Confidential Human Factors

Incident Reporting Programme

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The Charity

Aviation

Maritime

The Charity

Aviation

Maritime

Submit Report

FEEDBACK

CCFB 82

Report by report we can make aviation a safer place.

What do you do when something goes wrong onboard that relates to safety?

We all know what should happen; the event (or close call) should be reported internally as soon as you can do so. Sadly, all too often people feel that once the matter has been ‘sorted’ there’s no need to report and so it goes unreported. In the end, this means that important lessons are then not learned by your fellow crew and SOPs can’t be changed (if required) by your company.

Submitting a safety-related report about incidents can be scary, and there are plenty of rational reasons to be worried about doing it. As ex-cabin crew, pilots, engineers, and ground handlers ourselves, we know all about those fears at CHIRP, the Confidential Human-Factors Incident Reporting Programme. Those fears are known as the ‘four Rs’: revealing your identity, reprisals from managers, ridicule for speaking out, and rejection if your reports are ignored or suppressed. That’s why, over 40 years ago, CHIRP was founded and there are many other confidential reporting schemes worldwide (and outside of aviation) based on CHIRP. We are the UK’s only confidential, independent and impartial aviation safety reporting programme and across thousands of reports (some of which have shaped company or regulatory policy) we have never revealed a source.

Protecting you and your safety

As anyone with experience of working in aviation will know, a lot has changed in those 40 years. New ways of working onboard and commercial demands – as well as new technologies – have changed the industry, mainly for the better. One thing that has not changed is the need to continuously improve safety. At CHIRP Aviation we work hard to ensure that cabin crew, pilots, air traffic controllers, ground handlers and engineers can report safety-related incidents and near-misses easily and without risk to them or their job. Reports from other aviation communities, including General Aviation (light aircraft, gliders, skydiving, etc.) and Drone/UAS (pilots and operators) are also welcomed by CHIRP Aviation.

By sharing information with us, we may identify safety issues in the aviation industry so that others can learn from them and prevent such events in the future. Knowledge is power and the more reports received the more lessons can be shared. If we see safety trends being repeated across the Industry, we are able to share these with operators and regulators. We want to empower cabin crew; by allowing us to amplify your voice. By submitting a report you are helping to raise safety standards across the wider aviation industry for everyone.

The ‘how’ and ‘why’

While CHIRP is a safeguard for crew worried about the risk of speaking out, reporting to CHIRP does not replace official company reporting channels, it is often a requirement within an Operations Manual to report safety events within their Safety Management System (SMS). The most immediate way of making a difference to the safety of crew and passengers is for your company to be made aware of not only actual incidents but also near misses. However, if you feel unable to report internally, submitting a report to CHIRP ensures that those learnings are anonymised.

Reporting to CHIRP is simple, you can submit a report online or via our app in minutes. Anything that could be used to identify a reporter is removed by us and we liaise with the reporter (you!) every step of the process. Managers and colleagues will never know who has made a report.

The CHIRP cabin crew programme receives hundreds of reports a year, not all of them need actioning, however, the data from those reports helps the industry monitor trends and highlight areas that may be of concern. Our tri-annual newsletter features some of your reports, these reports allow our readers to learn from your experience and help to prevent the same incidents from recurring again. Some of these reports are also shared via our social media platforms, help us share our safety message by following us on Facebook, X, and LinkedIn

Improving industry-wide safety together

Recent reports have highlighted a range of concerns including commercial pressures and fatigue. Sometimes the reports lead to changes in company policy and, where needed, to intervention by the regulator.

Each report plays its part in raising awareness of important safety issues, wider trends and provides lessons for crew and aviation leaders alike to learn from. To make sure your colleagues have the opportunity to learn from your safety experiences, and to make the aviation industry a safer place to work, trust CHIRP. Report by report we can make aviation a safer place.

