The importance of occurrence reporting

Olivia Hogan-Gates 0:00

Hello, and welcome to our occurrence podcast safety special. Today we will be speaking with two aviation professionals to cover why it's so important to continue to make these reports.

So we today have Glenn Bradley, Head of Flight Operations at the Civil Aviation Authority in with us today.

Glenn Bradley 0:19

Good morning.

Olivia Hogan-Gates 0:20

Good morning. How are we?

Glenn Bradley 0:21

Great, thank you.

Olivia Hogan-Gates 0:22

Great. Can you quickly tell us how long you've worked for the CAA?

Glenn Bradley 0:26

I've been here, just coming up to five years now. Joined on September 11 '17. Easy to remember.

Olivia Hogan-Gates 0:32

Very easy day to remember especially in the aviation industry. What's your background in aviation? Can you give us a bit of detail into that?

Glenn Bradley 0:38

Questions like this always make me feel very old. So I started back in '87. I was really lucky. I joined the Air Force after university spent 12 years there, mainly flying tornadoes.

Olivia Hogan-Gates 0:49

Wow

Glenn Bradley 0:49

and left there and joined the airlines joined GB airways here at Gatwick, which is a British Airways franchise were bought out by EasyJet in '08 spent nine years then in various jobs, mainly as head of aircraft operations, and then joined the CAA back in '17, initially as flight ops manager aeroplanes and now as head of flight operations, and how are you finding it? It's interesting, it's very diverse, it's probably more diverse than I'd probably ever expected it to be, mainly because of the scope of what we had to deal with. And all the challenges had been thrown at us over the last five years with the various demise of a couple of large airlines and also COVID thrown in and EU exit on top of that,

Olivia Hogan-Gates 1:29

What does your day to day look like? It must be quite an interesting role.

Glenn Bradley 1:32

Absolutely. One of the reasons I love the job is because of the variety. And sometimes the variety can stretch a bit far, because there's lots of things that come in left field that you probably don't have any idea what the answer is or where to do it. But that creates a challenge. And I like a challenge. But the variety is the best thing about it. And every day is different. And the range of activity we cover, especially in flight operations, from commercial airlines, commercial helicopters, and the scale and scope of all that and all the diverse things, it just makes it very interesting.

Olivia Hogan-Gates 2:01

Well, we're here today to talk about occurrence reporting, and why it's important. So as a pilot, and as someone in the CAA, have you ever personally used occurrence reports to benefit yourself and help aid the industry?

Glenn Bradley 2:13

Absolutely, I've reported on lots of things. And I think with occurrence reporting, you have to remember, it's not just when things have gone wrong and reached a threshold that you must report it, it's about reporting into a system, a safety system, such that it can prevent, your information can help prevent, further events. So it's part of the intelligence gathering, such that the whole safety management system of an organization and ourselves can actually adapt and evolve to prevent future events.

Olivia Hogan-Gates 2:42

And why should people do it? And how can they do it? If they come across something in their day to day life or work related industry? How can they go about reporting it?

Glenn Bradley 2:52

Well, the first part of that is kind of believing in the system. And if you think of the whole system it doesn't know what it doesn't know. So we need to feed the intelligence into the safety management system such that it can adapt and evolve. Even if something hasn't gone wrong, if something's happened, and it's been corrected, well, that doesn't mean to say that somebody else isn't going to make the same mistake or encounter the same problem. So if you think of it as feeding intelligence into a larger system, and some of that can feel a bit like, well, I keep putting these reports in, but nothing's changing. If there's a lot of reports about lower level events, then is it a case of capturing that data and monitoring trends such that those can drive changes, it tends to be that major events might drive changes, but singular small events don't. But actually, that if you're part of the bigger picture, that's creating a set of data, that's demonstrating a trend that's demonstrating that something needs to change, then that's worth doing. The best way to report is to the organization that you work for, because it's their safety management system, that will make the change. There is other ways reporting. So within the normal airlines or safety management system, you'll have a safety report method of reporting. Some of those will reach a threshold where they become mandatory occurrence reports where they have to be reported to ourselves, you can report directly to ourselves. Bearing in mind, of course, you're potentially bypassing the people that can make the change, but there's no reason why you can't report direct to us. And if there's a confidentiality issue, there's various methods, they can report directly or indirectly to us one through CHIRP, which is a confidential reporting system, which is independent from us. And everything remains confidential with that, and also through our CAA whistleblowing process.

