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Mick Skinner Deputy Director (Engineering) PowerPoint Presentation
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Mick Skinner Deputy Director (Engineering)
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  1. CHIRP UK Confidential Human Factors Incident Reporting Programme IFA Technical Symposium Dubai 24 March 2010 Mick Skinner Deputy Director (Engineering)

  2. What is the basis for an independent, voluntary, confidential reporting system in the UK? • ICAO Annex 13 -Aircraft Accident and Incident Investigation recommends that Member States put in place a voluntary, non-punitive incident reporting system that protects information sources, to complement a mandatory incident reporting scheme. • (Annex 13; Para 8.2 & 8.3). • EU Directive 2003/42/EC Article 9 -Voluntary Reporting (reflected in Article 142 of The Air Navigation Order [UK]) establishes the conditions for a voluntary reporting system that a member state elects to put in place. • Civil Aviation Publication CAP 784 – State Safety Programme for the United Kingdom published in February 2009 meets the ICAO requirement for Contracting States to produce an SSP. Chapter 5; Para 2.5.3 states that CHIRP fulfils the role of a voluntary safety reporting scheme for the UK as recommended by ICAO Annex 13.

  3. South Korea KAIRS (2000) United States ASRS (1976) Singapore SINCAIR (2004) Japan ASI-NET (1999) Taiwan TACARE (2000) Canada CASRP (1985) SECURITAS (1995) Australia CAIRS (1988) REPCON (2006) Spain SNS (2007) Brazil RCSV (1997) Russia VASRP (1992) United Kingdom CHIRP (1982) France REC (1999) China SCASS (2004) Germany EUCARE South Africa SASCO New Zealand ICARUS Confidential Reporting – Other ICAO Member States

  4. Immunity in the UK • Aeronautical Information Circular – 47(2001) provides limited regulatory immunity against third-party reports. Same as MOR system. (Statement by Chairman CAA), but not against gross negligence / wilful acts • Public Interest Disclosure Act 1998 – ‘Whistleblowers Act’ provides legal immunity against “Whistle-blowing” in cases where public safety is concerned, yet to be tested legally in Air Transport. • However, the risk of exposure is minimised through CHIRP processes. Contact details are not retained – no audit path back to reporter. The CHIRP Charitable Trust

  5. Essential Requirements for an Effective Confidential Reporting System • Establish and retain the confidence of users • Proven Independence from - Regulators • - Management • - Employment Groups • Develop and maintain the respect of regulatory and management agencies • Develop effective methods of publishing information • Maintaining confidentiality - paramount The CHIRP Charitable Trust

  6. Programme - Background CHIRP is the UK confidential reporting programme for Aviation (H - Human Factors) and Maritime (H - Hazardous) communities Development 1982 - Programme established (RAF Institute of Aviation Medicine) 1992 - Management transferred to DERA (Centre for Human Sciences) 1994 - Independent Industry-wide Review 1996 - Charitable Trust formed - Independent Management - Funded by CAA (SRG) 1997 - Aviation Programmes progressively expanded 2002 - Maritime Programme commenced; funded by DfT The CHIRP Charitable Trust

  7. CHIRP Aviation Programme Development and Scope Commercial Air Transport - Pilots (1982) - Air Traffic Control Officers (1985) - Engineers / Approved Maintenance Organisations (1997) - Cabin Crew (2001) General Aviation (1999) - Light Aircraft, Gliders, Micro-lights, - Para-gliders, Balloons The CHIRP Charitable Trust

  8. Reporting Relationships { Fatal Accidents AAIB Injury Accidents { Precursors CAA MOR Incidents { CHIRP Normal Operations CHIRP is Complementary to Other Systems of Reporting The CHIRP Charitable Trust

  9. What is the link ? Company Reporting Procedures & Risk Assessments Voluntary Confidential Reporting Regulator MORS

  10. Individuals Individual follow-up & feedback is most important AAIB CAA CHIRP Companies How does CHIRP do this?

  11. How Does CHIRP Ensure Confidentiality? • Confidentialnot anonymous. Permits closed loop process • Follow-up – letter • telephone • interview on private basis • No action taken without reporter’s consent • Personal details and original report are not retained. Returned to reporter (provides level of immunity) • Reports technically disidentified for dissemination and retention • Controlled third-party access to report data for research The CHIRP Charitable Trust

