The Lifecycle of an Occurrence Report

Imagine you are on the TV show "Who Wants to be a Millionaire". It's 1 Million Euro (or Dollar/ Pound or any other currency) question. The question in front of you is "Why do we report safety events and hazards in aviation?" 

You've used all your lifelines and the 50/50 has left you with these two options - what would you choose: 

1. Because you are required to do so by Regulation (EU) 376/2014 on the reporting, analysis and follow-up of occurrences. 

2. Because it is the right thing to do so we can manage risks in the aviation system. 

Both are right of course but the reality is that reporting is all about mindset. While it is for compliance, the real reason is about understanding risks and learning how to improve safety. 

This article follows up our previous one on the "Importance of safety reporting" by providing more information about what happens to safety reports (SR) from when they are submitted to an organisation (in this case our fake airline Safewings around which we base our Conversation Aviation magazine) through to what happens when a SR becomes a Mandatory Occurrence Report (MOR) that has to be reported to the National Aviation Authority (NAA).

The Safewings Safety Report process:

This is what a basic safety report looks like (or should look like) in an organisation. 

1. 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, 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. 

2. 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”.  

3. 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. 

4. 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. 

5. 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. 

6. 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. 

7. 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. 

The Life of an MOR:

If a report is determined to be reportable to the National Aviation Authority (NAA) as a Mandatory Occurrence Report (MOR), this is what happens then.

1. MOR decision: The first decision 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. 

2. 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. 

3. 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. 

4. 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). 

5. From our 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 Safewings. 

Hopefully, seeing what happens to a report and how it drives learning and improvement you will see the value of reporting and be encouraged to keep report more often. 

Of course it really requires a positive mindset that encourages reporting and this is a key part of the EASA safety map. Check that out on the page here and understand more about how to set the conditions in an organisation that really enables reporting to drive your Safety Management System.