Latest from CHIRP
ATFB 155
Safety Culture
CHIRP reporting themes
My first six months as Air Transport (AT) and Advanced Air Mobility (AAM) programme manager in CHIRP’s aviation team has been both enlightening and professionally rewarding. Having previously been a member of the Air Transport Advisory Board (ATAB) I was very familiar with how CHIRP’s advisory boards dealt with the human factors based reports presented to them for discussion, but now that I’ve taken on the newly created AT/AAM PM role, I have more insight into the reports as they arrive into CHIRP, and importantly, I’m able to have direct contact with the individuals who report in to us with their concerns. Reporters’ motivations for submitting confidential reports to CHIRP vary greatly, as you’d expect, but a few common themes involving safety culture are appearing from my first six months in the job. I thought I’d share some of these with you having been given this opportunity to write my first editorial for Air Transport FEEDBACK. But before I do, I wanted to set the scene regarding what I believe is meant by the term ‘safety culture’ in aviation, as the concept is very pertinent to the subject of Air Safety Reporting (ASR) in general, and confidential reporting in particular.
Safety, in its broadest sense, represents the priority given by an organisation, at every level of operation, to keep employees and customers free from harm. Culture, as it relates to humans working within socio-technical systems, refers to the prevalent attitudes, behaviours, and beliefs that exist amongst a majority working within the organisation. Culture, in a nutshell, determines what is deemed acceptable behaviour within an organisation. Therefore, when a genuine safety culture is said to exist in an organisation, it will reflect a commitment by senior leadership, and all others in the organisation, to prioritise safety and to continuously learn and make improvements based on events that occur and the personal experiences of employees. The organisation promotes and values those attitudes, behaviours, and beliefs that facilitate safe outcomes, and always above other considerations, such as those associated with short term financial or operational pressures. Positive safety culture includes clearly defined safety responsibilities and accountabilities, effective teamwork to achieve a common set of well understood safety goals, open and honest reporting of hazards and near misses, errors, mistakes, incidents and accidents, and finally, a feeling of trust throughout the organisation that safety really is, yes, let’s go ahead and say it… “the number one priority”. An easily said strap line, and one that is arguably overused, but is in fact a very high bar to reach, particularly in the cut and thrust world of 21st century commercial aviation!
Here at CHIRP we often receive reports that highlight what can happen when an employees personal experience of their organisation’s safety culture is at odds with what is said on the company’s SMS intranet site, or on notice board posters in Flight Ops, and therefore falls short of the ideal. A recent confidential CHIRP report stated that there was a perceived “punitive culture’’ prevalent at an airline and the reason that the reporter felt compelled to write to CHIRP was because they feared retribution and actions against them if they submitted an internal ASR. Another report into CHIRP stated that the employee had submitted an ASR but had still not received an acknowledgment from the safety team, let alone a detailed reply. Sometimes, CHIRP is told, the reply to an ASR is simply that the report “is now closed’’. It is worth remembering that an effective safety culture can only exist when all employees feel able to report without fear of a negative outcome. The concept of Just Culture attempts to capture how this is done, which as James Reason identified, is when an organisation has a “just and fair approach” to errors and mistakes as and when they are identified. But this only works both ways; SMS require employees to submit internal reports to identify hazards and risks, but in return, the leadership must be genuinely willing to hear from employees, even when staff believe management have made errors and mistakes, for example in the interpretation of CAA regulations for Flight Time Limitations and setting rosters that will, based on FRMS reports and ASR reports from employees, result in fatigue.
CHIRP receives reports from individuals who believe that their organisation is playing a sort of game with the regulations, setting schedules and rosters for example that are, by the letter of the regulation, arguably “legal’’ but in the opinion of reporters are not conducive to safe operations when a busy flying roster is considered. Fatiguing rosters, and based on reports received latterly, insufficient or interrupted rest periods, are currently two of the most common reporting subject areas for CHIRP aviation. A worrying aspect that I have noted is that many reporters don’t believe that the safety culture prevalent at their airline encourages them to submit FRMS reports or more generally ASRs about their personal experiences of fatigue. And the very last recourse open to crews, calling in unfit due to fatigue, is viewed by many of the reports we receive at CHIRP as a punishable event in reality. This type of personal experience will determine how the reporters perceive overall safety culture in the organisation, something that is hard to change in a short space of time. CHIRP will always speak up for reporters who feel unable to submit ASRs, backed up with our ability to engage directly with the airlines themselves, but at all times ensuring the confidentiality of the reporter is preserved.
