Peter Tait

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CHIRP
Collaboration with CAA as a Pathway for Safety
Improvement.
Peter Tait Chief Executive
COPAC 5th Flight Safety Seminar Madrid 23-24
October 2008
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Introduction

• The CHIRP Charitable Trust manages confidential
  reporting programmes for the UK aviation and
  maritime industries.
• The Maritime programme commenced operation in
  2003 and is funded by the UK Government
  (Department for Transport.)

3

• Aviation Safety Reporting in the UK
• CHIRP Structure and Processes
• Reporting Trends and Recent Issues

4
Aviation Safety Reporting in the UK

• Reporting/Investigating safety incidents is part
  of UK aviation culture
• The UK Air Accident Investigation Branch was
  formed in 1915.
• CAA Mandatory Occurrence Reporting (MOR) scheme
  started in 1975.
• Covers wide range of Technical/Operational
  deficiencies.
• Reports from Flight crew, ATCOs, Engineers.
• Approximately 13,000 reports per year.
• Submission of reports is required by CAA (SRG).
  

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Aviation Safety Reporting in the UK (contd)

• Airline/National Air Traffic Services Reporting
  Systems
• All UK airlines operate a company safety
  reporting system.
• The British Airways BASIS system has been adopted
  by several UK and overseas airlines. The
  advantage of a common reporting system is that it
  permits a Safety Information Exchange between
  participants.

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Aviation Safety Reporting in the UK (contd)

• Confidential Reporting Systems
• CAA(SRG) Confidential Reporting Scheme
• Little used.
• Airline Confidential Reporting
• Some airlines operate Human Factors and/or
  confidential reporting schemes.
• UK Confidential Human Factors Incident Reporting
  Programme (CHIRP)
• Independent, voluntary confidential programme.
• Supplements other reporting processes.
• Commenced operations in 1982, restructured in
  1996.
• 450-500 reports/year.

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Some EU countries have similar aviation
reporting schemes others have developed them
more recently. A mandatory reporting scheme is
now required by the European Aviation Safety
Agency.
Aviation Safety Reporting in Europe

• From 2009, a Safety Management System will
  become an ICAO requirement.

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Reporting Relationships - UK
CHIRP is Complementary to the Formal Methods of
Reporting
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Where does CHIRP fit in the UK Reporting Process?
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How does CHIRP do this?
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CHIRP Aviation Programmes
Commercial Air Transport - Pilots (1982) - Air
Traffic Control Officers (1985) - Engineers /
Approved Maintenance Organisations (1997) -
Cabin crew (2001) General Aviation (1999) -
Light Aircraft, Gliders, Micro-lights, -
Para-gliders, Balloons
The CHIRP Charitable Trust
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CHIRP Key Features

• CHIRP is an independent Charity (Foundation) and
  is sponsored by a grant from the UK Civil
  Aviation Authority, which is funded by the UK air
  transport industry.
• The programme has the commitment of senior
  management. The Board of Trustees (14) includes
  
• Chief Inspector Air Accidents Investigation
  Branch
• Group Director Safety Regulation CAA
• Chief Inspector Marine Accident Investigation
  Branch
• Chief Executive Maritime and Coastguard Agency
• Six independent aviation trustees, three
  independent maritime trustees
• An independent Chairman

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CHIRP Key Features (contd)

• The Trust invites nominees from the principal
  aviation interests to become members of the CHIRP
  Advisory Boards.
• Each nomination is reviewed every three years to
  ensure that the Board retains current operational
  expertise.
• Annual performance reports are submitted to the
  programme sponsors and circulated widely to
  operational managements.
• The Aviation Programmes are subject to an
  independent review every five years. The review
  is conducted by members of the Advisory Boards
  and other industry specialists including the CAA.
  The terms of reference for the review are agreed
  with the CAA.

