TABLE OF CONTENTS

ANNEX 1: Summary of the questionnaire sent to EU Member States............................................ 2

ANNEX 2: Summary report of the contributions received to the online public consultation on a possible revision of Directive 2003/42/EC on occurrence reporting in civil aviation and its implementing rules............................ 13

ANNEX 3: ENCASIA's opinion concerning the revision of Directive 2003/42/EC....................... 23

ANNEX 4: Seminar on "Just Culture in the context of Occurrence Reporting schemes”................ 27

ANNEX 5: Study on the establishment of a common risk classification of civil occurrences at EU level   31

ANNEX 6: Occurrence reporting obligations in European legislation............................................ 36

ANNEX 7: Examples of costs involved by an aircraft accident..................................................... 54

ANNEX 8: Specific objectives with corresponding problem drivers............................................. 56

ANNEX 9: Assessment of administrative burdens........................................................................ 57

ANNEX 10: Detailed economic impact examples on the industry................................................. 66

ANNEX 11: Detailed data on the economic impact on the European Union budget...................... 68

ANNEX 12: Rate of fatal accidents per 10 million flights per world region.................................... 69

ANNEX 13: Acronyms and abbreviations................................................................................... 70

ANNEX 14: Bibliography........................................................................................................... 71

ANNEX 1: Summary of the questionnaire sent to EU Member States

A questionnaire has been transmitted to all 27 EU Member States through a letter from DG MOVE Director General Mr Ruete on 7 April 2011. 26 Member States completed the questionnaire and sent their answers to the Commission. One Member State (Slovakia) did not reply. This document summarizes the position of the 26 Member States which replied to the questionnaire.

It has to be taken into account that this paper may not reflect the real situation in EU Member States but is an accurate summary of the written replies by the Member States to the questionnaire sent to them. Some on-site visits have been also performed by the European Commission to confront with the reality and learn about best practices in few EU Member States (France, United Kingdom and Spain). The summary of these visits is not included in this paper but has been taken into account when drafting the Impact Assessment.

1.           EU legislation on occurrence reporting in general

(a) What are the main problems the authorities of your Member State, or operators under the regulatory responsibility of those authorities, encounter in day to day application of the EU legislation on occurrence reporting? Which elements do you think a revision should look at?

Three Member States stated they did not encountered major problems with the application of the legislation on occurrence reporting (Directive 2003/42 and its implementing regulations).

Regarding the issues expressed by the other 23 Member States, they can be categorised as following:

· Lack of personal dedicated to occurrence reporting: six Member States expressed their difficulty to carry out the tasks defined in the legislation due to a lack of sufficient personal.

· Legal nature of the legislative act: the implementation of the Directive into national laws has created differences in its application. Two Member States are suggesting replacing the Directive by a Regulation to ensure a consistent application of the provisions on occurrence reporting.

· Inconsistence with reporting obligations resulting from other EU rules: six Member States stated that the existence of other occurrence reporting obligation in different pieces of legislation (i.e.: Regulation 1702/2003, Regulation 2042/2003, Regulation 859/2008 “EU-OPS” and Regulation 2096/2005) creates confusion. Reporting obligations are not harmonized in terms of notification procedures, delays or addressees, and if the Directive 2003/42 is focusing on reporting by individuals, the other acts are more focusing on reporting obligations by operators. These Member States would like the Commission to harmonise the various reporting obligations in the revision of the Directive or at least regroup them in a single document.

· Scope of the Directive: several Member States found an insufficient clarity on what kind of occurrences should be reported. Two Member States would like to enlarge the scope of occurrences to be mandatory reported (in some Member States all occurrences are mandatory reported) while two other Member States would like to reduce it.

· Insufficient clarity on how to report occurrences and low quality of data: eight Member States expressed their concern with these issues and the lack of harmonisation in the reporting process. They are suggesting that the revision should include a standardisation of occurrence reporting systems and of reporting forms. The establishment of an obligation to report under ECCAIRS format is also proposed by two Member States. Four Member States recommend the Commission to requesting a minimum set of data to be mandatory contained in occurrence reports.

· Just culture: it is the issue mentioned most frequently by Member States. Ensuring the appropriate protection of safety information and of reporters is necessary to reach a good reporting level. The situation is quite diverse between the Member States and some of them stated that their reporting culture is low because individuals are feared to report and to be prosecuted by justice or blamed by their hierarchy. In some cases the just culture is either partially applied or not applied at all by the judicial system because the competent legal authorities are not in general familiar with this notion. Some Member States also expressed that they encounter problem because "gross negligence" is not explicitly defined in the Directive. Several Member States would like the protection of information still given a high priority and ensure that similar just culture level is present in all Member States. A Member State also suggested that "Just culture" should be explicitly defined in the revision of the legislation.

· The legislation does not take into account the existence of EASA: two Member States noticed this issue and stated that roles are not clearly defined, including the place of EASA within the system.

· Lack of provisions on analysis and safety actions: some Member States stated that the current legislation only regulates data collection and storage and does not explain how to use the collected data for safety purposes. Member States are suggesting that the new legislation should include provisions on the analysis of occurrences and develop processes to achieve safety improvement. For one Member State the legislation could also address the effective monitoring of safety performance, the setting of safety targets and the establishment of safety action plans to address safety deficiencies. Some Member States would like the legislation to reflect better the Safety Management System (SMS) philosophy, in taking into account the role of the operator and in addressing analysis and implementation levels.

· Absence of severity risk classification: several Member States suggested that the new legislation should include such a common scheme at European level.

· Reporting of occurrences where a foreign operator is involved: two Member States reported that they were not able to correctly oversee the safety of air transport operated in their airspace as they could not collect occurrences from operators which are operating under their territory but registered in another Member State. A Member State is suggesting establishing specific contact points in every national authority responsible for occurrence reporting to deal with occurrence information between Member States. Grant an access to all information contained into the ECR could also address this issue.

(b) How many persons are working on occurrence reporting in your Member State, in the organisations referred to in Article 5 of Directive 2003/42/EC? How many of those work on data analysis and quality of the data?

It is difficult to establish an accurate average of the number of individuals working on occurrence reporting in the European Union because in most of the Member States if not all, some persons are only working part time on occurrence reporting tasks (collection, coding, quality check, analysis etc.). Calculate what the equivalent could be in terms of full time occupation for each Member State or estimate a European average would therefore be hazardous and not give a precise picture of the current situation. In addition, due to budget constraints, many Member States are understaffed and their situation does not reflect the number of employees necessary to comply with the obligations imposed by EU legislation. Two Member States admitted that due to lack of personnel no one in their administration was working on data analysis: data are only collected and stored.

What can be determined from the Member States replies to the questionnaire is that in many Member States there are individuals working on occurrence reporting both in the Civil Aviation Authority (CAA) and in the Safety Investigation Authority (SIA). In some Member States these tasks are only performed by either the CAA or the SIA. In one Member State, occurrence reporting tasks are performed within an agency which is independent from the CAA but chaired by the DGAC Director. The number of individuals directly working on occurrence reporting in the Member States (part-time or full-time) goes from one to 24.

(c) Could you please describe the process in your Member State, including the responsibilities of organisations and of the competent authorities, concerning the evaluation and analysis of information on civil aviation occurrences?

According to their replies to the questionnaire, Member States can be divided in three different categories regarding the process established nationally for evaluating and analysing occurrences data collected in application of Directive 2003/42:

Member States relying only on analysis done at operators' level: this is the situation in two Member States where systems are mainly relying on the work done at operators' level and action taken at the authority level is limited. Operators collect occurrences within their entity, analyse issues reported and correct the safety deficiencies where relevant. At national level, some analysis tasks are performed through regular meetings and actions can be taken. These Member States also publish trends and analysis results.

Member States with mature or almost mature system: 8 Member States are in this category. They do not all have the same level of maturity but each of them have established a system for analysing data occurrences and take safety actions to correct deficiencies when it is necessary. Four of these Member States seems to have established a mature/almost mature system which contains all or part of the following elements: mechanisms for collecting, assessing and storing occurrences; quality checks tools and procedures; safety warnings for occurrences which require immediate actions; meetings on regular basis for reviewing and analysing occurrences and if necessary transmission to operational department responsible for further analysis within their scope; set up of specify study groups; identification of main risk area; development of safety indicators; set up of a strategic action plan or of safety measures; oversight of the implementation of safety actions; publication and circulation of trends, statistics, occurrences summary etc; input to the State Safety Program.

(d) Do you believe that Regulation (EC) No 1330/2007 on dissemination of information on civil aviation occurrences has had a positive impact on aviation safety in your Member State? Please comment.

Member States seem not to be very familiar with the mechanisms established in Regulation 1330/2007 on dissemination of information as on the 26 replies to the questionnaire, 15 replies are totally away from the point.

Regarding the 11 Member States which have actually replied to the question, six Member States never received a request in application of the Regulation, and the five others only received a very low number of requests. Member States results clearly show that Regulation 1330/2007 is very rarely used and not even known in many Member States. For one Member State the Regulation has had a positive impact on safety because it helped the national authority to improve just culture and confidentiality by defining the means and limits for dissemination of information on civil aviation occurrences. For another Member State, its effect has been positive because it has standardised the whole system of disseminating information on occurrences within the EU. A Member State stated that the Regulation 1330/2007 was not fulfilling its initial expectations notably due to the very limited number of requests received. It suggested that the de-identification of occurrences reports (narratives not accessible) make them quite useless from a safety perspective and that could explain the lack of interest in this mechanism.

(e) In what way could EASA best contribute to the improvement of air safety through its involvement in occurrence reporting at the EU level?

Apart from one Member State which would not like to see EASA playing a key role in occurrence reporting and another one which has no suggestion to formulate on this issue, all 24 other Member States stated that the Agency should be part of the occurrence reporting system and thus contribute to the improvement of air safety in a pro-active system.

According to Member States, EASA should perform analysis of the ECR data and use this information notably for developing safety trends. This could allow the identification of major risks at the European level. They also think that EASA could coordinate the work done at national level regarding occurrence analysis. Some Member States suggested that the Network of Analysts which has been created recently within EASA could be an appropriate instrument for this coordination role. It could allow Member States to exchange experiences on occurrences analysis, facilitate their cooperation and monitor the overall safety in Europe. Several Member States also would like EASA to give training and develop guidance on best practices for data exploitation.

Few Member States noticed that the current limited access of EASA to data contained in the ECR is an important curb to the possibility for EASA to play any substantial role in occurrence reporting. If EASA would be given any task in this area, these Member States suggested that the Agency should then have access without restrictions to occurrences data stored in the ECR.

2.           European Central Repository (ECR) and exchange of information

(a) What are, in your view, the strong and weak points of the ECR? Does the ECR help you meet your mandatory obligations? How could the quality of the data in the ECR be improved?

For the majority of the Member States, ECR strongest point is the centralisation in one single database of a huge amount of safety information through the integration of the occurrences collected at national level. Member States stated that the potential benefit of this data is important for safety purpose and that it could provide increased protection to citizens. ECR is seen as a potential very good base for analysis which could lead to substantiated analysis results and actions. But Member States opinion is that ECR cannot be used as it should be mainly because of two factors: the lack of access to occurrences narratives which prevent the possibility of an in-depth data analysis and the lack of data quality in the Repository.

For Member States, the non-access to occurrences narrative (notably due to EU legislation which imposes rules on confidentiality and de-identification) means not only that it dramatically reduces the usefulness of the ECR for meaningful safety purposes but also that the quality of event coding cannot be checked. Moreover, many Member States are pointing out the low quality of the data integrated into the ECR. They said it is notably due to a lack of harmonisation of coding standards between the Member States.

To the last question related to the ways of improving data quality, Member States suggested the following ways of actions:

· harmonise event coding and standardise the occurrence reporting process,

· impose some mandatory data fields to be filled when the occurrence is reported and develop some quality rules to indicate how they should be filled,

· impose the use of the ECCAIRS software to occurrence originators,

· give an access to occurrences narratives and impose on Member States to check that narratives do not contain information such as the names of individuals or operator name to ensure protection of the reporter,

· carry out promotion and sensitisation actions to raise awareness of operators on occurrence reporting,

· organise trainings both at EU and national level,

· develop quality check tools,

· establish an EU common risk severity classification scheme.

(b) Do you use the ECR data? If yes for what purposes?

6 Member States stated that they are using ECR data; 8 used it occasionally and 12 Member States never used it.

The fact that Member States never used ECR data or only on rare occasion is notably due to their lack of access to pertinent data (mainly narrative) and to the fact that the limited information to which they can have access within the ECR cannot be exploited for safety purposes. Some Member States used ECR data in case of accident and serious incident investigation, to find out if an investigation has been done in another Member States in similar cases. It is used also in some specific to determine trends (e.g. laser pointer attacks, volcanic activity reports) and to check the reporting culture.

(c) Are there any restriction or special conditions that you consider necessary to give other Member States and EASA access to all information on civil aviation occurrences that you currently collect?

For almost all Member States, the conditions described in the current legislation are sufficient and no supplementary restriction should apply. However the protection given by the legislation is not understood in the same way in all Member States.

For some Member States (4), it means dis-identify information related to the reporter of the occurrence and they consider that it would be sufficient restriction to give EASA and all Member States access to the ECR. For other Member States (6), the de-identification should also cover information related to the operator. Indeed they are worried about the fact that this information could lead for example EASA to increase the number of inspections against an operator identified as unsafe or less safe. According to them, this could push operator to under-report and thus would have a negative effect in terms of safety. And 15 Member States state that no specific restriction would be necessary or that the current situation is adequate without detailing their understanding of the current legislation. Finally many Member States are underlining that data contained in the ECR should only be used for safety purposes only. A Member State is suggesting that a user's charter should be signed.

(d) Please give an assessment of the amount of 'reportable occurrences' that the mandatory occurrence reporting scheme of your Member State currently captures?  almost 100%       above 50%    less than 50%            less than 30%

The answers given by the 26 Member States which replied to the questionnaire can be classified as following: percentage cannot be assessed: 1 Member State (4%); less than 30%: 1 Member State (4%); less than 50%: 4 Member States (15%); above 50%: 17 Member States (65%) and almost 100%: 3 Member States (12%).

The following chart illustrates Member States' assessment of occurrences collected through MORS in comparison with the total volume of reportable occurrences.

(e) Do you consider that the occurrence information currently required to be collected by Member States under Directive 2003/42/EC is adequate?

18 Member States answered positively to this question, most of them without giving explanations to their reply. However it appears from the more detailed answers that Member States did not all have the same understanding of this question. It is thus difficult to draft any pertinent conclusion from Member States replies to this point.

Two Member States state that the list of occurrences which should be mandatory reported is too large and that it may be better to get less occurrence reports but with better quality. At the same time, one of these Member States is highlighting that some occurrences are not captured in application of Directive 2003/42 (incident from maintenance organisation outside EU operating on EU registered aircraft). Some Member States suggest that occurrence collection according to the Directive could be improved notably with guidance, including criteria to determine if an event should be reportable. For one Member State, Directive 2003/42 is adequate because who should report and what should be reported is well defined in the legislation.

(f) In your opinion, what would be the benefits of the introduction of a formal standardisation process for occurrence reporting at the EU level?

According to 19 Member States out of 26, the introduction of a formal standardisation process would bring important benefits notably in improving data quality and enabling analysis at the EU level. It would also be positive in terms of workload reduction for the authorities which collect, process and store the data. Some Member States also recognised that it would help in identify duplication and improve the quality and the usefulness of the ECR. Some Member States highlighted that standardisation will be a very difficult task to implement and warned against a too detailed or too bureaucratic standardisation process which could cause some people to skip reporting and would require operators to invest financially to adapt their scheme towards a more standardised one.

(g) In your view, what should be the minimum amount of information that each occurrence report (or type of occurrence reports) should contain?

Only 10 Member States answered to this question in enumerating a list of data fields which should be mandatory for them. The 16 other Member States answered more vaguely in stating that standardisation on this matter is positive but that it will be difficult for them to determine which precise data fields should be mandatory. According to them this is notably due to the fact that it depends of the nature of the event, for example if an aircraft is involved in the occurrence certain type of data (aircraft related information) should be asked but it will not be always the case. Some Member States answered that any data which could help to identify the causes of the occurrence should be transmitted without specifying which ones.

Regarding the 10 Member States which gave a precise list, mandatory data fields suggested the most often can be classified as following:

· Initial information on the occurrence: date (10 Member States); location (10 Member States); UTC Time (8 Member States); information about occurrence category (accident, serious incident or occurrence- 5 Member States); injury to persons (5 Member States); damage to aircraft or to third party (3 Member States).

· Narrative (10 Member States).

· Information relative to the aircraft: aircraft model, registration number, serial number (9 Member States); aircraft category (6 Member States); operator, state of registry (5 Member States).

· Information on the flight: itinerary (departure and arrival – 4 Member States); weather conditions (3 Member States); flight phase (3 Member States); airspace type (3 Member States).

· Reporter's contact details (3 Member States).

(h) In your view, what would be the benefits of a common EU risk severity classification scheme for occurrence reporting?

All Member States supported the proposal to introduce a common EU risk severity classification scheme. According to them, it should notably bring a common standard approach towards Europe. Such a scheme would also lead to the identification of potential risks at EU level and allow the establishment of common safety performance targets. Some Member States advised the Commission to ensure a simple and easy mechanism in order to ensure its applicability and eventually to base such a scheme on the work done in the ATM area (Eurocontrol's Risk Analysis Tool- RAT).

(i) What types of actions are taken by the competent authorities of your Member State in a follow-up of the evaluation/analysis of occurrence reports received?

According to their replies, most of the Member States ' actions are limited to analyse data and disseminate information through internal or public reports including trends. In some Member States outcome of occurrences analysis are also taken into account when oversight/audits tasks are performed. In few Member States (4), the process established goes beyond analysis and information and also includes corrective actions with appropriate follow-up to ensure the effectiveness of actions taken. One Member State would like the new legislation to include clarification on authority's responsibilities in the case where an analysed occurrence has been determined with a high risk of severity.

(j) How do you think the analysis of the ECR data could be best organised at the EU level?

Most of the Member States would like EASA to play a leading role in the analysis of ECR data at EU level. Indeed 16 Member States favour this option and consider EASA would be the most appropriate actor to manage such an analysis. Many Member States specified that this should be done through a network of analysts involving analysts both from EASA and the Member States. Such a structure should notably identify safety concerns, develop action to improve safety where necessary and report to the Commission according to Member States.

Some Member States also referred to the publication of trends at European level based on ECR data. However one Member States underlined that given the low quality of occurrences information contained in the ECR any statistic may not be reliable. Few Member States also mentioned standardisation and improvement of analysis tools as a way of action. One Member State stated that review overall safety performance would be necessary and that a communication strategy should be developed to inform the public about safety information.

(k) How many occurrences do you receive on average annually (we are speaking here of occurrences only, without accidents and serious incidents)?

When dealing with number it is once again very difficult to be truly accurate. Indeed some Member States gave estimation and some others sent a precise number. Moreover, most of the Member States specified the rate for the year 2010 while several States made an average of what they received during the last years. Finally in some cases it is relative to the number of reports received, in some others to the number of occurrences and not specified in many cases.

Taking into account the remarks above, what came out of Member States' replies is that in 2010 around 111,400 occurrences reports were received in 26 Member States, which makes an average of around 4,300 reports by Member States. The level of reports received varies strongly from one State to another and goes from 60 reports a year to 45,000 occurrences.

3.           Voluntary occurrence reporting schemes

(a) Is there a voluntary occurrence reporting scheme in your Member State (if, yes, which organisation is tasked with its operation)? If yes, how is the information provided by this scheme is used to improve safety; how the protection of the reporter is ensured in practice, including its de-identification?

Most of the Member States have established a Voluntary Occurrence Reporting Scheme (VORS): 23 States out of 26.

In two Member States the VORS is only dedicated to general aviation. In the others it concerns also commercial air transport and is, in almost all cases, managed identically to the Mandatory Occurrence Reporting Scheme (MORS).This means that voluntary reports are collected by the same authority and that the information is processed and protected the same way than it is in the MORS. In two Member States voluntary reports are through anonymous emails. One Member State specified that next the VORS established by the authority, a VORS is in place at the operator level. The information on existence or absence of VORS at operator level has not been transmitted by the other Member States. In one Member State, three VORS are established: the one collected by the authority in the same manner than the MORS, a "Whistle blowing" system managed also by the authority and a VORS dedicated to Human Factor type events handled by an independent organisation. Two Member States specified that they established their VORS following an ICAO/USOAP audit as the establishment of VORS is an ICAO Standard. One Member State underlined some inconsistence between ICAO and EU concepts of VORS: according to ICAO VORS are aimed to capture sensitive information while Directive 2003/42 Article 4(2) focuses on voluntary reporting by people not required to report under MORS.

(b) Do you integrate the occurrences from your voluntary occurrence reporting scheme in your mandatory occurrence database?

Out of the 23 Member States which have established a VORS, 14 are integrating the occurrences generated from this scheme into their mandatory occurrence database and 9 do not. Several Member States specified that voluntary reports information is verified and evaluated before it is integrated in the database.

(c) Do you send the occurrences from your voluntary occurrences reporting scheme to the ECR? If yes, how do you ensure that there is no duplication of occurrences reported?

The replies to this question are similar to the previous one: 14 Member States and 9 Member States do not. As usually the same authority manages MORS and VORS in the same database, checking out the absence of duplicate is part of the quality process in many Member States.

4.           Protection of information

(a) Please describe what type of measures your Member State has taken to ensure the confidentiality of information on civil aviation occurrence and to ensure that employees who report incidents are not subject to any prejudice by their employers,, in accordance with Article 8 of Directive 2003/42/EC; Do you consider that these measures are sufficient?

Member States stated they have implemented Article 8(2) onto their national legislation and therefore ensured that the identity of the person reporting the occurrence and his personal details are never recorded into the database. In two Member States, confidentiality is reinforced by the disintegration of all original reports (email, fax and so on), only remains occurrences reports within the database without name or personal details from the reporter. In few Member States, persons handling original occurrences reports are required to sign a confidentiality charter.

Regarding Article 8(3) which asks Member States to refrain from instituting proceedings based on occurrences reports except in cases of gross negligence Member States claimed it has been transposed in national law but often without explaining precisely how. One Member State specified that under its national legislation a person can never be prosecuted for reporting under MORS but may be subject to prosecution for not having reported an occurrence within 72 hours after it occurred.

Article 8(4) imposes on Member States to ensure that employees who report incidents of which they may have knowledge are not subjected to any prejudice by their employer. Member States stated that this provision is also applied under their territory but not always specifying the way it is enforced. In some Member States protection of the employee towards his employer is ensured by Labour law or Aviation Act.

All Member States but one found the measures in place to be sufficient. It is however difficult to assess precisely the level of Just Culture environment based on Member States' replies as they are not enough precise or incomplete.

(b) How many requests a year, on average, do the competent authorities of your Member State receive concerning access to information on civil aviation occurrences?

The situation is quite diverse between Member States in regards to the level of requests for accessing occurrences they receive. Indeed 8 Member States never received such a request while in others the number goes from 1 to more than 500 on average by year. In 2010 around 1.000 requests have been received which gives an average of 40 by Member States if we take into account the 26 Member States which gave the information. However, only 18 Member States received requests and in most of them the average is between one and ten each year.

(c) In how many cases, since the adoption of the Directive, has the information on occurrences been used as evidence in judicial proceedings?

23 out of the 26 Member States which replied to the questionnaire stated that information on occurrence reporting has never been used as evidence in judicial proceeding. One Member State specified that its national legislation does not allow the use of such information in legal proceeding, but only for administrative sanctions in case of gross negligence (which occurred twice). Another Member State underline that according to Just culture principles occurrences reports cannot be used as evidence in absence of obvious negligence or intentional causing of incidents. In three Member States occurrence information has been used as evidence before court. For two of them it has been used in less than 5 instances. The last one specified that such information has been transmitted many times to courts and prosecutor's office but that they do not know precisely how many times.

ANNEX 2: Summary report of the contributions received to the online public consultation on a possible revision of Directive 2003/42/EC on occurrence reporting in civil aviation and its implementing rules

1.           Introduction

The European Commission has organised a public consultation on a possible revision of European legislation on occurrence reporting in civil aviation, which is one of the key initiatives for implementing the Commission Communication on "Setting up a Safety Management System for Europe".

The public consultation was opened on the 24th of June 2011 on "Your Voice in Europe" internet website and closed after 12 weeks on the 15th of September 2011. This public consultation refers to Directive 2003/42/EC on occurrence reporting in civil aviation, Commission Regulation (EC) No 1321/2007 of 12 November 2007 laying down implementing rules for the integration into a central repository of information on civil aviation occurrences and Commission Regulation (EC) No 1330/2007 of 24 September 2007 laying down implementing rules for the dissemination to interested parties of information on civil aviation occurrences.

The aim was to collect the views of relevant stakeholders and the general public to feed an Impact Assessment concerning the possibility of revisions to EU legislation on occurrence reporting. The consultation phase of the Impact Assessment was completed by a questionnaire to Member States and the organisation of a Seminar on the specific issue of Just Culture. The ultimate objective of revising EU legislation would be to improve aviation safety by establishing the context and elements necessary for moving towards an efficient proactive and evidence based aviation safety system. This consultation has allowed the Commission's services to better understand the shortcomings of the current legislation, the position of stakeholders, public authorities and citizens on available options and also to receive suggestions from the mentioned entities.

This report seeks to provide an overview and to present the responses reflecting the major positions of respondents. However, whilst all contributions have been perused and considered, the report does not summarize all the comments received.

2.           Respondents

61 contributions were received by the European Commission further to this public consultation: 13 by public authorities (21.3%), 37 by organisations (60.7%) and 11 by citizens (18%). All respondents agreed to have their views made public in this summary.

The respondents who have classified themselves as citizens, however, do not represent the proportion of society not professionally involved in aviation as 4 of them are pilots and 6 are aviation professionals entrusted with tasks related to aviation safety. Only one of the respondents in this category is not part of the aviation community. This can be explained by the fact that while having direct impact on citizens' safety the issue of occurrence reporting is rather technical for someone not familiar with aviation safety systems.

Regarding respondents within organisations category, they can be classified as following:

Category of organisation || Replies || % age of category's respondents

Aerodrome || 1 || 2.7

National unions or associations for aviation professionals || 11 || 29.7

European or international unions or associations for aviation professionals || 5 || 13.5

Airlines || 5 || 13.5

European or international airlines associations || 3 || 8.1

Air Navigation Service Providers || 3 || 8.1

Manufacturers || 2 || 5.4

Manufacturers association || 1 || 2.7

Legal Counsel or firms || 2 || 5.4

Consultants || 4 || 10.8

The vast majority of the respondents is aviation professionals or has at least a minimum knowledge of the subject discussed. They can have divergent points of interest whether they represent regulators, industry or employees but they all had a legitimate interest to reply to the consultation.

3.           Consultation

The questionnaire was divided into 30 questions with subtopics as follows:

· Respondent information

· Current functioning of the Directive

· Collection of civil aviation occurrences and protection of reporters

· Completeness and quality of the data

· Analysis of occurrences reported

· Options for revising the legislation

· Additional comments

Some questions requested compulsory replies while for others, the most technical ones, there was no obligation to reply. This aimed to allow citizens' participation in the consultation even if they do not have the technical background to reply to each single question. There were references to the background documents explaining the context and the objectives sought by the Commission. The comments deviating from the consultation subject have not been taken up in this note.

The opinions presented in this note do not reflect the Commission's official position.

4.           Presentations of responses

4.1.        Current functioning of the Directive

Ä      The first part of this section focuses on the respondents' assessment of the current European legislation and their opinion on the issues which should be looked at during the revision process.

Most of the respondents are of the opinion that the legislation is incorrectly and ineffectively implemented by most of the Member States and suffers from a number of shortcomings which affect its potential benefit in terms of aviation safety. Some of them also blame the lack of concrete results and of true evidence based approach. They state that the European legislation on occurrence reporting is not working as it was expected. This position is not always shared by public authorities but is widely expressed by stakeholders and citizens. It can be observed that legislation shortcomings identified by respondents broadly correspond with the list of suggested issues which should be addressed by the review.

The figure below illustrates respondents' assessments of the issues that the revision should look at (the possibility was given to choose more than one issue).

It appears that the issues most frequently mentioned are "Just Culture"[1] and "Analysis of occurrences at EU level" (both 70.5%). The issues related to standardisation of data entry process (60.7%), data quality (50.8%) and completeness (49.2%) are also often pointed out along with the establishment of a European risk classification scheme (54.1%). Regrouping all occurrences reporting lines in a single EU legislation (49.2%) is also an important issue for the respondents.

On the Just culture issue, most of the respondents states that, while the Directive provides some provisions to protect the information and the occurrence reporter, these rules are not correctly applied by Member States or industry. According to their opinion, individuals are afraid to report mistakes as they fear blame or even prosecution. Some of the respondents support their position by giving examples of situation where individuals have been fired following a report they made. This opinion is almost unanimously shared by aviation professionals (pilots, air traffic controllers, technicians) but is also supported by many respondents representing the industry.

