"JUST" CULTURE

We note the recent decision in a Swiss court regarding the Uberlingen mid-air collision of 2002 and reproduce the words from the IFATCA press release issued in response to the decision.


MEDIA Release-----------------------------------------------------------

The district court in Bülach, Switzerland, has found four middle managers of Skyguide guilty in the case surrounding the Uberlingen mid-air collision of 2002. The same court has acquitted four others, including air traffic controllers and technicians.

That the court has gone beyond the front-line operators represents a new development from the legal aftermath of recent ATC-related accidents (we think of Brazil, for example). It is encouraging to note that accountability in a complex socio- technical system is expected at all organizational levels, not just at the sharp end.

We continue to be troubled, however, by criminalization of so-called human errors, whomever these errors may be attributed to. Whether those accused are controllers, technicians, managers, or directors legal pressures and criminalization hamper the free-flow and exchange of safety-related information across all organizational levels within a strong safety culture.

IFATCA believes that all personnel should be held accountable for their decisions and actions in a safety-critical system; however, experience has shown that criminal prosecution makes no contribution to improving system safety. IFATCA is signatory to the October 2006 joint resolution on the detriment to aviation safety of the “criminalization of error” issued by the Flight Safety Foundation (FSF), the Civil Air Navigation Services Organisation (CANSO), the Royal Aeronautical Society in England (RAeS) and the Academie Nationale de L’Air et de L’Espace (ANAE) in France. We repeat our call for all stakeholders to recognize the valuable contribution a just culture environment will make to aviation safety.

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It is very important that pilots and ATCs require a "JUST CULTURE"; in every accident or incident there is a natural tendency to seek out the reasons why it occurred. In fact from a systemic view point it is required.

Unfortunately human nature, particularly involving loss of life, in searching for the reasons of why something went wrong the quick concept is to proportion blame; normally to the humans involved in the process. This is particularly true in aviation; probably more so than in any other industry, with the exception of massive accidents like Chernobyl nuclear accident or the Bhopal tragedy.

In an aviation accident, normally what happens it the "air traffic controller" made an error which led to the events; particularly so when it involves mid-air collisions.

The person who was at the console at the time (or the previous controller) made an error; but is that the same thing as being negligent, or worse criminally negligent?

Whilst the controller directly involved in the Uberlingen accident was never charged, I wonder if he lived longer (he was murdered by a family member of a victim of the collision) whether he would have been.

Of interest in this case is that 'back office' decision makers were charged, because the accident happened during the night where single staffing was prominent, where the system and back-up systems were in a state of degradation (not functioning correctly). They have been held accountable for decisions which may have been allowed to occur without the appropriate safety assessment prior to the event.

I wonder if this accident was two buses, involving the same level of loss of life, whether people from the roads authority would have been charged for approving road works on the highway?

Human errors will always occur, "to err is human", the air traffic system is designed around systemic barriers for error prevention and error detection; modern systems advise the controller when conflicts are about to or are occurring. But at times of degradation these sometimes do not work; these systems very much rely on the use of radar surveillance; so over the majority of the worlds skies no collision detection system exists.

TCAS (ACAS - Airborne Collision Avoidance System) is the 'ultimate fallback' to controller or ATS systemic error; but TCAS relies on the correct application from the pilot view point (which was a significant factor in this case). TCAS uses the information from onboard equipment of the other aircraft in the vicinity; it may 'over react' at times and suggest avoiding action when a separation standard actually exists. If this reaction occurs due to false data (e.g. faulty height read-out) from the other aircraft then TCAS can make a disastrous avoiding action decision.

Every-time there has been a significant error in aviation, the media in particular looks for the person(s) to blame. In recent times controllers from Switzerland, Japan, Brazil and Kenya have all been prosecuted for making an error; not that the error itself was negligent or deliberate, but because of the consequence of that error.

A key advantage of a JUST CULTURE is accurate reporting for investigation and thus development of improved error prevention strategies; where a JUST CULTURE does not exist, errors are hidden or covered up to possibly prevent the retribution of the system. Controllers making mistakes are normal, systems catching the mistakes is required.

A "JUST CULTURE" would treat every like type error in the same manner, regardless of the consequence; despite the emotions involved.