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A TIO N

Foreword Theworlddrivesin so manydifferentgears.How going to be internal and external factors a progressivedevelopmentin the evolutionof can controllersin many Statesget a salaryof affecting its operations(terrorism,accidents, the air transportindustry,as longas thereis: US$10- yes,one zero USDollars- per month international crisis, industrial disputes,wars, and be expectedto be highlymotivatedand to conflicts,virusesand health syndromes,etc.). ✓ co-operationin the form of consultationwith givetheir maximumperformance while carrying The aviation industry,from time to time, is the end userswho havethe operational out difficultATCduties,and at the sametime to enteringperiodsof recession,sometimesgreat knowledgewith whichto turn the capabilities worry about his/her personal financial ones (September11 events, major accidents, of technologyinto a service, problems? According to the American Iraq war, SARS)and sometimessofter ones. ✓ co-operation with othersystemusersto make psychologistAbraham Maslow's Hierarchyof Today,evena normalpassengeris afraid to fly. it happenand realisetheir goals,and Needs,how can a human being becomeself- Therefore,restoringpassenger confidencein air actualisedandperformat his/herutmostbefore travel, in order to ensurethe survivalof the ✓ co-operationwith the systemitself. satisfyingtheir basicphysiologicalneeds. How airlines,is vital for the whole of the aviation would like to assureall serviceproviders canwe expectsomeof our membersto give us industry,includingus. Controllerscan say that IFATCA that the Federationis preparedto offer its this is not our business. As air traffic controllers hundredsof dollarsperyearin orderto paytheir annual subscriptionfees or even to attend it doesnot matter if the planeswe controlare expertiseto engenderdevelopmentof the air conferences? full or half-emptybecauseour job is the sameif transport industry. Therefore, the era of we controlan emptyAirbus340 or a full Boeing suspicionof intentshouldgiveway to an era of do not mutualrespect,trust and cooperation. My personaldream and, at the sametime, a 777; but this is not so. If the passengers feasible target is to attend an International refill thoseplanesrapidly,therewill be fewerof Conference of IFATCA andduringthe roll call to them to controland consequently, lessrevenue I will close my statement by borrowing hearthe Presidentstating : "Memberspresent for our employers, the ATSproviders.If incomeis somethingthat my colleagueon the EB,Andrew reduced, cutswill haveto be made.Also,many Beadle, stated in the IFATCACircular of :127out of 127! Thatwill be the day! viewthe controllers'voiceof concernof asbeing November2000, a conceptthat I totally agree Thesecondmessagegoes to all our associate barriersto progress.I, myself sometimesfeel with and firmly believein : professionalsin the aviation industry( pilots, "unwanted"when I defendthe interestsof my airlines, engineers, other professionals,air colleaguesin various forums. This view, of The future .... navigation service providers, travellers, course, is unfounded as controllers do The future is not some place we are understand, do sympathizeand do sharethe goingto ..... regulatoryauthorities,institutions,etc.) : concernsand worries of our customers, the Theaviationcommunity is a verydynamicand airlinesround the world when they are hit by The future is something that we are volatile world and as such, there are always crisis.Controllersalsodo accept technologyas creating!

SAFETY MANAGEMENT SYSTEM

serco

Thelnternotionol CivilAviation Orgonisotion requires thato Safety Monogement System (SMS) beputin place ofevery airport withATC during 2003ondwithinAirport Operations byNovember 2005.Asforbock asl 999,Serco commenced thedevelopment ofo corporate-wide SMS tosupport itsinterests inthemanagement ofsolety critical operations. Thiscovers thenuclear androil industries, aswellasworld-wide aviation services, ondhosledtothedevelopment ofonaviation-specific SMS, which weorenowspearheading across ourglobal oviotion business. Serco Aerospoce isresponsible forSerco Group's AirTraffic Control ondAerodrome Operations intheEuropeon Union.Serco Aerospace isworking towords hoving theirSofety Management System implemented otallUK8.European units- military 8.civil- byJuly2003. During theimplementation phose, theAviation Sofety Monogers fromeach Serco geographical region hove been working withtheirrespective Notional Aviotion Safety Regulators toseek approval of theirindividual Aviation Safety Management System. AllAviation Safety Management Systems derive fromtheSerco Group Aviation Standard. IntheUK,weorealsoproviding consultancy onSMS issues foro number ofnon-Serco airport companies.

~~~

~llt:lllv Business Development Manager Serco Aerospace Enterprise House, 11 Bartley WoodBusiness Pork Bartley Woy,Hook,HontsRG279XB T:01256745900 F:01256745930 E:dfortet@serco.com

Safety Matters THE CONTROLLER

Editorial don't agreewith thesechanges,then pleasefeel raised in these articles is the need for legal CONTROLLER Changesfree to write to the Editorwith your comments protectionof the individualcontrollerswho may and criticisms.

haveto facechargesin a criminalcourt. Some Member Associationshave legal protection A JustCulturefor IncidentReporting schemesin place,othersmaynot. However,it is also clear that many MAs believethat, in the This will the first issue of The CONTROLLERIn this issue,therearetwo articlesdealingwith event of such legal action being taken, their under the new arrangementsagreed with the impactof the legalsystemon the actionsof employershavea responsibilityto providethat ExecutiveBoard. The ControllerManagement controllersinvolved in either an accident or legalprotection. Thatmaybe correct- but it is Group ceased to exist on 31 May when serious incident. The articles speak for worth checkingand clarifyingthat this is the but they indicatethe difficultiesthat correctposition. If it is not and no other legal responsibility for the administration and themselves financing of the journal was passedto the will be encounteredin establishing a just assistance is available, any unfortunate Executive Board. We have contracted a incidentreportingsystem.In a recentEuropean controller taken to court would be in very company- McMillan-Scott pie - to takeoverthe surveyon legal impedimentsto non-punitive vulnerableposition. responsibilitiesfor advertising,journal layout incident reportingconductedthrough auspices andpresentationin ourcontinuingdriveto bring of the Eurocontrol Performance Review And Finally ... The CONTROLLER back to profitability. The Commission,one important finding was "Jn editorial content remainstotally with IFATCA. many States, there are significant legal Thisjournal survivesthroughthe efforts of our Our objectiveis to ensurethat the viewsof the constraints to non-punitive A TM safety regularand occasionalcontributorshoweverwe reporting.Asa result,manystaff feel are alwayson the lookoutfor freshtalent, new internationalcontrollercommunityareprojected occurrence subjectmatterand ideas.Soif youfeel that you in a clear, visually attractive and objective inhibitedfromreporting.Thisis particularlyso mannerthroughthe pagesof this journal. At where Stateshave "Freedomof Information" could be part of the team that keeps The afloat, I would love to hearfrom the sametime,to ensurebalanceandprovidean legislationin placeand havenot takenstepsto CONTROLLER alternative perspective,other individualsand protect safety reports from its application." you. Pleasedon't let "English" not being your organisations fromaviationrelatedbackgrounds Through highlighting these and other cases, first language be a reason or obstacle for are invitedto contribute. I hopethat you, the IFATCA hopes to influence those State stoppingyoufrom makingcontact- we havethe reader,will find the changesto your liking and authoritiesthat havelegalimpedimentsto non- meansto overcomelinguisticproblems.Also,I that they enhancethe imageof IFATCAas a punitive reportingto re-considertheir laws in would like to hear from anyonewho has an responsibleand mature organisation.If you the interestsof public safety. Theother issue interestin the editorialsideof the journal.