Respondents also regret the lack of confidentiality of the data reported and the low level of protection from the judicial authorities. Respondents claim that the Directive provisions regarding the protection of information should be reviewed and notably include elements agreed at international level such as ICAO Annex 13 and its Attachment E in order to create a "no blame" environment to encourage individuals to report safety related deficiencies or mistakes.

Respondents underline that the current legislation is incomplete as it only contains provisions on the collection, storage and dissemination of occurrences but does not explain how safety improvement should be made based on the data collected. It does not contain obligations to analyse and use data collected and therefore is unable to achieve the safety improvement goal. Respondents believe that the revision should go further and introduce a general framework for reporting, collecting, validating, assessing, disseminating, analysing occurrences, taking safety actions and ensuring their follow up to monitor improvements to safety.

The poor data quality is also frequently mentioned and is notably caused, according to respondents, by a lack of standardisation and by the wide variety of data quality between MS. They underline the vital importance of getting reliable data to be able to establish correct safety indicators. They regret the absence of a standard for the content, format or quality of data reported and consider that occurrences data as incomplete, unreliable and unusable. The bad quality of data encoded in national databases subsequently brings about the bad quality of data included in the European Central Repository (ECR - which regroups data contained in all EU MS national databases) and therefore gives a distorted picture of the safety situation. This issue of data quality is also commonly mentioned by public authorities, and many organisations also refer to this problem.

The absence of an obligation to assess occurrence risk level and of a tool allowing this assessment is often evoked by the contributors to the consultation and is considered as a limit to any efficient analysis both at national and European level.

Some respondents consider that the list of occurrences to be reported is incomplete. Suggestions are made to add an obligation to report occurrences related "fatigue" and "contaminated air". Some other respondents, mostly from the air traffic management sector, would like the legislation to impose the reporting of all safety relevant occurrences and also to include safety occurrences detected by automatic tools.

Certain respondents, in particular industry employees, underline that service providers (airlines, ANSP, manufacturer etc…) do not transmit all occurrences collected to the public authorities.

Respondents regret the presence of inconsistent occurrence reporting obligations in several European legislative acts outside of the Directive (mainly EU rules related to EASA competencies) and suggest regrouping them in a single legislation.

Some respondents deplore the lack of data exchange between MS and the absence of full access to the ECR. This creates an incomplete system of safety oversight in some Member States as they only have knowledge of occurrences involving operators registered in their territory but not the ones occurring in their airspace but involving airlines registered in another MS.

In addition to the issues already identified by the Commission and presented above, respondents also raise a number of shortcomings and elements which should, to their opinion, be addressed in the review.

They refer to the important discrepancies and inconsistencies of interpretation and implementation between Member States in the application of the legislation. Respondents suggest that the directive should be replaced by a regulation in order to ensure a better harmonisation in the application of the legislative provisions.

Some respondents, mainly service providers or their representatives, complain about the lack of feedback towards the reporters and the industry on actions taken following an occurrence report. They suggest granting them access to the European Central Repository.

Several respondents, representing the Air Traffic Management (ATM) community, urge the Commission to ensure consistency between the revision of the Directive which covers all operational areas and the work done in the ATM area, notably regarding the list of occurrences to be collected, the risk assessment scheme and the list of mandatory data fields.

Some respondents observe that the European definition of an "occurrence" (safety relevant incident outside of an accident or a serious incident) is not consistent with the international agreed definition of "safety occurrence" contained in ICAO terminology which refers to any event which is or could be significant in the context of aviation safety (including accident and serious incident).

Several respondents, mostly in the organisation or citizens' category, complain about the lack of resources and of expertise within public authorities entrusted with the occurrence reporting responsibility. They consider that MS staff are not trained enough and are not able to correctly assess the occurrence reports they receive.

Finally, certain respondents consider that the directive is becoming outdated by the introduction of certain ICAO obligations such as the State Safety Programme. They also regret that the legislation does not address the operator level and suggest that it should comply with Safety Management System fundamentals as set up by ICAO. According to them the legislation should address each level of the system: service providers, national authorities, European Union.

Ä      The second part of this section requests respondents' opinion on whether collection and analysis of occurrences should play a role in the prevention of aircraft accidents. The reply to this question is widely positive as 95% of the respondents support this approach, while 3.3% do not and 1.7% has no opinion on this point. The consultation also includes a question on whether, in addition to the work done at national level, an analysis of civil aviation occurrences should take place at the EU level. On this issue, the support is almost as large, with 88.5% of positive answers from respondents, 8.2% adverse opinion and 3.3% without opinion.

According to contributors the establishment of an analysis obligation at European level along with the appropriate framework for allowing such a task will notably allow the full picture of the safety situation in Europe to be obtained through a large database of occurrences. This much broader data set will help to identify hazards and key risks as well as safety trends which are sometimes not identified by a single MS. The respondents also consider that it could help to define a European-wide vision of emerging trends and issues and that it could allow a better sharing of information between MS. Several respondents suggest that it could be a support for Member States with insufficient human resources. Finally, a few respondents mention that it should inform the European Aviation Safety Plan.

4.2.        Collection of civil aviation occurrences and protection of reporters

Ä      Respondents were asked to assess if the scope of occurrences required to be collected according to the Directive 2003/42/EC was adequate or not. A small majority of them consider the scope as pertinent (56.1%) while 40.4% consider it as not appropriate.

Ä      The next question was related to the functioning of the Mandatory Occurrence Reporting Scheme (MORS) as established by the Directive. The replies indicated that 66.7% of the respondents consider this system as inefficient, 20% expressed their satisfaction with the current scheme and 13.3% have no opinion on this issue. The respondents explained this assessment of the MORS by a number of issues among which: the absence of standardisation in the data entry process, the lack of clarity on what should be reported, an inadequate protection of reporters and the insufficient implementation of Just Culture principles (issue mentioned the most frequently), the lack of data protection rules, the low quality of data, the under allocation of human resources at MS level, the poor level of competencies of persons encoding occurrences reports, the duplication of occurrences, the difficulty in using reporting forms and finally the absence of any feedback.

Ä      Participants in the consultation were asked to evaluate whether all reporting obligations should be regrouped in a unique European legislation or if it should remain as it is currently. The vast majority of respondents favour the first option (76.3%); while 13.6% do not wish to change the situation and 10.2% do not have an opinion on this issue.

Ä      On the question of the mandatory reported occurrences scope, around 2/3 of the respondents express their satisfaction with the list established within the Directive (65.5%). The rest supported the mandatory reporting of all safety relevant occurrences (31%) or do not expressed their position (3.4%).

Ä      Regarding the issue of Just Culture, a wide majority of respondents affirm that occurrence reporters are not sufficiently protected from blame or repressive action in Europe (73.8%) and that Just Culture principles are not correctly implemented and respected in the EU Member States (71.7%). The opinion is notably shared by almost all the respondents from the organisation and citizens categories but not exclusively.

A few respondents, mostly public authorities, affirm that the situation is satisfactory in some MS but the majority of respondents consider that many aviation professionals do not report occurrences as they fear being prosecuted or fired. They considered it is notably due to the fact that Just Culture is a relatively recent concept and that it is still a growing concept, and far from being implemented in all MS. According to respondents, the situation is very different from one State to another and there is a very disparate approach of to Just Culture concept across the EU. They regret a lack of protection in some MS which has led to the transmission of certain occurrence data to Justice in a few cases. In their opinion, the variety of judicial systems and legislation in European Member States effectively override and challenge the protection from blame or repressive actions. They recognise that some mechanisms have been established but regret that they are ineffective as they have no legal value. Respondents also consider that the absence of a "gross negligence" definition contributes to the current situation as there is no clear line defining when the reporter has to be protected and when he should be blamed. They would also like the definition of "Just Culture" to be included in the revised legislation. Some respondents suggested that Directive Article 8, related to the protection of information, should be strengthened to ensure reporter protection. Most of the respondents assess that without an appropriate implementation of the Just Culture concept and protection from blame and prosecution, the goal of the legislation could not be reached as relevant occurrences will not be collected.

Ä      In the last part of this section public consultation contributors were asked for their opinion about the potential establishment of a voluntary occurrence reporting scheme managed at European level in order to collect occurrences not included in the list of events to be mandatory reported. 59% of the respondents support this idea and consider that it will bring an added value in terms of safety while 36.1% are opposed to this proposal. According to some supporters of such a scheme, the European Aviation Safety Agency (EASA) should be entrusted with the responsibility to manage it while some others would prefer an independent body without specifying what this entity should be. Several respondents would support the creation of a European Safety Investigation Authority (or Accident Bureau) to manage the European voluntary occurrence reporting scheme. Finally few respondents would prefer giving this responsibility to the European Commission or to Eurocontrol.

4.3.        Completeness and quality of the data

Ä      Respondents consider that the quality and completeness of data integrated in national databases as well as in the European Central Repository is insufficient. They believe that formal standardisation would help to address, at least partially, this issue. 80.3% of them support the introduction in European legislation of a minimum content of mandatory information to be contained in an occurrence report.

In addition, only 8.5% of the respondents are opposed to the establishment of mandatory data fields. On defining what mandatory data fields should be included in the legislation, they suggest it should include basic information such as data, location, narrative, occurrence category and then, depending on whether it involves an aircraft, an aerodrome and so on, more specific information. A few respondents suggested that ICAO ADREP core taxonomy or ESARR2 mandatory data fields could be a good starting point for defining the list at EU level. Some respondents suggested organising training to ensure a better harmonisation and quality of occurrence reports. A few respondents express the view that a single reporting form should be introduced. According to the respondents' opinion, without any standardisation, data could be wrong and therefore trend or statistics based on this data would be invalid.

Ä      Regarding the issue of risk classification, the establishment of a common European risk classification scheme is widely supported by the respondents (73.8% in favour, 13.1% against, 13.1 without opinion).

4.4.        Analysis of occurrences reported

Ä      Most respondents (78%) consider that the analysis of occurrences at European level should be done in collaboration with the Member States. Some of them also would like the industry associated with this work or even a group of aviation experts.

Ä      Respondents expressed that, in the European Union, occurrences should be analysed at national level and then at European level to identify European key risks areas. Some of them consider full access to the ECR as a necessary condition to perform any kind of analysis at EU level.

Ä      According to a majority of contributors the coordination and the management of the analysis of occurrences at EU level should be given to the European Aviation Safety Agency (in collaboration with the MS and the European Commission for some of them). Several respondents even refer to the recently created group within EASA: the "Network of Analysts" which regroups safety analysts from Member States, the Commission and Eurocontrol. However a certain number of respondents would still prefer the creation of a European Safety Investigation Authority or a similar independent entity to be entrusted with this task. Finally a few contributors believe that this responsibility should be given to the European Commission or to Eurocontrol.

4.5.        Options for revising the legislation

In this part of the questionnaire the Commission has presented different policy options for the revision of the legislation and submitted them to a preference choice in the public consultation.

As described in the document, the following hypotheses are envisaged:

· Repeal Directive 2003/42/EC and implementing Regulations (EC) N° 1321/2007 and N° 1330/2007 (option A)

· Maintain current legislation and continue to ensure its proper implementation (option B)

· Provide additional support for the implementation of current legislation (in particular development of additional functionalities to the "ECCAIRS" reporting system, supporting data quality control and analysis, development of additional guidance material, organisation of workshops for the authorities etc.) (option C)

· Launch a substantial revision of the EU legislation on occurrence reporting to address issues such as clarification of the reporting obligations, standardisation of data entry into ECR, more systematic quality assurance processes, revision of the access rules to ECR, the issue of protection and use of sensitive safety information; and establishing a framework and tools for the analysis of occurrences at EU level (option D)

· In addition to option D, create, in an appropriate organisational set-up, a European voluntary occurrence reporting scheme, allowing aviation professionals and organisations to report occurrences directly to an EU-based system on a voluntary basis (option E)

It appears from the replies that option A has been misunderstood by some respondents as they either believe that repealing the legislation means that it will be replaced by a new one, or that this option has to be chosen in coordination with another one (more often D) to ensure that the two legislations will not coexist. As a consequence that option is partly over ranked in comparison with the presumed real intent of the respondents. The Commission would like to clarify the meaning of this option: repealing existing legislation means that this matter is not regulated anymore by European legislation but by national rules alone. Revising the existing legislation at EU level will lead to the repealing of this legislation once the new rules are adopted. The charts below represent, for each option, the percentage of its ranking by respondents. Ranking 1 means it is the favourite option and ranking 5 means it is the least favourite one. For example, the first table should be read as following: 8.2% of the respondents ranked option A as their favourite option, 14.8% in second position, 11.5% in third, 11.5% in fourth and 54.1% of the respondents ranked it at their least favourite option.

It clearly comes out of the respondents ranking that launching a substantial revision of the EU legislation on occurrence reporting (option D) is the preferred option and that the repealing of the existing legislation (option A) is the one with the lowest respondents preference.

Maintaining the current situation (option B) is ranked 4th in terms of favourite options. Regarding option C and E, the opinion of the respondents is not stated as clearly. Indeed 14.8% ranked the option to provide additional support for the implementation of current legislation as their favourite, 32.8 % in second position and 31.1% in third. The option which combines the substantial revision of the legislation with the establishment of a European voluntary occurrence reporting scheme is ranked first by 26.2% of the respondents, second by 13.1%, third by 23%, fourth by 26.2% and fifth by 11.5%.

Respondents notably vouch their choice by the identification of an important number of shortcomings in the current legislation as presented in section 4.1 of this summary. They consider that the European legislation is not efficient enough and that it should be strengthened and completed. Respondents believe that substantial changes are necessary to allow an improvement of aviation safety.

Respondents consider that an effective occurrence reporting is crucial for the establishment of an evidence based safety system inside a comprehensive safety management system in the European Union and its Member States.

ANNEX 3: ENCASIA's opinion concerning the revision of Directive 2003/42/EC

1.           Introduction

On 27 June 2011, the European Commission sent a letter to the ENCASIA Chairman to ask for the Network’s opinion on the revision of Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation. This revision process will probably lead to a new Regulation of the European Parliament and of the Council on occurrence reporting.

The Network Members went through the same process as ENCASIA stems from the revision of Directive 94/56/EC on accident investigations. This led to Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC. The upcoming revision of Directive 2003/42/EC has been anticipated by Regulation 996 as mentioned in its third recital: “Reporting, analysis, and dissemination of findings of safety related incidents are fundamentally important to improving air safety. Therefore the Commission should bring forward a proposal to revise Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation before 31 December 2011.” Directive 2003/42/EC is referred to several times in Regulation 996, especially through Recitals 11 and 12, which deal with the exchange and analysis of safety information. The Regulation has enlarged the role of safety investigation authorities by defining the concept of safety investigations in Article 2(14). It formally deals with proactive data. It is therefore crucial that safety investigators have access to incidents and occurrence databases to encourage safety action and safety recommendations based on all types of occurrence for the prevention of air accidents. Hence, the right balance must be found so that the future Regulation on occurrence reporting will be complementary in the overall European safety scheme.

The ENCASIA opinion will discuss the following topics that are deemed critical in performing its safety mission: 1) Notification of incidents; 2) Incident selection and investigation; 3) Access to databases; 4) National and European environment.

2.           Notification of incidents

Safety investigation authorities are tasked to investigate serious incidents. The guidance to define a serious incident can be summarized in the Appendix of Regulation 996 and in Annex 13, Attachment C, paragraph 2: “The incidents listed are typical examples of incidents that are likely to be serious incidents. The list is not exhaustive and only serves as guidance to the definition of serious incident.”

This important paragraph provides flexibility to safety investigation authorities to select serious incidents. To carry out such a selection, the safety investigation authorities must be aware of all incidents immediately in order to start an investigation and to preserve key evidence. Article 9 of Regulation 996 already states that: “Any person involved who has knowledge of the occurrence of an accident or serious incident shall notify without delay the competent safety investigation authority of the State of Occurrence thereof.” Presently, the notification of incidents is organized at the level of each Member State in line with Articles 4 and 5 of Directive 2003/42/EC. Therefore, the future Regulation on occurrence reporting should ensure that the provisions related to collecting, evaluating, processing and storing occurrences will maintain safety investigation authorities in the loop so that they can start an investigation without delay. It will be necessary to establish a mechanism that will strike a balance between:

· having access to all incidents and

· setting up a selection process at the level of the operators and regulators to avoid data overflow.

It is indeed the prerogative of the safety investigation authority to determine if the incident needs to be investigated or not, in accordance with the Article 5 (4) of Regulation 996 “Safety investigation authorities may decide to investigate incidents other than referred to in paragraphs 1 and 2 in accordance with the national legislation of the Member States, when they expect to draw safety lessons from them”.

3.           Incident selection and investigation

The incident selection process is not an easy one, as it can be influenced by other factors such as resources and workload. Regarding the treatment of incidents, the European Civil Aviation Conference will organize a workshop on the treatment of incidents in May 2012 in Denmark. This workshop will mainly deal with the issues around the handling of incidents, including their selection for investigation and the lessons they held. Its outcome should be very useful for guiding the selection process for ENCASIA Members.

The following paragraphs offer brief and provisional guidance on how incidents could be dealt with by being broken down into three levels:

Level 1: Basic Preliminary evidence shows that the existing safety nets (procedures, systems, etc.) worked as per design. A “basic” incident illustrates successful mitigating actions and provides feedback on previous remedial measures that appeared to be right. A basic investigation can be quickly closed but it is important to store the successful actions in a database in order to have data and some indicators on the resilience of the system. As a matter of fact, the next release of the ECCAIRS database (ECCAIRS 5) will include a new module to code positive factors. This concrete emphasis on what went right should also encourage more reporting.

Level 2: Standard A local investigation can be undertaken by industry when:

· deficiencies are identified whilst applying a given procedure,

· an aviation professional works beyond its field of expertise or its prerogatives.

This type of investigation leads to safety measures that improve the safety management system of an operator. A “standard” incident can be disseminated locally through a short report and stored into a database so that the effectiveness of the remedial measures can be evaluated.

Level 3: In-depth investigation (serious incidents) If the incident meets the criteria of Regulation 996, then a full investigation should be started by the safety investigation authority as “the difference between an accident and a serious incident lies only in the result”. We can also say that if the consequences appear to be merely a matter of favorable circumstances, meaning that no safety barriers or mitigations were identified, then the occurrence should be investigated in depth. This loops back with the positive factors that are part of ECCAIRS.

4.           Access to Databases

From a technical standpoint, data can be exchanged using the ECCAIRS database. As stated previously, the implementation of release 5 will bring along new modules of high interest for safety investigation authorities such as safety recommendations, positive factors and new features to customize the end-user’s interface. In summary, ECCAIRS represents an effective technical solution that covers all types of occurrences and provides increasing flexibility for civil aviation and safety investigation authorities. The recurrent challenge is related to the extensive resources required to implement the new functionalities and to process vast numbers of occurrences in a consistent way with high quality standards.

The various feedback loops at national levels have been organized in accordance with Article 5 of Directive 2003/42/EC that covers the collection and storage of information. It is crucial that the new legislation will ensure easy legal and practical access to all repositories for safety investigation authorities. Access to the safety recommendation database mentioned in Article 18(5) is already included. As an imperative, ENCASIA needs unconditional access to all incidents and occurrences for more effective safety investigations. This also includes access to the central repository established under Commission Regulation (EC) No 1321/2007 of 12 November 2007. Accident and incident reports are more effective if they reference similar cases which may then support safety recommendations. This independent compilation of events also provides more validated data for the risk analysis subsequently performed by regulators. In addition, Regulation 996 (Recital 28; Article 2(15); Article 17(2)) stipulates that safety recommendations can be released after a safety study, thus having a greater evidential basis leading to safety actions.

5.           National and European Environment

Regulation 996 already provides a sound environment for independent and effective safety investigations. The revision process that will take place shall strengthen the independence of each national safety investigation authority as well as ENCASIA’s independence. The Regulation also contains important provisions on protection of sensitive safety information (Article 14 and 15). The protection of safety information from inappropriate use is essential in ensuring its continued availability, as the use of safety information for other than safety-related purposes may inhibit the future availability of such information, with an adverse effect on safety. ICAO has recently started an ad-hoc task force whose mandate is to enhance guidance on safety information protection. This work will certainly enhance existing ICAO documentation on the protection of sensitive safety information. This could be of interest for the revision process. For ENCASIA, it is important that the revision process as well as the work carried out by the ICAO multidisciplinary taskforce do not blur or bring doubts on the information that is protected under Regulation 996, especially under Article 14(1). The revision of Directive 2003/42/EC will probably have an effect on the State Safety Programmes (SSPs). An SSP requires the coordination of multiple authorities within a State, to identify safety deficiencies requiring action, to determine mitigation strategies in response to these deficiencies, to implement these strategies and to monitor their implementation and effectiveness. The distribution of those responsibilities, as part of a State Safety Programme, shall maintain the independence of the safety investigation authority with regard to the oversight of NAA functions, as service provider. This shall be the same environment for the European Safety Plan coordinated by EASA.

6.           Conclusions: Opinions of ENCASIA Members

In Article 2(1) of Directive 2003/42/EC, an occurrence means “an operational interruption, defect, fault or other irregular circumstance that has or may have influenced flight safety and that has not resulted in an accident or serious incident, hereinafter referred to as ‘accident or serious incident’, as defined in Article 3(a) and (k) of Directive 94/56/EC”. The ICAO definition encompasses accidents, serious incidents, incidents and all types of reportable events. This revision process should also enhance this definition, which is often confusing when the term “occurrence” is mentioned. It is important to better define the scope of the future Regulation on incidents that also deals with safety so that it is complementary with Regulation 996 and both will be well-understood by the civil aviation industry.

From an editorial standpoint, Regulation 996 refers to Directive 2003/42/EC several times through its recitals and articles. There will also be a practical need to update these provisions when Directive 2003/42/EC will be repealed.

In summary, the key aspects for ENCASIA are:

· Unrestricted and straightforward access to data to enlarge the evidential basis.

· Independence of the safety investigation leading to effective safety actions and safety recommendations.

The revision process should take into account the practical experience gained with Directive 2003/42/EC and should aim at setting up a system that would clarify the various reporting channels while producing feedback to encourage more effective safety reporting.

For the reasons previously mentioned, ENCASIA Members strongly support the revision of Directive 2003/42/EC. A new Regulation on incident reporting will complement Regulation 996, which is already a key pillar of the European civil aviation safety system, and will strengthen this system.

ANNEX 4: Seminar on "Just Culture in the context of Occurrence Reporting schemes”

- Summary of discussions - 19th April 2012, Brussels

The European Commission held a Seminar on the subject of “Just Culture in a context of occurrence reporting schemes" in civil aviation in Brussels on 19th April 2012.

The Seminar was part of the consultation process for the Impact Assessment on the revision of EU legislation on occurrence reporting in civil aviation. It was preceded by a questionnaire sent to Member States and an online public consultation. One of the outcomes of these consultations was that Just Culture was the most frequently mentioned issue and that both stakeholders and Member States expect the Commission to address this issue and improve the current situation in the revised legislation. Therefore the Commission decided to organise a Seminar on Just Culture in order to more closely involve interested parties in the preparation of the legislative proposal and to have an open debate on how this issue could be tackled within the revision.

The Seminar gathered together around hundred participants representing all aviation players, including the following entities: the European Aviation Safety Agency (EASA), Eurocontrol, Civil Aviation Authorities from Member States (MS) and neighbouring countries, Safety Investigation Authorities from MS and neighbouring countries, MS Permanent Representations, Air Navigation Services Providers from Member States, Airports, Engineers associations, Airlines and airlines associations, Pilots and Air Traffic Controllers associations, a major manufacturer, an Air and Space Academy, consultant organisations and an university.

Eckard SEEBOHM, Head of the Aviation safety Unit in the DG MOVE of the European Commission, opened the Seminar by underlining that this initiative and the revision of the EU legislation on occurrence reporting were core elements of the European Aviation Safety system's transition towards a more proactive and evidence based system. He also emphasised the importance of the Seminar for the Commission's preparative work.

Frederik KAMPFE (European Aviation Safety Agency (EASA), Deputy Chief Legal Adviser) presented the “Evolution of Just Culture in occurrence reporting from a legal perspective”. He explained how Just Culture principles have been incorporated into different EU legislative texts, notably Regulations No 996/2010 and No 691/2010 where the expression "Just Culture" is explicitly mentioned and defined for the first time. The speaker also explained that, while the provisions ensuring Just Culture principles implementation should be present in legislation, legislation alone could not solve all Just Culture issues. For Just Culture to be fully implemented it should be complemented by initiatives outside of the legislative framework.

Jean-Pol HENROTTE (European Commission, DG MOVE, Single European Sky Unit) made a presentation on “The measurement of Just Culture: a Safety Performance Indicator”. He presented the Commission Regulation (EU) No 691/2010 laying down a performance scheme for air navigation services and network function, which is the first legal recognition of the Just Culture concept and definition at EU level. The speaker explained the on-going work for measuring Just Culture and specified that the legislation did not introduce new requirements for the implementation of Just Culture but only attempted to measure its implementation.

Captain Paul REUTER (European Cockpit Association (ECA) representative) made a presentation on the Just Culture "Perception" by aviation professionals. He began his intervention by explaining that humans and aviation professionals will continue to make errors and that if punishment is beneficial for intentional mistakes it may bring negative effects when applied to unintentional errors or mistakes. The speaker also underlined that the fear of punishment and the consequent low reporting level, could mislead and blind organisations as to their risks. He presented bad examples where reporting led to punishment and consequently decreased the level of reports. Captain REUTER emphasised that Just Culture does not mean immunity and that mistakes should be differentiated from wilful acts. The line between the two is however sometimes difficult to draw with precision and the speaker stated that acceptable and unacceptable behaviours should be defined. Finally he underlined that provisions regarding the relation with judiciary should be clarified in order to offer reporters the appropriate protection.

Captain Giancarlo BUONO (International Air Transport Association (IATA) Assistant Director Safety and Operations for Europe) presented the Industry perspective on Just Culture. He underlined the importance of Just Culture for operators as essential to their Safety Management System and therefore that reporters should be protected. The speaker also stated that protection does not mean immunity and that gross negligence and wilful misconducts should be punished. In addition, he specified that within an SMS environment, an operator should take effective action to mitigate the risk, including, if required, training or re-training of an individual.

Sandra ORUS (French DGAC Legal Affairs Deputy Director) and Fabienne HERLEDAN-REUMOND (French DGAC, Deputy Head of Safety Management Coordination Office) began their presentation by introducing the French occurrence reporting system. It was followed by the presentation of the link between judicial authorities and Just Culture in France. Sandra ORUS specified that if in few cases safety reports have been seized by judicial authorities, they have never been retained at charge in a judicial decision against the reporter. She also explained that in order to raise the awareness of judges to specificities of the aviation world and to promote Just Culture, France has organised exchange sessions between judicial authorities and the CAA which had had a positive impact.

Sean PARKER (Head of Safety Data in United Kingdom Civil Aviation Authority) made a presentation on "Just Culture in UK Civil Aviation" during which he explained how the UK has been able to effectively implement Just Culture principles. To ensure reporters confidence and trust, Just Culture principles had been included in UK legislation and guidance material. In addition the UK CAA has put efforts into publicity and training to complement what could not be achieved through legislation or guidance. Regarding confidentiality, he explained that while the UK CAA receives more requests under the Freedom of Information Act for occurrence reports than for any other information, occurrence reports are currently protected and are exempt from general access to information by citizens.

Captain Régis FUSENIG (Air France, Flight Safety Department) presented the concept of positive safety culture introduced in his company after the accident to AF447. He explained that all the company, including the higher management levels has committed to ensure Flight Safety. He specified that the ideal of a positive safety culture in order to learn from mistakes and correct deficiencies has been implemented both at individual and corporate levels. He then detailed the processes recently established within his airline in order to achieve this objective.

Job BRUGGEN (Safety Manager at Air Traffic Control the Netherlands) made a dynamic presentation about Just Culture and how this issue has been addressed in aviation in the Netherlands. He presented the "Delta" case in which air traffic controllers had been prosecuted following an incident they had reported and had subsequently been found guilty, but with no sentence imposed. As a consequence of this proceeding the reporting level of ATM occurrences dropped seriously. Following the judgment on the Delta case, a new system had been established within the Netherlands: occurrences which could possibly lead to a prosecution are analysed by a group of persons from both aviation and the judiciary. If this group decide the event may possibly warrant a prosecution, the occurrence in sent to the aviation police who have instructions to not prosecute unless there is evidence of gross negligence or a wilful violation. Since this system has been established no reporter has been prosecuted following an occurrence report. The speaker also mentioned that defining gross negligence in EU legislation may be helpful to draw the appropriate line.

Roderick VAN DAM (Chairman of the Eurocontrol Just Culture Task Force) presented notably the work done by the Just Culture Task Force which gathers together representatives from both aviation and judiciary worlds. He reminded the meeting that the Just Culture concept used errors to improve the system but did not tolerate gross negligence and wilful misconduct. The speaker underlined the difficulty in drawing the line between errors and gross negligence but, contrary to the previous speaker, urged the Commission not to define the term "gross negligence" within the legislation. Roderick VAN DAM emphasised that there are limits to what legislation can do. In that perspective he presented the Model Prosecution Policy developed by the Task Force, inspired by current practices in the Netherlands and the UK, and on which the Commission has been consulted, The Policies should be submitted for endorsement of EUROCONTROL Member States in May 2012. Finally he briefly covered other initiatives and the on-going debate, notably at international level, related to the Just Culture issue.

