National Academies Press: OpenBook

Airport Incident Reporting Practices (2019)

Chapter: Chapter 1 - Introduction

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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Suggested Citation:"Chapter 1 - Introduction." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Incident Reporting Practices. Washington, DC: The National Academies Press. doi: 10.17226/25465.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

5 Objective This synthesis examines current practices for defining, collecting, aggregating, analyzing, protecting, and reporting airport organizational incident information. However, there is not universal agreement as to what constitutes an incident. The traditional purpose for collecting incident data is so an airport operator can monitor existing operations, identify current hazards and risks, forecast future possibilities, identify and understand safety trends, improve operational and functional tasks, and monitor progress toward various goals of the airport. Another purpose though is to gain knowledge and understanding of how the organization functions. When discussing incident reporting, one’s frame of reference may include concepts of safety, hazards, risk indicators, performance indicators, enterprise risk management, culture, climate, and other related terms. While incident reporting is often viewed as having negative safety connotations, more recent viewpoints consider incidents as having positive connotations. For this reason, a broad approach to incident reporting in organizations is assumed in this synthesis. Collecting incident data allows an organization to better understand what makes it successful, in addition to identifying events that can lead to damage, loss, or injury. This synthesis is intended to serve as an informative document for those airport operators seeking information about establishing processes that address concerns of operational safety, worker safety, risk management, and organizational effectiveness. It helps identify different types of incidents that can occur on airports, how the incidents are reported, how the data are tracked, and how the data are used. The full airport environment is considered in this synthesis, to include incident collection from the airfield, terminal, landside, and tenant operations. The chapters and appendices further contain examples of safety and key performance indica- tors, leading and lagging indicators, case examples of airports using incident reporting processes, and sample forms used by airports. Confusion may exist as to whether this report, in using the term “incident reporting,” might not also be describing a safety reporting, hazard reporting, or threat and error management (TEM) system. There is commonality among the uses. This report assumes a broad interpretation to the term “incident reporting” to include safety reporting, hazard reporting, and TEM. It also includes incidents related to the achievement of organizational goals and to events exceeding acceptable organizational risk tolerances. It further views incidents as having positive, neutral, and/or negative aspects. The following additional objectives were sought: • Review and synthesize the literature on incident reporting. • Survey and interview airport organizations and present case examples of incident reporting. C H A P T E R 1 Introduction

6 Airport Incident Reporting Practices • 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 would then help address the status of organizational communication, commitment, training, and procedures as they relate to an overall safety and performance culture. • Help identify what information can be used to more completely understand normal operations. An earlier ACRP synthesis investigated safety reporting methods and systems for airports certificated under Title 14 Code of Federal Regulations (CFR) Part 139 (14 CFR Part 139) by assessing practices, processes, and systems used to collect and analyze safety data and infor- mation. Specifically, ACRP Synthesis 58: Safety Reporting Systems at Airports (Landry 2014) considered two aspects of safety data reporting by Part 139 airport operators: mandatory (required as part of regulatory compliance or management oversight) and voluntary, such as safety committees, safety groups, or as part of a safety management system (SMS) proposed for Part 139 airports. ACRP Synthesis 58 included research on large, medium, small, non-hub, GA, and joint civilian/military use airports at various locations throughout the United States. As it applies to the different-sized airports, the study breaks out the results for all airport operators interested in collecting, analyzing, and reporting safety data. This current synthesis complements and substantiates the information contained in ACRP Synthesis 58. Readers of this synthesis are encouraged to review ACRP Synthesis 58 for more detailed information about types of mandatory and voluntary reporting that occurs on airports, methods used to collect and analyze information, software systems available, data use and sharing with external entities, and legal concerns about data sharing. This current synthesis differs from ACRP Synthesis 58 in its target of investigation and in its explanation of incident reporting. This synthesis’s focus is more on incident reporting as it relates to near misses and observable events, rather than to accident reporting. It ties incident reporting to risk management, indicators, and to organizational performance. Lastly, it looks at incident reporting as it affects, or could affect, the whole airport and not just the airfield. Incident Reporting Overview Ask any airport executives or employees at an airport what their top goal is and the more likely response is “Safety!” The goal of safety is routinely emphasized in the aviation and airport industry and stems from the regulatory bodies and from public expectations. The mission of the FAA is to provide the safest, most efficient aerospace system in the world. For this reason, incident reporting tends to take on a safety-centric approach. It is an important element of achieving a safe operation. But recent emphasis on incident reporting from the risk manage- ment perspective emphasizes a more enterprise-centric approach to use of the term, as applied to all areas of the organization, not just safety. Both approaches are presented throughout this synthesis. Safety-Centric Data Whereas a universal goal of airports across the continent is safety in their operations and activities, it is common for an airport organization to collect information that helps identify how safe its airport may or may not be. The information collected will vary among airports. The ability to reduce the impact of health, safety, and environmental issues within an airport

