506.2 - guidelines for safety investigations

Employees are to inform _____, as soon as possible, of any reportable occurrence. If they are not available, ______ shall be informed.

their immediate supervisor or manager, the ACC Shift Manager

Managers shall immediately arrange for the removal of ATS personnel directly involved in the occurrence, from operational duties, until the circumstances have been fully examined.

Removal from operational duties is mandatory, except where it is immediately clear and obvious to both the employee and manager that the incident was ___.

caused solely by external influences and that full responsibility rests elsewhere

A critical incident is any incident that has sufficient emotional power to cause an employee _____.

a strong and sometimes overwhelming reaction

An Operations Safety Investigation (OSI) is may be one of 2 levels:

• OSI 1: ATS OI, less than OSI 2 defined criteria

• OSI 2: ATS OI

  • Staffing, equipment or procedures were determined to be a contributory factor

  • Training was involved

  • Spacing reduced to less than 50% of what was required

  • Recommended by an Operations Manager and approved by the Manager, ATS Evaluations & Investigations

  • Deemed appropriate by the Manager, ATS Evaluations & Investigations

Do Safety Investigations (SI) fall within the parameters of an OSI?

No, but warrant further investigation

What type of occurrence does an OSI investigate?

ATS operating incidents

What does the GEMS Model stand for?

Generic Error Modelling System

The GEMS model is designed to _____ and describes different human performance errors (execution, monitoring, or planning) based on ______.

analyze human error, the level of performance

What are the different levels of performance described by the GEMS model?

• Skill-based

• Rule-based

• Knowledge-based

Skill-based level performance is characterized by ______ that are carried out automatically with the occasional conscious check on progress.

routine, highly practiced tasks

Skill-based mistakes are unintentional deviations from a good plan of action. They are typically actions that are associated with ______

slips and lapses

A slip is an unintentional action where the failure involves _____.

attention

A lapse is an unintentional action where the failure involves _____.

memory

A perceptual slip/lapse is where a person misrecognizes an object, sound or situation, in large part, because of _______.

expectation and habit

Rule-based performance is characterized by situations that are familiar and which require ____.

some conscious evaluationR

Rule-based mistakes occur while attempting to solve a familiar or trained-for problem. The two basic forms are _____.

misidentifying the situation, misidentifying the solution

Misidentifying the situation occurs when the person does not recognize ____ and misapplies otherwise good rules, e.g. mistakenly categorizing a medium aircraft as a light and not issuing a wake turbulence cautionary.

the counter-indications

Misidentifying the solution occurs when people correctly identify the situation, but do not apply a correct solution. This typically occurs when ____.

the rules themselves are wrong

Knowledge-based performance is characterized by ______ for which people have no ready-made solutions

novel or atypical problem situations

Adaptations involve ______ from established rules and procedures, but the goal is not to commit a malevolent act.

deliberate deviations

What level of performance can adaptations be at?

All levels of performance

Short-cuts are adaptations that people make because ____.

they follow the path of least resistance

Workarounds are _____ that people make to get the job done, because if they literally followed the rules, they would not be able to do their jobs efficiently.

adaptations

What does PETE stand for?

Person, Equipment, Task and Environment

The PETE model is the main source of Human Factors information because it captures ______.

the context of an occurrence

What are the key attributes of the PETE model?

• Systems approach

• User-centered design philosophy

• Task-based

After the GEMS analysis has been completed and the PETE factors have been examined, investigative personnel will identify _______ that may have mitigated the occurrence.

any defence barriers

What should final reports contain?

Actions taken or planned as a result of the occurrence