The Seminar concluded with an open debate focusing on how to improve Safety Culture and how to better implement it through the future EU legislation on occurrence reporting.

It came out of the debate that while occurrences reporters are very unlikely to be prosecuted and convicted on the basis of an occurrence they have reported, the fear that they would be influences the level of reporting. Therefore, and taking into consideration that, according to the Treaties, the European Union has no competence to regulate judicial authorities, this perception by individuals should be addressed in the legislation and beyond in order to ensure a high level of reporting culture. It also came out of the discussions that aviation professionals, the industry and the regulators have all the same understanding of the Just Culture principles i.e. an environment where reporters are not blamed for errors or mistakes they have reported but where gross negligence and wilful misconduct are not tolerated.

Therefore, it shows that all aviation players understand not only the importance of occurrence reporting as an essential element of an efficient safety system, but also that each of them has to respect Just Culture principles in order for the system to be effective.

The conclusions of the Seminar were discussed and adopted and are detailed below:

Ä Establish and ensure a high level of Just Culture environment across the European Union Member States is essential for an efficient European Safety Management System based notably on the systematic analysis of data including occurrence reports.

Ä An appropriate Safety Culture in the European Union and its Member States will be an important contributor for reaching the objective to reduce the number of fatalities caused by aircraft accidents

Ä Despite the introduction of certain provisions in the European legislation Just Culture principles are not equally and appropriately implemented across Member States

Ä The definition of Just Culture as enshrined in Commission Regulation (EU) No 691/2010 should be included in the revised legislation on occurrence reporting

Ä The new legislation on occurrence reporting should clarify and reinforce the provisions included in Directive 2003/42/EC Article 8 notably to directly impose rules on employers and to ensure the adequate protection of information contained in operators, national and European databases

Ä Mandatory and Voluntary Occurrence Reporting Schemes should both be non-punitive except in the case of gross negligence or wilful misconducts and afford protection to the sources of the information

Ä The new legislation should limit the use of occurrence reports data to safety improvement purposes only

Ä Guidance material (including on the understanding of gross negligence) and training should be developed to allow a better understanding and implementation of the Just Culture concept

Ä Consideration should be given to address the access and use of occurrence reports by judicial authorities and to create communication channels between safety authorities and judicial authorities

Ä Consideration should be given to the potential extension of individuals' personnel data protection from Article 8(2) to organisation databases

Ä Consideration should be given to pros and cons of the establishment of a focal point at European level allowing individuals to report breach of "Just Culture" principles they have experienced.

ANNEX 5: Study on the establishment of a common risk classification of civil occurrences at EU level

1.           Introduction

The purpose of this study is to review the background, and highlight the issues, of the development and implementation of a common European Risk Classification Scheme as a part of the Impact Assessment on the possible revision of EU legislation on Occurrence Reporting in civil aviation. This existing legislation is focused on the reporting of safety occurrences in the aviation system and could be revised to include the effective analysis of the occurrence reporting data. The proposal to develop a common risk classification scheme will support that analysis activity through the facilitation of risk analysis. The purpose of such a scheme is therefore to be able to classify (or score), in terms of safety risk, occurrences in civil aviation.

Such a scheme should be applicable to all the occurrence data that is part of the legislation, however it would also benefit Member States and the European Union, and particularly the industry and the wider public, if such a scheme was applicable to all safety incident data that forms part of safety management activity within the aviation domain.

2.           Risk Measurement

Risk classification is fundamentally about the measurement of risk and that involves two dimensions:

(1) The severity of the potential outcome – i.e. how bad will it be if the risk is realised

(2) The probability that the outcome will be realised – i.e. how likely is it to happen

The second term can be further considered in two parts: a) the probability that the safety occurrence will occur and b) the probability that the safety occurrence, when it occurs, might progress to the undesired outcome. At this point it is important to draw a distinction between ‘Risk Classification’, as is being considered by this scheme, and ‘Risk Assessment’.

Risk assessment is typically an activity of taking a system and then making judgments about it to predict the risk that it involves[2]. Risk Classification however, as in the case of this exercise, involves the scoring of safety occurrences in terms of risk and then ultimately using those classified/scored safety occurrences to observe the risk manifest within the system. The importance of this distinction is that the risk classification therefore involves the observation of events that have already occurred and hence there is no requirement to determine their probability of occurrence (term 2a above) so the dimension 2 need only be the probability that the safety occurrence might progress to the outcome (term 2b).

3.           Existing tools and techniques

There are various existing tools and activities in progress that have the potential to provide value, and efficiency, to the development of a common European scheme. This section highlights some that have already been discussed in the context of this scheme and the potential role they could play in its development and implementation:

· ECCAIRS 5 - ODA2 risk classification approach – The latest ECCAIRS 5 product has an embedded risk classification scheme that was developed by the ODA-2 working group at the request of the Joint Safety Strategy Initiative steering group. This classification scheme, completed in 2006, is a three step risk classification process that covers a) most probable accident outcome, b) remaining safety barriers & c) frequency of occurrence.

· ARMS Event Risk Classification (ERC) – The ARMS (Aviation Risk Management Solutions working group) was an industry driven follow up activity to ODA-2, focused on developing practical solutions that could be applied across the industry. One of the outcomes of ARMS was the ERC approach to assigning risk scores to occurrences. The ERC (Event Risk Classification) is fundamentally the first two steps of the ODA-2 approach as the ARMS group recognised that the frequency term was a function of data analysis not classification. The ERC approach is being increasingly widely adopted across varied segments of the aviation industry which, along with its JSSI heritage and very close links to the existing ECCAIRS 5 tool, make it a good starting point for the development of a common European scheme.

· Eurocontrol Risk Analysis Tool (RAT) – This is fundamentally a tool for the application of a risk classification to air traffic management incidents. It is not applicable to events outside of the ATM domain but would likely be the method of choice for implementation of a European scheme by air traffic service providers due to its widespread adoption in Europe. It would therefore be logical and beneficial that a European scheme is fully compatible with the RAT approach for ATM events and that the RAT was able, either as is or with minor modifications, to satisfy the requirements of the European scheme.

· Common Risk Classification Framework – This is an activity being pursued by the UK CAA to apply some of the underlying principles of the RAT to the wider aviation domain by using industry recognised techniques for gathering expert judgement. This is therefore, like the RAT, focused at the application/tool end of the spectrum, but being based on some of the ARMS principles offers a valuable insight into how such application might develop and hence how the scheme might be best placed to facilitate that development in the future.

Other schemes in EC Member States - There are likely other areas of work and techniques that will be of benefit to the development of the scheme and these will need to be identified and considered as the development progresses. The UK CAA has an existing risk classification scheme for mandatory occurrence reports but is looking to move it forward to latest practice and hence are actively involved in the development of this common scheme.

4.           Common scheme

The objective of this activity is to develop a common scheme for the aviation system so, by implication, commonality across both national and functional boundaries of the aviation system. Commonality in measurement terms means measuring the same things (the dimensions identified above), to the same point (in this case comparable risk outcomes) using the same, or equitable, scales. The precise method you use to measure it does not necessarily have to be common, an issue that will be covered later.

Common risk outcomes are an important need across the aviation system both within individual organisations and particularly across the wider functions of the aviation system.[3] For a common scheme to function the outcomes need to be common, or at the very least directly equitable with each other. As this legislation is about aviation safety these outcomes also need to be in terms of actual physical loss (expressed in terms of fatalities, injuries and physical damage). Outcomes expressed in terms of human fatality and injury can be directly equated[4] and physical damage can be equated on a financial basis, one significant challenge in developing this scheme will be agreeing if and how to equate the human outcomes with the damage outcomes in financial terms[5]. Comparable outcomes is one dimension of our measurement paradigm, the other is that of the probability of the outcome being realised. Probability is a recognised measurement term and therefore provides a ready basis for common measurement in terms of outcomes per X occurrences. The problem that normally arises in probability terms: ‘over what timescales or operating dimension to measure’, is not an issue in pure risk classification[6]. With regards to the probability axis the more significant question that the development of a common risk classification scheme needs to consider is how to measure it. By definition risk measurement will always involve the forward projection of an event or scenario into an adverse outcome and therefore the probability is an estimation of how likely that projection is to be realised. A human’s ability to estimate a probability is very dependent upon their experience in observing the event and the outcome, so with the very low rate of outcomes experienced in aviation that estimation becomes very difficult. A partial solution to this difficulty that is becoming increasingly popular within the aviation domain (and is part of many of the existing approaches discussed above) is by describing the problem in terms of barriers and using the assessment of the barriers as a direct approximation to the probability.

It is an open question as to the level of common definition of methods or tools for implementation that is necessary, or appropriate, for inclusion in the scheme. The most effective and efficient method of application of the scheme is likely to be very different for example between a small local maintenance organisation and a major international airline operation. The crucial thing is that they are measuring the same thing (dimensions or axis) using comparable scales, the tools they use to do that can be chosen by them as long as they meet the purposes of the scheme. A parallel to this would be in the measurement of distance: it is defined what the measurement principle is and the scale, but how you measure it varies dependent upon the situation. Notwithstanding the above it is also recognised that the legislation of a common method to apply the scheme has the potential to provide a greater level of commonality. It is therefore an area of consideration as to how much focus is applied to this area in the development of the scheme. One possible, and pragmatic, approach would be to define the core basis of the scheme and allow the industry to develop the appropriate methods for application. As ‘best practices’ start to emerge it would then be an option to encourage widespread adoption of these at a later date. With regards to applicability of the scheme it would logically be assumed that it would be applicable to all the data that is included in the occurrence reporting legislation. It is however also to be noted that many organisations collect occurrence data that goes beyond the requirements of the legislation and it would both be logical and beneficial that the scheme also be suitable for application to such data.

5.           Expected benefits of a Common EU Scheme

The benefit of a risk classification scheme is that it provides a risk measurement basis against which to manage risk. There is much truth in the saying ‘you can’t manage what you can’t measure’ and a risk classification scheme works to overcome this limitation.

The industry itself will benefit from a common scheme through each organisation being able to see how they contribute to aviation risk as a whole. Aviation is an increasingly integrated and joined up system and organisations are progressively recognising the need to work together on risk management. The use of a common risk classification scheme will facilitate this through a joined up view of risk performance, enabling organisations to effectively share and compare risk performance information with others to make the most efficient use of their combined resources.

For Member States the application of a common risk classification scheme is vital to enable effective and efficient oversight across the different parts of the aviation domain. Furthermore the scheme will also bring efficiency benefits through the reduction in duplication caused by the application of dissimilar risk classification at many levels in the reporting chain.

At an EU level the application of the scheme across Europe, and the common measure of safety performance it provides, will facilitate effective and proportionate regulation & oversight focused on delivering acceptable levels of risk exposure from aviation for all EU citizens. It should be recognised that such a common scheme is a vital part of great co-operation at EU level in the management of risk in the aviation domain and will be an essential contributor to risk reduction within an expanding European aviation system. Ultimately such a scheme will benefit the EU and its citizens by helping to deliver the necessary cross industry safety benefits that will not be realisable with States and organisations measuring and managing risk in an uncoordinated way.

6.           Feasibility, timescales and costs

The development of a common European Risk Classification scheme will require agreement at an international level of, at the very least, the core risk management principles (the dimensions and scales of risk classification). Building upon existing international work should make it feasible to achieve agreement within a short timescale of less than two years. If the definition of tools and methods is considered a necessary part of the defined scheme then longer timescales will result through the need to develop significant new work and then gain international agreement on it.

From a technical standpoint the development of a scheme at the level of core principles should be relatively straight forward as it will involve only the definition of the terms to be captured and the scales against which to score them. With regards to implementation in occurrence reporting systems; at a Member State level ECCAIRS will be the main platform for implementation so if the scheme developed closely matches that of the ODA scheme already implemented then it will clearly be feasible for implementation in ECCAIRS. If the scheme is applied at a lower level across the industry then it will impact a range of commercial and bespoke incident reporting systems. The commercial systems however often have user configurable risk classification functions, the use of which is already moving towards the best practice that this scheme will seek to define, so the technical impact on those systems will likely be limited. There will be costs incurred in the development of the risk classification scheme including international meetings, direct development work and the publication of documents for consultation. There will also be costs incurred through the implementation of the scheme across the industry including occurrence reporting software changes, procedure changes and training. Taking each of these in turn (assuming a scheme that addresses only the core risk measurement principles) the following provides a very high level estimate of the potential cost implications:

Scheme development – (8 meetings of 10 people – 80 man days, direct development and documentation – 80 man days) – Total of 8 man months 50% divided between participants and 50% to EASA/Commission.

System modification – assuming a solution that is similar to the existing ECCAIRS ODA-2 system then modification to the existing ECCAIRS 5 risk classification function should be limited to less than 1 man month’s work. For other systems, where user definability of the risk classification function will not suffice, a similar workload could be assumed. The scope of systems that would be impacted by such a scheme has not been determined but an estimate of about 12 man months total effort should cover the modification of a very wide range of occurrence reporting systems across the European aviation domain.

Procedure changes and training – Again the impact of this will be dependent upon the level to which the risk classification scheme is implemented, at a state level it will clearly impact 27 organisations but beyond that there are potentially many hundreds of others who could be involved in the use of such a common risk classification scheme. Full assessment of the cost implications of procedures and training would again require greater knowledge of the scope of the implementation of the scheme, but an initial estimate is 6-18 man months effort.

ANNEX 6: Occurrence reporting obligations in European legislation

EU legislative act || Article, paragraph || Who has to report || Who receives the report || What should be reported || Which delay to report

Directive No 2003/42[7] || Article 4, para.1 a) || The operator or commander of a turbine-powered or a public transport aircraft || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Directive No 2003/42 || Article 4, para.1 b) || A person who carries on the business of designing, manufacturing, maintaining or modifying a turbine-powered or a public transport aircraft, or any equipment or part thereof, under the oversight of a Member State || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Directive No 2003/42 || Article 4, para.1 c) || A person who signs a certificate of maintenance review, or of release to service in respect of a turbine-powered or a public transport aircraft, or any equipment or part thereof, under the oversight of a Member State || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Directive No 2003/42 || Article 4, para.1 d) || Air traffic controllers and flight information officers || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Directive No 2003/42 || Article 4, para.1 e) || A manager of an airport within the Community || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Directive No 2003/42 || Article 4, para.1 f) || A person who performs a function connected with the installation, modification, maintenance, repair, overhaul, flight-checking or inspection of air navigation facilities for which a Member State ensures responsibility || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Directive No 2003/42 || Article 4, para.1 g) || A person who performs a function connected with the ground-handling of aircraft, including fuelling, servicing, loadsheet preparation, loading, de-icing and towing at a European airport || Member State competent authority and then the European Central Repository (ECR) || Occurrences which endanger or which, if not corrected, would endanger an aircraft, its occupants or any other person. || Determined by national implementing measures

Regulation No 1702/2003[8] (Part 21) || 21A.3.b) || The holder of a type-certificate, restricted type-certificate, supplemental type-certificate, ETSO authorisation, major repair design approval or any other relevant approval deemed to have been issued under this regulation || The European Aviation Safety Agency (EASA) || Any failure, malfunction, defect or other occurrence of which it is aware related to a product, part or appliance covered by the type-certificate, supplemental type-certificate, ETSO authorisation, major repair design approval or any other relevant approval deemed to have been issued under this regulation, and which has resulted in or may result in an unsafe condition[9] || 72h

Regulation No 1702/2003 (Part 21) || 21A.265.f) || Holder of a production organisation approval || The holder of the type-certificate, restricted type-certificate or design approval. EASA and the Member State competent authority || All cases where products, parts or appliances have been released by the manufacturer and subsequently identified to have deviations from the applicable design data, and investigate with the holder of the type-certificate, restricted type-certificate or design approval to identify those deviations which could lead to an unsafe condition[10] || As per 21A.3.b) or as accepted by the competent authority of the Member State

Regulation No 1702/2003 (Part 21) || 21A.265.f) || The manufacturer acting as supplier to another production organisation || The other production organisation || All cases where it has released products, parts or appliances to that organisation and subsequently identified them to have possible deviations from the applicable design data. || As per 21A.3.b) or as accepted by the competent authority of the Member State

Regulation No 2042/2003[11] (Part M) || M.A.202 || Any person or organisation responsible under M.A.201 (responsible of continuous airworthiness) || The State of registry, the organisation responsible for the type design or supplemental type design and, if applicable, the Member State of operator || Any identified condition of an aircraft or component that hazards seriously the flight safety || 72h

Regulation No 2042/2003 (Part M) || M.A.202 || The person or organisation maintaining the aircraft is contracted by an owner or an operator to carry out maintenance, the person or the organisation maintaining the aircraft || The owner, the operator or the continuing airworthiness management organisation || Any such condition affecting the owner's or the operator's aircraft or component || 72h

Regulation No 2042/2003 (Part 145) || 145.A.60 || The organisation [to qualify for the issue or continuation of an approval for the maintenance of aircraft and components] || The competent authority, the state of registry and the organisation responsible 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 || 72h

Regulation No 2042/2003 (Part 145) || 145.A.60 || The organisation contracted by a commercial operator to carry out maintenance || The operator || Any such condition affecting the operator's aircraft or component || 72h

Regulation No 859/2008[12] (EU-OPS) || 1.420 b) || The commander or the operator of an aeroplane || The competent Authority || Any incident that endangers or could endangers the safety of operation; deficiency of technical limitations endangers or could endanger the safety of operation || 72h

Regulation No 859/2008 (EU-OPS) || 1.420 b) || The operator || The organisation responsible for the design or the supplier or, if applicable, the organisation responsible for continued airworthiness, at the same time as a report is submitted to the Authority || Any failure, malfunction or defect in the aeroplane, its equipment or any item of ground support equipment or which cause or might cause adverse effects on the continuing airworthiness of the aeroplane || 72h

Regulation No 859/2008 (EU-OPS) || 1.420 d) 1. || The commander || The air traffic service unit concerned and the Member State competent authority || Whenever an aircraft in flight has been endangered by: a near collision with any other flying device; faulty air traffic procedures or lack of compliance with applicable procedures by air traffic services or by the flight crew; failure of air traffic services facilities || Without delay

Regulation No 859/2008 (EU-OPS) || 1.420 d) 2. || The commander || The air traffic service unit concerned and the Member State competent authority || Whenever an aircraft in flight has manoeuvred in response to an ACAS resolution advisory ||

Regulation No 859/2008 (EU-OPS) || 1.420 d) 3. || The commander || The air traffic service unit concerned || Whenever a potential bird hazard is observed || Immediately

Regulation No 859/2008 (EU-OPS) || 1.420 d) 3. || The commander The operator, if the bird strike is discovered when the commander is not available || The Member State competent authority || Bird strike in case of significant damage to the aircraft or the loss or malfunction of any essential service || After landing

Regulation No 859/2008 (EU-OPS) || 1.420 d) 4. || The operator || The Member State competent authority and the appropriate Authority in the State where the accident or incident occurred || Dangerous goods incidents and accidents || 72h

Regulation No 859/2008 (EU-OPS) || 1.420 d) 5. || The commander or, in his/her absence, the operator || The local Authority and to the Authority in the State of the operator || An act of unlawful interference on board an aircraft || As soon as practicable

Regulation No 859/2008 (EU-OPS) || 1.420 d) 6. || The commander || The appropriate air traffic services unit || A potentially hazardous condition such as an irregularity in a ground or navigational facility, a meteorological phenomenon or a volcanic ash cloud is encountered during flight || As soon as practicable

Regulation No 290/2012[13] || ARA.GEN.125                         || The competent authority || EASA || Safety-significant information stemming from the occurrence reports it has received ||

Regulation No 290/2012 || ORA.GEN.160 || The organisation || The Member State competent authority and to any other organisation required by the State of the operator to be informed || Any occurrence as defined in Directive 2003/42/EC ||

Regulation No 290/2012 || ORA.GEN.160 || The organisation || The Member State competent authority and to the organisation responsible for the design of the aircraft || Any incident, malfunction, technical defect, exceeding of technical limitations, occurrence that would highlight inaccurate, incomplete or ambiguous information contained in data established in accordance with Part-21 or other irregular circumstance that has or may have endangered the safe operation of the aircraft and that has not resulted in an accident or serious incident. || 72h

Draft Cover Regulation laying down requirements and administrative procedures related to aerodromes NPA 2011-20 (B.I)[14] || ADR.OR.C.030 || The aerodrome operator and the provider of apron management services || The competent authority, and to any other organisation required by the State where the aerodrome is located || Any occurrence as defined in Directive 2003/42/EC. || As soon as practicable, but in any case within 72 hours

Draft Cover Regulation laying down requirements and administrative procedures related to aerodromes NPA 2011-20 (B.I) || ADR.OR.C.030 || The aerodrome operator and the provider of apron management services || The competent authority and to the organisation responsible for the design of aerodrome equipment || Any incident, malfunction, technical defect, exceeding of technical limitations, occurrence or other irregular circumstance that has or may have endangered safety and that has not resulted in an accident or serious incident. || As soon as practicable, but in any case within 72 hours

Draft Cover Regulation laying down requirements and administrative procedures related to aerodromes NPA 2011-20 (B.I) || ADR.OR.D.030 || All personnel and organisations operating or providing services at the aerodrome || The aerodrome operator || For the mandatory reporting: any accident, serious incident and incidents; for the voluntary reporting: any defect, fault and potential safety hazard which could impact safety ||

Draft Cover Regulation laying down requirements and administrative procedures related to aerodromes NPA 2011-20 (B.II) || AMC1-ADR.AR.C.060 (a) || The competent authority || ICAO || Wildlife strike (or near-misses) ||

Draft Cover Regulation laying down requirements and administrative procedures related to aerodromes NPA 2011-20 (B.I) || ADR.AR.A.025.b) || The competent authority || EASA || Safety-significant information stemming from the occurrence reports it has received. ||

Draft Cover Regulation laying down requirements and administrative procedures related to aerodromes NPA 2011-20 (B.I) || ADR.AR.A.030 || The aerodrome operator (not explicit) || The competent authority || Safety information ||

Annex VIII the draft Commission Regulation on ‘Air Operations — OPS’ Part-SPO — IR || SPO.GEN.105 Crew responsibilities || The crew member || The pilot-in-command || Any fault, failure, malfunction or defect, which he/she believes may affect the airworthiness or safe operation of the aircraft, including emergency systems; and any incident that was endangering, or could endanger, the safety of the operation ||

Annex VIII the draft Commission Regulation on ‘Air Operations — OPS’ Part-SPO — IR || SPO.GEN.106 Task specialists responsibilities || The task specialist || The pilot-in-command || Any fault, failure, malfunction or defect, which he/she believes may affect the airworthiness or safe operation of the aircraft, including emergency systems; and any incident that was endangering, or could endanger, the safety of the operation. ||

Annex VIII the draft Commission Regulation on ‘Air Operations — OPS’ Part-SPO — IR || SPO.GEN.107 Pilot-in-command responsibilities and authority || The pilot-in-command || The appropriate air traffic services unit || Any hazardous weather or flight conditions encountered that are likely to affect the safety of other aircraft. || As soon as possible

Annex VIII the draft Commission Regulation on ‘Air Operations — OPS’ Part-SPO — IR || SPO.GEN.107 Pilot-in-command responsibilities and authority || The pilot-in-command || The competent authority and the designated local authority || An act of unlawful interference || Without delay

Annex VIII the draft Commission Regulation on ‘Air Operations — OPS’ Part-SPO — IR || SPO.GEN.155 Transport of dangerous goods || The operator || The competent authority and the appropriate authority of the State of occurrence in the event || Any dangerous good accident or incidents; the finding of dangerous goods carried by task specialists or crew, or in their baggage, when not in accordance with Part 8 of the Technical Instructions || Without delay

Annex VI the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCC — IR || NCC.GEN.105 Crew responsibilities || The crew member || The pilot-in-command || Any fault, failure, malfunction or defect, which he/she believes may affect the airworthiness or safe operation of the aircraft, including emergency systems; any incident that was endangering, or could endanger, the safety of the operation ||

Annex VI the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCC — IR || NCC.GEN.106 Pilot-in-command responsibilities and authority || The pilot-in-command || The appropriate air traffic services unit || Any hazardous weather or flight conditions encountered that are likely to affect the safety of other aircraft. || As soon as possible

Annex VI the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCC — IR || NCC.GEN.106 Pilot-in-command responsibilities and authority || The pilot-in-command || The competent authority and the designated local authority || An act of unlawful interference || Without delay

Annex VI the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCC — IR || NCC.GEN.150 Transport of dangerous goods || The operator || The competent authority and the appropriate authority of the State of occurrence in the event || The event of any dangerous goods accidents or incidents || Without delay

Annex VII the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCO — IR || NCO.GEN.105 Pilot-in-command responsibilities and authority || The pilot-in-command || The appropriate air traffic services unit || Any hazardous weather or flight conditions encountered that are likely to affect the safety of other aircraft || As soon as possible

Annex VII the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCO — IR || NCO.GEN.105 Pilot-in-command responsibilities and authority || The pilot-in-command || The competent authority and shall inform the designated local authority || An act of unlawful interference || Without delay

Annex VII the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCO — IR || NCO.GEN.105 Pilot-in-command responsibilities and authority || The pilot-in-command || The nearest appropriate authority || Any accident involving the aircraft that results in serious injury or death of any person or substantial damage to the aircraft or property || By the quickest available means

Annex VII the draft Commission Regulation on ‘Air Operations — OPS’ Part-NCO — IR || NCO.GEN.140 Transport of dangerous goods || The pilot-in-command || The competent authority and the appropriate authority of the State of occurrence || Any dangerous goods accidents or incidents || Without delay

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || ARO.GEN.125 Information to the Agency || The competent authority || EASA || Safety-significant information stemming from the occurrence reports it has received ||

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || ORO.GEN.160 Occurrence reporting ||  The operator || The competent authority, and to any other organisation required by the State of the operator to be informed || Any accident, serious incident and occurrence as defined in Regulation (EU) No 996/20102 and Directive 2003/42/EC || Within 72 hours of the operator identifying the condition to which the report relates, unless exceptional circumstances prevent this

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || ORO.GEN.160 Occurrence reporting || The operator || The competent authority and the organisation responsible for the design of the aircraft || Any incident, malfunction, technical defect, exceeding of technical limitations, occurrence that would highlight inaccurate, incomplete or ambiguous information contained in operational suitability data or other irregular circumstance that has or may have endangered the safe operation of the aircraft and that has not resulted in an accident or serious incident || Within 72 hours of the operator identifying the condition to which the report relates, unless exceptional circumstances prevent this.

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || CAT.GEN.MPA.100 Crew responsibilities || The crew member || The commander || Any fault, failure, malfunction or defect which the crew member believes may affect the airworthiness or safe operation of the aircraft including emergency systems, if not already reported by another crew member; any incident that endangered, or could have endangered, the safety of the operation, if not already reported by another crew member ||

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || CAT.GEN.MPA.105 Responsibilities of the commander || The commander || The competent authority || Whenever an aircraft in flight has manoeuvred in response to an airborne collision avoidance system (ACAS) resolution advisory (RA), ||

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || CAT.GEN.MPA.105 Responsibilities of the commander || The commander || The air traffic service unit || Whenever a potential bird hazard is observed || As soon as flight crew workload allows

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || CAT.GEN.MPA.105 Responsibilities of the commander || The commander || The competent authority || Bird strike that results in significant damage to the aircraft or the loss or malfunction of any essential service || After landing

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || CAT.GEN.MPA.200 Transport of dangerous goods || The operator || The competent authority and the appropriate authority of the State of occurrence || Any dangerous goods accidents or incidents; the discovery of undeclared or misdeclared dangerous goods in cargo or mail; or the finding of dangerous goods carried by passengers or crew members, or in their baggage || Without delay

Annexes to the draft Commission Regulation on ‘Air Operations - OPS’ || SPA.RVSM.115 RVSM height-keeping errors || The operator || The competent authority || Height-keeping errors caused by malfunction of aircraft equipment or of operational nature, equal to or greater than: a total vertical error (TVE) of ±90 m (±300 ft); an altimetry system error (ASE) of ±75 m (±245 ft); and an assigned altitude deviation (AAD) of ±90 m (±300 ft) || Within 72 hours

Acronyms: ADR- Aerodrome; SPO- Specialized Operations; NCO- Non-commercial operations with other-than-complex motor-powered aircraft; NCC- Non-commercial operations with complex motor-powered aircraft; CAT- Commercial air transport operations; SPA- Special Approvals

ANNEX 7: Examples of costs involved by an aircraft accident

(a) Search and rescue and wreckage recovery

In the case of the Air France Flight 447 accident costs involved with the location of the wreckage and its recovery are estimated to be about €114 million. €34.6 million were necessary for underwater operations research and recovery (costs shared between the BEA, the French Safety Investigation Authority, Airbus and Air France) and €80 million for the search and rescue operations (surface research, paid by French and Brazilian Governments[15]).

