Near Misses (Hansard, 3 March 1988)

§ Mr. Channon

I have discussed the present arrangements for reporting and investigating air misses with the chairman of the CAA, and I have asked him to review them. We both agree that the purpose of the procedures must be first to enhance flight safety by encouraging reporting so that lessons can be learnt from each incident; and, secondly, so far as is consistent with that, to strengthen public confidence in the air traffic control system through maximum openness and impartiality in the reporting and investigation of air misses. The chairman has now written to me with proposals that I warmly welcome as going a long way to meet our joint objectives. The text of the chairman's letter is as followsWe have discussed the recent reports of airmisses and the procedure for reporting and investigating them. You asked me urgently to review these arrangements. I am now in a position to make a preliminary report. We are in agreement that the procedures for handling information about airmisses and for investigating them should meet two objectives:—

(i) Primarily, they should be designed to enhance flight safety by providing lessons from which all involved in aviation can benefit. This means that they should encourage the reporting of incidents by pilots and air traffic controllers, make for the speedy, accurate and impartial investigation of airmisses and draw on all relevant expertise in identifying causes and remedies.
(ii) Secondly, they should give the public confidence in the air traffic control system by making available, wherever reasonably possible, prompt and accurate information about airmisses and their causes and provide for investigations that are not only expert and impartial but are seen to be so.

As you know, the present procedure is that all reported airmisses, military and civil, are brought to the attention of the Joint Airmiss Working Group (JAWG) by the Joint Airmiss Section (JAS) of the NATS. JAS provides the Chairman and Secretariat of the JAWG, but otherwise the Working Group consists entirely of independent members from outside NATS, including representatives from the armed services, civil airlines and pilots and other airspace users. JAWG, having had all airmisses investigated, analyses them and three times a year circulates the results of its analyses in confidence to the aviation community in a volume known as the "Blue Book". We agree that these arrangements for providing information about airmisses, for investigating them and for reporting the outcome are entirely satisfactory for operational purposes. The CAA publishes statistics for airmisses three times a year based on the results of the JAWG's investigations. These show that there has been no deterioration in safety in the air 653W over the United Kingdom. Indeed the figures for risk-bearing airmisses involving commercial aircraft in recent years show a downward trend. In my view, this present system meets the primary objective well. I am most grateful to the NATS Staff in JAS and to the whole membership of the JAWG for the important work they have carried out so painstakingly and effectively over the years. However, the system was not designed with the secondary objective in mind. I have therefore considered particularly how the procedures might be modified so as to meet the second objective without impairing achievement of the first. My proposals are set out below.

Initial CAA Reaction to an Airmiss It has been our practice, in line with the well-established principle of confidentiality, neither to confirm nor to deny the occurrence of an airmiss. Nevertheless, airmisses do become public knowledge and, as recent incidents clearly show, the ensuing publicity without any official information, can present a misleading impression. I have therefore decided that as soon as we know an airmiss has occurred involving an aircraft on a commercial air transport flight, we will from now on announce it with whatever reliable information is immediately available.

Joint Airmiss Working Group One of the criticisms of the present arrangements for investigating airmisses has been that JAWG is within NATS and may thus appear to be insufficiently independent of the organisation providing most of the UK's air traffic control services. I am entirely satisfied that JAWG (with its outside membership) has always in practice functioned quite indepndently of NATS in carrying out its investigations. It should in any case be borne in mind that an airmiss may result from a failure in the aircraft as well as on the ground. However, in order to establish the JAWG's independent status still more clearly, I propose to have the Chairman of JAWG submit its reports in future directly to me and the Chief of the Air Staff as the Joint Chairmen of the Air Traffic Control Board. Moreover, I intend to consider with JAWG some enlargement of its membership, with a view for example to including on it one or two members currently active in air traffic control operations.

Publication of .J A W G Airmiss Investigations At present the results of airmiss investigations are circulated widely within the aviation community but are not made public. This policy is designed to maintain the confidence of pilots and airspace users so as to encourage the full and frank reporting which is essential to ensure that airmisses are fully analysed and essential flight safety lessons drawn from them. It has served the cause of flight safety well over many years. Recently, however, it has been undermined by the frequency with which incomplete information has been unofficially disclosed. I accept that there is a legitimate public interest in the outcome of investigations of airmisses involving commercial air transport aircraft in U K airspace. I have decided therefore that the outcome of these investigations should be published. It is important that this is done in a way that not only satisfies public interest but also avoids jeopardising confidence in the objectivity and impartiality of the investigation system. I intend therefore to seek the advice of aircraft operators and pilots on the manner of publication as well as taking into account other comments that I receive. I shall reach a decision without undue delay.

Reporting of Incidents by Air Traffic Controllers Recently, it has been alleged that the reporting procedures for controllers are inferior to those for pilots and that controllers' reports, being submitted via their line managers, are sometimes delayed or suppressed. I do not accept these allegations. Nevertheless, we are now in the process of devising improved reporting procedures which will be better designed for recording potentially serious incidents between aircraft and will provide for controllers to send reports direct to the Authority's Safety Data Analysis Unit. We will be consulting controllers' representatives on these procedures 654W before introducing them. Our objective is to ensure that any incidents observed by controllers but not by pilots will be reported.

Conclusion I believe that the procedural changes described above will go a very long way to meet both the objectives I set out at the beginning of this letter. Not only should they maintain the already-proven effectiveness of the system in analysing the causes of airmisses and distributing information about them within the aviation community; they should also enhance its openness and the visibility of its independence and in doing so help reassure the public about the safety of our airspace.