Type of reporting systems features to facilitate the just culture implementation
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Tony LICU Programme Manager – EUROCONTROL DAP/SAF European Safety Programme for ATM (ESP) April 2006 – Baku/Azerbaijan [email protected] Type of Reporting Systems Features to facilitate the Just Culture Implementation. European Organisation for the Safety of Air Navigation.

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Type of Reporting Systems Features to facilitate the Just Culture Implementation

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Type of reporting systems features to facilitate the just culture implementation

Tony LICU

Programme Manager – EUROCONTROL DAP/SAF

European Safety Programme for ATM (ESP)

April 2006 – Baku/Azerbaijan

[email protected]

Type of Reporting Systems Features to facilitate the Just Culture Implementation

European Organisation for the Safety of Air Navigation


Presentation topics

Presentation Topics

Purpose of Reporting Systems

Different types of Reporting Systems

Required qualities of Reporting Systems

Implementation of Reporting Systems


Objectives

Objectives

Detailed

  • Know the pros and the cons for different types of reporting systems

  • Appreciate what type of reporting system is best suited for your organisation


G arpi papa india

G-ARPI (Papa India)

  • 18 June 1972 – Trident aircraft G-ARPI en route London to Brussels

  • 3 pilots, 3 cabin crew, 112 passengers

  • Crew roster

  • Industrial dispute

  • Delay

  • Medical

  • Pilot failings

  • Aircraft crashed killing all on board


Type of reporting systems features to facilitate the just culture implementation

HOW DO WE LEARN

HOW DO WE GAIN EXPERIENCE


Type of reporting systems features to facilitate the just culture implementation

English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


Type of reporting systems features to facilitate the just culture implementation

English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


Type of reporting systems features to facilitate the just culture implementation

English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


Type of reporting systems features to facilitate the just culture implementation

Indispensable to highly qualified professionals

INDIVIDUAL

LEARNING


Type of reporting systems features to facilitate the just culture implementation

common

English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


Type of reporting systems features to facilitate the just culture implementation

Purpose of Reporting Systems?

Indispensable to efficient system improvement

ORGANISATIONAL LEARNING


Type of reporting systems features to facilitate the just culture implementation

Different types of Reporting Systems

Human

Automatic


Type of reporting systems features to facilitate the just culture implementation

Complementarity

Reporting Systems [Human]

Mandatory

Voluntary

Nominal

Confidential

Anonymous


Mandatory reporting

Mandatory Reporting

1.Legislation Required

2.Legal Definition of Reportable Occurrence

3.Define What Should be Reported

4.Define Who Should Report


Voluntary reporting

Voluntary Reporting

Factors Resisting Change

1.Personal

2.Professional

3.Organisational

4.Political


Voluntary reporting1

Voluntary Reporting

Factors Driving Change

1.Personal

2.Professional

3.Organisational

4.Political


Type of reporting systems features to facilitate the just culture implementation

Coverage

Reliability

of entry data

Efficiency

Strictly

defined

High

Reactive

Non limited

Good

Proactive

Non limited

Good

Proactive

Non limited

Questionable

Proactive

Restricted

Type of Reporting Systems Features

System

Features

Mandatory

Voluntary

Nominal

Confidential

Anonymous


Confidential reporting

Confidential Reporting

  • Historically, proportion of Human Factor occurrences reported remains small – common failing

  • Reluctance to admit personal errors

  • Partially overcome by introducing a Confidential reporting system e.g. UK CHIRP

  • Could be Anonymous….!


Automatic reporting

Automatic Reporting

  • Latest way to monitor safety requirements

  • Complementary to Human reporting

  • Problem of “big brother” attitude

  • Being trialled at Maastricht for aircraft proximity


Type of reporting systems features to facilitate the just culture implementation

Ease

of

reporting

Independence

TRUST

Motivation

&

Promotion

FEEDBACK

Acknowledgement

Required qualities of Reporting Systems


Atm investigation process

ATM Investigation Process


Motivation and promotion

Motivation and Promotion

  • ATM staff must be motivated to report, and the trend must be maintained

  • Controllers educated about benefits derived by reporting actual or potential deficiencies


Ease of reporting

Ease of Reporting

  • Staff must not perceive reporting as an extra task

  • User friendly reporting system

  • Staff trained in use of investigative/problem solving methods and database


Acknowledgement

Acknowledgement

  • Reporters like to know whether their report was received

  • What will happen to a report

  • What to expect and when


Independence

Independence

  • Some degree of independence to be granted to reporting system managers


Feedback

Feedback

  • Communication should be frequent, using both formal and informal channels

  • Reward and recognition


Trust

Trust

  • All reporting is dependant on trust;

  • Between reporters, managers, providers and authority;

  • A Just Culture


Summary

Summary

  • Importance of a Reporting System;

  • Information to be developed in a Reporting System;

  • Differentiate between the different types of reporting systems;

  • Know the pros and the cons for different types of reporting systems;

  • Appreciate what type of reporting system is best suited for your organisation.


Type of reporting systems features to facilitate the just culture implementation

Implementation of Reporting System

1

chance

2

mis-management


Type of reporting systems features to facilitate the just culture implementation

“NO OCCURRENCE“

means

“NO REPORTED OCCURRENCE”


Thank you

Thank you!

Questions?

?


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