Guidelines Accident Investigation Root Cause Analysis.pdfVIP专享VIP免费原创优质

1GuidelinesonAccidentInvestigationandRootCauseAnalysisACIAsiaPacificFirstEditionMay20192PrefaceItmaybesaid“oneaccidentisonetoomany”butwhenoneoccurs,itisimportanttodrawlessonsfromittohelppreventfuturerecurrenceofsimilaraccidents.ThissetofguidelinesisaimedathelpingACIAsiaPacificairportsidentifytherootcauses,oftennotthesameastheseemingcause,ofaccidentsandincidents.Themethodofdatacollectionsuchassourcesofinformationandthetechniquesininterviewingwitnesses,oneofthemostimportantinformationsources,aresuggested.Severalapproachestosystematicallyanalyzingtheinformationcollectedaredescribed,fromthebasicfive-whyanalysistothemoresophisticatedATSBInvestigationAnalysisModel.Theguidelinesalsoprovideanoutlinestructureoftheaccidentinvestigationreportforthereader’sreference.Alistof“dos”and“don’ts”aregivenattheendtohelpavoidcommittingcommonmistakesintheinvestigationprocess,basedonthepracticalexperienceoftheMembersofACIAsiaPacificRegionalOperationalSafetyCommittee,theauthorsofthisbooklet.AcknowledgementACIAsiaPacificexpressesitssinceregratitudetoallMembersoftheACIAsiaPacificRegionalOperationalSafetyCommitteewhoparticipateddirectlyinthedraftingofthisdocument,inparticular,NarayanasamyVenkatachalapathy(Hyderabad),wholedthegrouptaskedwiththisdraftingwork,andJoséMarçal(Macau)whoactedasgroupleaderatoneoftheworkingsessions.NottobeforgottenandnolessimportantofcourseareotherCommitteemembers:AbdulHakimAlShaibani(Bahrain),DavidWilson(Oman),JoséMendes(Yangon),NaushadKannu(Dubai),TurkiAl-Aufi(SaudiArabia),PhethaiChanthima(Thailand),WingYeung(HongKong)whoaltruisticallygavedisinterestedadvicesinthewritingofthisdocument,tothebenefitsoffellowairportmembersintheregion.ACIAsiaPacificshouldalsothankAlishaTham(Singapore),DarinaKuasakul(Thailand),FareedMalek(Bahrain),KelvinSee(Changi),KazuyaIino(Narita),NaserMohamedAlMannaei(Bahrain),andRezaRakhshaniMoghaddam(Iran)forhavingactivelyparticipatedandcontributedinthedraftingwork.ACIAsiaPacific,May201931.PurposeThepurposeoftheseguidelineson“AccidentInvestigationandRootCauseAnalysis”istohelpACIAsia-Pacificmemberairports:•Drawlessonsinpastaccidentssoastobetterpreventreoccurrenceofsimilaraccidentsandincidentsinthefuturebyunderstandingandaddressingtherealrootcausesofsuchaccidentsandincidentsratherthansuperficialsymptomsofsafetyissuessuchasimmediatecauses;•Meetlocalregulatoryrequirementsonaccidentinvestigation;and•Identifysafetyhazardsandmitigatesafetyrisksasrequiredbyaproperaerodromesafetymanagementsystem(SMS)tobuildupariskregister.Whiletheseguidelinesareprimarilyforaccidentinvestigations,ACIAsiaPacificmembersairportsmaywishtousethemforinvestigatingincidentsandnearmissesinsupportoftheirSMS.Disclaimer:TheseguidelinesareprimarilyaimedatprovidingtechnicaladvicetoACIAsiaPacific’sMemberairportsintheinvestigationofaccidentsandincidentsontheairsideinvolvingpersons,vehicles,groundhandlingequipment,andaircraft.HowevertheyareNOTwrittenforthepurposeofinvestigatingaircraftaccidentsasdefinedinAnnex13totheConventiononInternationalCivilAviation(ChicagoConvention).ACIAsiaPacificMembersareremindedthatnationalregulationsmustbecompliedwithinaccidentinvestigations.ACIAsiaPacificshallnotbeheldresponsibleforlossordamagecausedbyerrors,omissionsormisinterpretationofthecontentsoftheseguidelines.2.CollectionofEvidenceThefirststepinaccidentinvestigationistocollectevidencepertinentto...