As another example, during the Swissair Flight 111 accident investigation, which occurred in 1994, costs were estimated by the Transportation Safety Board of Canada around CAD $46.5 million (€35.7 million) for among which CAD $35 million (€27 million) for the activities linked to research and recovery of the wreckage and passengers.

(b) Aircraft physical damage

The costs related to the physical damage to the aircraft can vary depending on the aircraft type. Indeed an old Boing 707 has a value around $1.5 million[16] (€1.12 million) while a brand new Boeing 747 values in excess of $333 million[17] (€262 million).

According to the NLR Air Transport Safety Institute the average value of the western-built jet aircraft in the European fleet is about $25 million (€20 million) and therefore the average insurance value of these aircraft is around $46.25 million (€36.22 million).

(c) Accident Investigation

Investigation costs can vary depending on the difficulty of the process. These costs usually range from €0.1 million to €100 million and the average investigation cost is about €2.5 million[18].

As an example of accident investigation cost, the investigation of the SA 365 Helicopter G-BLUN accident which occurred in Morecambe Bay in 2006 and involved 7 fatalities has cost around £1.6 million (€2 million)[19].

(d) Fatalities

According to the NLR Air Transport Safety Institute: "Estimating costs associated with fatalities can be difficult and controversial. A person’s life is beyond price. It is, therefore, usually accepted that money cannot compensate for the loss of life itself. However, a price may be put on the material impact on others of a person’s death e.g. compensation (indemnity) for loss of support etc., and, separately, on society’s assumed desire to reduce the risk of a fatality"[20].

Usually costs associated with fatalities are expressed as a Value of a Statistical Life (VOSL)[21]. This number can tremendously vary depending on the passenger nationality. Thus, in the United States VOSL has been evaluated around €4.54 million per fatality[22]. For Europe, Eurocontrol has estimated in 2011 the VOSL around € 2 million[23].

With an average number of 85.2 passengers per flight and 9 crew members, the average VOSL lost in Europe for a fatal accident where all occupants died in the crash can be evaluated around €188.4 million per accident.

If we take a specific example such as the year 2009, which was a terrible year for European air transport, the number of fatalities due to aircraft accidents of EASA Member States' operators[24] reached 264 and therefore the order of magnitude for the VOSL lost in air accidents in Europe for the year 2009 can be estimated at €528 million.

(e) Insurance

Airline hull and legal liability worldwide losses for the year 2011 were about $1.18 billion[25] (€933 million) which is the lowest incurred cost of airline claims since 2004. In comparison the losses in 2010 were estimated at $2.15 billion[26] (€1.7 billion).

ANNEX 8: Specific objectives with corresponding problem drivers

ANNEX 9: Assessment of administrative burdens

1.           Introduction

Administrative burdens are defined as the costs incurred by different stakeholders in meeting legal obligations to provide information on their action or production either to public authorities or to private parties. Information is understood in a broad sense, i.e. including labelling, registration, monitoring and assessment needed to provide information.

The administrative burdens are calculated as changes in costs compared to the baseline scenario.

The identification and assessment of administrative burdens have as far as possible been following the steps in the EU standard cost model and has been presented to the support cell for the calculation of administrative burdens in the Secretariat-General.

2.           Identification of administrative burdens

The table below summarises existing and foreseen legal obligations to provide information and the expected changes in each policy packages, as well the introduction of new legal obligations and their impact.

Type of information || Baseline scenario || Policy package 1 || Policy package 2 || Policy package 3 || Burdens on …

Safety occurrences in the scope of MORS to be reported by individuals to … || Member States             (Dir. 2003/42; Art. 4) || Member States || Organisations and then transmitted to Member States || Organisations (under a unique data format) and then transmitted to EASA || Industry

Safety occurrences in the scope of VORS to be reported by individuals to … || Possibility for Member States                                    (Dir. 2003/42; Art.9) || Possibility for Member States || Organisations and / or Member States || EASA (under a unique data format) || Industry / EU

Exchange of information between MS || MS shall exchange the information collected             (Dir. 2003/42; Art.6) || MS shall exchange the information collected || MS shall exchange the information collected || Abolished || Member States / EU

Publication of annual safety review || Possibility for Member States                                        (Dir. 2003/42; Art.7) || Possibility for Member States || Obligation for Member States || Obligation for EASA || Member States / EU

Information contained into national occurrence databases transferred by MS to … || The European Central Repository (Reg.1321/2007; Art.2) || The European Central Repository || The European Central Repository || Abolished || Member States

Information on accidents and serious incidents to be transferred to … || The European Central Repository (Reg.1321/2007; Art.3) || The European Central Repository || The European Central Repository || The European Central Repository || Member States

Occurrence reports shall contain certain mandatory data fields || / || / || Introduction of new requirement || Introduction of new requirement || Industry/ Member States

Information regarding the risk classification of occurrences || / || / || Introduction of new requirement || Introduction of new requirement || Member States / EU

                        No additional cost               Marginal additional cost                Additional costs                               Savings on existing costs

3.           calculation of administrative burdens

The occurrence reporting Directive and its implementing Regulations impose information obligation on stakeholders in the aviation industry and on national authorities to collect, transfer, store and disseminate information on safety related occurrences. In the present situation there are reported around 120,000 occurrences annually. The identified policy packages (PP1, PP2 and PP3) operate on 7 different fields of action, where changes in information obligation can potentially influence administrative burdens. These fields are:

· Mandatory occurrence reporting (section 3.1)

· Voluntary occurrence reporting (section 3.2)

· Exchange of information between Member States (section 3.3)

· Publication of annual safety review (section 3.4)

· Transference of information from Members States to the European Central Repository (section 3.5)

· Mandatory fields in occurrence reporting (section 3.6)

· Risk classification of occurrences (section 3.7)

Policy package 1 does not change any information obligation within the occurrence reporting system. The policy package operates primarily through providing better guidance, training and support within the present setup. This means that the policy option will not result in significant changes in administrative burdens compared to the baseline scenario[27] and are as a consequence not analysed further in the following sections.

3.1.        Mandatory occurrence reporting

In the current legislation Member States require that mandatory occurrences are reported by individuals (pilots, air traffic controllers, engineers, ground handlers etc.) to the competent Member State authority.

Policy Package 2 changes this requirement so individuals are required to report mandatory occurrences to their organisation which shall then transmit the data collected to the competent Member State authority. This is a codification of the existing practice. Indeed, in most Member States close to all reports (98%) received by the competent authorities are from organisations and not directly from individuals. This means that no additional administrative burden will be caused by this element in PP2.

In Policy Package 3 individuals shall report to their organisation which shall then transmit the data collected to EASA (European database) under a single data format (ECCAIRS data format). Today several different reporting systems and reporting forms are used among the industry to collect values for the same variables. Sending data to the European central database using a single data format would not necessary require the industry to replace their system by the one used at European level. The preferred option would probably be to develop a conversion program transferring the existing data format into the single format would. This would be less expensive and would not require intensive training. It is estimated by the Commission Joint Research Centre (JRC) that the development of a conversion program will incur, for each system, a cost of €15,000 on average. In addition while there are around 5,000 organisations in Europe receiving reports from individuals JRC estimates that the number of reporting systems used by the industry to collect occurrences is around 20. This gives a total cost of €300,000 for conversion data programs. This is a one-time administrative burden which will fall on the private sector.

3.2.        Voluntary occurrence reporting

In the current situation Member States may designate one or more bodies to put in place a system of voluntary reporting to collect and analyse information on observed deficiencies in aviation which are not required to be reported under the system of mandatory reporting.

Policy Package 2 changes this requirement in imposing both on the industry and on Member States to give individuals the possibility to report occurrences outside of the mandatory scheme by the establishment of voluntary reporting schemes. This is also largely a codification of the existing practice. Indeed the means to report already exists within the industry and in the Member States and most industry organisations and as well as Member States (23) have already established voluntary reporting systems. This means that no additional administrative burden will be caused by this element in PP2.

In Policy Package 3 organisations shall establish voluntary schemes and send the data collected to EASA under a single data format (ECCAIRS data format). In addition EASA shall establish a European voluntary reporting scheme where individuals could report directly occurrences beyond the ones collected under the mandatory scheme. The data conversion cost into ECCAIRS data format is already included in the previous section (3.1). The cost for establishing a voluntary occurrence reporting scheme at EU level has been evaluated by EASA around €2,200,000 by year (10 staff × €150,000 and €700,000 for operational costs).

3.3.        Exchange of information between Member States

In the current situation Member States shall exchange the data collected and integrated in their national databases. In practice, very few MS (less than five) have established bilateral informal agreements regarding the exchange of occurrence information and the exchange of information between Member States is done through the European Central Repository (ECR) which contains occurrences reports from all Member States and whose operation is supported by the EU budget.

Policy Package 2 will no modify this requirement.

Policy Package 3 by cutting the Member State level will involve savings for the costs related to Member States support with the use of the ECR. This is evaluated yearly around less than €50,000 savings for the EU budget.

3.4.        Publication of annual safety review

In the current legislation Member States are encouraged to publish an annual safety review to inform the public about the level of safety.

Policy Package 2 changes this requirement in imposing Member States to publish once a year such a review. In reality 15 Member States already publish an annual safety review including information about the occurrences they have collected. Therefore the additional cost will only concern 12 Member States. The average cost for preparing the review has been evaluated around one man month during 3 months which means 12 men months x 3 months. In the European Union the average agreed normal working week in local government was 37.8 hours[28] which is equivalent to an average of 163.674 hours by month (there are on average 52/12 = 4.33 weeks in a month). Therefore the additional working time by Member State is evaluated to 3 x 163.674 = 491 hours. The average hourly earnings in the EU27 have been evaluated in 2010 around €32.1 for the professionals' category[29]. The additional administrative burden for Member States therefore corresponds to 32.1 x 491 x 12 = 189,133 euros per year.

In Policy Package 3 Member States do not have to publish an annual safety review, instead EASA has to do so. The costs saved by Member States would be equivalent to 15 men months x 3 months every year. EASA already publishes an annual safety review which includes a section on occurrences and the content of the ECR therefore it would not imply additional cost to the EU budget. The saving for Member States is equivalent to 15 persons x 3 working months (i.e. 491 hours) x 32.1 euros = 236,417 euros per year.

3.5.        Transference of information from Members States to the European Central Repository

In the current legislation Member States shall transfer into the ECR all occurrences contained in their national database. In addition information on accidents and serious incidents shall be sent to the ECR. This latter obligation is unchanged in each policy package.

Policy Package 2 will no modify the existing requirement.

In Policy Package 3 the cost of transferring occurrences from national databases to the ECR is not present anymore as occurrences are directly sent by organisations or individuals to the European database. This saving is already included is the calculation of the economic impact of Policy Package 3 on Member States in the section 5.3.3 of the Impact Assessment.

3.6.        Mandatory fields in occurrence reporting

This new requirement imposes that certain data shall be filled in occurrence reports. The number of data fields will be limited around 10/15 fields, will concern basic information (such as date, time and location of the occurrence, narrative etc.) and will vary depending the occurrence category. The cost will be mostly borne by the industry and is similar in both policy packages.

Mandatory data fields already exist in certain organisations notably in the ATM area however it is not possible to evaluate the number of organisations already imposing such an obligation. The extra cost is evaluated around 5 minutes of additional work on average by the number of occurrences collected by year (i.e. 120,000 occurrences every year on average) and therefore is equivalent to 600,000 minutes i.e. 10,000 additional hours of work every year. The additional administrative burdens for the industry in Policy Packages 2 and 3 is evaluated around 10,000 x 32.1 euros = 321,000 euros.

3.7.        Risk classification of occurrences

This new requirement imposes that Member States will have to indicate for each occurrence received its level of risk according to a European common risk classification scheme. The development of the common scheme and the necessary training it will require have already been calculated in the section related to EU budget (5.3.6). The additional administrative burdens are corresponding to the additional working time necessary to fulfil the requirement.

In Policy Package 2 the additional work for Member States staff is evaluated around evaluated around 5 minutes of additional work on average for each occurrence received. Therefore it corresponds to 120,000 occurrences x 5 minutes which means 10,000 additional hours of work every year. The additional administrative burdens for the Member States is evaluated around 10,000 hours x €32.1 = 321,000 euros.

In Policy Package 3 this task will be undertaken by EASA and is already included in the evaluation of Policy Package 3 impact on the EU budget in the section 5.3.6 of the Impact Assessment.

4.           Summary of the administrative burdens

Table 1: Total administrative burdens in policy packages 2 and 3

|| Annual || One time

Policy Package 2 || + €831,133 || /

Policy Package 3 || + €2,234,585 || + €300,000

Table 2: Administrative burdens on business

|| Annual || One time

Policy Package 2 || + €321,000 || /

Policy Package 3 || + €321,000 || + €300,000

Table 3: Administrative burdens on public authorities

|| Annual

Policy Package 2 ||

Member States || + €510,133

EU budget || /

Policy Package 3 ||

Member States || - €236,415

EU budget || + €2,150,000

Table 4: Overview of the administrative burdens

|| Type of obligation || Description of required action || Costs / savings on || Rate (euro/hour) || Time (hours) || Price (per action) || Frequency || No of entities || Total administrative burdens (euros)

Mandatory occurrence reporting || || || || || || || || ||

Policy Package 2 || Report civil aviation occurrences || Industry collect data; data are sent to MS and then to the ECR || Industry/ Member States || / || / || / || / || / || /

Policy Package 3 || Report civil aviation occurrences || Industry collect data; data are sent to the ECR in a single data format || Industry/ EU budget || / || / || 15,000 || One time || 20 || + 300,000

Voluntary occurrence reporting || || || || || || || || ||

Policy Package 2 || Report civil aviation occurrences || Industry collect data; data are sent to MS and then to the ECR || Industry/ Member States || / || / || / || / || / || /

Policy Package 3 || Report civil aviation occurrences || Industry collect data; data are sent to Member States and then to the ECR; a EU VORS is established || Industry/ EU budget || / || / || (10x150,000) + 700,000 || Every year || / || + 2,200,000

Exchange of information between Member States || || || || || || || || ||

Policy Package 2 || / || / || / || / || / || / || / || / || /

Policy Package 3 || Member States level disappear || Support to MS on the use of the ECR || EU budget || / || / || 50,000 || Every year || / || - 50,000

Publication of annual safety review || || || || || || || || ||

Policy Package 2 || Publish an annual safety review || Publish an annual safety review || Member States || 32.1 || 491 || / || Every year || 12 || + 189,133

Policy Package 3 || No annual safety review to publish || No annual safety review to publish || Member States || 32.1 || 491 || / || Every year || 15 || - 236,415

Transference of information from Members States to the ECR || || || || || || || || ||

Policy Package 2 || / || / || / || / || / || / || / || / || /

Policy Package 3 || Member States level disappear || Cost of sending data to the ECR deleted || Member States || / || / || / || / || / || /

Mandatory fields in occurrence reporting || || || || || || || || ||

Policy Package 2 || Mandatory fields || Fill mandatory fields in occurrence reports || Industry || 32.1 || 0.83 || / || Every year || 120,000 || + 321,000

Policy Package 3 || Mandatory fields || Fill mandatory fields in occurrence reports || Industry || 32.1 || 0.83 || / || Every year || 120,000 || + 321,000

Risk classification of occurrences || || || || || || || || ||

Policy Package 2 || Classify occurrences' risk || Classify occurrences according to a common EU scheme || Member States || 32.1 || 0.83 || / || Every year || 120,000 || + 321,000

Policy Package 3 || Classify occurrences' risk || Classify occurrences according to a common EU scheme || EU budget || / || / || / || / || / || /

ANNEX 10: Detailed economic impact examples on the industry

In order to get more information on the implementation of Regulation (EC) No 216/2008 requirements which imposes certain occurrence reporting requirements on the industry and therefore to assess the possible economic impacts of PP2 and PP3 on the industry in comparison to the current situation, the Commission has contacted the major organisations' representatives in the European Union. Unfortunately several organisation representatives did not reply to the Commission and therefore some key information for certain categories of organisations is not available.

In the paragraphs below data regarding certain categories of organisations is presented but it does not represent an extensive study on the impact on every industry player.

(a) Airlines

Commercial air transport in the European Union is mainly operated by major airlines, low cost airlines, regional airlines and business airlines.

The Association of European Airlines (AEA) brings together 34 major European airlines (among which 27 from the EU) which collectively carry 376 million passengers and 6 million tons of cargo each year[30]. All AEA airlines are also members of the International Air Transport Association (IATA). IATA requests airlines to hold an IATA Operational Safety Audit (IOSA) accreditation as it is a pre-requisite of IATA membership and to successfully pass the IOSA audit every two years, in order to maintain a valid membership. The establishment of a Safety Management System (SMS) is incorporated into the IOSA programme[31]. This means that to become a member of IATA each airline has to establish a mechanism to collect occurrences, to analyse them in order to identify safety hazards and deficiencies, to take remedial action necessary to maintain an acceptable level of safety and to provide for continuous monitoring and regular assessment of the safety level achieved.

Regarding low cost airlines, most of them are grouped in the European Low Fares Airline Association (ELFAA) and collectively carry over 160 million passengers every year. Low fares airlines currently account for over 35% of scheduled intra-European traffic[32] shared among 9 airlines (among which 8 are from the EU). Most of them are not members of IATA and the Commission has not received information regarding an obligation to implement an SMS for these airlines. However, the major low fares airlines, such as Easyjet[33] and Ryanair[34], have established strong Safety Management Systems.

Regional airlines are grouped in the European Regions Airline Association (ERAA) which represents 57 intra-European airlines carrying 70.6 million passengers to 426 destinations in 61 European countries every year[35]. 20 of those airlines are member of IATA and therefore have established a SMS. The Commission has not received the requested information for the other members.

No information is available regarding business aviation.

Overall, regarding European commercial air transport, the economic impact of PP2 and PP3 compared to the baseline scenario will vary from zero to moderate as most of EU airlines have established at least a basic occurrence reporting system including analysis of data.

Regarding general aviation, the obligation to report occurrences is already included in the existing legislation and the additional requirement of analysis and corrective actions would be carried out by either Member States authorities (PP1 and PP2) or by EASA (PP3). Therefore, compare to the baseline scenario, none of the three policy package will have an economic impact on the non-commercial air transport in the EU.

(b) Airports

Regarding airports, the Commission did not receive the requested information. But one could assess that most European airports have established a system to collect and assess occurrences. Indeed ACI (Airport Council International), which represents over 400 airports in 46 European countries and account for over 90% of the commercial air traffic in Europe[36], have launched a new safety advancement initiative that aims to ensure that airports contribute proactively to the demands of a safe and secure air transport system through management systems[37].

(c) Air Navigation Service Providers (ANSPs)

Eurocontrol has evaluated SMS costs[38] for ANSPs to be 1,357,943 euros (1.7% of the total cost base of an ANSP) for the overall development and implementation and to 1,154,987 euros (1.7% of the total cost base of an ANSP) for the overall maintenance and day-to-day operations. Costs related to occurrence reporting systems[39] as established in PP2 and PP3 are around 28% of the overall development and implementation costs and around 38% of the overall maintenance and day-to-day operations costs. However as the Common Requirements regulation requires all ANSPs to have a SMS to obtain a certificate[40], it can be determined that none of the policy packages will involve additional economic costs on ANSPs compared to the baseline scenario.

ANNEX 11: Detailed data on the economic impact on the European Union budget

The EU budget would be affected by policy packages 1, 2 and 3 compared to the baseline scenario. Regarding the European Central Repository, in the current situation, the Commission is already supporting the technical tool (ECCAIRS) allowing the collection of occurrences. The amount yearly allocated to this tool is on average around €500,000 and would be slightly increased in all three packages by between €50,000 and €100,000. On the development of the common EU risk classification scheme, its economic impact in all policy packages is the same and would be around € 90,000 for the development of the scheme, the support and the organisation of training and would not be renewed every year. It would be allocated for a period of 18 months.

In Policy Package 2, the formalisation and development of the EASA analysis coordination role would notably require additional human resources which are estimated at two persons (€300,000 per year including 2 x €130,000 on the budget line “staff expenditure” and 2 x €20,000 on the budget line “infrastructure and operating expenditure”). An additional mission budget of €40,000 would be used to support Member States on-site and €25,000 would be used to support outreach activities such as workshops and seminars across Europe. Therefore the estimated budget costs would amount to €365,000.

In Policy Package 3 in order to ensure the completion of its tasks, the safety analysis section of EASA would necessitate four Safety Data Units (unit 1: large aeroplanes/operators; unit 2: small aeroplanes and rotorcraft; unit 3: ATM, aerodromes and ground occurrences; unit 4: processing, publications, translations, quality and administrative support). Each unit would have to coordinate the reception and evaluation of occurrences and the dissemination of information and be composed of one Head of Unit plus 9 officers and technical assistants. To ensure that the 4 units provide a comprehensive and reliable service they would be managed by a Head of Department, Deputy and staff. In addition 4 staff would be need for managing the interface stakeholders and the various national, EU and international authorities, and 4 additional staff to manage IT contractors and service providers, websites and maintenance of specialised software tools. A few additional experts would be needed to work on various issues. Therefore in Policy Package 3, 54 new posts would be created among which 44 new temporary agents which would cost approximately € 6.6 million every year (44 x €130,000 on the budget line “staff expenditure” and 44 x €20,000 on the budget line “infrastructure and operating expenditure”) and 10 new administrative posts which would cost approximately € 1 million per annum (10 x €90,000 on the budget line “staff expenditure” and 10 x €10,000 on the budget line “infrastructure and operating expenditure”). In addition IT tools, workflow tools, research developments, licenses, insurances and contacted services would need in the order of € 4 million and an additional mission budget of € 200,000 would be used to support Member States and industry on-site. Finally a budget of €100,000 would be used to support information sharing and outreach meetings across Europe. The total estimated budget costs would amount to €11.9 million.

In summary, in comparison to the baseline scenario, the impact on the EU budget would be increased by around €165,000 in PP1, €530,000 in PP2 and €12.065 million in PP3.

ANNEX 12: Rate of fatal accidents per 10 million flights per world region

The figure below represents the rate of fatal accidents per 10 million flights per world region (2002 – 2011, scheduled passenger and cargo operations)[41]

ANNEX 13: Acronyms and abbreviations

ADREP            →        Aviation Data Reporting Program

ANSP  →                    Air Navigation Services Provider

ARMS →                    Aviation Risk Management Solutions

ATM                →        Air Traffic Management

CAA                →        Civil Aviation Authority

CAST              →        Commercial Aviation Safety Team

DG MOVE      →        European Commission Directorate-General for Mobility and Transport

EASA              →        European Aviation Safety Agency

ECCAIRS      →          European Coordination Centre for Accident and Incident Reporting Systems

ECR                 →        European Central Repository

ENCASIA       →        European Network of Civil Aviation Safety Investigation Authorities

ESSAR2          →        Reporting and Assessment of Safety Occurrences in ATM

EU                   →        European Union

IA                    →        Impact Assessment

IAB                  →        Impact Assessment Board

IASG               →        Impact Assessment Steering Group

ICAO              →        International Civil Aviation Organisation

JRC                 →        European Commission Joint Research Centre

MORS             →        Mandatory Occurrence Reporting System

MS                  →        Member States

PD                   →        Problem Driver

PP                    →        Policy Package

RAT                 →        Risk Analysis Tool

SARPs             →        ICAO Standards and Recommended Practices

SIA                  →        Safety Investigation Authority

SMS                →        Safety Management System

SO                   →        Specific Objectives

TFEU               →        Treaty on the Functioning of European Union

US                   →        United States of America

USOAP           →        Universal Safety Oversight Audit Programme

VORS              →        Voluntary Occurrence Reporting System

VOSL              →        Value of a Statistical Life

ANNEX 14: Bibliography

1.           EU Treaties, Regulations and Directives

Treaty on the Functioning of European Union (OJ C83/47 of 30.3.2010, p.47)

Council Regulation (EEC) No 3922/91 of 16 December 1991 on the harmonization of technical requirements and administrative procedures in the field of civil aviation (OJ L 373, 31.12.1991, p. 4)

Council Directive 94/56/EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents (OJ L 319 of 12.12.1994, p. 14)

Commission Regulation (EC) No 1702/2003 of 24 September 2003 laying down implementing rules for the airworthiness and environmental certification of aircraft and related products, parts and appliances, as well as for the certification of design and production organisations (OJ L 243 of 27.09.2003, p. 6)

Commission Regulation (EC) No 2042/2003 of 20 November 2003 on the continuing airworthiness of aircraft and aeronautical products, parts and appliances, and on the approval of organisations and personnel involved in these tasks (OJ L 315 of 28.11.2003, p. 1)

Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation (OJ L 167, 4.7.2003, p. 23)

Commission Regulation (EC) No 2096/2005 of 20 December 2005 laying down common requirements for the provision of air navigation services (OJ L 335 of 21.12.2005, p. 13)

Commission Regulation (EC) No 1321/2007 of 12 November 2007 laying down implementing rules for the integration into a central repository of information on civil aviation occurrences (OJ L 294 of 13.11.2007, p. 3)

Commission Regulation (EC) No 1330/2007 of 24 September 2007 laying down implementing rules for the dissemination to interested parties of information on civil aviation occurrences (OJ L 295 of 14.11.2007, p. 7)

Regulation (EC) No 216/2008 of 20/02/2008 of the European Parliament and of the Council on common rules in the field of civil aviation and establishing a European Aviation Safety Agency, and repealing Council Directive 91/670/EEC, Regulation (EC) No 1592/2002 and Directive 2004/36/EC (OJ L 79, 19/03/2008, p. 1)

Commission Regulation (EC) No 859/2008 of 20 August 2008 amending Council Regulation (EEC) No 3922/91 as regards common technical requirements and administrative procedures applicable to commercial transportation by aeroplane (OJ L 254, 20.9.2008, p. 1)

Commission Regulation (EU) No 691/2010 of 29 July 2010 laying down a performance scheme for air navigation services and network functions (OJ L 201, 3.8.2010, p. 1)

Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation (OJ L 295 of 12.11.2010, p.35)

Commission Regulation (EU) No 290/2012 of 30 March 2012 amending Regulation (EU) No 1178/2011 laying down technical requirements and administrative procedures related to civil aviation aircrew pursuant to Regulation (EC) No 216/2008 of the European Parliament and of the Council (OJ L 100, 5.4.2012, p. 1)

2.           EU policy and reference documents

Commission Decision No 98/500/EC of 20 May 1998 on the establishment of Sectoral Dialogue Committees promoting the Dialogue between the social partners at European level (C(1998) 2334)

EU Charter of Fundamental Rights (JO C 364 of 18/12/2000 p.1)

European Commission Impact Assessment guidelines (SEC(2009)92)

Commission Regulatory Impact Assessment on investigation and prevention of accidents and incidents in civil aviation (COM/2009/611 final)

Commission Communication on "Smart Regulation in the European Union" (COM (2010)543)

White Paper 2011 "Roadmap to a Single European Transport Area - Towards a competitive and resource efficient transport system" (COM/2011/0144 final)

Commission Communication on "Setting up a Safety Management System for Europe" (COM/2011/0670 final)

Memorandum of Cooperation between the European Union and the International Civil Organisation providing a framework for enhanced cooperation (JO L 232 of 9/9/2011 p.2)

European Aviation Safety Plan and Programme (SEC/2011/1261 final)

Annual Safety Review 2005, European Aviation Safety Agency

Annual Safety Review 2010, European Aviation Safety Agency

Annual Safety Review 2011, European Aviation Safety Agency

Report of the High Level Group for the Future European Aviation Regulatory Framework, http://ec.europa.eu/transport/air/doc/hlg_2007_07_03_report.pdf

Flightpath 2050: Europe's vision for aviation, Report of the High level Group on aviation research, 2011

Occurrence Reporting and Accident and Incident Investigation in EU Civil Aviation, Study commissioned by the European Parliament, (IP/B/TRAN/IC/2009-024)

Working time developments in 2010; European Industrial Relations Observatory

EU transport in figures, statistical pocketbook 2011 (ISBN 978-92-79-19508-2)

European Central Repository: two years of aviation safety data integration, Charalambos Moussas, Commission JRC technical report 2010 (JRC56867)

Data integration: building a common repository of civil aviation information Charalambos Moussas, Commission JRC technical report 2009 (JRC51772)

3.           International Conventions and related documentation

Convention on International Civil Aviation, signed in Chicago on 7 December 1944, ICAO Doc. 7300/8

Annex XIII "Aircraft Accident and Incident Investigation" to the Convention on International Civil Aviation, 10th edition, July 2010

ICAO Safety Management Manual, Second Edition 2009, ICAO Doc 9859

Final Report on the Safety Oversight Audit of ICAO States (confidential)

11th meeting of the African Civil Aviation Commission agenda item 7 meeting report: Legal aspects of safety issues (outcomes of the ICAO COPAC Safety Seminar), May 2011, (ATC/11-WP/11)

4.           Other governmental documents, studies and reference Material

Legal and cultural issues in relation to ATM safety occurrence reporting in Europe, Report commissioned by the Eurocontrol Performance review Commission, (September 2006)

Report on the resolution of double ATM safety regulation in Single European Sky States, Eurocontrol Safety Regulation Commission, Double Regulation Ad-Hoc Group (DRAHG), November 2007

Eurocontrol Just Culture Guidance Material for Interfacing with the Judicial System, (Edition 02.2008)

