pablo hernández coronado, director of safety analysis and quality management, aesa
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Agencia Estatal de Seguridad Aérea
Paseo de la Castellana nº 67
28071 Madrid (Spain)© AESA 2011Queda terminantemente prohibida la reproducción total o parcial de este documento, así como su uso indebido y/o su exhibición o comunicación a terceros.
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CHALLENGES IN THE PROTECTION OF SAFETY INFORMATION
EXPERIENCE OF THE SPANISH OCCURRENCE REPORTING SYSTEM
SPANISH OCCURRENCE REPORTING SYSTEM
Pablo Hernández-Coronado Quintero
Director of Safety Analysis & Quality Management
National Aviation Safety Agency (AESA)
Madrid, 24th March 2011
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SPANISH OCCURRENCE REPORTING SYSTEM 2
EXPERIENCE OF THE SPANISH ORS
OUTLINE
• Introduction• Inputs to State Safety Programme• Spanish ORS • Protection of Information• Reporting Culture in Spain• Challenges• Conclusion
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SPANISH OCCURRENCE REPORTING SYSTEM 3
INTRODUCTION
“Methods for improving safety reporting are still in an early stage of development.
Very few organizations today are collecting the type and amount of data that will become the norm as SMS programmes move forward”
Daniel Mauriño
(ICAO Journal #2 /2009)
EXPERIENCE OF THE SPANISH ORS
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SPANISH OCCURRENCE REPORTING SYSTEM 4
EXPERIENCE OF THE SPANISH ORS
INPUTS TO STATE SAFETY PROGRAMME
SSP
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SPANISH OCCURRENCE REPORTING SYSTEM 5
EXPERIENCE OF THE SPANISH ORS
ROLE OF AN ORS Oriented towards the capture of information to detect:
Emerging threats and safety issues Adverse trends and active/latent failures
Its efficiency depends on the management of a large volume of data (reports) and its ability to use it to perform safety analysis
Working Methodologies Individual occurrences (short term) Statistical analysis (medium and long term) Ad hoc safety studies
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SPANISH OCCURRENCE REPORTING SYSTEM 6
EXPERIENCE OF THE SPANISH ORS
REPORTING CULTURE
40.000
14.000
8.800
1.200 1.400
0,00E+00
6,00E+05
1,20E+06
1,80E+06
2,40E+06
3,00E+06
0
10.000
20.000
30.000
40.000
50.000
FR UK ES GE IT
OCCURRENCES FLIGHTS
147
62 474 9
FR UK ES GE IT
OCCURRENCES PER 10.000 FLIGHTS
© AESA 2011Queda terminantemente prohibida la reproducción total o parcial de este documento, así como su uso indebido y/o su exhibición o comunicación a terceros.
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SPANISH OCCURRENCE REPORTING SYSTEM 7
EXPERIENCE OF THE SPANISH ORS
REPORTING CULTURE IN SPAIN
0
2.000
4.000
6.000
8.000
10.000
12.000
0
200
400
600
800
1.000
1.200
1.400
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
FIRST QUARTER SECOND QUARTER THIRD QUARTER FOURTH QUARTER
Number of Reports
MONTHLY 06 MONTHLY 07 MONTHLY 08 MONTHLY 09 MONTHLY 10
ACCUMULATED 06 ACCUMULATED 07 ACCUMULATED 08 ACCUMULATED 09 ACCUMULATED 10
5.002
4.292
3.354
1.269
11.103
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SPANISH OCCURRENCE REPORTING SYSTEM
0
200
400
600
800
1000
1200
1400
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
REPOPRTS
MONTHS
VOLUNTARY REPORTS ACCUMULATED CHART
INDIVIDUALS
PROFESSIONAL ASSOCIATIONS
8
EXPERIENCE OF THE SPANISH ORS
MANDATORY VS VOLUNTARY
9776; 89%
1156; 11%
MANDATORY REPORTS VOLUNTARY REPORTS
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SPANISH OCCURRENCE REPORTING SYSTEM 9
EXPERIENCE OF THE SPANISH ORS
PROTECTION OF INFORMATION: THREATS
ACCIDENT INVESTIGATION
OCCURRENCE REPORTING
DATA COLLECTION & PROCESSING
CONFLICT OF INTERESTS
IMPROPER USE
LEAKS
DISCIPLINARY MEASURES(EMPLOYER / SANCTION)
LEGAL PROSECUTION(COURT / BLAME)
ADMINISTRATIVE PROCEEDINGS (AUTHORITY /
SANCTION)
UNCONTROLLED DISSEMINATION
(MEDIA /PUBLISHING)
REPORTING CULTURE
DEGRADATION
PROTECTIONACCESS
DISSEMINATION
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SPANISH OCCURRENCE REPORTING SYSTEM 10
EXPERIENCE OF THE SPANISH ORS
PROTECTION OF INFORMATION: MEASURES
TRUST + REPORTING
LEGAL BARRIER
THRE
ATS
PROCEDURE BARRIER
ENVIRONMENT BARRIER
LEGAL
Reporter Immunity (except willful act and/or gross negligence)
Restricted dissemination of information
Functional Independence between Report Management and the rest of the Departments
PROCEDURES
De-identification before loading into database
Reports shredding (every 15 days)
ENVIRONMEN T
Physical separation between facilities (reports management/AESA)
Restricted LAN
Encrypted Database
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SPANISH OCCURRENCE REPORTING SYSTEM 11
EXPERIENCE OF THE SPANISH ORS
CHALLENGES: BORDERS AROUND “OCCURRENCE CONCEPT”
AMBIGUITIES DEFINITION
Lack of suitable methods to set “ the line” for unacceptable behavior; who sets the line? Potential adverse effects on reporting culture
Possible overlapping with AIB Occurrence is a very wide conceptORS overloading due to high volume of input reportsSafety is always mentioned in labor conflicts
COMMON UNDERSTANDING AND AGREEMENT WITH REPORTERS ARE NEEDED !!!
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SPANISH OCCURRENCE REPORTING SYSTEM 12
EXPERIENCE OF THE SPANISH ORS
CHALLENGES: THE ROAD TO SUCCESS
© AESA 2011Queda terminantemente prohibida la reproducción total o parcial de este documento, así como su uso indebido y/o su exhibición o comunicación a terceros.
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SPANISH OCCURRENCE REPORTING SYSTEM 13
EXPERIENCE OF THE SPANISH ORS
CONCLUSION An ORS is oriented towards the management of a large volume of
data (reports) and its ability to use it to perform safety analysis The protection of safety information is NOT only ensured by Law.
Regulation, procedures and physical barriers make the system more robust
Despite its youth, the Spanish ORS has reached a significant level of reporting
Need to set a clear definition of occurrence, and to differentiate honest mistakes from unacceptable behaviors
Key areas to achieve success are feedback provision and quick response to implement mitigations
THANK YOU FOR YOUR ATTENTION
AGENCIA ESTATAL DE SEGURIDAD AÉREA
Paseo de la Castellana nº 67
28071 Madrid (Spain)Cód
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