Federal Aviation Administration Aviation Safety Action Programs Training Module F: Participating in the ERC Meeting Version Date: 30 April 2012

Federal AviationAdministration

Aviation Safety Action Programs

Training Module F: Participating in the ERC Meeting

Version Date: 30 April 2012

2Federal AviationAdministration

Module F: Participating in the ERC Meeting 30 April 2012

Welcome and Instructions

• Instructor introduction– My ASAP background

– Other relevant information

• Housekeeping logistics– Duration/schedule, meeting room details, travel

logistics, restrooms, expectations for asking questions, breaks, emergency information



Student Introductions

• Name• Affiliation• Level of experience with ASAP• Something interesting (i.e., fun fact)



Overview of ASAP Training

• Training materials have been developed for:– Module A: Building ASAP Foundations

– Module F: Participating in the ERC Meeting

• Module F builds upon Module A – Module A should be completed before Module F

• Modules are being developed one at a time– Modules A and F—which cover the actual ASAP report

review process—were deemed the two most critical modules, and, thus, developed first



Overview of ASAP Training (Cont’d)

• Other training modules yet to be developed– Module B: Training ASAP Stakeholders– Module C: Collecting ASAP Reports– Module D: Preparing for the ERC Meeting– Module E: Facilitating the ERC Meeting– Module G: Performing Post-ERC Meeting Tasks– Module H: Analyzing ASAP Data– Module I: Communicating ASAP Data and Results– Module J: Conducting Internal ASAP Reviews– Module K: Managing Multiple ASAPs (if appropriate)



Module F: Overview of Contents

• Presentation of materials is logical– Roughly follows the order in which the ERC should

complete its duties

– Presented in a serial manner, though the ERC's work often requires an iterative process

• Materials include the best of all information available about the program– FAA ASAP guidance and industry best practices

• Audience consists of current or future members of an ASAP that is up and running



Module F: Overview of Objectives

At the completion of Module F, given these training materials as well as ASAP guidance materials and supporting resources course participants should be able to:

Obj 1 Describe the ERC and the purpose and processes of the ERC meeting

Obj 2 Apply teamwork strategies to the ASAP report review process

Obj 3 Conduct a thorough ASAP report investigation

Obj 4 Determine ASAP report acceptance

Obj 5 Reach consensus on the key decisions regarding an accepted ASAP report to determine its disposition

Obj 6 Determine and communicate the appropriate corrective action(s) and/or recommendation(s)

Obj 7 Determine the disposition of an accepted non-sole-source ASAP report with sufficient evidence of an apparent violation

OVERVIEW



Module F: Introduction

• Purpose of the training– Provide the knowledge, tools, and strategies

necessary for ERC members and ASAP Managers to overcome challenges and be successful

• Introductory Video– "Challenges for ASAP" presentation made in 2003 by

Dr. Thomas R. Chidester, Aerospace Human Factors Scientist with specialized experience in ASAP

– Describes high-level ASAP challenges

TChidester VTS_01_1_00.WMV



Challenges for ASAP and Strategies for Mitigating

• Identifying contributing factors– Strategies for accomplishing presented in Objective 3

• Handling a high volume of data– Strategies for accomplishing presented in Objective 3

• Recommending corrective action(s) beyond individuals– Strategies for accomplishing presented in Objective 6

• Providing operational feedback/publication– Strategies for accomplishing presented in Objective 6



Outline for Objective 1

Describe the ERC and the purpose and processes of the ERC meeting

Topics (T) and Activities (A):

T1-1 Purpose, roles, and responsibilities of the ERCT1-2 Overview and purpose of the ERC meetingT1-3 Consistency in the ASAP report review processA1-4 Practice applying a consistent strategy for reviewing ASAP reports

OVERVIEW

OBJECTIVE 1

OBJECTIVE 2

OBJECTIVE 3

OBJECTIVE 4

OBJECTIVE 5

OBJECTIVE 6

OBJECTIVE 7



Purpose of the ERC

• Ensure investigation of ASAP reports

• Identify causal contributor(s) of reported event and determine corrective action(s) and/or recommendation(s) to: – Reduce/eliminate likelihood of recurrence of that event

– Improve aviation safety

• Communicate safety threats to stakeholders

• Track completion

• Follow of a consistent process

T1-1: Purpose, roles, and responsibilities of the ERCOBJECTIVE 1



Responsibilities of the ERC

• Review and analyze submitted ASAP reports

• Determine whether reports qualify for inclusion in program

• Identify actual or potential threats to safety from information in reports, additional data gathered, and resulting analysis

• Specify corrective action(s) and/or recommendation(s), if applicable

• Use consensus to make critical decisions




Qualities of a Successful ERC Member

• Commitment to safety

• Expert knowledge about work of represented employee group, such as:– Work processes and changes in work over time– Policies, procedures, and regulations that guide the

work performed– Tools and equipment used

• Understanding of Threat and Error Management (TEM) model or other root cause analyses process




Purpose of the ERC Meeting

• Use information provided in ASAP report and gather additional information to:– Discuss and review each ASAP report

– Reach consensus on several key decisions

– Identify causal contributor(s) of the event

• Use a consistent process to review each report– Develop or adopt tools or processes to ensure

consistency (e.g., checklist, flowchart, decision tree)

T1-2: Overview and purpose of the ERC meetingOBJECTIVE 1



Report Review Process: Overview


• Legend



Report Review Process: Part 1

• Report acceptance process






• Process result (i.e., decision to accept or not)




