Airport Incident Reporting Practices (2019)

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1 This synthesis examines current practices for defining, collecting, aggregating, analyzing, protecting, and reporting airport organizational incident information. It serves as an infor- mative document for those airport operators seeking to understand the nature of airport incident reporting and its importance for organizational learning and effectiveness, risk management, operational safety, and worker safety. Additional objectives of the synthesis included the following: • Review the literature on incident reporting. • Survey and interview airport organizations and present case examples related to incident reporting. • Identify incident data that can be used as benchmark measures for assessing overall airport performance, risk, and safety analysis. • Identify leading/lagging indicators and metrics used by airports. These indicators can then help address the status of organizational communication, commitment, training, and procedures as they relate to an overall safety and performance culture. An incident reporting system can be utilized to flag or provide potential early warning of drifts in actions toward a stated goal or an adverse event or loss. The drift in actions or behaviors can provide either a positive, neutral, or negative indication of an airport’s strategic and managerial direction. The use of common indicators can provide early warn- ings of organizational or operational changes, or can help management discover weaknesses in an airport system. Indicators allow for evaluation and monitoring of a situation, and ultimately the correction and prevention of an incident, or the successful achievement of a goal. It is essential to study incidents to learn how a complex airport actually works. When discussing incident reporting, reference is made to safety, hazards, indicators, performance, enterprise risk management, culture, climate, and other related terms. However, there does not exist universal agreement as to what constitutes an incident. For this reason, the synthesis took a broad approach to incident reporting in organizations. It views incident reporting as a means to improve airport organizations through the analysis of data. With data, better-informed and higher quality decision-making can be exercised. The challenge for airport organizations is to identify what data to collect and to pay attention to, given the numerous types of incident data that could be analyzed. A second challenge is how to utilize the incident data in either a proactive or preventive manner. Case examples are presented to illustrate how incident reporting is being conducted at several airports. The accurate reporting of incidents can be influenced by a number of factors. Two such factors are an organization’s safety culture and the actions of supervisors who enforce reporting requirements. S U M M A R Y Airport Incident Reporting Practices

2 Airport Incident Reporting Practices This synthesis helps airport operators gain perspective on the use of incident reporting systems and terms, the importance of incident reporting in an enterprise risk management program, and how an airport’s safety culture can affect incident reporting. Information provided and resources identified in this synthesis can further assist airport operators to • Establish and document organizational and safety reporting practices. • Identify reporting mechanisms, indicators, metrics, dashboards, and benchmarks used in safety and risk management analyses and in organizational performance and evaluation. • Understand the role of incident reporting in enterprise risk management practices. • Strengthen workplace safety policies and practices. • Gain intelligence about daily operations through the use of leading and lagging indicators. Often, the depiction of an iceberg helps symbolize the nature of incident and accident potential. The visible above-water portion of an iceberg characterizes incidents, accidents, and risks that are known. The larger below-water portion of an iceberg characterizes incidents that are unknown or that go unreported. One role of airport management is to constantly determine the number, size, and movement of metaphorical icebergs that exist at their airport. Differences in the definitions and meanings of the term “incident” can make it difficult to compare data (and hence metaphorical icebergs) between airports if incidents are not standardized and measuring the same things. Airports seeking to make comparisons to other airport organizations will need to use caution and ensure that measures being compared are similar. This synthesis defines incident as something that is out of the ordinary. This definition allows for the capturing of data that can be positive, neutral, and/or negative; and can be centric to any topic of choice, that is, safety, business, risk, information, security, information technology (IT), and so on. The term “incident” then takes on a plain data connotation that, once analyzed, can be used as a window for viewing the operation of an airport, no matter the element being analyzed. Collecting incident data allows an organization to better understand what makes it successful, and not just something that leads to loss, damage, or injury. In both safety-centric and enterprise-centric incident reporting, the goal is to obtain knowledge, and in particular, collective knowledge about the organization and its environment. Incident reporting carries different connotations depending on the experience and per- spectives of the user. The definition of “incident” used for this synthesis has two primary meanings that can be categorized as safety-centric and enterprise-centric. The more common understanding of an incident is safety-centric. It refers to an event, activity, occurrence, opportunity, or similar happening that could or does affect the safety of personnel, equip- ment, or operations at an airport. Current practice at airports tends to capture primarily safety-centric data. The survey found that the other meaning of incident, enterprise-centric, is gaining momentum and importance. It is related to business and organizational risk and performance. It relates to an event, occurrence, activity, opportunity, or similar happening that can affect particular organizational goals or performance pathways. Incident reporting systems have basically two functions: 1. They identify factors and conditions that can influence organizational performance. 2. They can enable proactive and predictive safety strategies that allow for better management and achievement of safety, business, or strategic goals. This synthesis complements and substantiates the information contained in ACRP Synthesis 58: Safety Reporting Systems at Airports (Landry 2014). While ACRP Synthesis 58

Summary 3 focused on 14 CFR Part 139, Certification of Airports, this current synthesis encompasses the whole airport and involves a risk management approach. The focus is more on inci- dent collection and reporting related to near misses and observable events, rather than to accident reporting. It ties incident reporting to risk management, metrics, safety and performance indicators, and organizational performance. General characteristics and best practices of incident reporting systems culled from the literature search, survey, and interviews include the following key attributes: • The organization supports and encourages a culture of reporting hazards and incidents. • Reporting is made easy and received from a broad range of sources. • Avenues exist for employees, tenants, users, and the general public to participate in the reporting process. • The reporting system is non-punitive and protects the privacy of those who make reports. • A structured process is in place for reviewing and investigating incidents, identifying root causes and the weaknesses in the system, and developing action and implementation plans. • Feedback is provided to the person making the report, if the report is not anonymous. • Investigative results are used to improve safety systems, hazard control, risk reduction, and lessons learned through training and continuous improvement. • Information or summaries of investigations are disseminated to stakeholders in a timely manner, as part of the feedback and culture process. The chapters and appendices contain examples of safety and key performance indica- tors, leading and lagging indicators, and various forms and case examples of airports using incident reporting processes. A common conclusion found in the literature search is that a balance is needed between lagging and leading measures when selecting performance measures. Eleven airports participated in the study, primarily large and medium hub airports. Underrepresented in the survey are responses from small-hub, non-hub, and general avia- tion (GA) airports, as airport managers in those categories did not express a willingness to participate in the study. It is recognized that the subject matter, including discussion of enterprise risk management and having formal incident reporting systems in place, may have contributed to the poor response. It is possible that airports in the underrepresented categories do not have well-developed incident reporting systems, or do not have any systems in place at all. However, small airports can benefit from the information provided as they can model the activities of the larger airports. The following are key findings from the study: • Few airports have formal incident reporting systems that capture incident data other than those related to the need for regulatory compliance. • Incident reporting, data collection, and analysis processes are not fully developed at airports, especially voluntary reporting capabilities. • Airports with better-developed incident reporting practices tend to have a champion within the organization who supports and shepherds the processes. • The breadth and depth of an incident reporting system is determined by each airport, based on resources available and commitment of management to establish a culture of safety. • There is variation among airports as to which person or department has responsibility for incident data collection, reviewing, analyzing, and reporting.

4 Airport Incident Reporting Practices • Safety and key performance indicators, dashboards, and scorecards are used by only a few airports. • Safety and key performance indicators, leading indicators, and hazard identification are not well understood at a majority of airports, indicating a need for training and education in those areas. • It is difficult to benchmark or compare safety and key performance indicators among airports, as they reflect the individual goals of an airport, and those goals can vary widely given the type, size, and nature of an airport.