Airport Incident Reporting Practices (2019)

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Airport Incident Reporting Practices A Synthesis of Airport Practice Stephen M. Quilty SMQ Airport ServiceS Abingdon, VA 2019 Research sponsored by the Federal Aviation Administration Subscriber Categories Aviation • Administration and Management • Policy A I R P O R T C O O P E R A T I V E R E S E A R C H P R O G R A M ACRP SYNTHESIS 95

ACRP SYNTHESIS 95 Project 11-03, Topic S04-20 ISSN 1935-9187 ISBN 978-0-309-48032-1 Library of Congress Control Number 2019938501 © 2019 National Academy of Sciences. All rights reserved. COPYRIGHT INFORMATION Authors herein are responsible for the authenticity of their materials and for obtaining written permissions from publishers or persons who own the copyright to any previously published or copyrighted material used herein. Cooperative Research Programs (CRP) grants permission to reproduce material in this publication for classroom and not-for-profit purposes. Permission is given with the understanding that none of the material will be used to imply TRB, AASHTO, FAA, FHWA, FMCSA, FRA, FTA, Office of the Assistant Secretary for Research and Technology, PHMSA, or TDC endorsement of a particular product, method, or practice. It is expected that those reproducing the material in this document for educational and not-for-profit uses will give appropriate acknowledgment of the source of any reprinted or reproduced material. For other uses of the material, request permission from CRP. NOTICE The report was reviewed by the technical panel and accepted for publication according to procedures established and overseen by the Transportation Research Board and approved by the National Academies of Sciences, Engineering, and Medicine. The opinions and conclusions expressed or implied in this report are those of the researchers who performed the research and are not necessarily those of the Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; or the program sponsors. The Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; and the sponsors of the Airport Cooperative Research Program do not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the object of the report. Published reports of the AIRPORT COOPERATIVE RESEARCH PROGRAM are available from Transportation Research Board Business Office 500 Fifth Street, NW Washington, DC 20001 and can be ordered through the Internet by going to http://www.national-academies.org and then searching for TRB Printed in the United States of America AIRPORT COOPERATIVE RESEARCH PROGRAM Airports are vital national resources. They serve a key role in trans- portation of people and goods and in regional, national, and interna- tional commerce. They are where the nation’s aviation system connects with other modes of transportation and where federal responsibility for managing and regulating air traffic operations intersects with the role of state and local governments that own and operate most airports. Research is necessary to solve common operating problems, to adapt appropriate new technologies from other industries, and to introduce innovations into the airport industry. The Airport Cooperative Research Program (ACRP) serves as one of the principal means by which the airport industry can develop innovative near-term solutions to meet demands placed on it. The need for ACRP was identified in TRB Special Report 272: Airport Research Needs: Cooperative Solutions in 2003, based on a study spon- sored by the Federal Aviation Administration (FAA). ACRP carries out applied research on problems that are shared by airport operating agen- cies and not being adequately addressed by existing federal research programs. ACRP is modeled after the successful National Cooperative Highway Research Program (NCHRP) and Transit Cooperative Research Program (TCRP). ACRP undertakes research and other technical activi- ties in various airport subject areas, including design, construction, legal, maintenance, operations, safety, policy, planning, human resources, and administration. ACRP provides a forum where airport operators can cooperatively address common operational problems. ACRP was authorized in December 2003 as part of the Vision 100— Century of Aviation Reauthorization Act. The primary participants in the ACRP are (1) an independent governing board, the ACRP Oversight Committee (AOC), appointed by the Secretary of the U.S. Department of Transportation with representation from airport operating agencies, other stakeholders, and relevant industry organizations such as the Airports Council International-North America (ACI-NA), the American Associa- tion of Airport Executives (AAAE), the National Association of State Aviation Officials (NASAO), Airlines for America (A4A), and the Airport Consultants Council (ACC) as vital links to the airport community; (2) TRB as program manager and secretariat for the governing board; and (3) the FAA as program sponsor. In October 2005, the FAA executed a contract with the National Academy of Sciences formally initiating the program. ACRP benefits from the cooperation and participation of airport professionals, air carriers, shippers, state and local government officials, equipment and service suppliers, other airport users, and research organi- zations. Each of these participants has different interests and responsibili- ties, and each is an integral part of this cooperative research effort. Research problem statements for ACRP are solicited periodically but may be submitted to TRB by anyone at any time. It is the responsibility of the AOC to formulate the research program by identifying the highest priority projects and defining funding levels and expected products. Once selected, each ACRP project is assigned to an expert panel appointed by TRB. Panels include experienced practitioners and research specialists; heavy emphasis is placed on including airport professionals, the intended users of the research products. The panels prepare project statements (requests for proposals), select contractors, and provide technical guidance and counsel throughout the life of the project. The process for developing research problem statements and selecting research agencies has been used by TRB in managing coop- erative research programs since 1962. As in other TRB activities, ACRP project panels serve voluntarily without compensation. Primary emphasis is placed on disseminating ACRP results to the intended users of the research: airport operating agencies, service pro- viders, and academic institutions. ACRP produces a series of research reports for use by airport operators, local agencies, the FAA, and other interested parties; industry associations may arrange for workshops, training aids, field visits, webinars, and other activities to ensure that results are implemented by airport industry practitioners.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, non- governmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org. The Transportation Research Board is one of seven major programs of the National Academies of Sciences, Engineering, and Medicine. The mission of the Transportation Research Board is to increase the benefits that transportation contributes to society by providing leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisciplinary, and multimodal. The Board’s varied committees, task forces, and panels annually engage about 7,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individuals interested in the development of transportation. Learn more about the Transportation Research Board at www.TRB.org.