ChrisStock - Editor

Editorial Clarification

performanceas ATCmanagersin termsof the manningof ATCSectors andwhyin the process of number- and cost- of controllerhoursprovided automating,it appearsto be perfectlyacceptable fromsystemusers. Article on Human Centred Automation in versusdollarcost recovery in some ATC Units to engineer controller I certainlyrecallthat, overthreedecadesago, workstationsas single-operator CONTROLLER 1103 positionswhere whenI wascontrollingat Heathrow, management the efficiency- as well as safety - value of Thearticle on HumanCentredAutomationhad tacitlyemployed a distinctlyhands-offapproachin continual controller teamwork and mutual beenpassedto the Editorwho understoodthat dealing with their well trained and highly support,is entirelyprecluded. it was for publication.Thetext of the articleis motivatedstaff - and even went so far as to I shouldlike to concludemy remarkson Mr. identicalto that of a relatedsectionin Chapter2 providedormitoryfacilitiesfor useon the twelveFallon's thought-provoking article with a of ICAODoc.9758 - HumanFactorsGuidelines hourmidnightshifts.At HongKong'sKaiTakATC somewhatwild suggestion concerning the (longfor ATMSystems.BertRuitenbergwas involved Unit,therewasa verysimilararrangement for the term)strategicplanningof ATCservices.If it is in the production of this document as a nightcrew. Instarkcontrast.I laterheardof other acceptedthat humanlimitationsmakeit critically consultantto ICAO;it wasnot his intentionthat national Area Control Centres where advisableto minimise,if not totallyavoid,having the text shouldappearas an article underhis unenlightenedmanagementdid all that they controllers routinelyworkthroughthenight,could namein TheController.I wouldliketo apologise couldto ensureboredom- andconsequent fatigue a workableanswerbe foundin takingadvantage for anyembarrassment that publicationof this - by banningany kind of recreationalreading of the fact that ATCoperationscan now be articlemayhavecaused. material,at all times,from the operationsroom! conductedfrom remotelocationsestablishedin As Mr. Fallonso accurately states"Humansneed widely dispersed time-zones 7 For example, stressto operate". Thesebizarreedictswere duplicated enroute control centres, with formulatedin the patheticbelief that a human continuous mutualexchange of all flight planand beingcansit, mindin neutral,for manymiddle-of surveillance data,one locatedin BritishColumbia DearEditor the-nighthourswith the traffic load at or near andtheotherin Newfoundland, couldintelligently Pleaseconveymycongratulations to BrianFallon, zero,andthenbecapableof appropriate response exploitthe four-and-a-half hour time difference NATCA,on his clear and incisivearticle, "ATC to the demandsof the inevitable"pre-breakfast" betweenthesetwo locationsto largelyremovethe Safetyand You", publishedin 1st Quarter2003 trafficsurge! need for control staffs ever to work the issueof TheController. BrianFallon'sother point aboutthe needfor "graveyardhours". As a bonus,Canadawould It isto beferventlyhopedthat,world-wide,ATS teamworkin ATCis anotherlongcherishedideal axiomaticallyachievea mostviableoperational management authoritieswill takeseriousnoteof whichappearsto be in dangerof sinkingin the back-upcapabilityin the eventof unplannedloss Mr.Fallon'smainpointconcerning the undeniable headlongrushto automationwithoutdueregard of oneor othercontrol centre.(Provided political impactof humanfatigue factorsupon (safety- for the humancharacteristics of the peoplewho and/or nationalist objections could be critical)24-houra day ATCoperations.In these beardirectlegalresponsibility for providingsafe surmounted, this conceptcouldalsobe applicable days of ATC privatization,with its attendant andefficientservice.I believeit is fair to observe for pairsof ACC'soperatingon oppositesidesof creeping emphasison "controller efficiency" that sinceWorldWarII, astechnological advances othercontinentsandoceans.) rather than "controllerexcellence",there is a permittedtheeconomicreductionof airlinerflight great dangerthat seniormanagers- who have deckcrews,the "downsizing"almostuniversally Yourssincerely, eitherneverworkedirregularshiftsfor manyyears ceasedwhen we got down to two pilots.The at a time,or who havelong sinceforgottenthe reasonsare obvious. What is not so obviousis GordonWhitehead experience- will crudely measuretheir own why similar rationale is not applied to the

Lettersto the Editor

THECONTROLLER

ATC Safety

ONESAFESKYFOREUROPE A REVOLUTION IN EUROPEAN ATM? Marc Baumgartner,President andCEO AGAS establishedfour working Groups and safetyrelatedtrainingof all operationalstaff,as commissioned an ECAC-wide ATMSafetysurvey, a matterof priority,shouldbe allocated.States developeda StrategicSafetyAction Plan and should investigatethe feasibility of pooling agreed an Action Plan for RunwayIncursion humanresources(for safety regulations).Best Prevention. useshouldbe madeof harmonisedEurocontrol guidelines,recommended practicesand tools to also integrate human factors principlesin ATM. STRUCTURE OFTHEACTION PLAN

"Safetyshouldbe afforded the highestpriorityover commercial, operational, environmental andsocial Workingundera verytight timescale,the AGAS Incidentreportinganddatasharing group which was chairedby Mr. Phil Griffith pressure (Headof the SafetyRegulationGroupUK,SRG) National ATM regulatorsand ANSPsshould II

- AGASintroduction,April 2003 the Chairman of the Safety Regulation urgently allocatesufficient resourcesfor data Commissionof Eurocontroland Mr. George collection,analysis.Theyshouldimplementthe This article retracesthe main outcomeof the Paulson(DirectorSafety,Airspace,Airports & principles of a "just culture" in safety first SafetyAction Planwhich was adoptedat InformationServices)has produceda varietyof occurrencereportingand cooperateto define the Europeanlevelmid April 2003.It is the first recommendations.More specifically AGAS and adopt industry wide harmonised significantsteptowardsenhancingsafety,not as considersthe following areas to be of the mechanisms for sharingsafety-related data.This motherhood statements but with proposals highestpriority as they are likely to havethe should include cooperation with airlines to which are clearand shouldchangethe current greatestimpacton enhancingATMsafetyin the derivebestpracticewherepossibleandto share approachto SafetyImprovementmeasuresand shortterm: data on "lessons-learnt". An industry-wide SafetyManagement.Thefirst part of the article awarenessand education campaign for all in ATM describesthe approved Safety Action Plan, • Safety- relatedhumanresources stakeholders underlyingthe safetybenefitsof a contentandsomeof the recommendations. The • Incidentreportingand data sharing goodreportingcultureshouldbe initiated. secondpart is lookingat the possibleimpacton • Airbornecollisionand avoidancesystem (ACAS) the Air TrafficControlprofessionby this Action ACAS Plan and presentsan initiative aimed at the • Ground-based safetynets MembersAssociations,mainly in Europe,but • Runwaysand runwaysafetyEnforcement of Eurocontrolshould as a matter of priority, which couldbecomea documentto be usedby • EurocontrolSafetyRegulatoryRequirement continueto progressthe work currentlybeing the restof the world as well. Thisarticleshould (ESARR) and the monitoringof their undertakenon ACASII RADownlink.Thework bereadin conjunctionwith the Articlepublished implementation should cover technicalfeasibility and human 1 in TheController4/2002. • Awarenessof safetymattersSafetyResearch factorsaspects.Thecurrentwork shouldaddress & development(R&D) certainACASlogic performanceissuesand to Controllersdo not like revolutionin their daily developand proposemodificationsto the TCAS jobs. Normally they preferan evolutionary Areas,which havealreadybeenagreedby the II MOPS. approachto change.However,by acceptingthis Eurocontrol Provisional Council and the Action Plan on Safety,the EuropeanAviation Permanent Commission were selected for Runwaysafety communityhas adopteda revolution in Safety immediatefocus: for ATM. Theproposedrecommendations will NationalAviationSafetyAuthorities,Aerodrome ensure anevolutionaryincreaseinf Safety in Safetyrelatedhumanresources in ATM Operators,ANSPs,Aircraft Operators,Aircraft ATC. OperatorsAssociations shouldall, asa matterof As a matter of urgency,national ATM Safety high priority, implementthe recommendations Regulators and Air NavigationServiceProviders in the "EuropeanActionPlanfor the Prevention (ANSPs) should increase their efforts to of Runway Incursion" that relate to their implementESARR5 (XXX)within the agreed activities. time frame (31.10.2003).They should also ensurethrough the implementationof safety of European Safety awareness, the establishment of a safetyculture, Enforcement safetyattitude and behaviouramongstATCOs Regulatory Requirements (ESARRs) and Followingthe tragic accidentsin Milano Linate (teams and individuals).The introduction of monitoringof their implementation and the mid-aircollisionin the Southernpart of regular emergency,refresher,and competency Germany, the Eurocontrol Agency'set up a high- assurancein line with ESARRS and through Eurocontrol must ensure that ESARRsare level group on ATM safety to improvesafety team resourcemanagement training(TRM).The drafted in a clear and easily transposable managementand regulation within Europe, provision of sufficient human resourcesto manner and States must finalise the calledActionGroupfor AviationSafety(AGAS). enable the implementationand conduct of

PARTI

BACKGROUND

THECONTROLLER

ATC Safety implementationof ESARRsthat have been operationaleventswithin their national This Action Programme will evolve as formally approved.ExistingESARRs should be airspace,in accordancewith the /CAO circumstancesdevelop. For example, should reviewed to improve clarity. Means of provisions; furthersignificantATMsafetyimplicationsarise Complianceshould be developed.Although • that aircraftoperators'ACAStrainingfor following the accidentreport concerningthe 1 there is an SRC monitoring programmeto flight crewis in accordance with the /CAO July 2002 mid-air collision, the Action oversee the implementationof ESARRs,its ACASPerformance BasedTraining Programme will be adaptedaccordingly. currentstructurehaslimitationsthat preventits Objectives; developmentinto a strongmonitoringtool. The • that aircraftoperators'flight operations OTHER RELEVANT OUTCOMES need for an institutionalised oversight manualsincludeappropriateACAS OF AGAS programme,which will allow for actionsto be procedures; taken when a State is not compliant, was • that Air NavigationServiceProviders'ACAS identified. Such actions could range from trainingfor controllersis in accordance with SafetyImplementation Maturityin ECAC assistanceand education to national bodies EUROCONTROL ACASguidance; States incurring difficulties with implementation,to • that Air NavigationServiceProviders'ATC morepublicactionif non-compliance continues operationsmanualsincludeappropriate An independentsurveyof ECACStatessafety on the part of a recalcitrantState, with the ACASprocedures. regulatorsandANSPs, whichwasundertakenon implication that some of the information behalf of AGAS, demonstrated that the should: obtainedunder such a monitoringprogramme EUROCONTROL developmentof an ATMsafetyframeworkis not could be disclosed.Regularmonitoring was • continueto progressthe work currentlybeing consistentacrossECACand implementationof undertakenon ACASII RADownlinkas considered the key to assist achieving the ATM2000+Strategyin respectof the safety quicklyaspossibleto covertechnical compliance.In orderto avoidduplication,it was objectiveis at an earlystage.A few Stateshave feasibilityand humanfactorsaspects; proposedto investigatewhetheror not sucha well definedsafetyframeworksand understand programmecanbealignedwith the ICAOSafety their safetyrequirements. However,the majority • maintainthe work currentlybeing AuditsProgramme. of States have only introduced safety undertakento addresscertainACASlogic frameworkswithin the last five yearsand have EveryArea is then defined in the report under performanceissuesand to developand made limited progressin manyareas,but they ActionsRequiredwhich givesa very full list of proposemodificationsto the TCASII MOPS. recognisethat they havesomeway to go before actionsand recommendations. Variousactorsin their systems reach maturity and optimum the ATM domain request approximately50 Actionby: Stateregulators,aircraftoperators, efficiency.A small numberof Statesare at the actions.As an examplethe chapteron ACASis /CAO,JAA,and EUROCONTROL. earlystagesof assessing the safetyrequirements reproducedbelow: Finance: Thereshouldbe no costimplications and have problems understandingwhat is in the actionsrequiredfor ACAS. requiredand how thoserequirements shouldbe CurrentSituation.Both airborneand ground- Timescale:Theissueis considered amongthe addressed. The figure below shows a basedsafety nets are last resort systemsto areasof immediatefocus. cornparison of the maturity of national preventaircraft accidents.In normaloperation regulatorsand ANSPsin 32 ECACStateswhere the safetynetsare triggeredin cascade,i.e. the both regulatorsand ANSPsrespondedto the TIMESCALE airbornesafetynetswill be launchedonlyif the survey.It can be seenthat the maturityof the ground system (controller and groundbased • ActionProgramme regulatorsvariesgreatlyand is ohen belowthat schedulecompletesafetynets)fails. of the ANSP.The majorityof both State ATM November2003 regulatorsand ANSPslie betweenthe mature • FormalActionProgramme Implementation There are extensive ACAS prov151onsand and earlystagescategories. Launch- January2004 guidance material included within /CAO • Mid-Implementation Progress Assessment· documentationand that of EUROCONTROL, the November2004 JointAviationAuthoritiesand individualState's • TargetImplementation Date- January2006 Figure 1 : AEATsurvey on Civil Aviation Authorities. It is essentialthat • ProgressImplementation Safety EvaluationImplementation of ESARRin 32 ECAC theseare reviewed,reinforcedwherenecessary, July2006 States and applied correctlyby all thoseinvolvedin ACASoperations.