Olivia Hogan-Gates 4:30

And how often are these reports monitored to find trends?

Glenn Bradley 4:33

We have teams of people working on this all the time, and I get daily updates on the high level reports that come in, but they all come in, they all form part of a data picture that determines the safety actions that we need to take as the regulator and that might be changing regulations that might be sending out a safety notice about guidance or advice or just general communications and education, but they're monitored constantly. There's a requirement to report an event within 72 hours and we have timescales where we have to respond by as well.

Olivia Hogan-Gates 5:03

Well, I suppose in your experience as a pilot, and as part of the CAA, have you seen firsthand how these reports have helped the industry?

Glenn Bradley 5:10

Absolutely, a lot of times you see incidents come in, or events happen. And there'll be an investigation on the back of that, depending on the severity of the incident, and what's caused it. And we do see things changing because of it. And sometimes it goes back to the guidance from the manufacturer of the aircraft might be wrong, or there might be something lacking. So they'll change that. And there's lots of different things that happen that if there's something severe enough, we might set up a work group or an industry forum to address the issue. And we've done that with laser attacks on aircraft. We've done that with bird strikes. So there's various different things that once we have the data and the information, we can actually use a different program or project to address it.

Olivia Hogan-Gates 5:47

And what are the more popular trends that you do see across the board?

Glenn Bradley 5:51

That's a difficult question, because it depends on the circumstances. So if you look at the scenario we have now with the industry recovering from COVID, the airline industry specifically is very used to being in a stable scenario and has been for years. And so trend monitoring is kind of easier, we're now we've had a massive downturn. And now a lot of demand, a lot of people wanted to go flying. And there's stresses around resourcing, around airports and crew. So there's different challenges. And it might be around delays, crew fatigue, all sorts of infrastructure issues that we're seeing. And because of all that, we're doing a lot of work with the industry to support and help them across the board as indeed of the government as well, because it's it's a wider issue than that. But on the safety side, the important thing there is that we get the information so we can monitor to make sure when the industry is in a struggling situation, as it has been over the last couple of months, that safety is not being compromised. So all the barriers that are in place, remain effective. And that's, you know, probably what we're looking for such that when something will go wrong. By the nature of life itself, we need to make sure that it failed in such a way that it fails safely and nobody is put at risk.

Olivia Hogan-Gates 6:57

You mentioned, crew fatigue, there are very strict and legally enforced regulations in place to control the errors of pilots and other operational roles. Has this been a big thing coming out of COVID-19?

Glenn Bradley 7:11

It has and if you bear in mind that a lot of people have worked at a different level for the last couple of years, and some people have not worked at all. And we're coming back into an environment where there's been a lot of change, a lot of changing procedures, people, experience levels, a lot of people have left the industry and not come back. So across the board, staffing levels are reduced, and that puts stress on the system. And on top of that we've got airspace restrictions, because of the Ukraine. So that's puts pressure on the European air traffic service, which means there's delays and everytime there's a delay, or there's a lack of staff or something, it's all putting stress on the system. So what would be a normal, relatively easy day out, can become difficult and extended because of delays and problems. So everything potentially adds stress to the system, which is an uncomfortable situation to come back to work for if you've not worked for a long time in a relatively benign scenario. So hence, the important thing is to understand where things are not working as well as they can, and understanding how effective the barriers are remaining to when things do go wrong. And we do see things we see things go wrong, and we see things going wrong in such a way that is not a safety issue. So the flight has been cancelled, which will be the right thing to do. Because the crew might be out of hours or whatever. And it's not their fault. It's part of the system. But as I say the system is failing in a safe way.

Olivia Hogan-Gates 8:31

Great. Thank you very much. Would you be able to give our listeners some advice? If they're contemplating putting a report in and they're unsure about it? Could you give your own advice on how you would go about that?

