Explanatory Memorandum to COM(2000)847 - Occurrence reporting in civil aviation - Main contents
Please note
This page contains a limited version of this dossier in the EU Monitor.
| dossier | COM(2000)847 - Occurrence reporting in civil aviation. |
|---|---|
| source | COM(2000)847  |
| date | 19-12-2000 |
Contents
- 1. Previous Community initiatives
- 2. Mandatory incident reporting
- 2.1. Current situation
- 2.2. Feasibility of a Community mandatory incident reporting system
- 2.3. Creating the necessary framework
- 3. Confidential incident reporting
- 3.1. Current situation
- 3.2. Feasibility of a Community confidential incident reporting system
- 3.3. Creating the necessary framework
- 4. Conclusion
- SUBSIDIARITY / PROPORTIONALITY
- a) What are the objectives of the proposal in relation to the obligations of the Community and what is the Community dimension of the problem-
- b) Does competence for the planned activities lie solely with the Community or is it shared with the Member States-
- d) What kind of action is at the disposal of the Community-
- e) Is uniform regulation necessary or is it sufficient to draft a Directive, which outlines the general objectives while leaving execution to the Member States-
- COMMENTS ON THE VARIOUS ARTICLES
- Article 2
- Article 3
- Article 4
- Article 6
- Article 7
- Article 8
- Article 9
- Article 10
- Article 11 to 13
Even before Community competence in the field of transport safety was confirmed by the amendment of Article 75 of the Treaty i, the Commission undertook constantly to share in the efforts to improve air transport safety : the first piece of Community legislation specific to air transport was a Directive of 1980 on accident investigation i. It then adopted its 'Communication on Community initiatives concerning civil aviation incidents and accidents' i. Which suggested a policy to prevent accidents by launching initiatives in three areas: accident investigation, mandatory occurrence reports and confidential reporting systems.
The adoption of a Directive on accident and incident investigation in November 1994 i was the first definitive achievement of this policy. That Directive aims at improving air safety by ensuring that any accident or serious incident is properly investigated with the sole objective of preventing its recurrence. However the limitations of this approach are mainly that, as the number of accidents is fortunately very low, the opportunities to learn from them are limited and that lessons are drawn only after a tragedy has already happened.
It is now proposed to complement this first initiative with a more proactive one that will address both mandatory and confidential reporting of incidents, defects or malfunctions which may constitute a hazard for civil aviation operations, called under the generic term of 'occurrences'. Since accidents are usually preceded by a number of these 'precursors', a better knowledge of occurrences may help to eliminate some of the causal factors leading to an accident and therefore prevent its happening.
Chapter 7 of Annex 13 to the Convention on International Civil Aviation recommends that 'States should establish formal incident reporting systems to facilitate collection of information on actual or potential safety deficiencies' (7.3).
In view of this recommendation, the Commission has investigated the status of implementation of ICAO SARPs i on mandatory occurrence reporting systems. In a study carried out on behalf of the Commission, IFALPA i found that only few Member States collect mandatory occurrence reports and even fewer stored, retrieved or analysed the related data.
Taken at the level of individual States, the number of significant occurrences may not be large enough to give an early indication of a potential serious hazard or to identify trends. The efficiency of a reporting system and the quality of the safety information that could be derived from it would therefore be improved if each Member State had access to a wider information base thanks to an exchange of information on occurrences. This is also confirmed by another recommendation from the same ICAO i document: 'When practicable, States should establish systems, including data bases,.... The data base systems should use standardised formats to facilitate data exchange' (7.4).
Such is however not the case currently; existing data bases being not able to interconnect.
The Joint Research Centre of the Commission (JRC) was tasked to develop a tool enabling Member States to collect occurrence reports and exchange data without the need to change their current system, and furthermore to put at the disposal of Member States which do not have a data base or collect occurrence reports, the means for such collection and exchange.
This led the JRC to start a pilot project called ECCAIRS (European Co-ordination Centre for Aviation Incident Reporting Systems) under the supervision of an external Steering Committee consisting of representatives of Denmark, France, Germany, Italy, Portugal, Sweden, United Kingdom, ICAO and the Commission.