Comparsion of Self Assessment Maturity Scores from ANSPs and Regulators

Airborne CollisionAvoidanceSystems(ACAS) are mandatedfor manyaircraft,but application of procedures,internationally,has beenshown to be sometimesinconsistent.Thisneedsto be addressed, urgently. Action Required. AGAS considers that the followingactionsarerequired:

100 a, "' ... 80

ANSP

---

Regular

0 ()

en 60 >, .... 40 ::I .... Cll

StatesCivilAviationAuthoritiesshouldensure:

·;:

• nationallegislationandA/Psinclude provisionsrequiringthe carriageand operationof ACASII in accordance with the ACASpolicyagreedby the ECACStates; • nationallegislationandA/Psdefinepilot and controllerresponsibilities duringACASII

:E 20

THECONTROLLER

Early Stages

of Implementation

0 -l-~~~~~~~~,.......,.--r---.--,-,-,---r---.-..,.......,,-,--r---,--,-r,--,--,-,-.-, 1 2 3 4 5 6 7 8 8 1011121314151617181920212223242526272829303132

States

ATC Safety Legislation

developed depends heavily on basic ATM knowledge, cultural background and the awarenessof the ATM as a serviceof general ISA REVOLUTIONpublicinterest.

PARTII

In addition to their responsibilities as Members of ICAO,EUROCONTROL MemberStateshave SAFETY IN ATCan obligationto implement,in a timely manner, NEEDED? EUROCONTROL SafetyRegulatoryRequirements (ESARRs)once they have been formally SafestYearin numbersof fatalitiesin approved.ForvariousreasonsmanyStatesare aviationwas 1984with 624 fatalities not meetingthat commitmentand currentlegal SafestYearin numberof accidentsin mechanismsto securecomplianceare few and aviationwas2001 with 34 accidents in practiceineffective. Aviation SafetyNetwork

Let'stry to approachsafety:Safetyof a system can be definedin ATMas beingthe interaction between Procedures,Peopleand Equipment. Thesethree elementscan be brokendown into other elements.Onlyby integratingProcedures, Peopleand EquipmentasATMtogetherwith the Ground and Airborne parts will the Total At present as most EUROCONTROL Member Safety is the "raison d'etre" of Air Traffic AviationSystemSafetybe formed.A schematic Statesmust transposeinto their national legal Control.IFATCA, asthe globalprofessionalvoice view taken from the EurocontrolWorkshopon order EUROCONTROL regulatorydecisions,such of Controllers,has for manyyearsbeenasking ESARR 4 (Risk Management in ATM) as ESARRs, implementationis slow and uneven for its assurance.This claim for more Safety, introduction: acrossthe States.Thetranspositioninto national although most of the time pertinent and law may also result in differencesat national justified, has always been refuted with From a mathematicalpoint of view the ATM level rather than a fully harmonised argumentsthat Safetyis inherentin the system. system can be defined into tolerable safety EUROCONTROL-wide application of However many of our membership have levelsandat a certainpoint the mathematicians requirements.Monitoringof implementationis experienced is that for variousreasonsSafetywas tend to saythat it is not safeanymore.IFATCA 5 at presentlimited. Overallthis meansthat the easily pushed into a status of "Backstage". talking about a Target Levelof Safety in its' level of maturity of safety frameworksis not Delays, economics, culture, management publicationsand policies.Butwhat is it?' consistentacrossECAC.The adoption of the arrogance, ATCO misbehaviour' and higher European Community Single European Sky political objectivesetc. have been invokedto A level of how far safety is to be pursuedin a Regulationsand the accessionof the European reduce Safety to an economicalacceptable given context is assessedwith referenceto an Communityto EUROCONTROL should provide minimum.Why have the controllersthen not acceptableor tolerablerisk.Thisnotion of TLSis legalstrengthto the implementationof ESARRs, beenable to highlightthe importanceof Safety widely usedin ICAObut relatedand limited to which,oncethey havebeentransposedinto EC and make it a real selling argument?Do we specific types of accidents or causes to law, will be directlyapplicableand enforceable reallyneedto wait for a seriousincidentand/or accidents. ESARR4 introduces a high-level within a proportionof ECACStates. accidentto show the outsideworld in a tragic quantified input to the design of the ATM anddramaticwaythat safetyshouldtakea more systems,in the form of a TargetLevelof Safety (TLS)expressedas the maximumprobabilityof European ActionPlanfor Prevention of prominentrole in our daily work? But do we as ATM contributing directly to an accident. professionals understandsafetycorrectly?Have RunwayIncursions Referring to ESARR4 and to a recent we understood the public service we are Everyweekthereare3 to 4 runway amendment to Annex 11 SafetyMinimum/TLS 1 working in and if yes, what are we doing to incursionsin the ECACarea. could also be expressed,in addition, as the improve the understandingbeyond the radar maximumprobabilityof occurrenceof incidents In July2001a joint runwaysafetyinitiativewas screenor the towers? in ATM.Typically;suchTLSappliesto the ATM launched by GASR, JAA, ICAO and Approachingsafetyin ATCis alreadya difficult systemsas a wholeand not directlyto eachand EUROCONTROL to investigatespecificrunway of the ATMsystem. and steep learning curve, understandingit everyelement/piece safety issues and to identify preventative becomeseven more delicate. Developinga actions.The TaskForcethat was subsequently Safetyculture in ATCtakesmanyyearsfor any Aeronauticaldata:a) criticaldata,integritylevel formed to carry out this work comprisedof organisation,be it a professionalorganisations, lx/0-8: there is a high probability when using representatives from the JAA, EUROCONTROL, an ATCTeamor an Air TrafficServiceProvider. corruptedcritical data that the continuedsafe ICAO,GASR,ACI,AEA,ECA,ERA,IATA,IAOPA, The way it is approached,understood and flight and landing of an aircraft would be IFALPA,IFATCAand many other professional severely at risk with the potential for organisations,includingAir NavigationService Providers(ANSPs)and other Aircraft Operators. This initiative concludedits work with a report containing 56 recommendationsgrouped in variouschapters(GeneralPrinciples, Aerodrome Operator Issues, Communications,Aircraft OperatorIssues,ANSPIssues,Data collection and Lesson sharing, Regulatory Issues, , AeronauticalInformationManagement,Future / People Work NewTechnology & HumanFactors). r J

Rapidand co-ordinatedimplementationof the recommendations is necessary to reduce runwayaccidentsand incidentsand improve safety.Theneedto sharesafety-related informationand introducea harmonisedand consistentapproachto the collectionand analysisof data is keyto reducingthe risksof runwayincursions.

: Equipmen l I

, Procedur \

THE CONTROLLER

ATC Safety well. But is educationsufficientto understand safety? Understandingsafetycan be a total academic approach,which can turn out to be totally uselessin the operationalfield. Understanding safety has to do with the degree of safety awareness. In a recentlypublishedarticlein The Controller4/2002, PhilippeDomagalause.da model presentedby ProfessorPatrickHudson (Leiden Unviersity) which I would like to mention,usinggraphics': To developa SafetyCulturein an ATM service needsnot only understandingand awareness, but mostlycommitment.Commitmentcan only be achievedif all the actorsaretalkingthe same languageand are informed about what the objectivesof developinga safety culture are. Many "successful"companiesoutsideaviation haveunderstoodthis and startedsystematically to investin Safety,which only broughtabout a changein the safetyculture.Whatis safefor an AviationRegulatormight turn out to be totally unsafefor the ATCOor the pilot. An acceptable catastrophe; over a Functional Hazard Analysis to the riskfor an ATCOmightbe seenunacceptable for /CAO Annex 11 - Air Traffic Services2.18 Mitigation Meansand the establishmentof a ANSP Managers.What is important is that AeronauticalData SafetyCaseit can takemonthsor years.Seldom Safetyis not takenfor grantedor inherent,but will the shopfloorlevelATCObe awareof this that safetyis provenand assuredand becomes Withoutgoinginto verydeepanalysisone could until he is confrontedwith informationat the an integralpart of the daily life of all categories definewhat an acceptableand/ortolerablerisk operationallevel,througha briefingand/orthe of personnel.Theneedto manageSafetymore is. Eurocontrolhas illustrated schematically refreshertraining. And sometimes- still too in a harmonisedway has been identified by 10 what shouldbe understood(seefigurebelow). often- he is beingtold that somethingchanged political decision makersat ECAC and the duringhandover.Soapproachingsafetyis more EuropeanUnion.The ECACTransportMinisters Having establishedwhat the Target Level of than 1000ft,5 nauticalmilesand a little bit of have endorsedthe ATM2000+Strategywhich Safetyand/orthe acceptableand tolerablerisk luck. However,to understandsafety,everybody states"to improvesafetylevelsby ensuringthat to work with new procedures,equipmentand working in aviation should have a basic the numbersof ATM induced accidentsand humanfactors/resources are, relatedissueswill knowledge of elements such as TLS, Risk serious,or riskbearingincidents,do not increase then go into a secondstage. How will the Management,FunctionalHazardAnalysisand and,wherepossible,decrease",with a doubling system meet the Target Level of Safety? mitigation measures. This countsespeciallyfor of traffic a reductionof the costsandthe delays. Normally,a lot of expertstend to say that a the humanoperator.To keepthe Humanin the Eurocontrol has established thorough safety case has to be established.In short, a loopstartswith hisbasiceducationaboutsafety. RegulationRequirements for its memberstates safetycase'will establishthat a new procedure Duringthis, educationtheories'and field work (togetherwith its memberstates and all the meets the TLS as required. Normallythis is on humanerrorsin Aviationshouldbe taughtas stakeholders)"implementation datesare set. achievedwith a FunctionalHazardanalysis. Operationalandsystemexpertssit togetherand elaboratea list of possiblehazardswhich could occur when introducing a new piece of equipment,a new procedureand a new human GENERATIVE factors/resources relatedissue.Thisanalysisis documented and possibly all hazards are identified.Thenthe hazardsare quantifiedand mitigationmeansare proposed.Thesecondpart of the SafetyCasewill concentrateon what has to be done to have the mitigation meansin place the day of the introductionof any new elementsin the current aviation system.This might be a lot of work, which is frequently underestimated byATCOs, ANSPsandthe Safety Regulator.In a state of the art SafetyCase,all relevantstepshaveto be documented. In mostcasesATCOswill be confrontedonly at this stagewith the safetywork, whichhasbeen done so far. Fromthe establishmentof a TLS

THE CONTROLLER

ATC Safety ESARR1(tentativetitle - NationalATM SafetyRegulatoryFramework) ESARR2Reportingand Assessment of Safety Occurrences in ATM1.1.2000 ESARR3Useof SafetyManagementSystems by ATMProviders3.10.2003 ESARR4RiskAssessment and Mitigationin ATM ESARR5SafetyRegulationRequirements for ATMServices'Personnel ESARR6Softwarein ATMSystems

recommendations and thereforeinfluencedto a large extent by those managingit. In order to maintainthe momentum,morehasto be done from bottom-up- that meansby YOUas an Air Traffic Controller otherwisethe old devils of failed managers and failed management decisionsin ATM will repeat themselves.And you as ATCOswill be once again used as the scapegoat.

