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providers into areas where we don’t need to go. They could
limit how we can use our resources to manage risk. So, we
must make sure the playing field is levelled up. There is always
a temptation to settle for the lowest common denominator
because there is a cost associated with achieving a higher
level, but we are looking for the bar to be continually raised in
a way that is not prescriptive.”
NATS was the first ANSP to implement a formal structured
safety management system in 1990. This formal approach is
founded on documented safety policies, safety principles and
safety procedures, and the system forms the basis for risk
assessment, safety assurance, safety control and safety
monitoring. Much of this pioneering effort has been
assimilated into the Common Requirements.
A key element in managing safety is creating a structure
that makes it possible to clearly identify who is accountable
for what. “It is very clear who is responsible for safety in our
organisation,” Cusden said.
NATS also has a mature incident reporting system, which
Cusden describes as “the foundation” of any safety
management system. “It is the fuel for the system and allows
us to measure how well we are doing,” he said.
“You have to have the right culture in place in the
organisation for effective incident reporting. People need to
feel confident that reporting incidents will not be detrimental
to their career. We prefer to call this a ‘just’ culture rather
than a ‘no blame’ culture because if an incident is clearly the
result of someone being grossly negligent, then they must be
held accountable and we would reserve the right to take
appropriate action,” Cusden said. “Incidents may be caused
by equipment problems or incorrect procedures, not just
human error. We must know when things have gone wrong in
order to change and constantly improve our system”. A view
echoed by Jenny Beechener in her article ‘Just Culture’.
“The legislative environment should also not be punishment
based,” he said. “If reporting can lead to legal action, why
would anyone report anything? From a safety management
perspective, you are better served by learning the lessons of
an incident rather than punishing the individual responsible.
Our regulator, the UK Civil Aviation Authority, has also agreed
not to prosecute at a legislative level.”
ATM AND AIRPORTS: CHALLENGES FOR EUROPE
64
Incident reporting is a key weakness in Europe and although
the situation is beginning to improve, “the process is not
comprehensive and the quality of the safety data obtained
varies significantly from State to State,” says George Paulson,
the EUROCONTROL Director of ATM Programmes. In his view,
“despite the clear benefits of sharing aircraft
accident/incident information, some States and service
providers remain concerned that their safety-related
performance might be unfavourably compared with others.”
EUROCONTROL highlights incident reporting as the “least
mature” area within the SSAP Implementation Programme,
“mainly because of legal impediments to reporting, the lack
of a ‘Just Culture’ within States, and a shortage of qualified
and trained manpower.“
However, it points out that most States and ANSPs have
now established a focal point for safety data collection. In
addition, a voluntary safety data policy has been agreed with
ANSPs through the Chief Executives Standing Conference
(CESC), a magazine – Hindsight – has been launched and
issued to controllers to disseminate lessons learned, and a
‘Level-Bust Action Plan and Toolkit’ has been provided.
The NATS incident reporting system, which is not
confidential, is complemented by the UK Confidential Human
Factors Incident Reporting Programme (CHIRP), which has
been in operation since 1982 and is available to flight crew
members, air traffic controllers, licensed aircraft maintenance
engineers, cabin crew and the GA community.
Personal details of anyone who makes a report to CHIRP are
kept confidential and are returned to the reporter on closure
of their report. With their approval, the information is made
available in a disidentified form to whoever can take action to
remedy the problem. Important information is also
disseminated as widely as possible within the industry to help
improve safety standards.
CHIRP, which operates as a registered charity, complements
the UK CAA’s Mandatory Occurrence Reporting system and
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A vision for European aviation(16)
