development of voluntary reporting system of aviation safety information in japan satoshi ishida...
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Development of voluntary reporting system of aviation safety information in Japan
Satoshi ISHIDAAviation Safety and Security
Promotion Division, JCABJAPAN
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia13-17 June 2011
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
3. Establishment of voluntary information system (③) under Non-punitive circumstances
1. Definition and framework of State Safety Programme (SSP) (①)2. Equalized statement of Safety Management System (SMS) framework (②)
Annex 1 Annex 6-Ⅰ Annex 6-Ⅲ Annex 8 Annex 11 Annex 13 Annex 14
Personnel Licensing
Operation ofAircraft
-Commercial Aeroplanes
Operation ofAircraft
-Helicopters
Airworthinessof Aircraft
Air TrafficServices
Aircraft AccidentAnd IncidentInvestigation
Aerodromes
SSPDefinitions
SMSFramework
①SSPDefinitions
SMSFramework
SSPDefinitions
SMSFramework
①① SSPDefinitions
SMSFramework
① SSPDefinitions① SSP
DefinitionsSSP
Definitions
SMSFramework
①
SSPFramework
Attachment C
SSPFramework
Attachment J Attachment J Attachment A Attachment D Attachment F
SSPFramework
SSPFramework
SSPFramework
SSPFramework
Attachment C
SSPFramework
Appendix 4 Appendix 7 Appendix 4 Appendix 6 Appendix 7
②② ② ② ②
Voluntary reporting system
①
③
① ① ① ① ① ① ①
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Amendment of Annexes to the Chicago Convention (effective date: 11/2010)
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Transition to new management system of aviation safety in Japan
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FY2010 FY2011 FY2012 FY2013
ICAOUSOAP
SSP implementation
Development of Voluntary Reporting System
Framework for implementation
Performance-based SMS
ALOSSPI
Research and Examination
Coordination with affiliates
Improvementof legal system
CSA Transition to CMA CMA
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Japan’s current reporting system:ASI-NET (Aviation Safety Information Network)
• Operated by a foundation since 1999• Reporting system aimed only at flight crew• Collected data: de-identified, not disclosed • Government ensures protection of safety
information by its inaccessibility to the reporting system
• No immunity from administrative sanction or criminal prosecution
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Reporting system of aviation safety information
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Mandatory reporting system by pilot in
command
CAA #76, 76-2
InjuryAccident
MajorIncident
which may cause accident
Minor incidentwhich may affect safe operation
Mandatory reporting system by operator
CAA #111-4
Pilots
Other Unsafe Operation / Condition
No access by JCABto the information reported through this system
CAA : Civil Aeronautics Act of Japan
ASI-NET ( operated by the
third party )Airlines / Cargos
Voluntary reporting system by operator
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Key points at issue for the development of voluntary reporting system
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Annex13, Chapter8, item8.3“A voluntary incident reporting system shall be non-punitive and afford protection to the sources of the information.”
1.
• ICAO standard requires “Non-Punitive”1 voluntary incident reporting system
• ASI-NET is intended only for air operators: A voluntary reporting system for all parties involved in aviation including ATC, CNS and airport operation is necessary
• Exploratory committee meetings were held this year to discuss toward effective implementation
• This presentation shows points at issue and opinions delivered at the exploratory committee
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Case study• US: Aviation Safety reporting System (ASRS) since 1976
– Operated by NASA
• UK: Confidential Human Factors Incident Reporting Program (CHIRP) since 1982– Operated by the CHIRP Charitable Trust
• EU: Directive 2003/42/EU
Based on the concept of “Just Culture” Willful misconduct and gross negligence are not covered Collected data: de-identified Disclosed in public (ASRS) / Not disclosed except summary report
(CHIRP) Immunity:
– Judicial proceedings not instituted for collected data– Mitigation of administrative sanction 7
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Scope of the voluntary reporting system
• Information to be collected– Handling of speculation/hearsay– Reporting format that promotes reporters to suggest
improvements
• Reporters considered– Passengers, employees involved in non-aviation field– Reporting through SMS operated by industry is
preferred rather than individual reporting in order to avoid bypassing organizational reporting systems and duplicated reports
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Operator of the voluntary reporting system
• Non-punitiveness and confidentiality of safety information are eventually achieved in ASI-NET, but not ensured by enforcement policy
• In the case that non-governmental institutions collect data reported by the government-operated fields (ATC, CNS, operation of some airports), information security must be considered
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
How to ensure Non-punitive circumstances
• Common understanding is needed for all parties involved in the aviation field
• Incentive is necessary to promote voluntary reporting
• Reviewed in light of personnel affairs, administrative guidance/sanction and criminal prosecution
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Personnel View
• Objective: aviation sector operated by the government in addition to private enterprises– ATC, CNS, operation of some airports
• Incident reported through voluntary reporting system should not be noted in the personnel record
• Impact on career may be considered
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Administrative View
• Administrative guidance should be considered non-punitive as a measure for ensuring safety– e.g. Letter of notice/warning
• Possible ways for reduction/exemption from administrative sanction:– Stipulation of waiver on enforcement policy– Segregation of collected data from the government
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Penal View
• Voluntary reporting system should not apply to accidents and major incidents with injury which are subject to the penal code
• As the cultural background, victims’ sentiment is valued rather than the importance of investigation of the cause of accident
• Further discussion is necessary based on particular cases collected through the voluntary reporting system for considering protection of reporters from criminal prosecution
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Securing confidentiality of the source of information
• Information of the reporter must be confidential and protected from regulatory/judicial authorities in a proper manner
• As with most voluntary reporting systems, reporter’s personal data is de-identified by using “confidential report”
• Personal information contained in the report should soon be deleted from the database 14
TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Future discussion of enforcement policy
• Role models were reviewed in the exploratory committee
• Further study is necessary for establishment of clear criteria for execution of administrative sanctions
• Development of effective and feasible enforcement policy along with administrative operation is needed
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
Conclusion
• A voluntary reporting system is now in the process of development in Japan
• Research and discussion of diverse aspects was conducted in the exploratory committee
• Discussion on the Non-punitive circumstances is focused on personnel affairs and administrative guidance/sanctions
• Further discussion is necessary for introducing an effective and feasible enforcement policy
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TPT-WG34, Brisbane, Australia
Thirty Fourth APEC Transportation Working Group Meeting, Brisbane, Australia , 13-17 June 2011
FIY: Safety Information Protection Task Force (SIP TF)
• The establishment of SIP TF is recommended in HLSC2010 and authorized in A37
• Scope: Making findings and recommendation for development/amendment of relevant ICAO SARPs and guidance materials
• A kick-off meeting was held on May 4-5, and working groups were established for further research and discussion
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