1. The NATS Review of ATM Occurrence Reporting Prepared for ICAO European Region Aviation Safety Seminar/Workshop (Baku, Azerbaijan, 5 -7 April 2006) by Jane Gothard Head of International Safety NATS

2. Background to the NATS Review
In November 2001 NATS began a review of its Occurrence Reporting process against a background of:
NATS already having a mature Occurrence Reporting Scheme;
NATS having no immediate concerns over occurrence reporting levels;
(2001 data Mandatory Occurrence Reports featuring ATC Error )
Some NATS units having established locally devised lower level reporting systems
125 (54.8%) of the MORS did not involve a loss of separation.
The presence of SMF has given NATS confidence about the reporting culture over time over time;

3. Review Objective
To determine improvements to NATS safety reporting which would:
Maximise capture of operational occurrences and observations;
Facilitate effective lesson learning;
Provide a single company-wide scheme.

4. Expectations To improve on what NATS has at present;
To have the confidence of the users;
To ensure continued alignment with regulatory requirements;
To be simple but effective;
To be accommodated within existing resource.

5. Review Team Membership
Sponsor: Director Airports
Leader: Terminal Control Watch Manager
The following areas of NATS were represented on the review team:
ATC Investigators
Human Factors experts
Operational Controllers
Air Traffic Services Assistants
Trades Union
Corporate Areas including:
Division of Safety & Quality
Engineering Policy & Assurance
Air Traffic Operations
External Representative: CAA SRG ATSSD

6. Information Gathering
Information was gathered from 2 sources:
Staff Questionnaire
External Best Practice Visits
A UK Airline
An Oil Company

7. The Staff Questionnaire
What inhibits reporting?
A sample of ATC and Engineering staff at Gatwick; ScOACC;
Aberdeen and London Terminal Control Centre were asked to rate
the following according to a five point scale:
Blame Culture
Too time consuming
Discouraged by peers
No feedback
Nothing will happen
Discouraged by management / supervisors
need to explain where the 6 reasons came from in the first place
( the groups previous experience) and the fact that the survey
gave the opportunity to identify other reasons - 2 others that are worth
recording are:
1 Its part of my normal job to correct mistakes
2 Assumption that others will do it
both of these reasons are cultural issues and should be addressed
by education

8. What Inhibits Reporting?
Questionnaire
Results
Response rate: +80%

9. What Inhibits Reporting? - Results
The results of the NATS survey showed that:
Most respondents rated perceived ‘Blame Culture’ as either the
primary reason or the secondary reason that may prevent them
from reporting all occurrences.
Most respondents rated ‘Discouragement by Management ’ as
either not a factor in decisions regarding reporting safety
occurrences or a factor of low importance.

10. External ‘Best Practice’ Visits
The Airline Scheme
Procedures detail 44 categories of events to be reported
- of these 50% are items requiring an Mandatory Occurrence Report to be submitted
- 50% relate to pilot performance.
Electronic monitoring on the flight-deck encourages reporting.
Aircrew competency issue following incident handled internally.
Reporting system utilises single form for both safety reporting.
50 confidential aircrew reports per annum
8000 aircrew reports per annum - of which 800 are MORs
Operating both “ASR” & “Confidential” Systems
- trying to phase out “Confidential” system

11. External ‘Best Practice’ Visits
The Oil Company Scheme
Safety Reporting system is an integral part of a wider ‘Safety
Culture’ programme.
Scope of scheme:
- All staff; Contractors & Visitors;
- All aspects of safety including ‘Health & Safety’.
Single report form for all events.
Emphasis on staff empowerment- what action did you take?
Report Nomination scheme.

12. Implementation Experience
Airline Experience
- Air Safety Reporting Scheme has taken 10 years to reach maturity.
Oil Company Experience
- original implementation plan too ambitious;
- buy-in needs to come from top - need to demonstrate by behaviour;
- comprehensive education system - from top down;
- 4 / 5 years before staff accept the system.

13. Key Issues with Occurrence Reporting
Perceived ‘blame culture’;
Lack of feedback;
Time consuming;
Nothing will happen;
Diversity of reporting schemes;
Limited reporting of low level or corrected events;
Limited NATS-wide dissemination of lessons learnt

14. Key Issues / Solutions Matrix

15. Key Proposals for Improvement
The solutions matrix addressed the key points raised in the staff survey.
In addition, the following improvements to occurrence reporting were
made:
Emphasis on a ‘just’ culture rather than a ‘no-blame’ culture;
The introduction of a in-house reporting process called ‘Open
Reporting’ to capture low level safety events that are in addition
to those captured by The CAA Mandatory Reporting Scheme;

16. Taking the Work Forward

17. The Pilot Process
UK CAA agreed to NATS introducing a trial ‘Open Reporting’ Process:
The trial was conducted at Aberdeen and London Terminal Control;
The trial scheme covered both ATC and Engineering Reports;
Trial was introduced in August 2003: duration 6 months;
The ATCO; Engineering and Air Traffic Assistant grades were involved
Health & Safety Issues were not included.
Pilot scheme - an internal review every month
- joint NATS/SRG review after 4 months;

18. Results of the Pilot
The introduction of the trial Open Reporting Scheme did not
prejudiced the existing CAA Mandatory Occurrence Reporting
scheme;
NATS was encouraged to see that the scheme quickly yielded
information that previous established reporting processes may not
have picked up, for example:
Poor technique in operational hand-over
Failing to apply best practice operating techniques.
Results of Trial:
Aberdeen – 65 ATC Reports in total
41 MOR
24 ‘Open’ Reports
LTCC – 373 ATC Reports in total
313 MOR
60 ‘Open’ Reports
Other topics reported:
Strip outfall
Avoiding action taken not leading to loss of separation
Incorrect telephone numbers on operational positions
Out of date maps

19. Transition into Operation from October 2004
Revised Safety Management Procedure:
Covers both Mandatory Occurrence Reporting and ‘Open’ reporting
New NATS Reporting Form
Including new box –
‘Other Information and Suggestions for Preventative Action’
Includes NATS/SRG Code of Practice
The opening statement in CAP382 (The Mandatory Occurrence Reporting Scheme) makes it clear that the purpose of the MOR scheme is to benefit flight safety and that it will not be the policy of the CAA to institute legal proceedings as result of events reported under the scheme. Additionally, it is stated that the CAA expects that employers will not act in a manner that may inhibit reporting through taking disciplinary action.

20. Results so far……….
2001 data
- 228 Mandatory Occurrence Reports (featuring ATC Error )
2005 data
- 5,400 Occurrence Reports Filed
- 3,800 Mandatory Reports (600 with some ATC Error)
- 1,600 Open Reports

21. EXPECTATIONS HAVE BEEN MET
To improve on what NATS had;
To have the confidence of the users;
To ensure continued alignment with regulatory requirements;
To be simple but effective;
To be accommodated within existing resource.    

22. End