If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user
Safety Occurrence Reporting
From SKYbrary Wiki
Safety reporting is the filing of reports and collection of information on actual or potential safety deficiencies.
Safety occurrence is the term used to embrace all events which have, or could have significance in the context of aviation safety, ranging from accidents and serious incidents, through incidents or events that must be reported, to occurrences of lesser severity which, in the opinion of the reporter could have safety significance.
Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies. It plays an essential role in accident prevention enabling the identification of appropriate remedial actions by prompt analysis of safety data and by the exchange of safety information.
The ICAO requirements laid down in several Annexes to the Chicago Convention, relating to the implementation of safety management systems (SMS), require that aviation service providers develop and maintain, within the scope of their SMS, a formal process for collecting, recording, acting on and generating feedback about hazards in operations. The process shall be based on a combination of reactive, proactive and predictive methods of safety data collection. More detailed requirements and guidance on safety occurrence reporting are contained in Annex 13 - Aircraft accident and incident investigation and Doc 9859 - Safety Management Manual.
Responsibilities for Reporting
The aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware. The responsibilities for reporting, collection and exchange of safety data, and investigation of safety occurrences are established by ICAO Annex 13 and amplified in European Parliament’s Directives, EU-OPS/JARs, in ESARR 2 and in national regulations.
Additionally, operational personnel are required to report certain categories of safety occurrences to their employers and to the national authority under a national mandatory occurrence reporting scheme and internal (to the organisation) reporting system.
It is important to establish clearly the relationship between the various reporting requirements set by international organisations and state regulators. ICAO Annex 13 puts requirements on States to establish and operate a mandatory incident reporting system to collect information about actual or potential safety hazards. In addition, States are encouraged to implement a voluntary incident reporting system to facilitate the collection of information that could not be captured by the mandatory incident reporting system. States should support incident reporting by creating a non-punitive environment through appropriate adjustments in their legislative and regulatory frameworks.
Mandatory occurrence reporting requirements for aviation service providers and operating personal are set by the State regulatory and investigation authorities in compliance with ICAO provisions. Such national regulatory reporting requirements and related means of compliance may vary widely throughout the States.
Safety occurrence reporting in Europe is also regulated by EASA requirements and EU directives. For example, EU-OPS recommends that "An operator shall establish procedures for reporting accidents and serious incidents..."  Furthermore, the operator must report the occurrence as quickly as possible, to the National Authority in the State of operator’s registration and to the Authority in the State where the occurrence took place. The report must be made within 72 hours of the occurrence and in case of an accident - before the aircraft is moved. The State of Occurrence of an accident or serious incident shall forward the notification with a minimum delay to the State of Registry, the State of the Operator, the State of Design, the State of Manufacture and ICAO. The notification shall be in plain language and contain as much details as readily available.
A harmonised and consistent reporting of safety occurrences is yet to be achieved by the aviation industry. ICAO has joined forces with aviation industry partners in an effort to develop common terms, definitions and taxonomies for aviation occurrence reporting systems in order to support safety data exchange and focus on common safety issues. A further step in the harmonisation of occurrence reporting in Europe is the coming into force of the Regulation (EU) No 996/2010 on the investigation and prevention of accidents and incidents in civil aviation.
In order to harmonise the reporting of safety occurrences in ATM, EUROCONTROL has adopted in 2000, ESARR2. This regulatory document established a list of ATM-related occurrences which, as a minimum, shall be reported and assessed.
Safety reporting systems should not be restricted to accidents and incidents, but should include reporting of hazards and unsafe conditions that have not yet caused an incident. For example, some organisations have put in place a mechanism for reporting of conditions considered dangerous or unsatisfactory by the operational personnel. Such reports are usually submitted under voluntary reporting arrangements and under internal reporting systems.
Most aircraft operators and air navigation service providers, aerodromes and maintenance organisations have established their own internal safety occurrence reporting system(s). Internal reporting usually includes all mandatory reportable occurrences, safety occurrences and observations subject to voluntary reporting and where available, automatic monitoring and reporting of events. A number of organisations use reporting forms based on (or the same as) those used by the national mandatory occurrence reporting scheme (MOR) in order to standardise procedures and to reduce delay if it is decided by the employer that a MOR form should be filed.
Occurrence reporting may take several forms according to the perceived severity of the safety hazard:
- Accident and serious incident reporting in accordance with standards laid down in ICAO Annex 13;
- Mandatory Occurrence Reporting in accordance with national regulations (includes also accidents and serious incidents);
- Voluntary Occurrence Reporting established in line with existing guidance
- Confidential Reporting, a specific voluntary reporting scheme existing in many countries, encouraging the reporting of occurrences which would probably not be reported in the absence of such a scheme. However, heavy use of a confidential reporting scheme may indicate a deficient organisation safety culture.
