A mere 4% of the issues affecting an organization may be known by its upper-level managers [1]. Considering that the remaining 96% of problems may only be known by a core group of non-management employees we call “frontline workers,” it’s no wonder that safety reports from frontline personnel are one of the most valuable assets to a flight department.

Ironically, though, a lack of safety reports can be misconstrued as indicating a high level of safety. This is not necessarily the case. Non-reporting creates a safety blindspot, leaving safety managers with no insight into what’s working, what isn’t, and the real threats that permeate the organization.

Underreporting is a familiar dilemma in many flight departments. Of the many factors that inhibit safety reporting, one prevalent issue is that frontline workers often lack knowledge of how, when, and what must be reported [2].

Even for organizations with a healthy reporting culture, it can be confusing for employees to know if something warrants a safety report. However, an essential first step to increasing the quantity and quality of safety reports is for both management and personnel to understand the differences between proactive and reactive reporting.

Reactive and Proactive Reporting

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Reactive reporting happens when something “bad” has already occurred, so the event needs to be documented. Historically, this has been the most common type of safety report. Typically, these are reports submitted after an event that resulted in an inadvertent regulatory violation, injuries, aircraft damage, and so forth. A reactive safety report is helpful in that it helps safety managers understand what happened in a particular situation so that recurrence can be avoided.

But looking at safety performance in a reactive sense is no longer recognized as the most productive way to measure safety and reduce risk. After all, to report reactively, something "bad" must happen.

On the other hand, a proactive safety report is based on identifying hazards before they materialize into potentially significant safety issues. When we identify hazards, safety managers can then find ways to control the risks associated with those hazards. Said another way, a proactive report identifies the “bad things” that could happen due to an unmitigated issue.

Through proactive reporting, frontline employees can help ensure that their managers are better aware of the safety issues before they result in a regulatory violation, injury, damage, or worse.

Nonetheless, understanding when to submit a safety report is still a confusing topic for most employees. After all, if we write a report for every minor issue we encounter, we’d spend the better part of our day filling out reports rather than performing our duties.

Fortunately, safety reporting isn’t as complicated or as daunting as one might think. To help better understand when it would be prudent to submit a report, there are five questions that every employee should ask them themselves.

Five Questions To Help You Decide Whether You Need To Write A Report

1. Did something "bad" happen?

If something “bad” has already occurred, writing a factual and reflective account of what happened is vital. The intention for submitting these reports is not about pinning the blame on someone, but instead, it is to allow the organization to understand causal factors of that event and determine why it happened. Once the safety team can better understand what went wrong, they can then find ways to help prevent it from happening again.

Similarly, writing an account of what happens allows you, the frontline employee, to reflect on valuable lessons learned from an event. The silver lining in these events is that the reporter can share their experiences with their coworkers that may help them make better and safer decisions.

Events with adverse outcomes might involve injuries or damage to equipment. It might be as serious as a runway excursion, or minor as a bird strike.

Even if your supervisor is aware of the details of an event already, there is still value in writing a report. Many flight departments have a list of mandatory reporting criteria that require a report when specific events occur. Check your organization’s Flight Operations Manual (FOM), or Safety Management Manual (SMM), to learn more about mandatory reporting criteria.

2. Do you need to protect yourself?

As humans, making mistakes is a natural part of life. Fortunately, a few well-known non-punitive reporting programs allow most frontline workers to report and self-disclose when they may have inadvertently violated federal regulations or company procedures. Submitting a safety report into one of these programs will grant immunity from potential civil penalty or certificate suspension (provided the report meets specific criteria).

The Aviation Safety Action Program (ASAP) and Aviation Safety Reporting System (ASRS) are the most widely used in the USA. In fact, since ASRS’s implementation in the 1970s, the system has received more than 1.5 million reports, creating the largest database of aviation safety information in the world.

Not only does this show a considerable willingness to participate in the program, but it also proves just how vulnerable we all are to the occasional slip-up!

In short, if you experienced an event that you feel may warrant the benefits of immunity, it would be wise to consider owning up and submitting the report via a channel that offers legal protections.

3. Did you have a “close-call”?

Close-calls are essentially narrow escapes from serious outcomes. If you’ve experienced a situation that came dangerously close to causing damages, injuries, or generally threatened the safety of the flight (but luckily did not) we refer to these as “close-calls.”

But what makes “close-calls” so interesting to study is that the hazard path that led to a close-call usually bears a striking resemblance to those that resulted in accidents and incidents, with one major exception. The exception is that in “close-calls,” there was a barrier in place that intervened that “saved the day.”

