News story: The evolution of incident reporting, from pure statistics to nuanced insight

Rarely did anyone attempt to grasp the wider implications of a particular incident for the future, or spot trends or patterns or read across issues to other aircraft. There was a corresponding lack of corporate memory as to related incidents which had occurred in the past…

The Nimrod Review: An independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006, Charles Haddon-Cave QC, October 2009, P149

I make recommendations for a new safety culture…

Ibid, P569

A reporting culture is one of the cornerstones of an engaged safety culture. As such, the Military Aviation Authority (MAA) requires that all air safety occurrences are reported and managed, with appropriate action taken, see RA 1410: Occurrence reporting. As such, the MAA provides the Air Safety Information Management System (ASIMS) as both a ‘bottom-up’ and ‘top-down’ system: ASIMS is designed to help the defence aviation community report air safety occurrences in order that Aviation Duty Holders (ADH), see RA 1020: roles and responsibilities: ADH and ADH facing organisations, may actively manage air safety, monitoring and mitigating associated Risks to Life (RtL) within their defined areas of responsibility (AOR) to As Low As Reasonably Practicable (ALARP) and Tolerable. In addition, ASIMS is used by the MAA in the monitoring and oversight of the Defence Aviation Environment (DAE) as a whole and is one of the main tools used to establish the ‘risk picture’ across the DAE, enabling the MAA to practice risk based assurance.

As with any system of this kind, there are 2 components that make it a success, or failure. The design of the system itself, and the willingness and ability of personnel to fully engage with it, with the former often influencing the latter. Following the analysis of ASIMS report data-quality in 2013, it was recognised that, whilst there was a healthy reporting culture (with reporting increasing year-on-year), codification of why incidents occurred was inconsistent, hindering the MAA’s ability to gain a true picture of aviation safety risk held by Defence.

Whilst personnel understood the need for and were willing to report incidents, they either could not, or would not, complete the process. One major issue was the outcome-focussed taxonomy, which led reports to focus in on the outcome of an occurrence, not what led to that outcome. Another issue was allowing reports to be closed-down without mandating that investigation findings were declared.

Consequently, in April 2016 the MAA introduced a major ASIMS upgrade. From improved codification and taxonomy, to the introduction of hashtags, the upgrade has provided a step change in the ability to positively influence aviation safety through improved recording, trending and analysis of safety occurrences. The most significant changes are discussed below. However, the system remains reliant on the willingness of personnel to fully engage.

The stats

Currently, every location in which military aviation is conducted, and every unit which conducts military aviation, has access to ASIMS through DII. There are over 19,400 user accounts* belonging to 1,063 units registered at 212 stations** (including every aviation-capable ship). An average of 13,000 individual reports are raised each year, and there are over 225,000 unique reports stored on ASIMS (the vast majority of which pre-date the system).

*It should be noted that a user account is not required to raise an occurrence report within ASIMS.

**ASIMS statistics page dated 15 January 2018.

Investigations

The ASIMS v3 upgrade added the requirement to record the level of investigation being undertaken: Local Investigation (LI), Occurrence Safety Investigation (OSI) or Service Inquiry (SI). Investigators could devote as much or as little time to the investigation as required to satisfy the Aviation Duty Holder/Accountable Manager (ADH/AM) Review Group that the details of the occurrence have been accurately identified and recorded. If appropriate for the occurrence, an LI could be as simple as performing a desk-level investigation.

Findings

The introduction of a mandatory requirement to complete the Findings section and the associated recommendation details for the Cause and each Causal Factor was the single biggest element of the upgrade. The understanding of why an incident occurred was further enhanced by allowing multiple findings, which improved our overall analysis of occurrences.

This mandatory requirement to report findings, and the ability to report multiple findings has caused some additional work for the report investigators, but has added far greater value to each report submitted and thus the insight possible from analysis of ASIMS.

From 1 April 2015 to 31 March 2016, only 27% of reports recorded why an occurrence had happened. Following the upgrade, from 1 April 2016 to 31 March 2017 that figure had risen to 93%, however, there is still some way to go. Recent analysis (December 2017) has shown that 25% of Causal Factors are recorded as ‘Cause Undetermined’.

Further understanding of why this is the case is ongoing: defence aviation cannot claim to have good corporate memory, or an effective learning culture, if a quarter of occurrences are not codified in such a way as can be readily exploited.

Why record multiple findings?

A technical fault in flight may have resulted in a report-worthy safety incident. However, the subsequent investigation may establish that an associated maintenance activity had been both incorrectly completed and not properly supervised. The conclusion is that 3 elements led to the incident occurrence and each element requires investigation:

why was the maintenance activity being carried out incorrectly?
why was supervision inadequate?
why did the technical fault in flight lead to an air safety incident?

