Day 3: Seven (7) Hours of Instruction
Case Study and Discussion: The student reviews an Aviation Accident or Incident Report. The lesson presents skills to develop and ask questions during an interview session based upon information gained from the report. The group discusses the human, organizational, technical, and environmental factors related to the incident or accident. Students practice Hazard Identification, Risk Assessment and Category Identification. The case study brings attention to the importance of fact finding and team discussions regarding what really happened by practicing interview skills and using the information gained to determine root causes and corrective actions to mitigate recurrence of the issues discovered.
Safety Performance Monitoring & Measuring: This module defines what is includes in monitoring safety performance and method of measurement. It discusses methods to monitor safety performance, safety performance analysis and reporting. It discusses the concepts related to Safety Performance Indicators (SPIs) and targets. The value of internal evaluation programs (IEPs) and employee safety surveys. The student is challenged to consider a fundamental reason for having an IEP, i.e. promote and ensure compliance and for preventing an incident or accident.
Incident Investigation Methods: This module explores the purpose and how to investigate following an incident. It examines an OSHA incident/accident investigation guide book and covers the essential elements to include: evidence collection, interviewing witnesses and involved employees, determining and examining contributing factors. Boeing investigation techniques are presented and discussed (MEDA, REDA, PEAT, CPIT). This provides the student with an understanding of the interplay between errors, deviations, and causal factors.
Emergency Response Plan (ERP): This module provides insight into ERP requirements from an ICAO perspective. References cited include ICAO Annex 19, Chicago Convention, ICAO Document 9859, Safety Management Manual, and advisory information from national authorities. Focus is placed on the objective of an ERP, as well as recommended contents for post-accident considerations. The module discusses media management, family assistance planning and NTSB interface. Conformity checklists are reviewed.
Safety Training Plans: This module highlights the role of training in preventing accidents and incidents. Techniques are explored to develop a training plan by reverse engineering the accident causation model by Dr. James Reason. ICAO guidance is presented and discussed with focus on hazard taxonomy and how this can assist the safety leader in developing a strategic approach to training. A training gap analysis tool is presented and shared with each attendee that they can apply in their own organization.
Root Cause Analysis: This module explores the various techniques of root cause analysis. The techniques presented and discussed include: Events and Causal Factor Analysis, Change Analysis, Barrier Analysis, 5-Whys, and the Ishikawa Fish Bone Diagram. Practical examples are provided and discussed. An exercise is completed using a scenario-based event.
Auditing and Internal Evaluation Programs: During this module, the student reviews key audit terms and audit principles based on ISO 19011: Guidelines for Auditing Management Systems. The importance of designing a comprehensive Internal Evaluation Program. Elements of auditing include Preparation, Performance, Reporting and Follow-up. Concepts include: values of audit integrity, fairness, confidentiality, independence, and evidence-based conclusions, determining audit scope, audit objectives, population sampling and auditor training requirements. The student is presented with various audit criteria which can be applied to a wide variety of organizations, each one having a focus on safety risk management. The module presents an example of industry tools utilized to perform audits and evaluations to include the ICAO, FSF, IBAC and FAA. Evidence Gathering Techniques are reviewed. Interviewing techniques are explored to include salient points from ISO 19011.
Discussions on how to document findings based on the audit criteria, audit objectives, and collected evidence. Benchmarking and Best Practices. Awareness of Hypercompliance and the normalization of deviance are discussed. Differences between compliance and conformity. Appropriate use of auditor observations and recommendations. Corrective action plans and follow up criteria. Exercise to practice audit techniques.
Review and Discussion: Students discuss lessons learned from the day's lessons and how they can apply the information at their organization.