Eurocontrol Cost-Model for the development, maintenance and day-to-day operations of a Safety Management System (February 2009)

Reporting and assessment of safety occurrences, Eurocontrol Safety Regulation Commission, December 2009

Eurocontrol Long-Term Forecast - Flight Movements 2010 – 2030 (Doc 415 of 17 December 2010 CND/STATFOR)

Standard inputs for Eurocontrol cost benefits analyses, March 2012, https://www.eurocontrol.int/sites/default/files/content/documents/official-documents/reports/2012-standard-inputs-cost-benefits-analysis.pdf

The Mandatory Occurrence reporting scheme Information and Guidance, United Kingdom Civil Aviation Authority (CAP 382)

United Kingdom Safety Performance Volume 1, United Kingdom Civil Aviation Authority (CAP 800)

French Arrêté du 17 août 2007 fixant la liste d’événements et d’incidents d’aviation civile, (JORF 18/09/2007)

Recueil et analyse des incidents d'aviation civile, French Civil Aviation Authority, 2009

Second Interim Report and Final Report on the accident on 1st June 2009 to the Airbus A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro – Paris(Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile) : http://www.bea.aero/en/enquetes/flight.af.447/flight.af.447.php

Instructions with regard to criminal investigation and prosecution in the event of the reporting of occurrences in civil aviation pursuant to Article 130.4 of the Dutch Judiciary Organisation Act, June 2006 (2006A015)

Accident costs for a causal model of air transport safety, NLR Air Transport Safety Institute (ALC Roelen and JW Smeltink - 2008)

Aircraft accident report, Helios Airways Flight HCY522, Boeing 737-31S at Grammatiko, Hellas on 14 August 2005 (11/2006, Hellenic Ministry of Transport and Communications, Air Accident Investigation & Aviation Safety Board) http://www.aaiasb.gr/imagies/stories/documents/11_2006_EN.pdf

Benefit-Cost Analysis, United States of America Federal Aviation Agency, www.faa.gov/regulations_policies/policy_guidance/benefit_cost/

Expenses related to the Swissair Flight111 accident investigation (Bureau de la sécurité des Transports Canada)

5.           Monographs

Flying in the face of criminalization: the safety implications of prosecuting aviation professionals for accidents, Sofia Michaelides-Mateou and Andreas Mateou Ashgate, 2010

Just Culture, Balancing Safety and Accountability, Sydney Dekker, Ashgate, 2007

6.           Articles, Speeches and Non-Governmental reference Documents

Safety and business benefit analysis of NASA's Aviation Safety Program, Brittany Campbell and Sherry Borener, American Institute of Aeronautics and Astronautics

Charter for Just Culture in aviation, Charter co-signed by ACI, AEA, CANSO, ECA, ERA and ETF

Commercial Aviation Safety Team (CAST) Plan, http://www.cast-safety.org

Accident Pyramid, Frank E. Bird Jr, 1969

Global Aviation Information Network Operator's Flight Safety Handbook, 1999

The dollars and sense of risk management and airline safety, FSF Icarus Committee, Flight Safety Digest, Flight Safety Foundation, May 1999

A roadmap to Just Culture: Enhancing the safety environment, Global Aviation Information Network report, September 2004

Analysis Capabilities Specification document – Mandatory Occurrence Data, Second JSSI Occurrence Data Analysis Working Group, February 2006

Do you have a Safety Culture? Robert L. Sumwalt, Aero Safety World, Flight Safety Foundation, July 2007

The criminalisation of human error in aviation and healthcare: a review, Sydney Dekker, Safety Science, 2010

Aviation Safety Management Systems Return on Investment Study, Centre for Aviation Safety Research, Parks College of Engineering, Aviation and Technology, Saint Louis University, February 2011

Blame Culture? Nick Mower, Regional International (European Regions Airline Association Journal), May 2011

Criminalisation is eroding safety culture, Mike Ambrose, Regional International (European Regions Airline Association Journal), May 2011

Just Policy, Brad Brugger and Pete Siruceck, Aero Safety World, Flight Safety Foundation, September 2011

Ascend Aviation insight – Performance and Safety Review – Special Bulletin 2011

Annual Report 2011, Easyjet, http://2011annualreport.easyjet.com/performance-risk/principle-risks.aspx

AF447 underwater search and recovery operations: a shared government –industry process, Oliver Ferrante, Michael Kutzleb and Michael Purcell, Presentation before ISASI 2011

Comment volerons-nous en 2050? Report from the French Air and Space Academy, 2012

[1]               Reference to the definition of Just Culture as provided in Regulation (EC) 691/2010 was included in the public consultation: "Just culture "means a culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated.

[2]               A noteworthy area of confusion here is that some risk assessment activities result in the scoring of the resulting assessment using a ‘risk classification’; this is not the same as the activity of risk classifying occurrences.

[3]               For example risk outcomes might be accidents in the Flight ops domain but for maintenance it would often be the risk of an unairworthy aircraft, furthermore the ANSP might be considering risk of a loss of separation: these are not directly comparable to each other.

[4]               There is significant experience of equating injuries with fatalities in other industries.

[5]               There are recognized approaches to the cost of human life, the question is whether this scheme will choose to consider that.

[6]               The issue of timescales or operating dimension only affects term 2a) – how often the occurrence might occur – i.e. once per day, per 1,000 sectors, per 1M landings… For term 2b) the probability need only be expressed as a probability per occurrence.

[7]               Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation; OJ L 167, 4.7.2003, p. 23.

[8]               Commission Regulation (EC) No 1702/2003 of 24 September 2003 laying down implementing rules for the airworthiness and environmental certification of aircraft and related products, parts and appliances, as well as for the certification of design and production organisations; OJ L 243 of 27.09.2003, p. 6.

[9]               Unsafe condition on all aircraft as per article 4 of basic Regulation No 216/2008.

[10]               Unsafe condition on all aircraft as per article 4 of basic Regulation No 216/2008

[11]               Commission Regulation (EC) No 2042/2003 of 20 November 2003 on the continuing airworthiness of aircraft and aeronautical products, parts and appliances, and on the approval of organisations and personnel involved in these tasks, OJ L 315 of 28.11.2003, p. 1.

[12]               Commission Regulation (EC) No 859/2008 of 20 August 2008 amending Council Regulation (EEC) No 3922/91 as regards common technical requirements and administrative procedures applicable to commercial transportation by aeroplane; OJ L 254, 20.9.2008, p. 1.

[13]               Commission Regulation (EU) No 290/2012 of 30 March 2012 amending Regulation (EU) No 1178/2011 laying down technical requirements and administrative procedures related to civil aviation aircrew pursuant to Regulation (EC) No 216/2008 of the European Parliament and of the Council; OJ L 100, 5.4.2012, p. 1.

[14]               Legislation currently under preparation

[15]               Information provided by BEA (Bureau d'Enquête et d'Analyse)

[16]               NLR Air Transport Safety Institute - Accident costs for a causal model of air transport safety (ALC Roelen and JW Smeltink - 2008)

[17]               http://www.boeing.com/commercial/prices/

[18]               Idem

[19]               Source: Air Accidents Investigation Branch (AAIB).

[20]               NLR Air Transport Safety Institute - Accident costs for a causal model of air transport safety (ALC Roelen and JW Smeltink - 2008)

[21]               The VOSL research method does not measure the value of life per se, which is priceless and cannot be monetised. Instead it puts a monetary value on the willingness of individuals to accept slightly higher or lower level of risk.

[22]               www.faa.gov/regulations_policies/policy_guidance/benefit_cost/

[23]               https://www.eurocontrol.int/sites/default/files/content/documents/official-documents/reports/2012-standard-inputs-cost-benefits-analysis.pdf

[24]             228 fatalities for aeroplanes, 18 for helicopters, 18 for general aviation and aerial work - European Aviation Safety Agency, Annual Safety Review 2010.

[25]             Ascend Aviation insight – Performance and Safety Review – Special Bulletin 2011.

[26]             Idem.

[27]             As a result of better guidance the time consumed by reporting should actually diminish.

[28]             Source: European Industrial Relations Observatory (EIRO)

[29]             Source: http://adminburden.sg.cec.eu.int/Manuals%20and%20documentation/Forms/AllItems.aspx

[30]               http://www.aea.be/

[31]               http://www.iata.org

[32]               http://www.elfaa.com

[33]               http://2011annualreport.easyjet.com/performance-risk/principle-risks.aspx

[34]               http://www.ryanair.com/doc/investor/SafetyRecord.pdf

[35]               http://www.eraa.org

[36]               http://www.aci-europe.org/

[37]               http://www.airports.org/cda/aci_common/display/main/aci_content07_banners.jsp?zn=aci&cp=1-4612-4615^40215_725_2__

[38]               Eurocontrol Cost-Model for the development, maintenance and day-to-day operations of a Safety Management System, February 2009.

[39]             This includes costs relative to mandatory reporting system voluntary reporting system, investigation of safety occurrences, management of safety related changes and risk assessment and mitigation.

[40]             Information provided by the Civil Air Navigation Services Organisation – CANSO.

[41]               Source: European Aviation Safety Agency, Annual Safety Review 2011.

TABLE OF CONTENTS

1........... Procedural issues and consultation of interested parties.................................................... 5

1.1.        Context of the proposal................................................................................................... 5

1.2........ Organisation and timing................................................................................................... 6

1.3........ Consultation and expertise.............................................................................................. 6

1.4........ Impact Assessment Board.............................................................................................. 7

2........... Problem Definition.......................................................................................................... 8

2.1........ Background on air safety................................................................................................ 8

2.1.1..... General background....................................................................................................... 8

2.1.2..... Accident prevention systems........................................................................................... 9

2.1.3..... Description of the current occurrence reporting system in Europe................................... 10

2.2........ Problem description – EU and Member States insufficient ability to use experience feedback for preventing accidents...................................................................................................................... 12

2.2.1..... The collection of occurrences is not optimal................................................................... 13

2.2.2..... Data integration: the low quality of information and the incompleteness of data................ 17

2.2.3..... The legal and organisational obstacles for ensuring adequate access to information contained in the European Central Repository (ECR)............................................................................................. 19

2.2.4..... Lack of occurrence analysis at Member States and at European levels and of appropriate corrective and preventive actions......................................................................................................... 20

2.2.5..... Problem tree................................................................................................................. 21

2.3........ Who is affected, in what ways, and to what extent?....................................................... 21

2.4........ How the problem could evolve?.................................................................................... 22

2.4.1..... Evolution of the situation from an aviation safety perspective.......................................... 22

2.4.2..... Evolution of the situation from an economic perspective................................................. 24

2.5........ Does the EU have the right to act?................................................................................ 25

3........... Objectives.................................................................................................................... 26

3.1........ What is the general policy objective?............................................................................. 26

3.2........ What are the specific objectives?.................................................................................. 26

3.3........ What are the operational objectives?............................................................................. 27

3.4........ Consistency with horizontal policies of the European Union............................................ 28

4........... Policy options............................................................................................................... 29

4.1........ Pre-screening............................................................................................................... 29

4.2........ Identification of possible policy measures....................................................................... 30

4.3........ Identification of policy packages.................................................................................... 36

4.4........ Legal instrument............................................................................................................ 39

5........... Analysis of impacts....................................................................................................... 41

5.1........ Introduction and rating of impacts.................................................................................. 41

5.2........ Impact on aviation safety............................................................................................... 41

5.3........ Economic impacts......................................................................................................... 43

5.3.1..... Economic impact of Safety Management Systems.......................................................... 43

5.3.2..... Impact on the industry................................................................................................... 44

5.3.3..... Impact on Member States............................................................................................. 45

5.3.4..... Impact in the internal market and competitiveness of EU companies............................... 46

5.3.5..... Administrative burdens.................................................................................................. 46

5.3.6..... EU Budget................................................................................................................... 46

5.3.7..... Summary table of the economic impact of implementing the various PP.......................... 48

5.4........ Social impacts.............................................................................................................. 48

5.5........ Environmental impacts.................................................................................................. 49

5.6........ Impact on fundamental rights......................................................................................... 49

5.7........ Impacts on simplification of existing legislation................................................................ 50

5.8........ Impacts on third countries............................................................................................. 50

5.9........ Summary of impacts compared to the baseline scenario................................................. 50

6........... Comparing the Policy Options....................................................................................... 51

6.1........ Effectiveness................................................................................................................. 52

6.2........ Efficiency...................................................................................................................... 52

6.3........ Coherence.................................................................................................................... 53

6.4........ Preferred option........................................................................................................... 53

7........... Monitoring and Evaluation............................................................................................. 53

1.           Procedural issues and consultation of interested parties

Identification

Lead DG: Directorate-General for Mobility and Transport

Agenda planning: 2011/MOVE/028.

1.1.        Context of the proposal

The proposal to revise the legislation on occurrence reporting in civil aviation is a key part of the European Union's overall efforts to improve aviation safety by moving from a system which is mainly reactive and focuses on preventing accidents reoccurring by understanding their causes, towards a system which is more proactive and evidence-based and uses information coming from daily occurrences[1] in order to prevent accidents occurring.

Recital 3 of Regulation (EU) No 996/2010 of the European Parliament and of the Council on the investigation and prevention of accidents and incidents in civil aviation[2] requests the Commission to revise Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation[3].

The White Paper 2011 "Roadmap to a Single European Transport Area - Towards a competitive and resource efficient transport system"[4] sets out a list of initiatives to be implemented among which "Improve the collection, quality, exchange and analysis of data by reviewing legislation on occurrence reporting in civil aviation"[5].

The Commission Communication on "Setting up a Safety Management System for Europe"[6] reaffirms that to allow hazard identification "information is a vital component of any safety management system" and that occurrence reporting is a core element of such a system. It therefore underlines the necessity to review EU legislation on occurrence reporting in civil aviation to build an efficient safety system in Europe.

This Impact Assessment accompanies the Commission proposal which revises Directive 2003/42/EC and its implementing regulations[7]. This document notably endeavours to identify the shortcomings of the current legislation.

1.2.        Organisation and timing

This Impact Assessment (IA) has been prepared and drafted by the European Commission’s Directorate-General for Mobility and Transport (DG MOVE). Its preparation was assisted by an Impact Assessment Steering Group (IASG) created in May 2011 to which all the interested Directorates-General[8] of the Commission were invited to participate. The IASG met three times between May 2011 and July 2012[9]. The main elements of the proposal along with those of specific interest for the IASG members were extensively discussed during the IASG. A final version incorporating the comments made during the last meeting was circulated in August 2012. Final comments received were fully incorporated into the present report.

1.3.        Consultation and expertise

During the IA process extensive consultations took place in respect of the general principles and minimum standards for consultation of the interested parties by the Commission. The Commission consulted all 27 Member States through a questionnaire sent out on 7 April 2011 which aimed at understanding the way the current legislation was implemented and consulted Member States on possible options for addressing the shortcomings identified in current EU legislation[10]. The Commission received answers from all Member States but one (Slovakia). The Commission also conducted on site visits to few Member States.

The Commission consulted interested stakeholders and the general public through a public consultation which was opened on 24 June 2011 and closed on 15 September 2011 (12 weeks) on the "Your Voice in Europe" Internet website[11]. In total, 61 replies were submitted in response. DG MOVE also received contributions from stakeholders in various forms.

As requested by Commission Decision 98/500/EC[12] which stipulates that each sectoral social dialogue committee, for the sector of activity for which it is established, "shall be consulted on developments at Community level having social implications", the Commission made a presentation before the Civil Aviation Social Dialogue Committee on 23 June 2011 where the Committee was invited at this occasion to formalise a position on the review where necessary.

In addition, the opinion of the European Network of Civil Aviation Safety Investigation Authorities (ENCASIA) was also sought in accordance with Article 7(3) of Regulation (EU) No 996/2010[13].

All interested stakeholders and authorities were invited to a workshop organised by the Commission which focused on the "Just Culture"[14] issue and which took place on 19 April 2012[15].

The Commission also asked the opinion of the European Data Protection Supervisor. Finally, a study on the establishment of a common risk classification of civil occurrences has been carried out[16].

Inputs from all consulted parties were taken into account in the analysis of the different policy options presented in this Impact Assessment and, where relevant, are presented in the document.

The Commission has been informed that the European Parliament has commissioned a study[17] which was carried out by an external expert on both accident investigation and occurrence reporting issues. This study, published in January 2011, had been requested by the Transport Committee to provide Members of the European Parliament with background information aimed at supporting them in their decision making process task for amending the legislation on accident investigation. The Commission has carefully analysed the text regarding the elements related to occurrence reporting within this study.

1.4.        Impact Assessment Board

Following the submission of a draft report to the Impact Assessment Board (IAB) on 5 September 2012 and a hearing with the IAB on 3 October 2012, the Board sent its opinion on 5 October 2012.

The recommendations of the IAB were duly taken into account and the main modifications were the following:

– The problem definition was made clearer and better explains the issues encountered with the current legal framework;

– The objectives were better specified and more closely linked to concrete monitoring indicators; monitoring indicators were reviewed;

– More detailed information on the content of each policy package was provided and the views of stakeholders was better specified;

– The assessment of impacts was better explained.

2.           Problem Definition

2.1.        Background on air safety

2.1.1.     General background

Air safety steadily improved over the last decades[18]. This was notably due to the combined efforts of the aviation regulators and the industry.

However, whilst the European average annual rate of fatal accidents in scheduled passenger operations has improved until 2004, since then the rate has remained more or less stable[19]. During a similar period air traffic movements in Europe grew from approximately 7 million flights per annum in 2000 to 9.5 million flights per annum in 2010.

Looking to the future, according to Eurocontrol[20], the growth in aviation flights in the Eurocontrol area[21] is most likely to increase to 16.9 million flights per annum by 2030, close to 1.8 times more than in 2010. Therefore, with a stable fatal accident rate, this will likely lead to an increase in the number of accidents as a by-product of steadily increasing traffic volumes.

Figure 1: Rate of fatal accidents in scheduled passenger operations – EASA MS and third country operated aeroplanes (fatal accidents per 10 million flights) [22]

Accidents almost never happen by chance; they are often preceded by a number of occurrences. In addition there are often not resulting from a single failure but from a combination of incidents. The fact that for each accident an important number of precursor occurrences exist is illustrated in the figure below, inspired from the Heinrich Pyramid[23].

Figure 2: The Accident Pyramid[24]

The principle behind this accident pyramid is still applicable to the present situation where for a limited number of accidents there are a much higher number of incidents. Indeed, for the year 2011, 3 fatal accidents and 38 accidents occurred[25] while 447 serious incidents[26] and 68,386 incidents[27] have been reported to the Member States.

2.1.2.     Accident prevention systems

The current aviation safety system is primarily a reactive system relying on technological advances, sound legislation underpinned by effective regulatory oversight, and detailed accident investigations leading to recommendations for safety improvements. However whilst the ability to learn lessons from an accident is crucial, purely reactive systems have now shown their limit in continuing to bring forward improvements. Preventing accidents reoccurring is essential but insufficient to reduce the number of accidents in a context of air traffic growth. Safety efforts should focus on preventing an accident occurring in the first place by addressing incidents and therefore support the establishment of a more proactive and evidence-based safety system.

Safety in civil aviation is significantly influenced by the inherently international nature of this industry. International co-operation is thus essential to ensure network safety and development of coordinated policies and globally agreed standards. The International Civil Aviation Organisation (ICAO) has encouraged the transition towards a proactive and evidence-based safety approach with the progressive introduction of formal requirements for safety management systems[28] since 2001 and has been formally recognised during the 2010 High Level Safety Conference with the decision to develop a new Annex to the Chicago Convention dedicated to safety management process.

The effectiveness of such a proactive and evidence-based system greatly depends on the ability to systematically analyse all available safety information, including information on civil aviation occurrences. Indeed, data is vital to identify safety hazards, for without sound information any attempt to identify the hazards would be guess work.

Collecting and analysing occurrences is not sufficient and should be complemented by actions to establish an effective proactive and evidence-based system leading to concrete aviation safety improvements and saving citizens lives. As explained in the ICAO Safety Management Manual[29], an effective "safety data management builds upon three clearly defined steps. The first two steps (…) are the collection of safety data on hazards and the analysis of safety data, to turn data into information. The third, and often overlooked, step is the mitigation or response activities to hazards (...) as a consequence of the safety information developed". One could add a fourth step with the oversight of corrective actions taken in order to ensure that the safety risk is eradicated.

2.1.3.     Description of the current occurrence reporting system in Europe

The International Civil Aviation Organisation has laid down provisions requiring States to establish occurrence reporting systems, to analyse data collected and to use it for safety improvements[30], but the lack of enforcement mechanisms at ICAO level has led to a diverging implementation of these principles across European Member States.

At European level, the transition towards a proactive and evidence-based aviation safety management system has already started with the adoption of Directive 2003/42/EC which requires each Member State to set up a mandatory occurrence reporting system (MORS). Under this legislation Member States are requested to collect, store, protect and disseminate between themselves information on certain civil aviation incidents. The Directive lists examples of occurrences to be reported and details the list of aviation professionals who shall report occurrences to their Member State competent authority. In reality most individuals do not report occurrences directly to the Member State authority but report to the organisation[31] which employs them, which then sends reports to their State of registration[32]. Member States are also encouraged to establish voluntary occurrence reporting schemes (VORS) which allow the collection of occurrences not covered by the mandatory system. Occurrences collected under the MORS are stored by each Member States in a national database and are then sent to the European Central Repository (ECR). This database has been established by the Commission in order to facilitate the dissemination of information between Member States through aggregated data at the EU level[33]. In September 2012, some 628,000 occurrences were stored in the ECR and this figure is growing daily. The ECR represents a number of potential benefits for both the EU and the Member States[34] and notably allows a better identification and analysis of specific EU-wide air safety issues and trends, as well as enables the monitoring of the overall performance of the EU aviation safety system, an issue essential for successful implementation of the European Aviation Safety Plan and Programme[35]. However, the current legislation limits the access to certain data contained in the ECR. The dissemination of the information contained in the European Central Repository to interested parties is regulated by an implementing regulation[36].

It should be noted that, in parallel to the system established by Directive 2003/42/EC and its implementing rules, a number of other reporting requirements exist under European law but also outside the EU system[37]. These parallel requirements have led to the existence of a number of other occurrence databases at European level other than the European Central Repository.

The current legislation does not include provisions indicating how Member States should use the data collected for the benefit of aviation safety. Therefore this has led to quite diverse and divergent approaches among Member States depending on the level of ICAO requirements implementation.

At European level, Regulation (EU) N°996/2010 has, in its Article 19, established the principle that occurrences contained in the ECR should be analysed by the European Aviation Safety Agency (EASA) and the Member States. This cooperation is now under way, notably with the establishment of a Network of Analysts, but the practical implementation of this legislative provision is negatively affected by the failures of the current system notably the lack of access to pertinent information contained in the ECR.

The figure below summarises the current occurrence reporting system in the European Union.

Figure 3: Current occurrence reporting system in the European Union

2.2.        Problem description – EU and Member States insufficient ability to use experience feedback for preventing accidents

As it has been illustrated by figure 2 above for each fatal accident there is an important corresponding number of occurrences which can be precursors to the accident. Accident investigation reports illustrates this fact by underlining that accidents are often preceded by a number of precursors which were not investigated or not addressed in an appropriate manner. Two examples illustrate this assessment: the Helios Airways crash which occurred on 14 August 2005, and the Air France 447 accident in the Atlantic on 1st June 2009.

In the Helios Airways accident investigation report[38], the Hellenic Air Accident Investigation and Aviation Safety Board underlined that the accident aircraft experienced a pressurization incident few months before the accident and listed a number of occurrences involving pressurisation problems on Boeing 737 which occurred in Europe. It also stated that in the NASA Aviation Safety Reporting System (ASRS) database 171 reports of air conditioning and pressurization problems that involved Boeing 737 aircraft were integrated during the period 1994-2004. Regarding the Air France 447 crash the French Accident Investigation Authority[39] stated: "As of 3 November 2009, Airbus had identified thirty-two events that had occurred between 12 November 2003 and 1st June 2009. According to Airbus these events are attributable to the possible destruction of at least two Pitot probes by ice. Eleven of these events occurred in 2008 and ten during the first five months of 2009."

While it is not the point here to assess the causes of the accidents mentioned and without hypothesising on what could or could not have happened under different circumstances, one could suppose that, had these precursors been addressed correctly and in an efficient manner, a possible contributing factor to the accident would have not occurred and the two accidents might have been avoided.

These examples illustrate the important benefit of using occurrences to identify safety risks and therefore trigger intervention actions to mitigate the risk. However, the current system in the European Union is not sufficiently efficient to achieve an effective proactive and evidence-based safety system. When taking into consideration the EU stable accident rate and the foreseen traffic increased, it becomes clear that the EU and its Member States are not sufficiently able to use experience feedback for an increased number of accidents.

This insufficiency is caused by a number of problem drivers which are not only due to incorrect and inconsistent implementation of the current legislation but also to regulatory failures. They are detailed below and summarised in section 2.2.5.

2.2.1.     The collection of occurrences is not optimal

In order to have a complete picture of the safety situation all occurrences which have or may have endanger aviation safety should be reported and collected in order to achieve full safety risks awareness. However, in the current situation this optimal collection of occurrences has not been achieved and can be explained by several causes.

(a) The scope of reporting differs between the Member States creating discrepancies in Member States reporting level:

Directive 2003/42/EC gives in its annexes a list of examples of occurrences to be collected under the Mandatory Occurrence Reporting Scheme (MORS). However when Member States implemented the Directive, differences in the way the list of occurrences to be reported has been implemented appeared. This has led to some important discrepancies between Member States in the scope of reportable occurrences. Indeed, while 17 Member States [40] assessed that above 50% of 'reportable occurrences' are captured by their MORS, 3 Member States consider that this level is close to 100% and one Member State that this level is under 30%.

Another figure illustrates this failure in the consistency of the Directive implementation: with a more or less equivalent traffic and fleet between France and Germany, France collects on average 45,000 occurrences yearly while Germany receives around 1,500 occurrences for the same period. This means that Germany collects 30 times less occurrences than France. This situation can notably be explained by the fact that in France the legal act implementing Directive 2003/42/EC encourages not only the reporting of occurrences listed in the annexes but equally the reporting of any other incident where it is justified for air safety[41]. In addition, France has established legal sanctions against those who fail to report any incident. These two combined elements lead to a very high rate of occurrence reporting within French aviation which makes France the biggest contributor to the ECR with over 50% of the occurrences integrated in the database. At the opposite end of the spectrum Germany has implemented the Directive in a much more restrictive way. Moreover when comparing these numbers to the EU average of occurrences collected each year (4,400 occurrences reports by Member States yearly on average) the interpretation could be drawn that the air safety situation is catastrophic in France because of the many occurrences found and excellent in Germany, whereas this important difference is mainly due to an inconsistent implementation of the Directive regarding the scope of occurrences to be reported.

(b) Individuals are afraid to report (the "Just Culture" issue)[42]:

Encouraging individuals to report occurrences they are aware of or that they were involved in is essential to an efficient aviation safety system. Indeed it has been estimated that "for each major accident involving fatalities, there are as many as several hundred unreported incidents that, properly investigated, might have identified an underlying problem in time to prevent the accident"[43].

To reach the goal of full occurrence awareness, individuals must be fully confident in the system because they are asked to report mistakes they may have made or contributed to. This confidence should be safeguarded by rules protecting the reporter and ensuring the non-punitive aspect of reporting while not absolving individuals from their normal responsibilities.

However while the European legislation clearly states that the sole objective of occurrence reporting is the prevention of accidents and incidents and not to attribute blame or liability, feedback received from stakeholders and results of the public consultation indicate that, in some Member States, some people are not reporting civil aviation occurrences because they fear blame or repression. Indeed, most of the respondents to the public consultation estimate that current rules are not correctly and consistently applied in all Member States notably because of their different legal systems and judicial environment. Certain stakeholders have supported this assessment by giving concrete examples where individuals have been dismissed following the reporting of an occurrence. This assessment of the situation is unanimously shared by aviation employees such as pilots, air traffic controllers or technicians but is also supported by the industry and the Member States.

This indicates that the "Just Culture" principle which guarantees that individuals are not "punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated"[44] is probably not equally respected in all Member States. This situation has a negative effect on the collection of occurrences by giving an incomplete picture of safety risks and thus on the efficiency of the system. This seems to concern both the collection of occurrences by the MORS as well as voluntary reporting schemes[45].

When speaking about the "Just Culture" concept in an aviation context, it is often linked to aviation professionals' fear of being prosecuted before a court and eventually facing criminal charges. This is a legitimate concern which usually rises in the context of an accident, as next to the technical safety investigation a judicial investigation is often opened. In a judicial investigation the judge is looking to establish whose and what kind of involvement has caused the accident and its consequences in terms of injuries and deaths. Indeed, if safety investigations are conducted with the sole purpose of making safety recommendations to prevent the recurrence of similar accidents without apportioning blame or liability, courts have an increasing tendency to rely heavily on accident investigations reports as part of their process[46]. This evolution towards criminalisation of accidents has led aviation professionals to be reluctant to collaborate with the safety investigation, and could have a detrimental effect on the willingness of individuals to report less serious events.

