eu-ai

European Aviation Artificial Intelligence High-Level Group

The Kickoff meeting of the European Aviation Artificial Intelligence High-Level Group took place at the EUROCONTROL headquarters in Brussels on 16 September 2019. This group, formed with experts from different aviation areas, is tasked to study how Artificial Intelligence can be included in ATM. Their ambitious target is to produce a report on the subject by the end of the year including recommendations. IFATCA is included in the team and will ensure that the operational point of view is covered in the final report.

rottenapple

Just Culture: Are we sustaining a false belief?

Prof. Dekker

By Sidney W. A. Dekker, currently a professor at Griffith University in Brisbane, Australia, where he founded the Safety Science Innovation Lab. He is also Honorary Professor of Psychology at the University of Queensland. He flew as First Officer on Boeing 737s for Sterling and later Cimber Airlines out of Copenhagen. In 2004, he wrote the following article in the aftermath of the Linate accident.

We like to believe that accidents happen because a few people do stupid things. That some people just do not pay attention. Or that some people have become complacent and do not want to do a better job.

On the surface, there is often a lot of support for these ideas. A quick look at what happened at Linate, for example, shows that controllers did not follow up on position reports, that airport managers did not fix a broken radar system in time, that nobody had bothered to maintain markings and signs out on the airport, and that controllers did not even know about some of the stop marks and positions out on the taxiway system. And of course, that a Cessna pilot landed in conditions that were below his minima. He should never have been there in the first place.

When we dig through the rubble of an accident, these shortcomings strike us as egregious, as shocking, as deviant, or even as criminal. If only these people had done their jobs! If only they had done what we pay them to do! Then the accident would never have happened. There seems only one way to go after such discoveries: fire the people who did not do their jobs. Perhaps even prosecute them and put them in jail. Make sure that they never touch a safety-critical system again. In fact, set an example by punishing them: make sure that other people like them will do their jobs diligently and correctly, so that they do not also lose their jobs or land in jail.

The problem with this logic is that it does not get us anywhere. The problem with this logic is that it does not work the way we hope. What we believe is not what really happens. The reason the logic does not work is twofold. First, accidents don’t just happen because a few people do stupid things or don’t pay attention. Second, firing or punishing people does not create progress on safety: it does not prevent such accidents from happening again. The only thing that we sustain by this logic of individual errors and punishment is our illusions. Systems don’t get safer by punishing people. Systems don’t get safer by thinking that humans are the greatest risk.

Let’s look at the first problem. Accidents don’t just happen because a few people do stupid things or don’t pay attention. Accidents are not just “caused” by those people. There is research that shows how accidents are almost normal, expected phenomena in systems that operate under conditions of resource scarcity and competition; that accidents are the normal by-product of normal people doing normal work in everyday organizations that operate technology that is exposed to a certain amount of risk. Accidents happen because entire systems fail. Not because people fail. This is called the systems view. The systems view is in direct contrast to the logic outlined above. The systems view sees the little errors and problems that we discover on the surface as symptoms, not as causes. These things do not “cause” an accident. Rather, they are symptoms of issues that lie much deeper inside a system. These issues may have to do with priorities, politics, organizational communication, engineering uncertainties, and much more.

To people who work in these organizations, however, such issues are seldom as obvious as they are to outside observers after an accident. To people inside organizations, these issues are not noteworthy or special. They are the stuff of doing everyday work in everyday organizations. Think of it: there is no organization where resource scarcity and communication problems do not play some sort of role (just think of your own workplace). But connecting these issues to an accident, or the potential of an accident, before the accident happens, is impossible. Research shows that it is basically outside our ability to imagine accidents as possible. We don’t believe that it is possible that an accident will happen. And what we don’t believe, we cannot predict.

