Incident Reporting and Data Sharing

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Incident Reporting and Data Sharing

• European SSAP Regional WorkshopTallinn, 29-30
  June 2004
• Giancarlo Ferrara EHQ/DAP-SAF

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AGAS on Incident Reporting and Data Sharing

• An important issue identified by the AGAS report
  is the implementation of comprehensive reporting
  systems and data sharing process by ANSPs.
• Incident reporting system are used to pick up ATM
  system failures that might eventually lead to
  more serious consequences had they not been
  detected in time.
• The findings of national and regional incidents
  reporting schemes can be exchanged so that trends
  and key risk areas can be identified and lessons
  can be shared across ECAC States.
• An incident reporting system also help to keep
  staff "in the loop and to raise awareness and
  safeguards that can mitigate any future risks of
  incidents/accidents re-occurrence.

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The need for European wide incident reporting
system

• Complete knowledge of all national safety
  occurrences (operational technical) is a
  thermometer to measure current safety levels,
  actions to be taken and measurement of progress.
• Complete knowledge of all safety occurrences in
  Europe allows to share causal factors, identify
  and prioritise major risk areas, launch European
  ad-hoc action plans etc...

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Triggering Safety Improvement Process

• No event reported . doesnt mean that a system
  is Safe!

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Criteria for a Successful Incident Reporting
System (1/2)

• An open reporting culture is essential
• Free from legal impediments.
• Encouraged by management (penalty and blame
  free).
• Voluntary reporting might help on top of
  mandatory reporting.
• ATCOs/Engineers need to see positive actions
  taken by management rapid and proper feedback
  and lessons dissemination, investment granted
  when required,.

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Criteria for a Successful Incident Reporting
System (2/2)

• A well documented system
• Easy reporting forms supported by an efficient
  process.
• Good description of causal factors and other
  facts.
• Incident investigators well trained.
• Data well kept and easy to track and analyse for
  trends.
• Compatible with EUROCONTROL and EU standards for
  data sharing purposes.

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AGAS WG2 on Reporting

• Problems relate mainly to the implementation of
  comprehensive reporting systems (aiming to cover
  all safety issues) and to the adequacy of the
  safety information extracted from the analysis
  process (as the basis to elaborate remedial
  actions) scope, type, quantity and quality of
  safety data collected in the reporting process
  varies significantly from State to State, and
  from Service Provider to Service Provider.
• AGAS Report Working Group 2 on Reporting

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AGAS Early Actions

• AGAS recommended Early Actions on Incident
  Reporting
• Early Actions were endorsed by EUROCONTROL
  Provisional Council and Commission in November
  2002
• In response to AGAS recommendations, initiatives
  have been undertaken by EUROCONTROL, States and
  ANSPs to introduce an improved scheme for
  incident reporting and sharing of lessons
  learnt.

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SSAP Highest Priority Areas

• During SSAP Launch Event in February 2004 Senior
  ATM Executives identified the following areas as
  having the highest priority
• Safety Data Sharing
• Provision of training on safety related matters
• RD coordination
• Provision of support to states by EUROCONTROL

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Current Situation

• Some States and ANSPs have applied considerable
  effort in implementing and improving reporting
  schemes but problems still exist across Europe
• Implementation of comprehensive reporting system
• Scope, type, quantity and quality of safety data
  collected
• Poor use of automated tools for safety data
  collection
• Lack of official PoCs for safety data collection
• Just Culture implementation still pending in
  some States
• Poor cooperation with Airlines and others ANSPs
• Etc.

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PRC Report on Occurrence Reporting Schemes in
Europe
A significant minority (36) of respondents
consider that their organisations internal
procedures are unsatisfactory with regard to
safety reporting in ATM This is one of the
main points of controversy between management and
ATCOs. Very few managers would countenance that
their safety reporting system needed to be
improved, while ATCOs considered that management
is slow or complacent in insofar as safety is
concerned. PRC Report on Legal Constraints to
Non-Punitive ATM Safety Occurrence Reporting in
Europe
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SSAP Actions Required

• Incident reporting and data sharing is a primary
  means for improving safety and reducing the risk
  of incident/accident reoccurrence.
• EUROCONTROL, ATM Regulators and ANSPs are
  requested to put more effort in the following
  action areas
• Resources
• Education and Awareness
• Data Collection and Analysis
• Harmonisation
• Data Sharing and Lessons Dissemination.

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Resources

• States and ANSPs to urgently allocate sufficient
  resources for safety data collection, analysis
  and dissemination of lesson learnt.
• ANSPs and EUROCONTROL to review arrangements for
  safety data collection, analysis and
  dissemination of lessons learned and ensure the
  resources needed

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Awareness and Education (1/2)

• Initiate an awareness and education campaign for
  all stakeholders, underlining the safety benefits
  of a good reporting culture.
• Widen the scope of the EUROCONTROL safety
  consultation process to integrate wide aviation
  community.
• Organise local awareness workshops for the
  aviation community ANSP, Airlines, Airports,
  Maintenance, and Regulators (action by
  Regulators, ANSPs, and EUROCONTROL).

