1. The NATS Review of ATM Occurrence Reporting Prepared for ICAO European Region Aviation Safety Seminar/Workshop (Baku, Azerbaijan, 5 -7 April 2006) by Jane Gothard Head of International Safety NATS jane.gothard@NATS.co.uk

2. Background to the NATS Review In November 2001 NATS began a review of its Occurrence Reporting process against a background of:  NATS already having a mature Occurrence Reporting Scheme;  NATS having no immediate concerns over occurrence reporting levels; ( 2001 data - 228 Mandatory Occurrence Reports featuring ATC Error )  Some NATS units having established locally devised lower level reporting systems

3. To determine improvements to NATS safety reporting which would:  Maximise capture of operational occurrences and observations;  Facilitate effective lesson learning;  Provide a single company-wide scheme. Review Objective

4. Expectations  To improve on what NATS has at present;  To have the confidence of the users;  To ensure continued alignment with regulatory requirements;  To be simple but effective;  To be accommodated within existing resource.

5. Review Team Membership Sponsor:Director Airports Leader: Terminal Control Watch Manager The following areas of NATS were represented on the review team:  ATC Investigators  Human Factors experts  Operational Controllers  Air Traffic Services Assistants  Trades Union  Corporate Areas including: Division of Safety & Quality Engineering Policy & Assurance Air Traffic Operations External Representative: CAA SRG ATSSD

6. Information Gathering Information was gathered from 2 sources:  Staff Questionnaire  External Best Practice Visits  A UK Airline  An Oil Company

7. The Staff Questionnaire What inhibits reporting? A sample of ATC and Engineering staff at Gatwick; ScOACC; Aberdeen and London Terminal Control Centre were asked to rate the following according to a five point scale:  Blame Culture  Too time consuming  Discouraged by peers  No feedback  Nothing will happen  Discouraged by management / supervisors

8. What Inhibits Reporting? Questionnaire Results Response rate: +80%

9. What Inhibits Reporting? - Results The results of the NATS survey showed that:  Most respondents rated perceived ‘Blame Culture’ as either the primary reason or the secondary reason that may prevent them from reporting all occurrences.  Most respondents rated ‘Discouragement by Management ’ as either not a factor in decisions regarding reporting safety occurrences or a factor of low importance.

10. External ‘Best Practice’ Visits  Procedures detail 44 categories of events to be reported - of these 50% are items requiring an Mandatory Occurrence Report to be submitted - 50% relate to pilot performance.  Electronic monitoring on the flight-deck encourages reporting.  Aircrew competency issue following incident handled internally.  Reporting system utilises single form for both safety reporting. The Airline Scheme

11. External ‘Best Practice’ Visits  Safety Reporting system is an integral part of a wider ‘Safety Culture’ programme.  Scope of scheme: - All staff; Contractors & Visitors; - All aspects of safety including ‘Health & Safety’.  Single report form for all events.  Emphasis on staff empowerment- what action did you take?  Report Nomination scheme. The Oil Company Scheme

12. Implementation Experience  Airline Experience - Air Safety Reporting Scheme has taken 10 years to reach maturity.  Oil Company Experience - original implementation plan too ambitious; - buy-in needs to come from top - need to demonstrate by behaviour; - comprehensive education system - from top down; - 4 / 5 years before staff accept the system.

13. Key Issues with Occurrence Reporting  Perceived ‘blame culture’;  Lack of feedback;  Time consuming;  Nothing will happen;  Diversity of reporting schemes;  Limited reporting of low level or corrected events;  Limited NATS-wide dissemination of lessons learnt

14. Key Issues / Solutions Matrix

15. Key Proposals for Improvement The solutions matrix addressed the key points raised in the staff survey. In addition, the following improvements to occurrence reporting were made:  Emphasis on a ‘just’ culture rather than a ‘no-blame’ culture;  The introduction of a in-house reporting process called ‘Open Reporting’ to capture low level safety events that are in addition to those captured by The CAA Mandatory Reporting Scheme;

16. Taking the Work Forward

17. UK CAA agreed to NATS introducing a trial ‘Open Reporting’ Process:  The trial was conducted at Aberdeen and London Terminal Control;  The trial scheme covered both ATC and Engineering Reports;  Trial was introduced in August 2003: duration 6 months;  The ATCO; Engineering and Air Traffic Assistant grades were involved  Health & Safety Issues were not included. The Pilot Process

18. Results of the Pilot  The introduction of the trial Open Reporting Scheme did not prejudiced the existing CAA Mandatory Occurrence Reporting scheme;  NATS was encouraged to see that the scheme quickly yielded information that previous established reporting processes may not have picked up, for example:  Poor technique in operational hand-over  Failing to apply best practice operating techniques.

19. Transition into Operation from October 2004 Revised Safety Management Procedure:  Covers both Mandatory Occurrence Reporting and ‘Open’ reporting  New NATS Reporting Form Including new box – ‘Other Information and Suggestions for Preventative Action’  Includes NATS/SRG Code of Practice The opening statement in CAP382 (The Mandatory Occurrence Reporting Scheme) makes it clear that the purpose of the MOR scheme is to benefit flight safety and that it will not be the policy of the CAA to institute legal proceedings as result of events reported under the scheme. Additionally, it is stated that the CAA expects that employers will not act in a manner that may inhibit reporting through taking disciplinary action.

20. Results so far………. 2001 data - 228 Mandatory Occurrence Reports (featuring ATC Error ) 2005 data - 5,400 Occurrence Reports Filed - 3,800 Mandatory Reports (600 with some ATC Error) - 1,600 Open Reports

21.  To improve on what NATS had;  To have the confidence of the users;  To ensure continued alignment with regulatory requirements;  To be simple but effective;  To be accommodated within existing resource. EXPECTATIONS HAVE BEEN MET

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