- Self-disclosure reporting systems (data from automatic and manual capture systems such as data from FDR and CVR, EUROCONTROL’s Automated Safety Monitoring Tool (ASMT) etc.)
The reporting arrangements referred to above shall be used to:
- Identify hazards and/or notify of potential systems weaknesses
- Analyse the reported information to identify safety risk
- Identify and implement improvements to eliminate safety shortcomings, eliminate hazards or mitigate their effects and to prevent hazard recurrence
Safety occurrence reporting should not be used to blame individuals or to hold them accountable for the safety occurrences or unsafe acts. It is a powerful tool for the establishment and verification of effective risk management strategies by aviation service provider organisations.
Effective Safety Reporting
Effective safety reporting of hazards by operational personnel is an important cornerstone of the management of safety. Therefore, an operational environment in which operational personnel have been trained and are constantly encouraged to report hazards is the prerequisite for effective safety reporting.
According to ICAO Doc 9859 Safety Management Manual, the effective safety reporting builds upon certain basic attributes, such as:
- a) senior management places strong emphasis on hazard identification as part of the strategy for the management of safety, and as a consequence there is an awareness of the importance of communicating hazard information at all levels of the organisation;
- b) senior management and operational personnel hold a realistic view of the hazards faced by the organisation’s service delivery activities, and as a consequence there are realistic rules relating to hazards and potential sources of damage;
- c) senior management defines the operational requirements needed to support active hazard reporting, ensures that key safety data are properly registered, demonstrates a receptive attitude to the reporting of hazards by operational personnel and implements measures to address the consequences of hazards;
- d) senior management ensures that key safety data are properly safeguarded and promotes a system of checks and balances so that reporters of hazards feel confident that hazard reporting will not be put to uses other than for which it was implemented (the management of safety);
- e) personnel are formally trained to recognize and report hazards and understand the incidence and consequences of hazards in the activities supporting delivery of services; and
- f) there is a low incidence of hazardous behaviour, and a safety ethic which discourages such behaviour.
According to ICAO there are five basic traits which are connected to the effective safety reporting systems (Figure 1).
The basic attributes of effective safety reporting discussed are explained as follows:
- Willingness. As a consequence of deliberate efforts by senior management to define the operational requirements needed to support active hazard reporting and to ensure that key safety data are properly registered, operational personnel are willing to report hazards, operational errors that might arise from exposure to hazards, as well as their personal experiences as appropriate.
- Information. As a consequence of the formal training to recognize and report hazards and to understand the incidence and consequences of hazards in the activities supporting delivery of services, operational personnel are knowledgeable about the human, technical and organizational factors that determine the safety of the system as a whole.
- Flexibility. As a consequence of holding realistic views of the hazards underlying the organisation’s service delivery activities and the development of realistic rules relating to hazards and to potential sources of damage, operational personnel can adapt hazard reporting when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing information to quickly reach the appropriate decision-making level.
- Learning. As a consequence of the awareness of the importance of communicating hazard information at all levels of the organisation, operational personnel have the competence to draw conclusions from safety information systems, and the organisation has the will to implement major reforms.
- Accountability. As a consequence of key safety data being properly safeguarded, and the promotion of a system of checks and balances that ensures that reporters of hazards feel confident that hazard reporting will not be put to uses others than for which it was implemented, operational personnel are encouraged (and rewarded) for providing essential safety information related to hazards. However, there is a clear line that differentiates between acceptable and unacceptable operational performance.
- Annexes to the Chicago Convention:
- Annex 1 - Personnel Licensing,
- Annex 6 - Operation of Aircraft, Part I - International Commercial Air Transport - Aeroplanes and Part III - International Operations - Helicopters, ** Annex 8 - Airworthiness of Aircraft,
- Annex 11 - Air Traffic Services,
- Annex 13 - Aircraft Accident and Incident Investigation and
- Annex 14 - Aerodromes, Volume I - Aerodrome Design and Operations
- ICAO Doc 9859 - Safety Management Manual, Third Edition - 2013;
- ICAO ADREP 2000 Taxonomy, 17 September 2010
- ICAO Integrated Safety Management website
- 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
- Regulation (EU) No 996/2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC
- Safety Regulatory Requirement - ESARR 2, Reporting and Assessment of Safety Occurrences in ATM
- EUROCONTROL Voluntary ATM Incident Reporting - EVAIR - PAN European voluntary ATM incident reporting programme
- The Transition From Event Reprts to Measurable Organizational Impact: Workshop Proceedings Report, Avers et al., FAA, 2014