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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