Reporting Culture

 A Key Element of Safety Culture

Chain of Events

The intent of my doctoral research was to learn what predicted manual flight. However, what I learned had a far greater impact on safety. What was learned could have prevented the Lion Air Flight 602, 2018 crash, Ethiopian Flight 302, 2019 crash, Atlas Air Flight 3591, 2019 crash, and even prevented the Air France Flight 447, 2009, crash.

There is never one reason an accident occurs, but always a chain of events. By breaking a link in that chain we have a chance to avoid the crash. At the core of all of the aforementioned accidents there were failures in safety culture, with a causal link to a reporting culture. People had knowledge that could have prevented the accidents, but they were fearful to speak out and airline management, manufacturers and/or regulators had information and chose not to act. 

Reporting Culture

A reporting culture is when employees are both encouraged and rewarded for reporting safety related concerns. Unfortunately, retaliation against reporting creates an environment where employees become fearful to report anything. While it is difficult to understand why an employer would be reticent to accept an idea to improve operational safety; it's disconcerting to believe they would retaliate simply because the employee provided an internal report. Perhaps it is simply ego of those involved. Perhaps the company is well aware of their operational practices but they identify the risk of life not worth the cost of the fix.  Far too often the business decision is to finance silencing the employee versus doing the right thing. 

Of 7491 Pilots Surveyed: 

Overall 54% of the population was unsure or did not believe their suggestions would be taken into consideration, 34% were unsure or unlikely to critique their training program, 41% lacked a belief or were unsure if the leadership in charge of developing training programs had the expertise of learning, 54% were unsure or believed it was best to keep quiet, and 46% were unsure or did not believe their company would exceed regulatory compliance.

The above responses identify a negative safety culture worldwide. Management may argue, but if the employee's believe it to be true that is the culture.  Without a reporting culture it is impossible to have a safety culture because there is no information sharing, no flexibility, and learning will not occur. If employee's are retaliated against when they bring information forward, the culture is not just. Therefore, of all the elements of a Safety Culture, a reporting culture is key. 

Aviation Safety Action Program (ASAP)

ASAP is a pilot self-reporting program to encourage pilots to report information for system improvement without fear of disciplinary action from the FAA. "The goal of the Aviation Safety Action Program (ASAP) is to enhance aviation safety through the prevention of accidents and incidents. Its focus is to encourage voluntary reporting of safety issues and events that come to the attention of employees of certain certificate holders" ( FAA.gov )

The concern is, when airlines allege that they have a robust reporting culture because of their ASAP program, is whether or not they have one at all. Do these leaders lack knowledge of the difference between ASAP and a Reporting Culture, or is this simply an excuse to use the FAA ASAP program because they don't have the required reporting culture?

ASAP Versus Reporting Culture

An ASAP program is a component of a Safety Management System (SMS), but not the Reporting Culture component of Safety Culture. The ASAP program became an FAA order (8000.82) on September 3, 2003; whereas SMS became a federal regulation in January 2018. An SMS demands a foundation of Safety Culture, to include a reporting culture. However, when the ASAP program became law over 14 years earlier, the ASAP program was designed for pilots to report themselves to the FAA with the claim that the errors were unintentional, and we would learn from them in order to create a fix. The fact is, ASAP is a program that was designed for pilots to report their own errors, or mechanics to report their errors, or the company to report their errors...

While there is more hidden within this program than most pilots are aware, due to evolution, airline management can report themselves and pilots can report to the FAA more than their own operational flight issues. It has been brought to my attention that some airlines do not have their ASAP program designed to allow this part of the program to work. However, for the most part, pilots are in a continued effort to mitigate risk by self reporting their flight mishaps.

Reporting Culture

A Reporting Culture, is where the pilot, or any employee, can report the company for anything they deem unsafe. Rarely do employees run to the FAA as their first course of action. Pilots want the best for their airline, so they report internally to help with that fix. But, often airline management and associated egos don't always have the same safety alignment as the front line employees.

