Mick Skinner Deputy Director (Engineering)

Mick SkinnerDeputy Director (Engineering)

CHIRPUK Confidential Human Factors Incident

Reporting Programme

IFA Technical SymposiumDubai 24 March 2010

• ICAO Annex 13 - Aircraft Accident and Incident Investigation recommends that Member States put in place a voluntary, non-punitive incident reporting system that protects information sources, to complement a mandatory incident reporting scheme.

(Annex 13; Para 8.2 & 8.3). • EU Directive 2003/42/EC Article 9 - Voluntary Reporting (reflected in

Article 142 of The Air Navigation Order [UK]) establishes the conditions for a voluntary reporting system that a member state elects to put in place.

• Civil Aviation Publication CAP 784 – State Safety Programme for the United Kingdom published in February 2009 meets the ICAO requirement for Contracting States to produce an SSP. Chapter 5; Para 2.5.3 states that CHIRP fulfils the role of a voluntary safety reporting scheme for the UK as recommended by ICAO Annex 13.

What is the basis for an independent, voluntary, confidential reporting system in the UK?

South KoreaKAIRS (2000)

United StatesASRS (1976)

United KingdomCHIRP (1982)

CanadaCASRP (1985)SECURITAS (1995)

AustraliaCAIRS (1988)REPCON (2006)

RussiaVASRP (1992)

BrazilRCSV (1997)

JapanASI-NET (1999)

TaiwanTACARE (2000)

SingaporeSINCAIR (2004)

FranceREC (1999)

ChinaSCASS (2004)

New ZealandICARUS

South AfricaSASCO

GermanyEUCARE

SpainSNS (2007)

Confidential Reporting – Other ICAO Member States

The CHIRP Charitable Trust

Immunity in the UK

• Aeronautical Information Circular – 47(2001) provides limited regulatory immunity against third-party reports. Same as MOR system. (Statement by Chairman CAA), but not against gross negligence / wilful acts

• Public Interest Disclosure Act 1998 – ‘Whistleblowers Act’ provides legal immunity against “Whistle-blowing” in cases where public safety is concerned, yet to be tested legally in Air Transport.

• However, the risk of exposure is minimised through CHIRP processes.

Contact details are not retained – no audit path back to reporter.


• Establish and retain the confidence of users

• Proven Independence from - Regulators

-

Management

- Employment Groups

• Develop and maintain the respect of regulatory and

management agencies

• Develop effective methods of publishing information

• Maintaining confidentiality - paramount

Essential Requirements for an Effective Confidential Reporting System


CHIRP is the UK confidential reporting programme for Aviation (H - Human Factors) and Maritime (H - Hazardous) communities

Development

1982 - Programme established (RAF Institute of Aviation Medicine)

1992 - Management transferred to DERA (Centre for Human Sciences)

1994 - Independent Industry-wide Review

1996 - Charitable Trust formed - Independent Management

- Funded by CAA (SRG)

1997 - Aviation Programmes progressively expanded

2002 - Maritime Programme commenced; funded by DfT

Programme - Background


CHIRP Aviation Programme Development and Scope

Commercial Air Transport

- Pilots (1982)

- Air Traffic Control Officers (1985)

- Engineers / Approved Maintenance Organisations (1997)

- Cabin Crew (2001)

General Aviation (1999)

- Light Aircraft, Gliders, Micro-lights,

- Para-gliders, Balloons


CHIRP is Complementary to Other Systems of Reporting

Normal Operations

Incidents

InjuryAccidents

Reporting Relationships

{CHIRP

Precursors

AAIB { Fatal Accidents

{CAA MOR

What is the link ?What is the link ?Company Reporting Company Reporting Procedures & Risk Procedures & Risk

AssessmentsAssessments

RegulatorRegulator

MORSMORS

VoluntaryVoluntaryConfidential Confidential ReportingReporting

How does CHIRP do this?

Individuals

CHIRP

CAA

Companies AAIB

Individual follow-up & feedback is most important


How Does CHIRP Ensure Confidentiality?

• Confidential not anonymous. Permits closed loop process

• Follow-up – letter– telephone– interview on private basis

• No action taken without reporter’s consent

• Personal details and original report are not retained. Returned to

reporter (provides level of immunity)

• Reports technically disidentified for dissemination and retention

• Controlled third-party access to report data for research


The CHIRP Organisation

• Charitable Company Status (provides a level of immunity)

• Executive Board (Trustees)– Independent Corporate and Professional Governance– Provide Strategic Direction– Monitor Performance

• CHIRP Advisory Boards (subject matter experts)

– Nominees from principal agencies– Offer guidance to Director CHIRP on specific issues– Provide feedback to Trustees on performance and effectiveness of the programme

Organisation and Structure

Chirp Advisory Boards(4)89 subject matter experts


CHIRP Executive Board (Trustees) (10)Mr Ken Smart (Chairman)

Capt T Sindall Capt C EltonAir Cdre R Peacock-Edwards

Capt D Chapman Capt C HodgkinsonCapt W Lowe Mr J SaullMr D King Maritime Trustees (4)

Staff (3 full-time and 2 part-time)Mr P Tait Chief Executive Mr M Skinner Deputy Director (Eng) Mrs K Arnold Administration Manager

Mrs J Ellis Admin Assistant Mr Bishnu Sunuwar Systems Administrator

UK-MEMS Review Board23 members civil/military

What are “Human Factors” ?

