Air traffic control voluntary incident reporting and controller retention are under threat. Eurocontrol states need to change some laws
Detailed information and data about what's going on out there is the lifeblood of any safety management programme. Unfortunately, in a variety of ways, newly established reporting systems for gathering safety-related European air traffic management (ATM) data centrally are in danger of being strangled before they have a real chance of producing results.
The law is the problem. It is scaring air traffic controllers - who would otherwise report incidents from which lessons could be learned and trends deduced - into silence for fear of prosecution. And if there were just one legal system it would be relatively easy to deal with, but Europe has as many systems as it has sovereign nations. Eurocontrol may be working hard to standardise ATM practices, procedures and standards across the continent, but air traffic service providers and their employees remain, quite properly, subject to national justice like other citizens in the course of their business.
Two weeks ago, commenting on the court judgements on a controller and three administrators given long prison sentences following the October 2001 Milan Linate runway collision (Flight International, 27 April-3 May, Rough Justice), we said that the sheer severity of the individual punishments "smacked of scapegoating" and that the ultimate message to controllers, airport managers and aviation civil servants is to "not improve, but keep your head down".
Testimony to this syndrome has come from the Netherlands air traffic control agency NVNL. It reports that, following police prosecution in 2000 of three controllers for a 1998 runway incursion at Amsterdam Schiphol, reporting of incidents by controllers has halved. Head of Eurocontrol's safety enhancement division Erik Merckx says such a reduction in reporting has not, at this point, been reflected across Europe. But the Eurocontrol centralised reporting system is young, it is not yet established as a trusted culture and, most dramatically, the effects of the Linate judgement have not had time to kick in yet. But they will. And in two weeks' time German accident investigator BFU expects to publish its report on the July 2002 Ueberlingen mid-air collision between a DHL Boeing 757 freighter and a Bashkirian Airlines Tupolev Tu-154M in which all 71 people in the two aircraft were killed. The event itself was horrifying enough, but since that incident the Swiss controller in sole charge of the sector at that time was murdered on his home doorstep, allegedly by a grief-stricken relative of some of those who died in the collision. This is vigilante justice at its worst, but after the Italian and Dutch court judgements, the air traffic control community will be left wondering what the judicial system in Germany or Switzerland might have done if the controller were still to be alive when the technical report is published.
Controllers and those who train and manage them are traditionally the kind of people who have chosen the job because it is challenging, because of the pride to be had from doing a difficult and essential job well. But is society now sending a different kind of message to controllers, and if it is how will they react? Already, admits Eurocontrol, one of the biggest threats to its ability to provide safety and capacity in Europe's skies is a shortage of controllers. Is this kind of treatment going to encourage existing controllers to stay on? Is it the kind of career young people are going to consider? The risk of harming the morale of those doing the job today is obvious, and all that can be hoped is that this will not show itself in a loss of system safety. Controllers are humans, so they can make mistakes. The system is designed to absorb normal mistakes without harm to airspace users, but the message getting across to controllers now is "one strike and you're out" if you happen to be in the seat on the day the system does not absorb your mistake.
If society does not want to send this kind of message to controllers and their colleagues in the ATM industry, it can make changes. The Danes have already changed their national laws to encourage a blame-free reporting culture for controllers as recommended by Eurocontrol. But they are the only nation in Europe to have done that so far. And although at present controllers' legal status in the event of a small mistake that has big effects is not at all clear, it could be made clear and fair by careful lawmaking. No-one is asking for protection from gross negligence, but if society does not get this one right it had better produce a totally automated ATM system fast because there will not be any controllers out there to keep the skies safe.
Source: Flight International