Introduction 7 organization can rest on how well an airport can track, manage, understand, and use information provided by an incident reporting system. Steps taken by organizations to ensure safety often begin with the desire to prevent accidents and incidents from occurring. An airport organization will put into place any number of differ- ent processes and systems to prevent accidents and injuries. A primary question to ask is, How can weaknesses in the processes and systems be proactively addressed (rather than reactively) to maintain a safe environment or to achieve specific performance goals? When developing measures that might be used in an incident reporting system, another question to ask is, “What is required from the airport organization in order to be aware of its safety level and enhance its safety performance?” (Reiman and Pietikäinen 2010, p. 32). Enterprise-Centric Data Organizations routinely seek to collect information that provides an indication of whether specific goals or program objectives are on target within the organization. Beyond safety goals, airport organizations develop strategic, business, financial, operational, marketing, environmental, and numerous other goals and plans. Meeting an established goal requires an organization to monitor and measure progress toward meeting those goals. Leading and lagging indicators can be used for these purposes. However, the use of any indicator requires the collection of basic data. Most airports collect data, but not necessarily in a formalized and all-encompassing manner. An incident reporting system is one formalized mechanism for collecting data. An example of an incident related to the attainment of goals could be a miscommunication of sorts that leads to a task not being completed, whether as a result of different languages, a language deficiency, use of cultural references, word choices, or something similar. An incident could also be where excellent communication was exercised to exceed the task requirements. Both types of incident reporting and data collection are important to obtain. Mandatory Reporting To obtain data and learn from accidents, regulatory requirements exist for airports to collect data on accidents, injuries, and other major incidents. Among these are the federal requirements of the NTSB, the Occupational Safety and Health Administration (OSHA), and the FAA. For example, regulations an airport must consider are 14 CFR Part 139, The Certification of Airports; 40 CFR Part 112, Oil Pollution Prevention; and 29 CFR 1910, Occupational Safety and Health Standards. Other state or local requirements may be required to support legal obligations, such as local law enforcement or medical reporting. Various state or local laws may also require reporting of accidents or incidents (i.e., police and insurance matters). Laws and regulations can require mandatory reporting of identified conditions, events, or situations. The information reported generally reflects an accident or major incident that has already occurred. Even with mandatory reporting requirements, of concern needs to be the number of incidents that are not reported, as they can be an indication of an opportunity lost to learn how to improve the organization. In one study of the rail industry data between 2005 and 2010, it was estimated that 500 to 600 reportable accidents were not reported (Safety and Standards Board 2011). Those numbers do not include the number of incidents that did not merit a mandatory report, according to the authors. Those were estimated to be three times as many by the same study. The studies suggest the depiction of an iceberg as a symbol of 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.

