Development of voluntary reporting system of aviation safety information in Japan Satoshi ISHIDA Aviation Safety and Security Promotion Division, JCAB

Development of voluntary reporting system of aviation safety information in Japan

Satoshi ISHIDAAviation Safety and Security

Promotion Division, JCABJAPAN

Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia13-17 June 2011

TPT-WG34, Brisbane, Australia

Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011

３． Establishment of voluntary information system （③）　 under Non-punitive circumstances

１． Definition and framework of State Safety Programme (SSP) （①）２． Equalized statement of Safety Management System (SMS) framework （②）

Annex 1 Annex 6-Ⅰ Annex 6-Ⅲ Annex 8 Annex 11 Annex 13 Annex 14

Personnel Licensing

Operation ofAircraft

-Commercial Aeroplanes

Operation ofAircraft

-Helicopters

Airworthinessof Aircraft

Air TrafficServices

Aircraft AccidentAnd IncidentInvestigation

Aerodromes

SSPDefinitions

SMSFramework

①SSPDefinitions

SMSFramework

SSPDefinitions

SMSFramework

①① SSPDefinitions

SMSFramework

① SSPDefinitions① SSP

DefinitionsSSP

Definitions

SMSFramework

①

SSPFramework

Attachment C

SSPFramework

Attachment J Attachment J Attachment A Attachment D Attachment F

SSPFramework

SSPFramework

SSPFramework

SSPFramework

Attachment C

SSPFramework

Appendix 4 Appendix 7 Appendix 4 Appendix 6 Appendix 7

②② ② ② ②

Voluntary reporting system

①

③

① ① ① ① ① ① ①

2

Amendment of Annexes to the Chicago Convention (effective date: 11/2010)



Transition to new management system of aviation safety in Japan

3

FY2010 FY2011 FY2012 FY2013

ICAOUSOAP

SSP implementation

Development of Voluntary Reporting System

Framework for implementation

Performance-based 　 SMS

ALOSSPI

Research and Examination

Coordination with affiliates

Improvementof legal system

CSA Transition to CMA CMA



Japan’s current reporting system:ASI-NET (Aviation Safety Information Network)

• Operated by a foundation since 1999• Reporting system aimed only at flight crew• Collected data: de-identified, not disclosed • Government ensures protection of safety

information by its inaccessibility to the reporting system

• No immunity from administrative sanction or criminal prosecution

4



Reporting system of aviation safety information

5

Mandatory reporting system by pilot in

command

CAA #76, 76-2

InjuryAccident

MajorIncident

which may cause accident

Minor incidentwhich may affect safe operation

Mandatory reporting system by operator

CAA #111-4

Pilots

Other Unsafe Operation / Condition

No access by JCABto the information reported through this system

CAA : Civil Aeronautics Act of Japan

ASI-NET （ operated by the

third party ）Airlines / Cargos

Voluntary reporting system by operator



Key points at issue for the development of voluntary reporting system

6

Annex13, Chapter8, item8.3“A voluntary incident reporting system shall be non-punitive and afford protection to the sources of the information.”

1.

• ICAO standard requires “Non-Punitive”1 voluntary incident reporting system

• ASI-NET is intended only for air operators: A voluntary reporting system for all parties involved in aviation including ATC, CNS and airport operation is necessary

• Exploratory committee meetings were held this year to discuss toward effective implementation

• This presentation shows points at issue and opinions delivered at the exploratory committee



Case study• US: Aviation Safety reporting System (ASRS) since 1976

– Operated by NASA

• UK: Confidential Human Factors Incident Reporting Program (CHIRP) since 1982– Operated by the CHIRP Charitable Trust

• EU: Directive 2003/42/EU

Based on the concept of “Just Culture” Willful misconduct and gross negligence are not covered Collected data: de-identified Disclosed in public (ASRS) / Not disclosed except summary report

(CHIRP) Immunity:

– Judicial proceedings not instituted for collected data– Mitigation of administrative sanction 7



Scope of the voluntary reporting system

• Information to be collected– Handling of speculation/hearsay– Reporting format that promotes reporters to suggest

improvements

• Reporters considered– Passengers, employees involved in non-aviation field– Reporting through SMS operated by industry is

preferred rather than individual reporting in order to avoid bypassing organizational reporting systems and duplicated reports

8



Operator of the voluntary reporting system

• Non-punitiveness and confidentiality of safety information are eventually achieved in ASI-NET, but not ensured by enforcement policy

• In the case that non-governmental institutions collect data reported by the government-operated fields (ATC, CNS, operation of some airports), information security must be considered

9



How to ensure Non-punitive circumstances

• Common understanding is needed for all parties involved in the aviation field

• Incentive is necessary to promote voluntary reporting

• Reviewed in light of personnel affairs, administrative guidance/sanction and criminal prosecution

10



Personnel View

• Objective: aviation sector operated by the government in addition to private enterprises– ATC, CNS, operation of some airports

• Incident reported through voluntary reporting system should not be noted in the personnel record

• Impact on career may be considered

11



Administrative View

• Administrative guidance should be considered non-punitive as a measure for ensuring safety– e.g. Letter of notice/warning

• Possible ways for reduction/exemption from administrative sanction:– Stipulation of waiver on enforcement policy– Segregation of collected data from the government

12



Penal View

• Voluntary reporting system should not apply to accidents and major incidents with injury which are subject to the penal code

• As the cultural background, victims’ sentiment is valued rather than the importance of investigation of the cause of accident

• Further discussion is necessary based on particular cases collected through the voluntary reporting system for considering protection of reporters from criminal prosecution

13



Securing confidentiality of the source of information

• Information of the reporter must be confidential and protected from regulatory/judicial authorities in a proper manner

• As with most voluntary reporting systems, reporter’s personal data is de-identified by using “confidential report”

• Personal information contained in the report should soon be deleted from the database 14



Future discussion of enforcement policy

• Role models were reviewed in the exploratory committee

• Further study is necessary for establishment of clear criteria for execution of administrative sanctions

• Development of effective and feasible enforcement policy along with administrative operation is needed

15



Conclusion

• A voluntary reporting system is now in the process of development in Japan

• Research and discussion of diverse aspects was conducted in the exploratory committee

• Discussion on the Non-punitive circumstances is focused on personnel affairs and administrative guidance/sanctions

• Further discussion is necessary for introducing an effective and feasible enforcement policy

16



FIY: Safety Information Protection Task Force (SIP TF)

• The establishment of SIP TF is recommended in HLSC2010 and authorized in A37

• Scope: Making findings and recommendation for development/amendment of relevant ICAO SARPs and guidance materials

• A kick-off meeting was held on May 4-5, and working groups were established for further research and discussion

17

Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia13-17 June 2011

Thank you

Documents

Development of voluntary reporting system of aviation safety information in Japan Satoshi ISHIDA Aviation Safety and Security Promotion Division, JCAB