Airport Incident Reporting Practices (2019)

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52 The information contained in this chapter includes a more detailed investigation into practices of incident reporting at several of the airports that responded to the survey. The respondents vary in job positions due to the selection method made by the airport chief executive or manager, to whom the invitation to participate was sent. For this reason, the information conveyed reflects the department assigned the task. Of value are the appendices that illustrate what or how those airports incorporate incident reporting, indicators, metrics, and safety culture into their organizations. Large Hub: Hartsfield-Jackson Atlanta International Airport, GA Hartsfield-Jackson Atlanta International Airport (ATL) is operated by the city of Atlanta. The interview was conducted with the safety management system manager. ATL was one of the original 2007 SMS pilot study airports. Since then, it has progressively worked toward full implementation. The last component missing is the full integration and deployment of its incident management software program. As found at other airports where SMS has progressed, it has a champion spearheading the effort. Typical of other airports, incident data are collected and synthesized in several different areas. The airport is a department of the city. The city does have an ERM in place at the executive level, which includes the airport. The Human Resource Department of the city has responsibility for worker safety and workers compensation, for which it has purchased an industry standard software program. The city follows OSHA guidelines in collecting and reporting incident data. Airfield operation uses a separate customizable industry standard software program for inci- dent reporting on the airfield, terminal, and landside functions. The Airport Safety Operations Compliance System allows multiple persons to document at one time all airport inspections and incidents, manage the Part 139 compliance process, document calls for service, issue Notices to Airmen (NOTAMs), and store operational and activity data for the facilities. A third industry standard software program is used by the city’s maintenance depart- ments, including the airport, for work orders system, inventory management, and building maintenance. Due to years of use and its valuable historical data, the software program will be the basis for the integration of SMS data. ATL’s IT department, which owns the data, will further customize the integration. For a detailed description of ATL’s incident reporting and SMS integration, an article on the integration is available from the Journal of Airport Management (Ayers 2018). C H A P T E R 9 Case Examples

Case Examples 53 ATL has a confidential reporting system available to anyone on the airport and to the general public. It is available by using a dedicated telephone line or on the web. The web location is three clicks from the main page under passenger information and safety buttons (http://www.atl.com/ passenger-information/safety/#1458853848034-8688430e-51d5). Neither the city nor the airport has a specific definition for incident. The intent is to encompass all activity or events that may affect or pertain to operational safety. ATL meets annually with its insurance carrier to review risk exposures, claims, and accident investigations. A three-member panel of senior managers receives weekly incident data for review. A scorecard is maintained for a number of indicators. For ATL, the SPIs used are (1) SMS training; (2) confidential hazard reporting; (3) safety recognition; (4) notice of violation; (5) landside incidents; and (6) Hazmat spills. At the city level, which includes the airport, the SPIs used as leading indicators are (1) training; (2) safety promotion; (3) audit inspections; (4) safety briefs/talks; (5) safety communication; and (6) type of causality. The scorecard is updated monthly, quarterly, and annually. As part of its culture, ATL’s SMS slogan is “Safety Always!” It is expected that every employee is responsible for communicating any information that may affect airport operations and for using the confidential reporting program to ensure that potential safety issues are addressed and corrected. The expectation is conveyed through initial badge training for new employees and then continuously through employee and public events that celebrate safety. In particular, ATL holds a safety expo, gives employee recognition awards, and routinely sponsors and conducts various safety training sessions. Posters are distributed to all tenants and placed throughout the airport (see Appendix E). Employee recognition awards are issued monthly in four categories: General Safety—Airside; General Safety—Landside; Fire and Life Safety (Airside and Landside operations); and FOD Removal and Management. The awards are made to an employee or team who displays excep- tional safety awareness in the day-to-day work environment. The types of safety behaviors that merit award consideration are those that clearly state activities of identifying hazards and any actions taken to mitigate risks of injury or accidents, including, but not limited to, the following: • Acting prudently to report and/or prevent a safety hazard or incident. • Promoting a positive safety culture to increase employee awareness of hazards and workplace safety. • Adhering to good housekeeping standards to enhance fire safety by avoiding blocked or obstructed aisles, exits, or fire extinguishers. • Preventing or removing hazards such as FOD in or around the Aircraft Operation Area. Large Hub: Dallas-Fort Worth International Airport, TX Information on the incident reporting system and ERM was obtained from the risk man- agement department at Dallas-Fort Worth International Airport (DFW). DFW is in the mid- dle stages of ERM development. Its efforts toward becoming proficient at incident reporting are in part because it is self-insured. Incident reporting will help promote and provide a better picture of the organizational risks that need to be addressed in reducing insurance costs. The implementation of the incident reporting system is viewed as less about risk itself than about discovering what is happening around the airport so the risk and insurance costs can be better managed. DFW had participated in the initial 2007 FAA pilot study related to SMS. It has progressed since then to a point where, if the final rule on SMS becomes regulatory in the future, it would

