The NATS Review of
ATM Occurrence Reporting
Prepared for
ICAO European Region Aviation Safety Seminar/Workshop(Baku, Azerbaijan, 5 -7 April 2006)
by Jane Gothard
Head of International Safety [email protected]
Background to the NATS Review
In November 2001 NATS began a review of its Occurrence Reporting process against a background of:
NATS already having a mature Occurrence Reporting Scheme;
NATS having no immediate concerns over occurrence reporting levels;
(2001 data - 228 Mandatory Occurrence Reports featuring ATC Error )
Some NATS units having established locally devised lower level reporting systems
To determine improvements to NATS safety reporting which would:
Maximise capture of operational occurrences and observations;
Facilitate effective lesson learning;
Provide a single company-wide scheme.
Review Objective
Expectations
To improve on what NATS has at present;
To have the confidence of the users;
To ensure continued alignment with regulatory requirements;
To be simple but effective;
To be accommodated within existing resource.
Review Team Membership
Sponsor: Director Airports
Leader: Terminal Control Watch Manager
The following areas of NATS were represented on the review team:
ATC Investigators Human Factors experts Operational Controllers Air Traffic Services Assistants Trades Union Corporate Areas including:
Division of Safety & QualityEngineering Policy & AssuranceAir Traffic Operations
External Representative: CAA SRG ATSSD
Information Gathering
Information was gathered from 2 sources:
Staff Questionnaire
External Best Practice Visits
A UK Airline
An Oil Company
The Staff Questionnaire
What inhibits reporting?
A sample of ATC and Engineering staff at Gatwick; ScOACC;
Aberdeen and London Terminal Control Centre were asked to rate
the following according to a five point scale:
Blame Culture Too time consuming Discouraged by peers No feedback Nothing will happen Discouraged by management / supervisors
0
10
20
30
40
50
60
Blame culture 42 45 18 4 6
Discouraged by peers 2 12 32 32 37
Time consuming 9 34 18 27 27
No feedback 14 26 34 22 19
Nothing will happen 13 31 33 17 21
Discouraged by management 2 14 14 30 55
Most important
Least important
What Inhibits Reporting?
Questionnaire
Results
Response rate: +80%
What Inhibits Reporting? - Results
The results of the NATS survey showed that:
Most respondents rated perceived ‘Blame Culture’ as either the
primary reason or the secondary reason that may prevent them
from reporting all occurrences.
Most respondents rated ‘Discouragement by Management ’ as
either not a factor in decisions regarding reporting safety
occurrences or a factor of low importance.
External ‘Best Practice’ Visits
Procedures detail 44 categories of events to be reported
- of these 50% are items requiring an Mandatory Occurrence Report to be submitted
- 50% relate to pilot performance.
Electronic monitoring on the flight-deck encourages reporting.
Aircrew competency issue following incident handled internally.
Reporting system utilises single form for both safety reporting.
The Airline Scheme
External ‘Best Practice’ Visits
Safety Reporting system is an integral part of a wider ‘Safety
Culture’ programme.
Scope of scheme:
- All staff; Contractors & Visitors;
- All aspects of safety including ‘Health & Safety’.
Single report form for all events.
Emphasis on staff empowerment- what action did you take?
Report Nomination scheme.
The Oil Company Scheme
Implementation Experience
Airline Experience
- Air Safety Reporting Scheme has taken 10 years to reach maturity.
Oil Company Experience
- original implementation plan too ambitious;
- buy-in needs to come from top - need to demonstrate by behaviour;
- comprehensive education system - from top down;
- 4 / 5 years before staff accept the system.
Key Issues with Occurrence Reporting
Perceived ‘blame culture’; Lack of feedback; Time consuming; Nothing will happen; Diversity of reporting schemes; Limited reporting of low level or corrected events; Limited NATS-wide dissemination of lessons learnt
Key Issues / Solutions Matrix
Per
ceiv
ed B
lam
e C
ultu
re
Lack
of
feed
back
Tim
e co
nsum
ing
Not
hing
will
hap
pen
Div
ersi
ty o
f re
port
ing
sche
mes
Lim
ited
repo
rtin
g of
lo
w-le
vel e
vent
s
Lim
ited
NA
TS
–
wid
e le
sson
le
arni
ng
NATS / SRG Charter x x x x
NATS internal code of practice x x x x x
Education programme for managers and staff
x x x x x x x
One simple readily available form x x x
Single, robust and uniform reporting process
x x x x
Inclusion of Health and Safety reporting
x x
Speedier initial investigation x x
Feedback mechanisms embedded in process
x x
Targeting of information to specific groups
x
General NATS-wide safety review publication
x
Freedom of access to relevant information
x x x
Key Proposals for Improvement
The solutions matrix addressed the key points raised in the staff survey.
In addition, the following improvements to occurrence reporting were
made:
Emphasis on a ‘just’ culture rather than a ‘no-blame’ culture;
The introduction of a in-house reporting process called ‘Open
Reporting’ to capture low level safety events that are in addition
to those captured by The CAA Mandatory Reporting Scheme;
UK CAA agreed to NATS introducing a trial ‘Open Reporting’ Process:
The trial was conducted at Aberdeen and London Terminal Control;
The trial scheme covered both ATC and Engineering Reports;
Trial was introduced in August 2003: duration 6 months;
The ATCO; Engineering and Air Traffic Assistant grades were involved
Health & Safety Issues were not included.
The Pilot Process
Results of the Pilot
The introduction of the trial Open Reporting Scheme did not
prejudiced the existing CAA Mandatory Occurrence Reporting
scheme;
NATS was encouraged to see that the scheme quickly yielded
information that previous established reporting processes may not
have picked up, for example:
Poor technique in operational hand-over
Failing to apply best practice operating techniques.
Transition into Operation from October 2004
Revised Safety Management Procedure:
Covers both Mandatory Occurrence Reporting and ‘Open’ reporting
New NATS Reporting Form
Including new box –
‘Other Information and Suggestions for Preventative Action’
Includes NATS/SRG Code of Practice
The opening statement in CAP382 (The Mandatory Occurrence Reporting Scheme) makes it clear that the purpose of the MOR scheme is to benefit flight safety and that it will not be the policy of the CAA to institute legal proceedings as result of events reported under the scheme. Additionally, it is stated that the CAA expects that employers will not act in a manner that may inhibit reporting through taking disciplinary action.
Results so far……….
2001 data
- 228 Mandatory Occurrence Reports (featuring ATC Error )
2005 data
- 5,400 Occurrence Reports Filed
- 3,800 Mandatory Reports (600 with some ATC Error)
- 1,600 Open Reports
To improve on what NATS had;
To have the confidence of the users;
To ensure continued alignment with regulatory requirements;
To be simple but effective;
To be accommodated within existing resource.
EXPECTATIONS HAVE BEEN MET