With every occurrence report you submit, you’re feeding data into safety systems that may prevent you from having an accident in the future.
The CAA may not immediately act on each and every report, but it does ‘bank’ them in the database, and that’s where they start to increase their value.
No matter how insignificant the event seems, reporting occurrences helps build a picture of the event. It could be the difference in determining a cause or causal factors, or identifying a trend.
Bird’s triangle says that for one fatal, serious or disabling accident suffered there were 10 minor accidents, 30 accidents resulting in property damage and a further 600 incidents of no injury or property damage.
Once a trend has been identified an investigation can be undertaken. As soon as an investigation is completed, the resulting outcomes can be used to alert the CAA and the industry.
While humans are the primary source of problems in aviation, they are also the primary source of solutions to those problems.
To help discover the role human factors plays in accidents, the Reason Model of Accident Causation describes the parts of our aviation system and how they work for and against us. The Swiss Cheese Model is used to identify where barriers and defences can be raised against risks. In particular, it is helpful to use when identifying the actions in the accident chain and where a different action could have changed the outcome.
In reality, all aviation participants need to report occurrences.
If you are unsure whether an occurrence should be reported, then it probably should be.
The pilot of an agricultural aircraft was conducting a pre-flight inspection when he felt a restriction in the aileron control system. On further examination, an aileron control cable was found to have failed. The operator and pilot reported the occurrence and an investigation conducted.
Upon investigation it was found this aircraft type had had a number of cases of control cable failure – but not all of these occurrences had been reported. Further investigation resulted in the aircraft manufacturer and a number of operators of the type, developing a modification to prevent the cable wear that led to the failures.
In this case, the cable failure could have had serious consequences. Reporting of occurrences would have highlighted the problem earlier.
You also have legal obligations and requirements for reporting under Civil Aviation Rules, Part 12 Accidents, Incidents, and Statistics and also the Health and Safety at Work Act.
Part 12, Accidents, Incidents and Statistics, defines who, when and how you report an accident or incident.
Advisory Circular AC 12-1, Mandatory Occurrence Notification and Information and Advisory Circular AC 12-2, Incident Investigation, provides information about standards, practices, and procedures to help you comply with the rule requirements.
Will you get Into Trouble?
Reporting occurrences promptly and fully is not only required, it is in your best interest. While it may be a little uncomfortable telling the CAA what happened, or that you made a mistake, you are far less likely to be the subject of safety action against your licence, or prosecution, if you are honest and open with the CAA.
The small number of prosecutions the CAA takes each year typically involve cases where people don’t report, or are learned of through other reports from the public or other participants.
In any case, the CAA is not allowed to use information submitted via a Part 12 report for prosecution. There are exceptions to that, such as where unnecessary endangerment is thought to have caused the occurrence or if it is established that false information has been provided.
While the CAA receives a good number of aircraft defect incidents, its database contains very few pilot error-related occurrences. Research concluded one of the major reasons for that was embarrassment.
Some people are also concerned they might get into trouble with their employers if they report an occurrence. Most aviation employers, however, understand that it is a legal obligation to report accidents and incidents to the CAA and the benefits that brings.
It helps if an organisation operates under a ‘just culture’ where employees feel comfortable in reporting errors in the knowledge that, within reason, they will not be blamed, ridiculed or punished.
In some cases you can report certain types of incident confidentially.
If you are embarrassed, or worried about the consequences of reporting, you can report confidentially to the CAA. Simply write or indicate anywhere you can on the reporting form that you request confidentiality. The CAA will remove all information that might reveal the identity of the source, including any identifying characteristics, names of individuals and organisations, and geographic references.
Requesting anonymity does, however, limit the scope of any investigation, because the CAA cannot contact you for more information, and that reduces the chances of finding out what caused the occurrence. It is also important to understand that confidentiality does not mean that the CAA can’t learn of the occurrence via other people or means. Confidentiality attaches only to the information you submit under Part 12.
Full Vector article here.