At the end of the implementation phase the Steering Committee concluded 'that the feasibility had been demonstrated.... Should a political decision to implement a co-ordinated system be taken, ...ECCAIRS could be the foundation for such a system. ...ECCAIRS would be an essential building block in establishing such (advanced analysis) techniques as it has the capability to bring together vast amounts of data from several sources'.
A presentation seminar of ECCAIRS was organised by the Commission in March 1998 and strong support was expressed by the majority of the participants representing all the air transport sector (Civil Aviation Authorities, Accident Investigation Bodies, Air Traffic Management, manufacturers, airlines, staff representatives, research institutes, safety specialists, etc). As a European system, it would greatly enhance the effectiveness of national systems by allowing the establishment of a network that would permit easy access to data covering a much larger region. Also, the future european aviation safety organisation will need this kind of data to do its work properly.
In addition, the ECCAIRS system is fully compatible with ICAO's ADREP (Accident/incident Reporting) system and would enable Member States to report automatically, thus improving the presently far from satisfactory fulfilment of their reporting obligation under the Chicago Convention. It should also be noted that a number of third countries have expressed their interest in the ECCAIRS system and that the Community could be in a position to lead the way to the standardisation of accident and incident reporting for the benefit of air safety in other areas of the world.
In the meantime, efforts to arrive at the harmonisation of technical reporting requirements in Europe have also taken place in JAA and EUROCONTROL. The Commission participated in the working groups dedicated to these initiatives and the results of their work has been integrated in the annexes to this directive which list reportable events. In this way, consistency in all the reporting requirements is ensured.
The Commission is now convinced that the establishment at Community level of a mandatory occurrence reporting system is feasible and has developed a tool, which can work as a centralised system for those Member States which do not want to develop their own data base, or a decentralised one to facilitate the exchange and integration of information with those who have one.
As a consequence the Commission considers that it is fully consistent with the provisions of Article 80 i that the Community takes initiative leading to the establishment of a Community mandatory reporting scheme to collect, record, exchange and disseminate information on hazardous or potentially hazardous occurrences.
In this way, the Civil Aviation Authorities and persons or organisations having an influence on air safety may learn from them and an assessment of the safety implications of each occurrence, both in itself and in relation to similar occurrences happening all over the Community, can be made so that necessary action is taken in due time. In addition, selected information shall also be put at the disposal of other relevant players in the field of air safety on a case by case when they can benefit from it for the improvement of air safety.
In order to do that however all Member States must trust each other on the status of the information, which will be exchanged. Failing that, it must be recognized indeed that countries which consider that such information is confidential, will not communicate it to other countries where it would be put in the public. There is a need therefore to agree on a common regime for the dissemination of the information. Because of the sensitivity of such information and the risk that raw data may create in the public wrong assumptions on the safety of aviation, it is considered wise to keep all detailed information confidential and to limit its access to official bodies. Since however data must be made available to professionals which can use it to improve aviation safety (operators, manufacturers, designers, training organisations, research establishments,...) it is necessary to empower the Commission to develop a policy and to make decisions on selective dissemination to such interested parties, so as they can get the necessary information to fulfil their tasks and contribute to improving their own and the global level of aviation safety. Moreover, as it is legitimate that the public at large knows what is the general level of safety of aviation in the Community, aggregated statistics will be published regularly.
Finally, witnesses of occurrences may not be encouraged to report them if they run the risk to be punished for possible involvement in such events. This would dry out the source of information, which is so necessary to further improve aviation safety. It is necessary therefore to agree on protecting the source of information.
It should be stressed however that such mandatory reporting is distinct from the internal reporting established by manufacturers, airlines or maintenance organisations, as part of their safety audit systems, to fulfil their safety responsibilities. It is not intended therefore to replace the ones by the others. On the contrary, these internal procedures should be used to channel reportable occurrences i and filter the large number of non-reportable occurrences, which could otherwise swamp the mandatory reporting systems.
Experience has shown that mandatory reporting is relatively successful at collecting information on technical defects and other incidents, which do not involve the responsibility of reporters. On the opposite, human errors, even if they are induced for example by wrong cockpit design or complicated procedures, are seldom reported and there is little chance they will surface spontaneously. Knowing that human factors are involved to a certain extent in about eighty percent of the accidents, reporting system providing for the confidentiality of reporters are essential tools for accident prevention.
