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Reporting Matters!

New EU Occurrence Reporting RegulationCover Poster ORR-2

On 15 November 2015, the new regulation EU 376/2014 on the reporting, analysis and follow-up of occurrences in civil aviation came into force across Europe. It requires aviation organisations to 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. It is a powerful piece of legislation that will contribute to the improvement of flight safety – provided we, pilots, as the first contributors of the system, feed the report database.

To guide pilots through this new legislation, we created this dedicated webpage, where you will find links to all kinds of material & articles. We will keep it up-to-date, so stay tuned!

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SMS & Just Safety Culture

On October 15, 2014 the deadline for SMS implementation expired. Do you remember: SMS? Safety Management System(s)? If all went well you should have received an initial training by now. If not, you will receive one soon. SMS is not just “another safety project”. ICAO dedicated a brand new Annex (19) to the concept. It’s all about defining a common and integrated way of managing safety within the aviation industry. Don't have much time? Take a look at this excellent one-minute summary. It's created by the FAA, but is fully compliant with EASA and ICAO-regulations

Four pillars of SMS 

SMS comprises of four pillars. First of all, we have to set the rules of the game in Safety Policies & Objectives. Next there is the day to day work: Safety Management and Risk Assessment. Basically we should be looking for hazards (anything that has the potential to cause harm e.g. weather, terrain, lack of training, inadequate supervision, unclear procedures,…), assess their associated risk and try to mitigate (read: minimize) that risk. Once we have the risk under control (read: it is at an acceptable level) then we should make sure we lock everything down through Safety Assurance – the 3rd pillar. Finally we should tell people what a good job we have done; we call this Safety Promotion

Just Culture

Let’s go back to the first pillar: Safety Policies and Objectives. One of the pre-requisites for an effective SMS is top-level commitment i.e. the company management should share a dedicated view on safety. A pre-requisite for this is the acceptance that – despite all training, procedures, protocols – human error is unavoidable. However this does not mean that we should not learn from lapses, slips, errors and mistakes! On the contrary. They are a valuable source to identify hazards (and eventually manage the risk). Therefore it is a requirement to have a so-called Safety Policy. Herein the Accountable Manager agrees to provide sufficient resources (funds and personnel) for safety management and he/she also agrees to act according to Just Culture principles. This means ensuring that no action will be taken against any employee who discloses a safety concern through the hazard reporting system, unless such disclosure indicates, beyond any reasonable doubt, gross negligence or a deliberate or willful disregard of regulations or procedures (intentional violation). In other words: “If you made a mistake, we will not blame you unless it is clear that you did it on purpose and with the intention to harm.”

Just Culture is of paramount importance. Without justness, safety professionals will never have the full picture. No one will write a report about their own mistakes if there is even the slightest fear of being sanctioned. The consequence is that hazards will remain hidden waiting to be a cause or a contributing factor for future incidents and/or accidents. 

As an example and contrary to popular belief: FDM is NOT an exact science. The system does not tell the story behind. Was there any turbulence? Were there any CRM issues? Fatigue? ATC pressure? Other traffic? What was the aircraft technical status before the flight? Etc. Therefore we need uninhibited voluntary reporting without fear of reprisal.

Safety Culture

Apparently EASA and the EC share this opinion. EU regulation 376/2014 (on the reporting, analysis and follow-up of occurrences in civil aviation) mentions the term not less than 11 times and sees it as ‘an essential element of a broader safety culture’. Somebody told me once: “A Safety Culture is what remains if you take away all SOPs” So imagine that tomorrow your fleet chief asks you to perform a flight and he tells you to throw away all books; to do whatever you want. Will you still use the checklist? Will you still wait for the Cabin ready call? Probably yes. This is all part of our inherent will to do our job in the safest way possible; not in the least out of some instinct of self-preservation. You could also see it as the attitude towards safety. Professor James Reason (yep, the cheese guy) recognizes different aspects in a Safety Culture: informed, reporting, learning, flexible and just culture.

Just Safety Culture

However here at BeCA we mixed the terms and we talk about Just Safety Culture (JSC), because we are convinced that the other aspects will follow automatically as soon as there is an open and honest atmosphere.

The goals of JSC are simple:

  • Encourage reporting
  • Establish facts to avoid them reoccurring
  • Learn from mistakes to improve safety
  • Implement a dynamic safety management system
  • Show “sleeping failures”

JSC is NOT

  • A piece of paper in an OPS Manual
  • A slogan in an email
  • A “top-down” concept
  • Limited to the (Flight) Safety department
  • Taken for granted

JSC is

  • Applicable in all circumstances
  • Part of company global culture and ethical values
  • Undermined by unjustified blame attitudes 
  • Must be encouraged and valued by all
  • A partnership approach with crews
  • Fragile, an everyday challenge

Reality check

Unfortunately the reality isn’t always in line with the theory. Until EU regulation 376/2014 comes into force on November 15, 2015 there are no hard laws; only company statements, beliefs and practices. It is impossible to talk about Just Safety Culture without a clear definition of intentional violations. A Non accusative and respectful approach towards crew and personnel is mandatory. All in all, it is a very fragile equilibrium.

So far we have seen examples of non-adherence at different levels:

  • Often, CEOs do not really understand/actively support advanced JSC
  • Safety Managers are not always independent and not kept in the loop by other managers or lack resources (team size & experience)
  • When HRs involved, JSC often turns into disciplinary measures. In our opinion cases of gross negligence should be transferred to HR only after careful analysis of facts, based on clear evaluation criteria (e.g. JSC flow chart)
  • JSC must be everywhere. Sometimes we heard: “Yes, but this event falls outside JSC”
  • In case of accident, external parties might not adhere to JSC logic: insurance, justice department, victims and their relatives, public, media/press, airline shareholders,…

What will BeCA do?

As a pilots association we want to offer our support to members, airlines and authorities in shaping the new tools that SMS brings us. Such as providing expert support in personal incidents, drafting a (common) FDM agreement and/or Just Safety Charter, assembling a peer review board, explaining new legislation, etc.

 

Sources - SMS

# Title Description

Sources - SMS

Culture Counts Article on Safety Culture in AeroSafety World magazine (Feb 2008 p18-23)

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