CRP STAFF FOR ACRP SYNTHESIS 95 Christopher J. Hedges, Director, Cooperative Research Programs Lori L. Sundstrom, Deputy Director, Cooperative Research Programs Marci A. Greenberger, Acting Manager, Airport Cooperative Research Program Thomas Helms, Senior Program Officer Stephanie L. Campbell, Senior Program Assistant Eileen P. Delaney, Director of Publications Natalie Barnes, Associate Director of Publications ACRP PROJECT 11-03 PANEL Joshua D. Abramson, Easterwood Airport Management, College Station, TX (Chair) Debbie K. Alke, Montana DOT, Helena, MT (retired) Gloria G. Bender, TransSolutions, LLC, Fort Worth, TX David A. Byers, Quadrex Aviation, LLC, Melbourne, FL David N. Edwards, Jr., Greenville–Spartanburg Airport District, Greer, SC Brenda L. Enos, Burns & McDonnell, Kansas City, MO Linda Howard, Independent Aviation Consultant, Bastrop, TX Patrick W. Magnotta, FAA Liaison Matthew J. Griffin, Airports Consultants Council Liaison Liying Gu, Airports Council International–North America Liaison Adam Williams, Aircraft Owners & Pilots Association Liaison Christine Gerencher, TRB Liaison TOPIC S04-20 PANEL Scott R. Brummond, Wisconsin DOT, Madison, WI Benjamin Goodheart, Magpie Human Safety Systems, Evergreen, CO David Ison, Embry-Riddle Aeronautical University, Portland, OR Edward K. McDonald, III, Port of Portland, Portland, OR Frank Rivera, Massachusetts Port Authority, East Boston, MA Roger Studenski, Jacksonville Aviation Authority, Jacksonville, FL Michael Yip, Dallas Fort Worth International Airport, DFW Airport, TX Dale A. Williams, FAA Liaison Ashley Sng, Airports Council International–North America Liaison Christine Gerencher, TRB Liaison C O O P E R A T I V E R E S E A R C H P R O G R A M S

ABOUT THE ACRP SYNTHESIS PROGRAM Airport administrators, engineers, and researchers often face problems for which information already exists, either in documented form or as undocumented experience and practice. This infor- mation may be fragmented, scattered, and unevaluated. As a consequence, full knowledge of what has been learned about a problem may not be brought to bear on its solution. Costly research findings may go unused, valuable experience may be overlooked, and due consideration may not be given to recommended practices for solving or alleviating the problem. There is information on nearly every subject of concern to the airport industry. Much of it derives from research or from the work of practitioners faced with problems in their day-to-day work. To provide a systematic means for assembling and evaluating such useful information and to make it available to the entire airport community, the Airport Cooperative Research Program authorized the Transportation Research Board to undertake a continuing project. This project, ACRP Project 11-03, “Synthesis of Information Related to Airport Practices,” searches out and synthesizes useful knowl- edge from all available sources and prepares concise, documented reports on specific topics. Reports from this endeavor constitute an ACRP report series, Synthesis of Airport Practice. This synthesis series reports on current knowledge and practice, in a compact format, without the detailed directions usually found in handbooks or design manuals. Each report in the series provides a compendium of the best knowledge available on those measures found to be the most successful in resolving specific problems. FOREWORD By Thomas Helms Staff Officer Transportation Research Board The focus of this report is on current practices for defining, collecting, aggregating, protecting, and reporting airport organizational incident information. This study is based on information acquired through literature review, survey results from 11 airports from a range of geographic locations and airport classifications, and personal interviews with representatives of seven airports. Results of the literature review and survey are presented. Case examples representing in-depth interviews are presented in Chapter 9. Steve M. Quilty, SMQ Airport Services, synthesized the information and wrote the report. The members of the topic panel are acknowledged on page iv. This synthesis is an immediately useful document that records the practices that were acceptable within the limitations of the knowledge available at the time of its preparation. As progress in research and practice continues, new knowledge will be added to that now at hand.