William Dean, Air Transport (AT) & Airborne Air Mobility (AAM) Programme Manager
For all CHIRP Aviation Team, see CHIRP bios.
As the newest member of the CHIRP team, taking over from Phil Young who is enjoying his well-earned second retirement, let me start with a brief introduction. I began my aviation career in 1988 with British Airways Engineering, working in several technical and operational roles, mainly involved with the maintenance of Concorde and Boeing aircraft. After a very enjoyable and satisfying 18 years, I moved to Ground Handling, having the privilege of leading the BA Baggage operation at Heathrow Airport for the next nine years. In 2016 I left the world of aviation to work for organisations in the fields of baggage systems maintenance and public mass transport.
Having now returned to the world of aviation, albeit in a support role, I have seen several recent CHIRP reports relating to Engineering training. When I cast my mind back to my own experiences of Engineering training in the 1990s, it was largely a hands-on affair, relying heavily on physical components and printed documentation. All types of training were delivered in classrooms, by experienced engineers who had accumulated decades of practical wisdom. My practical training was with real aircraft, often in hangar environments, supported by a wealth of personal experience from those working alongside me.
Fast forward to 2025, and talking to my former colleagues, the developments in Engineering training appear dramatic. They tell me about the use of Virtual Reality (VR) and Augmented Reality (AR), how they can “walk through” an engine, identifying components and performing simulated maintenance tasks in a fully immersive VR environment. They have access to sophisticated maintenance simulators, whilst interactive multimedia modules have replaced the old textbooks and manuals, I became so familiar with. Computer-based training (CBT) platforms are commonplace, allowing for self-paced learning and continuous assessment.
These developments have undoubtedly brought a host of advantages. Complex procedures can be repeated countless times in virtual settings, trainees can make mistakes and learn from them in risk-free environments, and the use of CBT allows individuals to progress at their own pace whilst continuously monitoring their understanding.
However, it is crucial to acknowledge some of the potential disadvantages, as highlighted in some recent CHIRP reports. The potential over-reliance on CBT and other digital training platforms can reduce the opportunity to interact with colleagues, sharing experiences and mentoring that I certainly benefited from in my early days. Has the use of CBT been taken too far, being seen by some organisations as a more efficient and easier solution to delivering training, especially in some less technical fields such as safety, quality, human factors and compliance? Do these areas of training, in particular, benefit more from the sharing of experiences and lively discussions that in-person group facilitations offer, even if they are perceived as being less efficient than CBT modules by organisations? I am certainly thankful for the experienced colleagues who so willingly shared their knowledge, skills and stories during my early days in Engineering – and the lasting impact these interactions had on the rest of my career.
And talking of sharing experiences, I would like to finish by thanking Phil Young for his patience and perseverance in preparing me for this role. It was a pleasure working alongside him, albeit briefly, and I wish him a long and enjoyable second retirement.
Kuldeep Nothey, Engineering Programme Manager
What do you think? We’d love to get your views on the topics covered in FEEDBACK. We don’t claim to have all the good ideas, and we may have missed something that relates to a report so please do contact us and give us your views. You never know, your thoughts might inspire the next editorial or perhaps give us more context for when we contact the companies. Please send any comments to mail@chirp.co.uk for the attention of CHIRP Air Transport Programme Manager and we can start a conversation.
AT FEEDBACK 154 – Report ENG767
I read the subject report with interest as I’m currently engaged as a Maintenance Controller.
Firstly, could I politely recommend that that the CHIRP responses remain factual from the start, i.e. in this case ‘It is the responsibility of the commander in charge of the aircraft that there are no outstanding defects’; what goes after that is pure speculation, not backed up by facts or investigation. Firstly, was there actually a ‘Smoke’ event? Was it condensation? (The report indicated that the ‘smoke’ dissipated quickly in my experience this is humid air, steam, condensation – very common in hot and humid climates).