What canyou do in this process?Youcanas an ATCOstart to acquiremore knowledgeabout Through the work of AGAS it has become ATM Safety. By reading relevant articles, apparent that, although the theoretical downloadpublicationsfrom all over the world approach to enhanced Safety Regulatory and ask yourself:"What can I do to makethe Requirementshas been taken, a lot of States systemsafer?"Furthermore, you canassistyour have not realised,nor understoodwhat was at managementto acquire the same level of stake. The EuropeanATM communitycannot knowledge.You shouldask to havesystematic start to talk about Safetyawarenessand safety ATCOtraining in Safety matters and Safety managementwithout understanding Safety. awareness,including understanding Human Manystateshave,for example,greatdifficulties Errorsin ATM. in implementingESARR2 becausethey realise that they would have,in certaincases,to make As a follow-upof the work of AGAS,a document amendments to the nationalcriminallawswhich will be prepared by IFATCA which will rankextremelyhigh in the hierarchyof domestic summariseall the recommendationsof the law andareconsequently particularlydifficult to Action Plans. Only by talking to your change. managementand the nationalSafetyRegulator (initially in the ECAC area) about the Management,in generalterms,shouldbe based recommendations of the ActionPlan,will yoube on understanding the product and its able to becomea championin Safety.These components,and understandingthe regulatory efforts will be co-ordinatedon an international mechanismof the industry.Fromthis general level by IFATCAfor the use of the national understanding,strategy and conceptscan be MemberAssociations. A dedicatedplatformfor developedand implementationof measurescan information sharing will be established. be formulated.In the end benchmarkingwill However,everyMemberAssociationof IFATCA help to positionthe producttowardsthe outside shouldwork towardsachievingthe realisationof world. Managingsafetyshouldbe lookedat as these recommendations. Although this Action the mainactivityfor the wholeATMcommunity; Planis focusedat the Membersof the European howeverwe are still far away - astonishingly Area,the restof IFATCAs' MemberAssociations enough- from the generalprinciplesmentioned can certainly learn a lot from these above. recommendations and usethem to achievethe changeswhich we desperatelyneed. However ThereforeIFATCAand its' Members'have to keepin mind that 70% of the recommendations continuously strive for the achievementof of the AGAS Action Plan are only implementinga safety culture in ATM or as recommendations which should have already expressedin the words of Prof.Hudson"Safety been introduced and show up the poor behaviouris fully integratedin everythingwe performanceof this process-orientated way of do". This includes much more than Safety handlingsafetyat a largeregionallevel. Regulationand SafetyManagement. A revolutionin ATCSafetyis needed- this for TheSafetyActionPlanfor ONESAFEEUROPEAN the sakeand the benefitof our industryand the SKY and the EuropeanAction Plan for the travellingpublic.It startswith you! Preventionof RunwayIncursionis a opportunity (to usea buzzword) - maybeevena revolution - for the whole ATM communityin Europeto 1 Domogala Philippe, « KeyIssue for2003-Safety», develop a long neededsafety culture in our business.With almost 100 recommendations TheController4/2002,vol.41ISSN0010-8073, IFATCA anda realistictime scalecontainedin the Action Plans, ensuring an evolutionary way of enhancingsafety.Vigilanceis neededsothat the MemberStates: Albania,Austria,Belgium, momentum is maintained and that States, Bulgaria, Croatia,Cyprus, the CzechRepublic, ANSPsand all the stakeholdersinvolvedreally Denmark, Finland,France, Germany, Greece, start to move towards a new safety culture. Hungary, Ireland,Italy,Luxembourg, theformer Howeverone has to be aware that the AGAS Yugoslav Republic of Macedonia, Malta, recommendations are only processorientated

Moldova,Monaco, the Netherlands, Norway, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey andthe United Kingdom. Eurocontrol's roleis to co-ordinate thedevelopment of a uniformsystemof ATM throughoutEurope 3

European ActionPlanfor Prevention of Runway Incursions

' i.e.Callingfor strikebysomeATMUnionin order to stoptrainingof newstudents - leadingto pay increase andreducenumbers of ATCOs 5

TargetLevelof Safety: Thelevelof safetywhKh thetotalsystemis designed to meet. www.eurocontrol.be/srddocumentsideliverables/ src_eatmp_ws/OS_need_for_method.ppt

SafetyCase: A safetycaseis an analysis presenting an overalljustification for the declaration thata particularsystems satisfiesits safetyrequirements.

' Amalberti R.,LeseffetspeNers del'utrasecurite, La Recherche, Paris,Avril1999. 9

HudsonP.,AviationSafetyCulture,Safeskies, Centrefor SafetyScience, LeidenUniversity, 2001. ECAC: European CivilAviationConference

SafetyRegulation andSafetyManagement Principles

SafetyRegulation is the process appliedbyStates, within nationallegaldutiesandframeworks, for establishing, overseeing and enforcingminimum safetylevelsin the public interest.It includes rulemaking, usuallyin theformof safetyregulatory requirements, togetherwith a meansfor ensuring compliance by thosesubjectto safetyregulation. Safety managementis the processused by organisations providingsafetyrelatedservices or productsto ensurethat all safetyaspectsof that provisionhavebeenadequatelyaddressed. The processincludesthe setting of organisational safetypoliciesand standards (whichmeet,as a minimum, the provisions of regulatory requirements), a meansfor measuringsafety achievement anda mechanism for therectification of deficiencies. Bothactivitieshavea common aim - the achievementof safety - and are complementary to oneanother.Thewayin which theyareimplemented depends uponthe structure andcapabilities of the industry.

THE CONTROLLER

McMILLAN

SCOTT

Toadvertisein the next issue of THECONTROLLER please contact DavidLancasteron tel: +44 (0)20 7878 2316, or email david@mcmslondon.co. uk

ATC Safety

SinglePerson Oper (SPO)or TheSlice Proportional Openi PaulNeering- TheNetherlands,SC4 Sincethe mid-air collisionover Oberlingenin July 2002 and the Tahiti incident in January 2003,wherethree Boeing747'swere savedby ACAS,investigations and publicationsaddressed both the benefits and the shortcomingsof TCAS/ACAS. Anotherelementin both cases(and many others) is the fact that Single Person Operations(SPO)were in force. The IFATCADefinition of Single Person Operations (SPO) is "operations where an operationalATCunit is providinga servicewith only one personpresenton duty,that beingthe ATCO". heard, advice afterwards is 'reduce or stop

investigations:'supposethis event took place duringSPO'(whenSPOis commonpracticewith the provider concerned)so lessonscan be learnedfrom it.

Providers and Regulators

Providerslookingat statisticsversuscostsmay gratefullyacceptthe SPOsituation,sometimes supported by comments from controllers traffic in suchcircumstances'. However,there is expressing the above mentioned historic always that phase to go through where a feelings.The argumentationmay then be used Practice controllerneedstwo mouthsand four handsat to introduceSPOin other working placesas Theuseof SPOcanoften be explainedawayby the sametime.Quitea problemin SPO.... If we well. As we saw in the Oberlingencase, a history.'It hasbeenin usefor so manyyearsand analyse the outcome of investigationsinto Regulator even accepts SPO until the first incidentsand accidentsat or nearairports,most accident(the ReactiveLevelaccordingto the we haveneverexperienced any problems'. of the time therearemoreaspectsto it than one categorisation by Prof. P. Hudson, Leiden Peoplein ATC tend to forget near-incidents personcandealwith let alonethe impacton the University).After the Oberlingenaccident,only quickly or considertheir solutionsas personal person involved. And if there were enough three providers,Belgocontrol,Eurocontroland rescues of safety and system, instead of people at the time of the incident/accident, SkyGuide,are known to have taken direct emphasisingthe shortcomingsof that system. seldom is the following question raised in positiveactionsand stoppedSPO. When reportsare made,the theoretical,often

Controllers Is it a form of thrill seekingon the controllers' part to accept SPO? Does it give job satisfaction?Is equipmentsuch that nothing distractscontrollerswhen performingtheir job? Or arewe talkingaboutcoincidences whenSPO is involvedin irregularities?Theanswerto the last questionis obvious- no.SPOis a largehole in the safety net of controllers'surveillancein the ReasonModel. Distractionduring(singleperson)operationscan be numerousand of a numerousvariety.I am sure everyone knows some examples.The performingof doubleseparatesurveillance tasks (two screensor TWRplus a screen)is a risk in itself and in SPOit is just enlargingthe hole in the surveillance slice. Combinationof tasks, like combiningsectors, will at least keepthe controller'seyesfocused on one screen,but if we talk about combining ApproachandAreaControl.... Fromthe analysis

THE CONTROLLER

ATC Safety

Relatedaspects

The Reason model Reason model

PreventingSPOwill have positive effects on otheraspectsin ATC: • Determininga minimumlevelof staffing in a safetyculture. • Theimmediatereliefof a personinvolvedin an incidenUaccident. • Thelegalsituationof the controllerin caseof an accident. • HumanFactorsin a wide range.

1 2

3 4

Conclusions ABCDEF Hazard

Accident Mid-air

Closing tendency

between two aircraft

of the Tahiti incident: 'When an individual controller combines a number of positions, diversescenariosand increasingworkloadscan quickly distract controllers. Controllers and supervisorsneed to be vigilant so that ATC positionscanbe separatedto facilitateeffective workloadmanagement'.

