Published on October 2nd, 2022 | by Mark Dwyer0
Do You Report?
Most if not all commercial pilots will be familiar with the acronym SMS or Safety Management System. At a basic level, it’s a process put in place by organisations such as airlines, flying schools, maintenance organisations etc. to capture safety-related information, feed it back to the organisation and then procedures or mitigations are put in place to prevent a reoccurrence in the future. This goes hand in hand with something called a ‘Just Culture’ – a philosophy within an organisation that encourages reporting of safety issues but does not seek to abortion blame for honest mistakes taking into account the reporters’ knowledge and experience.
According to the Annual Performance Safety Review for Ireland in 2021, Irish Air Operators submitted over 4,000 occurrence reports. These can be as minor as bird strikes, using oxygen for a passenger, opening a first aid kit etc. right up to more serious incidents like serious equipment failures or near misses. Each of these reports will be analysed as part of the safety management system and procedures changed to prevent a reoccurrence. These reports are often referred to as leading indicators as they precede an accident, and by trapping latent threats early in the error chain, accidents can be avoided.
Henrich’s pyramid says that for every one fatal accident there are 10 serious accidents or ‘near misses’ and a further 30 reportable incidents. Below that there are up to 600 errors or omissions that can start an accident sequence. These errors are trapped and reported in an established safety management system but what about general aviation? Fatal and serious accidents by their nature will always be reported to the Air Accident Investigation Unit (AAIU) but outside of that, there is minimal occurrence reporting within the general aviation community and this is robbing us all of the vital safety information that could be used to prevent future accidents from happening.
So why is occurrence reporting within GA so poor?
“Various categories of staff working or otherwise engaged in civil aviation witness events which are of relevance to accident prevention. They should therefore have access to tools enabling them to report such events, and their protection should be guaranteed.”Regulation 376/2014
There are probably a number of reasons for this. There’s no denying that some Aviation Authorities took a heavy-handed approach in dealing with certain reports in the past that drove a wedge between the Authority and the GA community. Thankfully this has changed over the past decade and EU Regulation 376/2014 gives complete protection to the reporter.
The other reason is education. As a general aviation pilot, were you ever shown how to file an occurrence report? Would you know how to file one if you did have an incident? What sort of incidents should you report? All very good questions so let’s take a look at some here.
Mandatory Occurrence Reports (MORs)
As the Pilot In Command (PIC) of an EASA aircraft (basically any aircraft with an EASA CofA), it is a legal requirement that you file a MOR for certain incidents. Some examples include:
- collision-related occurrences
- take-off and landing-related occurrences
- fuel-related occurrences
- structural defects
- system malfunctions
- maintenance and repair problems
For a full list, take a look at Article 4 of EU Regulation 376/2014 and Annex V of Commission Implementing Regulation 2015/1018 – both documents are freely available online. For aircraft that fall outside EASA aircraft such as those operating on an IAA Flight Permit, there is no mandatory requirement to file a report, but it is strongly encouraged. These are called Voluntary Occurrence Reports. They can be filed for the same reasons as listed above using the same form. Remember, unless you were intentionally breaking the law, or guilty of wilful misconduct or gross negligence, at the time of the incident or occurrence, you cannot be prosecuted for filing a report.
If you don’t feel comfortable making a report to the Authority about an incident, voluntary reports can be made to third parties who will de-identify the report and pass it on to the Authority. The General Aviation Safety Council of Ireland (GASCI) has a voluntary reporting feature on their website. See here.
There has always been a reluctance among Irish pilots to file reports for fear of ‘putting their head above the parapet’ but times have changed and there is a realisation that the data that can be obtained from these incidents can be of great value in preventing future accidents.
How can I file a report?
Occurrence reports are filed through a central European website called Eccairs2 which can be accessed at e2.aviationreporting.eu/reporting . It’s not the most user-friendly reporting structure but most reports can be completed within about 10-15 minutes. The IAA has also provided some short and helpful videos on how to use the EU portal at https://www.iaa.ie/safety/safety-reporting/eu-portal-training
Once submitted it will be directed to the relevant authority in Europe for further investigation. In the case of Ireland, this will be sent to the IAA Safety Regulation Division who will review the report and take any action required. In most cases, it will be de-identified and aggregated with other reports to indicate safety trends. Any negative trends can be addressed through various means.
This topic was recently discussed at the GASCI meeting. There is a clear negative trend over the last 12 months when it comes to landing accidents, just take a look at the AAIU website and you can see for yourself. Currency post-covid is most likely a factor but unfortunately, there are very few occurrence reports to back up our assumptions. If we apply Henrich’s Pyramid to this case, we should be seeing 50+ occurrence reports but in reality, there are very few.
The Irish aviation community is small. Inevitably, when there’s an accident, serious or fatal, we often know those involved personally. Therefore, do us all a favour and start reporting and maybe we can prevent a future accident.
For more information about Safety Report please visit https://www.iaa.ie/safety/safety-reporting
Main photo above from an AAIU Report unrelated to the content of this article