Creating a Safety Reporting System

[jaredyates]

This is a new thread to continue the discussion from the other thread:

Jared, this forum has been a huge source of help for me, along with your Bearhawk tips. I've found that people are very willing to help and share information on building and flying as the Bearhawk "fleet" grows and as we all learn.

One area that I would like to see a lot more information shared is failures and incidents that lead to Airworthiness Directives or Service Bulletins. All aircraft types have issues that become apparent over time. This is essential for the longevity of, and trust in the brand.

Vans for instance have an entire section of their website dedicated to Service Bulletins - they've taken something that could be viewed as detrimental to the brand, and turned it into a brand highlight - the way they handle defects and failures. It's out there for everyone to see. Here's an example for "cracking of wing aft spar web". They not only tell you about this potential issue, but they also tell how to inspect for it, and how to fix it. Same with Zlin aircraft and many others. In the certified world it is mandatory. But in the Amateur built world it's up to us, the builder.

For those that have shared this type of information, a huge thanks to you. It's not an easy thing to do, and is sometimes the consequence of a serious or embarrassing incident. But do know that it has been instrumental in helping others avoid similar pitfalls and we appreciate your sharing of knowledge and experience.

So I think the creation of a database to begin logging these issues as they affect our Bearhawk Aircraft is essential. Ideally a small group of owners might assess each item and it would be free from brand influence.

I've begun logging a few items that I felt would benefit owners in an attempt to share what I've learned on my own website under the term Pilot Experiences. As far as I'm aware there's currently no other other database logging of potentially serious issues so it's simply one way of getting the information out there.

Firstly, thanks for the effort and work you put in to benefit all of us Jared, it is much appreciated. This brainstorming session is another example of quest for improvement.

I agree with the sentiment already expressed, information is often available but finding it difficult for dinosaurs who are not IT savvy like me.

Secondly, history has shown that good reporting, recording, and dissemination of information is critical to safety management. We need a culture of open, honest and transparent reporting in order to identify issues, resolve them, and prevent reoccurrence.

I think Nev’s point about having a specific section of the website for ADs and Service Bulletins etc is a good one.

For example, Fuel Caps. Turns out Kiwis weren’t the only ones with fuel cap problems and the fix was really simple and effective. A platform that enables that sort of reporting, analysis and rectification would be a real step forward for Bearhawk in my opinion.

I also think that good data from builders on performance figures achieved real world would be helpful for new builders determining configurations of engine, prop, wheels etc.

Everyone wants their aircraft to be the best on the block. Any tips or tricks of configuration or rigging we can share to optimise performance, margin and safety has to improve the overall Bearhawk brand in my view.

In summary, I’d like to see a one stop site/platform where I could review plan revisions/amendments, safety notices, ADs, service bulletins, engineering notices, tips and tricks, and new issues encountered by others. I think this resource should be a members only resource to encourage honest reporting without fear of being taken out of context or misinterpreted by the wider world.

[Richard E]

I think that both Bissetg and Nev have made very important points. If owners, pilots or even manufacturers are aware of faults or problem experiences it is incumbent upon them to make others aware of the increased risk in this area. After all with a plane, peoples lives are at risk. I appreciate that manufacturers may not be so comfortable with any faults being aired publicly but they will be a whole lot less comfortable it it can be shown that they intentionally protected their brand by concealing or not revealing known issues.

Jarredyates would be doing exactly the right thing to support a section of this site (or another) being specifically to highlight concerns of owners/pilots openly, although in a moderated way. All planes, cars, boats and even kitchen appliances have their faults. Where they could possibly put lives at risk they need to be accepted and owned up to.

[jaredyates]

Just to be clear I don't think we're at a point where Mark or Bob in this case aren't being open about things, but rather that it isn't always easy for operators to know what kind of information is out there, and there aren't always good channels to pass information back to Mark and Bob.

[jaredyates]

Nev and Grant and I have been talking a little about this in the past few months and trying to think of ways to help promote sharing especially of safety-related information. I have been asking around about how other types and clubs have been handling safety reporting, and tried to get some ideas about what works well and what doesn't, but I really have more questions than answers.