Glenn Bradley 8:44

My advice is always report something no matter how trivial you think it is. Because it might be small to you. But there might be a hundred other people that have seen the same thing. And there's a problem with the system. So nothing is too small to report. The system has a way of processing the severity and the seriousness of these things. I think the more reports you see that demonstrates a healthy safety culture, which will mean people have got the right approach towards safety reporting, they feel comfortable and safe in doing that, even if they've made a mistake, because it might be preventing somebody else making a mistake. We operate in a just culture such that it's not a deliberately or willfully negligent act, then people won't be punished for what they do. Because the idea of the safety reporting system is that everybody learns from it. So report, if you see anything, if you think there's a problem, report it.

Olivia Hogan-Gates 9:31

Great. Thank you very much for your time today.

Glenn Bradley 9:34

Thank you very much.

Voiceover 9:37

You're listening to a special edition of the safety files podcast from the UK Civil Aviation Authority.

Olivia Hogan-Gates 9:45

Welcome back to our occurrence podcast, I am here with Adelle Roberts, who is our airspace modernisation lead at the Civil Aviation Authority. So Adele, how are you today?

Adelle Roberts 9:57

Hi, really good. Thank you, Olivia. It's nice to be in the office today, you don't get to come in very often at the moment, but lovely to have a day in the office today,

Olivia Hogan-Gates: 10:05

Great. And how long have you worked with the CAA?

Unknown Speaker: 10:07

I've been in the CAA about a year and a half now. So during the COVID pandemic, I was made redundant from my flying role. And I thought that was a good time to have a little bit of a change in my career, and I joined the Authority. And I started off in performance based regulation. So I was risk based oversight lead for our risk based oversight program. I was in that up until quite recently, and then I've just transitioned into my new role in airspace modernisation.

Olivia Hogan-Gates: 10:36

Fabulous, and what is your background in aviation?

Unknown Speaker: 10:39

So I'm one of those people that have always, always loved aviation, it's been my entire life and oh where did it start? So for me, it started, I was 14, and my brother had just done his private pilot's licence. And he would take me flying with him. So a very impressionable age. And I think that was it. That was the glue that started holding all of it together for me. So from there, I went through my education and then went off to university. Out of university, I joined the airlines straightaway, I didn't even make my own university graduation. I was on my initial training then for British Midland. So I was at British Midland for a little while, and then I went off and did my ATPL. So Airline Transport Licence, I did it in two parts. So I went off to British Aerospace, in Adelaide, Australia, which brought me up to a Commercial Pilot's Licence and then also had to convert that across to a UK licence. So I came back over to the UK, and did my instrument rating at Bournemouth. And then that brought me up to my frozen ATPL. I was really fortunate enough to then go back into working for British Midland as a first officer and stayed there and flew, I flew Fockers. And then when we started up, BMI baby, I flew the Boeing there. And then when BMI baby closed down, I went and flew the A320. And then after that, I was lucky enough to get a job at Virgin Atlantic. And I was there for 16 years until the pandemic hit. And like a lot of other pilots in the industry, I found myself for the first time, not flying an aeroplane. And that really was my catalyst to actually maybe do something a little bit different. So here I am, at the CAA absolutely loving it, still in aviation. And that's what's really important to me.

Olivia Hogan-Gates: 12:42

Well, you're obviously a very accomplished aviation professional. We're delighted to have you here today. Would you be able to tell us a little bit in your own words about occurrence reporting?

