CHIRP:
The UK Confidential Human Factors
Incident Reporting Programme
March, 2002.
Mr Peter Tait
Director, CHIRP
Kim O'Neil
Advanced Aviation Technology
Ltd.
1. Introduction
Although accident/incident rates in commercial
air transport operations have reduced to an extremely low level, the number of
accidents with Human Factors causes has not declined at the same rate and thus
are now the dominant cause in major accidents.
Incident reporting programmes have proved to be
valuable tools in the identification of safety related issues and the
definition of corrective actions. In those specific incidents involving human
error, the availability of an independent, voluntary and confidential reporting
medium has provided valuable additional information to that available through
the formal or mandatory reporting systems.
The UK Confidential Human Factors Incident
Reporting Programme, affectionately known as CHIRP, is an independent
confidential reporting programme in operation in the UK for those employed in
the civil aviation industry to report safety related incidents and events. This
Programme has now also been made available to UK Cabin Crew communities for a
one-year trial period.
2. The CHIRP Charitable Trust
The UK Confidential Human Factors Incident
Reporting Programme, CHIRP, has been operating in the UK since 1982. Following
a comprehensive independent review by the Guild of Air Pilots and Air
Navigators (GAPAN) in 1996, the Programme was restructured to enable it to make
a more effective contribution to the resolution of important safety related
issues in the UK air transport industry.
As a result, CHIRP was established in its
present form, as a charitable company limited by guarantee, on 1 November 1996.
The Programme receives a grant from the Civil Aviation Authority, which is
itself funded by the air transport industry. The corporate structure of CHIRP
was selected in order to provide a totally independent organisation, with
management and fiscal responsibilities held by an independent Board of
Trustees.
The Board of Trustees of CHIRP comprises seven
voluntary members and the Chief Medical Officer of the Civil Aviation
Authority, who is appointed on an ex-officio basis. The Chairman is Professor
Tony Nicholson, an acknowledged specialist in Aviation Medicine, and former
Commandant of the Royal Air Force School of Aviation Medicine.
The Trustees of CHIRP are supported by the Air
Transport Board and the General Aviation Advisory Board. The trustees are
nominees from the principal air transport and general aviation interests in the
UK, who contribute their expertise to safety issues raised through the
Programme. Current nominees to the Air Transport Board are drawn from the: RAF
Flight Safety Inspectorate, British Air Line Pilots Association, UK Flight
Operations Liaison Group, UK CAA SRG (3), Assoc Licensed Aircraft Engineers, UK
Flight Safety Committee, Independent Engineering Consultant, General Aviation
Mfrs & Traders Assoc, British Helicopter Advisory Board, UK Operators
Technical Group, Guild of Air Traffic Control Officers and NATS.
The role of the Advisory Boards is to provide
counsel on the most appropriate way in which specific issues might be resolved
and to advise the Trustees on the performance of the Programme. The composition
of the Board is reviewed regularly to ensure that the membership is appropriate
to the scope of the Programme. Advisory Board members act as individual expert
advisers and not as representatives of their sponsoring organisations.
Information is provided to the Advisory Board on a confidential basis and all
means of identifying the individual reporter are removed from reports prior to
any discussion.
CHIRP employs a permanent staff of four under
the management of a full-time Director. The organisation is located on the
(former) DERA Site at Farnborough.
3. The Programme
CHIRP receives confidential incident reports
from professionally licensed pilots, air traffic controllers, licensed
engineers and approved maintenance organisations employed within the UK air
transport industry, individuals involved with General Aviation, and Approved
Design and Production organisations. With effect from July 2001, the Programme
has been extended to Cabin Crew members on a one-year trial basis. A Cabin Crew
Advisory Group is to be formed to assist in this initiative.
After receipt, reports are validated as far as
is possible and reviewed with the objective of making the information as widely
available as possible whilst maintaining the confidentiality of the source.
Anonymous reports are not normally acted upon, as they cannot be validated.
When appropriate, report information is discussed with relevant agencies with
the aim of finding a resolution. Only fully de-personalised data are used in
discussions with third party organisations and the confidentiality of the
reporter is assured in any contact with an external organisation.