Secondly, the author of the response merely assumes all of the Human Factor Performance Influencing Factors (PIFs), without really knowing the facts… (There are many more PIF’s than 12….).
Furthermore, was the response of the Controller verified?
The subject of ‘smell events’ is a moot subject among maintenance engineers as we persistently find no valid reason for their submission, i.e. ‘brief whiff’, some crew ‘may’ have smelled something, often it’s attributed to de-icing and external issues.
Whilst we take smoke and smell events very seriously, they do obviously cause severe disruption, often causing a 36-hour AOG event. Unfortunately, it seems that some crews have used this to their advantage when disgruntled or in dispute with company policies. This trend could be seen when historic routes have been cancelled or curtailed.
CHIRP Response: The CHIRP Comment for ENG767 in the April 2025 issue of FEEDBACK serves as a useful reminder of the importance of the Tech Log as an essential communications tool with regards to recording the ‘fitness’ of the aircraft to operate.
With regards to the speculation about the root cause and potential seriousness of the notified ‘smell event’, CHIRP agrees that it’s not possible to be more certain of what the correct actions should have been in this specific event without further details. However, a more general discussion about such events, their frequency and potential seriousness is worthy of debate. In all such operational situations, there is the constant challenge of balancing commercial considerations against potential safety risks, and it is in such situations that organisations should rely on the knowledge, experience and judgement of all those involved – including Flight Crew and Maintenance Controllers. During our Engineering Programme Manager’s operational career, in such circumstances where there remained a level of uncertainty or a difference of views, his position had been to always err on the side of safety.
We hope that this report will also generate further discussion into the issue of ‘smell events’, just as you have done – namely their frequency, actions being taken to understand root causes and suggested ‘best practice’ responses.
AT FEEDBACK 149 & 153
The observations on Controlled Rest (Feedback 149 & 153) feed into a wider narrative: that the management of fatigue is a problem we can “science” our way out of. I have my doubts, and I am wary of the (former) editor’s call for more “definitive” regulation in this area, particularly his desire to see the CAA incorporate regulations on CR within their review of FTLs. I would argue that sleep science has not historically served aviation well and that by placing too much trust in a quantitative approach we kid ourselves that we have “fixed” a problem when in reality it is too complex, too personal and too unpredictable to be addressed in anything other than the most general terms.
Limitations on flight duties and roster patterns are, of course, essential but by attempting to present fatigue as a logical outcome that can be mitigated by adherence to a matrix of report times and time zones we are pretending to a level of agency that we simply don’t possess. The only metric that matters is how we, as crewmembers, are feeling on any given duty and therefore the most effective solutions are by nature ad hoc and flexible.
Indeed, the more rigidly we attempt to pin down sleep and rest behaviours, the more we imply that to feel tired is a failing on the part of the pilot concerned. This discourages accurate reporting. It also ignores the fundamental truth that sleep can be capricious and hard to come by no matter what the schedule – more so for some than for others. As a long and short haul pilot of many years, who struggles with sleep (and the two are probably not unrelated), I have come to accept that rest is not something that can be achieved just because it is available and whilst I cannot rely on CR either, I find it to be one of the few genuinely effective ways of keeping fatigue-related performance impairment at bay.
I understand the editor’s concern that CR has become a backdoor method for operators to have pilots tolerate longer, more punishing duties that would otherwise be flagged as unsustainable – and this is not acceptable – but CR itself is not the problem. An unpredictable threat, such as fatigue, requires an adaptable set of solutions, which is why, if more “definition” is felt to be required in this area, then it should still leave significant space for discretion by the operating crew. Left to others, any proposed regulation will likely focus on the potential pitfalls rather than the benefits, and risks being an exercise in the kind of false science that treats our fitness to operate as the output of an equation.
AT FEEDBACK 153
I am very impressed by the independent work CHIRP undertakes and the difficult line it walks between the reporter the industry and the regulator. It was very interesting to read the discussion on complex intercontinental rostering and your balanced response. However, the response does slightly contradict a previous comment by CHIRP which raised concerns with the underlying ‘sleep science’ and assumptions the modelling these rotations relies on. It would be interesting to consider the earlier CHIRP response in the context of a new operator finding its way and the learning of lessons that the industry should have already learned.