• Determination of the disposition




Report Review Process: Dispositions

• Accepted reports: – ERC response

– FAA Letter of No Action

– Administrative or Informal Action

• Excluded reports:– Refer knowledge of the event to FAA

– Refer knowledge of the event to regional flight surgeon

– Refer actual ASAP reports that involve Big 5 violations (i.e., criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification) to FAA




Benefits of a Consistent Review

• Ensures timely review of reports

• Ensures each report is reviewed thoroughly

• Encourages informed discussion by ERC members

• Builds trust among ERC members

• Helps get ERC back on track if members are having trouble reaching consensus

• Helps ensure underlying causes of events are identified and reduced or eliminated

T1-3: Consistency in the ASAP report review processOBJECTIVE 1



Strategies for a Consistent Review

• Require ASAP Manager and ERC members have clear understanding of the report review process

– ASAP Manager, ERC members and their alternates are to be thoroughly trained before taking on responsibilities

• Adhere closely to internal/external policies and procedures as well as ASAP guidance materials and supporting resources




Strategies for a Consistent Review (Cont'd)

• Ensure resources are readily available during ERC meetings to facilitate/promote their use– If one doesn't already exist, develop a manual of ERC

processes and procedures (e.g., an ERC SOP)

• Adopt a process that is consistent from one report to the next– Following the FAA's ASAP Report Process Chart, or

something similar, step-by-step may help members focus on the ERC's required tasks and aid them to make better decisions




Practice Applying a Consistent Report Review Process

• What strategies can an ERC use to ensure consistency in the report review process?– Spend some time brainstorming independently and

then we will share ideas with each other

A1-4: Practice applying a consistent strategy for reviewing ASAP reportsOBJECTIVE 1




Apply teamwork strategies to the ASAP report review process


T2-1 Team-building strategiesA2-2 Practice team-building behaviorsT2-3 Consensus-building strategiesA2-4 Practice consensus-building behaviorsT2-5 Conflict management strategiesA2-6 Practice conflict management behaviors

OVERVIEW

OBJECTIVE 2

OBJECTIVE 1

OBJECTIVE 3

OBJECTIVE 4

OBJECTIVE 5

OBJECTIVE 6

OBJECTIVE 7



Team-building Behaviors

• Build trust

• Ensure quality communications

• Embody key personal characteristics

• Implement consensus-building strategies

• Monitor performance

• Provide support

T2-1: Team-building strategiesOBJECTIVE 2



Build Trust

• Show value in opinions/knowledge of others

• Ask questions to capitalize on the experience of other members

• Share information with fellow ERC members that cannot be shared outside the ERC

• Demonstrate the ability to consider the "big picture" by acknowledging situational factors

• Express confidence in the member responsible for completing individual tasks




Ensure Quality Communications

• Verbal communication strategies:– State points and ideas clearly and briefly, maintain an

even tone of voice, summarize points made to ensure understanding, ask questions when there is lack of understanding or clarity

• Listening strategies: – Wait until another member has finished before

speaking, use appropriate body language, make eye contact, refrain from distracting activities




Embody Key Personal Characteristics

• Be professionally mature

• Be open-minded

• Possess integrity

• Have belief in shared goal of improving safety

• Display trust in ASAP and pride in being part of the ERC through words and actions

• Be willing to set aside personal/organizational biases and to compromise




Monitor Performance

• Build on positive interactions – Identify patterns of positive interactions

– Recognize and/or reward positive behaviors

– Codify and add positive patterns to the ERC Standard Operating Procedures (SOP) Manual, if appropriate

• Eliminate or minimize negative interactions– Identify reason (e.g., specific report type, personality

issues) and resolve as appropriate

– Ask non-voting ASAP Manager to provide an unbiased perspective and possible suggestions




Provide Support

• Make an effort to understand responsibilities of ASAP Manager and fellow ERC members

• Offer assistance with tasks if another team member is overloaded

• Make suggestions or provide advice or feedback when appropriate




Practice Team-Building Behaviors

• We need 3 volunteers for this activity

• Each volunteer will be assigned a role on ERC – Certificate holder, FAA, or employee group

representative

• We will practice team-building behaviors assuming assigned roles

• We will use Sample ASAP Reports to practice

A2-2: Practice team-building strategiesOBJECTIVE 2



Practice Team-Building Behaviors (Cont'd)

• What could you say or do to show the certificate holder/FAA/employee group representative that you:– Value his or her opinion?

– Appreciate the situational factors that may have contributed to the event?

– Want to capitalize on the experience of the certificate holder/FAA/employee group representative?

A2-2: Practice team-building strategiesOBJECTIVE 2



Reach Consensus: Definition

• "Voluntary agreement of all ERC members to each decision required by the MOU" – Must fall within each ERC member's range of

acceptable solutions

– Resulting decision should be in best interest of safety

– If consensus is not reached on decisions concerning an ASAP report involving an apparent violation(s), a qualification issue, or a medical certification or qualification issue, the FAA ERC representative will decide how the report should be handled

T2-3: Consensus-building strategiesOBJECTIVE 2



Reach Consensus: Key Decisions

• There are several critical decisions about which the ERC must reach consensus, including, but not limited to:– Acceptance or exclusion of report– Designation of report as sole-source or non-sole-

source– Assessment of risk associated with the event– Development of corrective actions and

recommendations– Final disposition of the ASAP report




Reach Consensus: Strategies

• Practice • Set and document conduct rules in ERC SOP • Ask questions to ensure discussions are

based on an accurate understanding of issues

• Be open to other points of view• Anticipate perspectives of other members by

considering how they will view the issue• Focus on the facts




Practice Consensus-Building Behaviors



representative

• We will practice consensus-building behaviors assuming assigned roles


A2-4: Practice consensus-building behaviorsOBJECTIVE 2



Practice Consensus-Building Behaviors (Cont'd)

• What could you say or do during this ERC meeting to help the team to:– Build consensus on the appropriate corrective action

and/or recommendation?