An additional problem is that the potential for having an accident can grow over time. Systems slowly, and unnoticeably, move towards the edge of their safety envelopes. In their daily work people — operators, managers, administrators — make numerous decisions and trade-offs. They solve numerous larger and little problems. This is part and parcel of their everyday work, their everyday lives. With each solved problem comes the confidence that they must be doing the right thing; a decision was made without obvious safety consequences. But other ramifications or consequences of those decisions may be hard to foresee, they may be impossible to predict. The cumulative effect is called drift: the drift into failure. Drifting into failure is possible because people in organizations make thousands of little and larger decisions that to them are seemingly unconnected. But together, eventually, all these little, normal decisions and actions can push a system over the edge. Research shows that recognizing drift is incredibly difficult, if not impossible — either from the inside or the outside of the organization.

Continue to part 2

SPECTRUM

Safeguarding the Aeronautical Frequency Spectrum

Europe is currently studying the possibility of low power audio “Programme Making and Special Events” (PMSE) equipment in the 960 – 1164 MHz band of the spectrum, which is currently reserved for aeronautical use.

Allocations and services operating in the 960-1215 MHz band (source: ofcom, UK)

Sharing this portion of the spectrum with other users would potentially affect systems widely used in civil aviation like Secondary Radar, DME, ADS-B, Multi-lateration and ACAS/TCAS. Aviation equipment more commonly used by the military like TACAN or Link 16 communication systems also makes use of this part of the spectrum. The same is true for future developments, like LDACS (L-Band Digital Aeronautical Communication System).

Aviation equipment has to comply with strict requirements and stringent rules apply to personnel training and licensing. Sharing a frequency spectrum that was so far reserved for a tightly regulated activity such as aviation raises many questions. The technical requirements for equipment is one aspect, but there are concerns on liability in case of accidents or incidents, where aviation systems suffer from interference from non-aviation equipment; or on the validity of safety cases developed before the entrance of these new stakeholders.

It is vital for safety that aviation systems are not compromised by sharing of a frequency band. To esnure these concerns are listened to before a final decision is taken, IFATCA and other major stakeholders have forwarded their concerns. In addition, IFATCA has requested its European Member Associations to contact their Aviation Authorities and invite them to participate in the Public Consultation that will end in September 2019.

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Just Culture: Learning or Punishing?

By Job Brüggen, Safety Officer of LVNL (Air Traffic Control The Netherlands).

Our feature articles on Just Culture, triggered by the conviction of an Air Traffic Controller in Switzerland, aim to trigger thoughts and ideas for how to proceed. This article is written as a personal opinion of the author and does not necessarily reflect the opinion of LVNL or that of IFATCA.

The Federal Court has given its verdict and this time it is final. The conviction of a Swiss controller strongly stirred the aviation community. For missing a “readback/hearback”, two aircraft came closer than our standards prescribe, and two electronic safety nets, STCA for the controller on the ground and TCAS for the pilots in the air saved the day, as they were designed to do. The controller on the ground was found guilty, by ‘unconscious negligence’, of disturbance of public transport and fined 60 days. End of story?

Let us ask ourselves what the effect of this verdict will be to all professionals in jobs that are meaningful to the general public and also carries certain risks to the same general public. Policemen, doctors, nurses, train drivers, pilots, controllers are professionals , but also humans. And humans make mistakes. If we want these people to perform these jobs for us, we must find a way how to deal with these inevitable errors.

I reckon there are five objectives of penal law:

  1. Specific prevention – to prevent the wrongdoer acting again by teaching him/her a lesson;
  2. General prevention – to deter other people not to do the same thing. That is why punishments or executions used to be very public;
  3. To add misery to the perpetrator – compensating for the wrong act in the view of (and on behalf of) the general public and underlining the privilege of the State to enforce the law, lest vendetta’s or family gangs would have its way again;
  4. To compensate for the bad things that have become upon those that were suffering from the bad act. That is, if compensation is at all reasonably possible;
  5. To show to the general public that the law itself is being upheld – and thus upkeeping faith that the justice system actually works.

Not being a lawyer, I am sure there are more goals that the justice system serves, but these five are generally accepted to be laudable and indeed useful for a society to maintain order in a country or state.

