KEMENTERIAN PERHUBUNGAN

DIREKTORAT JENDERAL PERHUBUNGAN UDARA

PERATURAN DIREKTUR JENDERAL PERHUBUNGAN UDARA

NOMOR : KP 242 TAHUN 2017

TENTANG

PETUNJUK TEKNIS

PERATURAN KESELAMATAN PENERBANGAN SIPIL BAGIAN 19-02

(STAFF INSTRUCTION 19-02)

SISTEM PELAPORAN SUKARELA

VOLUNTARY REPORTING SYSTEM (VRS)

DENGAN RAHMAT TUHAN YANG MAHA ESA

DIREKTUR JENDERAL PERHUBUNGAN UDARA,

Menimbang : a. bahwa pada butir 19.59 dalam Lampiran Peraturan

Menteri Perhubungan Republik Indonesia Nomor

PM 62 Tahun 2017 tentang Peraturan Keselamatan

Penerbangan Sipil Bagian 19 (Civil Aviation Safety

Regulations Part 19) tentang Sistem Manajemen

Keselamatan (Safety Management System) telah

mengatur bahwa setiap penyedia jasa penerbangan

harus melaporkan data kejadian dan informasi terkait

keselamatan lainnya yang telah diperoleh dari sistem

pelaporan sukarela (voluntary reporting system) kepada

Direktorat Jenderal Perhubungan Udara;

b. bahwa perlu disusun petunjuk teknis bagi Direktorat

Jenderal Perhubungan Udara untuk memproses data

kejadian dan informasi terkait keselamatan lainnya

sebagaimana dimaksud pada huruf a;

c. bahwa berdasarkan pertimbangan sebagaimana

dimaksud dalam huruf a dan huruf b, perlu

menetapkan Peraturan Direktur Jenderal Perhubungan

Udara Tentang Petunjuk Teknis Peraturan

Keselamatan Penerbangan Sipil Bagian 19-02 (Staff

Instruction 19-02) Sistem Pelaporan Sukarela (VoluntaryReporting System (VRS);

Mengingat : 1. Undang-Undang Nomor 1 Tahun 2009 tentangPenerbangan (Lembaran Negara Republik Indonesia

Tahun 2009 Nomor 1, Tambahan Lembaran Negara

Republik Indonesia Nomor 4956);

2. Peraturan Presiden Nomor 7 Tahun 2015 tentang

Organisasi Kementerian Negara (Lembaran Negara

Republik Indonesia Tahun 2015 Nomor 8);

3. Peraturan Presiden Nomor 40 Tahun 2015 tentang

Kementerian Perhubungan (Lembaran Negara Republik

Indonesia Tahun 2015 Nomor 75);

4. Peraturan Menteri Perhubungan Nomor PM 189 Tahun

2015 tentang Organisasi dan Tata Kerja Kementerian

Perhubungan (Berita Negara Republik Indonesia Tahun

2015 Nomor 1844) sebagaimana telah beberapa kali

diubah, terakhir dengan dengan Peraturan Menteri

Perhubungan Nomor PM 44 Tahun 2017 tentangPerubahan Kedua atas Peraturan Menteri

Perhubungan Nomor PM 189 Tahun 2015 tentangOrganisasi dan Tata Kerja Kementerian Perhubungan

(Berita Negara Republik Indonesia Tahun 2017 Nomor

816);

5. Peraturan Menteri Perhubungan Nomor PM 62 Tahun

2017 tentang Peraturan Keselamatan PenerbanganSipil Bagian 19 (Civil Aviation Safety Regulations Part19) tentang Sistem Manajemen Keselamatan [SafetyManagement System) (Berita Negara RepublikIndonesia Tahun 2017 Nomor 1098);

MEMUTUSKAN:

Menetapkan : PERATURAN DIREKTUR JENDERAL PERHUBUNGAN

UDARA TENTANG PETUNJUK TEKNIS PERATURAN

KESELAMATAN PENERBANGAN SIPIL BAGIAN 19-02 (STAFFINSTRUCTION 19-02) SISTEM PELAPORAN SUKARELA

(VOLUNTARY REPORTING SYSTEM (VRS).