Previously, only the top level would be recorded, i.e. the technical fault. However, by having the ability to add a separate finding for each phase of the occurrence, allowing each element to have their own outcome, cause and causal factors, it is possible to easily see which causal factor initiated which cause and subsequently led to the outcome.

In addition, this function enables improved analysis of the data; allowing deeper interrogation to establish not only multiple findings for a main outcome, but also multiple outcomes from a single finding.

Recommendations

Recommendations are formal and require ADH/AM approval. The upgrade introduced the requirement for the Investigator to make a recommendation against the cause and each causal factor for every finding. There are occasions when it is appropriate that no recommendations are made. These occasions must be positively acknowledged and recorded and as such, an associated free text field has been made available for this purpose.

Acceptable reasons for recording ‘No Recommendations’ are:

the risk remains ALARP and tolerable, therefore no mitigation or action is required
one recommendation mitigates multiple entries. Thus the mitigation is managed on one entry only and ‘Mitigated by Recommendation xxxx/xxx/Rx’ is entered in the ‘No recommendation’ field for the others
the intention is to implement local mitigation/prevention action however, it does not change the current level of associated risk and so does not required ADH/AM approval. These actions can be implemented and manged outside of ASIMS

Hashtags

The hashtag functionality enables the tracking and management of local issues as well as analysis of global trends. Hashtags are created via the MAA ASIMS helpdesk. However, Occurrence Managers (OMs) are responsible for reviewing every report within their AOR for completeness and accuracy and it is their responsibility to add appropriate hashtags to a report once created. This action is vital for ensuring the reliability of hashtags when interrogating ASIMS at either a local, or a global level. An example of adding hashtags can be seen at Figure 1.

ASIMS has proven that full, open, timely and accurate reporting of aviation occurrences is essential to the maintenance of aviation safety. The changes discussed here: the clarification of investigative levels, the mandatory reporting of findings and recommendations and the addition of hashtags to enable easier monitoring and analysis, all contribute to vastly improved data fidelity within the system.

Accurate reports, which include details of resulting investigations, allow important lessons to be identified and so play a major part in future accident prevention. ASIMS provides the mechanism for all reports to be passed to higher and other associated formations to form part of the wider situational awareness of the aviation safety risk picture, and for details of remedial or preventative actions to be recorded and promulgated through the appropriate specialist channels.

The success of all ASIMS activity is dependent upon User input and engagement, in a positive reporting culture. Continual upgrading of ASIMS to make it easier to use therefore directly influences the generation, maintenance and promotion of a positive reporting culture, which in turn influences aviation safety. For us to successfully interrogate ASIMS regarding both trends and culture, it is essential that the key fields are completed accurately. Fostering this behaviour is a key step on the path to a fully engaged Aviation safety culture, and we all need to play our part.

Further help and feedback

ASIMS continues to be developed and enhanced through the ASIMS Working Group and by suggestions from users. The Working Group is open to station flight safety teams and local occurrence managers and meets every 6 months, if you would like to get involved please contact the ASIMS helpdesk. If you have any suggestions or feedback on ASIMS please complete the online form, accessible from the ASIMS logon page, or contact the helpdesk via email dsa-maa-asims@mod.gov.uk or by phone 030 679 84188.

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News story: Cold weather prompts further health warnings from PHE

Updated: Updated story with latest warning.

Latest update

Forecasts that current cold weather is here to stay for a while, have prompted PHE to urge people to check on older friends, family and neighbours, who may feel isolated.

The Met Office has said that cold conditions, presently affecting all parts of the country, are likely to stay in place for several days, meaning most people will have to contend with snow, ice and low temperatures.

Spells of weather like this can put older people, those with underlying health conditions and young children, at risk from a range of conditions because cold weather forces their bodies to work much harder than usual.

Dr Angie Bone, of PHE’s Extreme Events team, said:

In events like this it’s possible that some people who are not in the best of health will stay at home, rather than risk venturing out in cold and icy conditions, and this can lead to feeling more isolated than usual.

That’s why as this colder period continues we should all check in on those we know, whether they’re friends, family or neighbours, who may be at risk, and offer to lend a helping hand. Do they need shopping or a prescription collecting? Can they get to GP or hospital appointments? Do they just need some company?

It can be all too easy for those of us who are fit and well and able to cope with the cold – but it’s really important to remember that it can leave some people feeling a bit cut off.

Read top tips for staying safe in colder weather.