Specific prevention and general prevention (objectives one and two) are unlikely to be served well here. Missing a readback/hearback is quite common in aviation and happens hundreds of times every day. Communication through half-duplex VHF channels is arguably one of the most critically weakest links in our system – it still amazes me we are using it. The aviation community is at best reminded that pilots and controllers have indeed serious accountabilities for ensuring safety. But they are humans and not infallible – the very reason why STCA and TCAS were invented anyway.

Objectives three and four (adding misery and compensating) completely miss the point here. There were no casualties hence what was there to compensate for? The Federal Court states that danger was created and I think nobody will dispute that. Flying inherently carries risk and risk already starts when the pilot gets out of bed at four in the morning to get to the airport and prepare for the flight.

That leaves us with objective number five: to show to uphold the law. How many people will feel more comfortable with the idea that Swiss controllers may report fewer incidents for fear of prosecution? It is legitimate to assume that Swiss controllers already report less or with less details than their colleagues in other countries, thus hampering the self-learning abilities that made aviation – inherently risky – so incredibly safe.

Note that nowhere I judge upon the acts of the controller or pilot whether they were good, normal, weak, reckless or exceptionally stupid. The Swiss judicial system, ticking like a Swiss watch, concluded that the behavior of the controller was negligent and not in accordance to professional standards, brutally brushing aside fundamental systemic questions: was the behavior of the controller seen as ‘normal’ in the community of controllers? Are other controllers experiencing the same events? Does the system elude controllers to fall into a spring loaded trap waiting to snap shut? What is the likelihood of this happening again? With this verdict, the answer to how we can prevent this systemic safety flaw from appearing again will be seriously hampered – not a pleasant thought for such a civilized country as Switzerland. My favorite phrase ‘learning is safer than punishing’ surely does apply.

“Never let a crisis go to waste” . It takes insight and courage to question as to why things are done the way they are. With the final verdict there now is a great opportunity for the Swiss people to reflect and ask themselves what they prefer: learning or punishing?

Job Brüggen
23 July 2019

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IFATCA Think Safety Workshop – Nassau, Bahamas

The 10th Think Safety course just wrapped up in Nassau, Bahamas. The course was coordinated by the Bahamas Air Traffic Controllers’ Associations and sponsored by the Bahahamian Air Navigation Service Division. The course brought together different stakeholders from the Bahamian aviation Industry.

Through an interactive workshop, facilitated by IFATCA’s EVP Europe Tom Laursen and Safety Culture expert Dr. Anthony Smoker, the participants had the opportunity to improve their understanding of safety processes, safety culture, and just culture.

30 kmh

Just Culture: Where are we going now?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just Culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed.

To describe one of the operational dilemmas that convicting individuals for being involved in incidents, we would like to tell a story that could happen to any of us:

Following the Swiss Federal Court verdict of an air traffic controller for an incident where nobody was hurt and no material damage was done, a conflict materialized between the duty of the judiciary and the needs of a safety-relevant reporting system in complex systems. Through this, aviation is subjected to a stress test.

You are driving your car on a small road in the countryside you are not familiar with. You find yourself suddenly driving 70 km/h by some houses with small children playing on the sidewalk. You suddenly realise you are in a village, but you missed the road sign. Looking back, you see it is there but the sign was mostly hidden by branches from a tree that outgrow towards the street.

You are a responsible driver and want to prevent somebody else falling in the same trap and possibly hitting a child, so you drive to the local authorities (a police station) and report your experience, arguing, one day someone might hit a kid involuntarily. The mayor is grateful and will trim the tree, the parents of the local kids probably agree, but the police officer says: you were driving 70 in a 50 km/h zone? Here you go: a 150 EUR fine!   

So, tell me, what are you going to do next time you find yourself in a similar situation? Go to the police again?

Is this the way we want to go in the future of Air Traffic Control?

It looks like today, the common law, which is applicable to every citizen, is also applied to an air traffic controller who reports an incident. If this is the case then should you do the same as most normal citizens do: i.e. not report your own mistakes or violation of laws to the authorities, whether it is your regulator or the police. You should not be incriminating yourself, there are even laws for this (like the USA 5th amendment).

