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says Skoniezki, explaining that ICAO standards and
recommended practices may have provided a good
framework on which to build a regulatory system, they were
not as specific as regulations need to be.
The ANSP leaders from countries that need help meeting
the new standards are provided with help – usually in the
form of courses, training and workshops – by
EUROCONTROL. The agency also sends teams out to the
ANSPs and National Regulators to help them, for example, to
set up an SMS for their organisation and respectively in
setting up their regulatory framework. “There is a definite
general improvement in awareness of what needs to be
done,” says Skoniezki.
Incident reporting and data sharing systems are vital for
testing the health of the system and for detecting the
existence of potential problems before they become
accidents. Theoretically, the centralised system
EUROCONTROL has set up should work well, but, Licu says, it
needs to be simplified so that front-line operators like pilots
and controllers are able to report, no matter which country
they are in.
Another vital component of a successful reporting system is
the need to change the way countries treat reports. At
present, some national cultures seek to blame an individual
for a known error, and the judicial system immediately sets up
an investigation to establish whether the error was criminal.
This state of affairs is the biggest single deterrent to an
effective reporting system, says Licu, who is in the early stages
of seeking ways to influence changes that would bring about
what he calls a “just culture”, in which people would feel free
to report. Under a just culture system, reported incidents
would only go before a court if it became clear that wilful
behaviour or gross negligence warranted it. Denmark, so far,
is amongst the few European countries that has made the
changes in its law to protect safety reporting systems and
encourage a ‘just culture’. Meanwhile, Licu says, so far 22 out
© Arne V. Petersen, Copenhagen Airports A/S
99
of the 42 ECAC States provide good-quality reporting.
Risk assessment and mitigation, says Licu, is a proactive
approach, which demands that a safety case is established
before any operational change is implemented. At present
the methodologies proposed are “still a bit academic” but
they are being developed by analysing the process of
introducing real operational changes, and identifying
generic best practice for that type of operation, according
to Licu. The main focus at present is to work with ANSPs
that have “low maturity” and to assist them through the
introduction of operational changes – the process uses
many of the same components that are parts of a good
SMS, according to Skoniezki.
Meanwhile, under the ESP, EUROCONTROL is in the early
stages of trying to assess the effectiveness of specific safety
programmes it has initiated: runway safety, level-bust and
air-ground communications, for example. For all these,
EUROCONTROL had generated awareness programmes, like
widely distributed interactive toolkits on CDs for pilots,
controllers and other interested personnel. These CDs break
down the causal factors of known incident types into
components the various players would recognise at a
personal level. It is early days yet, and Licu says the
imperfections in the reporting systems mean that the
effectiveness of these targeted improvement programmes
cannot yet be properly ascertained, but there is certainly no
negative feedback. A new initiative is a study of airspace
infringements – mainly by Visual Flight Rules (VFR) general
aviation aircraft entering controlled airspace unauthorised –
but Licu says it is too early in the programme to derive
mitigations, as it is still work in progress.
An intensive study of ATM incidents to identify the nature of
human error is also underway, and is coming up with some
results. The two most common categories for controller error
are decision-making and situational awareness. Often the
decision-making errors are based on a misapprehension of
details like specific aircraft performance; meanwhile,
situational awareness can be influenced by controller overload
on the one hand or under-stimulation at slack periods on the
other. Potential factors in overload are the two simultaneous
demands posed on controllers by the expectation that they
should provide efficient, schedule-driven service as well as
safe separation. That is a tall order, but one that pilots seem
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Partnership for Performance and Growth.(39)
