Occurrence Reporting in the Rotorcraft Community

John Franklin • 13 September 2023
in community Rotorcraft
1 comment

Occurrence reporting is the fuel that drives organisational learning.

Aviation staff should be encouraged to report occurrences and hazards because their knowledge is an essential part of your management system and helps to embrace the goal of continuous safety improvement. Reports are also a key source of intelligence for the European Plan for Aviation Safety (EPAS) and lead to many safety improvements.

At an organisational level the most important things you can do are:

-              Make sure that the process of reporting is as easy as possible and understood by your staff.

-              Have a learning mindset and create the trust needed for staff to tell you the things your organisation needs to know.

-              Use the reports you receive to better understand your safety risks to take mitigating actions.

-              Finally, make sure to give feedback to staff so they know what has happened.  

Pilot, instructor and technician Mona Seeberger talks about the importance of reporting as a key part of organisational learning in this video. 

Also, watch this Conversation Aviation discussion between John Franklin and Luxair's Pascal Kremer about how organisations can get the most out of their reporting system. 

There is lot more to it that this – this article provides more information on the basics of occurrence reporting.

Who Wants to be a Safety Millionaire?

Imagine you're at the final question of Who Wants to be a Flight Safety Millionaire (or whatever it might be called in your home country). You've used all your lifelines. You ask the audience a question about flight preparation. And your CEO helped you at the 250,000 point by actually getting a question right on Just Culture.  Now you have a shot at the big money. You used your 50/50 and you're left with two options for the question, "Why do you report safety occurrences and hazards in your organisation?


So What's the Best Answer?

Of course, in the complicated world of aviation, both are effectively correct. But if you only report to meet a legal requirement then you really are missing the point. Firstly, the main reason for the "occurrence reporting regulation" is to feed the wider European aviation system with meaningful information.   The better the information you provide in safety reports, the better the information we have on the real hazards and risks that aviation faces and the more effective our safety actions will be. In our Safety Map of the World, reporting is the fuel for system-level learning. You wouldn’t go on holiday and show pictures on the left to your friends when you get home. So why would we want to make safety decisions without the best safety picture possible?


The basics of who reports to who?

If you are an aviation professional who works for an organisation, then report through your organisation’s management system. Your organisation will then share it with the NAA and follow up after any local investigation once that’s complete.

If you are a General Aviation pilot or anyone not working directly for an organisation, then you should report directly to the NAA.

Both NAAs and EASA also run Confidential Reporting Systems should you feel unable to report directly to your organisation.

Reporting Inside Your Organisation 

The main purpose of reporting is to help your organisation to learn and ultimately manage risks effectively. We have defined the learning part of the map as “Inspire organisations and teams to talk about safety and then have a positive approach to learning and solving problems”. Everything is connected. Reporting allows you to better understand what your risks are, where you have resource challenges that need to be addressed, or where your staff might need more training or support, or where you have compliance challenges such as a procedure that wasn’t updated when a new piece of equipment or software revision was introduced.

There are 3 key things to focus on:

  • What went wrong and why (the traditional occurrences).
  • What went right and why (so you can focus on consciously replicating success). 
  • How work is actually done compared to what was imagined.

How Can You Do That?

Have the Right Mindset and a Simple Process

If you want your staff to report as a way of supporting organisational learning and not just because they had no other choice or the ability to hide what went wrong, you need to create the right culture and mindset. This means that you have to embrace every report you receive in a positive way. Staff will only report the really important things if they trust the organisation won’t punish them for an honest mistake, made, for instance, under pressure in tough conditions and if they actually believe you care enough to do something with every report.

Use your risk classification effectively to identify the occurrences with the greatest risk and then focus your investigation effort where it is needed the most. This leads to another interesting concept. Stop thinking of it as an “investigation” and more as an “organisational learning opportunity”. Change this mindset and you’ll be amazed at how much your staff will tell you. Every report gives you the chance to improve the effectiveness of your operation.

Make it easy, take action and give feedback?

The final thing about occurrence reporting is that the process has to be as simple and easy as possible. If staff are faced with 20 different forms that all look very complicated, the chances of them completing a useful report at the end of a busy day where something bad happened is pretty small. Make the process simple and train your staff how to use it and you will be amazed at what happens. Urgent issues call for immediate actions. Others can be delayed or put on hold. Provide feedback on action status with justification to keep reporting momentum and reporters’ motivation.

Reporting to other organisations

There are many situations where other organisations need to know that something happened so they can do their own learning. This is particularly true for technical issues. It is vital that your organisation informs the Original Equipment Manufacturer (OEM) so that they can identify and solve any potential airworthiness issues. Because aviation requires so many people from different organisations to work together, informing others about a hazard is really important. A great example is with birdstrikes. When airlines report also to the airport where hazards are identified this allows the airport to refine their risk picture and action strategy.

How reports are used at national and EU level

The reports your organisation sends to your National Aviation Authority is then analysed by your National Aviation Authority. This information then drives all sorts of safety activities. From the State Safety Plan (SSP), safety action teams to promotion and focussed oversight. Often the volume of reports received makes it difficult to provide feedback on every single one but every report adds value. At EU level all the reports end up somewhere called the European Central Repository (the ECR). The data is used to drive the European Safety Risk Management process that determines the actions to improve safety that you will find in the European Plan for Aviation Safety (EPAS). Without your data, EASA would be blind. So the system needs the best information possible, ideally from effective organisational investigations. 

In conclusion

Here are the most important things to remember:

-               Although occurrence reporting is a regulatory requirement in Regulation (EU) 376/2014, its main purpose is organisational and system-wide learning.

-               Create a learning mindset that helps staff to trust your reporting system.

-               Make the process easy, take action to mitigate risks and give feedback.

-               Occurrences that are reported help to drive safety improvements in the EPAS.


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