From analysis to prevention of aircraft accidents:
exploring technical innovation and culture change

The Course
The subject of last year’s Advanced Training Course, held at Forlì, was the role of management in aviation organisations and other complex systems in which human error is seen as the main determining factor in accidents.
Prof. James Reason’s lectures gave an ample demonstration of the way in which human error is not an indicator of negligence or incompetence. It is necessary to understand the underlying reasons for errors made by human beings in the course of performing their duties, in order to avoid such errors having potentially catastrophic results.
At the beginning of the 90s, analysis of accidents in complex systems looked at organisational management policy to identify the conditions most likely to lead to human error. This coined the phrase ‘organisational accident’ referring to catastrophic events in which the final, crucial error was the result of a series of latent defects capable of eroding the defensive barriers of the whole system.
All those involved in managing complex systems need information, tools and procedures to reveal shortcomings that could lead to human error, in order to understand how defence systems may be eroded, thus making it possible to predict such shortcomings and minimise or manage the consequences.
The current response to this need, in methodological terms, is a Safety Management System (SMS). The 2005 course provided the basic requirements for setting up an SMS in the context of air traffic, airports and those involved in flight operations.

Next October’s Advanced Training Course will tackle some aspects of an airport SMS in greater depth, from the point of view of typical accidental operating events, in particular, runway incursions.
The 2006 Advanced Training Course will put a great deal of emphasis on the process of analysing an accident or disaster, providing a concise and effective exposition of the regulatory framework for international civil aviation, together with reporting on the actual investigations following air disasters that inevitably have a high media profile.
The public perception of air crashes, the difficult task of communicating, outside expert circles, the knowledge gained from an objective analysis of the causes, the hermetically sealed language of specialists in their own field, can all frequently be obstacles to that cultural evolution necessary for an innovative relationship with high technology. This is a relationship that must be based on the operating strategies of front line personnel.
There have been notable delays in setting up the systems for reporting anomalous events, or ‘occurrences’ as they are referred to in EU Directive 2003/42/EC from the European Parliament and Council. Eurocontrol has identified the reason for these delays the lack of “the just culture”, at various levels in many member states, particularly at the legislative level, where the prevailing culture tends to militate against a meaningful exchange of information between frontline operators and management. The aim of this information exchange is to identify the mechanisms of human behaviour in extreme situations, with associated cognitive overload, and to define the relationship between these operating situations and the surrounding socio-technical environment. These mechanisms will be fully explored in the 2006 Advanced Training Course.
This year’s course at Forlì will again feature internationally renowned experts whose input will provide topics for discussion in what will be a profoundly innovative exploration of the relationship between human beings and high technology.

Who may attend the course
This course is essentially arranged for personnel assigned to safety and safety-related positions in an airline, an aerodrome, an air navigation service provider, aircraft industries or a government regulatory body who have a need to either review, evaluate, build, or improve upon a safety management plan. It is appropriate for safety officer who wants a more effective, realistic approach to safety program and for managers and supervisors who have responsibility for controlling risk in all complex systems.

Course topics
- Collection of evidence in aircraft accidents and reconstruction of logical sequence of events
- Human and organizational factors in safety management
- Hazard identification and risk management
- Risk management tools
- Management of complex hazardous systems
- Safety culture and senior management commitment
- Voluntary reporting of occurrences
- Documentation and references

Lecturers
Frank Taylor – Visiting Fellow - Cranfield Safety & Accident Investigation Centre
Göran Svensson – Inspector Swedish Civil Aviation Authority
Paul Louis Arslanian - Director Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (France)
Alain Agnesetti – Investigator Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (Francia)
Gavin McKellar – IFALPA Accident Analysis Chairman
Giuseppe Ardrizzo – Professor of Theory of Knowledge, Scuola Superiore “Majise”, Arvacata, Cosenza
Fabrizio Bracco – Professor at the Faculty of Psychology - University of Genova
Maurizio Catino – Professor at the Faculty of Sociology – University of Milan Bicocca
Francesco Preti - Performance Review Unit-Eurocontrol
Nadio Di Rienzo - General Manager ENAV S.p.A.
Mauro Pollio - President GESAC S.p.A. - Aeroporto Internazionale di Napoli
Fausto Cereti - President Assaereo
Silvano Manera - Director General of Civil Aviation
Franco Lodi – Master in Flight Safety – University of Bologna
Aldo Carlo Pezzopane – Master in Flight Safety – University of Bologna
Silvano Silenzi – Master in Flight Safety – University of Bologna

