Type of Reporting Systems
Features to facilitate the Just Culture Implementation
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Tony LICU
Programme Manager – EUROCONTROL DAP/SAF
European Safety Programme for ATM (ESP)
April 2006 – Baku/Azerbaijan
[email protected]
European
Organisation for the Safety of Air Navigation
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Presentation Topics
Purpose of Reporting Systems
Different types of Reporting Systems
Required qualities of Reporting Systems
Implementation of Reporting Systems
2
Objectives
Detailed
3
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Know the pros and the cons for different types
of reporting systems
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Appreciate what type of reporting system is
best suited for your organisation
G-ARPI (Papa India)
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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
5
English language
MET
ICAO PANS-RAC
NAVAIDS
Radar Theory
Radar Skills
International
Organisations
Aircraft Performance
6
English language
MET
ICAO PANS-RAC
NAVAIDS
Radar Theory
Radar Skills
International
Organisations
Aircraft Performance
7
English language
MET
ICAO PANS-RAC
NAVAIDS
Radar Theory
Radar Skills
International
Organisations
Aircraft Performance
8
Indispensable to highly qualified professionals
INDIVIDUAL
LEARNING
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English language
MET
ICAO PANS-RAC
Radar Theory
Radar Skills
NAVAIDS
common
International
Organisations
Aircraft Performance
10
Purpose of Reporting Systems?
Indispensable to efficient system improvement
ORGANISATIONAL LEARNING
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Different types of Reporting Systems
Human
Automatic
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Reporting Systems [Human]
Mandatory
Voluntary
Nominal
Confidential
Anonymous
Complementarity
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Mandatory Reporting
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1.
Legislation Required
2.
Legal Definition of Reportable Occurrence
3.
Define What Should be Reported
4.
Define Who Should Report
Voluntary Reporting
Factors Resisting Change
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1.
Personal
2.
Professional
3.
Organisational
4.
Political
Voluntary Reporting
Factors Driving Change
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1.
Personal
2.
Professional
3.
Organisational
4.
Political
Type of Reporting Systems Features
Coverage
Reliability
of entry data
Efficiency
Strictly
defined
High
Reactive
Nominal
Non limited
Good
Proactive
Confidential
Non limited
Good
Proactive
Anonymous
Non limited
Questionable
Proactive
Restricted
Features
System
Mandatory
Voluntary
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Confidential Reporting
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Historically, proportion of Human Factor
occurrences reported remains small – common
failing
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Reluctance to admit personal errors
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Partially overcome by introducing a Confidential
reporting system e.g. UK CHIRP
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Could be Anonymous….!
Automatic Reporting
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Latest way to monitor safety requirements
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Complementary to Human reporting
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Problem of “big brother” attitude
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Being trialled at Maastricht for aircraft
proximity
Required qualities of Reporting Systems
Ease
of
reporting
Motivation
&
Promotion
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TRUST
Independence
FEEDBACK Acknowledgement
ATM Investigation Process
A
SAFETY
OCCURRENCE
DETECTION
DETECTION AND
AND NOTIFICATION
NOTIFICATION
NOTIFICATION
REPORT
FACTUAL
FACTUAL INFORMATION
INFORMATION GATHERING
GATHERING
PRELIMINARY
REPORT
RECONSTRUCTION
RECONSTRUCTION
OCCURRENCE
SCENARIO
B
NOTIFICATION
REPORT
C
PRELIMINARY
REPORT
D
OCCURRENCE
SCENARIO
ANALYSIS
ANALYSIS
CAUSAL FACTORS,
SEVERITY, RISK
E
CAUSAL FACTORS,
SEVERITY, RISK
RECOMMENDATIONS
RECOMMENDATIONS AND
AND FINAL
FINAL REPORT
REPORT
FINAL
REPORT
F
FINAL
REPORT
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EXCHANGE
EXCHANGE AND
AND MONITORING
MONITORING
FEEDBACK
Motivation and Promotion
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ATM staff must be motivated to report,
and the trend must be maintained
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Controllers educated about benefits
derived by reporting actual or potential
deficiencies
Ease of Reporting
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Staff must not perceive reporting as an
extra task
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User friendly reporting system
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Staff trained in use of
investigative/problem solving methods
and database
Acknowledgement
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Reporters like to know whether their report
was received
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What will happen to a report
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What to expect and when
Independence
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Some degree of independence to be granted to
reporting system managers
Feedback
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Communication should be frequent, using
both formal and informal channels
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Reward and recognition
Trust
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All reporting is dependant on trust;
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Between reporters, managers,
providers and authority;
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A Just Culture
Summary
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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
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“NO OCCURRENCE“
means
“NO REPORTED OCCURRENCE”
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Thank you!
Questions?
?
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