ORGH.GEN.165 Safety reporting system

CONTENT, USAGE, CHARACTERISTICS OF THE SAFETY REPORTING SYSTEM

(a)The GH organisation’s reporting system should be adequate for the size of the organisation; it should be kept simple and include details on what, how, where and when to report.

(b)The reports should meet the requirements of point ORGH.GEN.160 on occurrence reporting in terms of time, format and information to be reported. The GH organisation should provide the means of and format for reporting when this is not established by the relevant authorities under point ORGH.GEN.160.

(c)The reporting system should:

(1)ensure confidentiality, and enable and encourage nonpunitive, free and frank reporting of any potentially safetyrelated occurrence or risk, including incidents such as errors or near misses, safety issues and identified hazards;

(2)provide acknowledgement to the reporter of the successful submission of the report — for small organisations, verbal acknowledgement may be sufficient.

(d)The reporting system, including internal safety reporting, should clearly express the purpose and objectives. The organisation should do the following.

(1)Contain procedures to implement a just culture.

(2)Identify those reports that require investigation and determine whether the event reported qualifies for reporting under points (b) and (c) of point ORGH.GEN.160. A small GH organisation should seek advice from its competent authority on this matter.

(3)Investigate the causal and contributing factors related to the occurrence, incident, error or near-miss event that was identified, including technical, organisational, managerial and human factors. The aim should be to understand what happened and how it happened and to prevent or reduce the probability and/or consequences of future recurrence. Complex organisations should analyse the collective data showing the trends and frequencies of the contributing factors.

(4)Take the necessary corrective actions based on the results of the investigation, to address the root cause of the event and to disseminate knowledge of relevant incidents and accidents and of actions taken to the employees concerned.

(5)Ensure, where relevant, cooperation with the aircraft operator and the aerodrome operator on occurrence investigations by exchanging relevant information to improve ground and flight safety.

(6)Participate in the investigation conducted by the aerodrome operator or the aircraft operator, as appropriate, where the organisation is directly affected by the event or the proposed mitigation measures.

(7)Ensure that the findings of investigations feed into the relevant recurrent training while maintaining the required confidentiality.

(e)Access to reports submitted should be restricted to personnel responsible for processing, storing and analysing them. A small GH organisation may apply a more flexible approach to this restriction, appropriate to its organisational structure.

SAFETY REPORTING CULTURE — UNDERSTANDING THE RISKS OF NOT REPORTING In a nonfunctioning or badly functioning safety environment, events go unreported due to fear of repercussions (possibly indicating poor or no just culture), lack of awareness, prioritisation of completing tasks over reporting safety issues, lack of training on occurrence reporting, etc. In a wellfunctioning safety environment, a just culture within the organisation facilitates the accurate reporting of events by GH personnel when they occur to ensure that the appropriate assessments are carried out.

(a)Key risk areas:

(1)damage done to the aircraft may go unnoticed by the flight crew or not be reported to them, especially for aircraft with carbonfibre structures;

(2)events are not properly understood as an accurate root cause analysis is much harder to perform.

(b)Potential consequences:

(1)unnoticed aircraft damage may endanger the flight;

(2)effective corrective actions cannot be put in place;

(3)damagerelated costs increase.

(c)Mitigation measures:

(1)include the SMS in the training programme for personnel, explaining the value of having a safety culture and a healthy, nonpunitive safety reporting system;

(2)apply a just culture and encourage open communication at all levels, topdown and bottomup, about safety actions, events, occurrences and mitigation, to encourage proper reporting, thus enabling damage assessment and event analysis.

SHARING OF SAFETYRELEVANT INFORMATION WITH INTERFACING ORGANISATIONS

(a)The relevant information to be shared with the aircraft operator or aerodrome operator, or both, to improve safety in GH and the operational procedures for addressing safety interfaces includes information, data, facts and analyses from various sources, such as:

(1)audits and inspections, their findings and associated corrective actions;

(2)safety reports;

(3)accident/incident investigations;

(4)safety studies and reviews from official and verified sources.

(b)Safetyrelevant information may also be communicated outside the regulatory framework of occurrence reporting as per point ORGH.GEN.160, which implements the essential requirements of Regulation (EU) 2018/1139 (Section 4.2.2 of Annex VII). For example, aerodrome safety committee meetings could be used to maintain regular communication on safety matters and share good practices, common procedures and safety information relevant to the interface procedures.

SAFETY INVESTIGATION TEAM It is recommended that the GH organisation ensure that the team involved in the analysis of the investigation includes:

(a)GH personnel that are competent in the area or subject of the occurrence;

(b)in the case of a complex GH organisation, a trained investigator or an individual that has received training in investigating occurrences.