What is Occurrence Reporting?

In a modern environment, occurrence reporting has become essential to aviation safety. The production of aircraft and the regulatory safety oversight has become so good that it is hard to do better in that area. Statistics and analysis of aviation occurrences tells us that the primary causes for aircraft accidents and serious incidents are in one way or another connected to human factors. This fact should, however, empower us to turn this human weakness into a success by learning from our mistakes. In that manner we can increase both flight safety and the enjoyment of all those who fly.

What is an Occurrence?

Occurrence is defined as an operational interruption, defect, fault or other irregular circumstance that has or may have influenced flight safety and that has not resulted in an accident or serious incident. That is why an Occurrence Report is a way that allows all parties to provide information about Occurrences to the Icelandic Civil Aviation Administration (ICAA).

New Law

Occurrence Reports that are received by ICAA are strictly confidential. It is not allowed to use an Occurrence Report as a document in a court of law or to punish the originator. However, only Occurrences that are defined as ‘gross negligence‘ e.g. alcoholic or drug abuse and intentional violation of air law do not fall under this protection.  The law also provides a protection of the information that is provided by the reporter. See also: Article 47, 47a, 138, 141 in the Aviation Act no. 60/1998 as well as regulation on Occurrence reporting no. 53/2006 and EU Directive  no. 2003/42/EB.
This means the ICAA does not keep a record of the names of originators who experience incidents and will not use it against them. The report will therefore free the originator from repercussions if he reports within 72 hours. If it is proven that the originator is guilty of gross negligence this protection will automatically be voided.

Changed attitude towards reporting

The decision to report an occurrence requires an attitude change. Human nature wants to hide the mistakes due to the fear of repercussions or punishment. But the occurrences have to emerge so we can learn by our mistakes. That’s why pilots need to be able to report technical failures, flawed procedures and their own honest mistakes so we can analyze the trends that could be a hidden source of dangers that could cause accidents or serious incidents. Honest reports are therefore a key ingredient towards increased flight safety.
The changes in the Aviation Act make it therefore safe to report to the ICAA. There is no advantage to the ICAA to revoke licenses or punish people in any way for their honest mistakes. On the contrary it is everyone´s benefit that people keep their licenses and that lessons are learned from reported occurrences. The main objective is to prevent accidents, not to blame anyone.
It is worth noting that airlines are obligated through EU OPS to report certain types of incidents. This is therefore not a new addition to the requirements, but rather an attitude change regarding occurrence reporting as well as the regulators' understanding of the real value of those reports and the need for the just culture policy.

Why should I report?

The main reasons for sending in a report are firstly to increase flight safety and secondly to prevent accidents.
As an example we can say that an occurrence has no statistical meaning to the pilot who experiences one. But if everyone reports similar incidents, a valuable source of information is created that can give us many clues on the root causes. For example, if there is an unusual increase of similar occurrences it is possible to intervene with better education and training and therefore reduce the probability of recurrence of such occurrences that could cause serious incidents and even accidents.

All countries in the European Union have started to record reported occurrences according to the EU Directive that came into force on July 4th 2005. That data along with the Icelandic data are collected into one big database. That database will give us the ability to compare our aviation safety to other countries. That will increase our learning and perspective on technical failures and the human response towards those failures. 
Aviation is about cooperation.  That is why it is necessary to learn from the mistakes being made.  That is why we report occurrences.

What should I report?

A list of what should be reported is available in the annex to Regulation 53/2006 regarding occurrence reporting. That list is not a complete one, rather those who report are to evaluate the occurrence based on the list.  This annex is to be used as a reference. An exception can be seen at the end of this document.

To whom should I report?

Accidents and Serious Incidents must be reported immediately to AAIB tel. 511-1666, 112 or email rnf@rnf.is according to the Aviation Act and the new regulation about Occurrence Reporting. The same regulation states that all occurrences, accidents and serious incidents shall be reported, on a ICAA form, to ICAA, sent by email or fax within 72 hours of the incident.

The forms can be accessed from the front page on this website and at the ICAA’s Flight Safety Division, Skogarhlid 12, 105 Reykjavik. Flight operators can use their own forms given that they are accepted by ICAA.

How are the reports handled?

All received reports are entered into an access restricted database where all original records of the occurrences are stored. The reports are then reviewed and a decision made on whether more information is needed. Then the occurrence is entered into a local version of the international database (ECCAIRS) which is designed, produced and financed by the European Union. This database was designed to describe occurrences in a detailed manner and is used both by CAA’s and AAIB’s in many countries. Operators can also use this database if they so please. Note that personal information as well as information that can link an individual to an occurrence is NEVER entered into the ECCAIRS database.
The ECCAIRS database can be used both for statistical purposes as well as an investigation tool. Here in Iceland this database is both used by ICAA for statistical analysis and by the AAIB for investigations on aircraft accidents and serious incidents. Public statistical information from the database will be published as often as needed.

Note that aircraft operators and others that can be considered an ‘interested party’ (see Commission Regulation (EC) No 1330/2007) are the only ones that can ask for information regarding their own occurrences.  Enquiries regarding rivals will be turned down.

Airline operators and other parties connected to flight operations can get information processed from the ECCAIRS database that can help them to make their flight operations even safer. An example of such information is statistical information regarding occurrences that are associated with the same type of aircraft they are using, the frequency of certain failures compared with other aircraft of the same type, frequency of TCAS incidents compared with other nations in Europe etc.