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Organisation and Structure (1)
CHIRP Executive Board (Trustees) (9) Mr K Smart
(Chairman) Capt D Chapman Capt W Lowe Capt C
Elton Air Cdre R Peacock-Edwards Capt C
Hodgkinson Mr J Saull Mr D King Capt T
Sindall Maritime Trustees (5)
Chirp Advisory Boards(4)
Chirp-MEMS Review Board
Staff (3 full-time and 2 part-time) Mr P Tait
Chief Executive Mr M Skinner
Deputy Director (Eng) Mrs K Arnold
Administration Manager Ms J Ellis
Administrator Mr J Allman-Talbot
Systems/Database Administrator
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Organisation and Structure (2)
Chirp Air Transport Advisory Board (28) Capt. C
Hodgkinson (Independent Chairman) Mr D
King Chief Inspector Air Accidents Mr C Hague
SBAC Capt W Lowe Independent Capt. D
Harrison Independent Air Cdre R Peacock-Edwards
Independent Air Cdre R Jones UK Flight Safety
Committee Mr J Saull Independent Mr B
Johnston Guild of Air Traffic Control Off Mr K
Smart Independent Capt L Jordan easyJet
Capt T Sindall Independent Mr S Lindsey NATS
- Operational Safety Capt M Alder British
Airline Pilots Assn Mr P Lowrence ATS (Ops)
ATSD - CAA (SRG) Capt. J Batty Business GA
Assn Mr J McKenna Head Strat, Pol Std, -
CAA (SRG) Capt E Bewley Head Flight Ops Insp (1)
CAA Mr M Newman Assoc Licensed A/C Engs Mr
C Brown British Airways Engineering Capt M
Pitt Independent Mr R Bradbury Guild ATC
Officers Capt P Preston Independent Capt A
Davis British Heli Advisory Board Capt B
Screen Independent Air Cdre I Dugmore Director
(DARS) Mr A Shaw Director Safety Highland
Airports Dr S Evans Chief Medical Officer -
CAA Capt S Solomon UK Flt Ops Liaison Group
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Organisation and Structure (3)
Chirp Cabin Crew Advisory Board (18) Ms S Knight
- (Independent Chairman) Mrs S Adair Senior
Cabin Safety Inspector CAA (SRG) Mrs A
Clark Cabin Services Advisor Eastern
Airways Mrs H Corcoran Senior Cabin Safety
Officer Thomas Cook Airlines Ms J
Dawson Safety Training Manager - bmi Ms J
Eldridge Safety and Security Adviser - British
Airways Mrs J Fisher Manager Cabin Safety
Office - CAA (SRG) Mr S Fitzpatrick Cabin Crew
Manager - Titan Airways Miss M Gooding Cabin
Safety Manager - Virgin Atlantic Mr C Hewitt
Acting Cabin Safety Manager - easyJet Ms J
Heslop Cabin Crew/CRM Team - Monarch
Airlines Mr S Jones Safety, Recruitment
Training Manager - flybe Mr D Kelly Regional
Officer - Unite Mrs V Robertson Cabin Safety
Manager - Thomsonfly Capt K Sachedina Independent
Flight Crew Member Mr I Tanner/Mr I Newman
Cabin Crew 89 /Unite Capt T Sindall
Independent Mrs D Warren-Price BASSA/Unite
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The Role of the Advisory Boards

• Review disidentified reports
• Provide advice on action to be taken
• Assess appropriateness of Third Party
  responses
• Review final draft of the relevant FEEDBACK
  newsletter
• Review information disseminated to
  management groups
• Provide feedback to Trustees on the
  effectiveness of the Programme

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How Do We Ensure Confidentiality?

• Confidential not anonymous. Permits closed loop
  process
• Follow-up letter/e-mail
• telephone
• interview on private basis
• No action taken without reporters consent
• Personal details and original report are not
  retained. Returned to reporter
• Reports technically disidentified for
  dissemination and retention
• Controlled third-party access to report data

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Immunity

• Aeronautical Information Circular 47(2001)
  provides limited regulatory immunity against
  third-party reports. Same as MOR system.
  (Statement by Chairman CAA), but not against
  gross negligence / wilful acts
• UK Law provides legal immunity against
  Whistle-blowing yet to be tested legally in
  air transport operations Evidence to date is
  that CHIRP process preferred.
• Risk of exposure is minimised through CHIRP
  processes

