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7-1
Chapter 7
HAZARD AND INCIDENT REPORTING
7.1 INTRODUCTION TO REPORTING SYSTEMS
7.1.1 Safety management systems involve the reactive and proactive identification of safety hazards.
Accident investigations reveal a great deal about safety hazards; but fortunately, aviation accidents are rare
events. They are, however, generally investigated more thoroughly than incidents. When safety initiatives
rely exclusively on accident data, the limitations of not having many case samples apply. As a result, the
wrong conclusions may be drawn, or inappropriate corrective actions taken.
7.1.2 Research leading to the 1:600 Rule showed that the number of incidents is significantly greater
than the number of accidents for comparable types of occurrences. The causal and contributory factors
associated with incidents may also culminate in accidents. Often, only good fortune prevents an incident
from becoming an accident. Unfortunately, these incidents are not always known to those responsible for
reducing or eliminating the associated risks. This may be due to the unavailability of reporting systems, or
people not being sufficiently motivated to report incidents.
Value of safety reporting systems
7.1.3 Recognizing that knowledge derived from incidents can provide significant insights into safety
hazards, several types of incident reporting systems have been developed. Some safety databases contain
a large quantity of detailed information. The systems containing the information obtained from accident and
incident investigations and safety databases can be grouped under the general term “safety data collection
and processing systems” (SDCPS). SDCPS refers to processing and reporting systems, databases,
schemes for exchange of information, and recorded information and include records pertaining to accident
and incident investigations, mandatory incident reporting systems, voluntary incident reporting systems, and
self-disclosure reporting systems (including automatic data capture systems and manual data capture
systems). Although incidents may not be investigated in any depth, the anecdotal information they provide
can offer meaningful insight into the perceptions and reactions of pilots, cabin crew, AMEs, ATCOs and
aerodrome personnel.
7.1.4 Safety reporting systems should not just be restricted to incidents but should include provision
for the reporting of hazards, i.e. unsafe conditions that have not yet caused an incident. For example, some
organizations have programmes for reporting conditions deemed unsatisfactory from the perspective of
experienced personnel (Unsatisfactory Condition Reports for potential technical faults). In some States,
Service Difficulty Reporting (SDR) systems are effective in identifying airworthiness hazards. Aggregating
data from such hazard and incident reports provides a rich source of experience to support other safety
management activities.
7.1.5 Data from incident reporting systems can facilitate an understanding of the causes of hazards,
help to define intervention strategies and help to verify the effectiveness of interventions. Depending on the
depth to which they are investigated, incidents can provide a unique means of obtaining first-hand evidence
on the factors associated with mishaps from the participants. Reporters can describe the relationships
between stimuli and their actions. They may provide their interpretation of the effects of various factors
affecting their performance, such as fatigue, interpersonal interactions and distractions. Furthermore, many
7-2 Safety Management Manual (SMM)
reporters are able to offer valuable suggestions for remedial action. Incident data have also been used to
improve operating procedures, and display and control design, as well as to provide a better understanding
of human performance associated with the operation of aircraft, ATC and aerodromes.
ICAO requirements1
7.1.6 ICAO requires that States establish a mandatory incident reporting system to facilitate the
collection of information on actual or potential safety deficiencies. In addition, States are encouraged to
establish a voluntary incident reporting system and adjust their laws, regulations and policies so that the
voluntary programme:
a) facilitates the collection of information that may not be captured by a mandatory incident reporting
system;
b) is non-punitive; and
c) affords protection to the sources of the information.
7.2 TYPES OF INCIDENT REPORTING SYSTEMS
7.2.1 In general, an incident involves an unsafe, or potentially unsafe, occurrence or condition that
does not involve serious personal injury or significant property damage, i.e. it does not meet the criteria for
an accident. When an incident occurs, the individual(s) involved may or may not be required to submit a
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Safety Management Manual (SMM) 安全管理手册(51)
