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new tool has been developed called
CARA (Controller Action Reliability
Assessment) to help estimate the
reliability of the key component in the
ATM system – the controller.
Safety culture
“Safety management, or ‘knowing how to
do safety’ is one thing,” says Kirwan. “But
safety culture – believing it needs to be done
and making sure safety happens – is another
thing, and remains a constant challenge.”
The EEC is testing a procedure of
traditional safety culture questionnaires,
adapted to ATM, followed by probing
interviews and, if necessary, by on-site
guidance. So far this work has involved
nine European Air Navigation Service
Providers (ANSPs), and will lead to a
Safety Culture Enhancement Toolbox in
2009 for ANSPs. In 2008 there will be a
special workshop on safety culture for
ANSP chief executives, to ensure that the
right key messages and understanding can
be passed down from the very top of
Europe’s ATM delivery organisations.
70
The EEC is testing a procedure of traditional safety
culture questionnaires, adapted to ATM, followed by
probing interviews and, if necessary, by on-site guidance
Accidents happen, but they are much less
likely to be repeated if the community
affected makes a systematic effort to learn
from the errors of the past. While aviation
understands this as well as any industry in
the world, there is still some way to go
before we can be reasonably sure that most
of the relevant lessons are being captured
most of the time.
On the one hand, ingrained national
habit may make controllers reluctant to
report incidents. On the other, there are
those who see the value of reporting, but
fear the consequences for themselves. In
parts of Europe they have recently had
good reason to do so – witness the
severe punishments inflicted on the four
people held responsible for the Milan
Linate runway incursion accident in
October 2001.
An earlier case was less catastrophic but
even more instructive about what can
happen if the full force of the law is used
against controllers who make mistakes.
This was the 1998 incident in which the
crew of a Delta Airlines Boeing 767
safely aborted a take-off from Amsterdam
Schiphol when they spotted a 747 being
towed across the runway. Though no
harm was done, a full report was
submitted. This led ultimately to three
controllers being judged guilty of causing
the incident. The case was first taken up
by the Dutch legal authorities in 2000 –
immediately, the volume of incident
reports by controllers in the Netherlands
fell by 50 per cent and it has taken
several years to recover.
EUROCONTROL has long recognised
that various national differences militate
against the creation of a Europe-wide ‘Just
Culture’ in which controllers reporting
honest mistakes need not worry about
their professional future, while those who
are indeed negligent are dealt with
appropriately. “It’s not about immunity,”
emphasises Tony Licu, manager of
EUROCONTROL’s European Safety
Programme (ESP). “If there is a wilful
violation, if an incident or accident results
from gross negligence, there should be
consequences.”
Launched in February 2006, the ESP is
designed to bring safety disciplines within
the 42 European Civil Aviation
Conference (ECAC) States up to a
common minimum level. It calls for highpriority
action in five areas of safety
management and regulation, with
particular emphasis on incident reporting
within a Just Culture, and on effective
sharing of the resulting information.
The result will be a Europe-wide
common safety framework for Air
Various national
differences militate
against the creation
of a Europe-wide
‘Just Culture’ in
which controllers
reporting honest
mistakes need not
worry about their
professional future
EUROCONTROL / IFATCA 2008: a collaborative approach to the future > Designing the network
71
As some States struggle to adopt regulations and procedures to make incident
reporting easier and less of a career risk, others have made impressive progress.
Brendan Gallagher examines what EUROCONTROL is doing to foster a unified
approach within the European ATM community
Developing a
‘Just Culture’
▼
mistake and action will be taken only to
improve safety. There is also a guarantee of
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