GAFB 96

You report it, we help sort it

Publicising occurrences, serious incidents and accidents is the life-blood of learning for others

As summer rapidly approaches, we’re all no doubt looking forward to what will hopefully be a season of good aviation weather and are dusting off our flying kit and equipment as we prepare to launch into the air. Part of the preparation activity is also to dust off our minds and think again about all those aviation complexities and our ability to deal with them. In the spirit of ‘Prior Preparation Prevents Poor Performance’ what can we learn from our activities last year and also from those who may have been unfortunate enough to have experienced an ‘occurrence’?

The AAIB publications are always an interesting read when it comes to learning from others’ misfortunes (their monthly bulletin is published on the second Thursday of the month and you can receive them by subscribing to AAIB emails). The various association magazines are also a good source of information (too many to name here and I’d risk censure from those I didn’t!), as are the CAA Clued-up and Safety Sense Leaflet publications. The collegiate nature of flying has always been a strong source of tips and advice about traps for the unwary, but the reporting of occurrences, serious incidents and accidents is the life-blood of learning, as is the wide dissemination of associated lessons that might be identified.

Thankfully, aviation accident rates are extremely low but they have remained relatively constant over the past few decades and a major challenge has been to develop effective processes to identify key causal factors that in some circumstances might lead to an accident, before the accident occurs. One element of this has been to improve the quality of feedback through not just the reporting of incidents but also the reporting of things that nearly happened (but were averted or didn’t develop into a reportable incident) in order to provide additional important information related to contributory causal factors. With aviation being a fundamentally human activity for the most part, some themes recur because we humans are ingenious in our ability to thwart attempts to eliminate errors and mistakes.

Unless things are reported, nothing is likely to change: just moaning in the bar or making anecdotal comments after the event will rarely result in things changing. Modern safety systems recognise ‘Just Culture’ these days, which means you won’t get into trouble for reporting concerns and so we all need to look beyond the ‘what’s in it for me?’ mentality so that issues are passed into and recognised by the ‘system’ (be it local club or more widely). Anyone can submit a report via the ECCAIRS2 Aviation Reporting Portal as the formal route for aviation reporting in UK, and more guidance on the use of the reporting portal is available in CAP 1496. However, although formal reporting systems make an important contribution to the feedback process, they are less successful in gaining information on Human Factors related aspects. Confidential Human Factors reporting systems were introduced to address this. It is important to understand that the confidentiality part applies to the identity of the reporter, not the information; whenever possible the information is disseminated as widely as possible, but in a disidentified manner so that the reporter cannot be recognised, and only with the reporter’s consent.

The UK State Safety Programme acknowledges CHIRP as the UK’s independent confidential voluntary reporting scheme. Broadly speaking, CHIRP provides a vital safety net as another route to promote change when all else fails, and for collecting reports that would otherwise have gone unwritten with associated safety concerns therefore not being reported.  Reports generally fall into two broad categories: those indicative of an undesirable trend; and those detailing discrete safety-related events, occurrences or issues. We also often act as an ‘Agony Aunt’ for those who seek our ‘wise’ counsel or just want altruistically to share with others lessons from what may not have been their finest hour. Beyond that, we often provide information and point people to the right sources/contact points for them to resolve their own issues and, depending on the concern and our resource availability, we also champion causes and act as an advocate or the ‘conscience’ of industry and the regulator where we can.

A member of the GA Partnership (GAP) group, CHIRP was recently the subject of their ‘Community in Spotlight’ initiative which highlighted the key elements of our work in the associated CAP2521 information sheet. Essentially, CHIRP operates through the use of four volunteer-based Aviation Advisory Boards comprising members from the principal relevant aviation interests in the UK who provide specialist expertise in the understanding and resolution of issues raised in CHIRP reports.

The four Advisory Boards are titled ‘Air Transport ‘(dealing with all aspects of commercial aviation other than cabin crew), ‘General Aviation’, ‘Cabin Crew’ and ‘Drone/UAS’ (with their associated obvious focus for each). The Advisory Boards are panels of peers who have rigour and credibility as experts in their own right and one of their principal roles is to review reports and issues raised and to provide counsel on the most appropriate way in which specific issues might be resolved. Report information is formally submitted to the Advisory Boards on a confidential basis with all personal details being removed from reports prior to discussion. The Advisory Boards also review the responses received from third-party organisations to assess the adequacy of any action taken in response to a reported concern.

The Advisory Boards are the great strength of the CHIRP process because they provide the breadth and depth of expertise that bestows on us the specialist intellectual horsepower and professional credibility to our work.  In addition, the Advisory Boards provide feedback to the CHIRP Trustees on the performance of the Programme.

The bottom line? CHIRP relies on you to report Human Factors related aviation safety concerns to us so that we can both help in their resolution and highlight relevant issues to others. We need your reports! Reporting is easy by using either our website portal or our App (scan the appropriate QR code shown or search for ‘CHIRP Aviation’ – avoiding the birdsong apps that come up if you just search for CHIRP and the legacy version that we are about to remove!). In our reporting portal you’ll be presented with a series of fields to complete, of which you fill in as much as you feel is relevant – not every field is mandatory, but the more information you can give us the better. Although you’ll need to enter your email address to get access to the portal, none of your details are shared outside CHIRP, and we have our own independent secure database and IT systems to ensure confidentiality.

Steve Forward, Director Aviation