8 Airport Incident Reporting Practices Voluntary Reporting It is the intentional seeking, or the voluntary acquisition of, precursor incident data that can prove most useful in preventing future accidents or in predicting future direction and risks. Every day at airports, incidents occur that narrowly avoid becoming accidents or causing serious injury, or that indicate the airport may be drifting from its stated goals. When these events or occurrences occur, they can be indicative of a gap in operational or performance capabilities. Often, these little incidents go unreported. But an airport organization cannot prevent a future accident or injury, or stay on course, if it does not know the possibilities that exist. In a workshop paper prepared for the National Academy of Engineering Program Office Accident Precursors Project, presenter Christopher Hart states, Most industries have begun to consider the feasibility of collecting and analyzing information about precursors before they result in mishaps. Too often, the “hands-on” people on the “front lines” note, after a mishap, that, they “all knew about that problem.” The challenge is to collect the information “we all know about” and do something about it before it results in a mishap. (Hart 2004, p. 149). Using Incident Reporting One of the primary purposes for identifying hazards, reporting of incidents, and the assess- ment of risks is to determine whether enough has been done to prevent an incident or accident that may lead to fatalities, injuries, ill health, and/or damage to aircraft (Civil Aviation Authority 2006). Another primary purpose, based on survey response to this report, is to determine whether a stated organizational goal is on track. An incident reporting system can be utilized to flag or provide early warning of potential drifts in actions toward a stated goal or an adverse event or loss. A drift in actions or behaviors can be in either a positive, neutral, or negative direction. Indicators can be used to provide early warnings of changes, or to 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 achievement of a goal. While viewing some indicators as a precursor to a future negative incident (often referred to as a lagging indicator), another view is to measure signs of changing vulnerabilities through the use of leading indicators (Kjellén 2009, p. 486). Understanding how vulnerabilities are manifested within an organization can heighten awareness to a possible incident precursor that previously was unknown. For this reason, recognizing incident precursors through root cause analyses or similar means can allow for corrective action that enhances goal attainment and safety. The indictors an airport organization chooses to monitor as part of an incident reporting system will be influenced by the need for risk control and for safety development. The Organisa- tion for Economic Co-operation and Development (OECD) views leading or activity indicators as being designed to help identify whether enterprises/organizations are taking actions believed necessary to lower risks (OECD 2008). The literature on incident management notes that analyses of near misses, close calls, incidents, mishaps, events, threats, errors, and similar occurrences are important for identifying future major incidents and accidents. It is essential to study incidents to learn how a complex airport actually works. The investigation of incidents and the determination of root causes can be effective in identifying and understanding the unforeseen and complex interactions that result in unsafe conditions or accidents, provided proper attention is paid to any lessons that can be learned. One key method for understanding hazard and risk possibilities at an airport is through use of a safety management system (SMS). An SMS contains policies, objectives, procedures,

Introduction 9 methods, roles, and functions for the purpose of controlling hazards and risks. Incident reporting is a fundamental component of an SMS. It includes the identification, reporting, and manage- ment of hazards and incidents that routinely exist or that can occur at an airport. An SMS helps an organization better understand and manage accident precursors, or the events leading up to an accident. Seven of the airports in this synthesis have an SMS program in place. None were fully implemented to date. However, three of the seven airports in the survey did indicate they could closely meet a requirement for implementation within the first 6 months of 2018, if required. A second key method for understanding the hazard and risk possibilities is to develop an organizational-wide enterprise risk management (ERM) program. A risk management program raises the level of awareness and understanding about hazards, risks, and opportunities into areas beyond those that would be covered by a Part 139 SMS. It would look at enterprise-wide risk and incident exposure within the other departments, facilities, operations, and strategic initiatives of the organization. A third key method for understanding the hazard and risk possibilities is to routinely conduct root cause analyses, whether as part of an SMS safety assessment (SA) or as part of an ERM assessment. Root cause analyses require the collection of incident data to better assess the probabilities of an event occurring or for viewing obstacles that can impede goal attainment. Synthesis Benefits From a safety-centric perspective, incident reporting helps identify areas for improvement in the safety of airport operations. This is accomplished through the timely detection of operational hazards and system deficiencies, learning from the investigation and analyses of those incidents, and the resultant improvement of the organization though training and safety implementa- tion. Accidents are prevented or organizational risks are reduced as a result of prompt analysis of collected safety and risk data, remedial mitigation actions taken, and the exchange of safety information both internal and external to the airport organization. From an enterprise-centric perspective, incident reporting helps airports gain access to operational intelligence throughout the organization. Accidents are prevented or organizational risks are reduced as a result of more effective understanding of where and how risk is created in the organizational system, and by supporting more intelligent allocation of resources to respond to risk in near real time, with consideration from varied user perspectives, and with knowledge of how work is actually done (B. Goodheart, personal communication, November 28, 2017). Information provided in this synthesis can assist airport operators in establishing and docu- menting organizational and safety reporting practices; identifying reporting indicators, metrics, dashboards, and benchmarks used in safety and risk management analyses and in organizational performance and evaluation; and strengthening workplace safety policies and practices. 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. Macrae (2016), who has researched airline incident reporting, also investigated incident reporting in the healthcare industry and makes the following statement on the function of an incident reporting system: The core functions of an incident reporting system are twofold. One is to use incidents to identify and prioritise which aspects of a healthcare system and its underlying risks need to be examined more closely.