Course timetable
Click here to see timetable >>

Abstracts
Göran Svensson
Illustration of safety management concepts
- Milano Linate runway incursion accident
- Hazard scenarios and interfaces in aerodrome accidents
- Fact based Resource optimisation
- SMS regulations

Frank Taylor
Professional profile and personal attitude of the accident investigator
- Ustica accident
- Lockerbie investigation

Paul Louis Arslanian
Accident investigation in civil aviation
A timely and properly conducted investigation is not only essential to recover a high level of safety; it restores also the confidence into the aviation system or the Authority. But this can not be the result of brilliant improvisation, it requires organisation and competences. ICAO Annex 13 gives guide lines and standards to the State members but, nevertheless, there are instances of not compliance with them. Discussion will be on how those shortcomings have a negative influence on effective prevention process.

Alain Agnesetti
A case study: a Boeing 727 flight GIH 141 crashed during takeoff roll at Cotonou (Benin). Presentation of some critical aspects of the technical investigation
On 25 December 2003, the aircraft arriving from Conakry (Guinea), operating to Kufra (Libya) and Beirut (Lebanon) and Dubai (United Arab Emirates) stopped over at Cotonou. During takeoff the airplane, overloaded in an anarchic manner, was not able to climb at the usual rate and struck an airport building located a hundred and eighteen meters past the runway end on the extended runway centerline, crashed onto the beach and ended up in the ocean.

Gavin McKellar
Focusing on Accident Prevention including Flight Data Monitoring
The focus and balance of accident prevention and risk. Investigating for cause or prevention. The non-punitive Flight Data Analysis experience. Making sure the FDA is used with crew input and part on the Accident Prevention Program. Identifying and implementing -plus monitoring-accident prevention measures. Principles of Operation and a Risk Management Model.

Giuseppe Ardrizzo
Steps to an ecology of safety

Fabrizio Bracco
Cognitive limitations and human error in high reliability systems
Turing claimed that “if a machine is expected to be infallible, it will not be intelligent, if it is expected to be intelligent, it will not be infallible”. Perhaps this stall is true for simple systems, but if we widen the analysis to high reliability systems we realize that it is necessary to develop a tight cooperation among designers, operators and researchers in the human factors domain, because if it is true that an infallible machine (i.e. reliable) cannot be intelligent, a well designed and managed system may be both infallible and intelligent.

Maurizio Catino
From human error to organizational errors: organisational models and accident aetiology in complex systems (6 hours)
Comparing different accident analysis models: political, engineering, human factor, organisational.
Principles of error management: errors and violations, instruments and models. Error inducing systems and vulnerable systems. A multi-level model of accident organisational analysis. The social and organisational set-up of error. Safety cultures and logics of inquiry: beyond the blame culture. Why it is difficult to learn from accidents: organisational myopia and veto players. Principles of High Reliability Organisations. Some case studies.

Francesco Preti
Safety performance review in European Air Navigation Services
Performance framework, indicators and data flow
Current status of the European safety performance review

Course Languages
Italian and English
During the whole Course, a simultaneous translation service Italian-English / English-Italian will be available.

Course Director
Prof. Franco Persiani – Dean of the II Faculty of Engineering - University of Bologna

Teaching Programme Coordinator
Capt. Franco Lodi

Certificate
Participants will receive a certificate on successful completion of the course and earn 5 university credits.

Application
Course Fee: € 1.200
The notice for admission to the Course and the application forms can be downloaded from: www.unibo.it
The deadline for the admission application is the 26th of September 2006 (documentation must be sent by registered mail with return receipt, or by first-class post (“posta celere”) with return receipt and shall have to arrive no later than 26th September 2006).

Course Location
The Course will be held in the Aula Magna of ENAV Academy in Forlì, Via Montaspro (nearby Forlì Airport).
How to reach ENAV ACADEMY >>

Organisation The Course is organised by ISAerS – Soc. Cons. a r.l. For further information please contact: Mrs Chiara Mattarelli e-mail:chiara.mattarelli@isaers.com Phone: +39 0543 473330 Fax +39 0543 787217

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