IFATCA Policy Since2001 we do have policy on SPOwithin IFATCA. "RosteringSinglePersonOperations(SPO)shall be avoided thus leaving room for the unexpectedor ForceMajeure." The policy was developed as a result of questionsof MemberAssociations dealingwith privatisation,and meantas a tool for MAs in a privatisedor a developingenvironment. Privatisation In March2003CANSO, the Civil Air Navigation ServicesOrganisation,said that ATCwas hit by the MiddleEastcrisisand reductionin traffic. In its pressreleaseit states 'Navigationcharges are calculatedby dividing the cost of service provisionby the numberof flights using the service'.The size of the working areasof ATC units, especiallyin the visual and radar rooms, hasneverbeencreatedin relationto the number of flights and their servicecost. Now that CANSOsays ANSP'sare short of incomeand asks for help at inter-Governmental level, it becomesclearthat ideasaboutprivatisationdo not coverall kindsof conjuncture. Evaluating the developmentsone can concludethat a certain incomefor the ANSP'sshouldbe guaranteedby Governments.At the same time, a minimum level of ServiceProvisionshould be set in relationto the incomeeliminatingthe needfor SPO.

THECONTROLLER

Safetyculture In a modernsafetyculturewe cannotignorethe risks of SPO.In Hudson'sclassification,many organisations are still at Level 1- the Pathologicallevel (who cares as long as we don't get caught)or 2 - the reactivelevel(safety is important,we do a lot everytime we havean accident),and are growing into Level 3, the calculativelevel(we havesystemsin place).By determiningwhat we are aiming at, namely banishmentof SPOand simultaneousseparate surveillancetasks,we can get through Level4, the Pro-active level (we still work on the problemswe find) pretty quickly and finally reachLevel5: Safetyis our businessand is fully integrated into everything the organisation does.Of coursehereit reflectsthe subjectof this article and not the full culture of an organisation,but I think it is a good and practicalexampleof how to get there.

SPOand performingseparatesurveillance tasks at the sametime are provenrisksin ATC.In our safetyculturewe shouldlearnlessonsfrom that and avoid both. ANSPs should take full responsibilityfor safety and the interest of controllers by eliminating SPO and ban performing of separate simultaneous surveillance tasks.

Are thereanycoincidences? In the Oberlingenaccidenttherewere.Theydo not contributeto the contentsof this article,but I don't want to withholdthem. • TheReasonmodelis alsoknownas the Swiss Cheesemodeland SPOwith doubletasking wasin oneslice. • IFATCA's policyon SinglePersonOperations wasacceptedin Geneva,Switzerland2001. • A few daysbeforethe accident,the Professional Committeeof the DutchGuild askedtheir Danishand Swisscolleaguesif they couldprovidea QuickReference List for ATCOsto be usedin caseof an incidentor accident. • Theholesin DutchLeerdammer cheeseare the samesizeas thosein SwissEmmenthaler.

THE SWISS CHEESE MODEL OF ACCIDENT CAUSATION SOME HOLES DUE TO ACTIVE FAILURES (e.g. mistakes,procedural violations)

HAZARDS

OTHER HOLES DUE TO LATENT CONDITIONS (e.g. faulty equipment, lack of staff training) SUCCESSIVE LAYERS OF DEFENCES, BARRIERS AND SAFEGUARDS

Legal Action

TheCourtMartialof Flight Lieutenant MalcolmWilliams RichardDawson- PresidentUKGATCO Just after midday on Tuesday25th February • Circumventthe badweather 2003, the Court Martial of Flight Lieutenant • Returnto an areaof knowngoodweather MalcolmWilliamswas concludedwhen he was • Conductthe exercisein an areaotherthan originallyplanned acquittedof all chargesrelating to the tragic loss of two USAFpilots and their F1Ss,in the CairngormMountains,Scotland,during March Before take-off, the risk assessmentboth in terms of the Daily Ops. Assessmentand the 2001. Flight LeaderAssessment was consideredlow. So endedthe longestrunningcourt martial in Thetwo pilotswerewell restedand hadallowed the history of the RoyalAir Forcewith costs goodtimefor the flight preparation.Theywould have been assistedin their navigationby INS, likelyto exceed£1.5m. TACANand a properlymarked1:500,000low levelmap. TheGuildhascalledfor an inquiry.

Lossiemouth,the lead pilot requested the 'minimumvectoringaltitude'.Thisphraseis not usedin UKair traffic control. Again, during the protractedhandover,radar contactwas lost with the aircraftin the areaof Ben Macdhui (Scotland's second highest mountain),and radio contactwas also lost. It wasthoughtthat the aircraftmayhaveachieved their low levelobjectiveand transmissions were beingshieldedby the high ground.

The RAF Distress and Diversion cell were informedwhen radarand R/Tcontactwas not the two restoredand eventuallywreckageof the two Thepurposeof this articleis to detailthe events After flying northfrom RAFLakenheath, which occurredin March2001which led to this aircraft were handedover to RAFLeucharsby aircraftwas found to the eastof the summitof tragedyand the subsequentcourt martial,and the ScottishAir TrafficControlCentre(SCATCC) BenMacdhuiat a heightof 4,058ft.amsl. to explainwhy the importanceof theseevents when approximately25 miles south east of cannot be over-emphasised. Individual Leuchars,descendingto Flight Level100. They THECHARGES. witnessesfor both the Prosecutionand the were both under a RadarInformationService Flt.Lt. Williamswas chargedon threecounts: Defencewill not be identifiedand the Guildhas (RIS), were identified and continued their no desire to apportion blame, but merely to descentto 3,000ft. FirstCharge provideyou with the mainareasof contention. The two aircraft routed through RAFLeuchars "Doingan act in relationto aircraftcausing In the spaceavailable,it would be impossibleto overhead and continued their descent to lossof life to a personcontraryto Section49 detail everyitem of evidencepresentedoverthe 2,200ft.On reachingthat altitudethe leadpilot of the Air ForceAct 1955,in that he,at Royal five weeksthat the court martialwas sitting. It stated a request to climb, head north and Air ForceStationLeucharson the 25th day is, however,essentialthat the chargesagainst repositionfor a furtherattemptto achievetheir March2001 when on duty as an air traffic Flt. Lt. Williamsareexplainedand that the main objective.It was suggestedthat they route to controllerand in radio communication with thrust of both the prosecutionand defenceare the east to let down in an area where the LieutenantColonelKennethJohn Hyvonen, groundwas relativelyflat, this beingthe normal detailed. USAF, the leadpilot of the formationof two procedurefor descentto low level in the local F15C aircraft, well knowing that the area. minimumsafetyaltitude for the airspacein THEHISTORY OFTHESORTIE. which the said aircraft were flying was Thepilotselectednot to acceptthis option and 6,500ft, informed the said Lieutenant The two F15s, piloted by Lt. Col. Kenneth commenced a climbto FlightLevel60,turningto Colonelthat the minimumvectoringaltitude Hyvonenand Capt. Kirk Jones,departedRAF the north under their own navigation. On was 4,000ft.,which act causedthe loss of Lakenheath with the objectiveof low levelflying reachingFlight Level60 a requestfor a higher life of the said pilot". This refersto the in LFA14 (LowFlyingArea14)in the Cairngorm level was requestedand climb continued to death of Lt.Col.Hyvonen. Mountains,Scotland. Flight Level80. A requestfor descentfollowed and a descentto 4,000ft.was given,the aircraft SecondCharge Theweatherinformationavailableto the pilots still receivinga RadarInformationService(RIS). would assist the crews in validatingthat the Confirmation of the descent altitude was "Negligentlyperforminga duty contraryto missionwasviable.Fromthe informationLFA14 requestedby the leadpilot. Section29A(b)of the Air ForceAct 1955", in looked good to excellentvisibility, scattered that he,at RoyalAir ForceStationLeuchars cloud base greater than 2,500ft. and the Theaircraftwere then approachingthe edgeof on the 26th day March2001when on duty possibilityof cloudon the hillsin placeswith the RAFLeuchars radarcover,the radardisplaywas as an air traffic controller and in radio possibilityof scatteredsnowshowers. then off-set,with a changeof rangescale,and a communicationwith Lieutenant Colonel radar handover to RAF Lossiemouth the leadpilot In the eventof encounteringbad weatheron a commenced.The reasonfor such a handover KennethJohnHyvonen,USAF, of the formation of two Fl 5C aircraft,well low level navigation exercise,pilots have a was in casethe aircraft were unableto make knowing the minimum safety altitude for the numberof options. low level capability while in communication airspacein which the said aircraft were with RAFLeuchars. flying was 6,500ft.so negligentlyperformed • Climbto their AbortAltitude(mission objectivesnot achieved)

During a protracted handover to

RAF

THE CONTROLLER

Legal Action informationprovideddid not match with the was a very seriouscriminal charge in which impactpoint,or any manoeuvre that couldhave causationmustbe proven. been carriedout by the aircraft from the last radarreturn,he simplymovedhisplotted lineto The Defencemadeclearthat the Crown'sview of causationwas that, from the top-of-descent, meetthe impactpoint). ThirdCharge the aircraftmadea straightline trackfrom FLBO The Prosecutorreminded the Court Martial to impactat 4,058ft.amsl.Andthe aircraftwere "Doingan act in relationto aircraftcausing Board that although the Board of Inquiry IMC (Instrument MeteorologicalConditions) lossof life to a personcontraryto Section49 memberwas aware of eye-witnessaccounts from 6,000ft.to impact. of the Air ForceAct 1955,in that he,at Royal made to the Grampian Police, he did not Air ForceStationLeucharson the 26th day considerthemworthyof furtherinvestigation. After detailing the recordedradar information, March2001 when on duty as an air traffic the evidenceof the Boardof Inquiry member controllerand in radio communication with The Crown'scaserelies uponthe fact that who was given the responsibilityfor plotting LieutenantColonelKennethJohnHyvonen, the aircraft maintained a continuous suchinformationwasquestioned.Hewas given USAF, the leadpilot of the formationof two descentfrom FL.80to the impactpoint.The informationthat the last radartraceshowedthe F1SC aircraft, well knowing that the radar plots point directly,or almost directly,to aircraftpassingto thewestof thesummitof Ben minimumsafetyaltitude for the airspacein Macdhuibut from his own flying experience,it the impactpoint,so supportingtheir theory. which the said aircraft were flying was was impossiblefor an aircraft to manoeuvre 6,500ft, informed the said Lieutenant The Crown concededthat with the pressure fromthe lastknownradarpositionto the impact Colonelthat the minimumvectoringaltitude