– Encourage ERC members to state their perspective?

• How might you know during an ERC meeting that a member is having difficulty seeing the situation from another member's point of view?

A2-4: Practice consensus-building behaviorsOBJECTIVE 2



Manage Conflict: Strategies

• Refer often to the MOU as well as ASAP guidance materials and supporting resources

• Work to ensure that all information about a report and any policies regarding how to address it are understood by all

• Continue to gather information about event

• Look at issues from the other ERC members' points of view

• Re-center the group on the facts

T2-5: Conflict management strategiesOBJECTIVE 2



Manage Conflict: Strategies (Cont'd)

• Take a break to give members a few minutes to step away from the discussion and clear their thoughts

• Delay discussion or resolution of a report until the next meeting

• Bring in alternate ERC members

• Bring in a conflict resolution specialist

T2-5: Conflict management strategiesOBJECTIVE 2



Practice Conflict Management Behaviors



representative

• We will practice conflict management behaviors assuming assigned roles


A2-6: Practice conflict management behaviorsOBJECTIVE 2



Practice Conflict Management Behaviors (Cont'd)

• What are words that you might hear or behaviors you might see that indicate that the ERC is in conflict?

• What could you say or do during an ERC meeting to:– Manage conflict?

– Encourage additional productive discussion about the event?

A2-6: Practice conflict management behaviorsOBJECTIVE 2




Conduct a thorough ASAP report investigation


T3-1 Initial review of the ASAP reportT3-2 Event type and causal contributor taxonomies A3-3 Practice applying an event type taxonomy to an ASAP reportA3-4 Practice applying a causal contributor taxonomy to an ASAP reportT3-5 Methods for collecting and evaluating information beyond that included in the ASAP reportA3-6 Practice conducting investigative tasks during an ERC meeting

OVERVIEW

OBJECTIVE 1

OBJECTIVE 2

OBJECTIVE 3

OBJECTIVE 4

OBJECTIVE 5

OBJECTIVE 6

OBJECTIVE 7



Conduct an Initial Review of the ASAP Report

• Assess risk to determine whether the safety-related event represents a substantive threat to safety– Evaluate severity of event and likelihood of recurrence

• Typically performed by the ASAP Manager, who has immediate access to incoming ASAP reports

– Give immediate attention to high risk events • May require an emergency meeting of the ERC

T3-1: Initial review of the ASAP reportOBJECTIVE 3



Conduct an Initial Review of the ASAP Report (Cont'd)

• Anticipate and gather additional information likely to be needed to determine the disposition of a report– The ASAP Manager may want to gather additional

information in advance of the ERC meeting to allow the ERC to be more efficient in processing reports

• Goal is to gather additional information, not to evaluate it– It is the ERC's responsibility to evaluate the

information as a team

T3-1: Initial review of the ASAP reportOBJECTIVE 3



Best Practice for ASAP Report Collection

• Require ASAP report submitters to: – Identify event type and causal contributor(s)

– Use taxonomies (i.e., classification systems) to do so

• ASAP Manager may review this information during initial review of the report

• ERC should also consider and evaluate it during their report review process

T3-2: Event type and causal contributor taxonomiesOBJECTIVE 3



Overview of Event Type, Causal Contributor(s), and Taxonomy

• Event type: the kind of safety-related event that occurred – E.g., altitude deviations, weight and balance errors

• Causal contributors: factor(s) that caused the event to occur – E.g., confusing policy, lack of training, distraction

• Taxonomy: a classification system that provides well-defined and standardized options from which submitters can choose




Importance of an Effective Taxonomy

• Improves quality of data collected

• Provides an important source of information regarding root cause(s) of an event

• Helps identify reports with common elements

• Facilitates communication about ASAP reports within certificate holder and industry– Order 8900.1 recommends adopting part or all of the

endorsed national taxonomy from the Aviation Safety Information Analysis and Sharing system or ASIAS




Characteristics of an Effective Taxonomy

• Contains a comprehensive set of non-overlapping categories

• Uses terminology familiar to stakeholders

• Provides definitions and examples

• Provides a way to record "other" issues that may not be reflected in existing taxonomy

• Requires submitters to select a category from a list of categories within taxonomy




Example Taxonomy of Event Types for Dispatchers




Practice Applying an Event Type Taxonomy

• Silently read and carefully review the Sample Dispatch Report for this activity

• Envision that you are in a dispatch ASAP ERC meeting

• Write down what you believe is the correct assignment from the dispatch taxonomy on the previous slide

A3-3: Practice applying an event type taxonomy to an ASAP reportOBJECTIVE 3



Practice Applying an Event Type Taxonomy (Cont'd)

• Which event type(s) did each of you assign to this report?

• What was your reasoning for selecting the event type(s)?

A3-3: Practice applying an event type taxonomy to an ASAP reportOBJECTIVE 3



Example Taxonomy of Causal Contributors for Pilots

• Policies or Procedures

• Human Factors

• Organizational Factors

• Hardware

• Weather or Environment

• Airspace or ATC

Note: each causal contributor would include a detailed definition with examples




Practice Applying a Causal Contributor Taxonomy

• Silently read and carefully review the Sample Pilot Report for this activity

• Envision that you are in a pilot ASAP ERC meeting working together to evaluate this report

• Write down what you believe is the correct assignment from the example pilot taxonomy on the previous slide

A3-4: Practice applying a causal contributor taxonomy to an ASAP reportOBJECTIVE 3



Practice Applying a Causal Contributor Taxonomy (Cont'd)

• Which causal contributor(s) did each of you assign to this report?