Pasal 1

Memberlakukan Peraturan Direktur Jenderal Perhubungan

Udara Tentang Petunjuk Teknis Peraturan Keselamatan

Penerbangan Sipil Bagian 19-02 (Staff Instruction 19-02)

Sistem Pelaporan Sukarela (Voluntary Reporting System (VRS)

sebagaimana tercantum dalam Lampiran yang merupakan

bagian tak terpisahkan dari Peraturan Direktur Jenderal ini.

Pasal 2

Direktur Jenderal Perhubungan Udara melakukan

pengawasan terhadap pelaksanaan Peraturan ini.

Pasal 3

Peraturan ini mulai berlaku sejak tanggal ditetapkan.

Ditetapkan di Jakarta

pada tanggal 22 September

DIREKTUR JENDERAL PERHUBUNGAN UDARA

ttd

Dr. Ir. AGUS SANTOSO, M.Sc

lai dengan aslinyaKEPALA BAGIAN HUKUM,

\

ENDAH PURNAMA SARI

Pembina (IV/a)NIP. 19680704 199503 2 001

LAMPIRAN

PERATURAN DIREKTUR JENDERAL PERHUBUNGAN UDARAnomor : RP 242 TAHUN 2017tanggal : :22 SEPTEMBER 2017

Staff Instruction

SI 19 - 02

Voluntary Reporting System (VRS)

Edition

Amendment

Date

REPUBLIC OF INDONESIA - MINISTRY OF TRANSPORTATIONDIRECTORATE GENERAL OF CIVIL AVIATIONJAKARTA - INDONESIA

SI 19-02

AMENDMENT RECORD LIST

Amendment

No.Issue Date Inserted By Insertion Date

Original

1. PURPOSE

2. REFERENCES

3. CANCELLATION :

4. AMENDMENT

SI 19 - 02

FOREWORD

This Staff Instruction prescribes responsibilities,

policies, and procedures to be used by the Directorate

General of Civil Aviation (DGCA) for the processing of

Voluntary Reporting System in accordance with CASR

Part 19. This Staff Instruction may be made available

to the public so that they may better understand the

authority and responsibilities of the DGCA.

This Staff Instruction should be used in accordance

with the applicable regulations.

The amendment of this Staff Instruction is approved by

Director General of Civil Aviation.

DIRECTOR GENERAL OF CIVIL AVIATION

Signature.

Dr. Ir. AGUS SANTOSO, M.Sc.

Salinan sesuai dengan aslinyaKEPALA BAGIAN HUKUM,

ENDAH PURNAMA SARI

Pembina (IV/a)NIP. 19680704 199503 2 001

Mi

SI 19-02

CHAPTER 1 GENERAL

1. PURPOSE

This staff instruction prescribes responsibilities, policies and procedures tobe used by the DGCA for processing Voluntary Reports.

2. REGULATORY REFERENCES

Civil Aviation Safety Regulation (CASR) Parts 19 established the regulatorybasis for reporting voluntarily detail ofoccurrences and other safety relatedinformation that may not be captured by the mandatory reporting systemwhich is perceived by the reporter as an actual or potential hazard to

aviation safety. Such reports may involve occurrences, hazards or threatsrelevant to aviation safety.

3. APPLICABILITY

This staff instruction applies to VRS Administrator team, Coordinator, SSPData Analyst and SSP Data Base IT programmer, SSP Representative (FocalPoint) Safety Representative Regional Office.

