Publication: ANÁLISIS Y PROPUESTA SOBRE LA INVESTIGACIÓN DE ACCIDENTES AÉREOS EN CHILE.
Date
2021
Authors
MARTÍNEZ ZÚÑIGA, IGNACIO NICOLÁS
Journal Title
Journal ISSN
Volume Title
Publisher
Abstract
La DGAC se ha encargado de investigar los accidentes e incidentes ocurridos a lo largo del territorio nacional, gracias a esta labor se ha podido crear este documento en el que se han recopilado 10 años de información obtenida de los informes de investigación registrados entre los años 2010 y 2020. Los resultados obtenidos de estos expedientes han permitido establecer un análisis que muestra la situación actual del proceso de investigación en Chile.
Para realizar este estudio se ha indagado en los modelos de análisis de causas, siendo el principal, el esquema H. Facts diseñado por la FAA, el cual se basa en los principios de identificación de fallas de seguridad del modelo de Queso Suizo de James Reason, con este se ha inspeccionado la metodología investigativa actual para clasificar las causas y factores de los accidentes e incidentes según cada categoría. Además se ha utilizado este sistema para proponer procedimientos para la investigación, para de esta forma identificar y categorizar las causas y factores que estos tienen, también, se han tomado ideas de otros conceptos como el Método de Causa y Efecto, para ver las correlaciones que existen entre cada causa-efecto que se presente; Bow-Tie para casos específicos en los que se tenga que analizar un evento en particular y el Árbol de Causas, para identificar que barreras fallaron dentro de lo que son las medidas de protección tomadas para la operación aérea.
Con el fin de obtener propuestas para la investigación, se han analizado las acciones y medidas efectuadas por otras agencias investigativas, como la NTSB, SHK y JTSB, además de examinar aspectos de provenientes de las normas ISO 9001-2015, la ISO 31000-2018 y del Sistema de Gestión de Seguridad (SMS). Entre las ideas que nacen de estos conceptos es; la formación de un equipo investigativo, evaluación e investigación del desempeño de otras organizaciones como los centros de mantenimiento, servicios de búsqueda de rescate y la propia autoridad aeronáutica en los casos que se estime necesario. Además, se ha decidido consultar las normativas y disposiciones que presenta actualmente la DGAC para sus investigaciones, siendo estás la DAR 13 (2021) utilizada para entender los conceptos asociados a un accidente o incidente y la DAP 13-02 (2017) que establece los procedimientos a seguir para un este tipo de eventos.
Al momento de haber recopilado cada accidente e incidente registrado en los informes de la DGAC, cada uno de estos han sido divididos acorde a los niveles que presenta el modelo H. Facts, clasificándolos según corresponda. Gracias a esto, se descubrió que las causas de los accidentes e incidentes están relacionadas principalmente a características del desempeño humano y a condiciones previas asociadas a estos. Por lo que tuvieron una alta predominancia en el Nivel I de Actos Inseguros y Nivel II de Precondiciones para Actos Inseguros. Mientras que, en el caso de los factores contribuyentes, este tipo de antecedentes cuentan con la misma predominancia que la presentada por las causas. Lo que demuestra que la concentración de las labores investigativas se encuentra en los niveles más bajos, siendo ínfimas las veces en que se presentan características asociadas a la Supervisión No Segura de Nivel III y a los Aspectos Organizacionales de Nivel IV.
Ante esta situación, se ha creado una propuesta investigativa que ha incorporado medidas provenientes de otras agencias; de la NTSB se ha obtenido la idea de formar un equipo de investigación, la creación de una base de datos, la investigación histórica de antecedentes y el seguimiento del caso. Mientras que de la SHK se agrega la investigación a organizaciones con una participación terciaria y por último de la JTSB se agregan las simulaciones y modelos digitales para casos que sean necesario. El modelo en sí incorpora estos elementos además de tomar como apoyo el modelo H. Facts para realizar las clasificaciones correspondientes para una base de datos. Resultando en un esquema similar al presentado por la DAP 13-04 (2017), pero agregando más información asociada a la aeronave y a la operación aérea que se estaba realizando, clasificando las causas y factores según el modelo H. Facts y haciendo un seguimiento posterior al caso. La información que posea el documento se codifica, para que de esta forma se pueda incorporar a una base de datos que permite registrar cada caso una vez finalizado su informe para de esta manera tener antecedentes asociados para próximas investigaciones.
Los presupuestos asignados para la implementación de la propuesta investigativa son de $174.553.183 pesos para el año 1, los cuales en el año 2 bajan a $166.621.825, esto ha representado un 71,25% y 68,02% de la inversión realizada en Seguridad Operacional en el año 2020. Con estos porcentajes se ha podido demostrar que estos valores son factibles.