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Awareness and Education (2/2)

• Introduce the reporting culture in the training
  of all personnel involved in safety related
  activities.
• Integrate a reporting module in the EUROCONTROL
  IANS training programme (by EUROCONTROL).
• Integrate a reporting module in the local ANSP
  training programme (by State Regulators and
  ANSPs).
• Implement and promote voluntary reporting system.

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Data Collection and Analysis (1/2)

• Implement the principles of just culture in ATM
  safety occurrence reporting.
• Survey the existing good practices for applying
  the principles of just culture (by Eurocontrol)
• Organise workshops for promotion of the concept
  of just culture in reporting (by Eurocontrol).
• Integrate a strategy of introducing the just
  culture concept in the local management process
  (by Regulators and ANSPs).

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Data Collection and Analysis (2/2)

• Establish immediately a focal function in each
  state for safety data collection (by States).
• Appoint the data collection focal point.
• Establish communication channels with EUROCONTROL
  Agency.
• Develop Strategies for the removal of legal
  impediments.
• Develop best practices for co-operation between
  ANSPs, Investigators and Airspace Users to
  identify remedial actions, and encourage
  no-blame culture.

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Harmonisation

• Develop, adopt and implement a common taxonomy
  for ATM safety occurrences (by EUROCONTROL, SRC).
• Adopt and implement the common scheme for
  severity assessment and a common methodology for
  the identification of causal factors across the
  aviation industry.

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Data Sharing and Lessons Dissemination

• Share safety information, notably on causal
  factors, lessons learned and remedial actions.
• Launch a pilot publication and web forum for
  sharing the lessons learned.
• Define Policy for sharing data between Agency and
  ANSPs and with IATA and for using safety data
  collected by SRC.
• Integrate safety data collection.
• Develop a model for Safety Data storage and
  access.

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SSAP Early achievements (1/2)

• A pilot publication entitled Hindsight was
  issued in May 2003 to publicise lessons learnt.
  
• A Just Culture Workshop has been organised on
  11 December 2003 with a wide stakeholders
  participation.
• A small working group has been established in
  cooperation with IATA to discuss and start
  sharing of accident/incident data.
• An activity has been almost completed by
  Eurocontrol to produce a level busts toolkit to
  spread new insights and safety improvement
  measures.

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SSAP Early achievements (2/2)

• The operational requirements and guidance
  material for Automatic Safety Data Gathering
  tools implementation has been developed.
• Guidelines for Investigation of Safety
  Occurrences in ATM have been developed.
• Checklist for safety occurrence reporting system
  have been developed.

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SSAP Short Term Planned Achievements (1/2)

• Work is ongoing to launch a Safety Web Forum to
  improve safety data sharing and dissemination of
  lessons learned among ANSPs.
• It is planned to improve and refine Hindsight
  publication process involving more States.
• A study is ongoing to identify ANSPs major
  impediments and propose recommendations for
  improving the implementation of comprehensive
  reporting systems in Europe.
• An Awareness Campaign for reporting is planned.

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SSAP Short Term Planned Achievements (2/2)

• Work is ongoing to update ATM common taxonomy
  together with a proper causal factors and
  severity classification scheme.
• A safety data repository of de-identified
  occurrences to analyse trends, key risk areas and
  to support ad-hoc european safety improvements
  initiative is going to be developed.
• The development of a complete training package
  for professionals involved in ATM safety data
  collection, investigation and sharing is in
  progress.

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Conclusions (1/2)

• Incident reporting and data sharing are primary
  mechanisms for improving safety and avoid
  re-occurrences in aviation industry.
• States ANSPs have to allocate sufficient
  resources for data collection and analysis.
• Eurocontrol, Regulators ANSPs have to introduce
  reporting culture during training of all
  personnel.
• EUROCONTROL, Regulators ANSPs have to implement
  the principles of a Just Culture in ATM
  occurrence reporting.
• States have to develop strategies for the removal
  of legal impediments.
• Regulators, ANSPs, Operators and EUROCONTROL have
  to share safety information.

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Conclusions (2/2)

• ANSPs have to share safety information among them
  and with EUROCONTROL in order to allow founded
  safety programmes monitoring and prioritization
  of major risk areas
• Work is already in progress on the subject, but
  it needs to be accelerated for having a common
  reporting systems across ECAC States.
• SSAP considers that work should be focused toward
  having a comprehensive system in place by January
  2006.

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• TKS FOR YOUR KIND ATTENTION
• Any Question?