My first key takeaway is that while having the software aspect of a reporting system is nice, what really matters is the safety culture behind it. This means that folks who encounter a problem need to feel like they can and should share that information, and the community needs to be eager to accept it. The general theory about safety reporting stresses how important it is to be non-punitive, but in this case since we are a grass-roots bottom-up effort, there is no authority that we are all reporting to, and our needs are a little different than a top-down program where our employer or regulator is staring over our shoulder. But in any case, it is clear to me that a sharing-oriented safety culture is not a destination that we should strive to achieve and be done with, but rather a journey or process that is ongoing. And we also need to have a good system in place to receive that information and get it back to the community.

At this point, I would summarize our safety reporting as this: If a pilot has a problem with a flying airplane, they might happen to call and talk to Bob or Mark about it. If Bob thinks it warrants further action, especially if he gets a few calls about the same thing over the years, he might issue a safety update. Mark frequently coordinates with Bob about calls he gets from kit customers, but at the moment, most of our Bob-involved reporting database is in Bob's head. The outputs of that process are at bearhawksafety.com, in the Beartracks, and if it's in recent years, discussed here. Thankfully we do also have a pretty robust participation here, for example with Nev's fuel cap discussion and plenty of other topics. Bob doesn't participate here, though sometimes folks make him aware of things that are here and his input makes it back.

Bob is a crucial resource and I wouldn't have gotten into building a Bearhawk if it wasn't for meeting him and having so much support over the years. But I fear as the community grows it isn't really sustainable or reasonable for Bob's head to be the only processor driving our safety system, if for no other reason than that lots of builders and operators don't think to call Bob when they have a problem.

As I try to map out what may be a good plan for how to get to a point of a community-driven reporting and sharing system, I'm not seeing a clear destination, so that's where I'd like to hear more about what a good system looks like. For example:

Does it require a login to be able to submit a report, and if so, is that login based on one of our existing platforms (here, bearhawk.tips, etc). If it doesn't require a login, how is spam mitigated (other than just by me manually filtering it)? Is it yet another login (please no!) that we have to establish and remember?

Once reports are submitted, are other Bearhawkers able to see the direct results of that submission, or should there be a digesting process that happens between acceptance and publication? If the first option, should reports be screened for problems like admission of regulatory deviation (I flew into the clouds while VFR, who knows what else) and removal of identifying information for non-participants (I was flying with my buddy Steve when...). If the second option, who does the screening/digesting (other than me please) and who makes the judgement decisions about what gets moderated?

Does it require a login to be able to see the system outputs? It's important for prospective Bearhawkers to have context and realize that all machines have difficulties, and just because there is a place where they can hear about negative experiences, that doesn't mean the type is fraught with vulnerabilities. To this point, do we "tap the brakes" on public difficulty sharing because competing types might not be doing it, or do we serve our own community first, and educate the public on why we do that and why it is better? How do we balance keeping the information as free and open as possible, yet without discouraging the submissions on the input side, because the submitter knows that the writing will be public later, and might be seen or criticized out of context (this is our aspect of the non-punitive concept from above)?

Once information is collected, how should it be organized and accessible? If someone comes to the Bearhawk as a builder or a buyer and wants to see reports from others, should they be presented chronologically, or through some type of taxonomy like the topics at bearhawk.tips (articles there are sorted by subject matter and location on the airplane, like wings, tail, fwf, etc). I can see how each would be useful and simultaneously not so useful. A database-driven presentation could allow the viewer to be presented with either option (chronological or topical) but that requires someone, the submitter or otherwise, to categorize the submission. Who does that step?

Can a safety system be administered only by its users, or does there need to be some sort of governing safety committee (with varying levels of formality) that handles some of the initial policy-setting and ongoing tasks? Is there interest and willingness from Bearhawkers who are willing to do that work?

