Development of voluntary reporting system of aviation safety information in Japan Satoshi ISHIDA Aviation Safety and Sec

1. Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia 13-17 June 2011 Development of voluntary reporting system of aviation safety information in Japan Satoshi ISHIDA Aviation Safety and Security Promotion Division, JCAB JAPAN

2. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Amendment of Annexes to the Chicago Convention (effective date: 11/2010) １．Definition and framework of State Safety Programme (SSP) （①） ２．Equalized statement of Safety Management System (SMS) framework （②） Annex 1 Annex 6-Ⅰ Annex 6-Ⅲ Annex 8 Annex 11 Annex 13 Annex 14 Operation of Aircraft -Commercial Aeroplanes Personnel Licensing Operation of Aircraft -Helicopters Airworthiness of Aircraft Air Traffic Services Aircraft Accident And Incident Investigation Aerodromes ① ① SSP Definitions ① SSP Definitions SSP Definitions SSP Definitions SSP Definitions SSP Definitions SSP Definitions ① ① ① ① ① ① ① ① ① ① ① SSP Framework SSP Framework SSP Framework SSP Framework SSP Framework SSP Framework SSP Framework Attachment C Attachment C Attachment J Attachment J Attachment A Attachment D Attachment F ② ② ② ② ② SMS Framework SMS Framework SMS Framework SMS Framework SMS Framework Appendix 7 Appendix 4 Appendix 6 Appendix 7 Appendix 4 ３．Establishment of voluntary information system （③） under Non-punitive circumstances ③ Voluntary reporting system 2

3. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Transition to new management system of aviation safetyin Japan CSA Transition to CMA CMA Framework for implementation Performance-basedSMS ALOS SPI Research and Examination Coordination with affiliates Improvement of legal system 3

4. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Japan’s current reporting system:ASI-NET (Aviation Safety Information Network) • Operated by a foundation since 1999 • Reporting system aimed only at flight crew • Collected data: de-identified, not disclosed • Government ensures protection of safety information by its inaccessibility to the reporting system • No immunity from administrative sanction or criminal prosecution 4

5. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Reporting system of aviation safety information Injury Accident Mandatory reporting system by pilot in command CAA #76, 76-2 Mandatory reporting system by operator CAA #111-4 Major Incident which may cause accident Minor incident which may affect safe operation Other Unsafe Operation / Condition Voluntary reporting system by operator ASI-NET （operated bythe third party） Airlines / Cargos No access by JCAB to the information reported through this system Pilots 5 CAA : Civil Aeronautics Act of Japan

6. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Key points at issue for the development of voluntary reporting system • ICAO standard requires “Non-Punitive”1 voluntary incident reporting system • ASI-NET is intended only for air operators: A voluntary reporting system for all parties involved in aviation including ATC, CNS and airport operation is necessary • Exploratory committee meetings were held this year to discuss toward effective implementation • This presentation shows points at issue and opinions delivered at the exploratory committee 1. Annex13, Chapter8, item8.3 “A voluntary incident reporting system shall be non-punitive and afford protection to the sources of the information.” 6

7. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Case study • US: Aviation Safety reporting System (ASRS) since 1976 • Operated by NASA • UK: Confidential Human Factors Incident Reporting Program (CHIRP) since 1982 • Operated by the CHIRP Charitable Trust • EU: Directive 2003/42/EU • Based on the concept of “Just Culture” • Willful misconduct and gross negligence are not covered • Collected data: de-identified • Disclosed in public (ASRS) / Not disclosed except summary report (CHIRP) • Immunity: • Judicial proceedings not instituted for collected data • Mitigation of administrative sanction 7

8. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Scope of the voluntary reporting system • Information to be collected • Handling of speculation/hearsay • Reporting format that promotes reporters to suggest improvements • Reporters considered • Passengers, employees involved in non-aviation field • Reporting through SMS operated by industry is preferred rather than individual reporting in order to avoid bypassing organizational reporting systems and duplicated reports 8

9. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Operator of the voluntary reporting system • Non-punitiveness and confidentiality of safety information are eventually achieved in ASI-NET, but not ensured by enforcement policy • In the case that non-governmental institutions collect data reported by the government-operated fields (ATC, CNS, operation of some airports), information security must be considered 9

10. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 How to ensure Non-punitive circumstances • Common understanding is needed for all parties involved in the aviation field • Incentive is necessary to promote voluntary reporting • Reviewed in light of personnel affairs, administrative guidance/sanction and criminal prosecution 10

11. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Personnel View • Objective: aviation sector operated by the government in addition to private enterprises • ATC, CNS, operation of some airports • Incident reported through voluntary reporting system should not be noted in the personnel record • Impact on career may be considered 11

12. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Administrative View • Administrative guidance should be considered non-punitive as a measure for ensuring safety • e.g. Letter of notice/warning • Possible ways for reduction/exemption from administrative sanction: • Stipulation of waiver on enforcement policy • Segregation of collected data from the government 12

13. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Penal View • Voluntary reporting system should not apply to accidents and major incidents with injury which are subject to the penal code • As the cultural background, victims’ sentiment is valued rather than the importance of investigation of the cause of accident • Further discussion is necessary based on particular cases collected through the voluntary reporting system for considering protection of reporters from criminal prosecution 13

14. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Securing confidentiality of the source of information • Information of the reporter must be confidential and protected from regulatory/judicial authorities in a proper manner • As with most voluntary reporting systems, reporter’s personal data is de-identified by using “confidential report” • Personal information contained in the report should soon be deleted from the database 14

15. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Future discussion of enforcement policy • Role models were reviewed in the exploratory committee • Further study is necessary for establishment of clear criteria for execution of administrative sanctions • Development of effective and feasible enforcement policy along with administrative operation is needed 15

16. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 Conclusion • A voluntary reporting system is now in the process of development in Japan • Research and discussion of diverse aspects was conducted in the exploratory committee • Discussion on the Non-punitive circumstances is focused on personnel affairs and administrative guidance/sanctions • Further discussion is necessary for introducing an effective and feasible enforcement policy 16

17. TPT-WG34, Brisbane, Australia Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011 FIY: Safety Information Protection Task Force (SIP TF) • The establishment of SIP TF is recommended in HLSC2010 and authorized in A37 • Scope: Making findings and recommendation for development/amendment of relevant ICAO SARPs and guidance materials • A kick-off meeting was held on May 4-5, and working groups were established for further research and discussion 17

18. Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia 13-17 June 2011 Thank you