Reason In The Method: Why We Need A Reporting Culture
Bob Kells and his investigation team had arrived at the accident
site by helicopter. It had been at least a day since the Twin Otter
had struck trees nine kilometres south west of Simbai in the
Bismark Ranges, Papua New Guinea, when the crew had tried to fly it
out of a steep valley.
It was an incredible sight. The fuselage was intact. The wings
had been taken off by the trees. Ahead of it was a precipice -- a
steep drop from which there may have been no survivors had the
aircraft gone over.
It was a unique situation. Bob had been able to interview the
crew in hospital and they talked openly about what had happened. He
had been on standby within hours of the crash as the civilian
leader of a joint civil/military team of investigators. The army
operated the aircraft but as it was a civil registered aircraft,
the accident investigation fell under the jurisdiction of the PNG
authorities. They had requested that the (then) Bureau of Air
Safety Investigation conduct the investigation.
That was in November 1997. The final investigation report,
number 9703719, was released to the public in June 1999. In that
period, action had been taken on a series of recommendations that
had highlighted significant deficiencies in the way the military
had conducted tropical mountainous flying training in Papua New
Guinea.
What types of lessons are learnt from investigations like this?
What did this one teach the aviation industry?
According to Dr Rob Lee, Director, Human Factors, Systems Safety
and Communications, if underlying organisational deficiencies are
left unchanged, the same kinds of occurrences would continue to
happen.
In the report, the crew of the Twin Otter was found to have been
operating within an organisational environment that had a 'low
level of experience and corporate knowledge regarding the
operations of fixed-wing aircraft...in tropical mountainous
areas'.
'Against this background, deficiencies were identified in the
planning and preparation for the exercise, including risk
assessment and the selection and briefing of the training pilot,'
so the report states.
Aviation safety across the world relies on the thoroughness of
accident and incident investigations and the timely reporting of
the findings. Dr Assad Kotaite, President of the International
Civil Aviation Organization (ICAO) said, 'Without this essential
information the efforts of industry, aviation administrations and
the ICAO cannot be effective in addressing hazards in the air
transport system.'
Since the 1950's Australia has had one of the world's most
comprehensive aviation occurrence reporting systems. By law,
anything that affects the safety of flight must be reported.
Under Annex 13 of the ICAO Standards and Recommended Practices,
Aircraft Accident and Incident Investigation, a mandatory reporting
system must be in place and supported by a non-punitive voluntary
system.
In 1988, Australia's mandatory open reporting system was
complemented by the Confidential Aviation Incident Reporting system
(CAIR), where the reporter's identity remains confidential. Through
both systems, the ATSB receives thousands of reports annually (see
table 1).
Table 1
Occurrences and accidents for 1998-1999�
| Category 2 |
Category 3 |
Category 4 |
Category 5 |
| Year |
Incident |
Accident |
Incident |
Accident |
Incident |
Accident |
Incident |
Accident |
CAIR |
| 1998 |
1 |
1 |
4 |
6 |
1,472 |
211 |
3,522 |
9 |
363 |
| 1999 |
- |
1 |
3 |
8 |
1,323 |
172 |
4,070 |
16 |
299 |
Most of these reports are of a relatively minor nature. "In the
mandatory reporting system we get around about 5,000 incidents and
about 3-400 incidents through the confidential system," Dr Lee
said.
"One of the features of the Australian system, unlike say in the
US where you only have to report certain categories of more serious
incidents, is that the information from relatively minor
occurrences can be analysed to see if there is an underlying reason
that might be causing the occurrences," Dr Lee said.
In 1996 the Bureau reviewed the way it stored and collected air
safety occurrence information. The Systemic Incident Analysis Model
(SIAM) was developed and provided a better way of using occurrence
data. It is based on the model developed by Professor James Reason
of the University of Manchester, who developed a conceptual and
theoretical approach to the safety of large, complex sociotechnical
systems such as aviation.
Major investigations such as the PA-31 accident at Young (1993)
the Boeing 747 accident at Sydney airport (1994) and the Class G
airspace demonstration (1999) were undertaken and reported using
the principles of the Reason model.
These investigations all had substantial impacts on rectifying
major latent organisational deficiencies in the aviation system
across government, corporate, regulatory and organisational
areas.
According to Dr Lee, if these investigations had not been
undertaken in accordance with the basic principles of the Reason
model, the significant systemic safety outcomes would not have been
achieved.
What safety lessons would be lost if there was no reporting
culture?
A great many issues have been identified by the analysis of
reports received through Australia's incident reporting systems.
Numerous lessons have been learnt and actions taken as the
following CAIR report from mid-1999 shows.
On taxi, we noted traffic of a C310 approaching the circuit
and a C182 departing. Upon runway entry and TCAS switching to T/A
R/A, we had indication of one aircraft only, which we identified as
the C310. We then asked the C182 if it was transponder equipped
and, if so, to switch it on. The reply was that they were equipped
and that they would switch it on. It appeared to me that they
hadn't forgotten to switch it on, but rather that they were unaware
of the requirement to have it switched on. We subsequently got a
return and used it to assist our separation procedures.
My view is that far too many aircraft are not using their
transponders correctly. These are predominantly low hour or OCTA
only pilots. I believe that having the relevant transponder
operating procedures within the 'Radar Services and Procedures'
section (both CASA and JEPPS) is misleading and results in this
information being missed by pilots who never operate in a radar
environment. I feel this information should be in the OCTA
procedures section as well.
Response from Airservices
The use of transponders is clearly defined and adequately
covered in AIP ENR 1.6 - Radar Services and Procedures - under
Section 8. However, AIP Book A/L 26, effective 2 Dec 99, has a new
section in ENR 1.1 which was submitted by CASA. The new section
advice is as follows:
- 68.1
- Pilots of aircraft fitted with a serviceable Mode 3A
transponder must activate the transponder at all times during
flight in non-controlled airspace, and if the transponder is Mode
3C capable, that mode must also be operated continuously.
- 68.2
- For further information on the operation of transponders,
including normal and emergency codes, see ENR 1.6 Section 8.
"Reporting systems serve as a vital early warning device so it
is important that people feel able to lodge a report on anything
that they think is affecting safety (see table 2). New methods of
analysing the information, such as the Systemic Incident Analysis
Model (see Flight Safety March-April) demonstrate the
operational value of a reporting culture. We have to know about
problems before lives are lost," Dr Lee said.
A sound reporting culture is one of the best defences against
that happening.
Table 2
Accident and incident reporting
requirements
| Accident |
Immediately notifiable |
1800 011 034 |
| Serious incident |
Immediately notifiable |
1800 011 034 |
| Incident |
Within 48 hours |
1800 011 034 or Fax 02 6274 6434 |
| CAIR |
As soon as convenient |
1800 020 505 or CAIR form |
- Incident and CAIR report forms are available on our website: Aviation Safety.