I'm asking these questions here because while I could create a system that works the way my brain wants it to work, that's not what we are needing. We need something that operates the way enough other people's brains work, so that they will use it.

It's so sad when occasionally some undesirable outcome (expense, damage, injury) happens in our community, no matter how large or small, and someone else says "I could have told you that". It is inconceivable to me that someone could own or build a Bearhawk and not participate here, subscribe to safety update emails, and read the Beartracks, which means there is a major opportunity for me to learn why that would be, and how we can make some type of SDR system that everyone will want to use.

[jaredyates]

Specifically as it relates to the forum, I struggle with the policy choice of tiered access. Should there be a section of the forum that is only open to certain qualifications, such as people who own a flying Bearhawk? My biggest concern is that it will discourage participation from someone who feels left out. My second biggest concern is that the kind of information shared in such a place is most important for the folks who are still building. But at the same time, if having a less-public venue encouraged participation from folks who were actually out there and flying, it may be worth it.

If there was a section of the forum that you didn't have access to, or if that section was read-only to you, would your feelings be hurt about it? What about if the information in there was exceptionally good?

[RobinDeMarco]

I would have no problem if a section for flying Bearhawks was made read-only to those of us still building. If we found something we had a question on or needed more information on, the main forum would still be here for us to ask. I think the biggest goal is to provide a space where the information can be shared and people feel comfortable doing so.

[jaredyates]

From the other thread:

The safety reporting system is a great idea, and while I don’t have all the answers I have a few opinions.
If we are defining the intent as creating a place to discuss safety issues, a forum makes sense. If it’s just a way to pass along safety info after the discussion has been had on our existing forum - perhaps just expanding the safety website is a better option. We can keep having the conversations on the existing forum with only a small bit of reorganizing.
On the assumption that we want to create a whole new safety conversation and data hub, I think the simplest and most straight forward location is right in a primary forum section. I am not sure how much freedom the forum has for customized organization and would consider a 2nd sister forum with identical login an option to give more flexibility in organizing. My reason for keeping it in the forum or sister forum is simplicity for the user - which is quite important for participation - and we really don’t seem to get a lot of random unwanted or particularly ignorant visitors (unless you do a lot more filtering than I have noticed - and thank you for letting my ignorant self slip through those cracks) so I don’t see a large threat of misinformation hurting the Bearhawk brand or similar issues. The ability to receive an email when a new safety topic is posted would be a boon as well.
Likewise, I think a post disclaimer at the top of each thread (or if we do the sister forum, a sticky thing on top of the opening page) would, if you feel it is necessary, give context to those who don’t understand aviation safety.
As for tiered access, I don’t see a lot of advantage there - at most just a tier for those who have started a project, own plans, or a flying BH. That way anybody who has a vested interest can get the information and will have at least some minimal context.

[Nev]

Jared I think your point regarding the sharing of safety related information is spot on. A close second is being able to easily access it. The forum is excellent in many aspects, but this is one area where in it's current form it doesn't cater well for. It currently contains quite a number of excellent safety related discussions, but they can be very difficult to find - even if you already know they are there. The 12 page fuel flow discussion comes to mind. It's also difficult to "connect the dots", with perhaps some people having a better understanding of a topic than others.

Safety Culture
We've got the makings of an excellent safety culture already as evidenced by the many good discussions and active forum participation. Also the fact that this thread has started its own discussion.

Collection
I feel that collecting the safety information needs to be done in a way that can be anonymous if needed, to encourage participation. Filing a safety related report is never easy. There's often a range of emotions attached, (including the inconvenience of filling out the form). If an incident has occurred then further discussion may be perceived as drawing further attention, and embarrassment, so perhaps keeping the collection "off-forum" and anonymous is one idea. The collection stage may end up collecting many small issues, some of which turn out over time to be irrelevant. But the system needs to be tolerant of this. A tag-like system behind the scenes might help to associate potentially related reports together.