54 Airport Incident Reporting Practices be ready. Most of the processes are in place. The one last major component, a computerized incident reporting system, is to be implemented in the near future. The risk management depart- ment has created an internal web portal to accept incident data to replace the current system of individual departmental collections. The interface system is a commercial program that allows for DFW to customize it as necessary to meet its needs. As part of its customization, DFW has developed the following as part of its drop-down menus for selecting incidents: Airfield Safety Event; Injury; Maintenance Request/Concern; Property or Vehicle Damage; Lost Property; and Other. The data are retained on DFW’s own password-protected servers. The incident reporting practices are supported by written policies from the governing board (see Appendix F). Data collected by the system will provide information required under airport certification, environmental protection, transportation security, and workers’ compensation regulations. Voluntary data collection will include hazard and near-miss reporting, and any data that have the potential for incurring insurable losses. Figure 12 describes sources of information intended to feed into the incident reporting program. Figure 12. Sources of input to incident reporting process at DFW Airport. Source: Courtesy of DFW Airport. Used with permission.

Case Examples 55 DFW adopts OSHA reporting requirements in its stewardship of the airport. It has over 1,800 employees, with more than 60,000 tenant employees subject to federal or state OSHA requirements. DFW does provide OSHA training for its employees and contractors. The approach of the risk management department at DFW in implementing the incident reporting system is that of a consultant to the other departments. The risk management department will be the coordinator of data through the web portal and help those depart- ments evolve their own reporting items. Risk management then generates KPI data that are used exclusively at the executive level, while offering to help the department meet the KPIs. Data entered into the reporting system results in the generation of an e-mail to risk management. Effort is being made to change the culture of the organization to not only become safer, but to help individual departments in their efforts to achieve overall goals of the organization, thereby enhancing safety, efficiency, and effectiveness of operation. For instance, aircraft rescue tracks response times, and human resources tracks lost time, off workdays, attendance, and work time. A dashboard on incident data is provided to a cross-functional risk council that reviews incident data. The most incidents occur in the vehicle maintenance area. Incident reporting is mandatory through the work order system. The work order system is tied to the incident reporting system for improved incident reporting, even down to the level of recording scratches incurred to vehicles. A facility scorecard is maintained for the facility. The airport’s airfield operations department uses a separate commercial incident reporting system for compliance with 14 CFR Part 139. The intent is to later integrate the airfield reporting into the new portal. DFW currently has a Ramp Operation Safety Team, a Runway Safety Action Team, and a Vehicle Operations Safety Team that review incident data from their respective areas. Incident data from the airlines, air cargo, and other tenants on the airport are not shared directly with the airport. However, DFW strongly believes in partnering with its business tenants. Through collaborative engagement with its tenants, means are found to mutually advance safety and performance through the establishment of meetings, discussion, and confidential disclosures. DFW does not ask tenants to provide internal documents on incidents, as tenants are not inclined to provide them and it could affect the collaborative environment. Large Hub: Houston Airport System, TX The Houston Airport System, which is part of a municipal government, operates three airports. Information for the synthesis was obtained from the Safety & Emergency Division at George Bush Intercontinental Airport (IAH). The Safety & Emergency Division houses the SMS and wildlife hazard reporting system. On its dashboard, the Houston Airport System maintains the following: • Passenger injuries by airport. • Occupational incident costs. • Fleet incidents. • Wildlife strikes per operation. • Preventable versus unpreventable accidents. • Severity of incidents. • Year-to-date safety (total cases and 5-year incident rate for each airport plus administration). • Industry benchmarks (air transportation services, janitorial services, office administration).