The danger of all this:

Once again, common sense means reporting incidents to prevent they become accidents. Our authorities are implementing Just Culture to protect us from disciplinary actions when dealing with incidents reporting and investigating, but this should also have been extended to the judiciary level. Failure to do so, will be treating us just like normal citizens before the law, but then, following that logic, we should act like most normal citizens too, and this means keeping our mistakes for ourselves.

We need to make the case for a change in the law for professionals, similar to the recent Italian laws for medical doctors; You should not be punished for doing your job according the best practices and for reporting and talking about your honest mistakes while performing your job. But this needs to be done FOR EVERY country that wants to apply Just Culture and a free incident reporting system.

Achieving this is one of IFATCAs top priorities.

windmills

Bridging the gap – are we fighting windmills?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed.

This article explains why we need to continue pushing for Just Culture and educate the Judiciary and prosecutors.

“Despite the efforts to bridge the gap between aviation safety (ultimately the passengers’ safety) and the judiciary, the Just Culture concept is challenged by the recent Swiss Federal Court decision.

These court cases in Switzerland have allowed Just Culture to be debated in public, with an understanding of the Just Culture concept and the acceptance that the Swiss legal framework has to change in order to be compliant with the ICAO and EU regulations and to continue the improvement of aviation safety.

A contribution factor to this could be the joint training for aviation experts and judicial authorities provided by Eurocontrol and the international umbrella organisation of air traffic controllers, IFATCA.

A few years ago such a debate would not have been possible as the notion and the importance of the Just Culture would have been unknown to most of the public and the administration of justice.”

Click here for the full article

justice-devos-1

Is the Justice System ready to adapt to a more connected and interrelated world?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed. In the second article we are asking: Is the Justice System Ready to adapt to a more connected and interrelated world?

Is the Justice System Ready to adapt to a more connected and interrelated world?

On 12 April 2013, two aircraft, a Ryanair and a TAP Air Portugal, unintentionally converged in the complex airspace over the Napf region (Lucerne, Switzerland). The safety nets on the ground and in the air worked as planned, so that the situation could be defused quickly. There was no personal injury or damage to property. In may 2018, the Federal Criminal Court in Bellinzona sentenced the air traffic controller on duty to a heavy fine for negligent disruption of public transport. The Federal Court has now confirmed this ruling. This is the first time in Switzerland that an air traffic controller has been convicted with legal effect.

The aviation industry has always been an industry where collaboration and connectivity has been at the forefront to achieve improvements. Especially safety and efficiency has been at the centre of attention. Improvements have been achieved through enhanced equipment, standards and rules, interdependence between many stakeholders, implementation of safety nets and collaboration between operators at the sharp end. In short it is fair to say that the Aviation Industry relies on teamwork to make it possible for the flying public to move from A to B.

Sidney Dekker (author of several books and articles about Just Culture) put it this way, ‘It takes teamwork to succeed as well as it takes teamwork to fail’. If this is true, then we have to ask ourselves whether it makes sense to convict and fine individuals for trying to do their everyday job? Of course, this doesn’t include cases where operators at the “sharp end” are guilty of wilful misconduct in any form. Such cases amount to acts of sabotage, gross negligence or substance abuse etcetera. But for all other cases where individuals, who happen to be the person executing and implementing the work of the team, it is time to think differently.

The justice system in Switzerland responded to an incident with the conviction of an individual. That might be the right thing to do according to the world of justice and courts. But if that is the case, Switzerland and maybe other countries, has a problem in a world with teamwork and connectivity and how they handle incidents and accidents. It is time to change the Justice System to adapt to a more and more connected and dependent world.

This verdict has implications for the everyday handling of air traffic in Switzerland and maybe Europe-wide. It has already led to a reduction in airspace capacity in and around Switzerland and depending on the on-going cases, (there are two more pending at the courts in Switzerland) it might have permanent consequences for the air traffic.

