(a conversation with some skydivers)
The reason you're reading this goes back to September, 1996. At the end of the riggers meeting that month, under any other business, the Chairman asked the committee to look at the possibility of setting up a confidential incident reporting system. This would enable any common recurring equipment problems to be identified. The membership could then be informed, hopefully preventing the same problems from happening again. It sounded simple enough, so being quite a simple chap, I took this request on.
Now in case some of you out there don't know exactly what a confidential reporting system is, here's a quick explanation.
Sometimes in life, and especially in aviation, things happen which we don't always want people to know about. This reluctance to tell a story could be for many reasons. Perhaps you might feel that you're in the wrong. “I'm bang to rights for this one” Perhaps you don't feel that it’s important enough to warrant a discussion. “It’s not a problem” Perhaps you think you might get someone in a whole world of trouble if you say anything.
“ I don't want to land anyone in it” Or perhaps speaking out could affect your position among your peers. “I’ll be laughed off the D>Z> if I bring this one up” There are loads of reasons why you should keep quiet, and they may be quite valid ones.
A confidential reporting system can solve all this. Now you can report on your experiences without any fear of embarrassment, or recrimination being directed at you or your mates. Much more importantly, you just might have identified a problem that was about to kill somebody, and which had you kept quiet, would have.
In order to research this concept of accident prevention, I spoke to many experienced people, in particular at Farnborough, where they've been running two of these systems for years. It’s been tried. It works. We are one of the few remaining elements of aviation in this country not to have such a system. As I dug deeper, I learnt more about the anatomy of an accident. Why do they happen? I discovered that the oldest saying I’d ever heard about accidents was true. It’s never one big thing that goes wrong. It’s always a whole list of little things at once.
The sudden once in a lifetime meeting of these little things creates a “Causal Chain”, and you have an accident, or in our language, a fatality. The removal of any one link in that chain could prevent the accident from happening.
Interesting? It would be nice, I think in the future, to have the resources to make a similar film based around a skydiving accident, and give one to every drop zone and rigging shop in the country. I hope you could see from the film something of that causal chain I was talking about earlier. The removal of any one single link in that chain of events could have prevented that accident. Even the simple task of moving the aircraft from one end of the hangar to the other, was a contributing factor, insignificant in itself, but still a link in that chain.
On the equipment side of things, within our own slice of aviation,
there are a few examples of small links-in-the-chain.
Now within Parachuting in this country, just as in that example of military
aviation, it goes without saying that there is already a reliable set of rules
and practices for ensuring the safe maintenance and operation of equipment.
but it can only really be amended as a result of lessons learnt the hard way.
There are a great many lessons learnt every day out there by operators and
maintainers of parachutes, but where such lessons are learnt as a direct result
of a bad attack of “cognitive failure” on the part of an individual, is he
likely to come forward with a report? Of course not , and for all the reasons
which I stated earlier. And that's where the Confidential Report System comes
in.
 |
 |
 |
 |
 |
At this point I’d like to give an example of one typical system and it’s operation. I'm afraid that all these systems suffer from a military disease, in that they love to use jargon and abbreviation at every opportunity. The system used by the Pilots and Air Traffic Controllers in this country is no exception. They have the Confidential Human-factors Incident Reporting System, or CHIRPS.
Of course you haven't, it’s confidential! This has a target population of approximately 19,000 Pilots and Air Traffic Controllers and even publishes a monthly magazine within the aviation industry. It is now funded by the CAA, but was originally set up at an RAF level, to act as an uninfluenced broker of information. They operate a secure office, answer phone and fax, and also use a free post mail drop facility.
Forms are provided in their monthly magazine, “Talkback”, on which the sender can fill in as much or as little name information as he/she wishes. At this stage there is name and address box on the form. This serves a dual purpose. It serves as a checback facility, to confirm the identity of the originator. It also provides a means of clarifying any relevant points with the originator of the report. Once the information has been sorted, and any points extracted which the editor feels may be relevant for the readers of the magazine, the report is “dis-identified”. This process removes all traces of the originators identity, and is vital to maintaining the confidentiality of the system. As a final security measure, the report is filed , and the name and address boxes removed from the form and returned to the owner.
The reports filed under the CHIRPS system have covered a wide
range of subjects over the years. It has highlighted many problems, among
them crew fatigue on long haul flights, bad positioning of controls in aircraft,
and even areas of poor radar coverage over the UK. It is unlikely, for example,
that anyone would have been able to identify how big the pilot fatigue problems
on long haul flights were, if this system had not been available as a Confessional
box for pilots . No aircrew was likely to walk into his managers head office,
and tell the boss that he sometimes falls asleep at the wheel!
Well, there's a brief overview of one such system and it’s basic make-up.
There is a big difference between an anonymous reporting system and a confidential one. Anonymity can be used to abuse the system. It can lead to anarchy. Confidentiality can lead to confidence in the system. It provides the ability to confirm and clarify relevant details. However, the other side of the coin is that once that information is confirmed, the manager of the system must assume a similar relationship to the reporter as the role of doctor or priest. The first abuse of that privileged position by the manager will severely damage the trust of the parachuting population in the system .
But not everyone uses riggers, and as I'm sure you know, a jumpers personal kit is ultimately his or her own responsibility. Our target population will be defined by cost limitations, but as far as I can see, this should be anyone who owns, uses or maintains parachute equipment.
The worst type of form is the tick box type. The form should attract a simple telling of a tale in simple English, with a big space available for the plain facts to be spelt out. Relevant details, such as experience levels, position held, equipment type and age, should be asked for in individual boxes. But the report should cater for the convenience of the reporter, not the managers filing system.
The manager must be capable of and allowed to input the necessary information at the right level within the skydiving community to have the right effect. Two obvious examples would be an input at each Riggers meeting, or liaison with the National Safety Coach on more urgent matters. The manager of the system will need considerable skill and tact in putting any information into the right system at the right point in it’s structure. The two greatest difficulties in dealing with reports are the maintaining of complete anonymity, and the possibility of a disgruntled party abusing the system for his own purposes.
There are many who have feared over the years that widespread distribution and publication of problems in skydiving could have a detrimental effect on the sport as a whole, by displaying the sport in a bad light to the general public. This is a valid point, but should be viewed alongside the alternative of keeping the skydiving population in the dark. The manager must have the right to make direct contact with all interested parties in aviation. Manufacturers, operators, and individuals.
A regular feature should be introduced, ideally in the magazine, to keep skydivers aware of the system, and bring solutions to the notice of the target population.
This is a difficult one! Post and phones cost money, and given our already hard pushed funds, would anyone be willing to guess where we as skydivers would find funding for this system? Should we ask someone to take on this role in addition to the job spec they already have? Perhaps we should combine our efforts in this field with the micro light, or pilot, or parascending fraternities. (TALK ABOUT MIKE RAYMAN’S JOB SPEC AND WORKLOAD)
Another difficult one. The site has to be somewhere where it
can be accepted as an honest broker of information. It is unlikely that an
office in a regulatory authority building in the sport would be acceptable
to the target population.
To summarise
1/ A Confidential Report System can identify human factors and equipment problems, which could cause an accident, early enough for a change in a critical link of the causal chain to be made.
2/ In order to work, reports have to be encouraged, by it being seen to work by the target population.
3/ The data can be used to help improve the design of a more efficient operating environment in the future.
4/ A Confidential Report System costs less to run than the accident it can prevent.