No personal details are retained from the
reports received. After ensuring that the report contains all the relevant
information, all personal details are returned to the reporter with an
acknowledgement letter. Each report is allocated a unique reference
identification. After the return of personal details, CHIRP is unable
subsequently to contact the reporter. The reporter may, if he/she wishes,
contact the CHIRP office for additional information by using the report
reference identification.
De-personalised data are recorded in a secure
database at Farnborough for analysis of key topics and trends. Dis-identified
data are made available to other safety systems and professional bodies.
4. CHIRP's Newsletter FEEDBACK
An essential element of any reporting scheme is
feedback to the reporter. In order to encourage confidence in the system, the
reporter must be sure that their concerns are taken seriously and given the
proper attention they deserve. This, in turn, helps to ensure that incidents
and safety related events are properly reported and that this information is
added to the fund of knowledge about human factors and their effects on
aviation safety.
In addition, it is also important that the
lessons are learned and widely disseminated. Indeed, without proper
dissemination, little improvement can be expected. To ensure that this occurs,
a newsletter, FEEDBACK, covering current topics from dis-identified reports and
including new report forms, is sent four times a year to all commercially
licensed pilots, air traffic controller officers and engineering personnel, a
circulation of around 30,000! Some reports are dis-identified further (e.g.
time and place, company, reporter's gender) before being published in FEEDBACK,
or making any data available to other agencies.
FEEDBACK maintains an awareness of Human Factors
issues among the flying, air traffic controller and aircraft maintenance
communities and provides a forum for discussion. A separate news-sheet,
entitled GA FEEDBACK and containing reports of particular interest to light
aircraft operations/leisure flying is distributed to the General Aviation
communities.
5. A Typical Report
Reporters may be deeply concerned about the
events in question and anxious that an appropriate resolution is found as soon
as possible. As an example, the following is a report that was published in a
recent issue of FEEDBACK along with the CAA's comments to the item as published
in FEEDBACK:
Fight Time Limitations
(FTL) Inadequacies:
|
"I have become increasingly concerned
about flight deck crews in this airline being abused and worked to a point
where I am convinced that a fatigue-related incident, with its potential for
loss of life, will occur. European Legislation including the Humanitarian Act
suggests that the CAA may be culpable by their inactivity by not enforcing
existing legislation (written to try to avoid fatigue in crews) or attending to
the 'old chestnuts' favoured by airlines that have been recognised as being not
in the spirit of the existing legislation and therefore in need of review.
Consecutive Earlies
By night-stopping a crew in Europe with
its 1hr time difference, a flight that appears to be an early (by my watch on
UK time and my body clock also on UK time) ceases to be so. The one night away
does not acclimatise me to European time and in fatigue terms offers no
protection or relief from cumulative fatigue. Lack of Rolling 7 Days
My body knows little of a Saturday. My
body however recognises day upon day of stress, minimum rest and maximum duty.
Insistence by the Company that a roster of six days, say 65 hours or so of duty
is legal because a Saturday falls within it when it would be illegal if
contained within the same roster week is pure abuse of the individual. FACT: 65
hours of duty without a break is dangerous. Off duty 30mins after
"Blocks"
Waiting on our aircraft for passenger
disembarkation and the eventual arrival of a crew bus often takes 25 minutes.
The exit through security and following bus ride can often then be a further 45
minutes. 40 of these minutes would be considered rest, sitting in a bus,
bumping our way to the hotel to often be processed to our rooms taking another
15 minutes. Queuing at reception and sitting on a bus is not rest, never has
been, never will be, off duty is when you get to your room, have control over
your movements and have the opportunity to shower, sleep, eat, etc. FTL
Not a Limit but a Target
FTLs used to be a limitation. Now they are
seen as a target, i.e. Pilot A works 20 one-hour sectors on a compact roster.