settinginformation(agreedevidence),the pilots point. He thereforedecidedto transposethe was 4,000ft.,which act causedthe loss of had brokentheir assignedaltitude of 4,000ft. plottedtrackto fit hisassumptions of a straight life of the saidCaptainJones". Thisrefers and that the rate of descentwas steeperthan line descentinto terrain. to the deathof CaptainJones. should be expected for aircraft flying in In short, the Defence believed the formationin IMC. Essentially, charges1 and 3 are causation Prosecution's view of the evidencewas 'if it and charge2 is of negligence. • TheCrown'scontentioncan be summarised doesn'tfit, fudge it'. by the followingbullet-points: Furthermore, the Boardof Inquirymemberfailed Althoughthesechargeswere brought • No pilot flies into terrainthat he/shecansee. to accuratelycalculatethe actual altitude to underRAFregulations,civilcharges Thepilotsdid what they weretold. couldbe broughtagainsta civilair which the aircraft would have descended,a trafficcontrollerundersimilar mistake he repeated in the Court. On the • Snowlevelswereat about2,000ft.amsl. circumstances. pressuresetting indicated on the altimeters • Thedescentfrom FL.80to 4,000ft.was found in the wreckage,the aircraftwould have advisedby Flt.Lt.Williams. levelledat 4,300ft. amsl. and overflown the • Theweatherreportgives3/8 cloudcoverwith impactpoint by some242ft. THEPROSECUTION CASE a base2,500-3,000ft.amsl. Additionalinconsistencies camefrom an expert It was the Crown's submissionthat Flt. Lt. • It is entirelyfeasiblethat BenMacdhuiwas witnessfor the prosecution who agreedwith the obscuredby cloudand snow. Williams'actionsfell belowthat of a competent Defence,undercross-examination, that the rate and carefulcontrollerand the pilotscarriedout • Thepilotswereawareof the proximityof high of descentimmediatelyprior to the aircraft his adviceto descendto altitude4,000ft.,which groundfrom their INS. disappearingfrom radar cover indicatedthat resultedin the accident.Theyclaimthat a pilot theyweredescending visually.Hefurtheragreed mustbe ableto assumethat the advicegivenis • Therewasan exchangeof confirming4,000ft. that the radartrack informationwould indicate between the pilots and ATC. safe. the aircraftpassingto the west of BenMacdhui • Thepilotswere partlyresponsible for the althoughthe point of impactwasto the east of The Crown's contention was that the court eventsleadingto the impact. the summitof BenMacdhui. martial was not about Radar Information • FltLt.Williamscontributedsignificantlyto the Service,but Flt. Lt.Williamsassumptionthat the accidentby creatinga falseenvironmentand The Defencemovedon to outline the positive aircraftwantedto achievelow-levelstatusand lulledthe pilots into a falsesenseof security. aspectsof their case. his failure to question the term 'Minimum VectoringAltitude'. In their view, 'Minimum The Crown prosecutionconcludedthat even • It was the Defence,not the Prosecution, who VectoringAltitude' was clearlyheard and not though the aircraft were operating under a hadobtainedthe weatherreportsand blockedby anothercall. It was their view that RadarInformationService(RIS),Flt.Lt.Williams barometricpressurecharts. the only proper responsewas a descentto should have recognisedas 'foreseeable'the 6,500ft.(the 100nm.Emergency SafeAltitude). consequence who of his actions in relation to the • It was the Defence,not the Prosecution, hadinterviewedall the eye-witnesses. Five highground.Whilstthe actionby Flt.LtWilliams TheCrown introducedthe evidenceof certain eye-witnesses hadmadestatementsto the mayhavebeenuncharacteristic, it was an error. membersof the RAFBoardof Inquiry,(whichhas GrampianPoliceon what they hadseen still to reacha conclusion).In concludingthe beforethe accident.Fourwereexperienced CASE evidenceof the two Boardof Inquirymembers, THEDEFENCE hill walkersand all five identifiedtwo aircraft the Prosecutoradvisedthe CourtMartial Board in closeformation,flying belowcloud.These that they shouldnot relyon the accuracyof the The Defencebriefed the Court Martial Board two aircraftweretwin-tail finnedand that they had 2 duties in terms of the charges plotting and mathematicalpropositionwhich reportedby eye-witnesses at a heightof was carriedout by a memberof the Boardof before them, summarisingprimarily causation approximately756m.or 2,300ft.Theywere on Inquiry.(Thismemberhad admittedto the Court on the majorcharge(1 and3) and negligence observedflying in the valleybeforeclimbing the alternative charge (2). The primary charge Martial that when the plotting of the radar his said duty as air traffic controlleras to informthe said LieutenantColonelthat the minimumvectoringaltitudewas4,000ft.".

THECONTROLLER

Legal Action towardshighgroundand low cloud.Noneof theseeye-witnesses were ever interviewedby the RAFalthoughthe existenceof theirstatementswasknown. • It was the Defence,not the Prosecution, who hadobtainedthe F-15low-levelOpsManual which indicatedthe responsibilities for pilots flying undera RIS.(Pilotsare responsible for their own terrainclearance). Theleadpilot of a pair of TornadoGR4aircraft operatingat low levelin the areaover onehour beforethe F-15s,describedthe weatheras the worst 'white-out' conditions he had ever experienced. White-outgivesa visualillusionof a clearwayahead,whichis in fact, highground.

terrain clearance. Controllers have no responsibility for terrain clearance while providing a Radar Information Serviceand furthermore,by regulation,pilots are not to descendbelow their safety altitude without beingeither visual with the surfaceor usinga TerrainFollowingRadar(TFR).Flt. Lt. Williams was working on the above basis and was entitled to believethat the pilots would fly in accordance with knownUKregulations.

A summingup by the JudgeAdvocatefollowed who gavethe Boarddirectionas to mattersof law.TheJurythen retiredto considerits verdict.

Flt. Lt. Williams could not have foreseenthe probable consequence of his action in descendingthe aircraft to 4,000ft. With no foreseeablity, therecanbe no questionof guilt.

After leavingthe Court,Flt. Lt. Williamsand his wife madea brief statementto the assembled pressand media.

After six and a half hours of deliberation,the jury of six senior RAFofficersreturnedto the Court. Flight Lieutenant Malcolm Williams was found NOTGUILTYof all charges.

They were followed by the GATCO TheDefenceremindedthe Boardthat, because President,part of whose pressstatement the controllerdoesnot knowwhetherthe pilots was as follows: TheDefencethen coveredthe causationaspect are in IMC, there is nothing to alert the (charges1 and 3). If the Court Martial Board controller of ordinary competence,exercising 'The Guild of Air TrafficControlOfficersis saw no causallink or if they had any doubt of reasonable care,to the possibleconsequences of pleasedto have supportedFlt. Lt. Williams throughouthis ordeal and delighted that the link (the link mustbe morethan a slight or their actions. the Court Martial has now endedwith him trifling link), then this mustmeanacquittal. beingacquittedof all charges. TheDefenceclosedwith the following: Charge 2 referred to negligenceand whilst He leaves this court with his negligencemustbe a factorin all threecharges, • Flt.Lt. Williamshad breachedno ATC professionalism,conduct and character it wasa separatechargeunderSection29 of the regulationin the conductof his duty. unblemished. RAFAct 1955.Fornegligenceto be proven,the CourtMartialBoardmustbe contentthat 'harm' • RAFATCregulationshad beenchangedas a Thisbringsto a closean unnecessary period resultof this accidentand the Boardwere had beencausedby Flt.Lt.Williamsactionsand askedto drawtheir own conclusions asto the of stressand traumafor himself,hisfamily that they would have to be sure that Flt. Lt. andthe relativesof the pilotswho losttheir Williamswascriminallyresponsible for hisact. If reasonbehindsucha change. lives'. theyhadanydoubt,theymustacquit.TheBoard wouldhaveto besurethat Flt.Lt.Williamscould • At worst, Flt. Lt. Williamsmayhavemadea The Court Martial system has only recently 'slip' but is that worthyof beingbrandeda have reasonably foreseen the probable been under investigation by the European criminalact? consequences of his act (the R/T descentto Court of HumanRights.This case highlights, 4,000ft.). once again, that a potential for a serious • Wherewas the justicein this prosecution, givenno breachof regulations,no controller miscarriage of justice still exists. The Board must view the question of responsibility for terrainclearance, and with negligence from the perspective of an the aircraft crashing into terrain for whichthe The legal charges raised can equally apply ATCO. to civil air traffic controllers and immediate pilotswereresponsible for separation. consideration is required by ATS providers The Prosecutionsuggestedthat a measureof to ensure that issues like vicarious liability • If the Board could see no guilt or any doubt as responsibilityrested with the pilots for the are addressed. to guilt, then this must mean an acquittal on accident.TheDefencerefutedthis, statingthat all charges. the pilots were wholly responsiblefor their

T~I=

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Legal Action