• What was your reasoning for selecting the causal contributor(s)?

A3-4: Practice applying a causal contributor taxonomy to an ASAP reportOBJECTIVE 3



Collecting Information Beyond that in the Report

• A thorough investigation of ASAP reports is essential for ensuring that ERC members obtain a complete picture of each event– Although the information included in the ASAP report—

including the event type and causal contributor identified by the report submitter—provide a critical starting place, additional information may need to be collected as part of the ERC's review of the report

T3-5: Methods for collecting and evaluating information beyond that included in the ASAP reportOBJECTIVE 3



Methods for Gathering Additional Information

• Talk with report submitter for clarity of event

• Review other reports filed about same event

• Talk with other crew members

• Talk with others who perform the job

• Read relevant policies/procedural manuals

• Request and review supporting materials

• Review relevant training materials

• Recreate event/revisit site of incident




Strategies for Gathering Additional Information

• Timing– Before: Some tasks may be done in advance of the

meeting and can thus increase the ERC's efficiency

– During: Some tasks may be best conducted during the ERC meeting

– After: Some tasks may not be known until ERC has discussed the event, and should thus be done after

• Assignment– The member who is best positioned—based on role,

timing, convenience—should gather the information




Practice Conducting Investigative Tasks During ERC Meeting

• Please break into groups of 3-4 students

• Review Sample ASAP Report for this activity

• Work together in your assigned groups to determine what aspects of the sample report your group believes need to be investigated

• Record what your group decides need to be investigated

A3-6: Practice conducting investigative tasks during an ERC meetingOBJECTIVE 3



Practice Conducting Investigative Tasks During ERC Meeting (Cont'd)

• Which aspects of the report did each of you decide needs to be investigated?

• What was your reasoning for "investigating" those aspects of the report?

• When and where might you go to obtain the information?

• How will you know when you are "done" with the investigation?

A3-6: Practice conducting investigative tasks during an ERC meetingOBJECTIVE 3




Determine ASAP report acceptance


T4-1 ASAP report acceptance criteriaT4-2 ASAP report exclusion criteriaA4-3 Practice applying acceptance and exclusion criteria to an ASAP report

OVERVIEW

OBJECTIVE 1

OBJECTIVE 2

OBJECTIVE 3

OBJECTIVE 5

OBJECTIVE 6

OBJECTIVE 7

OBJECTIVE 4



Determination of ASAP Report Acceptance or Exclusion

• ERC applies acceptance criteria contained in certificate holder's MOU – Reports must meet all MOU criteria for acceptance

• ERC reaches consensus on all criteria for acceptance or exclusion – Consensus: voluntary agreement of all ERC members

to each decision required by the MOU

T4-1: ASAP report acceptance criteria OBJECTIVE 4



Acceptance Criteria

• Employee of certificate holder and acting in an official capacity at the time event occurred

• Event does not appear to involve one or more of the Big 5 violations– Criminal activity, substance abuse, controlled

substances, alcohol, or intentional falsification

• Event appears to be an inadvertent violation – Results from inattention/lack of purposeful choice; not

the result of an alleged violator's conscious decision




Acceptance Criteria (Cont'd)

• Event appears not to involve intentional disregard for safety– Examples of intentional disregard for safety can be

found in AC-120-66B paragraph 14b

• Report was submitted on time according to the definition of timeliness in the MOU – Timeliness is typically within 24 hrs of end of duty day

– MOU may state "a sole-source report that meets all other ASAP acceptance criteria except timeliness will be accepted"




Acceptance Criteria (Cont'd)

• Reaching consensus on whether a report meets the acceptance criteria does not always entail a simple yes/no answer to these questions – It may require substantive investigation as described in

Objective 3




Acceptance Criteria – Special Cases

• Repeated violations by a single person may be accepted, but:

– Report must otherwise satisfy acceptance criteria

– ERC will consider corrective action(s) case-by-case• Newly assigned corrective action will likely need to be different

than the one originally assigned

• Non-reporting employees covered under MOU– Determined case-by-case whether employee knew or

should have known about apparent violation• ERC may offer non-reporting employee opportunity to submit




Acceptance Criteria – Special Cases (Cont'd)

• Non-reporting employees not under MOU– Determined case-by-case whether employee knew or

should have known about apparent violation• ERC may elect to explain ASAP/provide opportunity to submit

• Voluntary Disclosure Reporting Program (VDRP)-qualified reports

– Certificate holders should use VDRP to report their own violations revealed through ASAP

• ERC should notify certificate holder of possible certificate holder violations so that they can file a VDRP




ERC's Processing of Accepted ASAP Reports

• ERC must reach consensus on several key decisions, including whether:– Report involves a lack of qualification – ERC has a corrective action for the report submitter or

a recommendation for the certificate holder– A violation of 14 CFR occurred – All evidence of apparent violation was found through

report (i.e., sole-source or non-sole-source)– There is sufficient evidence of a violation of 14 CFR

outside of the ASAP report (for non-sole-source only)




Exclusion Criteria

• Several of the exclusion criteria are the reverse of the acceptance criteria:

– A Big 5 violation

• Criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification

– An act that was not inadvertent

– An act that displayed an intentional disregard for safety

– Untimely submission of non-sole-source reports as specified by the certificate holder's MOU

T4-2: ASAP report exclusion criteriaOBJECTIVE 4



Exclusion Criteria (Cont'd)

• Additional exclusion criteria:

– Reports of events that occurred when report submitter was not acting as an employee of the certificate holder

– Failure to complete ERC's corrective action• Failure of a report submitter to complete recommended

corrective action in a manner satisfactory to all members of ERC regarding a report initially accepted into ASAP will result in exclusion of report

• Failure of a certificate holder to follow through with corrective action acceptable to the FAA to resolve any safety deficiencies will ordinarily result in termination of the program




ERC's Processing of Excluded Reports

• ERC notifies submitter that report has been rejected from ASAP

• If report is rejected and constitutes a violation of 14 CFR, FAA ERC representative refers event to FAA– In most cases, ERC does not send ASAP report itself

to FAA; ERC only refers knowledge of event to FAA – However, if report involves one of the Big 5 violations

ERC will refer actual ASAP report to FAA• FAA may use such reports for enforcement purposes, and will

refer them to law enforcement agencies, if appropriate




Practice Applying Acceptance and Exclusion Criteria

• Silently read and carefully review the Sample ASAP Report for this activity

• As you read, determine whether you believe the report should be accepted or rejected and why

• Write down your thoughts

A4-3: Practice applying acceptance/exclusion criteria to an ASAP reportOBJECTIVE 4



Practice Applying Acceptance and Exclusion Criteria (Cont'd)

• Should the report be accepted or excluded from ASAP? Why or why not?– Safety-related event?

– An apparent violation and/or qualification issue?

– Employee on-duty?

– Requirements for timely reporting met?

– Alleged violation inadvertent?

– Alleged violation an intentional disregard for safety?

– Report involve one of the Big 5 violations?

A4-3: Practice applying acceptance/exclusion criteria to an ASAP reportOBJECTIVE 4




Reach consensus on the key decisions regarding an accepted ASAP report to determine its disposition


T5-1 Lack of qualificationT5-2 Corrective action(s) and/or recommendation(s)T5-3 Apparent violations of 14 CFRT5-4 Sole-source and non-sole-source ASAP reportsA5-5 Practice determining whether an ASAP report is sole-source

or non-sole-sourceT5-6 Sufficient evidence of an apparent violation of 14 CFRA5-7 Practice determining whether sufficient evidence of a

violation exists for an ASAP-reported event

OVERVIEW

OBJECTIVE 1

OBJECTIVE 2

OBJECTIVE 3

OBJECTIVE 4

OBJECTIVE 6

OBJECTIVE 7

OBJECTIVE 5



Does the ASAP Report Involve a Lack of Qualification?

• Two types of qualification – Medical certification or qualification issue

• E.g., medical disqualification

– Requires referral to FAA's Regional Flight Surgeon

– Airmen qualification issue • E.g., failing to possess the skills and competency required for

the certificate held

– Requires an ERC consensus decision regarding appropriate corrective action for the submitter

T5-1: Lack of qualificationOBJECTIVE 5



Does the ASAP Report Involve a Lack of Qualification? (Cont'd)

• ERC should avoid concluding human error as the only causal contributor to an event– Errors can be the result of many contextual factors,

only one of which may be the individual's skills (or lack thereof)

• ERC may need to gather more information to adequately determine whether the event involved a lack of qualification– Refer to Objective 3 for a comprehensive list of

methods for gathering additional information

T5-1: Lack of qualificationOBJECTIVE 5



What are Corrective Action(s) and Recommendation(s)?

• Corrective action(s)– Safety-related action(s) directed at an individual

– Completion required by the ERC to minimize or eliminate recurrence of safety event

– Tracked for completion

• Recommendations– Safety-related action(s) directed at a certificate holder

or other entity (e.g., airport, manufacturer, FAA)

– Encouraged and tracked for completion, but cannot be required by the ERC

T5-2: Corrective action(s) and/or recommendation(s)OBJECTIVE 5



ASAP Report Merit Corrective Actions or Recommendations?

• In some cases, it may be appropriate to assign a corrective action to an individual– E.g., the ERC determines that the a violation occurred

as a result of a lack of knowledge/skill

• In most cases, though, the underlying causal contributor of the safety-related event will be the result of a larger problem, and should thus result in recommendations to larger entities

T5-2: Corrective action(s) and/or recommendation(s)OBJECTIVE 5



Does the ASAP Report Involve an Apparent Violation of 14 CFR?

• No apparent violation of 14 CFR– E.g., safety-related concerns held by members of

employee group• In this case, ERC will provide a response to submitter and

communicate recommendation(s) to address safety-related concern, if appropriate, to submitter and appropriate entity

• An apparent violation of 14 CFR– E.g., flight deviation, failure to update a flight plan

• In this case, ERC will continue to the next decision point (i.e., whether the ASAP report is sole-source or non-sole-source)

T5-3: Apparent violations of 14 CFROBJECTIVE 5



Is the ASAP Report Sole-Source or Non-Sole-Source?

