Voluntary safety reporting systems are fundamental to identifying hazards before they result in accidents, yet their effectiveness depends entirely on how aviation professionals use such systems. While most organizations have established reporting channels and communicate just culture principles, the decision to submit a voluntary report remains deeply personal, influenced by trust in leadership, confidence in confidentiality, and belief that reporting will lead to meaningful change.
According to the U.S. Federal Aviation Administration (FAA), voluntary reporting without fear of reprisal is a critical component of aviation safety and a core element of a culture that prioritizes safety over competing goals and demands. “We strongly encourage everyone in the aviation industry to share information, and we thoroughly investigate all reports,” the FAA says.
According to Antonio Cortés, associate for aviation safety and human factors at GMR Human Performance, a British consulting firm of senior human factors professionals, even in organizations with a mature safety management system (SMS) and strong safety messaging, submitting a voluntary report is ultimately an individual decision made in a specific moment. “The strongest influencing factors are an employee’s sense of professionalism, his/her trust in a just culture, and most importantly, his/her belief that reporting will lead to meaningful action. That last factor often outweighs all others,” he says. “People ask themselves, sometimes unconsciously: Is this worth the effort, the exposure, and the emotional energy?”
According to Jurgita Baleviciene, head of safety at Avion Express, which provides aircraft, crew, maintenance, and insurance to other carriers, trust is the primary factor influencing safety reporting — specifically, trust in organizations and in those who process and investigate reports. “Just culture operates on a clear principle — if personnel admit mistakes openly and report them voluntarily, they will not face any disciplinary action,” she says “This recognises that everyone is bound to make a mistake every once in a while. However, just culture maintains clear boundaries —intentional safety violations are not tolerated, which is what distinguishes it from purely nonpunitive approaches.”
The European Union Aviation Safety Agency (EASA) believes that even in mature organizations, reporting decisions are shaped more by trust and perceived consequences than by the mere existence of a reporting channel. “There are a number of influencing factors for individuals, including perceived fairness (just culture in practice), confidence in confidentiality and protection, belief and feedback that the report leads to organisational learning, local leadership behaviour and the effort versus the benefit,” says an EASA representative. “Through the introduction of SMS software systems, many organisations have made great strides in making safety reporting easy, open and transparent.”
Encouraging reporting before having the capacity to process, prioritize, and act on reports is a fast way to destroy trust, according to Cortés. “If reports pile up without visible movement through the SMS hazard register, risk controls, and assurance loop, employees quickly conclude that reporting is symbolic rather than functional,” he says. “Leadership responses matter most in tone, timing, and transparency. When leaders acknowledge reports respectfully, avoid blame language, and clearly explain how reports feed into SMS decisions, trust accumulates one response at a time. Even when a recommendation cannot be adopted, a thoughtful explanation preserves credibility and keeps the reporting channel alive.”
When it comes to how leadership strengthens the decision to come forward, an important aspect is the need to make just culture predictable so that personnel see clear, consistent boundaries for human error and reckless behavior, according to the EASA representative. “In this way, they can anticipate fair treatment. Closing the loop through effective feedback on reports is important to ensure that follow-up and learning are part of the system,” the representative says. “Such learning should then be demonstrated through effective safety promotion and communication so personnel can see ‘you said/we did’ type examples, and show how reports changed procedures, training, resourcing, or design.”
According to John Goglia, a former U.S. National Transportation Safety Board (NTSB) member, the critical factor in the aircraft maintenance environment is whether personnel feel that their concerns are being heard. “This extends to the pilot community as well,” Goglia says. “Regardless of whether they submit a comment, or if one of their peers submits a comment, if it is essentially disregarded, then the cooperation level goes right down the drain. A good example of this is a major airline requiring first-line managers, if a suggestion or concern is brought to them, to get back to the person concerned by the end of the shift with some sort of answer.” The answer could be ‘I have referred it to the Safety Committee’ — essentially, it is an acknowledgment that one has been heard by management. This goes a very long way to keep the employees engaged.”