Filtering
Possibly the more difficult part is deciding what constitutes an issue ? Are the symptoms pointing a deeper underlying issue, or should they simply be taken at face value ? This is an area that typically drew conflicting opinions on the forum. Some items are very straight forward - an example might be where a forum report was made that stainless steel control cables appear to be exhibiting signs of wear around the 300 hour mark, and others reported that the galvanized cables seems to last much longer. However other items are not so clear cut - the fuel cap discussion is perhaps a case in point where opinions weren't aligned. I don't have any clear ideas of how to accomplish this other than to appoint one or two objective trustworthy members of the Bearhawk community.

Publishing
The system needs an effective method of publishing safety bulletins and perhaps also disseminating them by email directly to builders and owners. This would then present all the safety issues in one easy to find place. Personally I like what Vans have done. It's open and transparent to everyone. Maybe a dedicated section of the forum ?

[AKKen07]

It sounds like maybe we could use a multi-part system here. I think an anonymous submission to selected community members could be a simple addition to the bearhawksafety website, whereas the main forum has been and should continue to be an excellent place for initial conversations that could result in less forum-style output by those same selected volunteers. Would it be simple to create a forum section or sister forum for the "official" more organized output without the ability for others to create threads? Since the bearhawksafety site is already there - maybe it could be expanded for this purpose. The volunteer(s) could select any topic that merits a bulletin and the forum community/anonymous submitters could make additional proposals. I think anyone with aviation experience who is active in the BH world could do a good job with said volunteer position, eh Nev....? Eh? We can't make Jared do EVERYTHING.

[Bissetg]

Mark and Bobs availability and willingness to talk on the phone about issues has been amazing, but the Bearhawk machine is getting bigger and it’s not fair or reasonable to expect them to be there for us at the drop of a hat given the numbers of new builds etc. Let’s keep them in reserve for the stuff we can’t communicate amongst ourselves and new issues rather than us all asking them the same question.

It seems to me that there is a willingness to build a data base of issues. This could be done by a tab on the website that opens a form for the user to submit the problem or observation. That will get the database underway.

The information could be then collated in a searchable way. Eg.

Type: 4B
Part affected: Fuel Cap
Issue: Fuel Cap lost in flight
Observation: Fuel caps poorly fitting requiring prizing out of filler neck and lubricant to make work preventing correct locking in place.

Corrective action: Check filler neck diameter, If filler neck ID is circa 44mm fit size smaller O rings to caps PN -323

Comments: Ensure EZlube is only on the fuel cap threads to prevent Galling, not in filler neck.


The risk is that we don’t want a safety system to be hijacked as a bitch/spam forum so it seems that some level of participation filter could be applied, or make it for plans holders only to submit but read only to others???

In my mind the key to the success of this system will be simplicity and effectiveness.

[Battson]

Publishing
The system needs an effective method of publishing safety bulletins ...

We need to think carefully about this, CAA / CASA / FAA etc may decide that these represent SBs or ADs and compliance may be considered mandatory in some jurisdictions, unless we clearly state otherwise.

Obviously it varies from country to country, however I have strong indications that CAA particularly would consider such things. This is particularly relevant at the point of issuing the initial Certificate of Airworthiness, when they review compliance with existing ADs / SBs. The lack of a formal safety reporting system for Bearhawk Aircraft LLC has been raising during that process on several occasions - they are actively looking for it.

For example, I have added a section below for consideration, which may address this issue:

Type: 4B
Part affected: Fuel Cap
Issue: Fuel Cap lost in flight
Observation: Fuel caps poorly fitting requiring prizing out of filler neck and lubricant to make work preventing correct locking in place.

Corrective action: Check filler neck diameter, If filler neck ID is circa 44mm fit size smaller O rings to caps PN -323

Compliance requirement: For Information Only / Optional
(could also say "Recommended", or "Mandatory" depending on the seriousness of the issue - but at that point you need someone from Bearhawk Aircraft LLC to make the decisions, as it drives behaviour / costs across the whole community. Maybe easier to state they are "For Information Only" or "Optional" and leave it at that)

Comments: Ensure EZlube is only on the fuel cap threads to prevent Galling, not in filler neck.

