HAZARD REPORTING

• Do not let arguments develop or allow members to return to items already closed

• Make sure that the minutes are an accurate record of the committee’s conclusions

• Always let the committee know when action items are completed

• Ban mobile telephones from the meeting room!

3.4

HAZARD REPORTING

3.4.1 Staff must be able to report hazards or safety concerns as they become aware of them. The ongoing hazard reporting system should be non-punitive, confidential, simple, direct and convenient. Once hazards are reported they must be acknowledged and investigated. Recommendations and actions must also follow to address the safety issues.

3.4.2 There are many such systems in use. The reporting form for the Bureau of Air Safety Investigation (BASI), Australia Confidential Aviation Incident Reporting (CAIR) system could be adapted for this purpose (example reporting forms are provided in Appendix A). Ensuring a confidential and non–punitive system will encourage reporting of hazards. It should also allow for the reporting of hazards associated with the activities of any contracting agency where there may be a safety impact. The system should include a formal hazard tracking and risk resolution process. Hazards should be defined in a formal report. The report should be tracked until the hazard is eliminated or controlled to an acceptable risk. The controls should also be defined and should be verified as formally implemented.

3.4.3 What hazards should staff report?

3.4.3.1 All staff should know what hazards they are required to report. Any event or situation with the potential to result in significant degradation of safety and can cause damage and/or injury should be reported.

3.4.4 How will staff report hazards?

3.4.4.1 The Company might like to use existing paperwork, such as the pilot’s report, for flying operations. It is easy to provide a dedicated reporting form for other functional areas. Make sure that reports are acted upon in a timely manner by the person responsible for your safety program.

3.4.4.2 In a small organisation it may be difficult to guarantee the confidentiality of safety reports, so it is vital that a trusting environment is fostered by management. Make the reporting system simple and easy to use. Suggested reports:

• Pilot’s report

• Hazard/safety report form

3.4.4.3 The reporting system should maintain confidentiality between the person reporting the hazard and the Flight Safety Officer. Any safety information distributed widely as a result of a hazard report must be de-identified.

3.4.4.4 The system should include procedures such as:

• All safety reports go to the Flight Safety Officer

• The Flight Safety Officer is responsible for investigation of the report and for maintenance of the confidentiality of reports

• While maintaining confidentiality, the Flight Safety Officer must be able to follow- up on a report to clarify the details and the nature of the problem

• Anyone submitting a safety report must receive acknowledgement and feedback

• After investigation, the de-identified safety report and recommendations should be made widely available for the benefit of all staff

3.4.5 To whom will the reports go, and who will investigate them?

3.4.5.1 Management should be included in the risk management process. Decisions concerning risk acceptability should be made by management and they should be kept informed of all high risk considerations. Hazards that were not adequately dispositioned should be communicated to management for resolution.

3.4.5.2 Reports should be distributed to, as a minimum, the following:

• The person responsible for managing the safety programme

• The flight safety committee (if applicable)

• The originator of the report

3.4.6 Human Element in Hazard Identification and Reporting

3.4.6.1 The human is the most important aspect in the identification, reporting, and controlling hazards. Most accidents are the result of an inappropriate human action, i.e. human error, less then adequate design, less then adequate procedure, loss of situational awareness, intentional action, less then adequate ergonomic, or human factor consideration. Human contributors account for 80 to 90 % of accidents. To a system safety professional mostly all accidents are the result of human error.

3.4.6.2 At inception of a system, a hazard analysis should be conducted in order to identify contributory hazards. However, if these hazards were not eliminated, then administrative hazard controls must be applied, i.e. safe operating procedures, inspections, maintenance, and training.

3.4.6.3 The behaviour-based approach to safety focuses on the human part of the equation. The approach is proactive and preventive in nature. It is a process of identifying contributory hazards and gathering and analysing data to improve safety performance. The goal is to establish a continued level of awareness, leading to an improved safety culture.

3.4.6.4 To successfully apply the behaviour-based approach everyone in the organisation should participate. In summary, the people in the organisation are trained in hazard

identification. The concept of a hazard, (i.e. an unsafe act or unsafe condition that could lead to an accident), is understood. Participants develop lists of hazards in their particular environment and then they conduct surveys to identify unsafe acts or unsafe conditions. Hazards are then tracked to resolution. The process should be conducted positively rather

Section 3: Safety Program Activities June 2000

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than negatively. One does not seek to lay blame of assign causes. The participants are to be positively rewarded for efforts, thereby improving the safety culture.

3.4.7 Monitoring and Tracking (Feedback)

3.4.7.1 Maintaining the Air Safety Occurrence Database

3.4.7.1.1 Data for trend analysis is gathered from Air Safety Reports (ASRs) submitted by flight crew and ground crew. The purpose of these reports is to enable effective investigation and follow-up of occurrences to be made and to provide a source of information for all departments. The objective of disseminating reported information is to enable safety weaknesses to be quickly identified.

3.4.7.1.2 Paper records can be maintained in a simple filing system, but such a system will suffice only for the smallest of operations. Storage, recording, recall and retrieval is a cumbersome task. ASRs should therefore preferably be stored in an electronic database. This method ensures that the Flight Safety Officer can alert departments to incidents as they occur, and the status of any investigation together with required follow-up action to prevent recurrence can be monitored and audited on demand. 3.4.7.1.3 There are a number of specialised air safety electronic databases available (a list of

vendors is shown in Appendix B). The functional properties and attributes of individual systems vary, and each should be considered before deciding on the most suitable system for the operator’s needs. Once information from the original ASR has been entered into an electronic database, recall and retrieval of any number of single or multiple events over any period of time is almost instant. Occurrences can be recalled by aircraft type, registration, category of occurrence (i.e. operational, technical, environmental, etc.) by specific date or time span.

Note: IATA’s Safety Committee (SAC) operates a safety information exchange scheme (SIE) and compiles statistics using an electronic database. Stored records are de-identified and subscribers to the scheme have free access. Very small airlines (i.e. those having only one or two aircraft) can benefit in that they can measure their progress against the rest of the world and quickly identify global trends.

3.4.7.1.4 The database is networked to key departments within Flight Operations and Engineering. It is the responsibility of individual department heads and their

specialist staffs to access records regularly in order to identify the type and degree of action required to achieve the satisfactory closure of a particular occurrence. It is the Flight Safety Officer’s responsibility to ensure that calls for action on a particular event are acknowledged and addressed by the department concerned within a specified timescale. The database should not be used simply as an electronic filing cabinet.

3.4.7.1.5 Once the required action is judged to be complete and measures have been implemented to prevent recurrence, a final report must then be produced from consolidated database entries. The event can then be recommended for closure.