4. DEFINITIONS

a. Voluntary Report

Areport that is reported by aviation personnel voluntarily on actual or

potential safety deficiencies in their areas that would otherwise not be

reported through other channels, in order to enhance aviation safety.

b. Aviation Personnel

Aviation Personnel is an individual directly involved in aviation or an

organization involved in aviation ofwhich the individual belongs to anyof these groups:

1) Flight operations:

a) departure/en route/approach and landing;

b) aircraft cabin operations;

c) air proximity events;

d) weight and balance and performance.

1

SI 19-02

2) Aerodrome operations:

a) aircraft ground operations;

b) movement on the aerodrome;

c) fuelling operations;

d) aerodrome conditions or services;

e) cargo loading.

3) Air traffic management:

a) ATC operations;

b) ATC equipment and navigation aids;

c) crew and ATC communications.

4) Aircraft maintenance:

Aircraft/engine/component maintenance and repair activities.

5) Design and manufacturing:

Aircraft/engines/components design or production activities.

6) Approved training organizations:

Training activities involving flight operations.

7) Miscellaneous:

Passenger handling operations related to safety; etc.

c. Vision

It is a voluntary reporting system for improvement ofaviation safety inRepublic of Indonesia. It is also an abbreviation of "VoluntaryInformation for Safety Improvement in aviation". Because it is easy foraviation community in Indonesia to recognize, it will be used for

promotion of Voluntary Reporting System.

d. Analysis review working group (WG)

The WG is to confirm the analysis of report and comment for feedback

before a Voluntary Report Bulletin will be published to the aviation

community. The WG consist the SSP Office member and some expertswho DGCA assigned from an aviation community.

SI 19-02

e. Analysis report bulletin

It is to publish the analysis of report and comment of report to anaviation community.

SI 19-02

CHAPTER 2 PURPOSES OF VOLUNTARY REPORTS SYSTEM

The purpose of the Voluntary Reporting System is to enhance aviation

safety through the collection of reports on actual or potential safetydeficiencies which is directly reported by front-line personnel since theyobserve hazards as part of their daily activities.

The Voluntary Reporting System provides a channel for the voluntaryreporting of aviation occurrences or hazards or threats relevant to aviation

safety that would otherwise not be reported through Mandatory OccurrenceReport while protecting the reporter's identity.

The Voluntary Reporting System is a voluntary, non-punitive, confidentialreporting system established by the DGCA.

Reporters are encouraged to make use of their organization's internal SMS

voluntary reporting system where applicable, unless they have no access to

such a system or the incident or hazard is deemed beyond the scope of theirorganization's purview.

SI 19-02

CHAPTER 3 ADMINISTRATION OF VOLUNTARY REPORTS

1. RESPONSIBILITIES

a. The SSP Office is the office of primary responsibility for theoperation of the Voluntary Reporting System.

b. The SSP Administrator team are responsible for receiving andprocessing of the VRS and confirm whether the condition of voluntaryreport is satisfied or not and process it necessarily.

c. The SSP Coordinator are responsible:

1) to hold Analysis Review Working Group Meeting for review theanalysis once in three months;

2) to coordinate with focal point of related directorate to resolve highrisk situation;

3) to coordinate with focal point of DGCA regional office to resolve highrisk situation in his region;

4) to publish Voluntary Report Bulletin to aviation community once inthree months.

d. The SSP Data Analyst are responsible:

1) to analyze a voluntary report and make the draft of an analysisstudy sheet;

2) to make a Voluntary Report Bulletin once in three months.

e. The SSP Data Base IT Programmer must maintain the Website and

the Database of VRS.

2. RECEIPT OF REPORTS

Voluntary Reports are reported by the aviation personnel and/ororganization via various channels using forms as listed in the AC 19-02 VRS

Appendix 1-4.

SI 19-02

3. HANDLING OF THE VOLUNTARY REPORT

When the Voluntary Report received by the Administrator team via the 4

(four) sources as stated at paragraph 2 above, the report will be processedin accordance with Appendix A: Voluntary Report Flow Chart. TheAdministrator team receiving voluntary reports must confirm that thereports adhere to the following valid report requirements.