56 Airport Incident Reporting Practices The Houston Airport System has an ERM that is part of a larger City of Houston ERM, which is centered in the Office of the City Controller. KPIs are city-wide rather than airport specific, though the data can be broken down to individual departments, if desired. Key business risk areas determined for the airport are categorized as compliance, facility management, infor- mation technology, security, communication, financial management, inventory management, procurement, project management, and revenue management. Within those areas, airport management is keen to collect data to indicate their performance. Recently installed touchpad screens outside the terminal restrooms provide an example of newer incident reporting technology and capabilities. The pad allows travelers to send imme- diate feedback on bathroom conditions. The system, installed outside of restroom entrances, prompts travelers to rate their experiences with a happy or sad face. Drop-down menus allow for selection of a variety of conditions for quick notification to terminal maintenance. The Houston Airport System provides a number of different reporting forms as part of its SMS. Appendix G is a sample safety policy requiring incident reporting. Appendix H is a sample employee incident report form. Appendix I is an example of an incident reporting data entry screen on the internal IAH computer reporting system. Large Hub: Port of Portland, OR The Port of Portland has oversight of the Portland International Airport (PDX), two GA air- ports, a marine navigation and cargo system, and various transportation-related property. The safety management functions of the Port extend across all its areas of responsibility. Interviewed for the report were members of the risk management department, which manages general lia- bility, claims, and worker safety. It uses a commercial risk management information system to track necessary data. The safety department manages the SMS and safety risk management (SRM) processes, which are in their infancy. An example of the silo effect is evident at PDX, as the airport has two separate call centers. The tracking of incident data occurs separately within seven different departments: (1) Environ- mental, (2) Police, (3) Fire, (4) Communications Center, (5) Airfield Operations, (6) Property Management, and (7) Wildlife Management. The challenge for risk management is to integrate all seven. There currently is not an ERM in place. PDX does have a definition for the term “incident”—an event with an adverse effect on an asset of the organization. However, the definition is currently under review, as the use of the words “adverse effect” is thought to convey a negative impact on the organization. As the risk department is seeking to collect both positive and negative data, it intends to revise the definition to include all aspects and impacts. There is an assigned individual in the safety department who culls incident reporting data from the communications center. Similar to Seattle, that person reviews the incident data, categorizes the data, disseminates the data to responsible parties, follows through on resolutions, and compiles various reports. The Port of Portland does conduct an organizational safety culture survey. The public effort to promote safety and incident reporting stems from the organizational motto of “see something, say something.” The Port uses a number of means to promote hazard and incident reporting, such as a bumper sticker placed on airport vehicles, posters, and a wallet-sized reminder card as part of an employee’s call list.

Case Examples 57 Large Hub: Seattle-Tacoma International Airport, WA The Port of Seattle operates both a seaport and the airport. The Seattle-Tacoma International Airport (SEA) has an incident reporting system that has been in place for approximately five years. An original 2007 SMS pilot study airport, the organization recently formed the Aviation Safety Management Division, reporting to the director of aviation operations. As noted with other airports, a champion leads the internal SMS effort and is making strides to advance the hazard awareness and incident reporting culture. An established Communications Center, typical of most major airports, receives incident data of all types. Similar to the Port of Portland, there is one safety management specialist who is assigned the responsibility to review all the incidents, categorize and disseminate the information to responsible parties, reach out and engage tenants, and follow up on the resolu- tion. The process is referred to as “incident forensics and triage,” and follows the philosophy of necessary collaboration. Collaboration is necessary because the airport is at risk for tenant non-movement area vehicle activity and environmental spill activity related to fueling. The Port has customer satisfaction and safety as two of its high-performance strategies to meet overall goals. Similar to ATL, SEA uses a commercial management software program for risk tracking and assessment; another industry standard software program for its maintenance and inventory needs; and a third internally developed Airfield Incident Reporting System (AIRS) for its operations. The AIRS started as an Excel spreadsheet and evolved into an IT database system. The near-miss reporting program is part of the risk management program, but discussion is continuing on where best to house the hazard and incident reporting system. The airport seeks to improve its incident reporting capabilities through collaborative training and relationship efforts with its tenants. It subscribes to a commercial program that provides training and resources to improve an organization’s overall safety culture. SEA has developed a scorecard and publishes a composite safety score that includes (1) runway incursions (separate for vehicle and pedestrian/operational); (2) surface incidents; (3) ground incidents; (4) wildlife strikes; and (5) Part 139 discrepancies. The composite score consists of a 30%, 30%, 20%, 15%, and 5% ratio, respectively. For incidents, SEA uses an Ishikawa fishbone analysis. It has found that, as the hazard and incident reporting culture progresses, the number of hazards and incidents is going up. This is to be expected as people become more comfortable and confident with a just culture in existence. The airport also has an extensive closed-circuit television (CCTV) system for capturing incident data, though it is used primarily after-the-fact in the review and investigation process. Medium Hub: Columbus Regional Airport Authority, OH The Columbus Regional Airport Authority (CRAA) operates and manages the John Glenn Columbus International, the Rickenbacker International, and Bolten Field airports. Informa- tion on the survey was obtained from the Airport Operations Department. The interview was conducted with the chief operating officer. Approximately 10 years ago, the airport authority recognized the need for an ERM, based on suggestions from its insurance carrier. The ERM was initially developed within the insur- ance division, which is under the legal department. Most recently, in 2017, the authority hired a new director of administration in the Finance Department who had experience in the risk

