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26 Incidents at airports occur every day, but most are not recognized as being important or they do not rise to a level that results in their being recorded or documented. For those airport organizations that do collect data on incidents, comparison of the data with other airports is not yet a common practice, as variations exist in how airport operators may assess or classify the importance of incident data. The following section provides an overview of the importance of incident reporting. Incident Reporting as a Tool Incident reporting can be viewed as a tool that is used to look negatively for potential prob- lems within an organization, or can be viewed positively to catch emerging risks and to ensure work efforts stay on track within boundaries or margins of safety and performance. A high-level depiction of an incident reporting system can be described as being composed of three phases: data collection, data analysis, and subsequent learning (Figure 5). There is a tendency to think of an incident reporting system as applying only to the detec- tion portion of the model presented in Figure 5. A further tendency is to think of incidents only from the safety-centric perspective. This synthesis identifies an enterprise-centric perspective of organization risk and performance as being just as important. This makes the learning portion of the model important from the standpoint that incident data are analyzed and reported back to the organization so improvements can be made to the organization, rather than to just prevent a future incident. Organizational learning is a necessary activity for enhancing organizational effectiveness. One purpose for incident reporting is to identify hazards and risks that need to be examined closely and to determine the need for further investigation and analysis. From a safety-centric standpoint, an incident report helps trigger an inquiry that will improve the safety, health, and performance of an organization. Incident reports do not necessarily need to have much detail. The initial goal is to get people to report something out of the ordinary and to obtain objective and neutral information. Investigation and analyses will help identify the value of the data. The breadth and depth of an incident reporting system are best deter- mined by each individual airport. Some airports may take the position that the primary objective is to monitor, disseminate, and record for analysis only critical or potentially critical safety occurrences. Other airports extend incident reporting to the collection and monitoring of the normal flow of day-to-day defects or incidents. Other airports may identify the need to collect data related to variances in customer service or business processes. In either case, the reporting system requires clear C H A P T E R 4 Breadth and Depth of Incident Reporting The breadth and depth of an incident reporting system are best determined by each airport.
Breadth and Depth of Incident Reporting 27 definition and guidelines on what is being sought so employees know what data are necessary to report and be collected. The basic components and flow chart of an incident reporting system are similar to that of the safety reporting system illustrated in ACRP Report 131: A Guidebook for Safety Risk Management for Airports (Neubauer et al. 2015) and revised in Figure 6. In the survey, when asked if there was âa formal Hazard Incident & Risk Mitigation (HIRM), Incident Management System (IMS), or similar program that collects SPI, KPI, hazard or incident data,â seven of the 11 airports responded affirmatively [Question 1.c.]. However, responses to other questions on the survey established that the reporting systems are basic and not well developed at this point. For instance, mandatory reporting was established for eight airports. Interviews indicated the mandatory reporting generally applied to 14 CFR Part 139, Figure 5. High-level overview of an incident reporting system. Source: Hewitt 2011. Used with permission. Figure 6. Sample incident reporting flow chart for a large airport. Note: SPI = safety performance Indicator; KPI = key performance indicator. Source: Adapted from Neubauer et al. 2015. Used with permission.
28 Airport Incident Reporting Practices OSHA, and environmental reporting. A formal voluntary reporting system for near misses or similar incidents was evident at only six of the airports. Incident Reporting and Threat and Error Management Within the air traffic and air carrier sectors of aviation, the term âthreat and error managementâ is used in the same way that incident reporting is commonly used elsewhere. TEM has its origins in the human factors (HF) movement and how HF is tied to organizational and system performance. Threats are events or conditions that exist in an operation, similar to the holes and gaps identified in popular accident causation models attributed to James Reason (Reason 1997) and Christopher Hart (Hart 2004). Threats can be viewed as being comparable to hazards or incidents. Errors refer to the human component and are the actions or inactions of personnel at any level of the organization. The behaviors result in deviations or variations from an intended path or an expected outcome, similar to the concept of ERM. A third component of TEM is undesired states, which are the result of poor management of the threats and errors. Poor management can lead to situations where the margins of safety are reduced and a major incident or accident is about to happen. Or, poor management can lead to low organizational performance outcomes. In these cases, poor management refers to both individual and organizational management of the threats and errors. The two main resolves of TEM are threat and error reduction and/or threat and error containment. Reporting threats and errors is fundamental to future error and incident prevention. A basic tenet of TEM important for incident reporting is that of non-punitive reporting of errors. TEM practices evolved from the notion of a reporting culture, as espoused by Reason (Reason 1997). A reporting culture is an important and necessary component of a successful incident reporting system. Reporting culture is discussed further in Chapter 5.