Because the government realized that airline employers retaliate and the union grievance process is ineffective for addressing safety concerns, the Wendell H. Ford Aviation Investment and Reform Act for the 21st Century (AIR 21) was enacted to protect all airline employees for internally reporting "federal standard" safety concerns to their management, or if the employer refuses to listen, to the FAA. The AIR 21 statute became law in 2000, prior to the ASAP program, and prior to SMS.  

Because the AIR 21 statute was enacted in 2000 and SMS became law in 2018, AIR 21 dictates the report must be a federal standard violation. However, the federal regulation SMS mandates a reporting culture, which enables employees free to report anything to mitigate risk and prevent an accident, even if it's not a Federal Standard.  This conflict with laws will be addressed. 

But who protects manufacturer employees?

‘‘Aircraft Certification, Safety, and Accountability Act’’

Sadly employees of manufacturers were not protected under the Air 21 Act. And, the lack of a reporting culture and fear of retaliation had everything to do with the Max crashes. Therefore, on December 22, 2020, congress enacted the Aircraft Certification, Safety and Accountability Act, as a result of those who were fearful to report failures of their manufacturer employer.

Unfortunately, today, those good people at the FAA are not protected for reporting violations and failures within the FAA.  In that we have FAA leadership who has retaliated against a pilot for reporting safety, it's my opinion that FAA employees may be fearful of reporting their employer's actions and will not come forward. We have work to do. 

History of Protection:

• 2000: Air 21 protects all employees at airlines for reporting company-based violations of federal standards.

• 2003: ASAP protects pilots from FAA action for reporting their flight mishaps.

• 2018: SMS: Federal Law was enacted improve organizational performance, mandating a Safety Culture heading into NextGen.  This nothing short of CRM (Crew Resource Management) for the company, now alias: Corporate Resource Management.

• 2020: Aircraft Certification, Safety, and Accountability Act to protect employees for reporting during the manufacturing and certification process, with similar protections as AIR 21.

If management at your airline hangs its hat on having a robust reporting culture because they had 25,000 ASAP reports, be very wary as to whether or not you have a reporting culture at all. That high number of events without the fixes is a sign that the system is not working as it should. The goal is to ensure ASAP reports decrease annually, not increase.  If your online ASAP reporting system does not clearly provide direction and means to report the company under non-flight related issues, this may also indicate a non-reporting culture. Management may not understand that they, too, are protected under this program if the lapses are unintentional. And then... therein lies the answer.  If pilots or the company intentionally violate the law, the ASAP program will not protect you. 

How to Report

• Report to your employer in good faith your concerns in writing, and if able, provide a potential solution to the problem. 

• Provide the federal standard of the violation for reference. 

• Copy a number of managers to ensure there is adequate record if they choose to retaliate, or one person decides to ignore the concern.

• Never report anonymously, at least in the US, or you will not be protected. I personally do not believe there is anonymity within any organization.

• If you report to the company and they fail to listen, placing lives at risk, in the U.S. you can report to the FAA on the FAA online hotline.  

• Make a copy of your  FAA report prior to posting it, with the date on the document. Do NOT report anonymously. Save the number provided, as you'll use that later. 

Retaliated Against?

Under the Air 21 statute you only have 90 days to file a complaint through the agency: Wendell H. Ford Aviation Investment and Reform Act for the 21st (AIR 21). If you need assistance, contact Attorney Lee Seham, he knows the law and will guide you. 

If you would like to learn more about SMS, Safety Culture, Pilot Training, Learning, Understanding, and the history of accidents, or want to read the comments pilots worldwide contributed, you can download the doctoral research here: doctoral research  

If you prefer to read the book that resulted from the research, you can order a paper copy on this blog or find an ebook on Amazon: Normalization of Deviance, a Threat to Aviation Safety. 

Safety is Everyone's Responsibility!

Enjoy the Journey!

XOX Karlene