Valid Report Requirements:

1) The report is valid if the report was provided by an individual directlyinvolved in aviation or organizations involved in aviation of which theindividual belongs to.

2) The report is valid if during aviation activities, the individual directlyexperienced using his/her five senses an events adhering to thefollowing conditions (hearsay from third-parties are excluded):

a) An event that has the possibility to affect the safety of civilianaviation activities.

b) An event that is not required to be reported under MOR system andother related regulations, such as CASR 121.703 and CASR

135.703.

Additionally, for non-adhering reports, the Administrator team must

communicate to the individual providing the report that it cannot beaccepted.

After the communication, the Administrator must delete the report.

4. INTERVIEW REQUIREMENTS

The Administrator team should interview the reporter individually in casewhere the information is judged* to be insufficient to understand and

analyze the event being reported as follow.

When the Administrator team doesn't have clear information about what

happen to a reporter concretely even though the Administrator team check

the content ofa report, the Administrator team should interview to get moreinformation**

*it is important factor that the report includes 5W1H (Who, When, Where,What, Why, How). Therefore, the Administrator team should note it.

SI 19-02

*The Administrator team should recognize that it might be difficult to getmore information for analysis because the reporter can explain hazardsituation only, unlike investigation of aircraft accident and incident.

5. REMOVING CONCEALMENT INFORMATION FROM REPORT

After the above procedures 3 and 4 are complete, the Administrator team

must remove any information that may be used to identify individuals or

companies (Example: Person names, company names, e-mail addresses,physical addresses, phone numbers, flight numbers, etc.*) from thedatabase, etc.

After the concealment information, the Administrator team must register itto the Database.

6. ANALYSIS AND OTHER TASKS

a. After the above procedure 5 is complete, the SSP Data Analyst mustconsider the hazard of the event which includes the report and theworst-case scenario of the event which includes the report.

b. After the consideration, the SSP Data Analyst must analyze* the risk ofthe event using the ICAO safety risk assessment matrix Appendix B,based on the hazard and the worst-case scenario which the SSP Data

analyst considered.

c. If the SSP Data Analyst found High(Red) Risk condition, then :

1) The SSP Data Analyst must inform the SSP manager quickly.

2) When the SSP manager has been informed High Risk condition, the

SSP manager must inform SSP Coordinator to communicate with

focal point related directorate.

3) Focal point will inform related Directorate to direct service providerto resolve high risk situation.

d. If the SSP Data Analyst analyzed Moderate (Yellow) and Low (Green)Risk, then

1) The SSP Data Analyst must do classification by choosing theprimary factor, the related factor (if necessary) and the human

factor (if necessary) from the Factor Classification Table AppendixC.

SI 19-02

2) After the classification, the SSP Data Analyst must make Analysisstudy sheet Appendix D, based on the contents of report, theresult of consideration and analysis.

3) Moreover, the SSP Data Analyst must consider the comment of thereport and must add it to the sheet.

7. ANALYSIS REVIEW WORKING GROUP

a. To hold the Analysis Review Working Group (WG) once in threemonths, the SSP Coordinator must coordinate the date of the AnalysisReview Working Group with SSP Office member.

b. Analysis Review Working Group consist ofthree categories such as:

1) Large Aircraft/ Air Navigation Service

2) Small Aircraft/ Air Navigation Service

3) Cabin / Mechanic / Airport / Other

c. After the date of the Analysis Review Working Group (WG) has decided,the SSP Coordinator must inform the date to the Analysis ReviewWorking Group by letter and ask the SSP Data Analyst to prepare theAnalysis study sheet by letter.

d. At the WG, The SSP Data Analyst must explain content of the Analysisstudy sheet to the Analysis Review Working Group member.

e. The Analysis Review Working Group member must review the Analysisstudy sheet especially contents of the Hazard, the Primary Factor,Related Factor, the Human Factor, the Worst-Case Scenario Risk

Analysis and Comment.

f. If necessary, the Analysis Review Working Group member must show

their comment and opinion to the Analysis study sheet and ask the

SSP Data Analyst to revise the Analysis study sheet based on thecomment and the opinion.

g. After the WG, the SSP Data Analyst must revise the Analysis studysheet and update the Database by filling the additional information.

