ENR 1.

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ENR 1.14 AIR TRAFFIC INCIDENTS

General
The investigation of air traffic incidents is one of the best means available of identifying
the steps that must be taken to promote aviation safety. In order to assist the CAA in
identifying any problems and to take such steps as appear to be necessary, pilots and
aircraft operators are requested to report such incidents as quickly as possible. The
reporting procedures are described below.

1 Definition of air traffic incidents

An "air traffic incident" means a serious occurrence involving air traffic, such as-
1) a near collision; or
2) serious difficulty caused by:
a) faulty procedures or lack of compliance with applicable procedures; or
b) failure of systems or ground facilities.
c) Any other phenomena/action that has potential to jeopardise aircraft safety, while
in the air or ground, for the purpose of flight.
A near collision is an occurrence in which a collision between two or more aircraft is
prevented only by some fortuitous circumstances or the taking of some avoiding action
by one or more of the pilots concerned.
It is emphasized that any incidents affecting air traffic safety should be reported by
means of the procedure described herein.

2 Reporting of Air Traffic Incidents by pilots

2.1 A pilot who has been involved in an incident should proceed as follows:
a) During flight he/she should use the appropriate air/ground frequency for reporting
an incident of major significance, particularly if it involves other aircraft, so as to
permit the CAA to ascertain all relevant facts immediately.
b) As promptly as possible after landing he/she should submit a completed
appropriate CSSR Form published on SACAA website.
i) for supplementing a report of an incident made initially as in (a) above, or making
the initial report as such incident if it was not possible to report it by radio;
ii) for reporting an incident which did not require immediate notification at the time of
occurrence.
2.2 An initial report made by radio should contain the following information:-
– Callsign of aircraft making a report
– Position
– Flight level, altitude or height
– Avoiding action taken, if any, including reasons thereof
– Time of incident where possible

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NOTE: Incident report on Air/Ground radio should be kept as brief as possible, as the
communication facility might be required for continued operations by Air Traffic Services.
The Pilot in Command is required to complete and forward a comprehensive incident
report on appropriate form after landing.

3 Purpose of reporting.
The purpose of the form is to provide the CAA with as complete information on an air
traffic incident as possible in order that a proper investigation of the incident may be
made and the necessary steps taken to avoid a recurrence of similar incidents. Where
the form is completed properly, and in detail, it will normally not be necessary to call
for further information and it will be possible to complete the investigation with the least
possible delay.

4 CONFIDENTIAL AVIATION HAZARD REPORTING SYSTEM (CAHRS)

4.1 HAZARDS AND INCIDENTS
a) Hazards are negative indications of a safety trend, or a possibility for an incident or
accident.
b) Hazards include, but are not confined to, human factor errors, inadequate fire and
rescue services, bird siting at aerodromes or in migration, issues such as runway
markings which are difficult to see, lack of diligence given to aeronautical
information circulars, poor communication, ignorance about dangerous goods,
incorrect perceptions of ATC or pilots, ergonomics, confusion about which
frequency to use, visual illusions, medical problems, lack of or misunderstanding
of legislation, prevalence for near collisions, passenger behaviour, poor ramp
standards.
c) Many incidents are reportable to the Director of Civil Aviation in terms of Part 12 of
the Civil Aviation Regulations, 2011. These incidents must not be sent as a CAHR
report. In such cases, if this is reported to the designated body or institution, the
reporter must be advised of the correct method for such reporting. The designated
body or institution will still maintain the confidentially of such a reporter and will not
forward the report to the Director of Civil Aviation. However, the nature of the
hazard may be used for awareness purposes.
d) Confidential aviation hazard reporting is a tool for accident prevention in that
hazards are identified before there is loss of life, injury or damage, i.e. loss. It is not
a statistical tool. It is non-punitive.
e) For further information on identification of hazards and confidential reporting refer
to ICAO Technical Publication Accident Prevention Manual (Doc 9422).

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5 PROCEDURES
The confidential aviation hazards reporting system is operated as follows:
a) Reporting and receipt of reports
b) Allocation of reference
c) Place in safe keeping
d) Make contact with reporter, if necessary, for further information
e) Destruction of name and other details of reporter
f) De-identify report
g) Referral to others, if necessary
h) Publication of some reports
i) Summary of reports
j) Place on file
k) Data exchange.
5.1 Receipt of reports
1) A dedicated post office box is maintained. The key is kept by a designated
person(s) who undertakes to collect the mail and hand unopened to the analysts.
2) Reports may be submitted on the CAHR form or by any other medium.
3) Reports received by fax will not get guaranteed confidential.
4) Receipt may be accepted on electronic media but will not be guaranteed
confidential unless methods for such confidential reporting have been developed
and proven reliable.
5) Reports may be submitted by anyone in the aviation industry or who is concerned
about safety in aviation.
6) It is preferable that the reporters provide names and phone numbers so that
analysts can contact them for further information, if necessary
7) Anonymous reports, i.e. without name or phone number, will be accepted.
However, less significance may be attributed to such report as the reporter cannot
be contacted for further relevant information which may be required for analysis.
5.2 Allocation of reference
A reference shall be allocated for the report and will be used for any correspondence
or publication of the report where relevant.
5.3 Safekeeping
All reports with identifying information retained are kept in safekeeping (safe or locked
cupboard or room). Only the analysts have access to the documentation until reports
have been de-identified.