Reporting to CHIRP is easy by using either our website portal or our App (scan the appropriate QR code shown or search for ‘CHIRP Aviation’ – ignoring the birdsong apps that may come up!). In our reporting portal you’ll be presented with a series of fields to complete, of which you fill in as much as you feel is relevant – not every field is mandatory, but the more information you can give us the better. Although you’ll need to enter your email address to get access to the portal, none of your details are shared outside CHIRP, and we have our own independent secure database and IT systems to ensure confidentiality.
You report it, we’ll help sort it
CHIRP has recently received a number of concerning reports about security screening at UK airports. These reports come from across the industry – flight crew, engineers, cabin crew, and ground handlers alike. While the specific issues vary, some common themes have emerged:
- Inconsistent application of security measures
- Brusque or overbearing behaviour by security staff
- Lengthy waiting times
- Solid food items with a modicum of sauce being classified as ‘liquid’ and denied passage
So, what does this have to do with safety?
All our reporters highlight a troubling acceptance of poor treatment at airport security. Many now expect the worst and prepare themselves for the most stringent interpretation of the rules in an effort to ensure a smooth journey through screening. However, when treatment feels arbitrary or unreasonable, resisting the urge to react can be a significant mental challenge.
The effort required to stay calm – especially when you’re now going to be late for report or faced with inconsistency – can be considerable. Many crew report feeling anxious, frustrated and under pressure even before their duty day has begun. These stressors, though seemingly unrelated to flight operations, can significantly affect human performance and, ultimately, safety. For more on the effects of stress in aviation, see Skybrary’s article on stress and stress management.
To be clear, we are not advocating for security checks to be waived for crew or for standards to be lowered. Quite the opposite. Operating crew consistently express strong support for rigorous screening, recognising that it protects everyone – crew, passengers, and the wider public – by guarding against rogue elements. Crew also fully understand that they themselves are a potential hazard and that an aircraft in the wrong hands is a serious threat.
However, airports and airlines have a responsibility to ensure that security checks are conducted professionally and consistently. Otherwise, the knock-on effects on crew, who are humans not robots, can have unintended safety consequences. For example, one pilot reported being so wound up by their treatment through security, that they were still significantly distracted by it well into the flight. This a clear example of how pre-duty stress can affect operational focus.
What is CHIRP doing?
When CHIRP receives reports of security-related incidents that could impact flight safety, we raise them with the relevant airport and airline safety and security managers. Airports often resist change and argue that security regulations are being fully complied with, but with little regard for how the checks are conducted. There appears to be minimal concern for transparency, consistency, or the mental state of crew following these interactions. Worryingly, security staff often have little understanding of the safety-critical responsibilities crew members take on immediately after leaving the checkpoint.
Our advice for crew
While CHIRP continues to advocate on behalf of crew facing poor treatment at security, we also offer the following guidance for those dealing with this issue daily:
- Remain calm and professional. As hard as it may be, do not rise to provocation or complain during the screening process. Stay quiet, compliant and composed.
- Check in with yourself after screening. Recognising our own stress is notoriously difficult. If you feel angry, anxious, frustrated, or upset, try to pause and reset. Take a moment for yourself – find a quiet spot, have a coffee, do some breathing exercises, or whatever works for you. The military refers to this as getting back into the ‘mission bubble’. If your focus is disrupted, it’s your responsibility to restore your mindset before reporting for duty. It’s better to be late for report and fit to operate than to begin work mentally unprepared. Be sure to notify your company through the appropriate reporting system if this is the case.
- Stay calm in queues. If the problem is excessive queuing at security / lack of security checking resources, then provided you arrived at security by report time then try to relax; this is out of your control so don’t carry unnecessary guilt. Keep your head in the right place, ready to operate and calmly report once through and the extent of the delay is apparent.
- If you don’t feel confident reporting the issue internally, CHIRP is here for you. We offer a confidential, impartial and independent reporting option. Get in touch and we’ll support and advocate on your behalf.
Final Thoughts
Security checks are essential, but they should never have a detrimental effect on crew wellbeing, operational readiness, or aviation safety. You do not have to suffer in silence. Change can only happen by reporting the issues to the airlines and the other companies who employ the staff affected – in this context, it is the company’s themselves that have the power to influence change at airports rather than affected individuals.





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