• Sole-source means:– All evidence of violation is contained in or otherwise

discovered through the ASAP report

• For sole-source reports:– ERC acknowledges receipt of report (no FAA action)

• If report raises a qualification issue, ERC must address it with corrective action(s)

• If report does not raise a qualification issue, ERC will not assign corrective action(s)

– ERC shares with stakeholders any recommendation(s) given to other entities, as appropriate

T5-4: Sole source and non-sole source ASAP reportsOBJECTIVE 5



Is the ASAP Report Sole-Source or Non-Sole-Source? (Cont'd)

• Non-sole-source means:– Evidence of the violation exists outside of the ASAP

report and the FAA is aware of this evidence

• For non-sole-source reports:– ERC next determines whether there is sufficient

evidence of an apparent violation of 14 CFR• Sufficient evidence is discussed in Topic 5-6

T5-4: Sole source and non-sole source ASAP reportsOBJECTIVE 5



Practice Determining Sole-Source or Non-Sole-Source


• As you read, determine whether you believe the report should be considered sole-source or non-sole-source and why


A5-5: Practice determining whether an ASAP report is sole-source or non-sole-sourceOBJECTIVE 5



Practice Determining Sole-Source or Non-Sole-Source (Cont'd)

• Should the report be considered sole-source or non-sole-source? Why or why not?– Does the report include information that indicates it is

non-sole-source to the FAA?• What information suggests the FAA already knows of event?

– Additional investigation likely to reveal it is non-sole-source to the FAA?

• If so, what investigative tasks might reveal this information?

– What will happen if ERC decides it is sole-source?

– What will happen if ERC decides it is non-sole-source?

A5-5: Practice determining whether an ASAP report is sole-source or non-sole-sourceOBJECTIVE 5



Is there Sufficient Evidence of a Violation of 14 CFR?

• Sufficient evidence of a violation means:– Evidence (excluding what is in the ASAP report) would

likely have resulted in an FAA enforcement action, had the report not been accepted by ERC

• Non-sole-source without sufficient evidence– ERC closes report with an FAA Letter of No Action and

an appropriate ERC response to the submitter

• Non-sole-source with sufficient evidence – ERC closes report by determining appropriate type of

Administrative or Informal Action and an appropriate ERC response to submitter

T5-6: Sufficient evidence of an apparent violation of 14 CFROBJECTIVE 5



Is there Sufficient Evidence of a Violation of 14 CFR? (Cont'd)

• Certificate holder's use of ASAP reports – Certificate holder may not use the content of an ASAP

report to initiate or support any disciplinary action with the exception of the Big 5

– However, if the ASAP report is non-sole-source to certificate holder, this does not preclude the certificate holder from initiating or supporting disciplinary action if the certificate holder has sufficient evidence from a source other than the ASAP report that can be used to initiate or support disciplinary action

T5-6: Sufficient evidence of an apparent violation of 14 CFROBJECTIVE 5



Practice Determining Whether Sufficient Evidence Exists


• As you read, determine whether you believe:– The report is sole-source or non-sole source and why

– Sufficient evidence of a violation exists and why (or why not)


A5-7: Practice determining whether sufficient evidence of a violation exists for an ASAP-reported eventOBJECTIVE 5



Practice Determining Whether Sufficient Evidence Exists (Cont'd)

• Let's discuss:

– Is this a sole-source or non-sole-source report? • Why?

– Is there information in the report to indicate that sufficient evidence of a violation exists?

• Why or why not?

A5-7: Practice determining whether sufficient evidence of a violation exists for an ASAP-reported eventOBJECTIVE 5



Determine and communicate the appropriate corrective action(s) and/or recommendation(s)


T6-1 Strategies for determining corrective action(s) and/or recommendation(s)

T6-2 Strategies for communicating corrective action(s) and/or recommendation(s)

A6-3 Practice determining the appropriate corrective action(s) and/or recommendation(s)

OVERVIEW

OBJECTIVE 1

OBJECTIVE 2

OBJECTIVE 3

OBJECTIVE 4

OBJECTIVE 5

OBJECTIVE 6

OBJECTIVE 7




Corrective Actions and Recommendations: Purpose

• Prevent recurrence of the causal contributor to the safety-related event, thus increasing flight safety for all stakeholders

T6-1: Strategies for determining corrective action(s) and/or recommendation(s)OBJECTIVE 6



Corrective Actions and Recommendations: Definitions

• Corrective Actions– Any safety-related action(s) determined necessary by

ERC for an individual to prevent a recurrence of the event

– Report submitter is required to complete the corrective action to maintain report acceptance (i.e., binding)

• Recommendations– Any safety-related action(s) recommended by ERC

directed at a certificate holder or another entity (e.g., airport) to prevent a recurrence of the event

– ERC tracks but entity is not required to implement




Determination of Corrective Action(s)

• Determine root cause(s) of event

• Identify relevant party to receive

• Use a risk matrix to quantify level of risk associated with the event

• Determine the corrective action(s) and/or recommendation(s) that are most likely to address the identified causal contributor(s) and that is commensurate with the identified risk




Determine Root Cause(s)

• The best corrective action(s) and/or recommendation(s) are ones that will eliminate/ reduce likelihood of recurrence of root cause(s) of safety-related event

• As with the roots to a flower, ASAP Manager/ERC members often have to dig to uncover root cause(s)


{

{

Visible symptom(above the

surface/obvious)

Underlying or "Root"

Cause(s)(below the surface/not obvious)



Determine Root Cause(s) (Cont'd)

• No single approach exists• An iterative process is typically required

– Iterative steps of investigation, discussion, evaluation

• Potential strategies include:– Review the information the report submitter provided

regarding the event's causal contributors in light of the current information

– Use the "Five Why's" method in light of the current information




Evaluate Causal Contributor Information

• Review and discuss submitter's causal contributor(s) and evaluate its potential as the most likely underlying cause(s)

• Determine ERC's opinion of the most likely causal contributor(s)

• Evaluate any differences between report submitter's causal contributor(s) and the ones identified by the ERC

• Identify and record ERC's final decision




The "Five Whys" Method

• Use brainstorming to find causes– Ask "Why did the event occur?"