Stay safe,

Jennifer Curran

  • CC6328

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    Cabin crew training
    Cabin crew training

    Initial Report

    I have genuine concerns about some crew members’ knowledge when it comes to training. Mainly for recurrent training. We use a system of revision banks, which is essentially a bank of questions that everyone has access to and enables them to revise from. When it comes to the exam on recurrent training a selection of questions are pulled from these revision banks for the exam. So in theory they’ve gone through every single question in the bank of questions beforehand and when it comes to the classroom it’s a case of picking out the right word that stands out. This then promotes a culture of using said revision banks to revise from and not the necessary manuals to execute the job confidently as there is no incentive to read the manual when people can use revision banks which are the actual exams. This then in turn creates the wrong learning culture. Granted, it is a refresher. But it seems to have gone from a regimented environment of reading the manual and writing/drills/location diagrams etc to a free-for-all on a multi-choice exam to which everyone has access to. I’m not saying it needs to be how it was, but it’s gone too far the other way where now people don’t attempt to read the SEP manual and use revision banks as the main point of revision and then generally people achieve 100% in exams due to this.

    When crew do fail, it is even more concerning when they have had access to revision materials such as revision banks beforehand and still fail. Perhaps revision banks are acceptable but not to replicate the actual exam papers and select a random amount/selection from such aids? People become so focussed on them which cover a small amount of the associated manuals but not refreshing on all knowledge. It almost seems like a quick fix and people revise in this way without actually retaining the information because they just look for the right word or keyline in the choice of answers. This then begs the question that if something were to happen onboard what would they do?

    CHIRP Comment

    A crew member has the responsibility of maintaining their knowledge base which should be updated regularly rather than just once a year when preparing for Recurrent training. Crew members undergo evaluations all year round during pre-flight briefings, line checks, and/or onboard assessments. Assessments during recurrent training go beyond the formal test, over these two or three days there will be several opportunities for learning and evaluation, as well as practical equipment handling, competency-based training, and/or scenarios.

  • CC6466

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    Neurodiverse Crew
    Neurodiverse Crew

    Initial Report

    There has been an influx of new crew and many of them are posting on social media that they have ADHD and saying their symptoms make their role difficult e.g. can only work one position, can’t concentrate, short attention span, and are easily distracted, are unable to listen or carry out instructions, can’t organise tasks, have little or no sense of danger.

    They openly admit that this wasn’t disclosed at their medical.

    I am concerned that an ADHD diagnosis is not compatible with a safety critical role and how they would perform in an emergency.

     

    CHIRP Comment

    Most organisations have strict policies regarding the appropriate use of social media and any safety-related concerns raised on these platforms should be reported internally.

    Flying can be compatible with neurodevelopmental conditions and some neurodiverse characteristics may even be advantageous in the role as cabin crew. It is important that the sector adopts appropriate practices regarding diversity, equity, and inclusion to encourage others to pursue careers as cabin crew.

    A cabin crew initial medical is an in person physical assessment by a aeromedical examiner or occupational physician approved by the CAA. This usually commences with a questionnaire and declaration and then the physical assessment. When completing the medical questionnaire and declaration, it is essential to be truthful and obtain the available support if it is required. Medical requirements for cabin crew – information for airline operators | Civil Aviation Authority (caa.co.uk)

    If a crew member has declared their neurodevelopmental condition and passed their fitness assessment, completed their training to the satisfaction of the operator and performs appropriately when flying then as with any condition this is acceptable. However, should any condition prevent a crew member from performing their day-to-day role appropriately, especially any safety-related duties, then this would have to be managed accordingly via the SCCM/operator.

  • CC6397

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    Strong smell of fuel in the cabin
    Strong smell of fuel in the cabin

    Initial Report

    On taxi out there was a strong smell of fuel in the cabin, I rang my crew at the rear to ask them and they said it was very strong. I rang the Captain and asked are we behind another aircraft and drawing in their fumes to the cabin? He said he wanted to investigate. I asked him if he would make a PA, he said not right now? The smell was very strong, I had positioning crew in the cabin and I could see the SCCM looking at me, waving her hand in front of her face indicating that there was a smell in the cabin. 10 mins went by with no communication from the flight crew to our customers and they could hear the interphone call bell going off in the cabin by myself calling my crew at the rear and the flight crew calling them too. I was very frustrated that the flight crew left it for such a long time to communicate with our customers.