8

SI 19-02

8. ANALYSIS COMMITTEE APPROVAL

a. After the above procedure 7 is completed, the SSP Data Analyst mustproduce a Voluntary Report Bulletin by using bulletin format AppendixE, based on the content and comment ofAnalysis study sheet.

b. Voluntary Report Bulletin consists of three categories, Large aircraft/ANS, Small aircraft/ ANS, and Cabin / Mechanic / Airport / Other.

c. SSP Coordinator should share the Voluntary Report Bulletin to aviationcommunity.

SI 19-02

APPENDIX A VOLUNTARY REPORT FLOW CHART

SayThank you to the Reporter

: 1 Delete the report2. Inform it to reporter

"~]No

i Itme report cannotbeaccepted j

1. Revise a ECflactilncase of Interview)2. Removing Identify information from areport

3 Register a report to the Database.

t Database

Reporter requested to report toMOR system

ReporterInterview

1. Consider the Hazard and Worst-case scenario

2. Analyze a r«p<>rt by using ICAO safety "sk assessment matrix

1. Inform it to the Manager2. SSP Coordinator fpjlay, up tofocal point

j

Analysis Review Working Group

1. Classify the Factor

2. Make Analysis Study Sheet

Revise the Analysis StudySheet

Make a Voluntary Report Bulletin Share it to an Aviation Community

10

APPENDIX B RISK MANAGEMENT

Likelihood of Occurrence

Level Definition

Extremely Improbable Almost inconceivable that the event will occur

Improbable

Remote

Occasional

Frequent

Level

Catastrophic

Hazardous

Major

Minor

Negligible

Very unlikely to occur (not known to have occurred)

Unlikely tooccur, but possible (has occurred rarely)

Likely to occursometimes (has occurred infrequently)

Likely to occur many times (has occurred frequently)

Severity of Consequence (S)Definition

Equipment destroyedMultiple deaths

Alargereduction in safetymargins, physical distress or a workload such that theoperators cannot be relied upon to perform their tasks accurately orcompletely.Serious Injury.Major equipment damage.

Asignificant reduction in safety margins, a reduction in the ability oftheoperators to cope with adverse operating conditions as a result of increase inworkload, or as a result ofconditions impairing their efficiency.Serious incident.

Injury to persons

Nuisance.

Operating limitations.Use of emergency procedures.Minor Incident

• Little consequences

Assessment risk index Suggested criteria

:ptable unde

Acceptable after review of operationsMODERATE

SI 19-02

Value

1

Value

11

SI 19-02

APPENDIX C FACTOR CLASSIFICATION TABLE

PrimaryFactor

Aircraft [Remarks]Airport

Airspace Structure *If you think there areATC Equipment/NavFacility/ Buildings more than two factorsChart of Publication in the event, you canCompany Policy choose anotherEquipment/Tooling appropriate factor fromEnvironment - Non Weather Related Related Factor Field.Human Factor

Incorrect / Not installed / Unavailable Part **If you choose "HumanLogbookEntry Factor" from PrimaryManuals Factor Field and /orMEL Related Factor Field,Procedure you must chooseStaffing another appropriateWeather factor from HumanAmbiguous Factor Field.