• Use answer to previous question to ask "Why" again– Continue asking "Why" until there is no new answer

• Portray answers in a simple chart or sequence• Aim for 5 rounds of asking "Why"– Use 5 as a target to ensure thorough investigation




Example of The "Five Whys" Method

• Problem: The milk is sour– Why? The milk carton was left on the counter all day

– Why? John forgot to put it in the refrigerator

– Why? John was late for school

– Why? John overslept

– Why? John studied late




Example of the Five Whys Method (Cont'd)




Identify the Relevant Party to Receive

• Individuals in employee group represented?– Report submitter(s)

– Other individuals who did not submit a report

• A larger entity inside certificate holder?– Training Dept., Policy and Manuals Dept., Safety

Office, Crew Scheduling Office, Maintenance Dept.

• A larger entity outside certificate holder?– An airport authority, an aircraft or equipment engineer

or manufacturer, a software developer, the FAA




Quantify the Level of Risk

• Involves summarizing information regarding the severity and probability of recurrence into a single number or score

• Options include:– Use a risk matrix already created for another program

within their certificate holder– Create one specifically for the ERC's use– Use Risk Assessment and Action Matrix (8900.1–EDP)

• See Objective 7 for more information on the Enforcement Decision Process and the Risk Assessment and Action Matrix




Determine the Best Corrective Action(s) or Recommendation(s)

• The "best" corrective action(s) and/or recommendation(s) prevent recurrence of the causal contributor by:– Addressing the true underlying cause of the event– Looking beyond correcting the individual toward

ensuring identification of true underlying root cause(s)– Addressing the occurrence of similar events over time

• As such, the ERC should focus on making recommendations to larger entities, rather than corrective actions to individuals




Example Corrective Actions and Recommendations

• Corrective action(s) for individuals– Participate in simulator training, formal or informal

counseling/mentoring, change in work/rest schedule

• Recommendation(s) for certificate holders– Change policy/procedure, modify tools/equipment,

update/correct manuals and training

• Recommendation(s) for other entities– Change feature of an airport, modify aircraft checklist

or procedures, modify the design of avionics




Communicate the Corrective Action(s) and/or Recommendation(s)• Strategies:

– Ensure communications are timely

– Ensure communications are clear

– Ensure that the focus of the communication is on prevention of any future threat to safety

– Ensure that the corrective action(s) and/or recommendation(s) is reasonable

– Set specific/realistic deadlines for completion

– Consider having the employee group ERC representative contact the report submitter first

T6-2: Strategies for communicating corrective action(s) and/or recommendation(s)OBJECTIVE 6



Verify Completion of Corrective Action(s)

• ASAP Manager (or appropriate ERC member) verifies an individual's completion of the corrective action(s) to the satisfaction of all ERC members– Failure of any individual to complete corrective

action(s) for an apparent violation, a qualification issue, or medical certification or qualification issue in a manner acceptable to all ERC members may result in the report being excluded from the program or in the reopening of the case and referral of the matter for appropriate action(s)




Track Completion of Recommendation(s)

• ASAP Manager (or appropriate ERC member) tracks the entity's implementation of the recommendation(s)– Failure of an entity to implement recommendation(s) in

a manner acceptable to all ERC members should lead the ASAP Manager (or appropriate ERC member) to follow up to determine and document the explanation

– Failure of a certificate holder to complete recommendation(s) in a manner acceptable to all ERC members may result in termination of the program




Practice Identifying Corrective Actions/Recommendations

• Please break into groups of 3-4 students

• Review Sample ASAP Report for this activity

• Work together in your assigned groups to identify one or more appropriate corrective actions and recommendations

• Record the corrective actions and recommendations your group identified

A6-3: Practice determining the appropriate corrective action(s) and/or recommendation(s)OBJECTIVE 6



Practice Identifying Corrective Actions/Recommendations (Cont'd)

• Which corrective actions/recommendations did each of you assign to this report?

• What was your reasoning for selecting these corrective actions/recommendations?

A6-3: Practice determining the appropriate corrective action(s) and/or recommendation(s)OBJECTIVE 6




Determine the disposition of an accepted non-sole-source ASAP report with sufficient evidence of an apparent violation


T7-1 Determination of risk level using a risk matrixT7-2 Determination of appropriate Administrative or Informal Action

OVERVIEW

OBJECTIVE 1

OBJECTIVE 2

OBJECTIVE 3

OBJECTIVE 4

OBJECTIVE 5

OBJECTIVE 6

OBJECTIVE 7



Use of the EDP and its Risk Assessment and Action Matrix

• EDP and its Risk Assessment and Action Matrix– Decision making and risk assessment tools developed

for Flight Standards Service (AFS) investigative personnel

– May be used by ERC for their review of ASAP reports• Alternately, the ERC can use a risk matrix created for another

program within their certificate holder or create one for their ERC's use, rather than using the EDP's Risk Assessment and Action Matrix

T7-1: Determination of risk level using a risk matrixOBJECTIVE 7



Risk Assessment and Action Matrix

• ERC may use the tool to guide their analysis of the facts and circumstances for:

– Accepted non-sole-source ASAP reports with sufficient evidence

• ERC may use the tool to determine which of the following actions is appropriate:




Applying the EDP

• FAA enforcement personnel use for all cases– Follow all 3 steps

• ERC may use for accepted non-sole-source reports with sufficient evidence– Automatically skip to