58 Airport Incident Reporting Practices management private sector. The ERM is now being further developed under the Risk Manage- ment Office and the responsibility of the chief financial officer. While not part of the SMS pilot studies, the CRAA has pursued SMS implementation in conjunction with the ERM. The CRAA is intending to have an integrated SMS for all the Port enterprises. Currently, incident reports are entered into several separate electronic and manual databases. These include a commercial electronic logging system for airfield conditions and incidents, and an online safety hazard reporting system developed in conjunction with SMS implementation. Incident reports are reviewed by one individual, who forwards any action- able item to the department responsible for resolution. The gatekeeper monitors and closes out reports as necessary and compiles the weekly and monthly summary reports. Mandatory reporting is required for OSHA, 14 CFR Part 139, police and security response, medical and emergency response, and airfield maintenance. Incident reporting systems are currently housed in various departments with their own systems. The units gathering data are asset management, public safety, human resources, and airport operations. The goal of CRAA is to develop a central clearing house for incident data. The gatekeeper will be the manager of workplace safety, who reports to the senior manager of the Emergency Preparedness and Worker Safety Department. Voluntary incident reports are provided through a workplace suggestion box, e-mail, website (online safety hazard reporting), written correspondence, telephone, and social media methods. The maintenance-reporting component of the airfield commercial logging system ties the data to CRAA’s enterprise work order system. The maintenance department’s manual incident reporting system requires reports of near misses, as well as injuries and damages. A strong safety culture has employees reporting damage as minor as scrapes and dents incurred to vehicles and equipment. For OSHA reporting, CRAA is required to file the Ohio 300P form, which is equivalent to the OSHA 300 form. The reporting is made to the Public Employer Risk Reduction Program administered by the Bureau of Workers Compensation. A dashboard exists for the OSHA data only, which are developed by the manager of workplace safety and forwarded to senior leader- ship. A management-labor safety committee also exists to review incident data. A culture of safety is evidenced by the existence of a balanced scorecard developed and emphasized by senior leadership, the work of the safety committee and associated metrics (see Appendix J), regular weekly group meetings that review and reinforce incident reports, and toolbox talks. Small Hub: Sarasota-Bradenton Airport Authority, FL The Sarasota Manatee Airport Authority operates and manages the Sarasota-Bradenton International Airport (SRQ). The interview was conducted with the operations department manager. An ERM is in progress at SRQ. It is managed through the Human Resources Department, as part of loss prevention and control. There currently is no enterprise-wide incident reporting system other than the normal requirements of 14 CFR Part 139, police, and emergency response. However, the culture at SRQ is to provide means for reporting incidents through the use of a white courtesy phone, volunteer ambassadors, a web portal, police presence, and tenant employees trained to direct inquiries to the proper personnel. An example of its public access to reporting incidents was shown in Figure 7 in Chapter 5. The courtesy telephone rings into the air communications (AIRCOM) center. The AIRCOM center uses commercial SMS reporting software that allows for customization of its output. SRQ has adapted the form to include laser incident and drone incident reporting.

Case Examples 59 Also on the home page is the general AIRCOM daily log, an operations daily log, wildlife depredation and observation log, aircraft incident/accident report, medical incident report, supplemental incident/violation report, and several 14 CFR Part 139 reports. From the forms, a dashboard is generated that includes the following: • Active NOTAMs. • Operations daily log – number of entries/activities. • Open work orders. • Wildlife reports and depredation log. • Form access for medical, aircraft, violation, drone, and laser incidents. • Weather.