In September 1999, ICAO held an Accident Investigation and Prevention (AIG) Divisional Meeting in Montreal where aviation safety experts from 83 contracting states and 11 observer organisations reviewed the ICAO Standards and Recommended Practices, in particular those of Annex 13. They concluded inter alia that :
"A State should establish a voluntary i incident reporting system to facilitate the collection of information that may not be captured by a mandatory incident reporting system.
A voluntary incident reporting system shall be non-punitive and afford protection to the sources of information.
Note 1.- A non-punitive environment is fundamental to voluntary reporting.
Note 2.- States are encouraged to facilitate and promote the voluntary reporting of events that could affect aviation safety by adjusting their applicable laws, regulations and policies, as necessary.
Unfortunately, very few Member States have taken the necessary steps to allow the establishment of such confidential reporting schemes.
The Commission considers necessary that the Community provides the necessary framework to enable the setting up of a confidential incidents reporting programme which will encourage submission of voluntary reports of observed deficiencies in the aviation system perceived as an actual or potential hazard, and feed the aviation system with a view to contribute to the improvement of its safety level.
As already identified in the above mentioned study carried out by IFALPA, the single main element to obtain the trust and confidence of reporters in the confidentiality of the reporting system is to disidentify as early as filed the datas they give so that nobody down in the chains of dissemination and analysis can anymore identify them.
In order to evaluate the feasibility of the concept, the Commission supported financially the establishment of a confidential reporting system in Germany. This system, called EUCARE, ran as a research prototype from 1993 to 1999. Its operation was monitored by a Steering Committee composed of safety experts of Member States and chaired by the Commission. On the basis of this experience, the Steering Committee produced a Requirement Document, which describes in detail how a confidential reporting system should be organised in order to gain the confidence of all parties. The involvement of the Commission in this experience enabled it also to participate in the meetings of the International Council of Aviation Safety Systems, which is the world-wide association of confidential reporting systems, to benefit from experiences in other parts of the world.
Another study was also conducted i to evaluate the legal feasibility of confidential reporting in countries where legal provisions derive from the 'Napoleonic Code', in particular France and Spain. That study concluded that"...no truly relevant legal obstacle stands in the way of the establishment of voluntary air incident reports. ...The Community could ...establish the general legal framework for a standard voluntary aircraft incident reporting system ...From a strictly legal point of view it does not appear impossible to consider a system with operational principles that need not necessarily comply with the legal practices of each Member State and which therefore require special derogations from the criminal law".
The organisation at Community level of confidential incident reporting is therefore feasible and enough knowledge and experience has been gained by Member States and the Commission to facilitate a mostly human factor oriented network of confidential reporting systems.
Since human factors are closely linked with culture, communication and local habits, Member States seem well placed to organise confidential reporting at national level. However, confidentiality may be very difficult to guarantee in the small circle of aviation at that level. As a consequence, trust and confidence of the would-be reporters could perhaps be better served by regional or sub-regional bodies.
Trust and confidence furthermore seem to be easier to gain if bodies managing the reports are not themselves official or administrative organisations and if interested parties can participate in their oversight so that confidentiality is guaranteed. This indicates that the best organisational status for bodies in charge with confidential reporting is likely to be that of foundations involving all interested parties and sponsored by governmental bodies and the industry. There are already some organisations created by national authorities and the industry operating with success.
Therefore, the Commission considers that the best option is for the Community to act as a facilitator, so that interested parties can establish the necessary structures, or existing bodies can expand their activities in the Community.
To do so, it is necessary to overcome the legal difficulties revealed by the feasibility studies. It is indeed essential that report can be disidentified throughout the Community, without reporters or persons in charge of disidentification can be accused of falsification, nor of destruction of evidence in case an accident would be later the subject of judicial enquiries. The Commission therefore proposes that the Member States adjust their laws, regulations and administrative practices so as to allow the disidentification of reports of occurrences, which are not subject to mandatory reporting.
If necessary the Commission could also examine how the Community budget allocated to improving air safety could be used to support existing or new foundations when they meet the necessary conditions, as identified by the EUCARE study, to win the trust and confidence of all interested parties.
The improvement of air safety justifies that more efforts are made to prevent accidents. This could be done through a better knowledge and analysis of large samples of data about incidents and many other mishaps which, without presenting by themselves any character of seriousness, may reveal weaknesses or malfunctionings which, if not corrected and happening in conjunction, could lead to an accident.
