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EASA Annual Safety Review 2019 Published

Old 3rd Aug 2019, 16:10
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EASA Annual Safety Review 2019 Published

In the past few days EASA has published its Annual Safety Review 2019. Hopefully it makes interesting and useful reading for those involved in safety management especially. The review involves analysis of not just accidents and serious incidents but also occurrences reported to all the National Authorities in the EASA Members States.
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Old 5th Aug 2019, 09:34
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Thanks for sharing this.
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Old 5th Aug 2019, 14:47
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The comprehensive safety review is widely seen as the definitive position for Europe, but apparently without question or consideration of the data origin or management. Data sources are reported, but not precisely how these are populated or formatted.

The headline risk for CAT is loss of control; a risk projection based on past accidents. Why should these accidents be allocated solely to LoC, particularly as only reflecting the outcome opposed to considering other contributing or initiating factors:- system / technical failure / certification process - A330, MD 80, CRJ; cf accidents listing page 151.

Interestingly, crew awareness, implied by adverse contributions from monitoring and managing technical failures, now appears in the overall risk portfolio, but this too relates to selected key risk areas.

Current safety interventions focus on the headline items - LoC avoidance and recovery, yet both depend on awareness, thence knowledge, and action. What emerges is a view of many interacting contributing factors - typical of wicked problems, yet the review presents a linear, mechanistic approach for safety problems which at best can only be controlled.

Taking the EASA review at face value could be misleading, particularly with simplistic solution-seeking strategies leading to over focus on issues which have been, or should be controlled by other means, i.e. A330 now has modified components, MD 80 - other aircraft alert unavailability of takeoff configuration warning, CRJ could update alerting software, certification processes should reflect the need for wider system reviews, and of course human involvement in all of these areas.

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Old 5th Aug 2019, 18:45
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Thanks for the Feedback

Safetypee, many thanks for taking the time to feedback your thoughts.

Indeed the review only covers data from the EASA Member States. We provide a global overview of data collected through ICAO ADREP but not to any depth.

Your comment on the qualification of the data sources is good to know. We didn't want to provide too much detail about the reporting process in Reg 376 in the document but we will be doing some safety promotion material on the website soon as further background information. Hopefully this will help.

Also interested in the linear view you saw from the report. It's really hard to show the reality in a concise overview report. With the European Risk Classification Scheme we now look at the Key Risk Areas (accident outcomes) such as loss of control not just as historical accidents but not also as potential outcomes in both serious incidents and MORs. Again, we continue to try and improve how we represent these complex interactions better in the report.

Thanks again for taking the time to comment, it's really important to get this feedback if we are to meet the needs of the readers. Feel free to drop me a message also if it helps the discussion.
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Old 6th Aug 2019, 15:47
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The Review is a valuable tool as a public / political safety overview - governance and money; the point is enhanced by good graphic depiction.
However, within the industry it’s use requires deeper knowledge of the ‘tool’ and processes, data provenance, assumptions, and thus limitations in application.

The data sources are repositories of ‘findings’ from accidents, and occurrence reports from organisations and individuals across the industry - thence categorised - by whom, where. The value of each is bounded; accident reports by what is written, key findings, national / cultural viewpoints, focus and strength of recommendations. Also by the limits of investigation - perhaps only factual data, excluding speculative issues particularly relating to human activity.
MORs and individual input similarly at risk of bias, inward looking, self analysis, error admission leading to superficial solutions opposed to reasoned understanding. This is not to discount everything, but how to differentiate the value of the data; count errors or gain understanding of influencing factors.

Many ‘safety issues’ are collection ‘buckets’ for a wide range of events; i.e. grouping an approach to stall / autothrotle event with an upset due to wake turbulence, icing or storms, all categorised ‘LoC’. Similarly there are no indications of how contributing factors interact, the overall context, or relative importance.

Continuing with existing ‘linear’ thinking looking for explanation is increasingly frustrated by inability to define problems or identify clear ‘solutions’, together with bureaucracy and lengthy time scales.

An alternative is to consider a systems approach to thinking (1&2), not as a replacement, but as a different starting point for thoughts and managing ‘wicked issues’ - no agreed definition of the problem or solution. This requires acknowledging that there may be no solution, only containment where understanding the processes is vitally important; ‘better to travel safely than arrive’.

An alternative starting point need not change established methods for the ‘easier’ problems - according to definition; alternatively a change might help avoid interventions that could backfire due to unforeseen reactions.

Further concerns arise from projected ‘big data’ analysis; what value if we start with poor or corrupted data. Also, many current safety initiatives now quote the Review as definite data, justifying the need for action; solutions to address specific problems which might be artefacts of data collection in the first instance - ‘boot strapping’.

1 Sections 1 and 5
The point is not to change what we think, but to change the way we think about these issues.”

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