Step 3


Step 1

Step 2

Step 3



Determine the Severity of the Apparent Violation

• Severity is defined as:– Worst type of injury or damage that could realistically

occur from a generic violation of the type involved in the report

• The specific facts of the case should not be considered nor the likelihood of the severity being realized

• Severity may be classified as:– Catastrophic (death or severe injury)– Critical (severe injury or substantial damage)– Marginal (moderate injury or damage)– Negligible (minor or no injury or damage)




Determine the Severity of the Apparent Violation: Examples

• Catastrophic (death or severe injury)– A fuel exhaustion, irrespective of whether an actual

accident resulted– Operating with expired medical certificate, irrespective

of whether an actual medical condition exists

• Negligible (minor or no injury or damage)– Failing to carry a load manifest onboard the aircraft,

irrespective of any other factors because the failure to do so does not create a safety-of-flight condition

– Failing to enter update in logbook after installation of required component, irrespective of other factors




Determine the Likelihood of the Apparent Violation

• Likelihood is defined as:– Probability of worst type of injury or damage

realistically occurring, considering the specific facts of the case

• How likely is it that severity level would actually be realized, given the facts and circumstances involved?

• Likelihood may be classified as:– Frequent (likely to occur often)– Occasional (likely to occur sometimes)– Remote (unlikely to occur, would seldom occur, or so

unlikely can assume potential severity wouldn't occur)




Determine the Likelihood of the Apparent Violation: Examples

• For a restricted airspace incursion, likelihood becomes higher:– The longer the pilot operated in restricted airspace – The farther into airspace the pilot penetrated– The greater the number of other aircraft in the area

• For an aircraft operating without complying with Airworthiness Directives, the likelihood will be higher when:– If it is operated many hours beyond compliance date

rather than if it is operated only a few hours beyond




Determine Risk Level Associated with Safety-related Event

• Using the severity and likelihood criteria, the ERC determines the safety risk and corresponding action listed in EDP's Risk Assessment and Action Matrix




Determine Risk Level Associated with Safety-related Event (Cont'd)

• Legal Action and Remedial Training– These actions are not applicable for any ASAP reports– These actions are only intended for AFS investigative

personnel

• Administrative or Informal Action – These actions are only applicable for accepted non-sole-

source ASAP reports with sufficient evidence





• Illustration of how an ERC may modify the EDP's Risk Assessment and Action Matrix for the purpose of ASAP


Risk: HighAction: Administrative






• High Risk– Catastrophic + Frequent or Occasional – Critical + Frequent

• Low Risk– Marginal + Remote – Negligible + Occasional or Remote




Administrative Action

• Apply if the risk posed by the event is High, Moderate, or Low

• Possible Administrative Actions consist of:– Warning Notice

• A letter or form addressed to the apparent violator that advises that action/inaction was contrary to regulations, but does not warrant legal enforcement action; requests future compliance

– Letter of Correction• A letter to apparent violator either confirming their agreement

to complete corrective action within a specified time period or that identifies discrepancies or areas needing improvement

T7-2: Determination of appropriate Administrative or Informal ActionOBJECTIVE 7



Informal Action

• Apply if the risk posed by the event is Low– ERC must also verify the apparent violation does not

indicate a lack of qualification• Criteria is specified by step 2, criterion 3 in Electronic-EDP

(E-EDP) worksheet

• Possible Informal Actions consist of:– Oral Counseling

• Verbal guidance provided to apparent violator

– Written Counseling• Written guidance provided to apparent violator




Enforcement Investigative Reports

• EIR used to document, assemble, organize, and present all evidence and other relevant information obtained during an investigation– FAA ERC submits EIR to FAA, which is maintained in

employee's file for 2 years

• FAA ERC opens an EIR only for: – Accepted non-sole-source ASAP reports with sufficient

evidence of an apparent violation of 14 CFR in which Administrative Action is warranted

• EIR is not filed when Informal Action is used




Module FSummary



Module F Summary

• Module F: Introduction

• Objective 1: Describe the ERC and the purpose and processes of the ERC meeting

• Objective 2: Apply teamwork strategies to the ASAP report review process

• Objective 3: Conduct a thorough ASAP report investigation

• Objective 4: Determine ASAP report acceptance

SUMMARY



Module F Summary (Cont'd)

• Objective 5: Reach consensus on the key decisions regarding an accepted ASAP report to determine its disposition

• Objective 6: Determine and communicate the appropriate corrective action(s) and/or recommendation(s)

• Objective 7: Determine the disposition of an accepted non-sole-source ASAP report with sufficient evidence of an apparent violation

SUMMARY



Practice Participating in ERC Meeting

• We need 3 volunteers for this role play


representative

• I will play the role of the ASAP Manager

• Assuming the assigned roles, we will practice participating in the ERC meeting


Summary Activity: Practice Participating in ERC MeetingSUMMARY



Summary Activity: Practice Participating in ERC Meeting (Cont'd)• What is the first step in the process of

reviewing safety-related reports during the ERC meeting?– Role play the first step and discuss

• What is the second step in the process?– Role play the second step and discuss

• Continue this process until the ERC has completed its review and has determined the disposition of the report

Summary Activity: Practice Participating in ERC MeetingSUMMARY



Questions and Wrap-up

• Does anyone have any questions?

• Thank you for your participation in the training course for "Module F: Participating in the ERC Meeting"

Documents

Federal Aviation Administration Aviation Safety Action Programs Training Module F: Participating in the ERC Meeting Version Date: 30 April 2012