10 Airport Incident Reporting Practices The other is to organise broader investigation and improvement activities to understand and address those risks. These active processes of investigation, inquiry and improvement underpin learning. (p. 74) As compiled by the principal investigator, the research literature identifies a number of goals or purposes for the reporting and investigation of incidents: • Identify hazards and/or highlight potential systems weaknesses. • Analyze the reported information to identify safety or organizational risk. • Proactively find ways to prevent an accident or injury at some future time. • Bring to light valuable information that may not otherwise be discovered. • Confirm any safety efforts taken. • Determine costs associated with an event. • Fulfill legal requirements. • Determine compliance with applicable regulations. • Process worker compensation claims. • Engage the workforce, users, and other stakeholders in solving problems. • Develop positive attitudes and a culture of safety. As reported by Simmons (2015), effective incident reporting can have significant benefits: • Improvements in business performance and operational capability, • Protection of people, • Protection of brand and reputation, • Reduction in risk to the organization/operation, • Improved competitive and strategic advantage, and • Improved efficiency through effective integration of business and safety management systems. In addition to operational benefits, the research literature shows financial and economic benefits to be realized from implementing an incident reporting system. Having accidents and major incidents was found to negatively affect the financial results of an aviation organization. As shareholder and market value are lost, losses are absorbed as part of the regular costs of doing business, and individual departments or individual SMS interventions incur costs and/or savings associated with safety (Lercel et al. 2011). Lercel’s return-on-investment model illustrates the business benefits of safety programs, such as an SMS, by using a macro-to-micro analysis. It characterizes SMS in terms of an investment portfolio that consists of multiple safety programs with varying rates of return, risk, and maturity terms. The author’s premise was that it is a better use of aviation company funds to invest in SMS programs that will prevent accidents than to forego SMS and absorb the financial impact of accidents that could have been avoided. Maslen and Hayes (2016) suggest another important purpose for incident reporting systems— to obtain knowledge, and in particular, collective knowledge about the organization and its environment. They suggest in their research that the question isn’t so much what needs to be reported or learned from an incident. Instead they suggest, “What do people need to know to play their part in major accident prevention? And how is that knowledge effectively shared?” Audience The principal audiences for this synthesis study are the following: 1. Airport directors and executives, including finance and legal departments. 2. Airport operational and divisional managers. 3. Risk and safety management professionals. 4. Human resource and personnel directors.