Previous updates

17 January 2018

Colder weather has arrived in northern England prompting PHE warnings.

The Met Office today said North East, North West and Yorkshire and the Humber regions were all experiencing cold weather and were likely to continue doing so until the weekend.

Dr Thomas Waite of the Extreme Events team said:

Cold weather like this is part of winter – but just because we’re used to it doesn’t mean we shouldn’t take steps to protect ourselves from falling ill. Every winter thousands of people die from illnesses linked to exposure to the cold when indoor and outside – that’s why it’s so important we all look out for each other.

If you can check on family, friends and neighbours who are older, have young children or who have heart and lung conditions all these groups are particularly vulnerable to cold.

Keep a close eye on weather forecasts so you’re up to date with what’s happening in your area, keep homes heated to at least 18C and remember wearing several thin layers can be more effective than fewer thicker ones.

5 January 2018

Another wave of cold weather, including the chance of ice and snow for some, has prompted PHE to urge people to keep homes warm and to keep an eye out for friends, family and neighbours.

The Met Office says that the weather will start to turn much colder from tonight (Friday 5 January 2018) with the cold creeping down the country from the north and that the bad weather could remain until early next week.

Dr Thomas Waite, of the PHE Extreme events team, said:

As temperatures drop it’s really important to think about what you can do to prepare for the cold and protect more vulnerable friends and family from the ill-effects of the cold.

Ensure they wear lots of thin layers, have plenty of warm food and drinks to stay warm and check weather forecasts before heading out. Also wear shoes with a good, slip-resistant grip to prevent any accidental falls and when indoors stay warm and heat homes to at least 18°C.

This advice is important for everyone but particularly important if anyone in the home is very young, 65 or over or has a long term health condition.

27 December 2017

Arrival of cold weather across Yorkshire and the Humber, the North East and North West of England that is due to spread across the rest of the country has prompted further warnings from Public Health England to look out for others and to take extra care during the cold, snowy conditions.

A band of rain, sleet and snow followed by a very cold and frosty period is forecast to spread southeast across the country from today until Saturday.
Because every winter cold triggers thousands of illnesses and deaths across the UK, PHE is urging people to wrap up warm and take extra care when out and about.

Dr Thomas Waite of the Extreme Events team at PHE said:

Cold weather like this is part of winter – but just because we’re used to it doesn’t mean we shouldn’t take steps to protect ourselves from falling ill. Every winter thousands of people die from illnesses linked to exposure to the cold when indoors and outside – that’s why it’s so important we all look out for each other.

During this Christmas period many people will be out and about more, so it’s important to make sure you’re prepared when leaving the home. Also, there will be a number of people who will have been on their own all this time. If you can, check on family, friends and neighbours who are older, have young children or who have heart and lung conditions. All these groups are particularly vulnerable to cold.

Keep a close eye on weather forecasts so you’re up-to-date with what’s happening in your area, keep homes heated to at least 18°C and remember wearing several thin layers can be more effective than fewer thicker ones.

Steve Willington, Chief Meteorologist at the Met Office said:

A band of rain, sleet and snow will slowly clear east during Wednesday, with sunny but cold weather following. However some wintry showers could also move into North Sea coasts. A cold, breezy night follows with widespread frost, and a risk of ice. Thursday will then be cold and sunny, although wintry showers are likely to spread southeast from Northwest England into the Midlands. This will be followed by winds easing, and a very cold, and frosty overnight period. Milder conditions are expected to move across all parts by Saturday morning.

6 December 2017

Weather forecasters are warning that all parts of England could experience cold, snow and ice over the next week, prompting PHE to again warn people to plan ahead.

The change of weather will bring cold air to all parts of England from Thursday and is likely to affect all areas of the country over the weekend says the Met Office. At the same time, the Flood Forecasting Centre has reported a risk of coastal flooding impacts as high tides and strong winds affect the whole of the east coast of England and Cumbria.

Dr Thomas Waite of the Extreme Events team at PHE said:

It is unusual that we are warning about the risks from cold and floods at the same time, but that’s why it’s absolutely critical that people keep up to date with the Met Office’s weather forecasts and the Environment Agency’s flood warnings. There is lots we can do to prepare for cold weather. We can all keep an eye out for family, friends and neighbours who may be at risk.

Those with heart and lung conditions, younger children and older people, are at particular risk during cold weather. Experience shows us that every winter thousands of people are seriously affected and even die from illnesses linked to the cold. That’s why it’s so important that we all play a part in minimising the risks to health this winter.

If your home or business is at risk of flooding, you can sign up for flood warnings by phone, email or text message.