Adelle Roberts: 12:52

Yeah, absolutely Olivia. So I think for a pilot, thinking about safety management. So it's woven into almost every activity, a pilot overtakes. So if you think about the word safety in a pilot's mind, so it's that big, red, attention getter. And it really comes before everything. So making sure that every flight is as safe as it possibly can be. Now occurrence reporting, for me is the lifeblood of safety of safety management. So if you think about, you know, when we submit an occurrence report, you know, we're making sure that we are telling as many people as possible, you know, that we've seen something that we, as pilots feel impacts safety, or as the potential to reduce safety margins. So by making the occurrence reporting, we're making sure that that information gets to absolutely the right people that need to either disseminate it, or mitigate it, you know, so to do something about that thing that you've seen. So it's so super important, you know, you wouldn't see something that was unsafe, and, you know, post it on Facebook, for example, or put it in your Whatsapp group, you know, you need to make sure that that information, gets out there and benefits the entire pilot community, because the thing that you've seen, it might not have ended up in a bad situation on the day that you've seen it, but it has the potential to, so making sure that the thing that you've seen or the thing that you feel could potentially happen because of what it is that you've observed. getting it out there and getting it understood, and disseminating that information. Make sure as many people know as possible, you know, really, really increases safety, not only for your own organization, but you know, globally when you're talking about occurrence reports that are benefitting the entire aviation community globally. You know, it could be that one tiny thing that you've seen, which changes the outcome of an aircraft accident or incident, and I just feel like I said, I call it the lifeblood, the lifeblood of safety management.

Olivia Hogan-Gates: 15:00

You've flown many, many different aircraft. Have you any examples of seeing this firsthand?

Unknown Speaker: 15:07

Yeah, I'll give you I'll give you one example, probably of an occurrence report that I made quite a number of years ago. But I do think it's one of these ones that really had the potential to perhaps end up in quite a catastrophic incident. So let's take for example, I think it was an SOP that I found that was perhaps not the safest way it could be. I'll just rewind a little bit. So talking about aviation. So we know aviation is a system of systems and you know, SOP, so standard operating procedures, they're part of the system. But it's not always the case that you have an SOP for everything. So that's something to consider from a human factors perspective. But also, it could be the case that the SOP isn't particularly good for the scenario that it's been written for. So, you know, until SOPs are robustly tested, you don't know whether they're as safe as they possibly could be. So in this example, of the occurrence report that I made, I was down Route somewhere with a heavy aircraft. So a three forty six hundred. In an airfield that was hot, and an airfield that was high, I think it was around five and a half thousand feet. So pilots listening to this immediately know Okay, takeoff performance considerations. Now, the SOP for the takeoff performance calculation was get ATIS and use the data for the ATIS to calculate your performance. Now the particular airfield that I'm talking about has got a runway that's quite far away from where the tower is. So it occurred to me on this day was like, well, actually, what is the wind on the runway that we are departing on? And actually the ATIS, does that correlate to the runway? Or is the measurement point for the wind vector on the ATIS taken from somewhere else? So I called up tower and I spoke to tower and I just asked them a question I said, you know, where is the measurement taken from on the airfield for this wind reading on the ATIS, and it actually was from an instrument on the top of the tower. So obviously, then I asked for the wind for the actual runway that we were departing from to do my takeoff calculation. But that was something that played on my mind for the flight. And I was like, I need to say something about this, I need to make an occurrence report and just make it absolutely clear that, you know, perhaps, if you are at an airfield that's got a runway that's perhaps not very close to the rest of the terminal area, it has the potential to have quite a different wind. We know that a lot of places around the world, in fact, on the ATIS do give winds on there ATIS for the specific runway, but this airfield did not at the time. So that was something that I occurrence reported. And then of course, that then resulted in an SOP change for that airfield that you did, in fact, then go and request from tower the actual wind vector for the takeoff runway that you're using. So that's just one example that's happened to me, and it did have a positive effect on an SOP change. And if you can imagine I'd taken off on that runway with a very heavy A three forty six hundred, which, again, the pilots out there will understand, you know, they weren't the easiest things to get off the ground, particularly when it was hot, and particularly in those kinds of altitudes. You know, imagine arriving at your rotate point. And, you know, you've got the wrong wind in in that performance calculation, you can just imagine the worst case scenario in that event. So yeah, that's just one example of occurrence report. But, you know, there was another thing that I was thinking of, just as I was talking there and thinking about a system of systems and just, you know, sometimes looking at the human in the system, and is the system appropriate to the way that human operates in that system? And that get, let me give you an example. Imagine a triangle and imagine each point in this triangle, you've got a coffee shop, and you've got a bin and you've got a park bench. And the designer comes along and designs a path and the path goes from the coffee shop, to the bin, and then to the park bench. And the human comes along, and they buy their cup of coffee, and they look at the park bench, and the path to the park benches across some grass. And, you know, my question is, does the human take the path that goes by the bin to the bench? Or does the human walk across the grass? And the answer is the human walks across the grass. And I kind of guess that's what I'm trying to say with aviation being a system of systems. If the system doesn't work for the human, then that's the kind of thing that we need to know about so that we can make a positive change and make the system work for the human. So another aviation example because I know that was probably a little bit off track, but I just wanted to highlight the fact about making systems appropriate for humans. But another example of that would be perhaps if there was a trip pairing that was particularly fatiguing, and you know, you're arriving into your destination airfield, and you're recognizing that you're on approach and you're making more mistakes than usual, you know, maybe that's because you're more tired than usual. And that that's a system. So that's a system that's been created, that's a trip pairing that's been made. And, you know, it's probably been passed through the fatigue risk management program and scored on the scales that are used, which I forget the name of just at the moment. But by the by, you know, that's one of those things that all right, does it work for the human? Well, actually, no, it's got the potential to reduce safety margins, because the pilots tired. So you know, give an occurrence report, give that evidence to the safety management system, and then that can be mitigated. Without speaking up and without saying something about that fatigue, then the organisation, you know, if you're reporting to your organisation, you know, they're not going to know unless you say, so, I think that's really the importance of occurrence reporting. It's getting the information known. It's getting it shared, and it's getting it to the right people

