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decrease in their mental and performance
capabilities after an incident. The longer
people are not working at their normal
performance levels, the more this has an
effect on the performance of the overall
system, resulting in delays and a lowering
of capacity. If only one person is involved,
the effect may not be too dramatic, but if
you have quite a large number of
incidents several people might be affected,
and this can begin to generate a large
financial burden.
Cost benefit studies have shown the
positive effects of having implemented a
CISM programme. Barbarino says: “It’s
positive for the individual and the
company because it pays off. For
example, studies which have been done in
Deutsche Flugsicherung (DFS) in
Germany have demonstrated a positive
cost benefit factor of 1:3. You spend one
euro implementing and maintaining a
CISM programme, but the return on
investment is a factor of three.”
Supporting each other
CISM-trained controllers and peers from
DFS went to Switzerland to support the
Swiss air navigation service provider,
skyguide, following the Überlingen
accident in July 2002. Another, more
recent, example is the Portuguese CISM
team who supported its Brazilian colleagues
after the accident in 2006 in which a
Boeing 737-800 collided in mid-air with an
Embraer Legacy 600 jet over the Amazon
jungle. This highlights an evolving network
that is building up where CISM teams,
groups and peers from one country go to
the aid of those in need in other countries.
Perhaps an even more compelling
argument for CISM is the fact that service
providers also report that CISM
programmes have a positive effect on
safety culture. Barbarino explains: “CISM
allows people to deal with incidents more
openly and this promotes a learning
culture and a more open reporting culture.
It’s normal that errors are made and it is
also normal that we are affected by
incidents, but we have a chance to learn
from that. CISM is offering a learning
opportunity not only for the individual
and for the teams, but also on the
organisational level. We are trying to
minimise the idea of a blame and punitive
culture in order to achieve a Just Culture.”
CISM is based on the fact that in aviation, as in other
domains such as the military and police, people are
sometimes confronted with extremely abnormal situations
Manfred Barbarino
Human Factors Domain Manager, EUROCONTROL
EUROCONTROL / IFATCA 2008: a collaborative approach to the future > Operating the network
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EUROCONTROL / IFATCA 2008: a collaborative approach to the future > Operating the network
A decade ago, a prominent aircraft
manufacturer predicted that traffic
expansion would inevitably lead to a
spectacular growth in the number of aircraft
destroyed in accidents. That daunting
prognosis has not materialised. However,
it remains an indisputable concern.
“If traffic goes up, then the likelihood
that there will be more errors increases,”
says Mariann Hintz, ATM training expert
at EUROCONTROL’s Institute of Air
Navigation Services in Luxembourg and
chairman of the EUROCONTROL TRM
User Group. “We need to work on the
mitigation of the consequences or on the
reduction of the number of errors,” says
Hintz. A variety of safety-enhancing
initiatives relating to air traffic control
(ATC) equipment or processes already
address the observable issues. “But we are
also aware that air traffic controllers
[ATCOs] make errors, which their systems
do not know about, because not all the
errors that they produce have negative
consequences.”
It is estimated that each ATCO makes
ten errors every hour, notes the Irish
Aviation Authority (IAA). Although the
definition of ‘error’ in the ATC context is
still subject to debate, that observation
might be sufficient to send chills down the
spine of any air transport passenger.
probabilities, Europe has developed Team
Resource Management (TRM), a training
programme which tackles the millions of
small mistakes that occur in day-to-day
ATC operations.
EUROCONTROL launched an
initiative in 1994 addressing the human
errors in ATC that have no statistically
relevant consequences, with a study
investigating the possible benefits of a
tool that could be modelled on the
airlines’ Crew Resource Management
(CRM) techniques. The air transport
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