A Reviewof JAL907 /JAL958 NearMid-AirCollision OsamuTakeda- JFATC At approximately4 PM1600 on 31 January screen and alerted the controllers of the had issuedthe descentinstruction,the trainee 2001, I was doing routine editorialwork for a encounter. A trainee controller, under the tried to maintain separationby radar vectors the monthly journal of our union at in a supervisionof his OJTsupervisor,was working also and gave JAL958a heading (about 30 conference roomof a printingcompanyin Tokyo, with on radarat KantoSouthC. Thissectorhas degrees turn to the right) twice. However, when a staff colleagueof mine buzzed my an averageIFRtrafficvolumeof 500perday.The JAL958 did not acknowledgeany of these cellphone.Hesaid "Therewas has beena near trainee had a maximum14 aircraft under his instructions.HavingJAL958insightat all times, mid-air collisionbetweentwo JapanAir Lines control within nine minutes prior to the the captainof JAL907tried to avoidthe collision (JAL)aircraftoverYaizuNDB(YZ).Thereseemto encounter.The supervisorhad just finished by descendingvisually. The captain did not be someinjured persons.Pleasecomebackto giving a short comment on the trainee's acknowledgehis co-pilot'sadvicethat the DCthe office immediately."What flashedthrough handling of another encounterbetweentwo 10 was also descending.15 secondsafter its my mind then was my hope that the injuries differentaircraft,when the CNFALERTblinked. DescentRA, JAL958sTCASissuedan Increase were all minor and that controllerinvolvement Responding to the alert,thetraineegaveJAL907 DescentRA and JAL958increasedits descent was non-existent.However,when I returnedto a descentinstructionto FL350.Boththe trainee rate.In response, JAL907similarlyincreasedthe the office,the TV newscoveragewas reporting andthe supervisor allegedlylaterstatedthat the descentrate. They closed in on each other that manypassengers with severewoundshad descentinstruction"might have been callsign rapidlyin a descendingverticalchase,until the been hospitalizedhospitalised.I have been confusion". However,neither the Tokyo ACC captainof JAL958decidedto pull up at the last heavilyinvolvedin this incidenteversincethat managementnor the Aircraft and Railway minuteto avoidthe collision.Bothaircraftwere moment. Accident Investigation Commission(ARAIC) equippedwith Version6.04ATCAS(CollinsTTRtried to technically review technically the 920). Duringthe steepdescentmanoeuvre,the An The outline of this incident is as follows:. feasibilityof thesestatements. seatbeltsignswere kept off on JAL907and 88 JAL907(B.747-400D) boundfor OkinawaNaha passengers and 12 cabin attendantson board AirportdepartedTokyoHanedaAirportand was Anyhow,in the cockpitof JAL907,the TCAShad the B.747 were injured. No injuries were climbingwestboundto its assignedFL390via alreadytriggereda TA(eightsecondsbeforethe reportedon JAL958. radar vectorsto YZ. JAL958(DC-10-40)was descentinstruction)and then triggereda Climb cruisingat FL370eastboundfrom Pusan,South RA(threesecondsafter the descentinstruction From that day, the news media stormedthe Koreato TokyoNarita.Theywereboth underthe was issued).Theauralwarningof the ClimbRA gatesof TokyoACCandtried to interviewand/or control of TokyoACCKantoSouthC sectorof was recordedin the backgroundof the pilot's photographpeoplecomingin/out of the ACC. TokyoACC.The sky was clear and the pilots readback.Thedescentinstructionandthe Climb Once the possible callsign confusion was onboard JAL907had JAL958 in visual sight RA were almost simultaneous. Reportedly reported,ARAICand the policestarted active contact severalminutesbefore the encounter. concernedabout a high altitude stall, the investigations.Two days after the incident, The pilots even discusseda simulatedaction captainof JAL907decidedto ignorethe RAand ARAICinterviewedthe ACCstaff includingthe plan in case a TCASRA was triggered.When starteda descent.In the cockpitof JAL958,the two controllersinvolved. Five days after the JAL907turned south over YZ passingslightly TCAStriggereda TAfollowedby a DescentRA. incident,the policealso interviewedthem. We, below FL370,the Short Term Conflict Alert Thecaptainof JAL958decidedto follow the RA as the Uunion,expectedthat the occurrenceof (STCA)or "CNFALERT"blinkedon the radar and alsostarteda descent.Immediatelyafterhe injuriescoulddevelopchangethis incidentinto a criminal case,and decidedto arrangefor a lawyer.We havealsobeentrying,with the help from many of their colleagues,to supportthe two controllersboth physicallyand spiritually, and to alleviatepressures they musthavebeen feeling.Eventuallythe newsmedialost interest in this incident.As an the outlineof the incident l'LS65-------I-is was clarifiedand it becameclearthat this is was not just a near mid-air collision induced simply by human errors, we, as the union, decidedto launchour own specialcommitteeof investigationfor this incident.The Ministry of Transport (now called Ministry of Land, Infrastructureand Transport,or MLIT)has also established a specialcommitteefor to preventa recurrence preventionof a similar incident. Their committee has defined 30 preventive measures.

THE CONTROLLER

Legal Action

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A year and half after the incident,on 12 July convergenceto triggera visualalert (but not an instruction) to JAL907, it would not have 2002, ARAIC released its final accident aural alert) three minutes before the Closest avoidedthe initiation of RAs.Furthermore, the investigationreport.Thereportclaimedthat the Pointof Approach,if it locatesa threat on the captainof JAL907statedthat he had to avoida incidentwascausedby a chainof events,which present heading of each aircraft. However, high altitude stall and thus followed ATC's was triggeredby the two controllers'callsign duringthis encounter,it triggeredthe alert only descentinstruction.If he hadthoughtthat all he confusionThereport also includespropositions 56 secondsbeforethe CPA,morethan two and coulddo to avoidthe collisionwith JAL958was and recommendations addressed to the a half minuteslater than the prescribedthree- to descend,he would have descendedanyway Minister,as well as special recommendations minute warning time. HowWhy? Because regardlessof ATC'sinstruction.In other words, addressedto !CAO regarding amendmentof JAL907'sdeparture route (OCEANTransition) this incident (inducedby one pilot's following TCAS-related provisionscontainedin Annex 6 doglegs from westbound to southbound by RA and the other pilot's ignoring the RA) and PANS-OPS. Two years and three months some 70 degreesover YZ. The STCAdidn't occurredregardlessof the callsignconfusion. after the incident,on 7 May 2003, the Tokyo recognizeJAL958as a threat to JAL907until MetropolitanPoliceDepartmentbuilt a criminal JAL907turned towardsJAL958.This limitation The third issue is the lack of appropriate case of this incident. They have submitted a of our STCAhad not beenpublicizedamongthe provisionsregardingthe relationshipbetween report to the TokyoDistrict PublicProsecutor's controllersbeforethis incident.Somecontrollers ATCinstructionsand an RA.As of 31 January Office recommendingprosecutionunder the are aware of this systemlimitation from their 2001, neither the (then) Ministry of Transport Japanese criminal code against the two operationalexperience. nor Japan Air Lines had any provisionsthat controllers and the captain of JAL907 for covereda situationwhen there is a discrepancy professionalnegligenceresultingin injuriesand Thesecondissueis the relationshipbetweenthe between ATC instruction and an RA. Then, acts endangeringaviation safety. The charge callsignconfusionand the initiation of RAs.As I effective AIC006/01publishedby Japan Civil sheet claims that the major causesof the mentioned earlier, neither Tokyo ACC Aviation Bureau(JCAB)statesd "Once aircraft accident are were the controller's callsign Mmanagement nor ARAI( has tried to departs from an assignedATC clearancein confusion and the captain's decision to technicallyreview technicallythe feasibilityof compliancewith an RA,a controllerceasesto be manoeuvrercontraryto the RA.The captainof the alleged callsign confusion.Moreover,are responsible for providing ATC separation JAL907has claimedthat he did not makeany they able to technicallyprove technicallythat betweenthat aircraftand other aircraftaffected mistakes. there shouldnot have beenany RA if the two by the direct consequence of that RA controllersdid had not commit confusedthe manoeuvre".However,this AIC did not define We,as the union,havepinpointedvariousissues callsign confusion?Again, in the cockpit of anythingaboutthe pilot'sactionwhenthereis a hiddenbehindthis incident.Thefirst issueis the JAL907,it was only three secondsafter the discrepancy betweenATCinstructionand an RA. flaw in our STCAfunction. Our STCA "CNF descent instruction was issued that TCAS AIC006/01was amendedas of 22 August2002 ALERT"wasdesignedso that whentwo aircraft triggereda Climb RA. Also, in the cockpit of to AIC017/02whichreads,"Whenan RAoccurs, are predicted to converge within a vertical JAL958,it was four secondsbefore the initial in principle, pilots should manoeuvretheir separationof 700ft (1,600ft in the case of heading instruction (which was not aircraft in responseto the RA. Evenif the RA aircraftabove29,000ft)anda lateraldistanceof acknowledged by the pilot) that TCAStriggered manoeuvreis contraryto ATC instructions,in 5nm, athe symbol of "CNF" is displayed 3 a DescentRA.Evenif the controllerhadissueda principle,pilots shouldmanoeuvretheir aircraft minutesbeforethe occurrenceof the predicted climb instruction (instead of the descent in response to the RA. Pilots should not

THE CONTROLLER

LegalAction manoeuvretheir aircrahoppositeto an RA.This as soon as possibleafter the incident.A very preventivemeasures.However,multiplesimilar is becausethe directionof the threat aircrah's informativepresentationmadeby TomLaursen occasionsthat which have happenedover YZ, on the final dayof the never drew management'sattention until the RAis oppositeto that of own aircrah'sRAin the of SwissControlSkyGuide 2003Conference in BuenosAirestold us JAL incident.At the cost of this incident, our case of ACAS II - ACAS II coordinatedco- IFATCA assertionhas finally been understoodand is ordinated encounter".JCABdefines that the that CISMis a veryimportantissue. being materializedinto a systematicmishap only exceptionsto this provisionare: (1) other Circumstances surrounding Japanese ATC and analysis.However,it will be long time until this critical warning such as stall warning is triggered; (2) TCAS is apparently its safetymeasuresare still vulnerable.The30- is truly reflectedon the provisionsfor daily ATC preventivemeasures defined work. malfunctioning;and (3) the pilot hasthe threat item re-occurrence by MLIT still focus on hardware (e.g., aircrahclearlyinsight.Airlinesregulationshave We take this incidentseriouslyand are asking implementation of RA Downlink) and depreciate beenamendedto reflectthis amendment. sohware(e.g.,delayin the humanfactorsstudy that the two controllersbe permittedto return The fourth issue is airspace.The airspaceof in ATC).JCABwill implementRADownlinkand to operationalATCwork as soon as possible. which Kanto SouthC sector is in charge,has displayRAinformationon the radarscreen"to We,of course,renewour determinationneverto multiple military operatingareas(exclusiveto improvecommunicationbetweenthe pilot and let suchan incidentoccuragain.We cannotsay the civilian air traffic) for the Japaneseand the ATC". This will be done in parallel with the we have "enough" for safetybecause,as time UnitedStatesmilitary users.In addition,there introductionof Mode S at someof our radar rollson and asATCenvironmentchanges,a new had been changesin major traffic flows and sites.We,asthe union,havebeenareagainstRA riskfactorcanemergeat any time. subsequenttraffic saturationin Kanto SouthC Downlink becauseof concernsabout liability lmagomefor his cooperation sector,dueto volcanicactivityiesin the adjacent issues (controller's responsibility) and I thank Mr.Takeshi in translating my article to Englishand drawing usefulness. Because of our objection, the JCAB sector.At a publichearingheldby ARAICon 17 figures and list. has tentatively promised not to display the January2002, I requestedthat the Commission to researchtheseairspaceissuesandto reflectit downlinkedRAinformationon radarscreensfor OsamuTakedais Vice Chairmanof JFATCand them in their final accidentinvestigationreport. actualATC. However,ARAICdid not commenton anything Lessonslearned from this accident/incident Vice Chairmanof the WorkersUnion of the should be reflectedonto in the re-occurrence Ministry of Land,Infrastructureand Transport, regardingtheseairspaceissuesin the report. knownas ZENUNYU. The fifth issue is that ARAIC'sfinal accident Table: Comparsion of Sequence of Events between JAL907/958 near mid-air and Ueberlingen midinvestigation report is being used for the air collisions criminalinvestigationby the police.ICAOAnnex JAL907(8747)- JAL958(DC10) BTC2937(Tul154) - DHX611(8757) 13 stipulates that aircraft accident investigationsshould be independentfrom a 56 sec. STCA(CNFALERT) displayed. STCAalert out for maintenance. criminal investigations,however,investigation beforeCPA reportspublishedby ARAIChavesbeenusedfor the criminal investigations.Japanhas ratified JAL958TCASissuedTA. DHX611TCASissuedTA. 