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Aviation Reports Received
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(No Transcript)
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Flight Crew Programme Top 10 Key IssuesOctober
2007 September 2008 (1)
Security Ground 55 In-Flight 3
Communications External 23
Duty Rosters 33 Rest 7 Discretion 3 Length 3
Company Policies Operational 17 Safety
Reporting/Culture 1
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Flight Crew Programme Top 10 Key IssuesOctober
2007 September 2008 (2)
Procedures Inadequate 3 Incorrect/Conflicting 2
Application by Other Party 1 Knowledge
Of 1 Unavailable/Inaccessible 1
Handling/Operation Aircraft Handling 4 Airmanshi
p 1 Operation of Equipment 1
Air Traffic Management Level of
service 4 Seperation 1
Pressures Commercial 3 From Management 3
Ground Handling De-Icing 3 Loading/Boarding 2 R
efuelling 1
Aircraft Technical Systems 3 Design 1 Performance
1
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(No Transcript)
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ATC Programme Top 6 Key Issues October 2007
September 2008
Relationship Management Team 1
Communications - External Flight Crew 6
Air Traffic Management Near Loss of Separation 3
Security Ground 1
Airports Bird Control 1
Duty Rest 2 Rosters 1
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(No Transcript)
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Engineering Programme Top 5 Key Issues October
2007 September 2008
Regulation/Law Compliance With 2 Knowledge
Of 1 Absence Of 1
Security Ground 9 In-Flight 1
Maintenance Base 3 Line 3 Standards/Workmanship
2 Inspection Error 2
Procedures Unavailable 1 Interpretation 1
Aircraft Technical Design 1 Propulsion 1
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(No Transcript)
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(No Transcript)
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Cabin Crew Programme Top 10 Key Issues
October 2007 September 2008 (1)
Pressures From Management 16 Commercial 6 Time 5
Duty Rosters/Rostering/Shift 38 Crewing 18 Length
18 Rest 12 Disruption 5 Discretion 2
Regulation/Law Knowledge Of 16 Compliance With 8
Procedures Application by Third
Party 23 Inadequate 13 Incorrect/Conflicting 4 Kno
wledge Of 2 Understanding 2
Communications Internal Team/Shift/Watch 16 Ma
nagers 5
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Cabin Crew Programme Top 10 Key Issues
October 2007 September 2008 (2)
Environment Extreme Temperatures 3 Air
Quality 2 Noise/Distraction 2
Company Policies Operational 21
Security Ground 7 In-Flight 2
Works Council Referral TC/IR 11 Health and
Safety 5
Maintenance Base 4 Line 3 Standards/Workmanship 1
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MEMS Project Development

• Review feasibility of sharing MEMS data 21
  attendees
• CAA
• CHIRP
• UKOTG Operators
• EIMG Maintenance Organisations
• Boeing
• Airbus
• GE

London Meeting March 2001

• Pilot study initiated, funding gained from CAA
• MEDA based taxonomy agreed
• CHIRP offered central database management
• Constitution agreed with group of 8 UK members

MEMS Steering Group set up April 2001

• MEMS Steering group pilot study completed
• CHIRP MEMS database developed
• CHIRP website distribution set up
• Constitution revised for wider membership
• Data analysis capability developed

MEMS Steering Group closed April 2003

• Review Board established
• Independent chairman appointed-AAIB
• 4 members from UKOTG
• 2 members from EIMG
• 1 member from CHIRP
• 1 member from CAA
• 12 industry members

MEMS Review Board constituted April 2003
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Comparison of Maintenance Error Data CAA (MOR) /
Industry (MEDA)

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MEMS group benchmarking for SMS maturity review

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MEMS Group SMS ReadinessAreas of strength and
opportunity

Above
60
40
20
Average
10
40
40
10
10
10
30
Training
20
Risk Assessment
Communication
40
Trust by employees
60
Below
Audits
LM safety role
Leadership Commitment
Mgt of change
Safety Info system
Safety measures
Safety Mgt System
Safety as bus. issue
Learning organisation
Employee involvement
Employee safety views
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Summary

• The UK CHIRP Programme is independent of the
  regulator, management and employee representative
  associations.
• CHIRP receives reports on safety related issues.
• The confidentiality of the reporter is paramount.
• Where possible and with the consent of the
  reporter, safety issues are raised with senior
  operational managers and/or the CAA.
• The reporter receives feedback either
  individually or through the CHIRP FEEDBACK
  newsletter.
• The reporter has limited immunity from the CAA
  but is protected by the process.
• The Programme is subject to an independent review
  every five years.

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Questions?