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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

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


HOW DO WE LEARN

HOW DO WE GAIN EXPERIENCE


English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance



common

English language

MET

ICAO PANS-RAC

NAVAIDS

Radar Theory

Radar Skills

International Organisations

Aircraft Performance


Purpose of Reporting Systems?

Indispensable to efficient system improvement

ORGANISATIONAL LEARNING



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


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


Ease

of

reporting

Independence

TRUST

Motivation

&

Promotion

FEEDBACK

Acknowledgement

Required qualities of Reporting Systems



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.


Implementation of Reporting System

1

chance

2

mis-management


“NO OCCURRENCE“

means

“NO REPORTED OCCURRENCE”


Thank you

Thank you!

Questions?

?


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