Error Reporting

 It is an ICAO standard for all organisations involved in the design, production, operations and maintenance of aircraft to have an occurrence reporting system. Part145.A.60 requires all Part-145 approved organisations to report occurrences meeting certain criteria1 to the competent authority, state of registry and organisation responsible for the design of the aircraft. Whilst this requirement is primarily intended for technical problems affecting aircraft, it also extends to errors where these have resulted in "any condition of the aircraft or component....that has resulted, or may result, in an unsafe condition that hazards seriously the flight safety" (Part145.A.60(a)). This could include, for instance, failure to refit O-ring seals when replacing chip detectors. In any case, each Part-145 approved organisation is required to have in place a system for the reporting, collection and evaluation of occurrences, the aim being "to identify the factors contributing to incidents and to make the system resilient to similar errors" (AMC-145.A.60(b)(1)). This covers "any (potentially) safety related occurrence" (AMC145.A.60(b)(2)), which means that the problem or error does not necessarily have to have resulted in an outcome meeting the criteria for formal external occurrence reporting. Organisations are not expected to report and investigate every minor error that occurs, but should have a procedure explaining what they would expect to be reported and investigated, and what they wouldn't. The procedure, or system, is likely to be two-tier, covering both internal and external reporting. The JAA MHFWG report refers to such a system as an "Occurrence Management System" (OMS). An alternative term which is often used is a "Maintenance Error Management System" (MEMS), although this term is generally applied to occurrences which involve, or are likely to have involved, human factors. Further information on MEMS can be found in Chapter 10.

It may sometimes be difficult to judge when an error warrants formal external reporting as an occurrence, or just internal reporting. The decision is up to the person in the company responsible or occurrence reporting, and should be based upon formal occurrence reporting criteria plus common sense in determining whether value may be gained from reporting externally. If in doubt, report the occurrence externally - what you may think is a 'one-off' error may be happening in other organisations, and could be a flaw in the design or Maintenance Manual. 

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