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report. The reporting requirements vary with the laws of the State where the incident occurred. Even if not
required by law, operators may require reporting of the occurrence to the organization.
Mandatory incident reporting systems
7.2.2 In a mandatory system, people are required to report certain types of incidents. This
necessitates detailed regulations outlining who shall report and what shall be reported. The number of
variables in aviation operations is so great that it is difficult to provide a comprehensive list of items or
conditions which should be reported. For example, the loss of a single hydraulic system on an aircraft with
only one such system is critical, while on a type with three or four systems, it may not be. A relatively minor
problem in one set of circumstances can in different circumstances result in a hazardous situation. However,
the rule should be: “If in doubt — report it.”
7.2.3 Since mandatory systems deal mainly with “hardware” matters, they tend to collect more
information on technical failures than on the human performance aspects. To help overcome this problem,
States with well-developed mandatory reporting systems are introducing voluntary incident reporting
systems aimed at acquiring more information on the Human Factors aspects of occurrences.
Voluntary incident reporting systems
7.2.4 Annex 13 recommends that States introduce voluntary incident reporting systems to supplement
the information obtained from mandatory reporting systems. In such systems, the reporter, without any legal
or administrative requirement to do so, submits a voluntary incident report. In a voluntary reporting system,
1. See Annex 13, Chapter 8.
Chapter 7. Hazard and Incident Reporting 7-3
regulatory agencies may offer an incentive to report. For example, enforcement action may be waived for
unintentional violations that are reported. The reported information should not be used against the reporters,
i.e. such systems must be non-punitive to encourage the reporting of such information.
Confidential reporting systems
7.2.5 Confidential reporting systems aim to protect the identity of the reporter. This is one way of
ensuring that voluntary reporting systems are non-punitive. Confidentiality is usually achieved by
de-identification, often by not recording any identifying information of the occurrence. One such system
returns to the user the identifying part of the reporting form, and no record is kept of these details.
Confidential incident reporting systems facilitate the disclosure of human errors, without fear of retribution or
embarrassment, and enable others to learn from previous mistakes.
7.3 PRINCIPLES FOR EFFECTIVE INCIDENT REPORTING SYSTEMS
7.3.1 People are understandably reluctant to report their mistakes to the organization that employs
them or to the government department that regulates them. Too often following an occurrence, investigators
learn that many people were aware of the unsafe conditions before the event. For whatever reasons,
however, they did not report the perceived hazards, perhaps because of:
a) embarrassment in front of their peers;
b) self-incrimination, especially if they were responsible for creating the unsafe condition;
c) retaliation from their employer for having spoken out; or
d) sanction (such as enforcement action) by the regulatory authority.
7.3.2 Use of the principles outlined in 7.3.3 to 7.3.12 helps to overcome the natural resistance to
safety reporting.
Trust
7.3.3 Persons reporting incidents must trust that the receiving organization (whether the State or
company) will not use the information against them in any way. Without such confidence, people will be
reluctant to report their mistakes or other hazards they have noticed.
7.3.4 Trust begins with the design and implementation of the reporting system. Employee input into
the development of a reporting system is therefore vital. A positive safety culture in the organization
generates the kind of trust necessary for a successful incident reporting system. Specifically, the culture
must be error-tolerant and just. In addition, incident reporting systems need to be perceived as being fair in
how they treat unintentional errors or mistakes. (Most people do not expect an incident reporting system to
exempt criminal acts or deliberate violations from prosecution or disciplinary action.) Some States consider
such a process to be an example of a “just culture”.
Non-punitive
7.3.5 Non-punitive reporting systems are based on confidentiality. Before employees will freely report
incidents, they must receive a commitment from the regulatory authority or from top management that
reported information would not be used punitively against them. The person reporting the incident (or unsafe
　
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