Organisation’s HF

program
 • Human error has been identified as a dominant risk
factor in aviation operations.
• The errors trapped within daily operations are unlikely
Reporting to be detected in the absence of effective error
reporting.
Errors
• Error reporting is fundamental to the broad goal of
error reduction.
• At the organizational level, error reporting will only
become an accepted and encouraged activity if
aviation personnel feel safe in doing so.
 • Good industry practices is to ensure that errors
do not go unreported.
• Error reports should be used to find the root
Reporting causes of the errors, not to establish blame or
Errors liability.
• Personnel involved in reporting should be given
feedback of the results of the error analysis.
 • The use of a non-punitive approach to reporting is
recommended to encourage personnel to report
errors.
Reporting • The mechanism for reporting errors should be
Errors made straightforward and easily accessible at all
organizational levels.
• The electronic or hard copy reporting forms
should be made unambiguous and easy to use.
 Occurrence Reporting
Two types of Reporting;
1. Voluntary Occurrence Reporting
Reporting 2. Mandatory Occurrence Reporting
Errors
 1. Voluntary Occurrence Reporting
It is a proactive process and should include related
arrangements for collecting information about safety
Reporting concerns, issues and hazards which otherwise will
Errors not be revealed by a mandatory reporting system.
Voluntary error reporting facilitates the collection of
information on actual or potential safety deficiencies
thus contributing to the identification and
implementation of safety improvement measures.
 2. Mandatory Occurrence Reporting:
NCAR 145.A.60 OCCURRENCE REPORTING
(a) The organisation shall report to CAA Nepal, the
Reporting state of registry and the organisation responsible
Errors for the design of the aircraft or component any
condition of the aircraft or component identified by
the organisation that has resulted or may result in
an unsafe condition that hazards seriously the flight
safety.
 2. Mandatory Occurrence Reporting:
NCAR 145.A.60 OCCURRENCE REPORTING
(b) The organisation shall establish an internal occurrence
reporting system as detailed in the exposition to enable the
Reportingcollection and evaluation of such reports, including the
Errors assessment and extraction of those occurrences to be
reported.
(c) The organisation shall make such reports in a form and
manner established by CAA Nepal and ensure that they contain
all pertinent information about the condition and evaluation
results known to the organisation.
 2. Mandatory Occurrence Reporting:
NCAR 145.A.60 OCCURRENCE REPORTING
(d) Where the organisation is contracted by a
Reportingcommercial operator to carry out maintenance, the
organisation shall also report to the operator any such
Errors condition affecting the operator's aircraft or component.
(e) The organisation shall produce and submit such
reports as soon as practicable but in any case within 72
hours of the organisation identifying the condition to
which the report relates.
 2. Mandatory Occurrence Reporting:
NCAR 145.A.60 OCCURRENCE REPORTING
1. The aim of occurrence reporting is to identify the factors
contributing to incidents, and to make the system resistant to
Reportingsimilar errors.
Errors 2. An occurrence reporting system should enable and encourage
free and frank reporting of any (potentially) safety
related occurrence. This will be facilitated by the establishment
of a just culture. An organisation should ensure that personnel
are not inappropriately punished for reporting or co‐operating
with occurrence investigations.
 2. Mandatory Occurrence Reporting:
NCAR 145.A.60 OCCURRENCE REPORTING
3. The internal reporting process should be closed‐
Reporting loop, ensuring that actions are taken internally to
Errors address safety hazards.
4. Feedback to reportees, both on an individual and
more general basis, is important to ensure their
continued support for the scheme.
 2. Mandatory Occurrence Reporting:
The provisions in Chapter 8 of ICAO Annex 13 require the States to
establish mandatory occurrence (incident) reporting (MOR)
systems to facilitate the collection of information on actual or
Reportingpotential safety deficiencies.
Errors Further to that, ICAO requirements relating to the implementation
of safety management systems (SMS) require that aviation service
providers develop and maintain a formal process for effectively
collecting, recording, acting on and generating feedback about
hazards in operations, based on a combination of reactive,
proactive and predictive methods of safety data collection.
 2. Mandatory Occurrence Reporting:
NCAR Chapter C.9 and “CAA Nepal Directive on
Occurrence Reporting” may provide further
Reporting guidance on occurrence reporting.
Errors
 SMS Manual Reference
10.1 Reporting errors
As stated in our company safety policy "Himalaya
Reporting Airline believe in a just, transparent, non-punitive
Errors safety culture that encourages voluntary reporting
of errors and hazards."
 SMS Manual Reference
6.1 Just Culture Policy.
It states "A “just culture” is one that accepts that
Reporting humans are apt to make genuine mistakes,
Errors encourages the reporting of those mistakes, and will
not punish those who report their genuine mistakes.
However, it is also a culture in which a deliberate
departure from standard operating procedures,
rules, standards and best practice is not tolerated."
 • Protection of Reporting Personnel
• The objective of mandatory occurrence reporting is
to prevent safety occurrences, such as accidents
and incidents, not to attribute blame or liability if
Disciplinary they happen. The person filing a safety report needs
policy to have the strong assurance from the regulatory
authority and the employer that prosecution or
punitive actions such as suspension of licence will
not be sought unless the unsafe act is deliberately
committed or gross negligence is demonstrated.
 • It is stated in our company safety policy "No action will
be taken against as individual who submits a voluntary
report, unless it involves as illegal act, gross negligence,
or a willful disregard of procedure or regulations.“
•
Disciplinary Appendix-8, of SMS manual. The disciplinary policy
states "In order to decide whether a particular behavior
policy is culpable enough to require disciplinary action within
the SMS environment, in response to errors and
violations, a policy is required to decide fairly on a case-
by-case basis.
 • Human error investigation starts when we
know or suspect that it was a human
Error
action or lack of action that caused the
Investigation quality defect or deviation from the
process to occur (non-conformance,
failure).
 • SMS Manual Section 6 - Safety Reporting, Sub-
section 6.2 - HIM Safety Reporting and
Investigation Policy, gives an outline for the
Error reporting and investigating procedures.
Investigation • For Error investigation, as discribed in SMS
Manual Appendix - 8: Enforecement Policy "In
order support our disciplinary policy, James
Reason's Culpability Decision-Tree is used
which helps us to decide on the culpability of
an unsafe act."
 Error
Investigation
 • As per the Enforecement Policy in Appendix - 8,
following are the Disciplinary Actions for Unsafe Behavior
determined through Reason's Culpability Decision-Tree:
Action • Unsafe Behavior Disciplinary Action
• Human Error Counseling
to address
• Negligent Conduct Caution
problems • Reckless Conduct Warning
• Intentional "willful" Demotion / Violations
Termination
 • Feedback is simply defined as a process of
giving constructive suggestions by
supervisors, reporting managers as well as
Feedback peers aimed at improving performance,
reinforcing good behavior and improving
employees' morale and dedication to doing
their jobs.
 • Details of feedback for safety reporting is outlined
in SMS Manual Sub-section 6.3.2.3 Feedback:
• Safety Department staff will:
• Provide feedback to the reporter via email
Feedback regarding the receipt of his report.
• Provide feedback to the reporter after the action
take
• Provide feedback throughout the company via the
company safety promotion scheme if required.