In order to tackle the problem of human error on the flight deck (which accounts for the majority of commercial aircraft accidents), a database of self-reported errors in serious incidents is required in addition to the independent investigation of aircraft accidents and serious incidents, which is now required by EU Directive (94/56/EC). Confidential incident reporting systems already exist around the world. Although none should be regarded as a precise model for a European system, they do demonstrate the potential utility of the technique in acquiring data concerning human error. Incident reporting systems rely on gathering data from individuals about their mistakes and guaranteeing that their identities will not be revealed, especially to their employer or licensing authority. The legality of operating a confidential system, and of protecting the identities of reporters, must be closely examined in the context of different European jurisdictions. To ensure that benefit accrues, every effort should be made to maximise the feedback of information to aviation personnel and to integrate stored data with those data gained from other incident reporting programmes and accident databases on a world-wide basis. Such systems cannot be operated or funded by airlines or regulatory authorities if aviation personnel are to have faith in them. A European system should be funded centrally, and operated from a co-ordinating hub with satellite reporting stations in European states or regions. The establishment of an effective European confidential reporting system is possibly the single greatest innovation that could be made to improve European and world air safety. This importance should be recognised and reflected in the priority and funding that it is given. (Author/publisher)
Samenvatting