MOR – Mandatory Occurrence Reporting

[Ref AVIA4003 handout]

Intro – Safety data collection – Reporting systems

According to ICAO Annex 19 “Chapter 5 SAFETY DATA COLLECTION, ANALYSIS AND EXCHANGE”, the objective of those specifications is to support safety management activities by collection and analysis of safety data and by a prompt and secure exchange of safety information, as part of the State safety programme (SSP)

5.1.1 Each State shall establish a mandatory incident reporting system to facilitate collection of information on actual or potential safety deficiencies.

 

(HK) CAD 382 – THE MANDATORY OCCURRENCE REPORTING (MOR) SCHEME Information and Guidance

The MOR system has three main objectives:

  1. to facilitate the collection of information on actual or potential safety deficiencies;
  2. to use the reported information to improve the level of flight safety; and
  3. not to attribute blame

 

APPLICABILITY

5.1.1 mentioned that :

The AN(HK)O limits the aircraft covered by the MOR Scheme to public transport aircraft registered in Hong Kong over 2,300 kg. In practical terms this is interpreted as also covering any such aircraft operating under the jurisdiction of a Hong Kong
operator (e.g. leased aircraft). In the case of organisations providing a service or facility for aircraft operating over or in Hong Kong (e.g. Air Traffic Services, airfields, etc.), any occurrence meeting the required criteria should be reported regardless of the
nationality of the aircraft involved.

Nevertheless, for the purpose of promoting aviation safety, the Director-General appreciates the reporting of those occurrences stated in paragraph 5.3 (Items to be Reported) involving Hong Kong-registered public transport aircraft at or below 2,300 kg.

In short, all aircraft!

 

REPORTING PROCEDURE

6.1.4 Reports must be despatched within 96 hours of the reportable occurrence coming to the knowledge of the person making the report, unless exceptional circumstances prevent this.

6.1.1 The AN(HK)O places the primary responsibility for reporting with individuals: however the interests of flight safety are best served by full participation, in the investigation and follow-up, by the organisation involved. Therefore, wherever possible the Director-General encourages the use of company reporting systems, with a responsible person(s) within the organisation being nominated to receive all reports and to establish which reports from individuals within the organisation meet the desired criteria for an occurrence report to the Director-General.

 

Appendix B – Occurrences Required to be Reported (Scope of MOR system)

The Occurrence Reporting Scheme aims to identify those occurrences where the routine control procedures have failed. To achieve this objective, the criteria for a reportable occurrence need to be set (in terms of the effects on safety) above the normal day to day defects and minor incidents.

If to the judgment of the reporter, the malfunctioning or defect has endangered or may endanger the safe operation of the aircraft, the reporter shall furnish a report.

Generally speaking, there are 4 groups with a list of occurrence examples required reporting:

  1. Flight crew and Flight operations
  2. Aircraft Technical
  3. Aircraft Maintenance and Repair
  4. Ground Services, Facilities or Equipment

 

The following should be reported by Flight Crew:

2.1 Control of the Aircraft

(a) Avoidance manoeuvres: due to risk of collision with another aircraft, terrain or other object

(b) Rejected take-off resulting from or producing a hazardous or potentially hazardous situation (e.g. at speeds close to or above V1)

(c) Go around producing a hazardous or potentially hazardous situation

(d) Unintentional significant deviation from intended track or altitude (more than 300 feet), caused by a procedural, systems or equipment defect or human factor.

(e) Inability to achieve predicted performance during take-off or initial climb.

(f) Descent below decision height/altitude or minimum descent height/altitude in instrument landing conditions.

(g) Heavy landing – a landing deemed to require a ‘heavy landing check’.

(h) Unintentional contact with the ground, including touching down before the runway threshold.

(i) Over-running the ends or sides of the defined runway or landing strip.

(j) Significant inadvertent reduction in airspeed.

(k) Loss of control (including partial or temporary) regardless of cause.

(l) Loss of position awareness relative to actual position or to other aircraft.

(m) Breakdown in communication between flight crew “CRM” (crew resource management) or between flight crew and other parties (cabin crew, ATC [air traffic control], engineering).

(n) Abnormal vibration.

(o) Approach to, landing on, lining up on or taking off from a wrong runway (see also “runway incursion” at paragraph 4.3(d)) or airfield or not from a runway.

(p) Occurrence of stall warning or a ‘stick push’ operation, other than for training or test purposes.

(q) Operation of any primary warning system associated with manoeuvring of the aircraft e.g. configuration warning, stall warning
(stick shake), stall protection (stick push), over speed warning etc. unless:

(i) the crew conclusively established that the indication was false at the time it occurred, or
(ii) the indication is confirmed as false immediately after landing.

(t) Air Collision Advisory System (ACAS) Resolution Advisory except for an “unnecessary alert”, e.g. when triggered by a high rate of
climb/descent but standard separation not compromised.

