Occurrence Reporting in an EASA Part CAMO Organisation - Mandatory & Voluntary (Internal)
Sofema Aviation Services (www.sassofia.com) Considers roles and responsibilities related to the obligation to report occurrences both externally and internally.
CAMO.A.160 Occurrence reporting
Introduction - Regulation (EU) 2019/1383 identifies the obligation to implement an occurrence reporting system that meets the requirements defined in Regulation (EU) No 376/2014 and Implementing Regulation (EU) 2015/1018.
Note concerning reporting within the CAMO Environment:
Authors Comment - Whilst 2015/1018 essentially re-iterates the reportable events which have been identified for many years and found in AMC 20-8 the obligation to comply with 376/2014 identifies a number of significant obligations concerning reporter confidence and protection of information as well as disidentification of reporters.
The organisation shall ensure that any incident, malfunction, technical defect, exceeding of technical limitations, occurrence that would highlight inaccurate, incomplete or ambiguous information contained in data established in accordance with Annex I (Part-21) to Regulation (EU) No 748/2012 or other irregular circumstance that has or may have endangered the safe operation of the aircraft and that has not resulted in an accident or serious incident are reported to the competent authority and to the organisation responsible for the design of the aircraft.
The Competent Authority is at liberty to specify how to receive the information providing it includes all relevant elements required to describe the issue / event.
Reports shall be made as soon as possible, but in any case within 72 hours of the organisation identifying the condition to which the report relates, unless exceptional circumstances prevent this.
Concerning Design Approval Holder (DAH)
The ‘organisation responsible for the design of the aircraft’ will typically be the holder of a type-certificate, a restricted type-certificate, a supplemental type-certificate, a European Technical Standard Order (ETSO) authorisation, an approval for a repair or a change to the type design ((EU) No 748/2012.)
Sharing of Information
The organisation should share relevant safety-related occurrence reports with the design approval holder of the aircraft in order to enable it to issue appropriate service instructions and recommendations to all owners or operators. Liaison with the design approval holder is recommended to establish whether published or proposed service information will resolve the problem or to obtain a solution to a particular problem.
The Need for Follow up Reports
Where relevant, the organisation shall produce a follow-up report to provide details of actions it intends to take to prevent similar occurrences in the future, as soon as these actions have been identified. This report shall be produced in a form and manner established by the competent authority.
Comments Related to AMC 1 &2 CAMO.A.160 Occurrence reporting
The organisation should assign responsibility to one or more suitably qualified persons with clearly defined authority, for coordinating action on airworthiness occurrences and for initiating any necessary further investigation and follow-up activity.
If more than one person are assigned such responsibility, the organisation should identify a single person to act as the main focal point for ensuring a single reporting channel is established with the accountable manager.
This should in particular apply to organisations holding one or more additional organisation certificates within the scope of Regulation (EU) 2018/1139 and its delegated and implementing acts where the occurrence reporting system is fully integrated with that required under the additional certificate(s) held.
Introduction - CAMO Internal Safety Reporting
The overall purpose of the internal safety reporting scheme is to collect information reported by the organisation personnel and use this reported information to improve the level of compliance and safety performance of the organisation. The purpose is not to attribute blame.
The objectives of the scheme are to:
- Enable an assessment to be made of the safety implications of each relevant incident (errors, near miss), safety issue and hazard reported, including previous similar issues, so that any necessary action can be initiated.
- Ensure that knowledge of relevant incidents, safety issues and hazards is shared so that other persons and organisations may learn from them.
The scheme is an essential part of the overall monitoring function and should be complementary to the normal day-to-day procedures and ‘control’ systems; it is not intended to duplicate or supersede any of them. The scheme is a tool to identify those instances in which routine procedures have failed or may fail.
All reports should be retained, as the significance of such reports may only become obvious at a later date.
The collection and analysis of timely, appropriate and accurate data will allow the organisation to react to information that it receives, and apply the necessary action.
CAMO.A.202 Internal safety reporting scheme
As part of its management system, the organisation shall establish an internal safety reporting scheme to enable the collection and evaluation of such occurrences to be reported under point CAMO.A.160.
The scheme shall also enable the collection and evaluation of those errors, near misses, and hazards reported internally that do not fall under the “mandatory requirement”.
Obligations of the Internal System require:
- Identify the causes of and contributing factors to any errors, near misses, and hazards reported and address them as part of safety risk management in accordance with the following
- “The identification of aviation safety hazards entailed by the activities of the organisation, their evaluation and the management of associated risks, including taking actions to mitigate the risks and verify their effectiveness”
- Ensure evaluation of all known, relevant information relating to errors, the inability to follow procedures, near misses, and hazards, and a method to circulate the information as necessary.
- The organisation shall provide access to its internal safety reporting scheme to any subcontracted organisation.
- The organisation shall cooperate on safety investigations with any other organisation having a significant contribution to the safety of its own continuing airworthiness management activities.
General Obligations of the Internal Reporting Scheme.
Each internal safety reporting scheme should be confidential and enable and encourage free and frank reporting of any potentially safety-related occurrence, including incidents such as errors or near misses, safety issues and hazards identified. This will be facilitated by the establishment of a just culture.
The internal safety reporting scheme should contain the following elements:
- Clearly identified aims and objectives with demonstrable corporate commitment.
- A just culture policy as part of the safety policy, and related just culture implementation procedures.
- A process to:
- Identify those reports which require further investigation.
- When so identified, investigate all the causal and contributing factors, including any technical, organisational, managerial, or HF issues, and any other contributing factors related to the occurrence, incident, error or near miss that was identified.
- If adapted to the size and complexity of the organisation, analyse the collective data showing the trends and frequencies of the contributing factor.
- Appropriate corrective actions based on the findings of investigations.
- Initial and recurrent training for staff involved in internal investigations.
- Where relevant, the organisation should cooperate with the owner or operator on occurrence investigations by exchanging relevant information to improve aviation safety.
The internal safety reporting scheme should:
- Ensure confidentiality to the reporter.
- Be closed-loop, to ensure that actions are taken internally to address any safety issues and hazards.
- Feed into the recurrent training as defined in AMC3 CAMO.A.305(g) whilst maintaining appropriate confidentiality.
Personnel requirements - Safety Training (Including Human Factors)
With respect to the understanding of the application of safety management principles (including HF), all organisation personnel should be assessed for the need to receive initial safety training.
Personnel involved in the delivery of the basic continuing airworthiness management services of the organisation should receive both initial and recurrent safety training, appropriate for their responsibilities.
Feedback should be given to staff both on an individual and a more general basis to ensure their continued support of the safety reporting scheme.
Next Steps
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