    In the end, I asked one of my crew to walk through the cabin to show crew visibility and I walked from the front of the cabin to meet her. I verbally spoke to the forward passengers explaining to them that the flight crew are working through some checks and that we were aware of the smell in the cabin. Shortly after the captain made a PA, explaining what they were doing. We eventually returned to stand escorted by the fire services to a remote stand. The captain came out to talk to us after customers had disembarked to complete a report asking how strong the smell was, very strong. I did say to him in front of the crew that passengers had commented that the communication took a long time, he replied our checks and investigation of the smell takes priority over communicating.

    CHIRP Comment

    The cabin crew are the flight crew’s eyes, ears, and nose in the cabin, and cabin crew must report anything unusual to the flight crew as quickly as possible and safe to do so, whether it be a smell or anything visual such as smoke, or a medical incident.

    We know from training that the busiest times for flight crews differ from those of cabin crews, 10 minutes can feel like it goes very quickly (final landing checks come to mind), or it can pass very slowly such as when waiting for a gate on the last sector home.

    On this occasion the SCCM consulted the cabin crew at the back of the aircraft to gather more information before sharing their concerns with the flight crew, just as the flight crew would need to consult their instruments, each other, cabin crew in the relevant area, and possibly third parties (ATC, engineering, etc.) to gather more information before making a PA to the passengers. The flight crew will be attempting to diagnose the situation and advise the passengers when they have sufficient information.

    The SCCM was proactive by having crew walk through the cabin and communicating with the forward passengers. This could also have been backed up with a PA from the cabin crew to advise passengers that the crew were aware of the smell and more information would be available when possible.

  • CC6426

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    Crew Working Whilst Sick
    Crew Working Whilst Sick

    Initial Report

    I recently flew with one cabin crew who spent the entire day coughing and was clearly sick. I commented at the end of the day to her that she did not sound well, which she acknowledged and agreed she was sick with a blocked nose and ears. I told her she should call sick and that she might pass her sickness on to other crew members and passengers, to which she responded that calling in sick would cause her problems with the company and that it is better to work sick. I have experienced this many times with flight crew, but especially cabin crew. The sick crew member is aware that they are sick, but is afraid of the repercussions of calling in sick from the company. There seems to be a culture of fear about going sick which is dangerous for the crew member who is sick, as well as crew and passengers they are responsible for.

    CHIRP Comment

    Other than causing further illness and possibly injury, safety may be being compromised by crews feeling pressured to operate when they are unfit to do so, whether perceived pressure from your operator or personal pressures. We understand that pressures are not just financial but may be related to sickness polices, temporary contracts etc, but the safety implications of operating as crew when unfit to do so are clear. As a crew member you must ensure that you only report for duty when fit to do so.

    MED.A.020 Decrease in medical fitness

    1. Cabin crew members shall not perform duties on an aircraft and, where applicable, shall not exercise the privileges of their cabin crew attestation when they are aware of any decrease in their medical fitness, to the extent that this condition might render them unable to discharge their safety duties and responsibilities.

    UK operators like most companies are required to have processes in place to support employees whilst they are unwell. The CAA Flight Operations Group are doing some wider work with the industry on absence management which we will hopefully be able to update on later in the year.

  • CC6345

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    Reduced Safety Equipment
    Reduced Safety Equipment

    Initial Report

    During our preflight safety checks we became aware that there were 2 BCF extinguishers missing from doors 2 and doors 3, and 1 from the flight crew rest area. This meant that there were only 2 BCF in the cabin and 1 in the flight deck. On checking the tech log it revealed that the 3 BCFs had actually been removed at AAA.

    I brought this to the attention of the flight crew who were adamant that we could go as long as we had 2 BCFS and 2 water extinguishers in the cabin. Apparently this was on the MEL but as cabin crew we don’t have access to that and flight crew did not actually show me. The BCF and water were all  at doors 1 and 4 with nothing in between so, we repositioned them so we had 1 at doors 1 and 1at doors 3.