To obtain such large samples of data it is necessary to put in place a framework providing for the report of as many incidents as possible, the sharing of information and its dissemination towards those which can analyse it and draw the appropriate conclusions. Such a framework entails the establishment of mandatory and confidential reporting schemes, as well as the sharing of information on the basis of commonly agreed rules of confidentiality and dissemination.
Such are the objectives of the attached proposal.
The Commission has also considered the compatibility of the proposal with the principle of subsidiarity by addressing the following questions.
a) What are the objectives of the proposal in relation to the obligations of the Community and what is the Community dimension of the problem-
The main objective of the proposal is to increase air transport safety on the basis of article 80 i which requires the Community to take initiative in this field which is already covered by extensive Community legislation.
b) Does competence for the planned activities lie solely with the Community or is it shared with the Member States-
The envisaged action does not relate to an exclusive competence of the Community.
c) Which solution is most efficient in comparison between Community measures and measures of the Member States, what added value does the proposed Community action provide and what are the costs of no action-
Reporting systems operated by Member States in isolation are less efficient than a co-ordinated network with exchange of information enabling an earlier identification of possible safety problems. Experience has shown that incident occurring in one Member State were not known in other Member States and that similar circumstances led to a fatal accident.
Moreover, without establishing common legal bases for protecting the confidential reporting of incidents, such an essential tool for the improvement of aviation safety has no chance to prosper as necessary by lack of legal certainty across borders that reporters and persons working in the disidentification of reports may not be sued in one Member State for his involvement in confidential reporting in another Member State.
In order to provide for the establishment of reporting schemes in all the Member States the Community could provide incentives in the form of financial support, and establishment of a central data bank, but this would not suffice because Member States do not have the same policies on disidentification or the disclosure to the public of safety information. To solve these problems there is no other choice for the Community than adopting a legislation which specify a common regime in these fields.
e) Is uniform regulation necessary or is it sufficient to draft a Directive, which outlines the general objectives while leaving execution to the Member States-
In such a domain, uniformity is not necessary and it is considered sufficient to use a framework Directive, setting goals that the Member States will apply with a degree of freedom.
Accordingly, the Commission reached the conclusion that its proposal is consistent with the principles of subsidiarity and proportionality.
Article 1
This Article states the objective of the Directive.
This Article sets the scope of the directive. It extends the reporting requirement outside the Community because the State of registration or of operation of an aircraft needs to be aware of all occurences involving their aircraft, independently of the place where it happened.
This Article lays down the necessary definitions.
This Article lists the persons involved in the public transport operations, which should be required to report occurrences. It also leaves the door open to reports coming from other areas of civil aviation and leaves the possibility to add new categories of reporters and of occurrences
Article 5
This Article requires that occurrence reports are collected, evaluated, processed and stored in a database. For this purpose, Member States must entrust a competent authority, which could be the civil aviation authority or the accident investigation body.
This Article requires Member States to participate in an exchange of information. In order to facilitate it, the Commission put at the disposal of Member States a software that will enable them to fulfil this requirement. States, which already use another software, should seek to be compatible with the Commission software although it should be noted that compatibility was built from the start between this software and the ones presently in use in Member States.
This Article ensures that information gathered from the reports should be made available for improving safety. The information collected and exchanged will be available to each national civil aviation authority which will use it for its day to day work as safety regulator and to the entities investigating civil aviation accidents and incidents. The different categories of reporters may have access to the relevant level of information in order for them to realise the usefulness of their participation and to learn from experience of their peers. Other parties involved in the improvement of aviation safety such as research centres, training organisations or universities may also receive selected information for their own use. Release of this information will be made on a case by case and 'need to know' basis. The legitimate interest of the public to be informed of the safety level of aviation will also be taken into account by the publication of specific regular review and, if deemed necessary, extract from actual, disidentified reports.
This Article establishes the status of the information exchanged under this directive and aims at protecting the reporters and the information they supply in order to guarantee free and confident reporting for the benefit of safety. This Article also aims at creating a blame-free safety environment substituting preventive corrective action to punitive reaction.
This Article requires the Member States to adapt their legislation in order to enable the setting up of confidential reporting systems.
This Article establishes a Committee to assist the Commission in the implementation of the provisions of this directive.
Procedural Articles.