Fortunately, there are possible solutions to the problem. We suggest that justice systems start to look for systems problems instead of holding individuals responsible for systems mishaps and failures. Justice systems in Germany as well as in the Unites States are using corporate responsibility in cases where a system has affected society negatively.

swiss_tear

Are we burying Just Culture for good?

IFATCA will be publishing several short articles on our website in the coming days. The articles will be asking important questions about the current status of Just Culture triggered by the conviction of an Air Traffic Controller in Switzerland. It is the purpose to trigger thoughts and ideas for how to proceed.  In the first article we ask: are we burying Just Culture for good?

On 12 April 2013, two aircraft of the Irish Ryanair and the Portuguese TAP unintentionally converged in the complex airspace over the Napf region (Lucerne, Switzerland). The safety nets on the ground and in the air worked as planned, so that the situation could be defused quickly. There was no personal injury or damage to property. In May 2018, the Federal Criminal Court in Bellinzona sentenced the air traffic controller on duty to a heavy fine for negligent disruption of public transport. The Federal Court has now confirmed this ruling. This is the first time in Switzerland that an air traffic controller has been convicted with legal effect.

After decades of hard work convincing all parties of the benefits of Just Culture in Aviation and having seen the first safety benefits, a single court decision is setting us back significantly and can endanger the continued incremental improvement of safety.

The judiciary is not necessarily the biggest issue. Judges are applying the law or interpreting the law in a way they believe would protect society, which is their job, by convicting an individual Air Traffic Controller for a system shortcoming. The intent is to ensure the safety of the travelling public.

But are they really protecting the travelling public? IFATCA is a firm believer of the contrary: The conviction of professionals reporting their incidents is in fact endangering the travelling public by discouraging reporting and therefore making air travel less safe. 

It is time to reflect about our own role and the role of other key stakeholders.

Did we start at the wrong end? We basically made an error at the start in promoting Just Culture and its safety benefits without having paid enough attention to the fragile arrangements that Just Culture is built upon. We have no protection in place against the current case.

We indeed failed to link the Just Culture implementation to the judiciary from the outset. We were tempted by promises of good intentions and nice wishes but clearly those did not materialise. In fact, the Regulators (both in the EU and at State level) failed to link Just Culture implementation to a change in the laws of the various countries that would protect the professionals, reporting their mistakes, from prosecution.

All is not lost yet. The ball is in the camp of the Swiss State. This should become, as a matter of urgency, the first task of the State: to individually address this issue, and propose/present changes in the National law to decriminalise incidents reported under Just Culture. IFATCA is formally asking for this.

IFATCA fears that, if there is a failure to correct this rapidly, Air Traffic Controller Associations would have no other option at some point than to ask their individual members (the Air Traffic Controllers) to only report a minimum and restrict cooperation with incident investigations, in order not to incriminate themselves and avoid prosecution. This fear of reporting is likely to spread to other professions in aviation and will undermine decades of progress. This must be prevented, urgently, for the safety of the travelling public.

swiss_tear

The Swiss Justice System is setting new unheard-of standards for the Aviation industry.

Swiss Justice system convicts an individual Air Traffic Controller for a system shortcoming.

Yesterday the Swiss Federal Court rejected the appeal by an Air Traffic Controller, implementing a sentence from the Federal Criminal Court and made the sentence legally binding.

IFATCA expresses our deepest support and sympathy with the involved Air Traffic Controller. We can only imagine the stress and pain that he is going through.

With this sentence the Swiss Justice system chose to go against all advice from the Aviation Industry. It will be interesting to see what the further consequences of such a decision will be, both nationally but also internationally. If individuals, which are part of a system and working to the best of their abilities, will have to live with the fear of criminal charges every time they go to work, it will be difficult to uphold the current efficiency of the aviation system as well as it will be difficult to attract employees.

IFATCA has severe concerns about the consequences of this sentence, both for the individual Air Traffic Controller, but moreover for the entire Aviation System. It is time for aviation professionals and society to join forces and fight this unfortunate development.

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