In an ideal world there would be no need for CHIRP. In reality, aviation benefits from CHIRP and CHIRP needs the input of all “stakeholders”. Interestingly, there has recently been a number of Cabin Crew reports identifying engineering issues. CHIRP is of course very pleased to receive all reports and a crossover of sources is not necessarily a problem. The question here though is, if Cabin Crew are reporting engineering issues, is there a reluctance by engineers to report, or are they simply adjusting to a certain level of things being wrong (Norms or Learned Helplessness perhaps)?

One such report was in reference to a widebody aircraft with a large cabin panel missing! The Cabin Crew reporter’s initial concern was of something being secreted away in an area that was difficult if not impossible to inspect for security because the missing panel was high on a bulkhead. Did the engineer that carried-forward the panel consider the impact of other (non-malicious) FOD being dropped behind the area below the missing panel? Did they consider if any components (EWIS or otherwise) might be compromised by FOD? What are the implications of fire containment with a large cabin panel missing? Oxygen in the cabin air could feed a fire more easily of course. Although there is the chance that a missing panel could provide early fire detection, it is not really the work of a licenced engineer to make such a judgement. The operator did contact its design organisation for a temporary cover but a spare was procured before the temporary work was started. How was the missing panel carried-forward, it would not be in the MEL or CDL, and the operator in question does not use a Non-Essential Furnishings list (NEF)? On balance, an internal report was raised and appropriately processed. The Continuing Airworthiness Management Organisation (CAMO) in this case is an organisation within the airline and CHIRP received a professional response. However, internal reports from Cabin Crew or Engineering do not necessarily get submitted to a CAMO.

Whilst on the subject of CAMOs, CHIRP hardly ever receives reports from CAMO staff, whether they be Licenced Engineers or other appropriately competent staff. Due to the fact that the CAMO personnel are routinely identifying errors on flight and maintenance records, perhaps they feel as if being the last chance to put things right precludes them from reporting incorrect practice. We should think of the CAMO as the glue between Operations and Engineering. If it becomes evident that an in-house or contracted Maintenance and Repair Organisation (MRO) is preforming in an unsafe manner either as a single issue or continually, the CAMO has a responsibility to report it by submitting a Mandatory Occurrence Report (MOR) to the applicable Regulatory Authority. At a lesser level of concern, CHIRP is ready and willing to record, highlight and progress CAMO staff reports of any shortcomings. Maybe managers and engineer staff in CAMOs could raise the awareness of CHIRP to their competence-based colleagues.

CHIRP has very strict processes to ensure confidentiality but we do understand that, for any number of reasons, it is not an easy decision to submit a report. We encourage you to submit an internal report first when possible even though that might make subsequent confidential reporting to CHIRP more difficult. Your employer’s Quality/Compliance/Safety manager is not particularly interested in who you are, only what you report; although they do need to know who you are to give you feedback in accordance with the regulations. It stands to reason that many issues are not reported to anyone because confidentiality would be compromised if, for example, you were the only staff member on duty.

When a report arrives at CHIRP we issue a holding response to acknowledge receipt and a formal response is then sent by the most appropriate CHIRP team member. The formal response very often contains various questions, thereby requiring the reporter to commit more time. Sadly, some reporters never reply and the report does not continue. Junk Mail may be a causal factor here but it may be that the reporter is just relieved to have got something off their chest, or they simply did not envisage further work. CHIRP will not contact any other organisations without being given the go ahead from the reporter. Therefore, without questions being answered, reports cannot proceed to a conclusion, cannot be published for the benefit of us all and worse still, the reported issue remains a problem or a safety compromise.

Finally, two more reminders and a request. We need you to submit near-miss reports (where you nearly made an error) and we need you to self-report when you feel you should hold your hand up because you have made an error that others might repeat. CHIRP has to have buy-in from Quality/Compliance/Safety and Engineering management – being open with staff about CHIRP is in the interest of all stakeholders and we ask that you bring CHIRP into your processes so that this useful source of intelligence about things that might not otherwise be reported can be tapped.

Phil Young, Engineering Programme Manager

Comment No 1 – Judgemental editorial

I’ve just finished reading your latest edition of CHIRP (Ed 143) – I continue to spread the word about the great work you do at your organisation and know many crew who now are aware of CHIRP and its benefit; I know my friend has recently reported after losing confidence in their internal mechanisms.

I just had a question around the wording used within Page 2 of the edition’s editorial. It states that under Just Culture, “sometimes people should have known better (unprofessional)”, and I just wondered what your thought process was behind this? From my perspective, and considering Human Factors, this read as opposite to the intention of Human Factors and Just Culture and almost puts the blame back on the end user? I don’t know if I’ve misread that. The interesting point with Human Factors is to understand ‘why’ people should have known better. Was it a case of lack of rest, poor procedures, poor CRM, poor working environments, a degraded safety culture… equally even if an event is a ‘violation’ and someone ‘should have known better’, is it a case that the individual felt that they had no choice despite correctly knowing the procedure – i.e. in the case of on-time performance, lack of resource, and all the challenges we know exist in the industry currently. In which case it’s not unprofessional per se, it’s more likely a wider system issue.