However, while this perception is very strong among aviation professionals, it does not reflect the level of risk they encounter in reality. Indeed if, in a context of an accident, the risk of being prosecuted is high and the individual may be exposed to media and public attention, this risk is almost non-existent in the context of an incident. Indeed the absence of fatal consequences or important material damages may be sufficient to explain the lack of serious grounds for pressing criminal charges. To the Commission knowledge, outside of gross negligence or wilful violations acts situation, individuals have been prosecuted and convicted only once on the ground of an occurrence, in the "Delta" case in the Netherlands. In this case, three air traffic controllers were prosecuted after an incident in the Netherlands that they reported in 1998 and were found guilty for violation of the Dutch Air Traffic law. However no sentence was imposed[47].

Whilst the "Delta" case shows that the fear of being prosecuted following the reporting of an occurrence has dramatic consequences on the reporting level of occurrence reporting[48], this case is isolated and information for occurrence reports have never been used as evidence in judicial proceedings in 23 Member States[49]. In reality, in their day-to-day job, the risk for individuals is more of being publicly blamed or dismissed as a consequence of the mistake reported than of being prosecuted. Therefore it is very important to address the employee protection from prejudice by its employer and Directive 2003/42/EC has provided some principles in that sense. However, it appears from consultations that these provisions are insufficient and inconsistently applied in the Member States.

In addition, if it is clear that the risk related to the judicial process is quite low, the fact that individuals are afraid to report because their perception is different from the reality has a strong influence on the level of reporting. However the lack of EU competencies in this area prevents the adoption of any European harmonised rule on the use of occurrence before national jurisdictions.

(c) No obligation to establish voluntary occurrences reporting scheme:

As explained in section 2.1.3 mandatory occurrence reporting schemes (MORS) may not be sufficient to capture all relevant safety occurrences and could be complemented by voluntary reporting schemes[50]. Indeed mandatory schemes impose on specific persons to report defined occurrences but there are actual or potential safety hazards that may not have been captured by the mandatory system. This can be either because it relates to occurrences which are not in the list of occurrences to be reported or because they are witnessed by persons which are not in the list if individuals submitted to the obligation to report under the mandatory system.

Whilst VORS were only encouraged when Directive 2003/42/EC was adopted, the obligation to put in place VORS has now become an international requirement[51] imposing on States to establish such schemes next to their national MORS.

The current legislation does not provide any rules on whether occurrences from VORS should be integrated in national databases and sent to the ECR. This results in a situation where of the 23 Member States which have established a VORS, 14 are combining the data with MORS information while 9 Member States are not.

(d) Insufficient clarity in reporting obligations and in the flow of information

Directive 2003/42/EC provides the basis for the reporting of occurrences in civil aviation within the European Union through its article 4 which sets the requirements for the mandatory reporting of occurrences by aviation personnel to the relevant competent authority. In addition to the directive, occurrence reporting is also regulated by a number of other EU instruments[52]. Some aspects of occurrence reporting in the area of air traffic management (ATM) are regulated in Regulation No 691/2010[53] and No 2096/2005[54]. Many Member States have also implemented into their national legal systems occurrence reporting standards adopted some years ago by Eurocontrol (ESARR2). In addition, some of these requirements were adopted before the establishment of the European Aviation Safety Agency (EASA), which as the authority responsible for certification of aircraft in the EU is an addressee of an increasing number of occurrences, some of which are of relevance not only for EASA but also for the Member State authorities.

This multitude of requirements and reporting lines is a source of confusion for the authorities and the industry. Moreover, these different systems lead to duplication and fragmentation of information and analysis. In their replies to the Commission questionnaire, Member States have indicated their concerns with this situation and underlined that there is no harmonisation in terms of notification procedures, delays, addresses or identity of the reporter (individuals/operators). Half the replies to the public consultation also specify that this issue should be addressed and that all reporting lines towards Member States should be regrouped in a single act.

In addition, the flow of information is also not very clear. Indeed the Directive imposes obligations on Member States for the collection of occurrences directly from individuals and does not mention the organisation level. However in reality Member States received almost all occurrences reports from organisations and very rarely from individuals[55]. This evolution notably caused by the introduction of safety management systems by organisations, should be recognised in the legislation according to a number of stakeholders and Member States.

2.2.2.     Data integration: the low quality of information and the incompleteness of data

When occurrences are initially collected, they often only contain a narrative in which the reporter describes the occurrence. These narratives are then used to complete occurrences reports which include a certain amount of data[56]. It is understood that for a comprehensive understanding of potential safety deficiencies the availability of as complete and as good quality as possible set of data is necessary. However, this is not currently the situation and this affects the consistency and the usefulness of information contained both in national databases and in the ECR, and therefore its use for safety purposes. It also risks providing some misleading trends which could lead Member States and EU to focus efforts where they are not needed, or worse failing to identify a safety issue.

(a) Low quality of information

The complexity of the taxonomy used to fill occurrence reports and the lack of standardisation during the data entry process contribute to data quality deficiencies. This results in particular in missing values or different coding of similar occurrences. It has been underlined in the results of the public consultation[57] that the absence of a standard for the content, format or quality of data reported leads to incomplete, unreliable and unusable data. This may be partly caused by the lack of resources and of expertise within public authorities entrusted with the occurrence reporting responsibility[58]. In addition, occurrences reported do not seem to correctly reflect the safety situation in the European Union[59]. Finally, the practice of disidentification of data[60] applied by some Member States affects the ability to detect any duplicate occurrence records in the ECR.

Data quality issues are being addressed, to a certain extent, by providing coding guidelines, and organising coding workshops by EASA[61]. In addition, some Member States have developed data quality checking processes in order to ensure that data present in the report is consistent with the original narrative received from the reporter. However this practice is not present in all Member States and is not sufficiently harmonised.

(b) Incompleteness of data

Although all Member States send occurrence data to the ECR, some Member States still do not provide all the safety relevant information. This appears to be notably due to different interpretations of the existing legislation and leads to key pieces of information being missing from the occurrences reports in the ECR[62]. Furthermore some Member States do not send all the occurrence reports included in their national databases as requested by the legislation and a few Member States hardly send any data at all[63].

The Commission is closely monitoring this aspect and every three months produces a report on Member States data integration in the ECR including the level of integration of certain key data fields. Based on this information the Commission has taken actions[64] against several Member States which have led to improvements in the situation in most of the Member States concerned. However the lack of requirement for mandatory data fields in the legislation limits the possibility for the Commission to take additional actions regarding the completeness of data.

2.2.3.     The legal and organisational obstacles for ensuring adequate access to information contained in the European Central Repository (ECR)

The European Central Repository regroups all occurrences collected by Member States in application of the current legislation and stored in their national databases. Even though the ECR currently stores a substantial amount of information, access to this information for the competent authorities and decision makers is impeded. EU legislation obliges the Commission, when granting access to the ECR, to disidentify certain information, in particular information which could lead to the identification of the operator subject to an occurrence report. Although the purpose of such provisions is to protect sensitive safety data and ensure that they are not misused, its practical consequence is that important safety related facts such as the actual description of the occurrence ("narrative") is not available for the authorities. Without access to occurrences' narratives analysis possibilities are very limited. In addition, the exchange of information between Member States is impeded and this results in depriving Member States from safety information about occurrences which have taken place in their territory but have been reported to another Member State.

Although in practical terms, the current issue with access to ECR data is due to regulatory failure and derives from restrictions in the existing legislation, the core of the problem seems to be linked with Member States lack of confidence regarding the possible use of information on civil aviation occurrences[65]. Indeed, some Member States are afraid that ECR data may not be used for safety improvements but for benchmarking between airports or operators. Regulation (EU) No 996/2010 has partially addressed this issue in providing provisions limiting the use of ECR data by EASA and the Member States to "what is strictly necessary to discharge their safety related obligations". But some criticisms were expressed during the decision making process regarding this provision because it was not included in the appropriate legislation[66] i.e. the legislation on occurrence reporting.

This Member States limited access to ECR data combined with the bad quality of data leads to a lack of interest from Member States to use ECR data. Indeed 20 Member States expressed that they never or very rarely used ECR data[67]. This reveals the difficulty to currently exploit ECR data for meaningful safety purposes.

However in a substation where data quality would be improved and where Member States would get full access to the ECR, many Member States do see an important added value in the exchange of information on occurrences through the ECR.

2.2.4.     Lack of occurrence analysis at Member States and at European levels and of appropriate corrective and preventive actions

Directive 2003/42/EC does not indicate how the information collected should be used for contributing to safety improvements. It only encourages the publication of an annual safety review to inform the public about the level of safety. However the principle, for certain specified organisations, of analysing defined occurrences at national level is present in other pieces of legislation such as Regulation No 3922/91 (EU-OPS) and the general requirement on Sates has been agreed at international level but not yet transposed into EU law. Some Member States requested the revised legislation to address this regulatory failure by including provisions on the analysis of occurrences at national and EU levels and to develop processes to achieve safety improvements.

At national level, the situation varies considerably. In some Member States occurrence data is analysed and leads to the adoption of corrective or preventive safety actions. In some other States occurrence reports are not analysed or used for safety purposes. In consequence this means that there is no proactive and evidence based actions taken by the national authority in these States. This can be partly explained by lack of staff resources[68]. This lack of resources is obviously a major safety concern in that it means in some cases an impossibility to correctly implement EU legislation and therefore difficulties to carry out any additional task.

At European level, the obligation to analyse occurrences has been established for the first time in Regulation No 996/2010 in its article 19[69] but the framework and tools required to implement this article have yet to be developed. It seems in particular helpful to establish priorities for the analysis of all 628,000 occurrences contained in the ECR. Indeed the very large number of occurrences in the ECR is a limit to a systematic analysis of each single occurrence at European level and the absence of a common EU classification makes difficult any kind of prioritisation in terms of safety risks. This has been recognised in the Commission Communication on "Setting up a Safety Management System for Europe"[70] where it is stated that the absence of "a universally accepted risk assessment methodology in common use across the European Union for all the aviation domains which would enable a standardised approach and better priority setting to tackle those risks that pose the greatest threat to safety" should be addressed.

2.2.5.     Problem tree[71]

2.3.        Who is affected, in what ways, and to what extent?

The main actors affected by the drivers outlined in section 2.2 are all persons and organisations involved in the civil aviation system or benefiting from air safety, both at national and European level.

The European citizen and the travelling public in a global sense are affected by aircraft accidents. They have a legitimate interest in safe public aviation transportation. They are therefore benefiting directly from a system which contributes to prevent accidents by using experience feedback.

Authorities designated by their Member State to perform collection, storage, protection, analysis and dissemination of civil aviation occurrences[72] are directly affected by the revision of the current European legislation on occurrence reporting.

The European Union and in particular the European Aviation Safety Agency (EASA) are affected because of their role as safety regulators. In addition, the European Commission is running the European Central Repository and EASA could be entrusted with additional responsibilities regarding occurrence analysis at EU level and coordination with Member States.

Industry players[73] are affected because they are the entities responsible for putting in place a system allowing their employees to report occurrences and they are essential elements of a comprehensive Safety Management System.

Industry employees[74] are key elements to the system. They are affected because they are the source of occurrences and they may be reluctant to report occurrences notably if they are afraid of disciplinary action.

Third countries are also affected because they are flying to Europe and can benefit from safety improvement in the EU aviation system (notably in the ATM area). They could also benefit from an exchange of information of safety data as provided for in bilateral aviation safety agreements between the European Union and some third countries.

2.4.        How the problem could evolve?[75]

2.4.1.     Evolution of the situation from an aviation safety perspective

It has been demonstrated that aircraft accidents are often preceded by a number of incidents which, when not identified and addressed properly, might lead to an accident. This fact would, in itself, be sufficient to illustrate that efficient safety management systems based notably on the analysis of data collected from occurrences reporting schemes are necessary to prevent accidents. In addition, other elements can also illustrate the direct link between proactive safety systems based on the collection and use of occurrences and the rate of fatal accidents.

At international level the International Civil Aviation Organisation (ICAO) is monitoring States' compliance with its rules related to occurrence reporting and safety management[76] by assessing if States have established occurrences reporting schemes, and whether they are analysing the information collected to determine any preventive actions required. If we take the example of the region of "North America"[77], it has a rate of 1.6 fatal accidents per 10 million flights[78]. When looking at their USOAP audits reports, it shows that these two States are fully complying with the international requirements in the area of occurrence reporting and safety management. In comparison, the region "Europe Non EASA Member States"[79] has a rate of 32.9 fatal accidents per 10 million flights. When looking at USOAP audits reports it reveals that almost all States from this region have not implemented or incorrectly implemented ICAO requirements related to occurrence reporting and its follow up.

While aviation safety performance results from a wide range of various factors, the evidence above shows that there is a link between accident rates and occurrence reporting and that an efficient occurrence reporting system is a key element of a proactive safety system leading to improved aviation safety and therefore to a decreased number of fatalities due to aircraft accidents.

However, as illustrated by the problem drivers identified in section 2.2, the current legislation does not ensure an efficient and complete occurrence reporting system in the European Union. Indeed, as detailed in the section 2.2 on problem definition, in most Member States the occurrence awareness and the bad quality of data do not allow an accurate identification of safety risks. In addition many Member States have not yet implemented the international requirements regarding the analysis and follow up of occurrences. One can therefore conclude that without additional safety initiatives including an improvement of occurrence reporting in Europe, the station will evolve towards an increased number of aviation accidents and of related fatalities as a result of the growth in air traffic[80].

Making accurate estimations of the number of accidents and the resulting deaths which could occur if no action is taken is very difficult if not impossible. Accidents often do not result from only one cause but from a combination of elements including some which are harder to predict (e.g. weather conditions, human factors). Indeed, as illustrated by figure 4, such events do not happen in a linear way and are not easily predictable. Therefore, an accurate number of additional accidents cannot be determined precisely, and consequently it can be very misleading to make estimates of how many accidents would be avoided by the use of an efficient proactive and evidence based safety system.

Figure 4: European lives lost in air transport[81]

Period || European lives lost in EU-27 territory by any operator || European lives lost by EU-27 operators anywhere

2000 || 113 || 113

2001 || 122 || 125

2002 || 101 || 25

2003 || 5 || 5

2004 || 0 || 0

2005 || 144 || 125

2006 || 5 || 6

2007 || 0 || 1

2008 || 154 || 154

2009 || 9 || 228

2010 || 2 || 2

However, even if estimates in this area should be looked at very cautiously, the expected aviation traffic growth as presented in section 2.1.1[82] combined with the stability of fatal accident rate in the EU area since 2004, would involve an increased number of aircraft accidents by around 1.8 by 2030.

2.4.2.     Evolution of the situation from an economic perspective

Aircraft accidents fortunately do not happen very often (1.6 accidents per 10 million flights in Europe) but they gather a lot of attention from the media and the public when they occur and they are very costly for society, not only in terms of lives lost of course, but also in terms of monetary value.

It is however very difficult to precisely quantify the cost of air accidents in the EU due to lack of comprehensive studies in this respect. Furthermore, the cost of an aircraft accident can vary tremendously depending on the size of the aircraft, the location of the crash and many other aspects. Many elements should be taken into account to assess the economic impact of an accident[83]. A list of cost headings involved in an aircraft accident can be detailed as follows[84]: aircraft physical damage, possible loss of resale value, aircraft loss of use, aircraft loss of investment return, passenger and crew fatalities, site contamination and clearance, airline costs for delays, airport eventual closure, loss of staff investment, loss of cargo, mail and passenger baggage, search and rescue and cost of emergency services, airline immediate response, cost of accident investigation, eventual third party damage, loss of airline income/value/reputation (loss of passengers, decrease in share value and market capability), societal costs, emergency inspections of aircrafts, fines, punitive damages, criminal proceedings. One could add to that list the cost of the recovery of wreckage and bodies which can have a significant impact on the economic cost of an accident, notably if the aircraft has crashed in a location difficult to be reached such as in mountainous regions or the sea. A detailed list of costs involved by an accident is enclosed in Annex 7. It is very difficult to combine all the above mentioned elements and to assess with accuracy the global average economic impact of an aircraft accident. Indeed some of these elements cannot always be determined or be quantified in monetary value and some others vary tremendously depending for example on the circumstances, the location of the accident or the nationalities of the passengers.

There is no known study which has attempted to evaluate this monetary value on average given all the uncertainties and the variable factors involved by an accident. There is however a study from the US organisation CAST[85] which has calculated the accident cost per flight and has evaluated it around $76 (€60) per flight[86].

Taking into account the aviation traffic growth forecast for 2030 as presented in section 2.1.1 and the stable accident rate, accidents would increase by around 1.8 between 2010 and 2030. Based on the numbers provided by the CAST study, this means that the economic impact of accidents will increase from €570 million by year in 2010, to €1014 million by year in 2030[87]. Therefore it the situation remains unchanged, the economic impact of accidents will almost double by 2030.

2.5.        Does the EU have the right to act?

The right to act has already been recognised in Directive 2003/42/EC on occurrence reporting. This impact assessment concerns whether there is a necessity to modify this legislation and its implementing rules.

The right for the EU to act in the field of transport is set out in several articles of the TFEU[88], in particular in Title VI which establishes provisions for the European Transport policy. Article 91 (1) c) notably gives the Union competencies for laying down "measures to improve transport safety" under the co-decision procedure.

This competence in matters of air safety is not exclusive but a shared competence with the Member States as set out in article 4 of the TFEU. It is therefore necessary to justify EU action and to respect the subsidiarity principle as set out in Article 5 (3) of the Treaty on the European Union. This involves two aspects: ensuring that the objectives of the proposed action could not be achieved sufficiently by the Member States ("necessity test") and considering whether and how the objectives could be better achieved by action on the part of the Union ("test of European added value").

Firstly, regarding the "necessity test", there is a need to harmonise the reporting of occurrences to ensure consistency of data collected along with a better quality of data (including the scope of reporting) and ensure a more consistent and a better implementation of "Just Culture" principles in all Member States. It is also necessary to strengthen the information exchange between Member States and allow States to have access to information about occurrences which have occurred in their territory but have been reported to another Member State. Additionally issues such as access to the ECR data and establishing processes and tools to analyse ECR data cannot be achieved at national level as it involves a European database for which action should be taken at EU level. Equally the clarification of reporting obligations present in different EU legislation cannot be addressed at national level. Action at national level is absolutely necessary for the whole system to be efficient but is not sufficient to ensure the good functioning of the system as a whole and subsequently contribute to improve air safety.

Secondly, looking to the "test of European added value", Union action would bring safety benefits by strengthening and developing proactive actions based on occurrence analysis at national and EU level. In addition, an event that appears to be an isolated occurrence in a Member State, when looked at across the Union as a whole, can point to a need for action. Moreover, on aspects linked to the ECR, Member States support an analysis of the information contained in the ECR in a European context which will allow to perform safety analysis on a more significant amount of data and will help to the identification of key risk areas for the European Union.

3.           Objectives

3.1.        What is the general policy objective?

In application of the Treaty on the Functioning of the European Union Article 91, the European Union shall "lay down measures to improve transport safety".

In addition, the European Commission, in its 2011 White Paper "Roadmap to a Single European Transport Area - Towards a competitive and resource efficient transport system", set the goal for the European Union of becoming the safest region of the world for aviation transport.

In this context the proposed initiative general objective is to contribute to the reduction of the number of aircraft accidents, and of related fatalities, through the improvement of existing systems, both at national and European level, using civil aviation occurrences for correcting safety deficiencies and prevent them from reoccurring and from leading to an accident. This initiative is therefore an important element of the European aviation safety transport policy as defined in the Treaty.

3.2.        What are the specific objectives?

The general objective can be divided into four specific objectives (SO) which correspond to the problem drivers identified in section 2.2[89] and are detailed in the table below.

Problem drivers || Specific objectives

1. The collection of occurrences is not optimal || To ensure that all occurrences which endanger or would endanger aviation safety are collected and are providing a complete and clear picture of safety risks in the EU and its Member States (SO1)

2. Suboptimal data integration (low quality and incompleteness) || To make sure that occurrence reports stored in the national databases and in the ECR are complete and contain high quality data (SO2)

3. Legal and organisational obstacles for ensuring adequate access to information contained in the ECR || To make sure that all safety-critical information stored in the ECR is accessed adequately by competent authorities and that they are used strictly for safety improvement purposes (SO3)

4. Lack of occurrence analysis at MS level and at European level and of appropriate corrective and preventive actions || To ensure that reported occurrences are effectively analysed, that safety hazards are identified and addressed where relevant and that the safety effectiveness of the actions taken is monitored (SO4)

The picture below describes how the ideal system should work, taking into account both national and European levels.

Figure 5: Flow of information and processes in a complete proactive and evidence based system in relation to aviation occurrences

3.3.        What are the operational objectives?

The specific objectives can also themselves be translated into operational objectives.

SO1 would encompass the following operational objectives:

· reach a higher occurrence collection rate in the EU[90] through a harmonisation and clarification of reporting obligations

· a clarification and development of legislative requirements related to "Just Culture"

· the obligation to establish voluntary reporting schemes

· a clarification of the flow of information notably with regards to organisations.

SO2 would include the following operational objectives:

· the standardisation of data entry processes

· the establishment of mandatory data fields and

· the establishment of quality checking processes.

SO3 would have the following operational objectives:

· allow for the granting of full access to ECR data to appropriate safety authorities through the review of ECR access rules

· establish confidentiality rules and safeguards regarding potential misuse of the data.

SO4 would include the following operational objectives:

· the creation of an obligation to analyse occurrence data and to identify actual or potential safety hazards

· adopt preventive or corrective actions where appropriate

· oversee the efficiency of those actions and to create a common EU risk classification scheme for classifying occurrences.

Operational objectives corresponding to SO2 and SO4 have not been quantified because they are very much dependant on the resources allocated notably by Member States to the achievement of the specific objectives and therefore cannot be evaluated by the Commission.

3.4.        Consistency with horizontal policies of the European Union

The proposal is consistent with the overall policies of the EU and with the objective of transport safety improvement enclosed in the Treaty on the Functioning of the European Union (Article 91). Moreover, by improving aviation safety in Europe, they contribute to the attainment of the wider objectives of the Lisbon Agenda and EU consumer protection policy.

In addition, the objectives of this initiative are fully compliant with relevant fundamental rights and principles as embodied in the Charter of Fundamental Rights of the European Union, and by giving citizens the legitimate right to safe air transport it contributes in particular to the right of physical integrity and of freedom of movement.

The proposed revision of the current legislation is fully consistent with Regulation (EU) No 996/2010 which requests such a review in its Recital 3.

Finally, the proposal is in line with the Commission White Paper 2011 "Roadmap to a Single European Transport Area - Towards a competitive and resource efficient transport system" and with the Commission Communication on "Setting up a Safety Management System for Europe" as it implements actions foreseen in the both texts.

4.           Policy options

This section outlines the policy options which have been considered beside the "baseline scenario" detailed in section 2.4 by the Commission to address the problem areas described in Section 2 and to meet the policy objectives identified in Section 3.

4.1.        Pre-screening

The first option identified by the Commission is the repealing of the existing EU legislation. This would mean that requirements regarding the establishment of occurrence reporting schemes and the management of such schemes would only be taken at national level. It would also lead to the suppression of the European Central Repository (ECR) established by Regulation (EC) No 1321/2007 and which regroups all occurrence reports collected by Member States. Any coordination of action or any exchange of information between States would be done on voluntary basis and the coordination developed at EU level would disappear. The rules regarding the dissemination of the information to interested parties inside and outside the European would also be repealed. A limited harmonisation could still possibly remain between Member States as certain international principles related to occurrence reporting are enshrined at international level, but these principles are limited and the problem drivers identified in section 2.2 would not be addressed.

If Member States also decided to repeal the national measures implementing the Directive on the basis that the Directive has been repealed, it would mean that States would no longer collect and use occurrence reports and therefore would not take proactive safety actions based on the analysis of incidents. Even with a stable aviation traffic growth this could lead to an increased number of aircraft accidents and subsequently to more fatalities. In the foreseen traffic growth context, the consequences could be dramatic.

This option has been identified by more than 50% of the respondents to the public consultation as the least preferred option[91]. In view of the serious risk this option would pose to citizens' safety, this option has not been pursued further and will not be analysed in section 5.

The Commission also envisaged an option which would strengthen the enforcement of existing provisions. However, as the current problems are not due to an insufficient enforcement of the current legislation but to inconsistencies in the way the directive has been transposed by Member States and to lack of requirements in the current legislation, the Commission has considered that this option will not address any of the problem drivers and will not fulfil any of the specific objectives. Therefore this option has also been discarded.

4.2.        Identification of possible policy measures

In order to identify the best options to address the problem drivers identified in section 2.2 the tables below present, for each driver, a set of possible policy measures.

Issues identified in section 2.2 || Policy measures || Detail of the policy measure

Problem driver 1: The collection of occurrence data is not optimal (PD1)

A: The scope of reporting, regarding the type of occurrences, is different between the Member States creating discrepancies in the reporting level || 1. Guidance regarding the scope || Clarification regarding the scope of occurrences to be collected based on the list of occurrences annexed to the Directive and adaptation of national measures transposing the Directive to ensure consistency

2. Harmonise the scope of reportable occurrences || Replace the Directive by a Regulation and specify the scope of reportable occurrences under the mandatory system by annexing to the Regulation the list of occurrences which should be reported (this annex would be based on the current annex to the directive)

B: Individuals are afraid to report (the "Just Culture" issue) || 1. Guidance regarding interpretation and implementation of Article 8 || Some rules already exist in the Directive: guidance would be developed to ensure a better interpretation and implementation of these rules

2. Develop and complement existing rules protecting the reporter || Existing rules would be clarified and complemented: in particular include the definition of "Just Culture" (as defined in Regulation (EU) No 691/2010[92]), disidentify occurrence reports by removing details leading to the identification of the reporter, restricts the access to fully identified data, reinforce the principle of no blame except in cases of gross negligence and establish a national focal point which will receive complaints for breaches to "Just Culture" principles, assess them and propose actions to Member States when relevant.

C: There is no obligation to establish Voluntary Occurrence Reporting Scheme (VORS) and there is no clarification on what should be reported under VORS || 1. Recommendation and guidance on Voluntary Occurrence Reporting Scheme (VORS) || Commission Recommendation requesting Member States to implement the international ICAO Standard (ICAO Annex 13 Chapter 8[93]) imposing the establishment of VORS; guidance on what should be reported under MORS/VORS

2. Mandatory VORS in Member States || Modify the legislation in order to implement into EU law the ICAO Standard imposing the establishment of VORS; clarify within the legislation what should be reported under MORS/VORS

3. Replace Member States VORS by an EU VORS || Replace national VORS by an unique European VORS where individuals and organisations would report directly what does not come under the MORS scope; clarify within the legislation what should be reported under MORS/VORS

D: There are too many occurrence reporting lines in various EU legislations which create duplication and confusion || 1. Guidance and training || Guidance material would be developed together with a reference document specifying all reporting lines and the requirements applicable for each reporting line; training would be provided to explain the different obligations

2. Harmonisation of reporting lines || Simplify and harmonise all reporting requirements in terms of deadlines and content; modify reporting requirements in other relevant EU legislations to ensure appropriate consistency

E: The flow of information is not clear and there is no requirement for organisation to collect occurrences in the Directive || 1. Recommendation imposing occurrence reporting on organisations || Commission Recommendation asking Member States to implement the international ICAO Standard (Annex 6) requesting States to ensure the establishment of a Safety Management System within their industry

2. Include the organisation level in the revised legislation || Modify the legislation in order to implement into EU law the occurrence reporting related part of the ICAO Standard requesting States to ensure the establishment of an SMS within their industry

3. Include the organisation level in the revised legislation and transfer the obligation to collect occurrences from Member States towards a single body at EU level || Modify the legislation in order to implement into EU law the occurrence reporting related part of the ICAO Standard requesting States to ensure the establishment of an SMS within their industry; modify the legislation in order to transfer the obligation to collect occurrences from States towards a unique body which will collect directly, mainly from the industry, all occurrences coming from the MORS

Issues identified in section 2.2 || Policy measures || Detail of the policy measure

Problem driver 2: Data integration: The low quality of information and the incompleteness of data (PD2)

A: Occurrences come in very different forms and are not encoded and classified into databases in a harmonised way || 1. Develop guidance material and training || Develop guidance material regarding the filling of occurrence reports by individuals and the completion of national databases by national authorities with data issued from occurrences; organise training and workshop at national and EU level to ensure a better harmonisation of classification within and among national databases

2. Harmonise reporting, standardise the data entry process and develop guidance and training || Modify the existing legislation in order to ensure more harmonisation in reporting process and standardise the data entry process among States; in addition develop guidance material and organise training for national authorities

3. Impose the use of a single data format for occurrence reports and give the competencies to collect occurrence reports to a single body at EU level || Impose the use of the ECCAIRS data format for occurrence reports; modify the legislation in order to replace the Member States collection of occurrences by a collection at EU level through a single entity which will collect, process and store occurrences reports coming directly from individuals or from organisations.

