CHIRP
UK Confidential Human Factors Incident
Reporting Programme
IFA Technical Symposium
Dubai 24 March 2010
Mick Skinner
Deputy Director
(Engineering)
What is the basis for an independent, voluntary,
confidential reporting system in the UK?
•
ICAO Annex 13 - Aircraft Accident and Incident Investigation
recommends that Member States put in place a voluntary, non-punitive
incident reporting system that protects information sources, to complement
a mandatory incident reporting scheme.
(Annex 13; Para 8.2 & 8.3).
•
EU Directive 2003/42/EC Article 9 - Voluntary Reporting (reflected in
Article 142 of The Air Navigation Order [UK]) establishes the conditions
for a voluntary reporting system that a member state elects to put in place.
•
Civil Aviation Publication CAP 784 – State Safety Programme for the
United Kingdom published in February 2009 meets the ICAO requirement
for Contracting States to produce an SSP. Chapter 5; Para 2.5.3 states
that CHIRP fulfils the role of a voluntary safety reporting scheme for the
UK as recommended by ICAO Annex 13.
Confidential Reporting – Other ICAO Member States
United Kingdom
CHIRP (1982)
United States
ASRS (1976)
Canada
France
CASRP (1985) REC (1999)
SECURITAS (1995)
Russia
VASRP (1992)
Germany
EUCARE
Spain
SNS (2007)
South Korea
KAIRS (2000)
China
SCASS (2004)
Japan
ASI-NET (1999)
Taiwan
TACARE (2000)
Singapore
SINCAIR (2004)
Brazil
RCSV (1997)
South Africa
SASCO
Australia
CAIRS (1988)
REPCON (2006)
New Zealand
ICARUS
Immunity in the UK
• Aeronautical Information Circular – 47(2001) provides limited regulatory
immunity against third-party reports. Same as MOR system. (Statement
by Chairman CAA), but not against gross negligence / wilful acts
• Public Interest Disclosure Act 1998 – ‘Whistleblowers Act’ provides legal
immunity against “Whistle-blowing” in cases where public safety is
concerned, yet to be tested legally in Air Transport.
• However, the risk of exposure is minimised through CHIRP processes.
Contact details are not retained – no audit path back to reporter.
The CHIRP Charitable Trust
Essential Requirements for an Effective
Confidential Reporting System
•
Establish and retain the confidence of users
•
Proven Independence from
- Regulators
- Management
- Employment Groups
•
Develop and maintain the respect of regulatory and
management agencies
•
Develop effective methods of publishing information
•
Maintaining confidentiality - paramount
The CHIRP Charitable Trust
Programme - Background
CHIRP is the UK confidential reporting programme for
Aviation (H - Human Factors) and Maritime (H - Hazardous) communities
Development
1982 - Programme established (RAF Institute of Aviation Medicine)
1992 - Management transferred to DERA (Centre for Human Sciences)
1994 - Independent Industry-wide Review
1996 - Charitable Trust formed
- Independent Management
- Funded by CAA (SRG)
1997 - Aviation Programmes progressively expanded
2002 - Maritime Programme commenced; funded by DfT
The CHIRP Charitable Trust
CHIRP Aviation Programme
Development and Scope
Commercial Air Transport
- Pilots (1982)
- Air Traffic Control Officers (1985)
- Engineers / Approved Maintenance Organisations (1997)
- Cabin Crew (2001)
General Aviation (1999)
- Light Aircraft, Gliders, Micro-lights,
- Para-gliders, Balloons
The CHIRP Charitable Trust
Reporting Relationships
AAIB
CAA MOR
CHIRP
{
{
{
Fatal
Accidents
Injury
Accidents
Precursors
Incidents
Normal Operations
CHIRP is Complementary to Other Systems of Reporting
The CHIRP Charitable Trust
What is the link ?
Company Reporting
Procedures & Risk
Assessments
Voluntary
Confidential
Reporting
Regulator
MORS
How does CHIRP do this?
CAA
Individuals
Individual follow-up &
feedback is most important
CHIRP
Companies
AAIB
How Does CHIRP Ensure Confidentiality?
•
Confidential not anonymous. Permits closed loop process
•
Follow-up
•
No action taken without reporter’s consent
– letter
– telephone
– interview on private basis
• Personal details and original report are not retained. Returned to
reporter (provides level of immunity)
•
Reports technically disidentified for dissemination and retention
•
Controlled third-party access to report data for research
The CHIRP Charitable Trust
The CHIRP Organisation
•
Charitable Company Status (provides a level of immunity)
•
Executive Board (Trustees)
•
–
Independent Corporate and Professional Governance
–
Provide Strategic Direction
–
Monitor Performance
CHIRP Advisory Boards (subject matter experts)
–
Nominees from principal agencies
–
Offer guidance to Director CHIRP on specific issues
–
Provide feedback to Trustees on performance and
effectiveness of the programme
The CHIRP Charitable Trust
Organisation and Structure
CHIRP Executive Board (Trustees) (10)
Mr Ken Smart (Chairman)
Capt T Sindall
Capt C Elton
Air Cdre R Peacock-Edwards
Capt D Chapman
Capt C Hodgkinson
Capt W Lowe
Mr J Saull
Mr D King
Maritime Trustees (4)
UK-MEMS Review Board
23 members civil/military
Chirp Advisory Boards(4)
89 subject matter experts
Staff (3 full-time and 2 part-time)
Mr P Tait
Mr M Skinner
Mrs K Arnold
Mrs J Ellis
Mr Bishnu Sunuwar
The CHIRP Charitable Trust
Chief Executive
Deputy Director (Eng)
Administration Manager
Admin Assistant
Systems Administrator
What are “Human Factors” ?