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5.4 Make contact with reporter, if necessary, for further information and feedback
1) Contact with the reporter may be made only by the analyst. Extreme sensitivity is
exercised when phoning the reporter bearing in mind that if his or her identity is
revealed, the repercussions could be detrimental to the reporter and the future of
the reporting system.
2) When the reporter is contacted, he or she is advised of the action to be taken, that
identifying information will be removed and that all records of the reporter will be
destroyed.
5.5 Destruction of name and contact details of reporter
1) Once the analyst has obtained any necessary further information from the reporter
the name and contact details are removed from the report form.
2) The methods in which this is done, is determined by the designated body or
institution, such as by phone or by return of the section of the report which contains
the name.
5.6 De-identify report
1) All reports are de-identified through the removal of identifying information from a
report in a method that alters the information so that the reporter cannot be
identified.
2) Each report is treated on its own merit.
3) Generic terms are used to replace this information, e.g. types of aircraft,
aerodromes, routes.
4) It is accepted that with some reports the inevitable results of de-identification
results in non-specific apparently ineffective information. The relaxing of de-
identification may place the credibility of the confidentiality of the system in
jeopardy.
5) De-identification is always conducted even if the reporter indicates otherwise.
5.7 Referral to others if necessary
1) Unless the report indicates imminent catastrophe, referral is not immediate. A time
lag between occurrence and referral enhances confidentiality as the report does
not appear so specific. This reduces the possibility of a witch hunt response or easy
identification of the reporter.
2) The analysts identify relevant organisations, authorities, companies, e.t.c, which
may benefit from knowledge of a hazard and refer the report to them.
3) Referrals include a clause that this information has not been verified, but is in the
interest of aviation safety and is for information.

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5.8 Publication of some reports

1) De-identified reports may be published by the designated body or institution in a
feedback publication and reports may be used by any other media for the purposes
of aviation safety.
2) Any method of publication may be used if it is deemed to be suitable for the widest
relevant group.
3) The analysts may withhold some de-identified reports from publication, e.g. if a
report is not seen to be related to aviation safety, or if, even if de-identified, the
reporter could still be recognised. However, this does not prevent the analysts from
providing relevant organisations with the basic hazard.
5.9 Summary of reports
1) A summary of reports is maintained, and a copy is sent to the Director of Civil
Aviation quarterly.
2) Such summaries are available on request by any sector of the aviation industry.
5.10 Filing and data retrieval
1) All de-identified reports are filed by whatever means the designated body or
institution finds suitable.
2) All de-identified reports are preserved.
3) The filing system is such that retrieval is simple.
5.11 Data exchange
1) Any reasonable request for copies of de-identified reports will be made available
on request to any person. The designated body or institution has the right to refuse
a request if there appears any risk of the reporter being identified.
2) International guidelines and protocols on data exchange are followed.

6 MANNER IN WHICH SYSTEM IS OPERATED

6.1 Administration
1) Credibility in the confidentiality of the system is of the utmost importance. Those
involved in the analysis require an approachable personality, have the respect of
the industry, have experience in aviation and a knowledge of human factors. An
analytical person with a conceptual rather than focussed approach is essential.
2) An analyst is a person designated to analyse confidential reports and is entrusted
with the identifying details.
3) An assistant analyst is any person who assists the analyst but who is not provided
with identifying details.
4) The number of analysts is determined by the designated body or institution.
Analysts may be employees of the designated body or institution or be retained for
remuneration or on a voluntary basis. Analysts are selected for their expertise,

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confidentiality and sensitivity, with an understanding of human factors. They must

not be in the employ of any aviation operator, aerodrome operator or air traffic
service unit.
5) Assistant analysts are selected for their expertise and may be in the employ of an
aviation operator, aerodrome operator or air traffic service unit.

7 ADVISORY COMMITTEE
1) The designated body or institution must establish an advisory committee. Terms of
reference for the advisory committee for the following purposes:
a) To detect significant aviation safety trends arising from hazard reports;
b) to identify those safety trends that may be appropriate for investigation by other
committees or Working Groups;
c) communicate pertinent findings concerning safety to the Director of Civil Aviation
or appropriate sectors within the industry;
d) to provide expert opinion, information and assistance as and when required for
hazard analysis;
e) to disseminate information and alert bulletins to the disciplines that make up the
aviation industry;
f) to monitor the methodology, analysis and feedback of the confidential aviation
hazard reporting (CAHR) system; and
g) To assist the analysts in the editing of publication material
2) The committee must comprise of expert technical representatives from a wide variety
of sectors including employer and employee groups, aircraft owners and manufactur-
ers, airlines and general aviation, engineering and maintenance, recreational flying, air
traffic services, e.t.c.
3) The committee must meet regularly but not less than twice per year.

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CONFIDENTIAL AVIATION HAZARD REPORTING SYSTEM (CAHRS)

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