B: There is often no quality checking process to ensure the consistence of data || 1. Develop the existing guidance material and automatic data quality checker tools; organise trainings || Develop and complement the existing guidance material about data quality; develop automatic data quality checker tools and make them available to Member States; organise trainings and workshops about data quality

2. include the principle of mandatory quality checking in the legislation in addition to development of guidance, automatic tools and trainings || Modify the existing legislation in order to impose both on organisations and on Member States the principle of quality checking; to ensure the correct implementation of this provision develop and complement the existing guidance material about data quality; develop automatic data quality checker tools and make them available to Member States; organise trainings and workshops about data quality

C: Not all information is sent to the ECR and the data collected is not always reflecting the actual safety performance || Continue to ensure the proper implementation of the legislation || The Commission would continue to ensure the oversight of the data contained into the ECR and would launch infringement procedures where necessary in order to ensure that Member States send all data they collect to the ECR; in addition the existing or modified legislation could enter in the scope of EASA standardisation inspections to ensure a better oversight of its correct implementation

D: Not all key data fields are filled into the ECR for many occurrences || 1. Guidance material on what should be filled || Develop guidance material on completeness of data and develop a suggested list of fields to be included for each relevant category of occurrences

2. Establish mandatory data fields || Modify the legislation in order to establish the principle of mandatory fields; annex to the revised legislation the list of main mandatory fields and develop specific mandatory fields for each category of occurrences in implementing measures

Issues identified in section 2.2 || Policy measures || Detail of the policy measure

Problem driver 3: The legal and organisational obstacles for ensuring adequate access to ECR information (PD3)

A: Important occurrence information (narrative) is not accessible || Improve the exchange of information by ensuring broader access to the content ECR || Ensure broader access to ECR data notably in order to give appropriate safety authorities access to all safety information would require a modification of the legislation. This could be done through a modification of Commission Regulation No 1321/2007 which would include limited legislative changes or in a wider context as part of a more substantive legislative change which would regroup all provisions from the Directive and its implementing regulations in a single piece of law. In both cases access should be limited to define competent authorities at national and EU level and access should be given to all safety data contained in the ECR

B: Member States lack of confidence regarding the use of ECR data || Limit the use of ECR data to safety enhancement purposes || In order to allow wider access to data, their use would be strictly limited to safety purposes which would be defined in the legislation. This could be done through a modification of Commission Regulation No 1321/2007 which would include limited legislative change or in a wider context as part of a more substantive legislative change which would regroup all provisions from the Directive and its implementing regulations in a single piece of law. In both cases, data could only be used for the purpose of maintaining or improvement the level of aviation safety and not for benchmarking

Issues identified in section 2.2 || Policy measures || Detail of the policy measure

Problem driver 4: Lack of occurrence analysis at national and at European levels and of appropriate safety measures (PD4)

A: No systematic analysis of occurrences at Member States and EU level || 1. Recommendation and guidance || Commission Recommendation asking Member States to implement the international ICAO Standard (Annex 13 Chapter 8[94]) requesting States to analyse data issued from MORS and VORS and to determine appropriate action required

2. Introduce the obligation to analyse data at Member States and EU level || Modify the legislation in order to implement into EU law the ICAO Standard requesting States to analyse data issued from MORS and VORS and to determine appropriate action required; impose this obligation on organisations, Member States and at EU level

3. Introduce the obligation to analyse data and transfer Member States analysis competencies at EU level || Modify the legislation in order to implement into EU law the ICAO Standard requesting States to analyse data issued from MORS and VORS and to determine appropriate action required; impose this obligation on organisations and at EU level

B: No policy framework to achieve safety improvements based on occurrence analysis || 1. Recommendation and guidance || Commission Recommendation asking Member States to implement the international ICAO Recommendation (Annex 13[95]) requesting to implement appropriate corrective and preventive actions identified from occurrence analysis and to monitor their effectiveness

2. Introduce the obligation to correct safety deficiencies and monitor effectiveness || Modify the legislation in order to implement into EU law the ICAO Standard requesting to implement appropriate corrective and preventive actions identified from occurrence analysis at organisation, Member States and at EU level and to monitor the effectiveness of these actions at Member States and EU level

3. Introduce the obligation to correct safety deficiencies and monitor effectiveness at EU level only || Modify the legislation in order to implement the ICAO Standard requesting to implement appropriate corrective and preventive actions identified from occurrence analysis at national and at EU level and monitor the effectiveness of these actions at EU level

C: No tool to prioritise occurrence analysis || 1. Develop a common EU risk classification scheme and recommendation to use this tool || Develop at EU level a common EU risk classification scheme in order to classify occurrences in a harmonised way; make this tool available to Member States and industry; adopt a Recommendation asking Member States to classify their occurrences according to this tool

2. Impose the classification of occurrences according to a common EU risk classification tool || Modify the legislation to include the obligation for Member States or EU entity to classify occurrences according to a common EU risk classification tool; develop this tool at EU level and make it available to Member States and industry

4.3.        Identification of policy packages

To determine possible EU policy action, the Commission has considered first the possible application of an isolated intervention in each of the issues identified. However none of the policy measures taken in isolation presented above can achieve the objective of contributing to the reduction of aircraft accidents through use of occurrence data. In order to address the four problem drivers identified, the Commission proposes three policy packages besides the baseline scenario. All three policy packages are capable of reaching on a standalone basis the four specific objectives set out in section 3.2.

(a) Overview of policy packages

Policy packages Problem drivers || Policy package 1 || Policy package 2 || Policy package 3

Collection of occurrences is not optimal || Policy measures A1; B1; C1; D1; E1 || Policy measures A2; B2; C2; D2; E2 || Policy measures A2; B2; C3; D2; E3

Low quality of information and incompleteness of data || Policy measures A1; B1; C; D1 || Policy measures A2; B2; C; D2 || Policy measures A3; B2; C; D2

Obstacles to adequate access to ECR information || Policy measures A and B || Policy measures A and B || Policy measures A and B

Lack of occurrence analysis at Member States and at EU levels || Policy measures A1; B1; C1 || Policy measures A2; B2; C2 || Policy measures A3; B3; C2

(b) Policy package 1 – A better use of existing requirements to the benefit of a more proactive safety system

The first policy package (PP1) aims at improving the current system in establishing the basic elements of a complete occurrence reporting system and its contribution to aviation safety improvement through amendment to the legislation only to the necessary minimum and adoption of recommendations and guidance wherever possible. It contains the less intense policy measures identified above.

PP1 addresses the issues mentioned under problem driver 1 through the adoption of guidance material allowing clarification and better implementation of the existing legislation together with recommendation to implement agreed international requirements. This is complemented by development of training where appropriate. The policy measures included in PP1 allow a better, more harmonised collection of occurrences in EU Member States and clarifies the source of misunderstandings.

Regarding problem driver 2, PP1 continues and complements on-going development of guidance and training and therefore contributes to the improvement of the quality of occurrence data. In addition the Commission continues to monitor the completeness of occurrence reports sent by the Member States to the ECR.

On problem driver 3, PP1, through the modification of an implementing regulation to the Directive, grants full access to ECR data to competent authorities and, as a necessary corollary, restricts the use of data to safety enhancement purposes only.

Problem driver 4, which relates to areas not present in the existing legislation, is addressed through the adoption of recommendation requesting Member States to implement agreed international requirements related to the analysis of occurrences and the adoption of consequent measures in order the eliminate the safety risks identified. It is completed by development of a common EU risk classification scheme allowing a better prioritisation of actions.

This policy package has been considered as the favourite option by 14.8% of the respondents to the public consultation.

(c) Policy package 2 – The establishment of comprehensive occurrence reporting systems in the EU and its Member Sates contributing to a more proactive safety system for Europe

The second policy package (PP2) consists of a more ambitious package of policy measures entailing a substantial revision of EU legislation on occurrence reporting. PP2 seeks to improve the current system by establishing the necessary legislative requirements for ensuring an efficient occurrence reporting system at all levels (organisation, national authorities and EU level) and to contribute to the reduction of aircraft accidents through the establishment, at all levels, of processes for the analysis of data collected, the adoption of corrective or preventive measures where relevant and monitoring of the system efficiency in terms of safety improvements.

PP2 addresses problem driver 1 issues with the following policy measures: strengthen and complement the existing provisions on "Just Culture" issue notably by including the definition of "Just Culture" in the legislation, reinforcing the principle according to which employees are protected from blame expect in cases of gross negligence and establish a national focal point where individuals could report breaches to "Just Culture" principles and which could propose measures to be taken by Member States when relevant; simplify and harmonise reporting requirements by defining reportable occurrences and the conditions to report[96]; impose the establishment of VORS[97].

Regarding problem driver 2 this package includes the harmonisation of reporting process and the standardisation of data entry processes[98]; the development of guidance material and training; the introduction of mandatory quality checking and the development of automatic data quality checker tools; the introduction of mandatory data fields[99].

On problem driver 3, PP2, as PP1, opens full ECR data access to competent authorities and restricts the use of data to safety enhancement purposes on the basis of already existing provision in Regulation (EU) No 996/2010.

Finally problem driver 4 is addressed by the introduction into EU law of the obligation to analyse occurrences collected from MORS and VORS at organisation, Member State and European levels; the adoption of corrective or preventive safety actions where appropriate and the introduction of monitoring the efficiency of actions taken; the development of a common EU risk classification scheme[100].

Under PP2, the European Aviation Safety Agency (EASA) is entrusted with additional responsibilities. The Agency coordinates and manages a network gathering Member States' safety analysts with the purpose of performing safety analysis to support the European Aviation Safety Programme and Plan and to determine key risk areas for Europe.

This policy package has been ranked first favourite option by contributors to the public consultation and is supported by most of the Member States.

(d) Policy package 3 – The European centralised approach

This policy package (PP3) aims at improving the current system by transferring Member States occurrence reporting competencies to the EU level and establish, as in PP2, requirements for occurrence analysis together with the adoption of necessary safety actions and improvement monitoring. Under PP3, the responsibility to establish and manage occurrence reporting scheme(s) would be centralised at European level and transferred to a European entity, the European Aviation Safety Agency (EASA). PP3 builds on PP2 but replace the involvement of Member States authorities by EASA.

In order to address problem driver 1, PP3 includes most of the policy measures described in PP2 but the system differs in the sense that occurrences are either collected by organisations and sent directly to the European level, without going through the State level, or collected directly by EASA. Regarding VORS, Member States schemes are replaced by a unique European Voluntary Reporting Scheme where everything which is not collected by organisations and sent to EASA is collected directly by the Agency. In addition EASA is designated as the European focal point for report of breaches to "Just Culture".

On problem driver 2, PP3 imposes that occurrence reports are sent to EASA through a single data format (the ECCAIRS data format)[101]. Policy measures similar to the ones developed in PP2 are developed to address problem driver 2.

Problem driver 3 partly disappears in PP3 as occurrence reports are received directly by EASA which manages the European Central Repository fed by the reports EASA collects. The limitation of data use is similar to the policy measure described in PP2.

Regarding problem driver 4, PP3 includes the obligation to analyse occurrence reports at organisation level and at EU level, as well as the requirement to address them through corrective actions and to monitor the actions taken by organisations and assess their efficiency in terms of safety improvement. At EU level the analysis of occurrence reports contributes to update the European Aviation Safety Programme. Similarly to PP2, a common EU risk classification scheme is developed.

This policy package has not been presented in the public consultation but the policy measure which would establishing the European voluntary occurrence reporting system has been submitted to respondents to the public consultation and has been supported by 26.2% of respondents.

(e) Support to legislative change

While not giving indication on the content of such a review, the principle of an EU legislation comprehensive review, as foreseen in PP2 and PP3, is supported by the European Parliament and the Council which included a formal request for such a review in Recital 3 of Regulation (EU) No 996/2010. Member States confirmed their support to the modification of existing rules in their replies to the questionnaire sent by the Commission[102]. In addition, the Commission has underlined the necessity of revising the current legislation in the White Paper 2011 "Roadmap to a Single European Transport Area - Towards a competitive and resource efficient transport system" and reaffirmed it in the Commission Communication on "Setting up a Safety Management System for Europe"[103]. In complement to that unanimous institutional support, the European Network of Civil Aviation of Safety Investigation Authorities (ENCASIA) expressed its "strong support" to the revision. Finally public consultation respondents ranked PP2 as their favourite option.

4.4.        Legal instrument

The current European legislation on occurrence reporting in civil aviation is in the form of a Directive and two implementing Regulations. The legal instrument was considered to be adequate at the time the legislation was adopted as it aimed to introduce certain requirements into EU law whilst leaving Member States a degree of flexibility regarding the implementation of the agreed requirements. However the problem description in section 2.2 underlines that this choice of legal instrument has in a large part led to the considerable heterogeneity in the way the legislation has been implemented by Member States. While PP1 attempts to ensure more harmonisation in the implementation of the Directive through guidance material, recommendations and very limited legislative change, PP2 and PP3 are constructed in the form of a regulation. A number of reasons justify this choice.

In first place, the fact that these policy packages establish rights and obligations for the European Aviation Safety Agency prevents the use of a directive. Indeed, directives are acts of the European Union which require Member States to achieve a particular result without dictating the means of achieving that result. While a regulation is applicable in Member States’ internal law immediately after its entry into force, a directive must first be transposed by the Member States and can lead to diverging while not contradicting national laws. As directives by their very nature are result orientated they should not be used to lay down detailed instructions for the Member States. For this same reason, if the intention is also to establish rights and obligations for an EU institution or other body, such as an Agency, directives are not appropriate instruments since directives should not lay down detailed rules. Such rights and obligation should instead be laid down using regulations which are binding as to all contents, self-executing and do not normally require any implementing measures. Consequently, not only the legislation establishing EASA and the implementing rules to that legislation, but also any other legislation establishing rights and obligations for EASA are adopted in the form of a regulation. The same applies in PP2 and PP3 as they establish rights and obligations for EASA.

The second reason is that many shortcomings and problem areas identified with the current legal framework are linked to divergent implementation among Member States and therefore the practice resulting from the present Directive clearly shows that a directive is not the appropriate instrument to achieve unanimous application of the law in an area where it is needed for safety reasons.

The third reason is that similar to Directive No 94/586/EC[104] which has been replaced by a regulation[105], the Commission considers that the system has reached a certain level of maturity and that the EU and its Member States are ready to move towards a system which imposes similar requirements and in a more harmonised way.

The fourth reason is that the use of a regulation has been broadly supported by Member States and by respondents to the public consultation[106].

Finally, replacing the Directive and its implementing Regulations by a regulation is compliant with the objectives enshrined in Commission Communication on Smart Regulation in the European Union[107] notably in terms of EU legislation simplification and clarifying the legislation.

5.           Analysis of impacts

5.1.        Introduction and rating of impacts[108]

Traditional impacts such as economic, social and environmental impacts or the impact on fundamental rights will be assessed but most importantly the impact on aviation safety has to be assessed as it is an essential criterion for determining the best policy package. In the following subsections policy packages will notably be assessed in relation to the capacity to address the problems identified in section 2 and to reach the objectives presented in section 3. The different impacts will be presented and a rating of the specific impact for each policy package will conclude the subsection. The impacts will be rated in terms of negative (-) and positive (+) impacts.

5.2.        Impact on aviation safety[109]

Compare to the baseline scenario, PP1 would impact positively on the collection of occurrence data and therefore allow a better overview of safety deficiencies. Data quality and completeness would also be improved but the lack of formal legislative requirement for mandatory data fields could limit the harmonisation of data and involve a lack of certain safety information being available in the databases. By the adoption of a recommendation suggesting that Member States analyse the data collected through occurrence reporting schemes, to take appropriate corrective or preventive actions and to monitor the efficiency of the system in terms of safety, as required by international obligations, PP1 brings certain safety benefits compared to the baseline scenario. However the non-binding status of the recommendations and the lack of legal enforcement tools ensuring their implementation would limit the efficiency of PP1 in terms of safety improvement. Indeed, it would be for the Member States to decide on a voluntary basis about the application of recommendations.

Therefore, although compared to the baseline scenario PP1 would impact positively on aviation safety, the benefits would not be sufficient to facilitate a decreased number of accidents in a context of air traffic growth.

Compared to the baseline scenario, PP2 would allow a much better understanding of the safety situation and of its shortcomings. Indeed, in combining an efficient and wide collection of occurrences together with better quality and more complete data, PP2 would allow organisations, Member States and the European Union to have a complete set of data which would give a much more accurate picture of potential safety risks than at present. In addition, requiring an analysis of occurrences reported at the level of organisation, Member States and EU level with the obligation to address safety deficiencies identified by the adoption of corrective measures where appropriate, PP2 would allow an important diminution of the identified safety risks. Finally the adoption of an EU risk classification scheme would allow both Member States and the EU to better focus its efforts from a data driven perspective. Therefore, even in the perspective of air traffic growth, PP2 would bring large benefits in terms of safety by establishing a systematic collection, dissemination, analysis and use of occurrence reports for safety improvements, at each necessary level, all across Europe, and therefore contribute to reduce the number of aircraft accidents and fatalities.

The impact of PP3 on aviation safety is difficult to assess precisely as if it would have contradictory effects among Member States. It should lead to important safety improvements in certain Member States[110], but, at the same time, it would impact negatively in the Member States which have already established efficient safety management systems. In addition, each Member State would not be able to exercise an appropriate safety oversight of its airspace. Indeed Member States, as competent authorities for the certification of organisations, would be deprived of the direct knowledge of occurrences in areas they certify[111] and would not be able to exercise a direct follow up of organisations they certificate. Moreover, it would prevent States from addressing obligations under their State Safety Programmes.

Furthermore, achieving a good level of reporting culture is, in several Member States, the result of many years' efforts during which mutual trust has been built notably by the guarantee that data will only be used for safety purposes. Therefore under PP3 organisations could be more reluctant to report to EASA as they are to their national authority because their reporting could lead to an increased number of EASA standardisation inspections. At the same time the level of reporting from other sources would be impacted positively as a higher number of individuals may prefer to report directly to EASA rather reporting to their employer and fear blame. However if this consequence would be beneficial for the level of direct reporting towards the EU level, by depriving the organisation of the knowledge of its safety deficiencies, it would not result in a global positive safety impact. Finally, as more than 110,000 occurrences reports are received every year in the European Union on average, it would be unrealistic to assume that EASA would be able to systemically analyse and address all the occurrences received or at least oversee if they have been correctly addressed by the organisation which collected and transferred it.

Therefore implementing this option would have a very positive impact on certain Member States' safety and a very negative one on some others (among which those with the largest air traffic) and when looking from a global EU perspective it would not have a strong positive impact on aviation safety.

In summary, while all three options have a positive impact on aviation safety compared to the baseline scenario, only PP2 would have a sufficient positive impact on accident rate to absorb the increased traffic and reduce the number of accidents and related fatalities.

Option || Impact on Safety

Policy Package 1 || +

Policy Package 2 || +++

Policy Package 3 || +

5.3.        Economic impacts

Evaluate with accuracy each option economic impact compared to the baseline scenario is extremely difficult. As has been demonstrated in section 2, accidents do not happen in a linear way and forecasting the level of decrease in accident rate or number would not be based on solid evidence.

5.3.1.     Economic impact of Safety Management Systems

In order to compare the economic impact of policy packages with the baseline scenario, it is necessary to compare the costs of accidents in a system mostly reactive to the costs of implementing a proactive and evidence based system.

CAST[112] evaluates the cost of implementing safety enhancements in the context of a comprehensive safety management system around $500 million (€392 million), spread out over 10 years[113]. The organisation estimates that implementing the most promising safety enhancements was expected to reduce the $76 (€60) accident cost per flight[114] by $56 (€44) per flight, saving the industry more than $600 million (€471 million) a year[115]. According to this study it means that in a reactive system the costs of accidents, which are reflected on all flights, are evaluated around $76 (€60) per flight while in a proactive system these costs are reduced to $20 (€16) per flight. This reduction results from the decreased number of accidents (therefore of their cost) and takes into account the costs of implementing safety enhancements.

Based on CAST study[116] it would mean that, with safety enhancements based on the collection, analysis and follow up of occurrences, accident cost per flight in 2030 would decreased from €1,014 million in the baseline scenario (see section 2.4.2) to €270.4 million by year (€16 by 16.9 million flights). This means a saving of €743.6 million by year for 2030 compare to the baseline scenario. This number is also much below the accident cost per flight in 2010 (€570 million) with a traffic 1.8 times more important.

This underlines that the financial investments necessary for implementing safety enhancements notably through the collection and analysis of occurrences are less onerous than the costs incurred by an accident.

This assumption is confirmed by a study from the Centre for Aviation Safety Research in 2011[117] which compares the cost of implementing safety management systems (SMS) to the cost of accidents and presents a return on investment model for SMS. This study demonstrates that SMS provide significant financial benefit to organisations by instituting a proactive process of identifying risks and hazards followed by appropriate corrective actions which eliminate the hazards or reduce the risks to an acceptable level. It also affirms that it is "a better use of aviation company funds to invest in SMS programs that will prevent accidents than to forego SMS and absorb the financial impact of accident that could have been avoided".

However, if the principle of economic benefit is commonly agreed, the value of potential financial savings for each policy package compared to the baseline scenario is impossible to determine with accuracy as the number of accidents avoided cannot be determined and the level of safety enhancements under each policy package cannot be precisely quantified. It can be asserted that in the context of air traffic growth, PP1, by providing safety improvements, would have an economic impact at best only very slightly positive compared to the baseline scenario while PP3 would have a limited positive economic impact proportional to its impact on safety. PP2, by imposing the appropriate basis and elements for comprehensive safety management systems at each necessary level, would allow savings close to the one estimated in the paragraph above according to CAST figures and would therefore bring important economic benefits compared to the baseline scenario.

5.3.2.     Impact on the industry

The current Directive does not address the industry, it only imposes requirements on individuals and on Member States. However it has been underlined in section 2.2 that most occurrences are collected from individuals by organisations in the context of their safety management system and then sent to Member States. In addition basic requirements regarding the establishment of occurrence reporting systems and of analysis mechanisms are already imposed on some industry players by other EU legislations. Indeed these requirements are enshrined in the EASA Basic Regulation (EC) No 216/2008[118] and are imposed on design, manufacture and maintenance organisations (Annex I paragraph 3.a.4), on operators (Annex IV paragraph 8.a.5), aerodromes (Annex Va paragraph B.2.b), air navigation service providers (Annex Vb paragraph 5.a.vii). However while legislative requirements impose on the industry the establishment of occurrence reporting systems, it appears from the various consultations held by the Commission that these requirements are respected in very different ways depending on the organisation and the Member State they are registered in. In addition the lack of detailed requirements and of implementation means may contribute to the existing discrepancies.

Overall, in the area of commercial air transport most industry players have already established a safety management system and would not be strongly impacted by the obligation to collect, analyse and address occurrences. The impact of new requirements imposing to provide specific information, as the introduction of mandatory data fields, has been evaluated in the section related to administrative burdens[119]. On the non-commercial air transport the impact would be null as the obligation to report is already exists in the current legislation and the responsibility to analyis and assess occurrences would be on Member States in PP2 and on EASA in PP3. More detailed information on the economic impact on the industry is enclosed in Annex 10.

In summary, the economic impact of PP1 on the industry compare to the baseline scenario would be non-existent as it does not impose legislative requirements on organisations. Regarding PP2, depending on the organisation concerned and the level of maturity of its reporting system, the economic impact would vary from zero to limited. For PP3, although the impact of most of the policy measures would be similar to those identified for PP2, the policy measure imposing to send data into the ECCAIRS data format would however require certain investment[120].

5.3.3.     Impact on Member States[121]

As has been explained in section 2.2 there are significant discrepancies in the occurrence reporting systems maturity level among the Member States. Therefore the impact of the different policy packages compare to the baseline scenario would very much vary depending on this level of maturity. In addition, the precise number of individuals currently allocated to tasks related to the implementation of Directive 2003/42/EC and other occurrence reporting related tasks cannot be determined precisely for most of the Member States[122]. Therefore without an accurate knowledge of the impact on Member States in the baseline scenario it is even more difficult to define with precision the impact of the different policy packages.

Regarding PP1, as for PP2, the economic impact would be non-existent on certain Member States which already have developed mature systems, on other Member States the impact would go from very limited in PP1 to possibly more important impact with stronger requirements in PP2. This additional economic impact may involve additional human resources to cover the data analysis tasks and follow up actions in the Member States which have yet to develop such activities. This would impact between 15 and 20 Member States which will have to reallocate or have additional human resources in order to cover the new requirements. New requirements such as quality checking[123] may require some investment with the necessity to organise training at the initial stage. The cost of risk classifying occurrences has been evaluated in the section on administrative burdens (section 5.3.5).

Regarding PP3, the economic impact compare to the baseline scenario would clearly be positive as occurrence reporting competencies are transferred from Member States to EASA. Therefore it means that Member States would be able to save human resources in a level equivalent to the level of individuals allocated to occurrence reporting tasks in the baseline scenario.

5.3.4.     Impact in the internal market and competitiveness of EU companies

No matter what transport mode, accidents always reduce confidence in the safety of the transport system. It is particularly true in aviation transport where accidents usually involve a high number of fatalities and have a strong negative impact on public confidence in this particular mode of transport. Indeed it has been observed that accidents have an impact on the airline market value and on the level of tickets sold by the airline which has had an accident. Therefore by contributing to a reduction in the number of accidents involving European air carriers and European citizens, positive economic impacts would be expected with the implementation of the policy packages in proportion to their impact on aviation safety. Only PP2 further strengthen the sense that EU air carriers and aircraft of European design are safe and reliable, and therefore provide a positive impact on the internal market and the competitiveness. The quantitative dimension of its impact is however difficult to assess, mainly due to lack of a reliable methodology to assess the number of accident which would be avoided.

5.3.5.     Administrative burdens

Policy package 1 does not change any information obligation within the occurrence reporting system. The policy package operates primarily through providing better guidance, training and support within the present setup. This means that the policy option will not result in significant changes in administrative burdens compared to the baseline scenario. Policy packages 2 and 3 impacts are summarised in the figures below and more detailed information is attached in Annex 9.

It comes out of the analysis that policy package 2 is the most cost effective regarding the impact on administrative burdens.

Figure 6: Administrative burdens in policy packages 2 and 3

|| Annual || One time

Policy Package 2 || + €831,133 || /

Policy Package 3 || + €2,234,585 || + €300,000

Figure 7: Administrative burdens on business

|| Annual || One time

Policy Package 2 || + €321,000 || /

Policy Package 3 || + €321,000 || + €300,000

Figure 8: Administrative burdens on public authorities

|| Annual

Policy Package 2 ||

Member States || + €510,133

EU budget || /

Policy Package 3 ||

Member States || - €236,415

EU budget || + €2,150,000

5.3.6.     EU Budget

The EU budget would be affected by policy packages 1, 2 and 3 compared to the baseline scenario. Regarding the European Central Repository, in the current situation, the Commission is already supporting the technical tool (ECCAIRS) allowing the collection of occurrences. The amount yearly allocated to this tool is on average around €500,000 and would be slightly increased in all three packages by between €50,000 and €100,000. On the development of the common EU risk classification scheme, its economic impact in all policy packages is the same and would be around € 90,000 for the development of the scheme, the support and the organisation of training and would not be renewed every year. It would be allocated for a period of 18 months. In PP2, the formalisation and development of the EASA analysis coordination role would notably require additional resources which are estimated around to €365,000[124].

In PP3, the transfer of competencies from Member States to EASA would have a strong impact on the EU budget as an important number of staff would have to be hired by EASA to deliver the tasks previously done by Member States. The centralising of the collection of occurrences their analysis and the monitoring of actions taken by organisations in a single entity would allow for a better use of resources than have it collected in 27 Member States and therefore would not require hiring an equivalent number of staff. However, the collection and assessment of around 120,000 occurrences every year, notably in order to detect trends, identify precursors, and assess risks, would require important additional resources for the Agency. Today the safety analysis section of EASA has no direct regulatory function except the requirement to produce an Annual Safety Review. A complete centralisation of reporting in Europe would involve a very high workload. The standing database of more than half a million records would have to be constantly searched for patterns and trends of events to ensure a truly proactive approach to safety. The total estimated budget costs would amount to €11.9 million[125].

In summary, in comparison to the baseline scenario, the impact on the EU budget would be increased by around €165,000 in PP1, €530,000 in PP2 and €12.065 million in PP3.

5.3.7.     Summary table of the economic impact of implementing the various PP

Summarise all the elements described in section 5.3 in a single table is not easy as many impacts are different depending the Member State concerned or the area of the industry. In addition various unknown elements such as the number of accidents which might be avoided as well as the subsequent benefit for the aviation market makes it even more difficult to evaluate the balance between the negative and the positive economic impacts compared to the baseline scenario. Therefore it is not possible to compare economic impacts of the various policy packages on the basis of accurate money value savings but the comparison is based on a qualitative global evaluation of all the economic impacts mentioned in the paragraphs above.