Experience with confidential reporting systems reveals that confidentiality is often less critical than organisations assume. “In practice, the majority of safety reports are not truly anonymous because the nature of the issue and the operational context typically make the source identifiable to those familiar with the operation. What matters is not whether the report is confidential, but whether the organisation responds effectively to the information provided,” Goglia says.
Beyond Formal Reporting
The FAA encourages safety reporting through voluntary and/or anonymous reporting programs. “Our compliance program aims to address and correct safety issues as effectively, quickly, and efficiently as possible,” the FAA says. “We also require airlines and certain manufacturers to have SMS.”
Baleviciene highlights the distinction between mandatory occurrence reports required by regulation and discretionary voluntary reports. “Mandatory reports represent baseline compliance, not how robust any given company’s safety culture is. The true measure of safety culture lies in voluntary reporting rates. At Avion Express, approximately 70 to 75 percent of all safety reports are voluntary. Some organisations see 100 percent mandatory reporting only, suggesting personnel report only what they absolutely must, and nothing more,” she says.
Several considerations influence the decision to file voluntary reports, according to Baleviciene. “One is trust in the system, as personnel must believe that reporting will not be used against them and that just culture actually functions in practice, not just in policy documents. Another consideration is organisational transparency; personnel need visibility into how reports are processed and what outcomes result. Without this transparency, even well-intentioned reporting systems fail to build the trust necessary for sustained voluntary reporting,” she says. “Company size considerations are also important. Smaller organisations (with perhaps 20 pilots) can move faster and offer family-like relationships, while larger ones provide greater anonymity. However, the determining factor is not so much the size of the company but how much it commits to acting on reports and maintaining trust, regardless of who submitted them.”
According to Goglia, the critical element in maintaining a functional reporting culture is demonstrating responsiveness through feedback. “Safety issues often require extended periods to investigate and develop mitigation strategies, sometimes taking weeks or months with no visible action. When reporters receive no communication during this process, they perceive the system as non-responsive,” he says. “This perception is amplified because safety concerns are rarely known to only one individual — multiple personnel are typically aware of the same hazard. If the wider group observes that reports generate no feedback or acknowledgement, future reporting will cease regardless of confidentiality protections.”
Beyond the technical aspects of reporting systems, aviation professionals consider social costs, career risks, peer perceptions, and potential consequences for colleagues, Cortés explains. “A maintenance technician may hesitate to submit a report that reflects poorly on a crew already under schedule pressure. A flight attendant may worry about being labelled ‘overreactive’,” he says. “A dispatcher may fear being seen as someone who slows the operation. These are not procedural barriers; they are human-factors and cultural barriers.”
Perception, rather than objective reality, frequently drives reporting behavior, making it one of the most challenging aspects for organizations to address, Cortés says. “If an employee believes that just culture principles were not followed after a report, even if disciplinary action occurred for unrelated reasons, that perception alone can suppress reporting,” he says. “Once such a perception is shared informally within a peer group, the chilling effect spreads quickly. Organisations can blunt this effect through deliberate training that explains how misperceptions arise, how just culture decisions are made, and why outcomes may not always be visible to everyone involved.”
An EASA representative observes that beyond understanding how to file reports, people weigh personal risks, uncertainty about what qualifies as reportable, cognitive load, and past experiences. “In our safety promotion work with the industry, we support organisations to help show to their staff that reports [are] a positive part of safety learning that supports effective risk management,” the representative says. “Reports that are incomplete, ambiguous, or ‘weak signals’ are welcomed as vital parts of a good safety system. Organisations are also encouraged to provide psychological safety at the front line by training supervisors in supportive debriefing and non-defensive listening.”
From an individual’s perspective, reporting decisions typically center on processes and procedures, according to Goglia. “Everything that is done in the airline environment has a process behind it saying we are supposed to follow these steps. For pilots, it is a checklist and following air traffic control. For mechanics, it is following the maintenance manual or a test document they may have to use for a particular job,” he says. “When personnel encounter problems with established processes, they tend to deliberate before acting. They will probably live with it for a while, and then they will say it is wrong, perhaps because there have been some issues. Finally, they will put something in writing. They are usually not very quick; they want to make sure they are right because they do not want to be criticized.”
Training also sets expectations about what a voluntary reporting system is and is not, according to Cortés. “Without proper framing, employees may assume the system functions like a help desk: Submit an issue, trigger an immediate fix, receive a tidy confirmation email,” he says. “In reality, a functioning SMS routes concerns into a structured process of hazard identification, ownership assignment, risk assessment, and, later, assurance that controls are effective. The safety office does not ‘deliver safety’ as a product; it facilitates communication and advises decision-makers. When organisations explicitly teach this model, frustration decreases, patience increases, and reporting becomes more resilient.”
System Effectiveness
An EASA representative affirms that reporters need to see tangible outcomes from their submissions. “The things that matter most are timely acknowledgement and meaningful feedback, clear evidence of impact (such as changes to procedures, training, staffing, tools, or risk controls communicated back to the workforce), the representative says, adding that fair and consistent treatment and respect for confidentiality also are critical.
According to Goglia, acknowledging the person who submits a report is fundamental. The feedback loop must be “truly effective … as it helps the employees feel like their contributions are valued and tangible,” he says. An organization can actually save significant financial resources by listening to some of the people who have frustrations dealing with a given process.”
Organizations with positive safety cultures promote a questioning attitude, and their leaders create a respectful work environment where trust, honesty, and open communication are fostered, according to the FAA. “This requires an intentional approach and framework, including periodic assessment to determine where things stand and where improvements can be made. It reinforces that everyone is personally accountable for safety and must remain vigilant for conditions and behaviors that can compromise it,” the FAA says.
According to Cortés, the effectiveness of a voluntary reporting system is not measured by report volume alone, but by whether reporters see their input shaping risk controls, procedures, training, or equipment changes within the SMS. “This applies equally to pilots, maintenance technicians, flight attendants, dispatchers, and air traffic controllers. When reports disappear into a black hole, participation evaporates,” he says. “When a director of safety reads reports revealing operational workarounds [that he or she] is perhaps completely unaware of, that feeling can quickly turn into pride. It means someone trusts the systems enough to surface a hidden vulnerability. Such moments suggest that an effective reporting system is not a sign of failure but of organisational humility. It allows leaders to learn faster than the accident rate. And if one cannot occasionally say, ‘I didn’t know that was happening,’ the reporting system probably is not telling the truth.”
At Avion Express, systematic feedback mechanisms operate through multiple integrated channels, explains Baleviciene. “After each report, the person who submitted it receives detailed feedback … explaining what measures were taken and what improvements resulted. This personal acknowledgment prevents reports from getting lost in bureaucracy and encourages continued reporting,” she says. “Beyond individual feedback, we incorporate the most significant investigations and lessons learned into annual two-hour safety review training sessions for pilots and cabin crew. This is practical feedback that shows real events and their resolutions, including both problematic situations and exemplary practices worth emulating.”
Avion Express also communicates with its employees through the Safety Express magazine it publishes every four months in both electronic and printed formats. The magazine features key investigations categorized by area, safety survey results, and articles addressing current challenges. “Company-wide communication of significant changes resulting from reports ensures that all personnel — not just individual reporters —- see the tangible impact of the reporting system,” Baleviciene says. “This combination of personal acknowledgment and organisational transparency transforms reporting from an administrative obligation into a recognised form of professional contribution that genuinely improves safety for everyone.”
Image: © guvendemir | iStockphoto
Mario Pierobon, Ph.D., is the owner and scientific director of a safety consulting and training organization.
