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Type of Reporting Systems Features to facilitate the Just Culture Implementation

Tony LICU Programme Manager – EUROCONTROL DAP/SAF European Safety Programme for ATM (ESP) April 2006 – Baku/Azerbaijan antonio.licu@eurocontrol.int. Type of Reporting Systems Features to facilitate the Just Culture Implementation. European Organisation for the Safety of Air Navigation.

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Type of Reporting Systems Features to facilitate the Just Culture Implementation

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  1. Tony LICU Programme Manager – EUROCONTROL DAP/SAF European Safety Programme for ATM (ESP) April 2006 – Baku/Azerbaijan antonio.licu@eurocontrol.int Type of Reporting Systems Features to facilitate the Just Culture Implementation European Organisation for the Safety of Air Navigation

  2. Presentation Topics Purpose of Reporting Systems Different types of Reporting Systems Required qualities of Reporting Systems Implementation of Reporting Systems

  3. Objectives Detailed • Know the pros and the cons for different types of reporting systems • Appreciate what type of reporting system is best suited for your organisation

  4. G-ARPI (Papa India) • 18 June 1972 – Trident aircraft G-ARPI en route London to Brussels • 3 pilots, 3 cabin crew, 112 passengers • Crew roster • Industrial dispute • Delay • Medical • Pilot failings • Aircraft crashed killing all on board

  5. HOW DO WE LEARN HOW DO WE GAIN EXPERIENCE

  6. English language MET ICAO PANS-RAC NAVAIDS Radar Theory Radar Skills International Organisations Aircraft Performance

  7. English language MET ICAO PANS-RAC NAVAIDS Radar Theory Radar Skills International Organisations Aircraft Performance

  8. English language MET ICAO PANS-RAC NAVAIDS Radar Theory Radar Skills International Organisations Aircraft Performance

  9. Indispensable to highly qualified professionals INDIVIDUAL LEARNING

  10. common English language MET ICAO PANS-RAC NAVAIDS Radar Theory Radar Skills International Organisations Aircraft Performance

  11. Purpose of Reporting Systems? Indispensable to efficient system improvement ORGANISATIONAL LEARNING

  12. Different types of Reporting Systems Human Automatic

  13. Complementarity Reporting Systems [Human] Mandatory Voluntary Nominal Confidential Anonymous

  14. Mandatory Reporting 1. Legislation Required 2. Legal Definition of Reportable Occurrence 3. Define What Should be Reported 4. Define Who Should Report

  15. Voluntary Reporting Factors Resisting Change 1. Personal 2. Professional 3. Organisational 4. Political

  16. Voluntary Reporting Factors Driving Change 1. Personal 2. Professional 3. Organisational 4. Political

  17. Coverage Reliability of entry data Efficiency Strictly defined High Reactive Non limited Good Proactive Non limited Good Proactive Non limited Questionable Proactive Restricted Type of Reporting Systems Features System Features Mandatory Voluntary Nominal Confidential Anonymous

  18. Confidential Reporting • Historically, proportion of Human Factor occurrences reported remains small – common failing • Reluctance to admit personal errors • Partially overcome by introducing a Confidential reporting system e.g. UK CHIRP • Could be Anonymous….!

  19. Automatic Reporting • Latest way to monitor safety requirements • Complementary to Human reporting • Problem of “big brother” attitude • Being trialled at Maastricht for aircraft proximity

  20. Ease of reporting Independence TRUST Motivation & Promotion FEEDBACK Acknowledgement Required qualities of Reporting Systems

  21. ATM Investigation Process

  22. Motivation and Promotion • ATM staff must be motivated to report, and the trend must be maintained • Controllers educated about benefits derived by reporting actual or potential deficiencies

  23. Ease of Reporting • Staff must not perceive reporting as an extra task • User friendly reporting system • Staff trained in use of investigative/problem solving methods and database

  24. Acknowledgement • Reporters like to know whether their report was received • What will happen to a report • What to expect and when

  25. Independence • Some degree of independence to be granted to reporting system managers

  26. Feedback • Communication should be frequent, using both formal and informal channels • Reward and recognition

  27. Trust • All reporting is dependant on trust; • Between reporters, managers, providers and authority; • A Just Culture

  28. Summary • Importance of a Reporting System; • Information to be developed in a Reporting System; • Differentiate between the different types of reporting systems; • Know the pros and the cons for different types of reporting systems; • Appreciate what type of reporting system is best suited for your organisation.

  29. Implementation of Reporting System 1 chance 2 mis-management

  30. “NO OCCURRENCE“ means “NO REPORTED OCCURRENCE”

  31. Thank you! Questions? ?

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