pablo hernández coronado, director of safety analysis and quality management, aesa

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

© 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 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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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)



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INPUTS TO STATE SAFETY PROGRAMME

SSP


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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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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


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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


MANDATORY VS VOLUNTARY

9776; 89%

1156; 11%

MANDATORY REPORTS VOLUNTARY REPORTS


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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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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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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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CHALLENGES: THE ROAD TO SUCCESS


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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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pablo hernández coronado, director of safety analysis and quality management, aesa

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