Strengthening Occurrence Reporting:

John Franklin • 7 July 2023
in community Air Operations

Strengthening Occurrence Reporting: Ensuring Safety through Better Human Factors Analysis

Aviation safety is always our top priority, and behind the scenes, there are crucial reporting mechanisms that help things to continually improve and prevent accidents. When it comes to Human Factors (HF), there is a lot that happens in the cockpit, the hangar or other parts of the aviation system that we can learn from in order to improve safety.

When aircraft are designed, the manufacturer, who we well give their official term of Design Approval Holder (DAH) for the purposes of this article, expect flight crew to interact with the aircraft’ systems in a particular way. This expected flight crew behaviour forms the assumptions made by the DAH when demonstrating compliance with the initial airworthiness certification basis.

The challenge is to get enough operational information from the operational community so that DAHs and also authorities can understand where there might be issues with the flight deck design, operating procedures, training or a combination of these that need to be addressed.

EASA has just published an SIB covering the topic of the reporting of in-service occurrences involving HF and human interventions. The SIB is specifically focussed towards operators of large aeroplanes certified under CS25.

The importance of operators reporting to the DAH

As described in the introduction, the DAHs need information on how their aircraft perform in the real world of operations to help drive safety improvements and development in design. It is really important that HF related occurrences are reported to the DAH with as much information as possible so they can understand more about whatever has taken place and consider what information should be shared with other operators or what other action they need to take. The more information that operators can

The responsibility for investigation/ in-depth analysis of occurrences – but it relies on a positive reporting culture

Although the DAH is responsible for conducting in-depth analysis of in-service occurrences involving human interventions, they heavily rely on information provided by the airline operators or other organizations where the occurrences took place. It is hopefully obvious that without accurate and detailed reports from operators, the DAH cannot effectively carry out the analysis and address safety concerns.

As operators, without a positive reporting culture your staff will not tell you anything. Reporting is needed to help both your organisation and the wider aviation system (like the DAH) to know where risks are so they can be mitigated effectively. The nature of Human Factors means that your staff need to trust your reporting process before they will report something. Treat occurrence reports as learning opportunities that will enhance your operation and promote how you improved things after something is reported.

Make sure people know what to report and make the process as easy as possible.

Assuming the people trust your organisation and its reporting process, the next thing is to be clear about wha you want your staff to report. In terms of helping better understand the impact of design on real operations, we are specifically looking for reports on HF issues that might impact safety. We are specifically talking about things like perception/detection problems, errors in planning and decision making, response execution errors, and communication issues. More details on the specific HF issues can be found in the SIB.

By reporting these types of occurrences, you are really contributing to identifying potential hazards and improving safety margins. Don’t forgot to make sure reporting is as easy for your staff as possible. When something has not gone as planning or a new hazard has been identified, the last thing anyone needs is to have to spend a long time fighting with a bad computer system to report it.

Investigate for learning

The report itself from the pilot or other staff member is just the start of the reporting process. To help the DAH in their analysis, CAT operators should investigate with a learning mindset to ensure that the following information is included in occurrence reports:

  1. Operational context (e.g., time, date, ATC clearance, meteorological conditions).
  2. Aircraft status and any relevant MMEL items.
  3. Crew resource management (CRM) challenges, if applicable.
  4. Pilot training details.
  5. Details of how the occurrence was detected and how the crew recovered from it.
  6. Other relevant data, such as PIREPs, technical logbook data, FDM program data (if permitted), and ACARS data.
  7. Any previous similar events and their outcomes.

It cannot be reinforced enough – reporting and investigation exists to identify risks and implement mitigations. They are learning opportunities.

Processing reports and sending them to the right place

There is no need to do anything different to other occurrences in your operation. You should process these HF events within your management system. Thorough investigation for learning, analysis then including the right information you will really help the DAH to ensure comprehensive safety assessments. Once you have all the information on the occurrence, make sure to send it to the DAH so they can understand more about the situation and consider what action may be needed.


The systematic reporting of human factors occurrences to the DAH enables thorough analysis, identification of safety issues, and subsequent improvements in flight deck design, operating procedures, and training. Together, these efforts enhance overall aviation safety for all stakeholders involved.

The key points are:

  • Establish a positive reporting culture so people feel comfortable to report.
  • Make sure people know what to report and make the process as easy as possible.
  • Investigate occurrences to get the maximum learning and information.
  • Inform the DAH when it relates to the aircraft/ equipment.


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