What happened
An investigation was commissioned following a radio interference incident in Ivalo on March 13, 1995, and a cable break occurring in Ivalo on August 5–6, 1996. While the primary triggers were specific technical failures, the commission expanded its scope to conduct a comprehensive review of the reporting systems used within the Finnish aviation industry. The investigation sought to evaluate how safety-related incidents, technical defects, and hazards are documented and communicated between pilots, air traffic controllers, and the regulatory authority.
The investigation
The investigation committee conducted extensive research, interviewing nearly one hundred individuals, including pilots, air traffic controllers, and various personnel from the Finnish Civil Aviation Administration. To ensure the integrity of the findings and encourage honest disclosure, interviews were conducted confidentially to protect the anonymity of the participants. The committee also examined the administrative structures of the aviation authority, its internal working procedures, and various international reporting models to identify areas for improvement in the domestic system.
Findings
Through the interview process, a consistent picture emerged regarding widespread dissatisfaction with the existing reporting culture. The investigation identified several critical issues:
- Lack of feedback: The regulatory authority's reporting system lacks a comprehensive feedback mechanism. While technical defect reporting (AIR T16-3) provides some feedback, there is no equivalent system to inform pilots or controllers of the outcomes of their safety reports.
- Erosion of trust: The integration of the regulatory unit within a state-owned enterprise (the Civil Aviation Administration) has created ambiguity. Many aviation professionals perceive the authority's actions as being too focused on punishment rather than safety improvement.
- Ambiguity in regulations: There is significant confusion regarding the distinction between internal administrative reporting and official regulatory reporting, leading to errors in documentation.
- Inadequate resources: The authority lacks the necessary resources to process reports quickly or provide the detailed feedback required to foster a proactive safety culture.
- Reporting gaps: The investigation found evidence that even serious incidents have occasionally gone unreported due to the perceived risk of repercussions.
The committee noted that while technical failures account for approximately 20% of incidents, human factors contribute to roughly 80%. Therefore, a system that fails to encourage the reporting of human error is fundamentally flawed.
Safety action
- The committee recommended that the aviation authority investigate the development of a confidential reporting system managed by a third party.
- It was recommended that feedback must always be provided for all submitted reports and that safety reviews should be published based on the findings of these reports.