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Human error has been identified as a dominant risk factor in aviation operations. The errors trapped within daily operations are unlikely to be detected in the absence of effective error reporting.
Error reporting is fundamental to the broad goal of error reduction. At the organisational level, error reporting will only become an accepted and encouraged activity if aviation personnel feel safe in doing so. The following list depicts some good industry practices. It identifies common error reporting principles that can help to ensure that errors do not go unreported:
- Error reports should be used to find the root causes of the errors, not to establish blame or liability.
- Personnel involved in reporting should be given feedback of the results of the error analysis.
- The use of a non-punitive approach to reporting is recommended to encourage personnel to report errors.
- The mechanism for reporting errors should be made straightforward and easily accessible at all organizational levels.
- The electronic or hard copy reporting forms should be made unambiguous and easy to use.
Mandatory and Voluntary Occurrence Reporting
Voluntary error reporting facilitates the collection of information on actual or potential safety deficiencies thus contributing to the identification and implementation of safety improvement measures. It is a proactive process and should include related arrangements for collecting information about safety concerns, issues and hazards which otherwise will not be revealed by a mandatory reporting system. The principles of the successful voluntary reporting systems are described in detail in the dedicated article Voluntary Occurrence Reporting
Mandatory reporting systems imply that the individual at fault must report the error. However, analysis of serious errors almost always reveals multiple system failures and often the involvement of many individuals. The requirements for mandatory reporting is discussed in detail in the dedicated SKYbrary article Mandatory Occurrence Reporting
Error Reporting Barriers
Barriers to reporting must be addressed before a reporting system can have a substantial impact on operational safety. The barriers to error reporting fall primarily into the following categories:
- Fear of individual punishment or organisational repercussion;
- Belief that the operational error can be used as a measure of the individual's competence.
Generally, the voluntary reporting systems, being non-punitive, provide more useful information about errors and their causes than mandatory reporting systems. A major reason is that voluntary systems provide frontline personnel with the opportunity to tell the complete story without fear of punishment. The depth of information contained in these stories is vital to understanding the error. Staff who are forced to report errors are less likely to provide in depth information because their primary motivations are self protection and adherence to a requirement, not to help others avoid the same error. Voluntary systems also encourage practitioners to report hazardous situations and errors that did not cause harm but have the potential to do so.
Both mandatory and voluntary error reporting systems will prove futile in the absence of a strong, well designed system for analysis and response. When appropriate, the error reporting must result in effective, timely system changes that are visible, communicated and which are also upheld by accrediting bodies and national aviation authorities through standards that enhance aviation safety.
- Just Culture
- Safety Occurrence Reporting
- Reportable Incidents
- Human Error and Legal Process
- Protection of Safety Information Sources
- Safety Data Collection and Processing Systems (SDCPS)
- Using “Positive” Human Factors Data (OGHFA BN)
- Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014 on the reporting, analysis and follow-up of occurrences in civil aviation, amending Regulation (EU) No 996/2010 of the European Parliament and of the Council and repealing Directive 2003/42/EC of the European Parliament and of the Council and Commission Regulations (EC) No 1321/2007 and (EC) No 1330/2007;
- Commission Implementing Regulation (EU) 2015/1018 of 29 June 2015 laying down a list classifying occurrences in civil aviation to be mandatorily reported according to Regulation (EU) No 376/2014 of the European Parliament and of the Council;
- ESARR2 - Guidance for ATM Safety Regulators -Publication and Confidentiality Policy;
- ESARR2 -Establishment of “Just Culture” Principles in ATM Safety Data Reporting and Assessment;
- EUROCONTROL Voluntary ATM Incident Reporting (EVAIR)