Dear aviation voluntary reporting study participants,

Please find following a summary of the results for the Flight Crew Risk Assessment and Voluntary Reporting Systems Attitude study that you participated in between June-September 2014. I would like to offer my sincere gratitude to the pilot associations as well as all the pilots who volunteered their time for the study; without this commitment, research and hence improvements in aviation safety would be difficult.

The study had three main aims, namely to investigate: (1) pilot’s situational risk assessments; (2) operational factors that may influence the voluntary reporting of an incident; and (3) pilots’ trust in their organisations ‘Just Culture’.

270 commercial pilots completed the study. In relation to the first aim, the results revealed that when asked to assess the risk level in three risk based scenarios (low, medium, and high; as determined by subject matter experts and validated utilising ICAO risk assessment criteria), the pilot participants overestimated the risk level consistently in the low and medium risk scenarios. In the high risk scenario, pilots assessed the risk similarly to the subject matter experts. While not entirely ideal, there are some positives with this result, the most notable being that pilots expressed a level of caution in their risk assessment.

In terms of the second aim, pilots were more likely to report an incident or occurrence for a passenger carrying flight in contrast to a non-passenger carrying flight. ATPL holders willingness to report an occurrence using their airline’s SMS was stronger than CPL holders. This result indicates differences exist in reporting behaviour amongst commercial flight crew.

In relation to the third aim, the results revealed that just over half of the pilot participants (56.83%) stated that they were confident in their airline’s just culture policies, whilst approximately one-third (35.47%) lacked confidence in their airline’s just culture. The participants were asked if they had either previously withheld or selectively reported safety information and the reasons why. The results revealed that just over half of the participants (54.27%) irrespective of being confident or unconfident in their airline’s just culture policies, stated that they had either selectively reported or chose not to report safety information using their airline’s safety management system. This is despite approximately one-fifth (23%) stating that they were confident in their airline’s just culture. The participants indicated that fear of reprisal from their employer was the most prominent concern, and hence inhibitor to reporting. Other, less frequently stated reasons included; nothing ever changes (from previous reporting effort), and lack of enthusiasm for reporting.

From an applied perspective, we interpreted the results as follows. Airlines need to focus on improving/standardisation risk assessment amongst pilots. They also need to devote more effort to improve crew confidence in their reporting systems. Importantly, organisations need to dispel any fear employees have about reporting, in terms of reprisal from reporting safety related information. Organisations also need to actively provide feedback to crew about the outcomes of their reports and what changes have occurred as a result of reporting safety related information. Equally as important, organisations need to communicate to employees the reasons why no changes have occurred from reporting safety related information, to guard against perceptions that the information provided has been mismanaged or neglected. Such an approach will likely build confidence in reporting systems and the data extracted from these, allowing airlines and aviation governing bodies to further enhance safety. These results suggest organisations and authorities alike need to place a considerable amount of effort engaging with flight crew and developing trust, as it is a crucial component to cultivate and maintain a positive safety culture. Without this, data from pilots, such as information regarding observed hazards, errors, or error producing conditions will not be forthcoming, and hence the opportunity to enhance safety will be lost, and the full potential of safety management systems will not be realised.

If further information is required please contact me by email at:

Kevin McMurtrie
Research Trainee
School of Aviation
University of New South Wales