Introduction 11 5. Internal and external compliance auditors. 6. Airport consultants and independent practitioners. 7. Fixed or specialized aeronautical service operators operating on airports. Methodology Finding airport organizations with incident reporting systems other than those that are mandatory or regulatory was a challenge for this synthesis. The difficulty affected the study methodology. A three-step process was used: 1. A general mail inquiry was made to 105 selected airports of all sizes about whether the airport organization had a formal incident reporting system, and collects key performance indicator (KPI), safety performance indicator (SPI), or other similar data. A self-addressed return postcard was provided in letters mailed to 105 airports invited to participate. No response was received from 77 airports. 2. Airports that responded affirmatively to the inquiry were asked to formally participate in the study. Of the 28 airports that responded, 11 self-selected to further participate in the study (Table 1). A survey questionnaire was developed and pretested with three airports. A final survey was mailed to the 11 airports. Appendix A contains the survey and the responses to it. Throughout the report, a particular survey question is referenced by the use of brackets and italics: [Question]. 3. Based on the 11 survey responses, seven were selected for more in-depth analyses of their practices. Personal interviews were conducted with respondents. Their case examples are presented in Chapter 9. Underrepresented in the survey are responses from small, non-hub, and GA airports; no airport in those categories except one expressed a willingness to participate in the study. It is recognized that the subject matter, including discussion of ERM and having formal incident reporting systems in place, may have contributed to the poor response. It was surmised that airports in the underrepresented categories may not have well-developed reporting systems, or any such systems, in place. Literature Review Incident reporting is a broad topic. Subsequently, the literature review resulted in a plethora of information to be analyzed. The principal investigator reviewed literature using standard web-based search engines such as Google, Google Scholar, ProQuest, Transportation Research LH Atlanta Hartsfield-Jackson International Airport, GA LH Massachusetts Port Authority – Boston International Airport, MA LH Dallas-Fort Worth International Airport, TX LH Houston Airport System, TX LH Metropolitan Washington Airport Authority – Dulles International, VA LH Metropolitan Washington Airport Authority – Ronald Reagan Airport, DC LH Portland International Airport, OR LH Seattle Tacoma International Airport, WA MH Columbus Regional Airport Authority, OH MH Jacksonville Aviation Authority, FL SH Sarasota-Bradenton Airport Authority, FL LH = large hub MH = medium hub SH = small hub Table 1. Participating airports and hub designation.

12 Airport Incident Reporting Practices Information Services, and other academic and professional databases. Search terms used included incident reporting, leading and lagging indicators, metrics, safety and key performance indicators, near miss, enterprise risk management, dashboard, scorecard, organizational culture, and safety management system. Literature citations are included throughout the report in their appropriate and meaningful chapters and sections. Chapter 7 contains focused information related to research and resources on indicators and metrics. Report Organization Chapter 1 (this chapter) introduces the reader to incident occurrence and reporting at airports by providing an overview, explanation of benefits, the intended audience, the methodology, and how the literature review was undertaken. Chapter 2 seeks to explain the importance and difficulty in defining an incident, near miss, and other terms. Chapter 3 further lays a foundation for understanding incident reporting in relation to risk management and organization performance. Incident management is explained through exposure to risks and hazards. Also explained is the role of incident reporting in helping an ERM system make the connection between individual departmental or program initiatives and the accomplishment of strategic organizational goals. Chapter 4 explains how incident reporting can be viewed as a tool that is used to look nega- tively for potential problems within an organization, or positively to catch emerging risks and to ensure work efforts stay on track within boundaries or margins for safety and performance. Chapter 5 introduces safety management systems and the need for an organizational culture to exist that will promote the successful implementation of an incident reporting system. Chapter 6 introduces the relationship between incident reporting and various performance indicators and metrics, with emphasis on leading and lagging indicators. The distinction between safety and key performance indicators is explained and applied to airports. Outlined are some of the challenges an airport organization may encounter when selecting which incident factors are important to monitor. Chapter 7 summarizes previous research related to incident reporting systems and its application to airports. Included are sources of information and resources related to indicators and other metrics that can be used. Chapter 8 presents practical information from the study and the literature search on how incident data are collected and tracked. Chapter 9 provides summaries and case examples of airports selected for interview as part of the study. Chapter 10 provides conclusions and suggestions for further research.

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TRB’s Airport Cooperative Research Program (ACRP) Synthesis 95: Airport Incident Reporting Practices focuses on current practices for defining, collecting, aggregating, protecting, and reporting airport organizational incident information.

The report is designed to assist 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.

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.

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 report takes 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.

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