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CONFIDENTIAL AVIATION HAZARD REPORTING SYSTEM
Hazards and incidents
(1)
Hazards are negative indications of a safety trend, or a possibility for an incident or accident.
(2)
Hazards include, but are not confined to, human factor errors, inadequate fire and rescue services, bird siting at aerodromes or in migration, issues such as runway markings which are difficult to see, lack of diligence given to aeronautical information circulars, poor communications, ignorance about dangerous goods, incorrect perceptions of ATC or pilots, ergonomics, confusion about which frequency to use, visual illusions, medical problems, lack of or misunderstanding of legislation, prevalence for near collisions, passenger behaviour, poor ramp standards.
(3)
Many incidents are reportable to the Commissioner in terms of Part 12 of the CARs. These incidents must not be sent as a CAHR report. In such cases, if this is reported to the designated body or institution, the reporter must be advised of the correct method for such reporting. The designated body or institution will still maintain the confidentiality of such a reporter and will not forward the report to the Commissioner. However, the nature of the hazard may be used for awareness purposes.
(4)
Confidential aviation hazard reporting is a tool for accident prevention in that hazards are identified before there is loss of life, injury or damage, i.e. loss. It is not a statistical tool. It is non-punitive.
(5)
For further information on identification of hazards and confidential reporting refer to ICAO Technical Publication “Accident Prevention Manual” (Doc 9422).
Procedures
The confidential aviation hazard reporting system is operated as follows:
•
Reporting and receipt of reports
•
Allocation of reference
•
Place in safe keeping
•
Make contact with reporter, if necessary, for further information
•
Destruction of name and other details of reporter
•
De-identify report
•
Referral to others, if necessary
•
Publication of some reports
•
Summary of reports
•
Place on file
•
Data exchange.
Receipt of reports
(1)
A dedicated post office box is maintained. The key is kept by a designated person(s) who undertakes to collect the mail and hand unopened to the analysts.
(2)
Reports may be submitted on the CAHR form contained in Annexure A or by any other medium.
(3)
Reports received by fax will not be guaranteed confidential.
(4)
Receipts may be accepted on electronic media but will not be guaranteed confidential unless methods for such confidential reporting have been developed and proven reliable.
(5)
Reports may be submitted by anyone in the aviation industry or who is concerned about safety in aviation.
(6)
It is preferable that the reporters provide names and phone numbers so that analysts can contact them for further information, if necessary.
(7)
Anonymous reports, i.e. without a name or phone number, will be accepted. However, less significance may be attributed to such a report as the reporter cannot be contacted for further relevant information which may be required for analysis.
Allocation of reference
A reference shall be allocated for the report and will be used for any correspondence or publication of the report where relevant.
Safekeeping
All reports with identifying information retained are kept in safekeeping (safe or locked cupboard or room). Only the analysts have access to the documentation until reports have been de-identified.
Make contact with reporter, if necessary, for further information and feedback
(1)
Contact with the reporter may be made only by the analyst. Extreme sensitivity is exercised when phoning the reporter bearing in mind that if his or her identity is revealed, the repercussions could be detrimental to the reporter and the future of the reporting system.
(2)
When the reporter is contacted, he or she is advised of the action to be taken, that identifying information will be removed and that all records of the reporter will be destroyed.
Destruction of name and contact details of reporter
(1)
Once the analyst has obtained any necessary further information from the reporter the name and contact details are removed from the report form.
(2)
The method in which this is done, is determined by the designated body or institution, such as by phone or by return of the section of the report which contains the name.
De-identify report
(1)
All reports are de-identified through the removal of identifying information from a report in a method that alters the information so that the reporter cannot be identified.
(2)
Each report is treated on its own merit.
(3)
Generic terms are used to replace this information, e.g. types of aircraft, aerodromes, routes.
(4)
It is accepted that with some reports the inevitable results of de-identification results in non-specific apparently ineffective information. The relaxing of de-identification may place the credibility of the confidentiality of the system in jeopardy.
(5)
De-identification is always conducted even if the reporter indicates otherwise.
Referral to others if necessary
(1)
Unless a report indicates imminent catastrophe, referral is not immediate. A time lag between occurrence and referral enhances confidentiality as the report does not appear so specific. This reduces the possibility of a “witch hunt” response or easy identification of the reporter.
(2)
The analysts identify relevant organisations, authorities, companies, etc, which may benefit from knowledge of a hazard and refer the report to them.
(3)
Referrals include a clause that this information has not been verified, but is in the interests of aviation safety and is for information.
Publication of some reports
(1)
De-identified reports may be published by the designated body or institution in a feedback publication and reports may be used by any other media for the purposes of aviation safety.
(2)
Any method of publication may be used if it is deemed to be suitable for the widest relevant group.
(3)
The analysts may withhold some de-identified reports from publication, e.g. if a report is not seen to be related to aviation safety, or if, even if de-identified, the reporter could still be recognised. However, this does not prevent the analysts from providing relevant organisations with the basic hazard.
Summary of reports
(1)
A summary of reports is maintained, and a copy is sent to the Commissioner quarterly.
(2)
Such summaries are available on request by any sector of the aviation industry.
Filing and data retrieval
(1)
All de-identified reports are filed by whatever means the designated body or institution finds suitable.
(2)
All de-identified reports are preserved.
(3)
The filing system is such that retrieval is simple.
Data exchange
(1)
Any reasonable request for copies of de-identified reports will be made available on request to any person. The designated body or institution has the right to refuse a request if there appears any risk of the reporter being identified.
(2)
International guidelines and protocols on data exchange are followed.
Manner in which system is operated
Administration
(1)
Credibility in the confidentiality of the system is of the utmost importance. Those involved in the analysis require an approachable personality, have the respect of the industry, have experience in aviation and a knowledge of human factors. An analytical person with a conceptual rather than focussed approach is essential.
(2)
An analyst is a person designated to analyse confidential reports and is entrusted with the identifying details.
(3)
An assistant analyst is any person who assists the analyst but who is not provided with identifiable information.
(4)
The number of analysts is determined by the designated body or institution. Analysts may be employees of the designated body or institution or be retained for remuneration or on a voluntary basis. Analysts are selected for their expertise, confidentiality and sensitivity, with an understanding of human factors. They must not be in the employ of any aviation operator, aerodrome operator or air traffic service unit.
(5)
Assistant analysts are selected for their expertise and may be in the employ of an aviation operator, aerodrome operator or air traffic service unit.
Advisory committee
(1)
The designated body or institution must establish an advisory committee. Terms of reference for the advisory committee for the following purposes:
(a
To detect significant aviation safety trends arising from hazard reports;
(b)
to identify those safety trends that may be appropriate for investigation by other committees or Working Groups;
(c)
communicate pertinent findings concerning safety to the Commissioner or appropriate sectors within the industry;
(d)
to provide expert opinion, information and assistance as and when required for hazard analysis;
(e)
to disseminate information and alert bulletins to the disciplines that make up the aviation industry;
(f)
to monitor the methodology, analysis and feedback of the confidential aviation hazard reporting (CAHR) system; and
(g)
to assist the analysts in the editing of publication material.
(2)
The committee must comprise of expert technical representatives from a wide variety of sectors including employer and employee groups, aircraft owners and manufacturers, airlines and general aviation, engineering and maintenance, recreational flying, air traffic services, etc.
(3)
The committee must meet regularly but not less than twice per year.
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