The key to success

The fundamental issue is that there exists a positive attitude regarding occurrence reporting and that the just culture policy is intact and supported by authorities. Such a foundation will make the database strong, reliable and a helpful tool, contributing greatly to flight safety.

This is now a fact in Iceland. Therefore, everyone that takes part in flight operations e.g. airport staff, air traffic controllers, pilots, and mechanics can report occurrences without the fear of repercussions.

Steady development in flight safety

A positive attitude and an open mind towards occurrence reporting needs to be continually integrated into all companies that work in the airline industry. That way we will succeed, and that way we can decrease the number of accidents and serious incidents more than ever before.

That’s how we increase flight safety.

MANDATORY REPORTING OCCURRENCES
— Reference list of occurrences—

The following occurrences have to be reported on an ICAA form or other forms accepted by the ICAA Flight Safety Division. This list is in two parts.  On one hand are occurrences that void the aircraft’s airworthiness and on the other hand are various occurrences that are mandatory to report. A condition that makes an aircraft unfit to fly is usually discovered during inspections and routine maintenance, but occurrences happen during the operation of the aircraft. The following list is not exhaustive.
IF YOU ARE IN DOUBT, THEN FILE A REPORT.

A guide for filling out the ICAA form is available on the ICAA website www.caa.is.

    Un-airworthy Conditions (Reported by Maintenance)
  • 1. Serious cracks, permanent deformation, burning or serious corrosion or failure of structure of the aircraft or engine.
  • 2. Failure of any emergency system during scheduled testing.
  • 3. Failure of a life limited component before completion of the full life of the component.
  • 4. Any failure, malfunction or defect that is a result of complying with an AD or SB.
  • 5. Un-airworthy conditions must be reported to the CAA and Aircraft Type Certificate holder.

    Occurrences (Reported by Flight Crew and/or Maintenance)
  • 1. When a SYSTEM DEFECT occurs which adversely affects the handling characteristics of the aircraft or renders it unfit to fly.
  • 2. When DOUBLE Aircraft SYSTEM Failure Occurs.
  • 3. Flameout, shutdown or significant MALFUNCTION of any ENGINE.
  • 4. When there is warning of FIRE or SMOKE, or when fire, explosion, smoke, toxic or noxious fumes occur.
  • 5. TECHNICAL document ERROR that could endanger aircraft safety.
  • 6. When an EMERGENCY is declared.
  • 7. When SAFETY EQUIPMENT or PROCEDURES are defective or inadequate.
  • 8. When deficiencies occur in any OPERATING PROCEDURES or MANUALS.
  • 9. When there is incorrect LOADING of fuel, cargo or livestock, or DANGEROUS GOOD, or as significant LOADSHEET error.
  • 10. When OPERATING STANDARDS are degraded due to deficient GROUND SUPPORT facilities.
  • 11. When GROUND DAMAGE occurs.
  • 12. When a REJECTED TAKE-OFF is executed after take-off power is established.
  • 13. When an EXCURSION occurs, if any part of the airplane leaves the paved surface during taxiing, take-off or landing.
  • 14. When significant HANDLING DIFFICULTIES are experienced.
  • 15. When a NAVIGATOR ERROR occurs involving a significant deviation from the intended track.
  • 16. When a HEIGHT CONTROL error of more than 300 feet occurs.
  • 17. When there is an EXCEEDANCE of the LIMITING PARAMETERS for the AEROPLANE CONFIGURATION or when a significant UNINTENTIONAL SPEED CHANGE occurs.
  • 18. When COMMUNICATIONS fail or are impaired.
  • 19. Whenever a GO-AROUND or a WINDSHEAR GO-AROUND is flown.
  • 20. Whenever a GPWS WARNING occurs.
  • 21. Whenever STALL WARNING occurs.
  • 22. When a HEAVY LANDING CHECK is required.
  • 23. When serious LOSS OF BREAKING occurs.
  • 24. When the AEROPLANE IS EVACUATED.
  • 25. When the aircraft lands with FINAL RESERVE FUEL OR LESS remaining.
  • 26. When an AIRPROX (Air miss) or ATC INCIDENT or WAKE TURBULENCE event occurs.
  • 27. When significant TURBULENCE or WINDSHEAR is encountered or other SEVERE WEATHER.
  • 28. When crew or passengers are SERIOUSLY ILL, INJURED or become INCAPACITATED.
  • 29. When there is difficulty in controlling VIOLENT, ARMED or INTOXICATED passengers or when the passenger RESTRAINT KIT is used.
  • 30. When TOILET SMOKE DETECTORS are activated or vandalized.
  • 31. When an act of aggression, e.g. passengers or HI-JACK occurs.
  • 32. When SECURITY procedures are breached.
  • 33. When BIRD STRIKE or other FOREIGN OBJECT DAMAGE occurs.
  • 34. Any event where SAFETY STANDARDS ARE SIGNIFICANTLY REDUCED occurs.
  • 35. When TCAS resolution advisory occurs.
  • 36. Any event, which may provide USEFUL INFORMATION FOR THE ENHANCEMENT OF FLIGHT SAFETY.
  • 37. When the aircraft did not LAND at PLANNED destination.