  12. The CHIRP Organisation • Charitable Company Status (provides a level of immunity) • Executive Board (Trustees) • Independent Corporate and Professional Governance • Provide Strategic Direction • Monitor Performance • CHIRP Advisory Boards (subject matter experts) • Nominees from principal agencies • Offer guidance to Director CHIRP on specific issues • Provide feedback to Trustees on performance and effectiveness of the programme The CHIRP Charitable Trust

  13. Organisation and Structure CHIRP Executive Board (Trustees) (10) Mr Ken Smart (Chairman) Capt T Sindall Capt C Elton Air Cdre R Peacock-Edwards Capt D Chapman Capt C Hodgkinson Capt W Lowe Mr J Saull Mr D King Maritime Trustees (4) UK-MEMS Review Board 23 members civil/military Chirp Advisory Boards(4) 89 subject matter experts Staff (3 full-time and 2 part-time) Mr P Tait ChiefExecutive Mr M Skinner Deputy Director (Eng) Mrs K Arnold Administration Manager Mrs J Ellis Admin Assistant Mr Bishnu Sunuwar Systems Administrator The CHIRP Charitable Trust

  14. What are “Human Factors” ? Error prevention strategies Error

  15. 600 66 75 500 34 40 61 58 400 32 29 57 189 156 GA 44 80 110 80 79 98 Eng 300 155 178 Cabin 31 42 20 35 25 132 64 32 ATC 37 24 63 Air 69 200 29 31 16 88 18 20 19 12 245 245 190 100 176 173 170 153 145 140 120 0 2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 1999- 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 CHIRP Air Transport ProgrammeReports Received – 1999 to 2009 Total Reports to-date 7325 (Feb 2010) Air 4131 ATC 712 Eng 495 CC 1167 GA 820 The CHIRP Charitable Trust

  16. 200 180 160 140 120 100 80 60 40 20 0 2005 2006 2007 2008 2009 Flight Crew Reports - Top 6 Key Issue Topics Duty 1. Duty 2. Security 3.Comms- External Security 4. Company Policy 5. Procedures 6. Pressures

  17. ATCO Reports - Top 6 Key Issue Topics Procedures Air Traffic Management 1. Comms-External 2. Procedures 3. Air Traffic Mgt 4. Handling/Operations 5. Company Policies 6. Duty

  18. Engineer Reports - Top 6 Key Issue Topics Maintenance 1. Maintenance 2. Procedures 3. Regulation/Law Procedures 4. Security 5. Company Policy 6. Pressures

  19. 160 140 120 100 80 60 40 20 0 2005 2006 2007 2008 2009 Cabin Crew - Top 6 Key Issues Duty 1. Duty 2. Procedures 3. Company Policy Procedures 4. Pressures 5. Comms-internal 6. Regulation/Law

  20. 30 25 20 15 10 5 0 2005 2006 2007 2008 2009 General Aviation - Top 6 Key Issues Handling/Operation 1. Handling/Operation 2. Procedures 3. A/C Technical Procedures 4. Comms-External 5. Near Miss 6. Sit. Awareness

  21. UK- MEMS managed data input MEDA format data entryvia member ID & Password protection Group member Owned file Identified data Group member Owned file Disidentified data SIDD monthly report CAA MORmaintenance error data analysis Data analysis shared with group members & Industry

  22. Error types as % of total each year (data from CAA MOR)Q; Why do same basic patterns of error reoccur? %

  23. MEMS group SMS readiness review

  24. MEMS Group SMS Readiness Feedback2008Areas ofstrengthandopportunity Above 6 4 2 Training Average 1 4 4 1 1 1 3 Audits Risk Assessment 2 Safety measures LM safety role Communication 4 Trust by employees Employee safety views Employee involvement 6 Below Leadership & Commitment Mgt of change Safety Mgt System Safety Info system Safety as bus. issue Learning organisation

  25. different people……. same mistakes!

  26. Establishing a confidential reporting Scheme? • Links to ICASS group through the CHIRP website (secretariat) www.chirp.co.uk(see Links) • Contact Peter Tait or Kirsty Arnold for more information through CHIRP website or email confidential@chirp.co.uk

  27. And Finally…… Run!

  28. Any Questions? The CHIRP Charitable Trust