Chirpsing the CHIRP (Confidential Human-factor Incident Reporting Programme)
By Pete Allum
Have you ever gathered up your lines in shaky hands after an incredibly close call? You ‘dodged the bullet’ – as did everyone else involved – but you had the sense that, if you’d been just a little less lucky, something really bad could have gone down. What usually happens? Well, you shake it off, you get back on the next load and you forget the details of the dominoes that fell to get you that close to a bad day.
If you have, you’re certainly not alone. All of us have experienced that feeling. For many years, the only way to learn from an incident or accident in skydiving was to have the experience yourself – and, hopefully, walk away having learned some key lessons as an individual.
What if you could take a quiet moment with your phone in the corner of the hangar and jot down the sequence of events – completely anonymously – so that the data could be used to prevent the potentially awful results of a less lucky day?
British Skydiving already has a mandatory reporting system for injuries, malfunctions, off-landings, and any other incident which a CI feels are appropriate to report. However, for every significant incident there are usually many more ‘near-miss’ incidents which, often through pure luck, do not result in harm – but from which we could all learn.
Sadly – and predictably – many of these are never formally reported.
Reasons for not reporting may include not wanting to appear foolish or incompetent, not wishing to be in conflict with a PTO or DZ management and not wishing to incur a risk of disciplinary action or loss of ratings. Although there is some movement towards a ‘no-blame’ culture, many jumpers don’t feel confident, empowered or resourced enough to make these sometimes onerous formal reports to regulatory bodies. The result? We never get the chance to learn from the almost awful occurrences – and have a shot at preventing worse outcomes in the future.
Recently, my team and I have started to publish incident reports in the skydiving press. These reports have proven to be invaluable, allowing us to learn from incidents that have caused injuries (or even death, in some deeply unfortunate cases). In general, studying the variables involved has helped us to, as a sport, make important changes to the equipment and training procedures we use: to ascertain the causes, and then to find a way to prevent these incidents in the future.
The study of incidents has, up to this point, almost exclusively focused on technical issues, equipment errors, training procedures and weather conditions. However, limiting the reporting of incidents to situations that either cause injury or a malfunction means that we are missing out on two potentially life-saving elements:
- a) the learnings from a large number of non-catastrophic incidents which are currently off the current radar, and
- b) a platform for the effective study of the human factors that cause most incidents in the first place.
Within the aviation world, the anonymous reporting of close calls has been in place for many years. The USA has ASRS (which “captures confidential reports, analyses the resulting aviation safety data, and disseminates vital information to the aviation community.”) The USPA also has its own system of reporting incidents. In the UK aviation community, we have CHIRP (short for the Confidential Human-factor Incident Reporting Programme).
Here’s CHIRP’s charter, in their own words:
“On receipt of a safety-related report, the CHIRP Secretariat acknowledges it to the reporter, allocates it a unique reference identification and the information is reviewed with the objectives of determining any contributing factors and identifying potential corrective actions or resolutions that might be appropriate.
“As far as possible, the report is then discussed and validated with the reporter either by email, letter or telephone call.
“After ensuring that the report contains all the relevant information, and only if the reporter consents, the concern is then represented to the appropriate agency and the reporter is subsequently advised of any action taken in response to their report. Only disidentified information is used in discussions with third-party organisations, thus assuring the confidentiality of the reporter in any contact with an external organisation.
“Subject to the reporter’s agreement, at the end of the process the disidentified report, associated agency comments and summarising CHIRP comments are published in the relevant CHIRP ‘FEEDBACK’ newsletter in order to disseminate any lessons learnt or Human Factors matters of interest for the wider community.”
The goal of each of these anonymous reporting schemes is to learn from the hundreds of ‘minor’ incidents that happen every day. That is to say: to make deductions that integrate the additional data points that flow in, especially regarding the human factors that are at the root cause.
CHIRP puts it rather clearly:
“The people concerned are all those associated with the total system: not merely the front-end users, such as pilots and air traffic control officers, but also designers, equipment suppliers, maintainers, support personnel, instructors and so on.
“Thus the concept of a ‘Human Factors incident’ is extremely broad, and the pivotal tenet is that wider knowledge and understanding of the scope and causes of such incidents, caused by human error or failings, will reduce the chances of future accidents.
“CHIRP defines Human Factors as the consideration of mental and physical capabilities, limitations and actions that relate to the way humans interface and perform within their environment safely, comfortably and effectively.”
Now, it’s our turn
I’m happy to report that British Skydivers now have access to CHIRP as a resource: https://skydivethemag.com/reporting-chirp/
I just have one request for you today: bookmark it on your phone – and next time you land with shaky hands, give it two minutes of your time.
Let’s not wait for the severe injury or fatality to occur and for us to eventually and painfully learn from it. Let’s create a feedback loop on our dropzones that allows us to learn from the myriad small mistakes that occur on a daily basis, remember every failure is an opportunity to learn.
Pete Allum has been skydiving since 1979. A beloved Flight-1 coach and mentor, he has 36,500 jumps (as well as FAI world medals in CP and FS).
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To give an example: the premature deployment of a reserve after exit due to a loose handle pocket. The fix prescribed might look like putting out an advisory: firstly, that all rigs of that type be checked for efficient stowage of the reserve handle; secondly, that more thorough checking be carried out during scheduled maintenance.
