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Safety’s Cornerstone

Incident reporting” – really a form of feedback – dates back to ancient humans reporting, for example, which arrow flew accurately and then assessing why the others did not. The more technology has affected our lives, the more important incident reporting has become. In aviation, some simple forms of incident reporting were in place from the beginning.


February 23, 2009
By Roger Beebe

Topics

"Incident reporting” – really a form of feedback – dates back to ancient humans reporting, for example, which arrow flew accurately and then assessing why the others did not. The more technology has affected our lives, the more important incident reporting has become. In aviation, some simple forms of incident reporting were

     
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Accidents and incidents cost money and profits.


   

in place from the beginning. Early pilots reported back to designers and maintainers what worked and what did not. Manufacturers started to request more feedback as their aircraft and systems became more complex. By the Second World War, reporting systems came into general use. Companies realized that accurate and frequent reporting would prevent repetition of operational accidents and help to improve system and aircraft reliability. This led to more aircraft and crews for more operations, or in civilian terms, more profit.

Military operators around the world did not make maximum use of incident reporting until the seventies when flight safety had become a bigger issue. Wartime losses in training or combat were accepted as the cost of doing business. As aircraft and training of crews became more expensive, a different approach to preventing accidents began to take shape. Incident reporting and analysis was a cornerstone of this work. Most of the civilian reporting went back to the aircraft and equipment manufacturers for product improvement purposes. Civilian operators had different drivers; accidents and incidents cost money and profits. In addition, they did not give the paying passengers an acceptable degree of comfort.

My personal experience with reporting began as a maintainer on CF-104s in Europe in the early sixties. We completed forms known as Unsatisfactory Condition Reports that recorded the technical details of equipment failures. It was tedious and sometimes, being young, we did not appreciate the importance of this part of our work and its benefits. Operational incidents were also reported. We would see the results of some of this in the RCAF safety magazines which we were encouraged to read in our spare time.

WHY DO WE REPORT?
The obvious answer is to improve the system and advance aviation safety, but for many it is because we are mandated to by regulations. In a perfect world we would all report without being asked, but life doesn’t work that way. Aviation safety regulators led by the U.S. Federal Aviation Administration and the U.K. Civil Aviation Authority and others realized in the sixties that flight safety improvements could be made if more data was available to the regulators, designers, manufacturers, maintainers and operators so they could analyze their products, procedures and practices for improvements. Another driver was the passing along of experiences so that we could learn by others’ actions, good or bad.

Today in Canada we have many forms of mandatory reporting which cover many areas of jurisdiction – environment, occupational health, medical, food safety, etc. Two such types of reporting which impact daily on the aviation industry are those that require accidents and incidents to be reported to the Transportation Safety Board (TSB), and to Transport Canada (TC). Our national air navigation service also has a major role in reporting. These demands fall onto organizations and individuals alike.

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In a perfect world we would all report without being asked, but life doesn’t work that way.


 

WHAT DO WE DO WITH REPORTS?
The reports flowing into either TC or the TSB generally follow similar routes but with somewhat different outcomes. The TSB analyzes its reports with an eye to advising the regulator, TC, of a pending or suspected safety issue and where it thinks regulatory changes may need to be made. TC receives some of the same data but also gets a large amount of data directly from the industry through service difficulty reports and daily occurrence reports from the air navigation system. In both cases, teams of experts in operations, engineering, human factors, manufacturing and maintenance review and take action on the findings. Some of the feedback from this work can be in the form of operations alerts, safety letters, service alerts and even Airworthiness

Directives. Some of this data can be used to trigger more direct regulatory action as well.
A large number of reports and incidents from one particular operator may lead to questions about the effectiveness of its Safety Management Systems or Quality Assurance Programs. This is the elephant in the room for many people. The question is how much of this data may be used for hard regulatory action.
Safety personnel are well aware that incidents themselves do not necessarily show non-compliance with regulations, standards or procedures but may indicate something related to the human factors present in any particular operation. To be a prudent operator or regulator this always needs to be checked out.

