This month the UK Civil Aviation Authority (CAA) has issued its latest Safety Sense Leaflet (SSL) for the general aviation community, providing a guide on occurrence reporting. The CAA advises that reporting is an important element of improving aviation safety and is often a legal requirement. Occurrence reports are submitted to the UK CAA via the ECCAIRS portal.
The CAA reviews reports and determines if any follow up action is required. The leaflet also covers reporting to the Air Accidents Investigation Branch (AAIB), Airprox Board and the Confidential Human Factors Incident Reporting Programme (CHIRP). The CAA confirms that all reviews of occurrences are conducted in accordance with ‘Just Culture’ principles, meaning that people are treated fairly and not punished for actions, omissions or decisions that are commensurate with their experience and training.
The aim of a Just Culture, says that CAA, is to promote continuous learning from previous mistakes and to encourage pilots to share safety related information. Operators of Part 21 aircraft – aircraft that hold a UK Certificate of Airworthiness – are subject to Mandatory Occurrence Reporting (MOR) rules defined under the Occurrence Reporting Regulations and are legally obliged to report such occurrences. An ‘occurrence’ means any safety related event which endangers or which, if not corrected or addressed, could endanger an aircraft, its occupants or any other person and includes in particular an accident or serious incident.
Occurrence reports relating to flight operations must normally be submitted by the pilot in command of the aircraft. Due to differences defined in the Occurrence Reporting Regulations, non-Part 21 aircraft, which are those aircraft operated on a Permit to Fly certificate, including homebuilt, some historic types and microlights are not subject to MOR, but the CAA nonetheless recommends that they submit occurrence reports via the Voluntary Occurrence Reporting (VOR) system.
The SSL defines multiple occurrence that should be reported via the MOR or VOR systems, under the headings of air operations, technical faults, emergency and other critical situations, interaction with ATC, and external environment and meteorological issues.
The SSL also provides separate listings of MOR occurrences specific to sailplanes, balloons and airships. The CAA says that Just Culture is important
because an open and honest reporting culture improves flight safety: “This has obvious benefits to everyone involved in aviation. As a GA pilot, you can contribute to this by reporting occurrences when required or when you feel that a report may contribute to an improvement in safety. You may wonder whether individual reports will ‘make a difference’. It may appear that the benefit of reporting an individual safety occurrence – that would otherwise go unnoticed – is negligible. One report in isolation may not have much impact, but it may be that other stakeholders have reported similar issues that indicate a trend in need of addressing.”
The CAA uses occurrence reports as a data source used to inform its safety policy and decisions, with occurrence data used to identify safety trends, hazards, risks and issues that have the potential to impact on the safety of the UK aviation system.
In terms of culpability, the CAA advises that it is important to acknowledge that ‘Just Culture’
does not translate as ‘no blame’. The CAA says that many occurrences lie somewhere between the two extremes of errors that are commensurate with experience and those which stem from gross negligence.
While the CAA says that individuals should always be treated fairly, if an occurrence reveals a lack of competence, appropriate retraining must be applied. The CAA also advises that occurrences that clearly indicate a disregard for risk or poor attitudes and behaviours, will be treated more harshly and may result in a loss of privileges, or in extreme cases, prosecution.
Air operation occurrence’s include:
• Unintentional loss of control.
• Landing outside of intended landing area.
• Inability or failure to achieve required aircraft performance expected in normal conditions during take-off, climb or landing.
• Runway incursion.
• Runway excursion.
• Any flight which has been performed with an aircraft which was not airworthy, or for which flight preparation was not completed, which has or could have endangered the aircraft, its occupants or any other person.
• Unintended flight into IMC (Instrument Meteorological Conditions) conditions of aircraft not IFR (Instrument flight rules) certified, or a pilot not qualified for IFR, which has or could have endangered the aircraft, its occupants or any other person.
• Unintentional release of cargo Technical faults
• Abnormal severe vibration (for example: aileron or elevator ‘flutter’, or of propeller).
• Any flight control not functioning correctly or disconnected.
• A failure or substantial deterioration of the aircraft structure.
• A loss of any part of the aircraft structure or installation in flight.
• A failure of an engine, rotor, propeller, fuel system or other essential system.
• Leakage of any fluid which resulted in a fire hazard or possible hazardous contamination of aircraft structure, systems or equipment, or risk to occupants. Emergencies and other critical situations
• Any occurrence leading to an emergency call.
• Fire, explosion, smoke, toxic gases or toxic fumes in the aircraft.
• Incapacitation of the pilot leading to inability to perform any duty. Interaction with air navigation services and air traffic management
• Interaction with air navigation services (for example: incorrect services provided, conflicting communications or deviation from clearance) which has or could have endangered the aircraft, its occupants or any other person.
• Airspace infringement. External environment and meteorology
• A collision on the ground or in the air, with another aircraft, terrain or obstacle.
• A near collision, on the ground or in the air, with another aircraft, terrain or obstacle requiring an emergency avoidance manoeuvre to avoid a collision.
• Wildlife strike including bird strike which resulted in damage to the aircraft or loss or malfunction of any essential service.
• Interference with the aircraft by firearms, fireworks, flying kites, laser illumination, high powered lights lasers, Remotely Piloted Aircraft Systems, model aircraft or by similar means.
• A lightning strike resulting in damage to or loss of functions of the aircraft.
• Severe turbulence encounter which resulted in injury to aircraft occupants or in the need for a post-flight turbulence damage check of the aircraft.
• Icing including carburettor icing which has or could have endangered the aircraft, its occupants or any other person.
There are a total of 14 Safety Sense Leaflets available to download from the CAA’s website.
