This document considers the requirement of forthcoming regulation NPA 2019-05 (C) related to the effective delivery of an Internal 145 Reporting System including Confidential Reporting.
AMC1 145.A.202 Internal safety reporting scheme focuses on the need for confidentiality and brings EASA Part 145 into alignment with EASA Regulation 376/2014.
Regulation (EU Reg. 376/2014 became applicable as of 15 Nov 2015, and requires aviation organisations in the EU to both adopt and maintain a proactive Just Culture to facilitate the collection of key safety data and information and to protect the reports as well as the information
Whilst we all recognise the importance of safety in particular within “our” Maintenance Environment we face as an industry the problem of (Some say) Chronic under-reporting of safety incidents.
Please consider when was the last time YOU filed a safety internal report?
What is the reason for underreporting?
Is it the fear of reprisals or is it a case of fundamental disconnection from the responsibility to accept a personal obligation to report?
Whatever the reason the reality is that there is without doubt insufficient occurrence reporting, which results in “open” not closed loops ineffective closure and a reduced ability to deliver proactive safety improvements. (If at all !)
Internal company rules need to be developed to implement a Just Culture Environment:
Just Culture-related provisions constitute a central element of the new reporting system.
What is ‘Just Culture’ – What does it entail?
‘Just Culture’ means creating an environment in which an employee feels confident to be able to speak up and raise a concern.
A genuine mistake or error is potentially valuable information that should be shared with the rest of the industry to drive changes in aviation safety.
But to share this information, aviation workers need to trust the organisation to be confident that their contribution is valued and that they will not be ultimately disciplined for doing so.
Just culture is often mistakenly referred to as a “no-blame culture”, which is very different from immunity, as gross negligence and willful misconduct are not tolerated.
What EASA Says about Just Culture?
“A culture in which frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”
Reporting Requirements of NPA 2019-05 (C):
AMC1 145.A.202 Internal safety reporting scheme focuses on the need for confidentiality
Authors Note that there are several elements related to the need to report an “event” as well as a comprehensive understanding concerning what hazards and exposures are suitable for reporting and which not!
1/ Mandatory – Something has happened, and we must report this in addition it may also require a Mandatory Occurrence Report – This will typically be decided by the Quality Assurance Dep
2/ Voluntary Report – An unacceptable hazard has been identified to which attention should be paid. (this should, in fact, form the “bulk” of the reports which are submitted. Such reporting activity is a very healthy measure of an effective SMS system.
3/ Confidential Reporting – Should provide for an internal reporting process where confidentially is assured. (Note this is not anonymous reporting)
Consider a number of challenges with confidential reporting
a) How to ensure confidentiality?
b) How to manage the information that has been reported
c) What happens within a small department – how is confidentiality assured?
How to view Confidential Reporting? Is it Good or Bad?
Actually Bad – Why?
Because the reporter does not have the confidence or support to be able to stand up and report so, in reality, the number of confidential reports submitted is a negative indicator related to the willingness to engage
AMC1 145.A.202 Internal Safety Reporting Scheme
(a) Each internal safety reporting scheme should be confidential and enable and encourage free and frank reporting of any potentially safety-related occurrence, including incidents such as errors or near misses, safety issues and identified hazards. This will be facilitated by the establishment of a just culture. Ie
(b) The internal safety reporting scheme should contain the following elements:
(1) clearly identified aims and objectives with demonstrable corporate commitment;
(2) a just culture policy as part of the safety policy, and related just culture implementation procedures;
(3) a process to:
(i) identify those reports which require investigation; and
(ii) when so identified, investigate all the causal and contributing factors, including any technical, organisational, managerial, or human factors issues, and any other contributing factors related to the occurrence, incident, error or near-miss that was identified;
(iii) if adapted to the size and complexity of the organisation, analyse the collective data showing the trends and frequencies of the contributing factors;
(4) appropriate corrective actions based on the findings of investigations;
(5) initial and recurrent training for staff involved in internal investigations;
(6) where relevant, the organisation should cooperate with the owner, operator or CAMO on occurrence investigations by exchanging relevant information to improve aviation safety.
(b) The internal safety reporting scheme should:
(1) ensure the confidentiality of the reporter;
(2) be closed-loop, to ensure that actions are taken internally to address any safety issues and hazards; and
(3) feed into the recurrent training as defined in AMC5 145.A.30(e) whilst maintaining appropriate confidentiality.
(c) Feedback should be given to staff both on an individual and a more general basis to ensure their continued support of the safety reporting scheme.
GM1 145.A.202 Internal safety reporting scheme:
(a) The overall purpose of the internal safety reporting scheme is to use the reported information to improve the level of the safety performance of the organisation, and not to attribute blame.
(b) The objectives of the scheme are to:
(1) enable an assessment to be made of the safety implications of each relevant incident (errors, near-miss), safety issue and hazard reported, including previous similar issues, so that any necessary action can be initiated; and
(2) ensure that knowledge of relevant incidents, safety issues and hazards is shared so that other persons and organisations may learn from them.
(c) The scheme is an essential part of the overall monitoring function and should be complementary to the normal day-to-day procedures and ‘control’ systems; it is not intended to duplicate or supersede any of them. The scheme is a tool to identify those instances in which routine procedures have failed or may fail.
(d) All safety reports that are judged to be reportable by the person submitting the report should be retained, as the significance of such reports may only become obvious at a later date.
(e) Typical occurrences to be reported are those in which aviation safety was, or could have been endangered, or which could have led to an unsafe condition.
If, in the view of the reporter, an occurrence did not endanger aviation safety but, if it was repeated in different but likely circumstances, would create an unsafe situation that could lead to an accident or serious incident, then a report should be made.
What is judged to be reportable on one class of product, part, or appliance may not be the same for another, and the absence or presence of a single factor, organisational, human, or technical, can transform an occurrence into an accident or serious incident?
(f) The collection and analysis of timely, appropriate and accurate data will allow the organisation to react to the information that it receives, and to take the necessary action.