 

2.2 Emergencies

(a) Fire, explosion, smoke or toxic or noxious fumes, even though fires were extinguished.

(b) The use in flight or on the ground of any emergency equipment or prescribed emergency procedures in order to deal with a situation

(c) The use of any non-standard procedure adopted by the flight crew to deal with an emergency

(d) An event leading to an emergency evacuation.

(e) Depressurisation.

(f) The declaration of an emergency – (‘Mayday’ or ‘Pan’).

(g) An emergency, forced or precautionary landing.

(h) Inadequacy or failure of any emergency system, equipment or procedures to perform satisfactorily, including when being used for maintenance, training or test purposes.

(i) Event requiring any use of emergency oxygen by any crew member.

 

2.3 Crew Incapacitation

(a) Incapacitation of any member of the flight deck operating crew, including that which occurs prior to departure if it is considered that it
could have resulted in incapacitation after take-off

(b) Incapacitation of any member of the cabin crew which renders him/her unable to perform essential emergency duties.

NOTE: ‘Incapacitation’ includes fatigue resulting from flying and associated duties, if confirmed by a qualified medical practitioner.

 

2.4 Injury

Any significant injury to any person which directly results from the operationmof the aircraft or its equipment but which is not considered to constitute a Reportable Accident.

 

2.5 Other Incidents

(a) A lightning strike which resulted in significant damage to the aircraft or loss or malfunction of any essential service.
(b) A hail strike which resulted in significant damage to the aircraft or loss or malfunction of any essential service.
(c) Icing encounter resulting in handling difficulties, damage to the aircraft or loss or malfunction of any essential service.
(d) Wake vortex encounter – an encounter resulting in significant handling difficulties.
(e) Windshear encounter – an encounter resulting in significant handling difficulties.
(f) A bird strike which resulted in significant damage to the aircraft or loss or malfunction of any essential service.
(g) Turbulence encounter – an encounter resulting in injury to occupants or deemed to require a ‘turbulence check’ of the aircraft.

 

3 AIRCRAFT TECHNICAL – The following should be reported by Flight Crew or Maintenance Staff:

3.1 Structure

(a) Any damage or deterioration

 

3.2 Powerplant

(a) Flameout, shutdown or significant malfunction of any engine

 

3.5 Systems and Equipment

(a)(i) Inability of the crew to control the system;

(b)(iii)(a) Failure or defect of passenger address system resulting in loss of or inaudible passenger address;

 

3.7 Aircraft Maintenance and Repair

(a) Non-compliance or significant errors in compliance with required maintenance procedures.

(d) Incorrect assembly of parts or components of the aircraft where the condition was not found as a result of the inspection and test procedures required for that specific purpose.

 

4 GROUND SERVICES, FACILITIES OR EQUIPMENT

The following should be reported by Air Traffic Control Services – by Flight Crew/ATCOs/Ground Ops Support Staff:

(a) Provision of significantly incorrect, inadequate or misleading information from any ground sources, e.g. ATC, ATIS, Meteorological
Services, maps, charts, manuals, etc.

(k) Unauthorised or illegal RTF transmissions

 

The following should be reported by Airfields and Airfield Facilities – by Flight Crew/Airfield Staff/ATCOs:

(b) Major damage or significant deterioration of surfaces of runways or aircraft maneouvring areas.

(f) Collision between a moving aircraft and any other aircraft, vehicle or other ground object.

(i) Significant spillage of fuel on airfield ramps.

 

The following should be reported by Passengers/Baggage/Cargo – by Flight Crew/Ground Support Staff:

(a) Difficulty in controlling intoxicated, violent or armed passengers

(b) Incorrect loading of passengers, baggage or cargo, likely to have a significant effect on aircraft weight and balance

(d) Inadequate storing of cargo containers or substantial items of cargo

(g) Incorrect labelling and packaging of dangerous goods

 

NOTES:

Above only extracted some examples from the origin PDF, for more details please refer to CAD 382

Also, please be noticed that the definition of a reportable occurrence vary depending on the laws of the country/area, the general principle is similar though.

 

Follow-up actions

The reporting of occurrence is important for further analysis to identify if any necessary corrective actions can be made to improve the level of safety. Therefore, the resultant findings and conclusions will be made available to appropriate organizations.

 

Protection of reporting personnel

The objective of MOR system is to collection information to improve the level of safety and not to attribute blame. In other words, when implementing the MOR system, a “Just Culture” should apply, which means that :

  • reports will be confidential
  • prosecution or punishment will not follow reports of unpremeditated or accidental breaches of regulations, except in cases involving dereliction of duty amounting to gross negligence or recklessness
  • employers will not take punitive measure following reports of unpremeditated or accidental breaches of regulations or procedures

 

Leave a Reply

Your email address will not be published. Required fields are marked *