Error prevention strategies


CHIRP Air Transport ProgrammeReports Received – 1999 to 2009

173

29

64

80

170

3137

42

80

120

12

88

32

98

145

20

63

25

110

140

19

69

35

79

190

24

155

32

61

245

31

189

34

66

245

20

156

40

75

176

16

178

29

58

153

18

132

44

57

0

100

200

300

400

500

600

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

2004-2005

2005-2006

2006-2007

2007-2008

2008-2009

GAEng

CabinATCAir

Total Reports to-date 7325 (Feb 2010)

Air 4131

ATC 712

Eng 495

CC 1167

GA 820

Flight Crew Reports - Top 6 Key Issue Topics

Rosters57%

Rest22%

Discretion3%Crewing

6%Length

10%

Disruption2%

0

20

40

60

80

100

120

140

160

180

200

2005 2006 2007 2008 2009

1. Duty1. Duty 2. Security2. Security 3.Comms- External3.Comms- External4. Company Policy4. Company Policy 5. Procedures5. Procedures 6. Pressures6. Pressures

Ground95%

In-flight5%

Duty

Security

ATCO Reports - Top 6 Key Issue Topics

0

2

4

6

8

10

12

14

2005 2006 2007 2008 2009

1. Comms-External1. Comms-External 2. Procedures2. Procedures 3. Air Traffic Mgt3. Air Traffic Mgt

4. Handling/Operations4. Handling/Operations 5. Company Policies5. Company Policies 6. Duty6. Duty

Use by others61%

Not Understanding

19%

Complicated5%

Unavailable5%

Use by reporter

10%

Air Traffic Management

Procedures

Separation68%

Level of service

32%

Engineer Reports - Top 6 Key Issue Topics

0

5

10

15

20

25

30

2005 2006 2007 2008 2009

Base38%

Line38%

Repair3%

Inspection6%

Work Standards13%

Servicing2%

1. Maintenance1. Maintenance 2. Procedures2. Procedures 3. Regulation/Law3. Regulation/Law4. Security4. Security 5. Company Policy5. Company Policy 6. Pressures6. Pressures

Compliance w ith88%

Knowledge of10%

Absence of 2%

Maintenance

Procedures

Cabin Crew - Top 6 Key Issues

Rosters, 36%

Length, 31%

Discretion, 9%

Crewing, 9%

Rest, 13%

Disruption2%

0

20

40

60

80

100

120

140

160

2005 2006 2007 2008 2009

1. Duty1. Duty 2. Procedures2. Procedures 3. Company Policy3. Company Policy4. Pressures4. Pressures 5. Comms-internal5. Comms-internal 6. Regulation/Law6. Regulation/Law

Knowledge of2%

conflicting2%

Use by others55%

Not Understanding

9%

Complicated16%

Unavailable4%

Use by reporter3%

Duty

Procedures

General Aviation - Top 6 Key Issues

A/C Handling by pilot48%

Airmanship38%

Operation of Eqipt14%

0

5

10

15

20

25

30

2005 2006 2007 2008 2009

1. Handling/Operation1. Handling/Operation 2. Procedures2. Procedures 3. A/C Technical3. A/C Technical4. Comms-External4. Comms-External 5. Near Miss5. Near Miss 6. Sit. Awareness6. Sit. Awareness

Use by Reporter46%

Use by Other33%

Inadequate5%

Not Understandable8%

Knowledge of8%

Procedures

Handling/Operation

UK- MEMS managed data input

Group member Owned file

Identified dataGroup member

Owned fileDisidentified data

Data analysis shared with

group members & Industry

MEDA format data entry via member ID & Password protection

CAA MORCAA MOR maintenance

error data analysis

SIDD monthly report

Error types as % of total each year (data from CAA MOR)

Q; Why do same basic patterns of error reoccur?

0

10

20

30

40

50

60

2004 2005 2006 2007 2008 2009

Installation

Approved data

Servicing

Poor Insp

Misinterp ofdata

FOD

%

MEMS group SMS readiness review

MEMS Group SMS Readiness FeedbackMEMS Group SMS Readiness Feedback 20082008

Areas ofAreas of strengthstrength andand opportunityopportunity

6

4

2

2

6

4

Average

Above

Below

14 4 1 11 3

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different people……. same mistakes!

Establishing a confidential reporting Scheme?

• Links to ICASS group through the CHIRP website (secretariat)

www.chirp.co.uk (see Links)

• Contact Peter Tait or Kirsty Arnold for more information through CHIRP website or email

[email protected]

Run!Run!

And Finally……And Finally……


Any Any Questions?Questions?

Documents

Mick Skinner Deputy Director (Engineering)