CHIRP Response: The comment the reader refers to was my shorthand to acknowledge that ‘Just Culture’ and ‘no blame’ don’t mean that there may not be consequences for those who might act in a reckless manner.  In this respect, the context and circumstances of every incident should of course be fairly examined to find out whether there are any systemic issues behind the incident but ‘no blame’ cannot be universally applied for example if people deliberately break the rules for their own gain when they know that what they are doing is not what they are supposed to do, or they conduct deliberate malicious sabotage. Any such review must distinguish between mistakes, errors, situational violations and exceptional violations as instances where there may be systemic lessons that should normally be addressed without ‘blame’ being apportioned. But instances of sabotage, recklessness or violation for personal gain are often ’blameworthy’ for want of a better expression and amount to professional lapses at the very least. Violation for organisation gain is another aspect that can lead to a marginal outcome, sometimes it’s easy to see that there were good intentions to someone ‘bending’ the rules to achieve the task, but sometimes it might be that someone was borderline ‘reckless’ in doing so. As ever in Human Factors analyses there are rarely black-and-white outcomes to anything and so ‘apportionment of blame’ is a matter for much debate.  That’s why it’s important that companies convene broad-ranging teams when reviewing safety incidents so that multiple perspectives about the motivations and thought processes that might have pertained can be offered to investigators.  Ultimately though, a purely ‘no-blame’ approach can lead to reckless behaviour if there are no consequences for inappropriate or egregious ‘unprofessional’ actions.

Comment No 2 – Fuel tables

Air Transport FEEDBACK Edition 143 contained an article under the heading ‘Fuel Tables’. I noted that you said, “It’s human nature to reflect upon one’s own performance in relation to others, and some less experienced captains might conceivably perceive implied pressure or incentives to carry less additional fuel even if they felt they needed it in what was ultimately a safety-critical decision”. You may already be aware of the similar perception problem about fuel ‘League Tables’ that, little more than 20 years ago, CHIRP had agreed should be addressed. In consequence, the CAA initiated what was termed a Special Objectives Check that required Flight Operations Inspectors assigned to relevant companies to look into the fuel planning policies and associated instructions. The results, together with the analysis and options/recommendations that followed, were contained in reports that were subsequently published both by CHIRP (ATFB Edition 58 – April 2001) and in the UK Flight Safety Committee Spring 2001 Issue 42 of Focus. Key within the reports were the texts contained within ‘Company Cultures on Fuel Planning and Usage’. These addressed shortcomings associated with what CHIRP termed ‘Fuel Leagues’ that reporters had described as implying pressure to depart with less fuel than they felt to have been adequate or indeed essential. To add detail to the report, two reporters (co-pilots) described how their captains had deliberately departed with less than the amount that should have been calculated in accordance with the fuel planning procedures specified in their company Operations Manuals – simply with the aim of ‘improving’ their exposed position in their related league tables. Now I wonder if lessons learnt during the process of managing the survey and publishing the results – with attendant recommendations – might have been lost? Perception is a powerful motivator, and I would hope that operators – and their line managers especially – will not promote a return to ‘League Tables’ as CHIRP then called them.

It doesn’t surprise me that concerted efforts are once again being made to reduce margins where cost savings are thought likely to be achieved, but it behoves industry to do so only where the safety of operations will not be compromised. It follows that at times like these, the regulator should ensure that a close watch is maintained upon what every company publishes as guidelines and what is applied by the captains they employ, most of whom I am sure would want both to save on costs as well as to demonstrate that they are worthy ‘company men/women’. Finally, the concept of Statistical Fuel Planning has been discussed many times in the past and I recall that many were previously uneasy about its lack of transparency and the inability of captains to carry out easily a gross error check on the amount of fuel thus specified.

CHIRP Response: It just goes to show that sometimes there are recurring issues in aviation that may have featured in the past and resurface with new circumstances and initiatives.  Although the company concerned in the recent report were keen to reassure CHIRP that their fuel usage graphs were not used to pressurise captains, and that their statistical algorithms for additional fuel requirements were robust based on historical analysis, the overall CHIRP view was that fuel usage graphs remain open to the risks of human nature because some may feel the need to improve their position on the graph so that they can avoid potential conversations with their fleet managers.  CHIRP understands that other companies also employ fuel usage monitoring, with some systems sending automated emails to captains depending on pre-set targets. Captains must resist being sensitive about their relative position or performance on their company’s fuel usage spectrum and must continue to employ context-specific judgement in the exercising of their command privileges in this respect.  Although there is a clear obligation not to load less than the planned fuel uplift, there are often times when a rational decision to add more fuel is appropriate where uncertainty or risk exists; it’s a command decision, and any responsible fuel monitoring process should not invite line managers to second-guess such judgements or even subliminally hint at associated incentives or disincentives.