als PDF

Weitere Magazine

Empfehlungen

Info

Safety performance satisfactory, ATCO in prison! Search for culprits – an increasing trend IFATCA has in the recent months been involved in defending air traffic controllers in incidents and/or accidents, which have been prosecuted by the judicial authorities. On a global level we have observed an increasing trend that media, public and judicial look for individual culprits in aviation, and not only when accidents occur. Like in the past when witch hunts were organized, societal needs are satisfied in the name of the (not necessarily religious) safety of the general public. Human Factors and systemic safety science have taught us that in high risk organization like civil aviation or in particular Air Traffic Control, only a systemic safety approach will lead to improvement of the safety performance. This however seems to be against human nature1 which demands errors receiving a punishment, based on a Judeo- Christian education starting at the creation of the world with the expulsion of mankind from paradise2. Why and How will safety performance be measured? ICAO through it’s Global ATM Concept has introduced the notion of performance for the future system. The overall system in order to be able to grow, will have to satisfy a bandwidth of performance in so called key performance areas. 11 are described in detail by ICAO. Organizations such as an ANSP will have to work with their own performance targets in order to achieve a regional or global performance standard which should meet a timeline. Safety is a key performance which is the most prominent at a global level, but as well at the Single European Sky II legislation and the NEXTGEN documentation currently available. ICAO is insisting to have the Annexes of the Chicago Convention translated into meaningful implementation at the operational level. Recently Safety Management Systems have been one of these important recommendations. Part of the Safety Management System are reporting systems (automated or operator report) which is the ✈ AEROSAFETYWORLD. March 2008 Safety baseline for a structured organizational learning. This kind of learning is the first step in an improvement of the Safety Management System. Eurocontrol has just recently established a methodology for States and ANSPs to measure the safety maturity of it’s member states. This would allow a measurement of safety performance in a level playing field and then being able to draw benchmarks from it. There is however a need for lessons learned dissemination and insight into the followup action with regard to the safety recommendation – as benchmarking will not be enough to have a learning effect. SES II – Safety Performance linked to incentives Part of the safety performance to be addressed through measurement and safety management systems are, reporting system, incident measurements etc. and traceability of procedures. This means that states have to make sure that the air navigation service providers and the state itself have reporting systems for incidents in order to measure «reactive safety». Under the SES II legislation it is foreseen that a bonus/malus (disincentives) system will be coupled to the performance targets. So in order to achieve the safety targets and the maturity of safety measures throughout the European system – a reporting system will be put in place in order to satisfy the regulators wishes – but not necessarily to improve the overall system. There is a possibility that this will lead to increased pressure to report incidents (by internal orders and/or AIPs and ATM Manual) in order to achieve a better (what Dekker calls an accountability bureaucracy) performance. There is a risk that only the data collection system will be measured and not necessarily the safety of the system. Why we need incident reporting? We have learned from the past that accidents being a rare event, are difficult to use only as a source for von Marc Baumgartner, President and CEO IFATCA 17 der flugleiter 2009/03
der flugleiter 2009/03 Safety 18 Safety Justice remedial action to the system that ATM requires a mandatory incident reporting system and a voluntary reporting system in order to improve the current system. Some of these incidents are even investigated by several Accident Investigation Boards following the Annex 13 recommendations of ICAO. These investigations have to take place under the umbrella of a Just Culture philosophy which can also be defined as a cornerstone in the process of Organizational learning. This just culture is defined by IFATCA/EUROCONTROL/ ECAC as: A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Just culture as a means to achieving the ultimate goal to have a safety system which is one of constant improvement facilitated by a free flow of safety information with the objective (next to an increase of safety information and an antidote against nil reporting system) to achieve a balance between the interests of safety (e.g. protection of safety information) and those of a proper administration of justice. This is when we have discovered that reporting for an ATCO is a risky business as it can lead directly to appearing in front of a prosecutor and legal investigation for a wrongdoing at the penal code level. Why accident investigators prepare the ground for criminalization of operational staff? Like in an accident some of the incidents IFATCA has been involved in have found out that the accident investigators –sometimes lack sufficient ATM knowledge or do not have any basic systemic safety approach in the way they are conducting the investigation. Many of the reports of the AAIB are written in a judgmental way – which are then used in those terms (or at least consulted by the prosecutors). All this is of course not foreseen in Annex 13, neither in the attachment Echo of ICAO – however it is a trend we were able to recently observe. ATCOs are being «ordered» by rules and procedures to report incidents, to give interviews as witness to the AAIB and to find themselves then accused for a crime (such as endangering public transport, or other penal code articles – depending on the gravity of the accident or incident), which they have, through their testimony (in good faith) to the AIIB investigator given– ammunition to have them indicted. Mind boggling! Proper training of Investigators and court expert needed?! IFATCA has found out that most of the AAIB around the world, lack sufficiently well educated and trained ATC investigators, which have learned what it means to look at an incident from a systemic point of view. Further, IFATCA is amazed to see that around the world that states ignore Annex 13 fundamentals and prosecutors are allowed to use the AIIB reports for their investigations, maybe stemming from the fact that data from safety investigation are evidence and judicial investigation will use this evidence. (see Dutch Safety Board’s first publication after the crash of the Turkish aircraft in Amsterdam). When confronted with court trials – IFATCA has been amazed in some cases to see – who is acting as ATC experts of prosecutors/court. In other cases these experts have never visited an ATC facility and do not separate reality from the movies i.e. what they have seen in the film called «Pushing Tin». IFATCA believes that a proper training is needed for ATC experts (including specialist aviation lawyers – or specially trained AT- COs) in both the investigation teams but also in the case of a prosecutor or a court needing ATC expertise. These people have to be trained and understand the systemic safety approach otherwise we will continue to see an increase of incident reports being transferred to a prosecutor or lead to condemnation based on judgmental behavior of these so called experts. Conclusion There is a need to be sure that the future performance based ATM system does not increase the criminalization of front end operators for the purpose of performance measurement. ATCOs do not go to work to commit a crime. They are striving to do the best in any given situation. The systemic approach to the current and future ATM system is clearly indicating – that if high risk or complex system do fail – it is a failure of the system and not a failure of an individual. If you end up with the conclusion that the reason for an incident was Human Error then this will not be the end it will be the starting point for an investigation as there is deeper trouble inside the system (Dekker). A court case will not always improve safety neither will it be always just. To avoid any kind of cut and dried opinions get us at least a recognition of the potential misrepresentation and or miscarriage of justice of the ATCO by having processes in place that ensures that fairness in representation by competent persons is in place.
Seite 1 und 2: 3/2009 Spannungsfeld „Just Cultur
Seite 3 und 4: Spannungsfeld „Just Culture“ -
Seite 5 und 6: liche Hürden gegeben und im LuftVG
Seite 7 und 8: der flugleiter 2009/03 Recht 14 In
Seite 9: der flugleiter 2009/03 Recht 16 Jus
Seite 13 und 14: und intellektuelle Intelligenz besc
Seite 15 und 16: der flugleiter 2009/03 ATC USA 32 d
Seite 17 und 18: Photo: FAA der flugleiter 2009/03 A
Seite 19 und 20: der fl ugleiter 2009/03 ATC Aktuell
Seite 21 und 22: der flugleiter 2009/03 ATC Aktuell
Seite 23 und 24: durch sogenannte „Marker Posts“
Seite 25 und 26: Himmel über der Wüste Wer hat die
Seite 27 und 28: auf die Stichelei des reicheren Nac

als PDF

Sie wollen auch ein ePaper? Erhöhen Sie die Reichweite Ihrer Titel.

Template löschen?

Als Template speichern?