Option || Economic impact

Policy Package 1 || Zero

Policy Package 2 || From - to ++

Policy Package 3 || From - to ++

5.4.        Social impacts

(1) Standards and rights related to job quality

As detailed in section 2.2.1b), in the baseline scenario aviation professionals are afraid to report occurrences notably because of the fear being blamed or fired by their employer. This situation is not only prejudicial to aviation safety but also creates difficulties in the relationship between employees and their employer and creates a negative working environment for employees. This situation can vary considerably depending on the legislative environment of a Member State or the internal company policy of an organisation. All three packages would, with varying impact, improve this situation compared to the baseline scenario. PP1 would clarify existing requirements with the adoption of guidance material to support the current provisions. PP2 would clarify and expend existing legislative provisions notably with the imposition of requirements directly on an employer; it would also open a possibility for individuals to report breaches of the law through the establishment of national focal points. PP3 would complement PP2 initiatives with the establishment of a voluntary occurrence reporting scheme at EU level where individuals could directly report occurrences without fearing blame from their employer or their regulatory authority. In addition, provisions regarding the access to ECR data and its use would be implemented in each policy package notably to limit it strictly to safety purposes. This would be complemented in PP2 and PP3 by measures regarding the access and use of data collected at national level. All these measures would impact positively on the working conditions of aviation professionals compared to the baseline scenario, while the impact would be greater in PP2 and PP3 than in PP1.

(2) Employment

In the baseline scenario, several causes may lead aviation employees to lose their jobs. Firstly the risk for employees of being dismissed for having reported irregularities, including of their own making, which would be addressed by the measures detailed in paragraph (1) above. Secondly an increased number of accidents might impact negatively the aviation industry market share and might also lead to civil or criminal litigations and affect professional careers. This issue would be solved in proportion of the safety impact presented in section 5.2. Therefore PP1 would have a limited positive impact on employment while PP2 and PP3 would be more efficient in terms of limiting employees’ risk of losing their job.

(3) Personal data

Occurrence reports often contain personal data such as reporter’s name and details. The current Directive in its Article 8 forbids names or addresses of individual persons to be recorded in Member States' occurrence databases. PP1 would not impact the current situation while PP2 and PP3 would guarantee a better level of protection of personal data through a direct implementation of disidentification and the inclusion of new provisions regarding the data collected by organisations.

(4) Public health and safety

Public health and safety are impacted by aircraft accidents and therefore policy packages would impact it positively compared to the baseline scenario in proportion of their impact on aviation safety.

(5) Summary of social impacts

Option || Social impact

Policy Package 1 || +

Policy Package 2 || From ++ to +++

Policy Package 3 || From ++ to +++

5.5.        Environmental impacts

Policy packages involve very few environmental impacts. In the baseline scenario they are limited to environmental damages caused by aircraft accidents and therefore the situation would be impacted in proportion to the improvements involved by the policy packages on aviation safety as described in section 5.2.

5.6.        Impact on fundamental rights

All Commission proposals have to be compatible with the Charter of Fundamental Rights of the European Union, and it is thus necessary to assess the potential impacts of the proposed policy packages on the fundamental rights as laid down in the Charter compared to the baseline scenario. Aviation safety is directly linked to the most important basic human right, the right to life and of physical integrity. Aviation passengers have no control on their mean of transport and therefore have a legitimate right to safe air transport. The proposed policy packages are expected to have overall positive impacts on the right of EU citizens to safe communication by air. The intensity of these impacts would be related to the intensity of the safety impacts discussed in section 5.2.

5.7.        Impacts on simplification of existing legislation

PP1's impact on the simplification of existing legislation would be zero as the Directive and its two implementing Regulations would remain applicable and only a few articles of the implementing rules would be modified.

PP2 and PP3 would however have a positive impact compared to the baseline scenario as it would lead to the replacement of the Directive and the two Commission Regulations by a single act, a regulation from the European Parliament and the Council, which would be directly applicable 20 days after its publication in the Official Journal of the European Union in all Member States as national legislation and would therefore not require national implementing measures.

5.8.        Impacts on third countries

Third countries operators and passengers would benefit from a safer European sky. Policy packages would therefore impact third countries in proportion of the intensity of safety improvements involved by each policy package as described in section 5.2.

5.9.        Summary of impacts compared to the baseline scenario

|| Policy Package 1 || Policy Package 2 || Policy Package 3

Safety impact || Low positive Safety improvement but insufficient to absorb traffic growth || High positive Important safety improvement sufficient to decrease accident rate || Low positive Safety improvement undermined by a number of elements

Economic impacts ||  

|| Impact on the industry || Zero No new legislative requirement || Medium positive Additional cost largely offset by the economic benefit of a reduced number of accidents || Low negative More costs and, as limited impact on aviation safety, limited benefit for the industry

|| Impact on Member States || Zero No new legislative requirement || Low negative Additional cost for some Member States || High positive Member States responsibilities transferred to EASA

|| Impact on internal market and competitiveness || Low positive Impact proportional to safety impact || High positive Impact proportional to safety impact || Low positive Impact proportional to safety impact

|| Administrative burdens /year || zero || Low negative - €831,133 || Medium negative - €2.235 million

|| Impact on EU budget / year || Close to zero - €165,000 || Low negative - €530,000 || High negative - €12.1million

Social impacts ||

|| Standards and rights related to job quality || Low positive Only guidance no additional legislative requirement || Medium positive Legislation provisions protecting employees || High positive Impact proportional to safety impact and set up of a VORS at EU level

|| Employment || Neutral || Low positive || Low positive

|| Personal data || Zero || Medium positive || Medium positive

|| Public health and safety || Low positive Impact proportional to safety impact || High positive Impact proportional to safety impact || Low positive Impact proportional to safety impact

Environmental impacts || Close to zero || Close to zero || Close to zero

Impacts on fundamental rights || Low positive Impact proportional to safety impact || High positive Impact proportional to safety impact || Low positive Impact proportional to safety impact

Impacts on simplification of exiting legislation || zero || High positive Directive and two implementing rules replaced by a Regulation || High positive Directive and two implementing rules replaced by a Regulation

Impacts on third countries || Low positive Impact proportional to safety impact || High positive Impact proportional to safety impact || Low positive Impact proportional to safety impact

6.           Comparing the Policy Options

Policy packages will be assessed regarding their contribution to the realisation of the policy objectives, as set in Section 3, in light of the following evaluation criteria:

• effectiveness – the extent to which options achieve the objectives of the proposal;

• efficiency – the extent to which objectives can be achieved at least cost;

• coherence – the extent to which options are coherent with the overarching objectives of EU policy, and the extent to which policy options are likely to limit trade-offs across the economic, social, and environmental domain.

6.1.        Effectiveness

PP1 would have a limited effectiveness in achieving the specific objectives (SO). SO1 (improve occurrence collection) would be insufficiently achieved as PP1 would not ensure a harmonisation of reporting among Member States and would not allow sufficient clarification of reporting lines and of flow of information. The issue of "Just Culture" would be partly addressed but the legislative requirements ensuring a proper implementation of the principles would not be adopted. SO2 (get complete and good quality data) would not be fully achieved whilst significant improvements are expected. PP1 would ensure the achievement of SO3 (give broader access to ECR data and restrict its use to safety purposes). PP1 would have limited effectiveness in achieving SO4 (identify safety concerns through occurrence analysis and address them) because the lack of legislative requirements would limit the implementation of recommendations.

PP2 would be effective in achieving SO1, with a clarification of reporting requirements, a harmonisation of reporting lines in the Member States and the establishment of rules ensuring better protection to the reporter. The standardisation of the occurrence reporting process and the establishment of mandatory data fields and of quality checking processes, together with the development of guidance material and training, would allow PP2 to effectively achieve SO2. It would also be effective in the achievement of SO3. SO4 would be effectively achieved by PP2 with the introduction of legislative requirements ensuring an analysis of occurrences together with the adoption of appropriate measures.

Whilst PP3, overall, is effective in achieving the four SO, it would not be as effective as PP2 in achieving the general objective of aviation safety improvement as defined in section 3.1. And SO1 would not be fully achieved as organisations would be more reluctant to send their occurrences to EASA than to their national authority.

6.2.        Efficiency

PP1 contains measures requiring very low implementation or administrative costs and contribute to achieve the SO but in a limited way which does not make this policy the most efficient in achieving the objectives.

PP2 implies certain costs mainly related to the introduction of new requirements regarding the use of data collected for safety improvements which has an impact varying from very limited to more substantial depending on the organisation or the Member State concerned, and a moderate impact on EU budget. These costs are expected to be offset by the important safety and economic benefits resulting from a decreased number of accidents Therefore PP2 can be considered as introducing efficient measures.

PP3 implies important economic savings for Member States but very high implementation costs for the EU budget (€12.1 million). Its expected safety benefits being less significant than in PP2, the decreased number of accidents may not be sufficient to offset the negative economic impacts. Therefore PP3 appears to be less efficient than PP2.

6.3.        Coherence

All policy packages are more or less coherent with the overarching objectives of EU policy. Indeed, all policy packages are designed to reach the specific objectives without implying significant negative impacts or addressing one type of impact to the expense of another. However, whilst all PP present a limited trade-off between the different types of impacts, PP2 presents the most limited trade-off.

6.4.        Preferred option

In terms of an effective contribution to the reduction of aircraft accidents and to the better protection of the public travelling on European air carriers, PP2 is the most attractive option. PP3 offers many benefits but is not the most efficient to achieve the specific objectives. PP1 completely achieves only the specific objective SO3.

PP1 is not costly and easy to implement, while PP3 is the most costly for the EU budget and may not reach the full safety benefits expected by a change of policy.

In terms of coherence PP2 ranks highest as it provides the most limited trade-off between the positive safety and social impacts on the one hand, and the economic impacts on the other.

According to the Financial Regulation (Article 27) and its Implementing Rules, ex ante evaluations are required where the resources mobilised exceed €5 million. Given that the preferred policy package will have an estimated impact on EU Budget of €0.53 million, the Commission has considered that the additional requirements contained in an ex-ante evaluation (e.g. full cost effectiveness analysis) are not applicable in this situation.

In view of the above the recommended package is PP2 as the benefits obtained are far greater than the costs. It is expected to contribute to improve aviation safety through a better collection of occurrences, an improved quality of data, a more appropriate access to information and the introduction of requirements regarding the use of occurrences for contributing to a reduction of aircraft accidents.

7.           Monitoring and Evaluation

The Commission would properly evaluate the implementation of the occurrence reporting Regulation five years after its adoption by the European Parliament and the Council and assess whether the adopted legislation should be revised.

In addition, the Commission will continually monitor a set of core indicators which will be used to measure how the policy measures would achieve the operational objectives.

Figure 9: Monitoring indicators

|| Operational objectives || Indicators || Source of data

SO1: improve occurrences collection || ||

|| Reach a higher occurrence collection rate in the EU through a harmonisation and clarification of reporting obligations || · Reporting rate level · Member States assessment of the collection level of reportable occurrences || Information provided by Member States analysts in the context of the Network of Analysts Questionnaires sent to stakeholders (Member States, EASA, industry, employees’ associations) three years after the adoption of the legislation

|| Clarify and develop legislative requirements related to "Just Culture || · Number of complaints received by national focal points · Stakeholders’ opinion on “Just culture” level · Use of occurrences by judicial authorities || National focal points Just Culture related fora and groups in Europe Questionnaires sent to stakeholders (Member States, EASA, industry, employees’ associations) three years after the adoption of the legislation

|| Impose the establishment of voluntary reporting schemes || · Number of voluntary systems established || Questionnaires sent to stakeholders (Member States, EASA, industry, employees’ associations) three years after the adoption of the legislation

|| Clarify of the flow of information notably with regards to organisations || · Rate of occurrences received from organisations and from individuals in Member States national databases || Questionnaires sent to Member States three years after the adoption of the legislation

|| SO2: get complete and good quality data || ||

|| Standardise data entry processes || · Number of occurrences sent by each Member State to the ECR || ECR occupancy status provided by the Commission Joint Research Centre

|| Establish mandatory data fields || · Rate of mandatory data fields filled by Member States || ECR occupancy status provided by the Commission Joint Research Centre

|| Establish data quality checking processes || · Number of processes established · Level of quality improvement || Information provided by Member States analysts in the context of the Network of Analysts Feedback from the ECCAIRS taxonomy group Questionnaires sent to Member States and industry three years after the adoption of the legislation

|| SO3: give broader access to ECR data and restrict its use to safety purposes || ||

|| Grant full access to ECR data to appropriate safety authorities || · Level of access to ECR data || Access rights allocated by the Commission Joint Research Centre

|| Establish confidentiality rules and safeguards regarding potential misuse of the data. || · Member States’ opinion about the use of ECR data · Use of data by press or by judicial authorities || Questionnaire sent to Member States three years after the adoption of the legislation Opinion of the ECCAIRS Steering Committee

|| SO4: identify safety concerns through occurrence analysis and address them || ||

|| Create an obligation to analyse occurrence data and to identify actual or potential safety hazards || · Number of occurrences analysed · Size of departments in charge of occurrence reporting in Member States || Questionnaires sent to stakeholders (Member States, EASA, industry, employees’ associations) three years after the adoption of the legislation Standardisation inspections European Central Repository

|| Adopt preventive or corrective actions where appropriate || · Number of actions adopted · Aviation accident rate || Questionnaires sent to stakeholders (Member States, EASA, industry, employees’ associations) three years after the adoption of the legislation EASA and Member States' annual safety reviews European Central Repository

|| Oversee the efficiency of those actions and create a common EU risk classification scheme for classifying occurrences. || · Number of additional corrective actions imposed by Member States · Number of occurrences risk classified · Possible determination of key risk areas for Europe || Questionnaire sent to Member States three years after the adoption of the legislation European Central Repository Information provided by the Network of Analysts

[1]               Occurrence is understood in this document according to its definition in Directive 2003/42/EC i.e. any safety event outside of accidents and serious incidents.

[2]               OJ L 295 of 12.11.2010, p.35.

[3]               OJ L 167, 4.7.2003, p. 23.

[4]               COM/2011/0144 final

[5]               First point of Initiative 17 "A European strategy for civil aviation safety".

[6]               COM/2011/0670 final

[7]               Commission Regulation (EC) No 1321/2007 of 12 November 2007 laying down implementing rules for the integration into a central repository of information on civil aviation occurrences, OJ L 294 of 13.11.2007, p. 3; and Commission Regulation (EC) No 1330/2007 of 24 September 2007 laying down implementing rules for the dissemination to interested parties of information on civil aviation occurrences, OJ L 295 of 14.11.2007, p. 7.

[8]               Secretariat General (SG), Legal service (LS), DG Justice (JUST), DG Employment (EMPL), the Joint Research Centre (JRC), DG Health and Consumers (SANCO), DG Enterprise and Industry (ENTR), DG Information Society and Media (INFSO) and DG Internal Market and Services (MARKT).

[9]               The IASG met in May 2011, June 2012 and July 2012

[10]             A summary of Member States replies to the questionnaire is attached in Annex 1

[11]             A summary of the public consultation is attached as Annex 2 and is also available on the Internet to the following address: http://ec.europa.eu/transport/air/consultations/2011_11_09_occurence_en.htm

[12]             OJ L 225 of 12.8.1998, p. 27.

[13]             ENCASIA’s opinion is attached in Annex 3.

[14]             As defined in Regulation (EC) 691/2010: "Just culture" means a culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Commission Regulation (EU) No 691/2010 of 29 July 2010 laying down a performance scheme for air navigation services and network functions, OJ L 201, 3.8.2010, p. 1.

[15]             The meeting summary and adopted conclusions are enclosed in Annex 4

[16]             This study is enclosed in Annex 5.

[17]             IP/B/TRAN/IC/2009-024

[18]             One of the indicators available to support this statement is the measure of passenger fatalities per 100 million miles flown which went from 5 in 1945 to below 0.05 in 1997 (European Aviation Safety Agency, Annual Safety Review 2005)

[19]             Source: European Aviation Safety Agency, Annual Safety Review 201, see figure 1

[20]             EUROCONTROL CND/STATFOR Doc 415 of 17 December 2010 - Long-Term Forecast - Flight Movements 2010 - 2030

[21]             Eurocontrol area includes 39 States among which EU-27, Balkans countries, Norway, Switzerland, Turkey and Ukraine.

[22]             Source: European Aviation Safety Agency, Annual Safety Review 2011

[23]             Heinrich's Pyramid is a pictorial description of the relationship between occurrences and more serious incidents and accidents. Heinrich's law is based on probability and assumes that the number of accidents is inversely proportional to the severity of those accidents. It leads to the conclusion that minimising the number of minor incidents will lead to a reduction in major accidents, which is not necessarily the case. Source: SKYbrary.

[24]             Source: Frank E. Bird Jr, Accident Pyramid, 1969.

[25]             These numbers relate to accidents for aeroplanes and helicopters involving EASA Member States operators.

[26]             Source: European Central Repository.

[27]             Source: European Central Repository.

[28]             ICAO defines safety management system (SMS) as a systematic approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures. The objective of a SMS is to provide a structured management approach to control safety risks in operations.

[29]             ICAO Document 9859, Second edition 2009.

[30]             Chicago Convention, Annex 13 "Aircraft Accident and Incident Investigation", Chapter 8 "Accident Prevention measures"

[31]             In this document organisation is understood as an aviation industry player (i.e. airline, airport, air navigation service provider, maintenance organisation and manufacturer).

[32]             Around 98% of occurrence reports received by the Member States are coming from organisations and not from individuals.

[33]             Commission Regulation (EC) No 1321/2007 of 12 November 2007 laying down implementing rules for the integration into a central repository of information on civil aviation occurrences, OJ L 294 of 13.11.2007, p. 3.

[34]             It is worth pointing out, that ICAO, recognising the benefits of data aggregation in aviation safety management, recommends in its Standards and Recommended Practices on accident prevention measures, the establishment of regional air safety databases and data sharing networks.

[35]             SEC/2011/1261 final.

[36]             Commission Regulation (EC) No 1330/2007 of 24 September 2007 laying down implementing rules for the dissemination to interested parties of information on civil aviation occurrences, OJ L 295 of 14.11.2007, p. 7.

[37]             For example Eurocontrol ESARR2 (Reporting and Assessment of Safety Occurrences in ATM)

[38]             http://www.aaiasb.gr/imagies/stories/documents/11_2006_EN.pdf

[39]             Second Interim report, details on the events are included in the final accident investigation report: http://www.bea.aero/en/enquetes/flight.af.447/flight.af.447.php

[40]             For more details please refer to Annex 1.

[41]             Arrêté du 17 août 2007 fixant la liste d’événements et d’incidents d’aviation civile, JORF 18/09/2007.

[42]             This issue is the shortcoming mentioned the most frequently both by the Member States in their reply to the Commission questionnaire and by respondents to the public consultation held by the Commission (70.5% of the replies). For more details please refer to Annexes 1 and 2.

[43]             GAIN Operator's Flight Safety Handbook, 1999.

[44]             Commission Regulation (EU) No 691/2010

[45]             In some States the legislation related to Freedom of Information allows the general public, including the press, to have access to a wide range of information including certain aviation safety data including in certain cases, occurrences reports. However, whilst this may influence the situation, it is not considered as the major impediment to a high level of reporting.

[46]             Indeed in several recent cases, sensitive aviation data obtained from the safety investigation has been considered as admissible in courts as evidence against those accused.

[47]             For more details on this case, please refer to Eurocontrol Just Culture Guidance Material for Interfacing with the Judicial System, Edition 02.2008, Appendix 2.

[48]             Indeed, during the "Delta" case legal proceedings the number of incident reports submitted by controllers dropped by 50%.

[49]             See Annex 1 for more details.

[50]             "Voluntary" does not mean here that it is not an obligation to establish VORS but it means that it collects data which are not collected by mandatory schemes. Therefore establish voluntary schemes can be mandatory.

[51]             ICAO Annex 13, Chap.8, Standard 8.2 "A State shall establish a voluntary incident reporting system to facilitate collection of information on actual or potential safety deficiencies that may not be captured by the mandatory incident reporting system".

[52]             A table summarising the different occurrence reporting lines is attached in Annex 6.

[53]             Commission Regulation (EU) No 691/2010 of 29 July 2010 laying down a performance scheme for air navigation services and network functions, OJ L 201 of 3.8.2010, p. 1.

[54]             Commission Regulation (EC) No 2096/2005 of 20 December 2005 laying down common requirements for the provision of air navigation services, OJ L 335 of 21.12.2005, p. 13.

[55]             Indeed Member States received around 98% of occurrences from organisations and only 2%n directly from individuals (mainly general aviation). This was mentioned at various occasions during the consultation phase and stakeholders, including Member States, would like the revision of the legislation to take into account the reality of the situation to better reflect the evolution of the last years and notably to include the Safety Management System (SMS) principle.

[56]             Such as for example occurrence date, location or category.

[57]             See Annex 2.

[58]             Respondents to the public consultation have considered that Member States staff is not trained enough and are not able to correctly assess the occurrences they receive in order to turn them into good quality occurrence reports.

[59]             Indeed, there are significant discrepancies between the reporting levels of Member States with relatively similar levels of aviation activity. Also, the largest percentage (almost 20%) of the occurrences currently stored in the ECR is Air Traffic Management (ATM) related – which does not reflect the actual safety performance of the European aviation system as the level of ATM contribution to occurrences is estimated in Europe between 4 and 6%. And the load of transmitted data is also not balanced, with peaks followed by periods of relative calmness.

[60]             The disidentification of data ensures the confidentiality of the reporting by deleting from the database any individual name or details according to the EU legislation. It is often extended to the deletion of information allowing the identification of the operator involved. Some States are practising a very broad disidentification and delete from the reports sent to ECR a large set of information. This situation contributes to the incompleteness and low quality of data within the ECR.

[61]             Over the last months this support has contributed to a reduction of around 10% of missing data fields in most key areas (EASA, April 2011).

[62]             As an example, in about 57% of cases even the basic information about the type of operation affected by an occurrence (i.e. commercial air transport, general aviation etc.) is not available. Some important fields are missing such as local date in 18%, occurrence category in 34% and event types in 44% of the occurrences.

[63]             For example, one Member State has only integrated two occurrences on the ECR since 2008.

[64]             The Commission has contacted the Member States concerned and helped them to meet their obligations where necessary. In a number of cases the Commission has also open pre-infringements procedures for non-compliance with the European legislation.

[65]             See Annex 1.

[66]             This is one of the reasons behind the formal request of the European Parliament and the Council for the review of the legislation on occurrence reporting.

[67]             See Annex 1.

[68]             Indeed, in the replies to the questionnaire sent by the Commission to Member States, around a quarter of the Member States expressed that they encounter difficulties in carrying out the tasks defined in the legislation notably due to a lack of sufficient human resources.

[69]             Art.19 (1): "EASA and the competent authorities of the Member States shall in collaboration participate regularly in the exchange and analysis of information covered by Directive 2003/42/EC".

[70]             See the Communication action 2 on developing an analysis of occurrences at EU level and action 3 on establishing a common risk assessment classification.

[71]             The problem tree illustrates the problem definition in the centre, the problem drivers on the bottom of the figure and the problem consequences on the top.

[72]             I.e. Civil Aviation Authorities (CAAs), Safety Investigation Authorities (SIAs) or any other entity entrusted with this function.

[73]             I.e. airlines, airports, air navigation service providers, maintenance organisations and manufacturers.

[74]             E.g. pilots, air traffic controllers and ground staff.

[75]             The issue of the possible evolution of the situation of EU aviation safety if no improvement to the current system occurs, and if all elements, including European legislation, remain the same, corresponds to the option called "baseline scenario".

[76]             ICAO is assessing whether the critical elements of a safety oversight system have been implemented effectively and in particular the correct implementation of the safety-relevant ICAO Standards and Recommended Practices (SARPs). In order to exercise this monitoring ICAO launched a programme called Universal Safety Oversight Audit Programme (USOAP).

[77]             This region includes the United States of America and Canada.

[78]             Please refer to Annex 12 for details about the fatal accident rates.

[79]             This region includes the Balkans States, Belarus, Republic of Moldova, Russian Federation and Ukraine.

[80]             A report from the French Air and Space Academy estimates that accident rates should be reduced worldwide by 75% until 2050 in order to compensate for the estimated growth of the traffic ("Comment volerons-nous en 2050?" Académie de l'Air et de l'Espace).

[81]             On-board fatalities and only those in aircraft with a take-off mass above 5 701kg from commercial air transport and general aviation; Source: EU transport in figures, statistical pocketbook 2011; ISBN 978-92-79-19508-2.

[82]             The expected growth is evaluated around 16.9 million flights per annum by 2030, i.e. close to 1.8 times more than in 2010.

[83]             These various costs are usually shared between airlines, airport operators, safety authorities and regulators, manufacturers, insurers and society.

[84]             NLR Air Transport Safety Institute - Accident costs for a causal model of air transport safety (ALC Roelen and JW Smeltink - 2008)

[85]             CAST (Commercial Aviation Safety Team) is an U.S. government-aviation industry partnership that has developed an integrated, data-driven strategy to reduce the commercial aviation fatality rate in the United States; http://www.cast-safety.org

[86]             This cost has been calculated for the period 1998-2007.

[87]             2010: €60 by 9.5 million flights; 2030: €60 by 16.9 million flights.

[88]             Treaty on the Functioning of European Union, OJ C83/47 of 30.3.2010, p.47.

[89]             Specific objectives are summarised in Annex 8.

[90]             It is difficult to assess an accurate objective for the occurrence collection rate as it is impossible to evaluate the total number of occurrences if they are not all reported.

[91]             For more details on respondents to the public consultation favourite options please refer to Annex 2.

[92]             "Just culture" means a culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated; Commission Regulation (EU) No 691/2010 of 29 July 2010 laying down a performance scheme for air navigation services and network functions and amending Regulation (EC) No 2096/2005 laying down common requirements for the provision of air navigation services; OJ L 201, 3.8.2010, p. 1.

[93]             Standard 8.2: A State shall establish a voluntary incident reporting system to facilitate collection of information on actual or potential safety deficiencies that may not be captured by the mandatory incident reporting system.

[94]             Standard 8.4: A State shall establish and maintain an accident and incident database to facilitate the effective analysis of information on actual or potential safety deficiencies obtained, including that from its incident reporting systems, and to determine any preventive actions required.

[95]             Recommendation 8.6: A State should, following the identification of preventive actions required to address actual or potential safety deficiencies, implement these actions and establish a process to monitor implementation and effectiveness of the responses.

[96]             This complies with Commission objectives of simplification and of better clarity of the legislation as expressed in the Commission Communication on "Smart Regulation in the European Union" (COM (2010)543) and this policy measure is supported by 76.3% of the respondents to the public consultation.

[97]             This would not require a lot of change in the Member States as 23 of them have already established a VORS.

[98]             This would bring benefits notably in improving data quality according to 19 Member States (see Annex 1).

[99]             This policy measure is supported by both public consultation respondents (80.3%) and Member States.

[100]            This policy measure is unanimously supported by Member States and is supported by the 73.8% respondents to the public consultation.

[101]            Few respondents to the public consultation and to the Member States questionnaire have expressed their support to this policy measure.

[102]            See Annex 1.

[103]            See section 1.1 for references to these acts.

[104]            Council Directive 94/56/EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents; Official Journal L 319 , 12/12/1994 P. 14.

[105]            Regulation (EU) No 996/2010 of the European Parliament and of the Council on the investigation and prevention of accidents and incidents in civil aviation

[106]            See annexes 1, 2 and 3.

[107]            COM(2010)543

[108]            This section provides the qualitative and quantitative assessment of impacts for each policy package described above in comparison to the baseline scenario impacts as described in section 2.4.

[109]            As explained in section 2.4 an accurate quantification of the safety impact is not possible and therefore the assessment of the safety impact would rather be qualitative.

[110]            E.g. States with no or almost no analysis and corrective actions processes implemented

[111]            Notably Air Operator's Certificate (AOC) for the airlines they certify.

[112]            CAST (Commercial Aviation Safety Team) is an U.S. government-aviation industry partnership that has developed an integrated, data-driven strategy to reduce the commercial aviation fatality rate in the United States; http://www.cast-safety.org.

[113]            This has been evaluated for the period 1998-2007.

[114]            See section 2.4.2

[115]            These savings are in cost avoidance (not profit), including loss of life, aircraft, devaluation of stock prices, insurance fees, and other indirect legal costs (http://www.cast-safety.org/faq.cfm).

[116]            While the CAST study is a US study, its results can be extrapolated to a European context, as it compares the cost of introducing safety management systems to the costs of accidents for the aviation community in general in a comparable safety environment.

[117]            Aviation Safety Management Systems Return on Investment Study, Centre for Aviation Safety Research, Parks College of Engineering, Aviation and Technology, Saint Louis University, February 2011.

[118]            Regulation (EC) No 216/2008 of 20/02/2008 of the European Parliament and of the Council on common rules in the field of civil aviation and establishing a European Aviation Safety Agency, and repealing Council Directive 91/670/EEC, Regulation (EC) No 1592/2002 and Directive 2004/36/EC, OJ L 79, 19/03/2008, p. 1

[119]            See Annex 9.

[120]            This cost is evaluated in the section related to administrative burdens (section 5.3.5).

[121]            In the Member States, occurrence reporting obligations are carried out either by the Civil Aviation Authority, by the Safety Investigation Authorities, by both or by an independent entity.

[122]            See Annex 1 for more details.

[123]            17 States have already some form of process for checking the quality of data, although the majority of these involved manual processes requiring human intervention.

[124]            Costs details are enclosed in Annex 11.

[125]            Costs details are enclosed in Annex 11.