This article was published as part of ECA`s #ReportingMatters campaign, in which we asked seven experienced pilots and accident investigators (referred to as ECA Just Culture Ambassadors) to write about Just Culture, safety & reporting matters in the aviation industry and beyond.
by Johan Glantz
I recently had the opportunity to listen to one of Boeings Safety Pilots as he gave a presentation on Aviation safety trends and Safety Management. As he got started, just on one of the first slides, I found a statement that really hit home with me.
It reads as follows:
Air Safety: Everyone is responsible!
Everyonein this sense means all of us in the industry: manufacturers, regulators, operators, as well as pilots and their associations, to name but a few. One of the ways we can affect the broader term of system safety, apart from the normal safe operation of our flights, is by writing reports when there is an issue that we think needs attention.
Here, I will try to explain why reporting is so crucial to system safety. And while doing so, I will also point out why we should report not only the mandatory events but also the times when nothing actually happens. Because those are the events where there is the potential to end up in an incident that will require a mandatory report. But then it is already too late.
Aviation is safer than ever – but we need to maintain that
Something most of us, working daily in aviation, is aware of is that over the last few decades, accidents in commercial aviation have declined while the traffic volume both in the number of flights as well as in passengers has increased significantly. One reason for this rather positive trend is that the aviation industry is willing to learn from accidents and incidents.
Once again, it is something we have been doing since the dawn of commercial aviation. All this helped us to achieve a recent flight safety level where a year can pass without any fatal accident in at least the two leading world regions. With aviation now being perhaps the safest mode of transportation available, how can we make it even safer, or as some would argue, how do we manage to maintain the present hard-earned safety level?
Difficult questions. Perhaps the only drawback of not having any or very few accidents or serious incidents is that there are fewer possibilities of learning in the same manner as we have had before. Another challenge is that of those few events that we now face, many are generally more and more complex and do not give any clear answer immediately. Thus, to move on from reacting on failures and evolve into an even safer industry we need to become proactive and predictive in our safety work.
How to be proactive in risk management
One of the ways to become proactive is to systematically manage risks in aviation. But how do you manage risk and what do we define as risk management?
Let’s take a few steps back and see how the current safety management system has evolved: There were techniques used both in parts of aviation and in other industries that in early 2000 made ICAO start working on a manual that gives guidelines on risk management. The work was first published in 2006 as the ICAO SMM (Safety Management Manual) Doc 9859. It has now evolved into a 3rd edition, and in 2013, a new ICAO Annex 19 was adopted. And this how we have now reached a point where Safety Management Systems will be mandatory throughout aviation within the next couple of years, depending on the region.
So the next question is how do we, as an industry, become proactive by managing risks?
As pilots, we are used to managing risks in our everyday working life. SMS with the airlines is mainly a tool for our employers, the operators. We pilots base our day to day risk management primarily on experience, among other things, of course.
So does it mean that it is possible for the operators to rely on experience to avoid accidents and incidents? It is. And to do this, there are numerous tools such as Flight Data Monitoring programmes, Line checks, Technical status statistics and operational performance reports, just to mention a few that are available to create statistics and Safety Performance Indicators. But this is still not enough to reach the safety level that we strive for and to become truly proactive and predictive.
The accident triangle theory
I am confident that most of us, at some point in our careers, have come across the accident triangle or iceberg theory. This suggests that for every accident there were 10 serious incidents, 100 incidents, and 1000 minor incidents with a similar event that didn’t end up as an accident.
The idea here is to look at the broader base of the triangle and by comparing statistics recognise when something is deemed to happen and suggest an action earlier to avoid an accident. And while it is possible to draw some conclusions with the tools mentioned before, the absolutely best source of risk management comes from the individuals involved and their first-hand experience of events.
Mandatory reporting, and perhaps to an even higher degree, voluntary reporting is, therefore, one of the best ways for us pilots to take an active part in improving our industry.
One of the obstacles for a safety management system over the years was that reports were often limited to cover only the mandatory issues, at best. Some went as far that actively discouraged reporting in order not to interrupt operations. With the new Regulation (EU) No 376/2014 and its defined Just Culture statement, however, the industry was given some of the necessary frameworks that it has lacked for years.
Today, we have the possibility to share responsibility and make good use of a shared reporting culture. We now have a base for everyone to take charge for our industry’s system safety by reporting without the fear of repercussions.
Of course, change does not come easy. But the foundations were laid down, and we have the chance (and obligation) to build on it.
See more articles about Just Culture:
- Just Culture — Who Decides Over ‘Just’? by Bert Bonke
- Pilot Fatigue - To Report or not to Report, that is the Question by Peter Beer
- Every incident or accident is different - The Need for a Just Culture Review Committee by Rudy Pont
- Just Culture is not about Matching Consequences with Outcome by Juan Carlos Lozano
Get more information about ECA Reporting Matters Campaign here: