REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL on the implementation of Regulation (EU) No 376/2014 on the reporting, analysis and follow-up of occurrences in civil aviation
Date: 2020-11-16
Institutions: Directorate-General for Mobility and Transport, European Commission
Subjects: accident prevention, air safety, air traffic, civil aviation, data collection, disaster resilience, disclosure of information, exchange of information, information network, transport accident

EN 

  EN 

   EUROPEAN COMMISSION  Brussels, 16.11.2020  COM(2020) 733 final  REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL on the implementation of Regulation (EU) No 376/2014 on the reporting, analysis and follow-up of occurrences in civil aviation  
 
 
EXECUTIVE SUMMARY 

This  report  summarises  the  Commission's  review  of  Regulation  (EU)  No  376/2014  on  the 
reporting,  analysis  and  follow-up  of  occurrences  in  civil  aviation  (the  Regulation)1,  as 
foreseen  by  Article  24(2)  of  the  Regulation.  This  review  provides  feedback  on  the  current 
functioning of the Regulation five years after it entered into force. It puts in perspective the 
main  objectives  of  the  Regulation  and  it  underlines  its  achievements  in  improving  the 
completeness  and  quality  of  the  occurrence  reports,  increasing  the  number  of  reports 
submitted and stored, and enabling the protection offered to reporters. On the other hand, the 
report  highlights  some  of  the  difficulties  met  during  the  implementation  of  the  Regulation, 
especially  as  regards  the  implementation  of  the  provisions  related  to  “just  culture”.  Finally, 
the report discusses the contribution made by the Regulation in terms of reducing the number 
of aircraft accidents and related fatalities. The findings presented in this report are supported 
by the data gathered in a study, contracted by the Commission, to evaluate the implementation 
of Regulation (EU) No 376/2014 on the reporting, analysis and follow-up of occurrences in 
civil aviation2.  

FOREWORD 

Aviation accidents are often the result of a chain of events, meaning that often they cannot be 
attributed  to  a  single  cause.  However,  this  also  means  there  are  multiple  opportunities  to 
prevent  them  before  they  occur  and  if  any  link  in  such  a  fatal  chain  is  removed,  then  an 
accident may be avoided. 

A  crucial  element  in  preventing  aviation  accidents  is  reporting  and  careful  analysis  of  all 
events and failures, even the smallest, in daily operations, which may indicate the existence of 
potentially serious safety hazards that may lead to accidents if not corrected. 

Occurrence  reporting  takes  a  system-wide  and  data-driven  approach  to  accident  prevention 
and recognises that moving beyond blame, except in certain defined situations, is essential in 
enhancing safety in a proactive way – these notions have been confirmed through decades of 
safety and human factors research. 

The current legislation on occurrence is Regulation (EU) No 376/2014. The rules set out how 
relevant  safety information relating to  civil  aviation  is  reported,  collected, stored, protected, 
exchanged, disseminated, analysed and acted upon.  

1.  INTRODUCTION  

1    Regulation  (EU)  No  376/2014  of  the  European  Parliament  and  of  the  Council  of  3  April  2014  on  the 
reporting, analysis and follow-up of occurrences in civil aviation, amending Regulation (EU) No 996/2010 
of  the  European  Parliament  and  of  the  Council  and  repealing  Directive  2003/42/EC  of  the  European 
Parliament and of the Council and Commission Regulations (EC) No 1321/2007 and (EC) No 1330/2007, 
OJ L 122, 24.4.2014, p. 18, http://data.europa.eu/eli/reg/2014/376/oj.  
“Ex-post  evaluation  of  Regulation  (EU)  No  376/2014  on  the  reporting,  analysis  and  follow-up  of 
occurrences in civil aviation – Final Report”, not yet published.  

2  

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Article  24  of  Regulation  (EU)  No  376/2014  requires  that  by  16  November  2020  the 
Commission  publishes  and  submits  to  the  European  Parliament  and  to  the  Council  an 
evaluation report on the implementation of the Regulation.  

Regulation  (EU)  No  376/2014  is  applicable  as  from  15  November  2015.  It  aims  to  prevent 
aircraft  accidents,  incidents,  and  related  fatalities  through  feedback  and  lessons  learnt  from 
occurrences.  An  occurrence  is  a  safety-related  event  which  endangers  or  which,  if  not 
corrected  or  addressed,  could  endanger  an  aircraft,  its  occupants  or  any  other  person.  The 
Regulation  seeks  to  ensure  that  relevant  safety  information  relating  to  civil  aviation  is 
reported,  collected,  stored,  protected,  exchanged,  disseminated  and  analysed.  This  in  turn 
facilitates the elaboration of appropriate mitigating measures by aviation stakeholders and the 
competent authorities so a safety action can be taken in a timely manner.  

This safety management process is reliant on the continued availability of safety information. 
A  key  feature  in  ensuring  that  front-line  aviation  professionals  report  occurrences  that  may 
pose a significant  risk to aviation, is the assurance of confidentiality of the reporting source 
and  of  the  appropriate  use  of  information.  To  this  end,  the  Regulation  grants,  under  certain 
conditions,  the  protection  to  the  persons  reporting  the  occurrences  and  other  persons 
mentioned  in  occurrence  reports  and  ensures  that  the  information  is  used  for  safety 
improvement purposes only.  

This  proactive  and  evidence-based  approach  is  implemented  by  the  relevant  aviation  safety 
authorities  of  Member  States,  by  organisations,  as  part  of  their  safety  management  system, 
and by the European Union Aviation Safety Agency (EASA). 

Regulation (EU) No 376/2014 is complemented by an Implementing Regulation3 establishing 
a list of occurrences in civil aviation to be mandatorily reported.  

The Regulation was preceded by Directive 2003/42/EC4, which required each Member State 
to  set  up  a  mandatory  occurrence  reporting  system  (MORS).  Member  States  had  to  collect, 
store,  protect  and  disseminate  between  themselves  information  on  certain  civil  aviation 
incidents.  The  Directive,  however,  did  not  include  provisions  related  to  the  analysis  of  the 
data  collected,  for  the  benefit  of  aviation  safety.  Considering  other  reporting  requirements 
existing  in  parallel,  both  at  the  European  and  international  level,  led  Member  States  to 
implement  Directive  2003/42/EC  in  rather  diverging  approaches.  This  in  turn,  resulted,  for 
instance, in the existence of multiple occurrence databases at the European level. 

3   Commission  Implementing  Regulation  (EU)  2015/1018  of  29  June  2015  laying  down  a  list  classifying 
occurrences in civil aviation to be mandatorily reported according to Regulation (EU) No 376/2014 of the 
1, 
Council, 
European 
http://data.europa.eu/eli/reg_impl/2015/1018/oj.   

Parliament 

30.6.2015, 

163, 

and 

the 

OJ 

4   Directive  2003/42/EC  of  the  European  Parliament  and  of  the  Council  of  13  June  2003  on  occurrence 

of 

p. 

L 

reporting in civil aviation, OJ L 167, 4.7.2003, p. 23, http://data.europa.eu/eli/dir/2003/42/oj . 

2 

 
 
                                                           
Consequently,  the  2012  Impact  Assessment  for  the  proposal  for  the  occurrence  reporting 
regulation5 identified the following specific objectives of the new Regulation:  

  To ensure that all occurrences which endanger or would endanger aviation safety are 
collected and are providing a complete and clear picture of safety risks in the EU and 
its Member States 

  To  make  sure  that  occurrence  reports  stored  in  the  national  databases  and  in  the 

European Central Repository (ECR) are complete and contain high quality data 

  To  make  sure  that  all  safety-critical  information  stored  in  the  ECR  is  accessed 
adequately  by  competent  authorities  and  that  they  are  used  strictly  for  safety 
improvement purposes 

  To  ensure  that  reported  occurrences  are  effectively  analysed,  that  safety  hazards  are 
identified and addressed where relevant and that the safety effectiveness of the actions 
taken is monitored  

The  overall  objective  of  the  Regulation  is  to  contribute  to  the  reduction  of  the  number  of 
aircraft accidents and fatalities. 

2.  IMPLEMENTATION  

Establishment of mandatory and voluntary reporting systems – Articles 4 and 5  

The provisions on the establishment of mandatory (MORS) and voluntary (VORS) reporting 
systems, set out in Articles 4 and 5 of the Regulation, were implemented by both the Member 
States  and  EASA.  In  practice,  this  means  that  each  Member  State  has  established  both 
mandatory and voluntary reporting mechanisms at the level of its aviation authority. It should 
be  noted  though  that  the  Member  States  were  already  obliged  to  have  mandatory  reporting 
systems in place under Directive 2003/42/EC prior to Regulation (EU) No 376/2014.  

Similarly, EASA has a functioning mandatory reporting system in line with the requirement 
set out in Article 4(4) and voluntary reports can be submitted directly to the Agency via the 
European Aviation Reporting Portal established by the European Commission services6.  

Some  gaps  have  been  identified  in  the  implementation  of  these  requirements  by  the 
organisations7. Prior to Regulation (EU) No 376/2014, the scope of Directive 2003/42/EC did 
not cover the organisations. Therefore, there is a difference between organisations that already 
had reporting systems in place (as part of their respective safety management systems) prior 
to the implementation of the Regulation and those that had to introduce such systems after the 
Regulation’s  entry  into  force.  Whilst  for  the  former  the  implementation  of  the  Regulation 

5   COMMISSION STAFF WORKING PAPER: Impact Assessment Accompanying document to the Proposal 
for a Regulation of the European Parliament and the Council on occurrence reporting in civil aviation, 
SWD/2012/0441 final, https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX:52012SC0441. 

6   https://www.aviationreporting.eu/AviationReporting/. 
7  

‘organisation’ means any organisation providing aviation products and/or which employs, contracts or uses 
the services of persons required to report occurrences in accordance with Article 4(6). Regulation (EU) No 
376/2014, Art 2(8). 

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merely required alignment of their existing systems with the new requirements, the latter had 
to develop reporting systems anew. Consequently, it was found that some organisations were 
lagging  behind  in  the  development  of  reporting  systems  at  their  level,  thus  resulting  in  less 
reporting than could otherwise have taken place. Similarly, in the field of voluntary reporting, 
some  organisations  indicated  that  they  did  not  have  a  voluntary  reporting  system  in  place. 
Finally, it has  been noted that some organisations do not  distinguish  between voluntary and 
mandatory reporting systems, having only one reporting system in place. 

In  a  similar  vein,  the  majority  of  Member  States,  while  having  established  both  reporting 
systems, also do not distinguish between the reports received via the VORS and the MORS in 
their respective national databases, as they rather prefer encouraging organisations to submit 
all reports to them, regardless of their status. Consequently, it has been difficult to determine 
the respective numbers of mandatory and voluntary reports submitted, as there is no easy way 
to distinguish from which reporting systems the occurrences stored in the ECR originate. This 
in turn has made it difficult to get a clear picture as to the extent individuals and organisations 
subject to MOR have fulfilled the Regulation requirements.   

Whereas it appears from the above that there is a need for Member States to ensure effective 
implementation  by  concerned  parties  of  the  relevant  provisions  of  the  Regulation,  it  can 
nevertheless be determined that one of the key objectives of the Regulation  - to increase the 
available  data  on  occurrences  -  has  been  achieved.  This  objective  has  been  met  as  the 
effective  implementation  of  the  Regulation  has  resulted  in  an  increased  number  of  reports 
submitted  and  thus  a  greater  amount  of  available  aviation  safety  information.  The  total 
number  of  occurrence  reports  stored  in  the  ECR  has  increased  significantly  since  the  entry 
into  force  of  the  Regulation.  As  shown  in  Figure  1  below,  in  2015,  there  were  just  over 
200,000 occurrence reports in the ECR in the given year. In 2019, the total number of reports 
transferred to the ECR in one year reached 291,458. Cumulatively, the number of occurrence 
reports contained in the ECR more than doubled during this period: from 1,125,264 reports at 
the end of 2014 to 2,548,578 reports in 2019.  

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Figure 1: Number of records in the ECR (source: JRC overview of ECR-ECCAIRS content) 

Collection, storage and exchange of information – Articles 6 and 9  

The  Regulation  lays  down  the  requirements  for  the  collection,  storage  and  exchange  of 
information  in  Articles  6  and  9.  Article  6  aims  to  ensure  the  flow  of  information  through 
collection,  evaluation,  processing,  analysis and storage. More specifically, Article 6 sets  the 
requirement for the organisations, Member States’ authorities and EASA to designate persons 
and processes to collect, evaluate, process, analyse and store details of occurrences reported 
pursuant to Articles 4 and 5. Those requirements were found to be implemented in full by the 
organisations as well as by the Member States and EASA, with persons and processes being 
designated at each level.  

Article  9  sets  out  the  modalities  of  exchange  of  information  between  the  Member  States, 
EASA and the Commission through the ECR. It, inter alia, lays down a requirement that the 
Member  States  transfer  within  30  days  the  occurrence  data  uploaded  in  their  national 
databases.  The  Member  States  were  found  to  have  established  the  mechanisms  for  the 
exchange  of  information  with  other  Member  States  and  with  EASA,  and  for  the  transfer  of 
such information into the ECR within the required timeline.  

The reporting flow (i.e. who reports to whom and when) is generally well understood by all 
stakeholders  involved,  although  some  issues  have  been  identified.  Sometimes  the  details  of 
occurrences  are  uploaded  to  the  ECR  by  one  Member  State  with  no  notification  to  the 
Member States concerned. However, there is a general expectation that the new ECCAIRS 28 
software, discussed below in further detail, will help on this aspect. 

Quality and content of occurrence reports – Article 7 

The  Regulation  lays  down  specific  requirements  for  standardised  data  entry  processes  and 
quality checking processes. Majority of those provisions were found to be implemented by the 
organisations,  Member States and EASA. Nonetheless, some organisations do not  appear to 
have a formal quality checking process, as required by Article 7(3), in place. In addition, the 
development  of  a  common  European  risk  classification  scheme,  as  provided  for  in  Article 
7(5), was only implemented partially. While the Commission,  in  close cooperation with  the 
Member  States  ad  EASA,  developed  the  scheme  by  the  deadline  of  15  May  2017,  as 
envisaged in Article 7(5), the task of defining the scheme in accordance with Article 7(6) is to 
be finalised, together with its implementing arrangements.  

Management of the European Central Repository – Article 8  

The ECR itself is  an important  EU contribution.  It  stores all occurrence  reports collected in 
the EU. Member States and EASA are required to  transfer all information  relating to  safety 
stored  in  their  respective  databases  to  the  ECR  in  a  timely  manner.  The  national  data  is 
integrated  in  the  ECR  and  checked  in  accordance  with  quality  criteria.  Direct  access  to  the 

8   European Co-ordination Centre for Accident and Incident Reporting Systems. 

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ECR is subject to strict rules and limited to the Member States’ competent authorities, EASA, 
and the Commission9.  

From  the  Regulation’s  entry  into  force  until  the  end  of  2020,  the  Commission’s  Joint 
Research  Centre  (JRC)  provided  the  operational  services  related  to  the  ECR-ECCAIRS 
interface.  As  confirmed  by  the  JRC,  the  ECR-ECCAIRS  interface  has  been  fed  with  data 
originating from the 31 contributing States10, as well as from EASA, on a daily basis.  

Following  a  change  of  strategy  and  after  an  impact  study11,  and  with  a  view  to  further 
enhancing  the  implementation  of  this  Regulation,  it  has  been  decided  by  the  Commission 
services  to  replace  the  current  ECCAIRS  platform  by  a  more  modern,  fully  re-engineered 
platform called ECCAIRS 2, and to transfer the management of the ECCAIRS suite from the 
JRC to EASA as of 2020. 

The requirement laid down by Article 8(2) for the Member States to regularly update the ECR 
was found to be fully implemented by all Member States. This is also the case with respect to 
the  EASA  requirements,  set  out  in  paragraph  3,  where  the  data  transfer  to  the  ECR  occurs 
automatically.  In  addition,  EASA  has  an  agreement  in  place  with  the  Commission  for  the 
transfer of data from the Internal Occurrence Reporting System (IORS) to the ECR, to ensure 
full compliance and coverage.  

Access to information stored in the ECR – Articles 10, 11 and 12 

Articles 10, 11 and 12 stipulate the arrangements for access to the information stored in the 
ECR.  Those  provisions are  fully  implemented  by  the  Commission,  which  is  responsible  for 
the  processing  of  data  stored  in  the  ECR,  and  by  the  Member  States  (so  called  “points  of 
contact”) who assist the Commission in relation to the requests for information stored in the 
ECR.  

Since  the  Regulation’s  entry  into  force  until  31  December  2019,  there  were  total  of  86 
requests for information based on Article 11 of the Regulation out of which six were refused 
on various grounds.  

Occurrence analysis and follow up – Articles 13 and 14  

Similar  to  requirements  for  reporting,  some  requirements  for  the  analysis  were  already  in 
place  prior  to  the  entry  into  force  of  the  Regulation  as  part  of  safety  management 
requirements. The provisions of the Regulation, as also stated in the guidance material for the 
Regulation12,  are  not  intended  to  create  another  analysis  requirement  alongside  the  safety 
management  requirements,  but  serve  the  purpose  of  reinforcing  the  need  for  the  analytical 

9   Regulation (EU) No 376/2014, Arts 8 and 10. 
10   EU  Member  States  (including  the  United  Kingdom,  until  1  February  2020),  Norway,  Iceland,  and 

Switzerland.  

11   Bearing Point, “Impact Assessment of ECCAIRS transition from JRC to EASA”, 12 June 2017.  
12   European  Commission,  “Guidance  Material  -  Regulation  (EU)  No  376/2014  and  its  implementing  rules” 
(2015) https://ec.europa.eu/transport/sites/transport/files/modes/air/safety/doc/guidancematerial376.pdf .  

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processes to be carried out. The overall situation has therefore not changed much, except for 
the introduction of strict timelines.  

As  regards  the  point  on  strict  timelines,  there  is  no  evidence  suggesting  that  the  30-days 
deadline for the preliminary analysis of occurrences by the organisations, laid down in Article 
13(4) and 13(5) is generally not complied with. However, many industry stakeholders noted 
that the timeline of 30 days for providing the preliminary analysis of the occurrences to the 
competent  authority  is  too  short.  Moreover,  the  Regulation  also  sets  a  deadline  of  three 
months from the initial report for the organisations to submit their final analysis. Regulation, 
however, allows for the possible extension of that deadline if duly justified13. 

At Member State level the Regulation requires the monitoring of the analysis by organisations 
which  they  oversee,  as  well  as  the  carrying  out  their  own  analysis  of  occurrences  directly 
reported  to  them.  On  the  basis  of  their  analysis,  they  are  expected  to  determine  any 
appropriate  corrective  or  preventive  action  required  to  improve  aviation  safety,  and  use 
information  obtained  from  the  analysis  of  occurrence  reports  to  identify  remedial  action. 
Similar to organisations, the competent authorities in the Member States all have processes in 
place to analyse occurrences. However, there are differences in the degree to which analyses 
are carried out and the depth of these analyses. The main reasons for this are concerns about 
the  clarity  of  the  requirements  for  analysis  at  national  level,  as  well  as  a  lack  of  resources. 
Furthermore,  some  Member  States  noted  a  degree  of  ‘imbalance’  between  the  requirements 
for  analysis  laid  down  by  the  Regulation  and  the  degree  of  details  included  in  the 
requirements  for  reporting,  collecting,  processing  and  storing  occurrences.  This  imbalance 
leads to a high workload associated with the collecting and processing of occurrence reports 
and leaves little time for the analysis and follow-up. 

At the EU level, there are two streams of analysis: EASA’s analysis of occurrences reported 
directly to the Agency by organisations for which EASA acts as a competent authority (based 
on  occurrences  stored  in  EASA’s  own  database)  and  a  collaborative  analysis  done  together 
with  Member  States.  Those  analyses  result  in  the  publication  of  the  EASA  Annual  Safety 
Reviews  and  in  the  development  of  Safety  Risk  Portfolios  (SRPs),  which  are  used  in  the 
publication of the European Plan for Aviation Safety (EPAS).  

The  EASA  Annual  Safety  Review  is  produced  by  the  Safety  Intelligence  and  Performance 
Department  of  EASA  and  is  based  on  the  data  contained  both  in  EASA’s  own  Occurrence 
Database as well as data contained in the ECR. As part of its risk management process, the 
Agency  also  defines  and  implements  appropriate  actions,  which  are  subject  to  a  continuous 
monitoring.  

EASA works with a range of collaborative partners through two main platforms: the Network 
of Analysts (NoA)14 and the Collaborative Analysis Groups (CAGs)15. The NoA is set up by 

13   Regulation (EU) No 376/2014, Art 13(4).  
14   The  NoA  comprises  EASA,  the  European  Commission,  EASA  Members  States  and  an  observer.  It  was 
initially  formed  as  a  voluntary  network  to  support  the  analysis  of  safety  data  for  the  European  Aviation 
Safety  Plan,  which  is  the  predecessor  to  the  EPAS,  in  2011.  The  implementation  of  Regulation  (EU)  No 
376/2014  has  formalised  the  role  of  the  NoA  and  underscored  the  importance  of  safety  analysis  in 

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Regulation (EU) No 376/2014 and pulls together data from different Member States to get a 
more  general  picture  of  safety  hazards  faced  by  the  EU  as  a  whole.  The  CAGs  are  expert 
groups set up by EASA that are responsible for analysing the safety of European aviation for 
specific aviation domains. They review available safety information, arrange in depth safety 
analyses  and  identify  emerging  issues.  They  also  monitor  the  safety  performance  of  their 
domain  and  provide  feedback  on  the  effectiveness  of  actions  taken.  Both  systems  are 
complementary  because  they  provide  analysis  at  different  levels  and  they  contribute  to  the 
Safety Risk Portfolios and to the safety actions which may be adopted in the EPAS. 

It  can  therefore  be  determined  that  the  implementation  of  the  Regulation  has  played  a 
significant  part  in  enhancing  the  analytical  capability  of  occurrences  throughout  the  Union, 
and  consequently  also  in  determining  appropriate  mitigating  measures  where  needed. 
Although considerable progress was noted, the analytical process is one likely to benefit from 
more effort at the Member State level and further technological developments. 

Confidentiality  and  appropriate  use  of  information  and  protection  of  the  information 
source – Articles 15 and 16  

The implementation of the Regulation’s provisions related to “just culture” and the protection 
and  appropriate  use  of  the  source  of  information  was  closely  analysed.  While  it  was  found 
that  all  Member  States  and  majority  of  the  organisations  put  in  place  processes  to  ensure 
anonymization of occurrence reports, the issue with traceability  – i.e. the possibility to infer 
the  persons  concerned  in  an  occurrence  report  based  on  the  circumstances  described  in  the 
report – remains, especially in the smaller organisations with less employees.  

Article 16(11) lays down an obligation for the organisations to adopt internal “just culture”16 
rules. The available information is not conclusive on whether this requirement has been fully 
implemented by all organisations.  

The  most  significant  shortcoming  in  the  implementation  of  the  Regulation  was  found  in 
relation  to  the  obligation  laid  down  in  Article  16(12)  for  the  Member  States  to  designate  a 
body responsible for the implementation of the “just culture” principles. Based on the reviews 
of the reports on the functioning of the “just culture bodies” submitted by the Member States 
in  accordance  with  Article  16(13)  and  additional  information  received  from  citizens,  the 
Commission  identified  11  Member  States  that  failed  to  designate  a  “just  culture  body” 
responsible for the implementation of paragraphs 6, 9 and 11 of Article 16. As a consequence, 
the Commission opened infringement cases and sent out 10 Letters of Formal Notice and one 

supporting the EPAS and improvement of aviation safety in Europe. The NoA currently meets twice a year 
and  on  ad-hoc  basis  whenever  is  needed.  Source:  https://www.easa.europa.eu/easa-and-you/safety-
management/safety-risk-management  

15   The CAGs consist of groups of industry stakeholders of EASA’s regulatory partners. Each CAG meets up to 
three  times  per  year.  There  are  currently  six  different  CAGs:  (1)  aerodrome  and  ground  handling;  (2)  air 
traffic management; (3) balloons; (4) commercial air transport aeroplanes; (5) general aviation; (6) human 
factors. Source: https://www.easa.europa.eu/easa-and-you/safety-management/safety-risk-management 
16   ‘just  culture’  means  a  culture  in  which  front-line  operators  or  other  persons  are  not  punished  for  actions, 
omissions or decisions taken by them that are commensurate with their experience and training, but in which 
gross negligence, wilful violations and destructive acts are not tolerated. Regulation (EU) No 376/2014, Art 
2(12). 

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Reasoned  Opinion  to  the  non-compliant  Member  States17.  The  Commission  also  sent  out  a 
number  of  EU  Pilots  to  the  Member  States  that  stated  in  their  reports  to  have  designated  a 
“just  culture  body”  but  where  there  were  still  doubts  as  to  whether  such  body  has  the 
competencies to discharge the function envisaged in the Regulation.  

On the other hand, at the industry level, the European social partners, members of the sectoral 
social  dialogue  committee for  civil  aviation  (CANSO, ETF, ATCEUC),  have jointly  agreed 
on  the  “ATM  Just  culture  tool  box”18.  It  targets  staff  and  managers  within  organisations 
providing  air  traffic  management  /  air  navigation  services  and  sets  guiding  principles  for 
implementing just culture and fostering a healthy and open reporting culture. 

3.  CONTRIBUTION  TO  REDUCING  THE  NUMBER  OF  AIRCRAFT 

ACCIDENTS AND RELATED FATALITIES  

The  general  objective  of  the  Regulation  is  to  contribute  to  the  reduction  in  the  number  of 
aircraft  accidents  and  fatalities  through  a  proactive  approach  resulting  from  the  specific 
objectives detailed in the preceding sections.  

The  degree  to  which  the  Regulation  has  directly  contributed  to  an  actual  decrease  in  the 
number  of  accidents  and  fatalities  in  civil  aviation  has  proven  difficult  to  measure,  both 
quantitatively and qualitatively.  

The  data  recorded  by  EASA  show  that  between  2010  and  201819  the  number  of  accidents 
involving the European operators has decreased in average terms. The decrease is even more 
evident  when  put  into  perspective  with  the  continuous  increase  in  air  traffic  in  the  same 
period. The rate of accidents has continuously decreased since 2014, while the rate of serious 
incidents stabilised after a peak in 2016.  

The  analysis  of  a  counterfactual  scenario,  i.e.  the  scenario  where  the  Regulation  would  not 
have been  adopted, suggests that in  the absence  of the Regulation, the rate of  civil  aviation 
accidents in Europe would have followed a constant trend after the third quarter of 2015 (after 
the Regulation entered into force). After the entry into force of the Regulation, there has been 
a decrease in the accident rate, from 3.5 accidents per 1 million flights to 1.3 accidents per 1 
million flights post-intervention.   

It has, however, not proven possible to do a retroactive prediction, with certainty, of the safety 
situation  and  the  number  of  accidents  and  other  safety  related  occurrences  that  would  have 
occurred in the absence of the Regulation. It also needs to be noted that the various elements 

17   The  Reasoned  Opinion  was  closed  as  the  State  provided  the  evidenced  that  the  Just  Culture  Body  was 
designated with the necessary competences to execute its function under Article 16(12) of the Regulation. 
The rest of the cases are still pending.   

18   https://ec.europa.eu/social/BlobServlet?mode=dsw&docId=11897&langId=en. 
19   EASA, ‘Annual Safety Review 2020’ (2020) 

https://www.easa.europa.eu/sites/default/files/dfu/easa_asr_2020.pdf;   
EASA, ‘ Annual Safety Review 2019’ (2019) 
https://www.easa.europa.eu/sites/default/files/dfu/Annual%20Safety%20Review%202019.pdf;   
EASA, ‘Annual Safety Review 2018’ (2018) 
https://www.easa.europa.eu/sites/default/files/dfu/218639_EASA_ASR_MAIN_REPORT_2018.pdf.  

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of the aviation safety system - aiming at the prevention of accidents and serious incidents - are 
closely interlinked and therefore it would be extremely difficult to single out the effect of just 
one of its features – i.e. the occurrence reporting, analysis and follow-up.  

Nevertheless,  given  that  the  Regulation  contributed  to  the  increase  of  the  number  of 
occurrence  reports  stored  in  the  ECR,  which  in  turn  might  have  had  contributed  to  the 
improvement of safety awareness and identification of safety risks, it may be ascertained that 
the Regulation has likely made a certain contribution to the reduction of the total number of 
accidents. 

4.  CONCLUSION 

Overall,  all  its  subjects  –  i.e.  the  Commission,  EASA,  the  EU  Member  States  and  the 
organisations  -  have  implemented  Regulation  (EU)  No  376/2014.  Nonetheless,  some 
shortcomings in  the implementation  of some of the Regulation’s provisions were identified. 
Most  notably,  a  significant  portion  of  the  Member  States  failed  to  designate  a  “just  culture 
body”  in  accordance  with  the  Regulation,  which  resulted  in  infringement  cases  being 
launched by the Commission.  

On  the  other  hand,  the  successful  implementation  of  the  Regulation’s  requirements  on  the 
establishment of mandatory and voluntary occurrence reporting systems resulted in a notable 
increase  in  the  number  of  occurrences  collected  since  the  Regulation’s  entry  into  force.  In 
addition,  the implementation  of the provisions on the establishment and  management of the 
European  Central  Repository  resulted  in  a  comprehensive  database  containing  occurrence 
reports  from  all  EU  Member  States.  More  occurrence  reports  to  be  analysed  then  in  turn 
allowed identification of potential safety hazards, particularly at the Member State and EASA 
levels. Consequently, it can be concluded that the Regulation, since its entry into force, has to 
some extent contributed to the reduction of accidents and related fatalities in the EU.  

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