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Safety<br />

Safety<br />

performance<br />

satisfactory,<br />

ATCO in prison!<br />

✈ AEROSAFETYWORLD. March 2008<br />

Search for culprits – an increasing trend<br />

IFATCA has in the recent months been involved in defending<br />

air traffic controllers in incidents and/or accidents,<br />

which have been prosecuted by the judicial<br />

authorities. On a global level we have observed an increasing<br />

trend that media, public and judicial look for<br />

individual culprits in aviation, and not only when accidents<br />

occur. Like in the past when witch hunts were<br />

organized, societal needs are satisfied in the name of<br />

the (not necessarily religious) safety of the general<br />

public. Human Factors and systemic safety science<br />

have taught us that in high risk organization like civil<br />

aviation or in particular Air Traffic Control, only a systemic<br />

safety approach will lead to improvement of<br />

the safety performance. This however seems to be<br />

against human nature1 which demands errors receiving<br />

a punishment, based on a Judeo- Christian education<br />

starting at the creation of the world with the<br />

expulsion of mankind from paradise2.<br />

Why and How will safety performance be measured?<br />

ICAO through it’s Global ATM Concept has introduced<br />

the notion of performance for the future system. The<br />

overall system in order to be able to grow, will have to<br />

satisfy a bandwidth of performance in so called key<br />

performance areas. 11 are described in detail by ICAO.<br />

Organizations such as an ANSP will have to work with<br />

their own performance targets in order to achieve a<br />

regional or global performance standard which should<br />

meet a timeline. Safety is a key performance which is<br />

the most prominent at a global level, but as well at the<br />

Single European Sky II legislation and the NEXTGEN<br />

documentation currently available. ICAO is insisting to<br />

have the Annexes of the Chicago Convention translated<br />

into meaningful implementation at the operational<br />

level. Recently Safety Management Systems have<br />

been one of these important recommendations. Part<br />

of the Safety Management System are reporting systems<br />

(automated or operator report) which is the<br />

baseline for a structured organizational learning. This<br />

kind of learning is the first step in an improvement of<br />

the Safety Management System. Eurocontrol has just<br />

recently established a methodology for States and<br />

ANSPs to measure the safety maturity of it’s member<br />

states. This would allow a measurement of safety performance<br />

in a level playing field and then being able<br />

to draw benchmarks from it. There is however a need<br />

for lessons learned dissemination and insight into the<br />

followup action with regard to the safety recommendation<br />

– as benchmarking will not be enough to have<br />

a learning effect.<br />

SES II – Safety Performance linked to incentives<br />

Part of the safety performance to be addressed<br />

through measurement and safety management systems<br />

are, reporting system, incident measurements<br />

etc. and traceability of procedures. This means that<br />

states have to make sure that the air navigation service<br />

providers and the state itself have reporting systems<br />

for incidents in order to measure «reactive safety».<br />

Under the SES II legislation it is foreseen that a<br />

bonus/malus (disincentives) system will be coupled<br />

to the performance targets. So in order to achieve the<br />

safety targets and the maturity of safety measures<br />

throughout the European system – a reporting system<br />

will be put in place in order to satisfy the regulators<br />

wishes – but not necessarily to improve the overall system.<br />

There is a possibility that this will lead to increased<br />

pressure to report incidents (by internal orders<br />

and/or AIPs and ATM Manual) in order to achieve a<br />

better (what Dekker calls an accountability bureaucracy)<br />

performance. There is a risk that only the data<br />

collection system will be measured and not necessarily<br />

the safety of the system.<br />

Why we need incident reporting?<br />

We have learned from the past that accidents being a<br />

rare event, are difficult to use only as a source for<br />

von<br />

Marc<br />

Baumgartner,<br />

President and<br />

CEO IFATCA<br />

17 der flugleiter 2009/03

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