CHIRP Air Transport Programme
Reports Received – 1999 to 2009
Total Reports to-date
7325 (Feb 2010)
600
500
Air
4131
ATC
712
Eng
495
CC
1167
GA
820
66
34
40
61
400
32
75
58
29
189
156
300
80
80
98
110
32
25
42
64
200
29
37
31
88
79
155
63
69
20
19
173
20
24
170
120
245
145
140
20022003
20032004
Cabin
132
245
176
153
0
19992000
The CHIRP Charitable Trust
20002001
20012002
20042005
20052006
20062007
20072008
ATC
Air
16
190
GA
Eng
18
12
100
44
178
31
35
57
20082009
Flight Crew Reports - Top 6 Key Issue Topics
Discretion
3%
Crewing
6%
Length
10%
200
180
Disruption
2%
160
140
Rosters
57%
Rest
22%
120
100
Duty
80
In-flight
5%
60
40
20
0
2005
2006
2007
2008
2009
Ground
95%
1. Duty
2. Security
4. Company Policy
3.Comms- External
5. Procedures 6. Pressures
Security
ATCO Reports - Top 6 Key Issue Topics
Unavailable
5%
14
Complicated
5%
Use by
reporter
10%
12
10
Not
Understanding
19%
8
6
Use by others
61%
Procedures
4
Level of
service
32%
2
0
2005
2006
2007
2008
2009
Separation
68%
1. Comms-External
2. Procedures
3. Air Traffic Mgt
4. Handling/Operations 5. Company Policies 6. Duty
Air Traffic Management
Engineer Reports - Top 6 Key Issue Topics
30
Inspection
6%
25
Base
38%
Work Standards
13%
20
15
Line
38%
Maintenance
10
Know ledge of
10%
5
0
2005
Servicing
2%
Repair
3%
2006
2007
2008
Absence of
2%
2009
Com pliance w ith
88%
1. Maintenance
2. Procedures
3. Regulation/Law
4. Security
5. Company Policy
6. Pressures
Procedures
Cabin Crew - Top 6 Key Issues
160
Disruption
2%
Discretion,
9%
140
Rosters,
36%
Crewing,
9%
120
100
Rest, 13%
Length,
31%
80
Duty
60
conflicting
2%
Complicated
16%
40
Knowledge of
2%
20
Use by others
55%
Unavailable
4%
0
2005
2006
2007
2008
2009
Use by reporter
3%
1. Duty
2. Procedures
3. Company Policy
4. Pressures 5. Comms-internal 6. Regulation/Law
Not
Understanding
9%
Procedures
General Aviation - Top 6 Key Issues
Operation of Eqipt
14%
30
Airm anship
38%
25
20
A/C Handling by pilot
48%
15
Handling/Operation
10
Use by Other
33%
5
Use by Reporter
46%
Know ledge of
8%
0
2005
2006
2007
2008
2009
1. Handling/Operation 2. Procedures 3. A/C Technical
4. Comms-External
5. Near Miss
6. Sit. Awareness
Inadequate
5%
Not Understandable
8%
Procedures
UK- MEMS managed data input
MEDA format data entry
via member ID & Password
protection
Group member
Owned file
Identified data
Group member
Owned file
Disidentified data
SIDD monthly
report
CAA MOR
maintenance
error data
analysis
Data analysis shared with
group members & Industry
Error types as % of total each year
(data from CAA MOR)
Q; Why do same basic patterns of error reoccur?
%
60
Installation
50
Approved data
40
Servicing
30
Poor Insp
20
Misinterp of
data
10
FOD
0
2004
2005
2006
2007
2008
2009
MEMS group SMS readiness review
MEMS Group SMS Readiness Feedback
2008
Areas of strength and opportunity
Above
6
4
2
Average
1
2
4
Below
6
4
4
1
1
1
3
different people……. same
mistakes!
Establishing a confidential reporting
Scheme?
• Links to ICASS group through the CHIRP
website (secretariat)
www.chirp.co.uk (see Links)
• Contact Peter Tait or Kirsty Arnold for more
information through CHIRP website or email
confidential@chirp.co.uk
And Finally……
Run!
Any
Questions?
The CHIRP Charitable Trust