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providers and airport operators have “in-house” reporting systems for the reporting of safety hazards and
incidents. If reporting is available to all personnel (not just flight crew), company reporting systems help
promote a positive company-wide safety culture. Chapter 16 includes a deeper examination of company
hazard and incident reporting systems.
7.7 IMPLEMENTATION OF INCIDENT REPORTING SYSTEMS
7.7.1 If implemented in a non-punitive work environment, an incident reporting system can go a long
way towards creating a positive safety culture. Depending on the size of the organization, the most
expedient method for incident and hazard reporting is to use existing “paperwork” such as safety reports and
maintenance reports. However, as the volume of reports increases, some sort of computerized system will
be required to handle the task.
What to report?
7.7.2 Any hazard that has the potential to cause damage or injury or that threatens the organization’s
viability should be reported. Hazards and incidents should be reported if it is believed that:
a) something can be done to improve safety;
b) other aviation personnel could learn from the report; or
c) the system and its inherent defences did not work “as advertised”.
7.7.3 In short, if in doubt as to an event’s safety significance, it should be reported. (Those incidents
and accidents that are required to be reported in accordance with State laws or regulations governing
accident or incident reporting should also be included in an operator’s reporting database.) Appendix 2 to
Chapter 16 provides examples of the types of events that should be reported to an operator’s incident
reporting system.
7-8 Safety Management Manual (SMM)
Who should report?
7.7.4 To be effective, incident reporting systems should include a broad reporting base. For specific
occurrences, the perceptions of different participants in, or witnesses to, an event may be quite different —
yet all relevant. Thus, State systems for voluntary incident reporting should encourage the participation of
flight and cabin crews, ATCOs, airport workers and AMEs.
Reporting method and format
7.7.5 The method and format chosen for a reporting system matters little as long as it encourages
personnel to report all hazards and incidents. The reporting process should be as simple as possible and
well documented, including details as to what, where and when to report.
7.7.6 In designing reporting forms, the layout should facilitate the submission of information. Sufficient
space should be provided to encourage reporters to identify suggested corrective actions. Listed below are
some other factors to be considered in designing a system and reporting forms:
a) Operational personnel are generally not prolific writers; therefore, the form should be kept as short
as possible.
b) Reporters are not safety analysts; therefore, the questions should be written in simple, everyday
language.
c) Non-directive questions should be used instead of leading questions. (Non-directive questions
include: What happened? Why? How was it fixed? and What should be done?)
d) Prompts may be required for the reporter to think about “system failures” (for example: How close
were they to an accident?) and to consider their error management strategies.
e) Focus should be on the detection and recovery from an unsafe situation or condition.
f) Reporters should be encouraged to consider the wider safety lessons inherent in the report, for
example, how the organization and the aviation system could benefit from it.
7.7.7 Regardless of the source or method of submission, once the information is received, it must be
stored in a manner suitable for easy retrieval and analysis.
7.7.8 Appendix 1 to this chapter contains guidance on limitations in the use of data from voluntary
incident reporting systems.
— — — — — — — —
7-APP 1-1
Appendix 1 to Chapter 7
LIMITATIONS IN THE USE OF DATA FROM
VOLUNTARY INCIDENT REPORTING SYSTEMS
Care needs to be taken when using data from voluntary incident reports. When drawing conclusions based
on such data, analysts should consider the following limitations:
a) Information not validated. In some States, voluntary confidential reports can be fully investigated
and information from other sources brought to bear on the incident. However, the confidentiality
provisions of smaller programmes (such as company reporting systems) make it difficult to
adequately follow up on a report without compromising the identity of the reporter. Thus, much of
the reported information cannot be substantiated.
b) Reporter biases. Two factors may bias voluntary incident data: who reports and what gets
　
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