States have a responsibility to ensure the safe conduct of aviation activities within their territory and airspace, as well as the safe operation of aircraft registered by them when operating outside their national boundaries. This responsibility includes the operation and maintenance of national reporting systems for accidents and incidents collectively referred to as “occurrences”.
Applicable ICAO Standards
Contracting States of the International Civil Aviation Organisation (ICAO) have agreed in Annex 13, Aircraft Accident Investigation, to the Chicago Convention that States shall investigate all accidents to aircraft within their territorial limits, and “…shall report to ICAO information on all aircraft accidents which involve aircraft of a maximum certificated take-off mass of over 2 250 kg”.
In addition, “…a State shall establish a mandatory incident reporting system to facilitate collection of information on actual or potential safety deficiencies”. Further, it is recommended that “a State should establish a voluntary incident reporting system to facilitate the collection of information that may not be captured by a mandatory incident reporting system. A voluntary incident reporting system shall be non-punitive and afford protection to the sources of the information”.
In addition, it is required that “…a State having established an accident and incident database and an incident reporting system shall analyse the information contained in its accident/incident reports and the database to determine any preventive actions required”.
The requirements for national reporting systems are therefore clear, and accompanied by a further requirement to establish an analysis capability to maximise the safety benefit from lessons learned from occurrences and their investigation.
Applicable European Requirements
Regulation (EU) No 376/2014 of the European Parliament and of the Council on the reporting, analysis and follow-up of occurrences in civil aviation has the specific objective “to improve aviation safety by ensuring that relevant safety information relating to civil aviation is reported, collected, stored, protected, exchanged, disseminated and analysed”.
The Regulation requires States to enact national legislation by which occurrences are reported to the competent authorities by a wide range of aviation practitioners including:
- Operators or commanders of turbine-powered or public transport aircraft;
- Designers, manufacturers, or those maintaining or modifying turbine-powered or public transport aircraft,
- Those who sign certificates of maintenance review, or release to service in respect of a turbine-powered or a public transport aircraft;
- Air traffic controllers and flight information officers;
- Managers of airports offering access for Community air carriers to intra-Community air routes;
- Those who install, modify, maintain, repair, overhaul, flight-check or inspect air navigation facilities;
- Persons involved in the ground-handling of aircraft, including fuelling, servicing, loadsheet preparation, loading, de-icing and aircraft towing.
The Regulation further requires that Member States shall “…designate one or more competent authorities to establish a mechanism to independently collect, evaluate, process, analyse and store details of occurrences reported…”
At European level, further legislation is being developed which will require national reporting systems to report data to the European Union Aviation Safety Agency (EASA). All relevant data must be reported to a European Central Repository managed by the Commission.
Reporting in ATM
In the ATM Sector, in the year 2000 EUROCONTROL approved ESARR 2 for implementation by Member States. Its provisions require States to:
- implement a formal means of safety occurrence reporting and assessment for all ATM-related occurrences that pose an actual or potential threat to flight safety, or can compromise the provision of safe ATM services, and
- ensure that all appropriate safety data are collated and reported to EUROCONTROL in terms of high level safety indicators.
ESARR 2 also defines a list of ATM-related occurrences which shall, as a minimum, be reported and assessed by States, provides a ATM harmonised taxonomy for use by States, and defines the system of indicators for the reporting of occurrences to EUROCONTROL. The specific objectives of occurrence reporting in ATM are to:
- Assess ATM safety performance and related trends over time;
- Identify key risk areas where the ATM system could contribute to safety improvement, and to take appropriate actions;
- Investigate, assess and draw conclusions on the extent of the ATM system contribution to the cause of all types of safety occurrences and to take corrective measures, whether regulatory or not;
- Draw conclusions on how the ATM system could improve safety even in areas where it is not involved in accidents or incidents, and
- Assess and monitor over time whether technical and operational changes introduced to the ATM system meet their predetermined safety requirements, and take appropriate actions.
Coordination of Requirements
The multiple requirements which bear upon European States as a result of their membership of European bodies has been recognised and addressed. The international organisations concerned have engaged in extensive coordination to ensure that all applicable requirements are aligned to the maximum possible extent, and that the definitions and taxonomies used are as consistent as possible. Beyond this, advances in technology have increased the opportunities for data exchange, and can help to minimise the number of separate reports to be submitted by a State.
A feature of all the above international provisions is that they are accompanied by a requirement for all reporting to be non-punitive. In this context, both ICAO Annex 13 and Regulation (EU) No 376/2014 explicitly state:
“The sole objective of occurrence reporting is the prevention of accidents and incidents and not to attribute blame or liability.”
In practice, it is now widely accepted that no system can, or should, be completely free of all blame. Situations involving gross negligence, wilful wrong-doing or criminal acts should be dealt with by appropriate penalties being applied to the individuals concerned. However, a line must be drawn between those situations and occurrences in which professionals are acting in good intent and within the limits of their capabilities - i.e. genuine slips, lapses and errors.
It is equally accepted that it is crucial to get this balance right. If not, the inappropriate handling of such cases can be vastly detrimental to the viability of national reporting systems.