Duty - 40 hours out of a possible 55. Pilot B works 20 one-hour sectors on a
shambolic roster taking 54 out of 55 possible hours. Pilot A worked 40 hours of
a possible 55 - 15 "unused". Pilot B worked 54 out of a maximum 55 result 98%
efficiency only 1 hour unused! (Must be desirable - NON!)
Fact is that unless the above are
addressed the unthinkable is going to happen and THEN fatigue will be
addressed. Let's get the CAA to act PRIOR to loss of life, clear them from the
potential culpability due to inaction and make flying the safe occupation that
it should be." |
CAA (SRG) provided the
following comments in response to FEEDBACK:
|
CAA (SRG) is currently reviewing three of
these issues and will shortly be promulgating the results of the review for
consultation.
With regard the fourth, post-flight duties
and Rest Periods, the Rest Period is defined as the end of post-flight duties
to the report time for the next duty. That period must equal the length of the
immediate previous duty or 12 hours, whichever is the greater. From CAP 371
Page 14 Para. 18 it can be implied that the absolute minimum Rest Period (even
after a Commander's Reduction of Rest) must include 10 hours 'at the
accommodation'. If the reported problems of transport, queuing, etc result in
less than 10 hours in the accommodation then this should be brought to the
attention of both the Commander and the company.
Furthermore, Notice to AOC Holders 6/94
Para. 9 requires that the time nominated must be a reasonable assessment of the
actual time taken to complete that post-flight duty. When the "allowance" for
post FDP duties is regularly exceeded then the company must revise that post
FDP period stated to represent better the actual time taken. |
6. Who Can Report?
In addition to pilots, air traffic controllers,
licensed engineers and approved maintenance organisations, it is now possible
for all qualified Cabin Crew members employed by UK Approved operators to
report events that they feel have a bearing on safety. To facilitate this
extension of the CHIRP scheme, contact details and guidance information are
given below.
7. How Do I Report?
There are a variety of ways in which CHIRP
reports can be made. These are:
By FREEPOST:
CHIRP, FREEPOST (GI3439),
Building Y20E, Room G15, DERA Farnborough GU14 0BR.
Submitted using a CHIRP report form or by
letter, e-mail telephone or fax:
By Telephone: 0800 214645 Freefone (UK only) or
+44 (0) 1252 395013.
Both lines are confidential and are manned
between 0830-1630 Mon-Fri, an answer-phone is available out of office
hours.
By Fax: +44 (0) 1252 394290
By e-mail: Confidential@chirp.co.uk
Data security requirements do not permit
electronic reporting (i.e. online submission). Hence to ensure confidentiality
no provision is made for electronic reporting.
8. What Do I Report?
Safety-related incidents or events involving:
- Yourself,
- Other people
- Your organisation or organisations you deal
with
Incidents/events can include:
- Errors
- Individual performance
- Health & Safety matters affecting
Operating Procedures
- Regulatory aspects
- Unsafe practices
9. What Do I Not Report?
- Incidents or events with no safety content
- Issues involving conflicts of personalities
- Industrial relations and/or terms and
conditions of employment problems
10. When Do I Report?
- When you wish others to benefit from an
important "Lesson Learned"
- When other reporting procedures are not
appropriate or are not available
- When you are concerned to protect your
identity (Please note: CHIRP publishes reports anonymously, but does not accept
anonymous reports)
- When you have exhausted company/regulatory
reporting procedures without the issue having been addressed
11. How to Report/Comment
The completed CHIRP report form, which may be
obtained in a variety of ways (in FEEDBACK, direct from CHIRP or downloaded
from the CHIRP website at www.chirp.co.uk) with additional pages if required,
should be sent in a sealed envelope to CHIRP
12. Summary
CHIRP aims to improve our understanding about
human factors issues that affect the safety of commercial air transport
operations. CHIRP is a confidential reporting system that aims to encourage
reporting, yet without identifying the reporter. It does this, so that
incidents and events that would not ordinarily come to light are examined for
the lessons they can provide on improving flight safety. There is no doubt that
a truly confidential system such as CHIRP provides a worthwhile adjunct to the
mandatory reporting systems and has manifestly been successful in its
objectives.
The CHIRP website can be found here. |