POSITIVE OUTCOMES OF REPORTING
One must believe that aviation safety is maintained and enhanced by incident reporting, or the entire exercise is suspect. It is hard to argue that the educational benefits and product improvements that come from incident reporting are not real. Operational incident reporting reminds and educates operators to be aware of the common human factors that can lead to operational incidents. Failure to follow tried and proven operating procedures and flying techniques come to mind. The vast flow of information in the airworthiness world leads to product improvements through modifications and enhanced service instructions. Equipment failures that have critical safety impact can be dealt with through Airworthiness Directives. These documents also alert the world community to the issue.

The aviation industry is very competitive but in the area of safety, the communication of incident-derived data maintains a cooperative work environment as the overall safety record of aviation has a direct effect on everyone involved. Incident reporting can also be seen as part of an organization’s due diligence – i.e., we had an issue and we shared it with the world and our regulator and then worked to resolve it.

DIFFICULTIES IN REPORTING
Humans inherently do not like to be embarrassed in front of friends and colleagues so we tend to hide our mistakes. It takes a lot of courage, training and commitment to fess up to our mistakes – it’s easier to write up a report on an equipment failure than to write one up on our own failure. “The bolt was corroded” is easier to write than “I forgot to clean it.”  Another factor is fear of ridicule. This can be devastating to one’s ego. Organizations can help by promoting incident reporting, review and discussion that result in a less intimidating environment.

Last but not least is fear of the law. The law can be the safety regulator or the civil and criminal law systems. Let’s not kid ourselves – the legal/regulatory system can be very frightening to those who are in most respects law-abiding and hard-working citizens. “If I report, to what extent I am opening myself up to a lot of grief? Maybe I should let this one pass.” Or, “Will the regulator use this incident to audit us? What if my boss thinks I caused the audit?” All of these thoughts are valid and need to be addressed.

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Well-educated and trained aviation staff will know why it is important to report incidents.


 

SOLUTIONS TO NON-COMPLIANCE
There are basically two ways to get people to report, or perhaps more correctly, a combination of two ways. The first is through education and the second is through regulation and enforcement. One would think that the preference would be through education. This would have to start in the aviation community college courses and be reinforced by company training, policy and procedures. Regulation can set the framework for what needs to be reported and how quickly, but enforcement is problematical primarily because one can only enforce what one can determine as evidence. As many incidents are the result of a single person’s performance, who would know? Only the honesty of the one causing the incident really counts. A reporting culture in a friendly environment is arguably the best system, with enforceable regulations as a safety net.

A safety culture set deeply into your organization is the best way to go. You may also add a reward system to it just to reinforce the desirability of reporting. Well-educated and trained aviation staff will know why it is important to report incidents to improve aviation safety. Human factors awareness training will help people understand that to err is human, but to not learn from your mistakes is detrimental.

IS A NON-PUNITIVE REPORTING CULTURE A JUST CULTURE?
Sometimes we confuse a just culture with a non-punitive culture. A just culture can have punitive measures built into it to deal with those who flagrantly ignore the norms of the organization and undermine the work of their colleagues. This is important in a reporting environment. One cannot condone those who do not report, as the information they have adds to the total. Also, those who report diligently will become disillusioned and perhaps stop if they see their efforts are not noticed and supported. The culture must reward those who conform and report, and motivate those who do not by some sort of sanction. This could be as simple as peer pressure. If all staff are alerted to the results of reporting by timely feedback, compliance will be voluntary. It is when no communication of results is evident that people fall by the wayside and fail to report results.

THE FUTURE OF REPORTING
There is no question that the future is bright and that incident reporting will be basic to all facets of aviation. Safety management systems demand robust communication and reporting. That’s just the start; analysis, action and feedback are as critical. The management systems in place now and being built for the future require this. One can argue that part of the safety record of modern aviation in Canada has been built on incident reporting.  Simply put, the benefit greatly outweighs the cost. Keep reporting.


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