Olivia Hogan-Gates: 21:25

Who should do these occurrence reports. And why do you think that it is important for them to do it?

Adelle Roberts: 21:29

Literally anyone can do occurrence reporting. So within, you know, a large organization like I've worked for, anyone throughout the whole structure of the organisation can carry out occurrence reporting. So you know, predominantly, we talk about pilots making their occurrence reports, but also cabin crew, absolutely, they are empowered to do so. We talk about just culture. And that's so important, you know, that people feel that they are going to be listened to, you know, and that they put their hand up, and they've seen something that either they believe is unsafe, or it has the potential to reduce safety margins, it needs reporting, you know, and everyone should be empowered with an organisation to feel that they can make an occurrence report at any time that they feel that they want to or they need to. And you know, I definitely had that where I've seen, you know, below wing crews, so such as turnaround coordinators, perhaps they've seen something, its absolutely right that they feed into the occurrence reporting system, make an occurrence report. But then, you know, that's look outside of an organisation, you know, anyone from the general public can make a report, directly to the CAA. You can do that straight from our website, if you see something that you think has the potential to impact aviation safety, that's absolutely something you can come to us directly as the CAA with, and also internally in the CAA for our own people, we can raise safety concerns. Now I live quite close to Heathrow Airport. And during the pandemic, I've noticed quite a lot of species of large birds getting closer and closer to the airport perimeter. I've got in my own garden, which is about three and a half miles on approach to nine, right, so that the southerly runway, I've got each evening, some very large red kites, and as we know, they kind of started up the M40, didn't they and they've slowly done very, very well and got closer and closer to London, and I'm just outside the M25. But we've got quite a lot of these big bird species now living really close to a massive international airport that has, now we're recovering from the pandemic, quite a lot of flights. So that's something that I've put through our own internal reporting system just to raise awareness that actually I'm seeing really big birds that I haven't seen historically. So that seems to be something thats on the increase. And of course, wildlife management in terms of airfields is incredibly reported important. So any data that feeds into any kind of reporting is used to gather evidence and look at areas where we can improve safety, and where we can put mitigations in place to improve safety. So yeah, occurrence reporting its not limited to the organizations, it's totally available to the general public and super important to us within the Civil Aviation Authority also.

Olivia Hogan-Gates: 24:26

Great. Well, Adelle, thank you very much for joining us today. Your insight into occurrence reporting and safety has been fabulous. So really appreciate the time and hopefully we'll speak to you again soon.

Adelle Roberts: 24:36

Thanks so much Olivia.

Olivia Hogan-Gates: 24:38

Today we have heard from Glenn Bradley, Head of Flight Operations and Adelle Roberts airspace modernisation lead here at the CAA. Their firsthand experience has given an insight into why it's so important to continue to log these reports. If you would like to get in touch with us, please email us at safetyfilespodcast@caa.co.uk. Thanks for listening.