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7-4 Safety Management Manual (SMM)
condition) must be confident that anything said will be kept in confidence. In some States, “Access to
Information” laws make it increasingly difficult to guarantee confidentiality. Where this happens, reported
information will tend to be reduced to the minimum to meet mandatory reporting requirements.
7.3.6 Sometimes reference is made to anonymous reporting systems. Reporting anonymously is not
the same as confidential reporting. Most successful reporting systems have some type of call-back capability
in order to confirm details or obtain a better understanding of the occurrence. Reporting anonymously makes
it impossible to “call back” to ensure understanding and completeness of the information provided by the
reporter. There is also a danger that anonymous reporting may be used for purposes other than safety.
Inclusive reporting base
7.3.7 Early voluntary incident reporting systems were targeted at flight crew. Pilots are in a position to
observe a broad spectrum of the aviation system and are therefore able to comment on the system’s health.
Nonetheless, incident reporting systems that focus solely on the perspective of flight crew tend to reinforce
the idea that everything comes down to pilot error. Taking a systemic approach to safety management
requires that safety information be obtained from all parts of the operation.
7.3.8 In State-run incident reporting systems, collecting information on the same occurrence from
different perspectives facilitates forming a more complete impression of events. For example, ATC instructs
an aircraft to “go around” because there is a maintenance vehicle on the runway without authorization.
Undoubtedly, the pilot, the ATCO and the vehicle operator would all have seen the situation from different
perspectives. Relying on one perspective only may not provide a complete understanding of the event.
Independence
7.3.9 Ideally, State-run voluntary incident reporting systems are operated by an organization separate
from the aviation administration responsible for the enforcement of aviation regulations. Experience in
several States has shown that voluntary reporting benefits from a trusted “third party” managing the system.
The third party receives, processes and analyses the incident reports and feeds the results back to the
aviation administration and the aviation community. With mandatory reporting systems, it may not be
possible to employ a third party. Nevertheless, it is desirable that the aviation administration give a clear
undertaking that any information received will be used for safety purposes only. The same principle applies
to an airline or any other aviation operator that uses incident reporting as part of its safety management
system.
Ease of reporting
7.3.10 The task of submitting incident reports should be as easy as possible for the reporter. Reporting
forms should be readily available so that anyone wishing to file a report can do so easily. They should be
simple to compile, have adequate space for a descriptive narrative and should encourage suggestions on
how to improve the situation or prevent a reoccurrence. To simplify completion, classifying information, such
as the type of operation, light conditions, type of flight plan, and weather, can use a “tick-off” format.
Acknowledgment
7.3.11 The reporting of incidents requires time and effort by the reporter and should be appropriately
acknowledged. To encourage further submission of reports, one State encloses a blank report form with its
acknowledgment letter. In addition, the reporter naturally expects feedback about actions taken in response
to the reported safety concern.
Chapter 7. Hazard and Incident Reporting 7-5
Promotion
7.3.12 The (de-identified) information received from an incident reporting system should be made
available to the aviation community in a timely manner. This could be done in the form of monthly
newsletters or periodic summaries. Ideally, a variety of methods would be used with a view to achieving
maximum exposure. Such promotional activities may help to motivate people to report additional incidents.
7.4 INTERNATIONAL INCIDENT REPORTING SYSTEMS
ICAO Accident/Incident Data Reporting (ADREP) System
7.4.1 In accordance with Annex 13, States report to ICAO information on all aircraft accidents that
involve aircraft of a maximum certified take-off mass of over 2 250 kg. ICAO also gathers information on
aircraft incidents (involving aircraft over 5 700 kg) considered to be important for safety and accident
prevention. This reporting system is known as ADREP. States report specific data in a predetermined (and
coded) format to ICAO. When ADREP reports are received from States, the information is checked and
　
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