The DGAC has overseen investigating accidents and incidents that have occurred throughout the national territory, thanks to this work, it has been possible to create this document in which 10 years of information obtained from the investigative reports recorded between 2010 and 2020 have been compiled. The results obtained from these files have made it possible to establish an analysis that shows the current situation of the investigation process in Chile. To carry out this study, the research has been done on the cause analysis models, the main one being the H. Facts scheme designed by the FAA, which is based on the principles of identification of safety failures of the Swiss Cheese model of James Reason, with this the current investigative methodology has been inspected to classify the causes and factors of accidents and incidents according to each category. In addition, this system has been used to propose procedures for the investigation, to identify and categorize the causes and factors that these have, also, ideas have been taken from other concepts such as the Cause and Effect Method, to see the correlations that exist between each cause-effect that is presented; Bow-Tie for specific cases in which a particular event has to be analyzed and the Tree of Causes, to identify which barriers failed within what are the protection measures taken for the air operation. With the purpose of obtaining suggestions for the investigation, the actions and measures carried out by other investigative agencies, such as the NTSB, SHK and JTSB have been analyzed, in addition to examining aspects from the ISO 9001-2015, the ISO 31000-2018 and the Safety Management System (SMS) standards. Among the ideas born from these concepts is the formation of an investigative team, evaluation, and investigation of the performance of other organizations such as maintenance centers, rescue search services and the aeronautical authority itself were deemed necessary. In addition, it has been decided to consult the regulations and provisions currently presented by the DGAC for its investigations, being these the DAR 13 (2021) used to understand the concepts associated with an accident or incident and the DAP 13-02 (2017) that establishes the procedures to follow for this type of events. At the time of compiling each accident and incident recorded in the DGAC reports, each one of them has been divided according to the levels presented by the H. Facts model, classifying them accordingly. Thanks to this, it was discovered that the causes of accidents and incidents are mainly related to human performance characteristics and previous conditions associated with them. Therefore, they had a high predominance in Level I of Unsafe Acts and Level II of Preconditions for Unsafe Acts. While, in the case of contributing factors, this type of antecedents has the same predominance as that presented by the causes. This shows that the concentration of investigative work is at the lowest levels, with very few cases of characteristics associated with Level III Unsafe Supervision and Level IV Organizational Aspects. In view of this situation, an investigative proposal has been created that has incorporated measures from other agencies; from the NTSB, it was obtained the idea of forming an investigation team, the creation of a database, the historical background investigation, and the follow-up of the case. While the SHK adds the investigation of organizations with tertiary participation and finally the JTSB adds simulations and digital models for cases that may be necessary. The model itself incorporates these elements in addition to taking as support the H. Facts model to perform the corresponding classifications for a database. Resulting in a scheme like the one presented by DAP 13-04 (2017), but adding more information associated to the aircraft and the aerial operation that was being performed, classifying the causes and factors according to the H. Facts model and making a subsequent follow-up to the case. The information contained in the document is coded, so that it can be incorporated into a database that allows recording each case once the report is completed, thus having associated background information for future investigations. The budgets assigned for the implementation of the research proposal are $174.553.183 CLP for year 1, which in year 2 decrease to $166.621.825, representing 71,25% and 68,02% of the investment made in Operational Safety in 2020. With these percentages it has been possible to demonstrate that these values are reasonable.
The DGAC has overseen investigating accidents and incidents that have occurred throughout the national territory, thanks to this work, it has been possible to create this document in which 10 years of information obtained from the investigative reports recorded between 2010 and 2020 have been compiled. The results obtained from these files have made it possible to establish an analysis that shows the current situation of the investigation process in Chile. To carry out this study, the research has been done on the cause analysis models, the main one being the H. Facts scheme designed by the FAA, which is based on the principles of identification of safety failures of the Swiss Cheese model of James Reason, with this the current investigative methodology has been inspected to classify the causes and factors of accidents and incidents according to each category. In addition, this system has been used to propose procedures for the investigation, to identify and categorize the causes and factors that these have, also, ideas have been taken from other concepts such as the Cause and Effect Method, to see the correlations that exist between each cause-effect that is presented; Bow-Tie for specific cases in which a particular event has to be analyzed and the Tree of Causes, to identify which barriers failed within what are the protection measures taken for the air operation. With the purpose of obtaining suggestions for the investigation, the actions and measures carried out by other investigative agencies, such as the NTSB, SHK and JTSB have been analyzed, in addition to examining aspects from the ISO 9001-2015, the ISO 31000-2018 and the Safety Management System (SMS) standards. Among the ideas born from these concepts is the formation of an investigative team, evaluation, and investigation of the performance of other organizations such as maintenance centers, rescue search services and the aeronautical authority itself were deemed necessary. In addition, it has been decided to consult the regulations and provisions currently presented by the DGAC for its investigations, being these the DAR 13 (2021) used to understand the concepts associated with an accident or incident and the DAP 13-02 (2017) that establishes the procedures to follow for this type of events. At the time of compiling each accident and incident recorded in the DGAC reports, each one of them has been divided according to the levels presented by the H. Facts model, classifying them accordingly. Thanks to this, it was discovered that the causes of accidents and incidents are mainly related to human performance characteristics and previous conditions associated with them. Therefore, they had a high predominance in Level I of Unsafe Acts and Level II of Preconditions for Unsafe Acts. While, in the case of contributing factors, this type of antecedents has the same predominance as that presented by the causes. This shows that the concentration of investigative work is at the lowest levels, with very few cases of characteristics associated with Level III Unsafe Supervision and Level IV Organizational Aspects. In view of this situation, an investigative proposal has been created that has incorporated measures from other agencies; from the NTSB, it was obtained the idea of forming an investigation team, the creation of a database, the historical background investigation, and the follow-up of the case. While the SHK adds the investigation of organizations with tertiary participation and finally the JTSB adds simulations and digital models for cases that may be necessary. The model itself incorporates these elements in addition to taking as support the H. Facts model to perform the corresponding classifications for a database. Resulting in a scheme like the one presented by DAP 13-04 (2017), but adding more information associated to the aircraft and the aerial operation that was being performed, classifying the causes and factors according to the H. Facts model and making a subsequent follow-up to the case. The information contained in the document is coded, so that it can be incorporated into a database that allows recording each case once the report is completed, thus having associated background information for future investigations. The budgets assigned for the implementation of the research proposal are $174.553.183 CLP for year 1, which in year 2 decrease to $166.621.825, representing 71,25% and 68,02% of the investment made in Operational Safety in 2020. With these percentages it has been possible to demonstrate that these values are reasonable.
Description
Keywords
ACCIDENTES AÉREOS , INVESTIGACIÓN DE ACCIDENTES