to making conclusions and recommendations and writing the final report. The participants are also introduced to the investigation of possible human error and latent organisational failure.
Practical training The practical training includes teamwork exercises on aircraft accident investigation cases, writing formal accident reports and drawing up recommendations.
Prerequisites There are no prerequisites to attend this course. It will be an advantage if the participant has a professional interest in aircraft accident/incident investigation.
Content in brief
- Introduction to Just Culture
- What should be investigated and by whom?
- The basics of investigation: purpose/goal of an investigation - different phases of an investigation - interconnection of the phases - causes and root causes
- Planning of an investigation
- Finding facts: ATCO investigation - aerodrome investigation - recordings
- Organisational investigation (facts)
- Analysis technique: practical exercises
- Human factors investigation
- Different human factors investigation tools: SHELL - HERA-JANUS - HFACS - SERA
- Case study: working/practising with different tools
- Conclusions and recommendations
- Report writing
- The methodology of report writing