[Nev]

Very good point raised. Something we need to consider once the system structure is in place.

[jaredyates]

This is something that is definitely on my radar as the various notices and such go out, and would be for any other system as well.

[Utah-Jay]

The BH community is like a heard of cats, plans, kits and planes are sold and ownership can/would/will be tough to track. I think if there was a list of current owners of any of the three that could be used to send out notification of a needs change or watch items it would help in preventing any issues either known or on a watch list.

I am a newbie to all of this, but if we had a central reporting point to get the word out to the entire community it would be great.

OK, my uninformed idea has been posted, feel free to ignore me

[jaredyates]

We have the safety update email list which is around 300 people who have signed up to get emails when Bob puts out an update. We could probably either create a similar audience or ask that group if any would want to not opt in to expanded publication. But unfortunately some folks don't want to be contacted and there's not much we can do about that.

[Bissetg]

Taking Jays point on board about comments vs posts. which I think is valid, that is a good point you raise Battson. Should definitely be a part of the solution.

[jaredyates]

The collection of input is fairly straightforward but once we have all of that input, how do we make it useful? Would we just be creating another mountain of info for a builder/operator to have to parse upon entering the community? Is that info that they have to absorb somehow anyway and at least there would be a mountain available? As new folks come and experienced folks go, it's a constant process to refresh the knowledge. This problem isn't unique to Bearhawks or even to aviation, but an oversight or missing transfer is much more consequential in aviation, especially since most of us are the builder/mechanic/inspector/pilot all in one. If we're missing some bit of knowledge, all four of those people are missing the same thing.

[gregc]

Just my 2cents-

I think "Some sort of governing safety committee (with varying levels of formality)" is a good idea.

- It could identify things that are not design or kit manufacturing issues
- It could gather more information and coordinate questions/concerns that need to go to Mark or Bob
- Would provide some experience with trying to add a little structure to the community effort (which I suspect will be helpful as the Bearhawk population grows)
- It might make some folks more comfortable reporting issues if they knew some more experienced folks were reviewing them prior to the wider audience

[Utah-Jay]

I’d rather have too much information than not enough

[Nev]

The collection of input is fairly straightforward but once we have all of that input, how do we make it useful? Would we just be creating another mountain of info for a builder/operator to have to parse upon entering the community? Is that info that they have to absorb somehow anyway and at least there would be a mountain available? As new folks come and experienced folks go, it's a constant process to refresh the knowledge. This problem isn't unique to Bearhawks or even to aviation, but an oversight or missing transfer is much more consequential in aviation, especially since most of us are the builder/mechanic/inspector/pilot all in one. If we're missing some bit of knowledge, all four of those people are missing the same thing.

Perhaps we could have a couple of "moderators" who read and then tag each report appropriately. By tagging them we are able to link a bunch of potentially related issues.

An example is the large quantity of fuel system posts on the forum where a number of them report uneven fuel tank quantities during flight, and a couple report fuel starvation issues. On their own it could look like a fuel system issue. But when viewed in context with a number of other posts relating to pilots experiencing difficulty flying with the ball centered, a different picture starts to emerge.

In this case the data collection would have taken quite some time, however a safety bulletin can now be issued informing owners of the importance of flying with the ball centered. It can also mention a strategy to mitigate risk (keep more fuel reserves), and a method to measure your "flying in balance" accuracy over time (record and compare the fuel pumped into each tank upon refueling).

Once an awareness of the issue and the simple fix is raised, the more serious consequences would largely be mitigated and seemingly unrelated issues are then removed from the table. In a functional reporting system we would likely see a huge reduction in reports. If similar reports were still being submitted (and tagged) then we could see that perhaps they related to a different issue altogether that then would attract our attention.

I guess what I'm trying to say is that once we get a basic system in place, let's issue the obvious Safety Notices first and this should lead to a huge reduction in reports. The remaining reports will be easier to deal with and can be tagged and discussed by a small group of moderators.