Every safety management system depends on a raw material that cannot be bought: information about what almost went wrong. The incident that did not become an accident, the approach that was continued when it should have been abandoned, the part installed with the wrong instruction and discovered the next day. The people who know this are the ones who were there. If they do not tell, the SMS is left with the indicators the system can measure on its own, and none of them shows what has not happened yet.
The question every operation should ask itself is not "do we have a reporting channel?". It is "why, having a channel, does almost no one use it?".
What just culture is
The term comes from James Reason, who in the 1990s described safety culture as a combination of four components: a reporting culture, a learning culture, a flexible culture and a just culture. The most widely used definition today is that of Regulation (EU) 376/2014, which deals with occurrence reporting in European civil aviation. In free translation, just culture is one in which front-line operators are not punished for actions, omissions or decisions commensurate with their experience and training, but in which gross negligence, willful violations and destructive acts are not tolerated.
ICAO deliberately does not define the term. Annex 19 and Doc 9859 prefer to establish the principles for protecting safety information and to describe a "just and balanced" culture as one of the components of a positive safety culture, leaving it to each State and each organization to say where the line falls.
And the line is the point. Just culture is not a culture without punishment. It is the clear distinction, known to everyone and applied consistently, between three things:
- Honest error. The person did what they did believing they were right, with the experience and training they had. Response: understand why the error was possible and fix the system.
- At-risk behavior. The person chose a shortcut knowing it existed, because the risk seemed small or because "everyone does it". Response: train, change the incentive, remove the informal norm.
- Gross negligence or willful violation. The person knew, had an alternative and chose the risk. Response: discipline.
An operation in which honest error is punished does not learn, because no one reports. An operation in which willful violation goes unpunished does not learn either, because those who follow the rule see that it carries no weight. Both are unjust, and both dry up reporting.
What RBAC 135 requires of the safety policy
This is not just good practice. RBAC 135, in section 135.705, requires the air taxi operator to define an operational safety policy that, among other things, includes a policy for operational safety reports and clearly indicates which types of behavior are considered unacceptable by the organization, as well as the circumstances in which disciplinary action will not be applied. The policy must be signed by the accountable manager, communicated with visible endorsement from senior management and reviewed periodically.
In other words: the Brazilian rule asks that the line between error and violation be written down and signed. Many safety policies meet the requirement with a generic sentence about "not punishing honest error". Few say, with examples, what the company considers unacceptable, and fewer still are applied with the consistency that makes the pilot believe them.
For maintenance shops, section 145.214 of RBAC 145 requires an SMS with safety policy and objectives and responsibilities defined at all levels, and the same reasoning applies: the mechanic who discovered their own wrong installation will only speak up if they know what happens next.
What Brazilian law already guarantees
There is a layer that many operators are unaware of. Law 12.970/2014 rewrote the chapter of the Brazilian Aeronautical Code on SIPAER and gave legal basis to the protection of reporting:
- Art. 88-A. The SIPAER investigation exists "solely for the benefit of the prevention of aeronautical accidents, aeronautical incidents and ground occurrences". It is not an instrument for determining fault.
- Art. 88-B. It is conducted independently of any other investigation of the same event, and those who take part in it may not take part in the others.
- Art. 88-I. The data from voluntary occurrence reporting systems are SIPAER sources. This source, and the analyses and conclusions of the investigation, will not be used as evidence in judicial proceedings or administrative procedures, and will be provided only upon court order. All information given to SIPAER "will be spontaneous and based on the legal guarantee of its exclusive use for prevention purposes".
The national channel is the RCSV, the CENIPA Report for Flight Safety (Relato ao CENIPA para a Segurança de Voo). Joint Ordinance 5.754/COMAER/ANAC, of 2021, defines it as part of the Brazilian State's voluntary reporting system, protected by Law 12.970: the report receives primary handling by CENIPA, the information is not made available before de-identification, the main purpose is statistical, and the identity of the author and of the people mentioned is safeguarded. The same ordinance draws the line: voluntary reporting is not for reporting facts that constitute a crime or an intentional violation of regulations.
That is: for the report that goes to the State, the protection exists in law. What is missing, in most operations, is protection inside the company, where the person reporting is one room away from whoever decides the schedule.
Why the report does not arrive
Anyone who asks pilots and mechanics hears the same reasons every time:
- "It will come back on me." The policy says it will not, but the last person who reported was called in for a talk.
- "Nothing comes of it." The report goes in, no one answers, the condition continues. Reporting becomes work with no return.
- "It was nothing much." The event was absorbed by routine. Without concrete examples of what the company wants to know, the pilot only reports what has already become an incident.
- "It's a hassle." The form is long, it is at the office, it asks for data the pilot does not have at hand.
- "Everyone will know it was me." In an operation with eight pilots, the "anonymous" report about Tuesday's flight is not anonymous.
None of these reasons is solved with a poster. The first is solved with the 135.705 policy written with examples and applied without exception. The second, with a response to every report and visible action. The third, with the list of what to report. The fourth, with the channel in the pocket. The fifth, with the option of real anonymity and with management treating the report by its content, not by its author.
Where Alis comes in
The Alis SMS module was designed for the part the law does not cover: reporting inside the company. The hazard report is made from the device, on the ramp or in the hangar, with a photo, and can be identified or anonymous; in an anonymous report, the author is neither asked for nor recorded. The report enters the occurrence investigation queue, goes to the risk matrix and continues to action follow-up. The dashboard tracks the indicator of non-mandatory reporting events, which is the most honest measure of how alive the reporting culture is. And the safety policy, with the line between error and violation, is documented in the same place where the SMS is audited.
The article on SMS in practice for RBAC 135 describes the four components of the system; the one on continuation bias shows the kind of event that only reaches the SMS if someone tells.
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This article is for informational purposes. The requirements cited are those of RBAC 135 (Amendment 07, section 135.705) and RBAC 145 (Amendment 08, section 145.214); the legal provisions are those of Law No. 12.970/2014; the RCSV is described according to Joint Ordinance No. 5.754/COMAER/ANAC, of 2021; the definition of just culture is that of Regulation (EU) No. 376/2014, in free translation. The text does not replace consulting the normative acts or the legal guidance and the guidance of the organization's SMS manager.