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 NATSjane.gothard@NATS.co.uk

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;

Taking the Work Forward

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

End