IMMUNITY-BASED REPORTING

3.5.1 It is fundamental to the purpose of a reporting scheme that it is non-punitive, and the substance of reports should be disseminated in the interests of flight safety only. 3.5.2 The evidence from numerous aviation accidents and incidents has shown that the lack of

management control and human factors are detrimental to the safe operation of aircraft. The management of safety is not just the responsibility of management, but it is

management who has to introduce the necessary procedures to ensure a positive cultural environment and safe practices.

3.5.3 Reviews of the safety performance of leading companies in safety-critical industries have shown that the best performers internationally use formal Safety Management Systems to produce significant and permanent improvements in safety. It is also important to develop a safety culture that encourages openness and trust between Management and the work force. For example, all employees should feel able to report incidents and events without the fear of unwarranted retribution. Reporting situations, events and practices that compromise safety should become a priority for all employees.

3.5.4 The aim of this guide is to introduce the elements of a safety management system. Each element will be measurable and its level of performance or efficiency will be measured at introduction and then at regular intervals. Specific and detailed targets will be set and agreed in each area to ensure continued incremental improvement of safety.

3.5.5 Confidential Reporting Programmes

3.5.5.1 It has been estimated that for each major accident (involving fatalities), there are as many as 360 incidents that, properly investigated, might have identified an underlying problem in time to prevent the accident. In the past two decades, there has been much favourable experience with non-punitive incident and hazard reporting programs. Many countries have such systems, including the Aviation Safety Reporting System (ASRS) in the United States and the Confidential Human Factors Incident Reporting Program (CHIRP) in the United Kingdom. In addition to the early identification and correction of

operational risks, such programs provide much valuable information for use in safety awareness and training programs.

3.5.5.2 These aspects are interdependent and a weakness in any one of them will undermine the integrity of the organisation’s overall management of safety. If the organisation is effective in all aspects, then it should also have a positive safety culture.

3.5.5.3 Reports should preferably be recorded in an electronic database such as BASIS (British Airways Safety Information System). This method ensures that departments are made aware of incidents as they occur, and the status of any investigation together with required follow-up action to prevent recurrence can be monitored.

3.5.6 Occurrence Reporting Schemes

3.5.6.1 Some States legislate a Mandatory Occurrence Reporting (MOR) scheme. If such a scheme does not exist it is beneficial for the company to initiate its own. Without prejudice to the proper discharge of its responsibility, neither the regulatory authority nor the company should disclose the name of any person submitting a report, or that of a

Section 3: Safety Program Activities June 2000

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person to whom it relates unless required to do so by law, or unless the person concerned authorises a disclosure. Should any flight safety follow-up action be necessary, the regulatory authority will take all reasonable steps to avoid disclosing the identity of the reporter or of individuals involved in the occurrence.

3.5.6.2 Occurrences Which Should be Reported to the Flight Safety Officer:

The following list is neither exhaustive nor shown in order of importance. Example reporting forms are provided in Appendix A. If there is any doubt, a report should be filed for any of the following:

• System defect occurs which adversely affects the handling characteristics of the aircraft and renders it unfit to fly

• Warning of fireorsmoke

• An emergencyis declared

• Safety equipment or procedures are defective or inadequate

• Deficiencies exist in operating procedures, manuals or navigational charts

• Incorrect loading of fuel, cargo or dangerous goods

• Operating standards are degraded

• Any engine has to be shut down in flight

• Ground damage occurs

• A rejected take-off is executed after take-off power is established

• A runway ortaxiway excursion occurs

• Significant handling difficulties are experienced

• A navigation errorinvolving a significant deviation from track

• An altitude excursion of more than 500 feet occurs

• An exceedance of the limiting parameters for the aircraft configuration or when a significant unintentional speed change occurs

• Communications failor are impaired

• A GPWS warning occurs

• A stall warningoccurs

• A heavy landing checkis required

• Serious loss of braking

• Aircraft is evacuated

• Aircraft lands with reserve fuel or less remaining

• An AIRPROX (Airmiss) or TCAS event, ATC incident or wake turbulence event occurs

• Significant turbulence, windshear or other severe weather is encountered

• Crew or passengers become seriously ill, are injured or become incapacitated

• Difficulty in controlling violent, armed or intoxicated passengers or when restraint is necessary

• Toilet smoke detectors are activated

• Any part of the aircraft or its equipment is sabotaged or vandalised

• Security procedures are breached

• Bird strike or Foreign Object Damage (FOD)

• Unstabilised approach under 500 feet

• Or any other event considered to have serious safety implications



3.5.6.3 The objective and systematic observation of activities being performed can yield much useful information for the safety management system and help to reduce losses. The aim is to reveal problems and shortcomings, which could lead to accidents. Typically such shortcomings can be inadequate equipment or procedures, lack of effective training, or the use of inappropriate materials. The outcome should be action to reduce and control risks.

3.5.6.4 Follow-up and Closure of Reports

3.5.6.4.1 Some reports can be closed on receipt. If follow-up is required, action will have been assigned to the appropriate department(s). The Flight Safety Officer will review responses and, if satisfactory, recommend closure of the incident at the next Flight Safety Committee meeting. If responses are unsatisfactory and do not address the problem, the incident must remain open for continuing review and action as required. 3.5.6.4.2 If a State Mandatory Occurrence Reporting (MOR) scheme is in effect,

recommendation for the closure of a report must be agreed with the regulatory authority. The authority and the reporter must be informed of action taken once the incident is closed.