1 Summary 5 Chapter 1 Introduction 5 Objective 6 Incident Reporting Overview 6 Safety-Centric Data 7 Enterprise-Centric Data 7 Mandatory Reporting 8 Voluntary Reporting 8 Using Incident Reporting 9 Synthesis Benefits 10 Audience 11 Methodology 11 Literature Review 12 Report Organization 13 Chapter 2 Terms and Definitions 13 Confusion Over the Term “Incident” 14 Defining Incident 16 Defining Near Miss/Close Call 17 Importance of Near-Miss Incident Reporting 18 Investigating Incidents 19 Chapter 3 Incidents Applied to Safety and Risk 20 Risk Management 20 Defining Risk 22 Hazards 22 Enterprise Risk Management 25 Scorecards and Dashboards 26 Chapter 4 Breadth and Depth of Incident Reporting 26 Incident Reporting as a Tool 28 Incident Reporting and Threat and Error Management 29 Chapter 5 Encouraging Incident Reporting 30 Safety Culture 31 Incident Reporting Practices and Culture 32 Culture Survey 32 Different Ways to Report Incidents C O N T E N T S

34 Chapter 6 Organizational Performance Indicators 34 Metrics, Measures, and Indicators 36 Safety and Key Performance Indicators 37 Reasons for Identifying Safety and Key Performance Indicators 38 Types of Safety and Key Performance Indicators 39 Leading and Lagging Indicators 40 Balance Between Leading and Lagging Indicators 42 Safety Culture as an Indicator 42 Customer Satisfaction as an Indicator 42 Training as an Indicator 43 Chapter 7 Research and Resources on Indicators and Metrics 43 Resources 44 Key Performance Indicators 45 Safety Performance Indicators 45 Leading/Lagging Indicators 45 Culture 45 Safety Management System and Safety Management Manual 46 Environmental 46 Automated People Mover 46 Health and Safety 47 Security 48 Chapter 8 Practices in Incident Reporting 48 Corroborating Incident Data 49 Overcome Barriers to Nondisclosure 49 Tracking Incident Data 50 Tracking Methods 51 Data Protection 52 Chapter 9 Case Examples 52 Large Hub: Hartsfield-Jackson Atlanta International Airport, GA 53 Large Hub: Dallas-Fort Worth International Airport, TX 55 Large Hub: Houston Airport System, TX 56 Large Hub: Port of Portland, OR 57 Large Hub: Seattle-Tacoma International Airport, WA 57 Medium Hub: Columbus Regional Airport Authority, OH 58 Small Hub: Sarasota-Bradenton Airport Authority, FL 60 Chapter 10 Findings and Conclusions 60 Findings 60 Challenges 61 Conclusions 61 Suggestions 62 Further Research 63 References 66 Acronyms and Abbreviations

67 Appendix A Survey Responses 72 Appendix B Terms and Definitions 80 Appendix C Typical Accident and Incident Statistical Rates 82 Appendix D Example of Safety Indicators and Metrics for 14 CFR Part 139 90 Appendix E Sample Poster and Web Display for Confidential Incident Reporting 91 Appendix F Sample Policy Requiring Employee Incident Reporting 95 Appendix G Sample Safety Policy Requiring Incident Reporting 97 Appendix H Sample Employee Incident Report Form 99 Appendix I Example of Computer Incident Reporting Data Entry Screen 101 Appendix J Sample Safety Metrics Dashboard Note: Photographs, figures, and tables in this report may have been converted from color to grayscale for printing. The electronic version of the report (posted on the web at www.trb.org) retains the color versions.