    Only having 2 BCFs is less than half of our normal equipment, I find it totally unacceptable. A night flight with tired crew and I am having to try and remind them at every opportunity where the operational BCF are in case of an emergency and we spend most of the flight time over the Atlantic.

    CHIRP Comment

    The Master Minimum Equipment List (MMEL) is a document, developed by the manufacturer and approved by the State of Design, that lists the equipment which may be inoperative at the commencement of flight without affecting safe operation of the aircraft.

    Operators then produce their own Minimum Equipment List (MEL) which is approved by the Regulator but, if this differs from the MMEL, it may only be via the inclusion of more restrictive limitations.  In the event of any defects being notified or arising before take-off, the Commander must review them against the MEL to ensure the aircraft can still be safely dispatched.  The continued operation of an aircraft with permitted defects should always be minimised, though mitigations or alternative measures may be put in place until maintenance action can clear the problem.

    The crew onboard should be working as a team, and if the SCCM is unsure of the content of the MEL then they should feel that they can clarify their concerns with the flight crew. The MEL is supposed to not only detail the allowable deficiencies but also how to comply with them, so the decision about how best to distribute the remaining extinguishers should be easily identified. The MEL should say exactly what is required and where it should be.

  • CC6453

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    Fatigue induced sleep whilst manning door
    Fatigue induced sleep whilst manning door

    Initial Report

    I operated two busy and long sectors. On outbound flight; arrived for duty 2 hours before report time. Commute to work was by car, taking approx. 1hr 30mins. After our flight briefing, we made our way to the gate but were informed aircraft was still disembarking pax and our crew boarding would be delayed by 1hr due to the late arrival of the aircraft. Arrived on time and got to the hotel at around 5pm local. Slept down route between 9pm and 1am local and could not gain more sleep despite efforts. I remained in my hotel room down route due to tiredness and the need to be rested and fit for duty on the return flight. However, on wake-up call, I felt like I had brain fog due to fatigue from poor sleep gained. I also felt anxiety at having to perform crew duty on another busy long sector flight, I did not feel adequately rested.

    We left the hotel the next day at 3pm local. My position involved being responsible for a door on both sectors, we operated with one crew member less than the full-service complement. Both sectors were passenger flights with 80-95% pax load. On both sectors I had over 2 hours inflight rest taken in a bunk, both flights turbulent and no sleep gained. No other break periods taken due to busy pax services and demands.

    On arrival back to UK airspace we were in a hold approach and I was sat on my jump seat for an extended period. I found myself fighting to not fall asleep. After landing we were stuck on the tarmac for 30 minutes due to a plane blocking our entry to the gate. During this wait I fell asleep on my jump seat, I estimate this was for a few minutes. My fellow crew members noticed and woke me up. This is the first time I have fallen asleep whilst manning a door in my 15+yrs career. It has shocked and concerned me in relation to failing in my duties around safety and security.

    I believe and express in these reports that now pax numbers have increased since the pandemic, the airline is failing in a duty of care to ensure I am able to adequately rest and sleep. I do not feel the time given down route is sufficient. I report this every time.  I have also included my anxiety around this and the increased demands this is having on my mental and physical health over time. I have previously stood myself down (once) siting cumulative fatigue after flights of this nature. On my return to duty the airline, whilst having to be supportive and non-punitive, have openly questioned me on my knowledge around my understanding of tiredness compared to fatigue. This induced a fear factor in myself making me less likely to call in unfit for duty due to fatigue on future flights. On reflection, I did not feel fit for duty on this return sector but feared standing myself down and impacting on the operation of the flight leaving them short of crew. I had a fear of reprisals from the company from this.

    CHIRP Comment

    CHIRP frequently receives reports regarding fatigue and we empathise with the crew as some duties can be very tiring.  We are all unique and resting methods before a flight, down route and post flight will differ from crew member to crew member. It is the crew member’s responsibility to make best use of opportunities and facilities provided for rest, it is also their responsibility to plan and use rest periods properly to minimise fatigue. Cabin crew should not be operating when they are unfit to do so.