Steve Willington, Chief Meteorologist at the Met Office, said:

Cold Arctic air is expected to spread south across all parts of England through Thursday and Friday. A brisk northerly wind will give significant wind chill. Whilst many areas will remain dry with sunny spells through the day, occasional snow showers are expected giving localised accumulations and icy patches. These are possible anywhere, although most likely in north-west and north-east England, and east coastal areas. A band of rain moving east on Sunday and Monday may turn to sleet or snow in Midlands, and areas northwards, potentially producing further accumulations. This period of cold weather is then likely to continue into next week.

27 November 2017

PHE is issuing further take-care warnings after forecasts have predicted a prolonged cold spell for all of England.

On Friday, the Met Office issued warnings that the north was likely to see colder weather. Today (27 November 2017), they have extended that warning for the whole of England and said that cold conditions could last until Saturday.

Dr Thomas Waite, of PHE’s Extreme Events team, said:

As the weather is going to get colder everywhere in the coming days, this is a really good time to check on those who may be at risk. People with diseases such as heart and lung conditions, older people, and young children can feel the ill-effects of cold weather more than the rest of us.

To stay well this winter, we all need to play a part. Is there someone you know who could be at risk when the weather gets cold? Could you help them out by fetching shopping or prescriptions?

When the colder weather arrives there are several things we can do to keep well: wear several thin layers instead of fewer thicker ones, keep parts of the home you’re using heated to at least 18°C and keep a careful eye on the weather forecasts.

Laura Paterson, Chief Operational Meteorologist for the Met Office, said:

Colder air will gradually spread south during Monday and Tuesday, with overnight frosts becoming more widespread, along with a brisk northerly breeze.

A period of more widespread cold temperatures is then expected from Wednesday onward, whilst showers down the east coast are also expected to be wintry at times with some snow and ice possible.

24 November 2017

Keep warm keep well warnings are being issued by Public Health England (PHE) today (24 November 2017), as weather forecasts suggest the winter’s first blast of cold weather is on its way.

Met Office forecasters have said today that by tomorrow (Saturday) temperatures in the north east, north west and Yorkshire and the Humber will fall below 2°C.

This first drop in temperatures has prompted PHE’s Extreme Events team to remind people all over the country that before cold weather arrives is the best time to prepare.

Dr Thomas Waite of PHE’s Extreme Events team said:

We’re well used to winter in this country so most people know what to do to protect their health before and during cold spells.

But there are people who may not take precautions and who are at a very real risk. We know that every winter thousands of people fall ill and many die because of exposure to cold both in the home and while outdoors.

Those most at-risk include older people, very young children and those with conditions like heart and lung disease. That’s why every cold season we urge people to look out for family, friends and neighbours who may be at risk. Ask yourself if you could check on a neighbour to see if there’s anything they need?

Paul Gundersen, Chief Operational Meteorologist at the Met Office, said:

Colder air has now reached most parts of England, with temperatures expected to fall further by Saturday, when the cold will be accentuated by strengthening winds. Wintry showers are also likely in places, but any snow showers are expected to be confined largely to higher ground. A temporary incursion of warmer air is expected on Monday, with the colder air forecast to return by Tuesday.

Top tips to prepare for colder weather

You should:

look out for friends and family who may be vulnerable to the cold and ensure they have access to warm food and drinks and are managing to heat their homes adequately
try to maintain indoor temperatures to at least 18°C, particularly if you are not mobile, have long term illness or are 65 or over
stay tuned for weather forecasts, ensure you are stocked with food and medications in advance, have deliveries or ask a friend to help
take weather into account when planning your activity over the following days
seek entitlements and benefits such as Winter Fuel Payments and Cold Weather Payments, which are available to some
avoid exposing yourself to cold or icy outdoor conditions if you are at a higher risk of cold related illness or falls.
discuss with friends and neighbours about clearing snow and ice from in front of your house and public walkways nearby

Power and utility companies have schemes which make at-risk groups a priority for reconnection following power cuts. Find out if you meet the criteria and if so, sign up. Visit ofgem.gov.uk for more information.

There’s lots of useful advice on the Stay Well This Winter website.

Dr Waite added:

We know that more deaths occur every winter in the UK than in the summer due to a wide range of causes including cold weather, influenza and other respiratory infections. The flu vaccination is the best protection we have against flu and it’s really important to have it if you are eligible. If we all keep a close eye out for each other over the coming months hopefully we’ll all be able to stay well this winter.

Congratulations letter by President Donald Tusk to the President of Cyprus Nicos Anastasiades

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