As we have talked about regularly in our Conversation Aviation magazine, occurrence reporting plays a crucial role in ensuring, hazard identification, risk mitigation and continuous improvement.
Many thanks to the Safety team at Ryanair for inspiring this article and providing lots of great input.
Do know what happens to a safety report once it's submitted?
We thought you might be interested in learning more about the stages of a Safety Report (SR), from the initial occurrence that you might submit to your organisations reporting system.
Then if a Safety Report becomes a Mandatory Occurrence Report (MOR) that has to be reported to the National Aviation Authority (NAA) where it finishes up in the European Central Repository (ECR) where EASA use it to help develop the European Plan for Aviation Safety (EPAS).
Sorry, lots of abbreviations there, but it wouldn't be aviation without a bunch of TLAs.
What happens to a safety report inside the organisation?
This is an example from our made-up airline "Safewings" that we use in our Conversation Aviation magazine.
Initial Occurrence Report
Things start with the SR, triggered by any event or hazard that compromises safety or poses a risk to our operation. It doesn’t matter what role you perform here at Safewings, anyone can submit a report. If you are in a crew or team, discuss together who will submit a report so we don’t duplicate our efforts.
Of course, this doesn’t mean that different people can’t submit different views on the same event, e.g. Pilots, ground staff, cabin crew, engineering etc. The SR outlines the basic details of the event, including an event descriptor, date, time, location, and a description of the event itself. Timely reporting is vital to initiate prompt follow-up activities and, in the case of MORs, there is a regulatory requirement to submit a report within 72 hours.
The more useful information you can provide in the initial report the better. Without this information it is hard to understand the risks that might be impacted and most importantly what to do about them.
Daily Review Meeting
The Safety Office reviews the reports received in the Daily SR meeting. This stage involves gathering essential information from all relevant departments, for example, flight operations, inflight, ground and Engineering. This phase sets the foundation for a more in-depth analysis and risk assessment. A decision will be made whether all the information is available to close the report, monitor the safety issue or if there is a need to investigate further through a “learning opportunity”.
OFDM Analysis
For some occurrences, the Daily Review will request that the OFDM data be downloaded and analysed. This stage aims to help provide more information on handling factors, environmental factors or equipment malfunctions that may have contributed to the event.
Cockpit Voice Recorders (CVR)
Sometimes an SR will report that the CVR needs to be pulled. The Daily Review will decide whether the unit should be retained or returned to line. If it is to be analysed then there will always be a request for crew authorisation in advance.
Learning Opportunities
Based on the decision made in conjunction with the relevant department at the Daily Review or follow-up with the operational department, a formal recommendation will be made for an investigation in the form of a “Learning Opportunity”. The goal is to understand the circumstances around the SR in more detail.
Learning Points
Once the learning opportunity is complete and has been reviewed at a weekly meeting held with the Safety Manager and representatives from the relevant departments, the learning points (actions) will then be agreed upon. These will include, at a minimum, feedback to those involved in the event and other actions for the promotion of the event, and proposals for procedural reviews or training/checking. It is important to emphasise that additional training and/or checking should never be viewed as a bad thing as these steps are designed to enhance knowledge and build confidence in dealing with similar situations in the future.
Did it Work?
The final step after any learning point is to continually monitor the specific risk or safety issue to check if the learning points implemented actually worked in practice. This also involves checking with operational teams on their effectiveness. You can also monitor the long-term effectiveness through monitoring of performance indicators.
The life of an MOR when a report goes to the NAA
MOR decision
The first decision for the organisation is whether the SR falls into the category of an MOR. The definition for that is in Regulation (EU) 376/2014 – the European Occurrence Reporting Regulation. The list of reportable occurrences are in something called an ‘Implementing Regulation’ to this main Regulation – Implementing Regulation (EU) 2015/1018.
Initial Report to the Authority
Having decided that a report is an MOR, we have a requirement to send an initial report within 72 hours to the relevant NAA depending on which country the AOC or other organisational approval is based.
Follow-Up Reporting
Where we are unable to provide the Authority with all the relevant information right away, we have a requirement to follow up within 30 days and to provide the full, completed internal investigation report/information within 3 months. This is really important, it's really hard to make good safety decisions based on half a story of an occurrence.
What Happens Next
It might seem like all the MORs that we send to the different Authorities we interface with just disappear into a black hole, however, the reality is somewhat different. Often we receive feedback on individual reports. Then all the reports are uploaded by the Authority into the European Central Repository (ECR). From here all of the collective reports are analysed by the Network of Analysts with EASA and the NAAs. This feeds into the EASA Annual Safety Review and other analysis work that drives the European Plan for Aviation Safety (EPAS).
From reports to strategic actions
EASA then has a number of domain-specific collaborative groups and advisory bodies that use the analysis and intelligence to develop strategic safety actions for Europe. This means that information from the reports that you submit gets to have an impact far beyond the walls of any individual organisation. These actions end up in the European Plan for Aviation Safety (EPAS).
Your reports really matter
Hopefully, seeing what happens to a report drives learning and improvement both at Safewings and out into the wider aviation community as you will see the value of reporting. Keep them coming….
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