    Despite a crew member reporting for duty well rested, this report discusses common scenarios in which a crew member may get tired/fatigued whilst on duty.

    If you do find yourself feeling tired onboard, simple activities such as taking a walk through the cabin, having something to eat, or sparking up a conversation with a passenger or colleague may help. Some people believe that a strong coffee or sweet food/drink can assist.

    There is no universal definition of tiredness/fatigue, and its experience and perception are subjective. Please remember to report any incidents of fatigue back to your company, a Just Culture should promote continuous learning, including lessons learnt from fatigue reporting and crew should not feel that they are unable to report fatigue or any other safety concerns internally. If crew don’t report their fatigue (or any other safety concerns) then the data won’t be there to highlight any concerns and provide the company with accurate information when reviewing rosters, routes and schedules.

  • CC6348

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    Pushing for an on-time departure, compromising safety
    Pushing for an on-time departure, compromising safety

    Initial Report

    A massive push for on time departure. Feel like there is a blame culture for why crew don’t start boarding on time, with it being recorded on our files when it is out of our control. The timings are in a perfect world of everything running smoothly, I feel as a SCCM I’m rushing my checks to hound other people for theirs to pass on to the ground staff who wants us (from the company) to board 10 mins early.

    I find myself shadowing crew members, mainly new crew or new to type of their checks as I’ll know I’ll get an email asking why the cabin was released 2 minutes late. It’s not good CRM to be going to my crew asking if they need help with their checks- it’s confusing to know what had been checked etc, they are their checks and AORs for a reason. We have to count everything, that takes time and new are just that NEW, they still don’t have a rhythm or routine. I feel awful having to keep asking as they rightfully take their time doing their checks. We all get to the aircraft at different times so I have no idea what checks have been done and by who, it there seems to be little or no time to get this done. As a SCCM, the last month or so has been the most stressful I’ve ever experienced flying, when in reality cabin crew are rarely the reason for flights not getting away on time. I feel the company are prioritising seconds and minutes over their crew being able to do their checks thoroughly and properly.

     

    CHIRP Comment

    Please do not allow yourself to be pressurised into not completing your safety checks properly. ‘Pressure’ is one of the most frequently reported key-issue safety concerns to CHIRP. Be it commercial pressure, time pressure and/or peer pressure whether the pressure is real or perceived, the results are frequently the same, in this reporters case it may have caused anxiety, a fear of something being missed and poor CRM. Passengers should not be boarding the aircraft until all the appropriate checks have been completed and the SCCM should have the confidence to say ‘no’ if the crew are not ready to board. The safety and security of the aircraft must come first.

    If the passengers are late boarding the aircraft, or any other reason that may cause a delay (checks/baggage/PRM/catering etc) then it is important to document exactly why. Operators often need to contact crew for clarification on why a flight has been delayed and this is normally a standard communication that allows delays to be monitored and potentially improved by the management.

  • CC6461

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    Crew Using Personal Phone Devices at Critical Stages of Flight
    Crew Using Personal Phone Devices at Critical Stages of Flight

    Initial Report

    I felt compelled to report to yourselves my observations of the growing trend of crew members distracted by the use of personal devices during critical phases of flight (taxi, take-off and landing). They have a complete lack of safety awareness. Whilst I am happy to challenge my colleagues around this behaviour, I have found I have been dismissed due same rank on board.  I have also on occasions witnessed this behaviour from the most senior crew member which makes reporting all the more challenging.  I have reported my concerns to the company in the past however, this continues. I often feel if an emergency were to occur unexpectedly, I would be the minority of crew ready to react. This is a commonly observed culture.

    CHIRP Comment

    Using any sort of PEDs whilst engaged in other tasks can cause distraction. Taxi, take-off and landing are classed as critical phases of flight and cabin crew should not be using personal devices during this time. There can be all sorts of circumstances that make it difficult to wait and whilst it may be tempting check your socials or send a quick message during the critical phases of flight, cabin crew members must be focused on the tasks ahead and be ready to act should an emergency situation arise. If an operational task requires it, cabin crew can use an electronic device as per their company Operations Manual which will specify the situations when this is permissible.