So, how do you know when you've had a close-call worth reporting? When reflecting on this, it helps to think back over what “saved the day” (i.e., how was a potential accident prevented from happening) and what would have happened had there not been that intervention?

Potential accidents can be lessened to a “close-call” status by the intervention of what's generally known as "defenses." Passive defenses might be something as simple as a seatbelt or safety harness. A safety harness won't prevent a mechanic from falling off a wing, but will reduce the amount of injury he or she may experience if it does happen.

There are also plenty of active defenses in aviation that work to prevent damages and injuries altogether. Enhanced ground proximity warning systems (EGPWS), for instance, alert the crew if they are getting dangerously close to terrain or are not properly configured for landing.

In the form of standard operating procedures, cross-checking, and crew resource management, human defenses are how some potential errors and threats are trapped before they manifest into undesirable outcomes.

Think of a recent close-call you may have had at work.

• If not for an EGPWS warning, could you have descended into terrain?
• If you didn’t cross-check a colleague, could they have installed the wrong sized part into an engine?
• Did you have to remove nuts from a catering order, even though the catering company had been advised of the passenger’s allergy?

These are all close calls -- events we can say “thank goodness that didn’t happen.” But that doesn't make these “close-calls” any less valuable and less worthy of a report. If the same event were to happen again, there's a possibility the consequences could be far worse.

Reporting close-calls is a significant first step in eliminating that safety blindspot that many organizations face.

Who knows, the information from your report could potentially save a life!

4. Despite immense challenges, did everything go well?

Safety reporting isn’t necessarily something to commiserate over—the study of human factors tries to understand how people adapt and successfully overcome complex challenges as well. Therefore, events with positive outcomes are worth reporting, too, as success stories.

Unlike machines, as humans, we can think "outside the box" and overcome situations when we are thrown curveballs. The human factors catchphrase for this is resilience, which describes how people "bounce back" despite challenging circumstances.

Consider an inflight malfunction where there is no emergency checklist. If the crew manages to resolve the issue and land safely, it is worth writing a report about it (even if there were no negative outcomes that resulted from it).

Writing a report can provide valuable information into how you, as a crew, faced challenges and applied your knowledge and training in a way that led to a safe outcome. Knowing how you responded enables the company to develop training and teach others how to act in similar circumstances.

5. Is there an accident waiting to happen?

There was no negative outcome and maybe even no close-call either. But you just don’t have a good feeling. You may have noticed something that could result in an incident or accident if left unchecked.

Perhaps it’s an ambiguously written procedure in a manual that people are struggling to understand. Or maybe the company bought a new type of aircraft but feel that the training has been lacking. Or perhaps there has been scheduling changes, and you’ve been finding yourself making more and more mistakes than usual due to feeling tired.

Proactive reporting is the holy grail of reporting. This is how flight departments trap hazards before they result in a potentially catastrophic event. Frontline workers are the subject matter experts of the operation and the ones living the job first hand. Therefore, they also have the most potential to provide insightful proactive reports.

However, there is a significant barrier in proactive and close-call reporting. Naturally, if nothing happened, we might not feel the urge to put ourselves or our colleagues in the spotlight.

So, what is to be done?

Reaching The Holy Grail

Effective safety reporting is a two-way street. In an organization that aspires to embrace a positive safety culture, all reports should be celebrated and rewarded whenever possible.

Employees must have the confidence that reporting safety issues is in everyone’s interest, and they will not be punished for voicing their concerns. Managers must also ensure that they embrace the hallmarks of a “just culture” and that safety concerns are taken seriously, confidentially, and that sufficient resources will be invested into correcting those issues.

Read more about safety culture in another one of our blogs here.

Conclusion

Undoubtedly, safety reporting (reactively or proactively) is beneficial to the company, your colleagues, and your customers. But if you have a hard time deciding whether to report something or not, ask yourself the questions above. Keeping these questions in your mind will help you adjust your sights to improve hazard recognition and promote safer behaviors too!

If you have any questions about safety reporting, contact us today!

References

1. Yoshida, S. (1989) Quality Improvement and TQC Management at Calsonic in Japan and Overseas. International Quality Symposium. Mexico, November 1989.
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2. Jausan et al. (2017) A holistic approach to evaluating the effect of safety barriers on the performance of safety reporting systems in aviation organisations. Journal of Air Transport Management (63) pp95-107.