Related

Factor*

Aircraft

Airport

Airspace Structure

ATC Equipment/ Nav Facility/ BuildingsChart of PublicationCompany PolicyEquipment/ToolinqEnvironment - Non Weather RelatedHuman Factor

Incorrect / Not installed / Unavailable PartLogbook EntryManuals

MEL

Procedure

Staffing

Weather

Ambiguous

Human

Factor**

Communication BreakdownConfusion

Distraction

FatigueHuman-Machine Interface

Physiological - Other

Situational AwarenessTime Pressure

Training /QualificationTroubleshootinqWorkload

Other / Unknown

12

SI 19-02

APPENDIX D ANALYSIS STUDY SHEET

Year Control Number Title

Information

of Reporter(1 individual /Organization (2)Duty of Reporter (3)Afftliaion of Reporter

Information

of related to Event

(1)EventDate (2)Time Frame (3)Weather (4)Visibility

(5)Phase (5)Location (6)Aircraft Model (7)Engine Model

ReportContent

Report Comment

Interviw Con tent

Hazard

Remarks

Estimated Factors

Primary Factor Related Factor 1 Related Factor 2 Related Factor 3

Human Factor 1 Human Factor 2 Human Factor 3

SupplementaryMatters

Supplementary Document Y/N Supplementary Photo/Map Y/NWorst-Case

Scenario

RiskAnalysisSeverityofConsequence Likelihood of Occurrence

••Risk Assesment

A/B/C/D/E 1/2/3/4/5 Low/Moderate/High

Voluntary ReportBulletin

Information

Publication

Y/N

WG agreement

Y/N

Publication No Title

Content

Comment from SSP office

Remarks

13

SI 19-02

APPENDIX E ANALYSIS REPORT BULLETIN FOMAT

1/(1

REPUBLIC OF INDONESIAMinistry of TransportationDirectorate General of Civil Aviation

From DGCA's Voluntary information for

Safety Improvement in aviatiON system(VISION)

VISION is a voluntary reporting system for improvement of aviation safety inIndonesia. Based of ICAO standard, we gather information on actual orpotential safety deficiencies that may not be captured by the mandatoryreporting system. We also share information which we analyze a voluntaryreport for aviation safety to aviation community as'Voluntary Report Bulletin".

Category No. Pages[Large Aircraft/ATC] 01-02 01~

[Small Aircraft / ATC] xx - xx xx - xx

[Cabin / Mechanic / Airport / Other] xx - xx xx ~ xx

[Information of VISION] xx ~ xx

[Large Aircraft / ATC]01:Title1

> Contents of a voluntary report<Comments of VISION>

> Contents of comments

02: Title2

> Contents of a voluntary report<Comments of VISION>

> Contents of comments

[Small Aircraft / ATC]03: Title3

> Contents of a voluntary report<Comments of VISION>

14

SI 19 - 02

APPENDIX E. ANALYSIS REPORT BULLETIN FOMAT (Cont'd)

> Contents of comments

04: Title-4

> Contents of a voluntary report<Comments of VISION>

> Contents of comments

[Cabin / Mechanic / Airport / Other]05: Title5

> Contents of a voluntary report<Comments of VISION>

> Contents of comments

Q6: Title6

> Contents of a voluntary report

<Comments of VISION>

> Contents of comments

REPUBLIC OF INDONESIA

Ministry of TransportationDirectorate General of Civil Aviation

^

•y

Please report your valuable experience and share it to aviation

community!

We will collect information on actual or potential safety deficiencies that

may not be captured by the mandatory reporting system from you. We

will also share it to you for aviation safety.

s Of course, we will never punish a reporter by using the information.

- Contact us >

Website: http://HUBUD.DEPHUB.GO.ID/SRP

Email: SSP DGCA@DEPHUB.GO.ID

Facsimile: 021-xxx-yyyy

DIRECTOR GENERAL OF CIVIL AVIATION

Salinan sesuai dengan aslinyaKEPALA BAGIAN HUKUM,

* \ "^hu^ENDAH PURNAMA SARI

Pembina (IV/a)NIP. 19680704 199503 2 001

Signature.

Dr. Ir. AGUS SANTOSO, M.Sc.

15