202 – Aviation Incident Reporting at CHIRP
Guest: Ian Dugmore Host: Markus Voelter Shownoter: Alexander Grote
As we have mentioned before on omega tau, aviation prides itself on a pervasive safety-culture that leads to a low accident rate. An important building block of this culture are incident reporting systems, where members of the community can confidentially report issues, risks or incidents, which are then followed up on, with the goal to resolve them. CHIRP is the organisation that handles this task in the UK. In this episode we talk to Ian Dugmore, the Chief Executive of CHIRP about the general idea, and about a few (typical) incidents reported to CHIRP.
Introduction of Ian Dugmore and CHIRP00:01:00
Aviation and Maritime Confidential Incident Reporting | Whistleblower
Incident Reporting Process00:06:10
Civil Aviation Authority | Safety Culture | International Civil Aviation Organization | iOS-App | Android-App | Incident and accidents in aviation
Standard operating procedure | Standard operating procedure in aviation | Commercial pressure | Crew resource management (SERA - Standardised European Rules of the Air) | European Aviation Safety Agency
General aviation | Micro light | Pre-Flight Checklist | Just Culture
Critical Incident Reporting Systems worldwide01:24:20
(Australia - Confidential Reporting Scheme (REPCON) | Canada - Confidential Reporting (SECURITAS) | China - Sino Confidential Aviation Safety System (SCASS) | Japan - Aviation Safety Information Network (ASI-NET) | Korea - Korean Aviation Safety Hindrance Reporting System (KAIRS) | MACAU - Macau Confidential Reporting System (MACCARES) | SINGAPORE - Singapore Confidential Aviation Incident Reporting (SINCAIR) | Spain - Safety reporting system | Taiwan - Taiwan Aviation Confidential Safety Reporting System (TACARE) | USA - Aviation Safety Reporting System | USA - Aviation Safety Reporting System(Wiki) | Germany - Luftfahrt Bundesamt | Germany - Vereinigung Cockpit (unitl 1992) | Germany - EUCARE, TU Berlin (unitl 1999))
Ian’s time in the military01:24:45
Omega Tau Phantom espisode | Tornado | Terrain-following radar | Mach Loop | UAV | ROZ
Once again weldone:-)
If you intend to make a podcast of the work on BFU/NTBS from UK/USA I some inputs.
As a glider pilot you know there has been several airproxes in the airspaces throughout Germany. Sadly the reports from BFU do not contain any proper root cause analyzes, this missing root cause analyze leads into reduced airspace for gliders.
Whats missing in the reports?
None of the reports investigates the safety management system at our comercial friends. Before stating up a route to an airport, the airliner has to do an analyze of eventual problems at this route, and the company has to train the aircrews how to avoid hazards, there crews has to be briefed about airspace other activities such as gliding and their behaviors and needs.
Every time there has been an airport the BFU has to visit the airliner and asses their safety management system and check the corrective and preventive actions.
If you study the incident report covering the danish Arcus where the airbrakes deployed at 200 kmh in 200m alt, you will be able to see the root cause analyze is missing.
Why did the welding break?
Why did SH’s quality management system not find the bad weldings at the incoming material inspection from the sub-supplier?
Why did SH approve a supplier not having the capabilities actual to weld critical parts etc.
To be brief. If we do not get any proper investigations/analyzes we are not able to have a decent learnings proces avoiding risks in the future. Especially when the just culture is almost none existing as Ian says, no comercial (almost) admits making failures.
If you revisit your episode System Health Management you will:-)
Thanks for the input, Peter. I will take it into account when I do an episode with the BFU. Right now it is not on the shortlist. But it will happen eventually :-)