53 sec. 50 sec. theChicagoConvention andhasclearlydeclared beforeCPA JAL907TCASissuedTA. BTC2937 TCASissuedTA. 52 sec. compliancewith Standardsand Recommended Practicescontainedin the Conventionand its 43 sec ATCinstructedJAL907to 44 sec. ATCinstructedBTC2937 to Annexes.To makemattersworse,ARAICdoes descend. descend, but the crew didn't not recognizethe significanceof ill-usageby the acknowledge. police using, controversially, of its own investigation reports and has repeatedly JAL958TCASissueddescent 36 sec 37 sec. BTC2937 initiateddescentas commentedthat such practicesare acceptable. RA. per ATCinstruction. In Japan,they still blamean accidenton human error,and usehumanerrorfor finger-pointingof JAL907TCASissuedclimbRA. 36 sec. BTC2937 TCASissuedclimb RA. individuals involved. We have requested,in collaboration with pilots unions, that they DHX611 TCASissueddescentRA. shouldchangesuchthis mentality.However,to DHX611 initiatedRAdecent. date, we have not seen any sign of 31 sec. improvement. JAL907initiateddescentas 29 sec. ATCre-instructedBTC2937 to per ATCinstruction descend. The sixth issueis the lack of Critical Incident Stress Management(CISM) in Japan. Upon 28 sec. JAL958initiated RAdescent. reflection,the two controllersinvolvedin the DHX611TCASissued"increase JAL958TCASissued 22 sec. 22 sec. JAL incident could did not receive stress descent"RA. "increasedescent" RA. counsellingby specialistsuntil more than one month after the occurrence.CISMis not fully 13 sec. DHX611reportedATC"TCAS understood in Japan and has not been descent". establishedyet. We, colleaguesof the two controllers,have been trying to supportthem 8 sec. BTC2937 TCASissued 5 sec. JAL907TCASissued eversincethe incident,but we arestill unsureof "increaseclimb" RA. "increaseclimb" RA. how best we could should communicatewith them.Anotherunionhaskindlyintroducedto us CPA CPA Nearmid-aircollision Mid-aircollision to a CISMspecialistfor the two controllers.We now think that we shouldhaveconductedCISM

THECONTROLLER

Safety

TCASUpdate Philippe Domogala - EuropeanEditor

Sincethe last issueof THECONTROLLER more informationhascomeout in the mediaon two TCASincidents:the JapanAir Linesincident in Tokyoand the Lufthansaone over MexicoCity. Theintentionhereis to brieflyinformyouof the latestdevelopments and makea few comments.

A police investigation, parallel to the Japanese official Aviation Investigation Commission, (ARAIC)startedimmediatelyafter the incidentand their reportaccusesthe three of actingnegligentlyin the minutesbeforethe accident.Accordingto the police report, the two controllers(a 28-year-oldtrainee and his The JAL incident over Tokyoin January2001 34-year-old female supervisor) wrongly took a dramatic turn when the Tokyo instructedFlight JAL 907 to descend,because metropolitanpolicedecidedto makea criminal they had mistakenthe aircraft for a different case.Theyforwardedpapers,which the Public flight. Prosecutorhad on the two controllersinvolved to the media(includinga Traineecontroller)and The 43 year old captain of Flight JAL 907 (a on one of the pilots, for acting negligently. 8747)will also be prosecutedfor negligenceas IFATCA hasstronglyreactedto this andlettersof he followedthe clearanceand camewithin 100 supportfrom many MAs havebeensent to the metresof JALFlight958 (a DC10).TheCaptain JapaneseControllers'Association,as well as of FlightJAL907 then ignoreda TCASwarning somelettersof protestto the StateAuthorities. beforetaking evasiveaction when he realized the danger.FlightJAL907'scaptainreportedly Theessenceof the situationis as follows: since said,"1 madethe right decision,sincethe plane some 100 passengerswere injured during the would havelost speedat a criticaltime if I had escapemanoeuvre,the State prosecutorsare heededthe (TCAS) warningsystem". treatingit as an accident,not an incident. Thesituationis beingcloselymonitoredby the IFATCA ExecutiveBoard.

We know you put safety first But it is hard, isn't it, to find the right peopleat the righttime to give it the priorityyou know it reallydeserves? We can help Safetyand Risk Assessmentis our business.We have workedwith Air NavigationServiceProvidersfor over ten years.We have the people,the knowledgeand the experienceto help you with safety management,safety cases and compliancewith safety requirements. If safety really is your numberone priority!! "Contactus and we will..." AEA Technology pie Aviation Department Stokes House, 401 The Quadrant Birchwood Park Warrington WA3 6AT United Kingdom Tel: +44 {0) 1925 25 4 606 Email: aviation@aeat.co.uk

The other incident was an airprox report made by a Lufthansa 8747 captain over Mexico City in October 2002 about a Mexicana Airbus A320. The problemhereis that the reportwascorrectly sent to the German InvestigatingAuthoritythe BFU which extrapolated the incidentfrom the pilot's report and the TCASdownloaded the DLHB747'sparameters, recorded to obtain a description of what might have happened, and decidedto publish these on their Internet website. The initial report (unfortunately, only in German) indicated that the controller and the ATC supervisor in Mexico

City did not act professionally. The report also sensationalised the distanceof the near-miss. The report states that the flightpath of both aircraft crossed and the vertical distance betweenthe two aircraftwasabout 100 feet. Duringthe Annual Conference in BuenosAires, the MexicanControllers'Associationshoweda recording of the radar screen and of the associatedR/Tduringthe incident,showinga considerable number of other factors not mentionedin the BFU report, and an actual minimumdistancebetweenthe two aircraft of .5 NM and 1600 feet. (Since the incident occurredwell within the rangeof the PRIAPP radar,the minimumlegal distancewas 3 NM.) TheMexicanrecordingsalsoshowthat the 8747 climbed 1000 feet aboveits assignedaltitude, an altitude at which there was alreadya third aircraft - a Learjet. The R/T exchangesthat followed relatedto the new situation, not the A320, which was no longer a factor, as it was over 2000feet below. Laterthe 8747 descendedon its own by 2000 feet, before being recleared to the correct altitude and backon course. Something which also comes up while watching the Mexicanrecordings,is the pilot flying the 8747, having probablydisconnected the autopilot to perform the RA, did not reconnectit after the RAs and the 8747 is showedcontinuingoff courseand at the wrong altitude for quite sometime after the incident. This fact is unconnectedto the airprox, but should be of concern to alI of us when confrontedwith aircraft reporting an RA in dense,busyTerminalairspace. IFATCAhas made contact with the BFU,to highlight our concernsand we expectto have made our point for future incidents. We understandthat TCASis a veryemotiveissuein Germany, followingthe LakeConstancecollision and that might explain the sudden hurry to publish only half of the facts and, possibly, comingto the wrong conclusion. On the regulations front, we were recently assuredthat Eurocontrolwould be pushinghard in the next meetingwith their UScounterparts, to have the resourcesand the funds made availableto resolvethe "reversal RAs" issue, highlighted as a major shortcoming in our previousTCASarticlesin the magazine.

THE CONTROLLER

The Lighter Side of Conference

ACCOMPANYIN PERSONS' PROG Buenos Aires,Arge SandraMaidens,Canada

Travelling along Alvear Avenue with its artistsandstreetperformers.Thecolourscheme Ah, BuenosAires- I had heardwhat a lovelyand and exclusiveboutiques,we of the differenthouseswasdictatedbywhatever vibrantcity it was. Our tour certainlyconfirmed palaces,embassies that. On MondayMarch1Jth right after lunch, intersectedAvenue9 deJuliowhich is oneof the paintwas left overfrom the boatsin the nearby we set out for Palermo. Thisis oneof the biggest widest,if not the widest,streetsin the world (7 port. La Boca is also famous for its football and wealthiest barrios or neighbourhoodsof lanesin eachdirection).It wasnamedin honour team, the Boca Juniors, who play in the BuenosAires,locatedin the northernpart of the for the datein 1816(Julythe 9th) that hascome Bombonerastadium,nestledin the heartof the city. It is knownfor its numerousgardensand to be the accepted date of Argentina's neighbourhood. Our last stopwas PuertoMadero,the newest parksas well as being a fashionableplaceto independencefrom Spain.We passedby the Theatre),BuenosAires' barrio of the city. Theport was constructedin live. We took a few minutesto enjoythe rose TeatroColon(Columbus gardens in Parque 3 de Febrero with its majesticoperahouse,then by the world famous 1882and operateduntil 1898when it could no obeliskat the heartof the avenueandon to the longercopewith the volumeof traffic. Maritime fountains,pathwaysand artificiallakes. Next, we were off to Ricoletato see the Plazade Mayo. Thissquare,situatedin front of operationswere transferredto a new port monumentdedicatedto Eva Peron,the very the governmentalpalace- the CasaRosada- (PuertoNuevo)and the old one was basically and left dormantuntil the 1990s. It wasthen that a influentialfirst lady of Argentinain the 1940s has beenthe site of manydemonstrations major rejuvenationof the area beganwhen its protests. Every Thursday afternoon, the Mothers and early '50s. We also passedthe Ricoleta cemeterywhereher bodywas laid to restin the of the Plazade Mayostill meetthereto demand warehouseswere transformed into trendy luxuryofficesand apartments. Duartefamilycrypt 20 yearsafter she had died to know the whereaboutsof family members restaurants, Our tour established,without a doubt, that at the age of 33. Borderingthis cemeteryof who disappeared during the 1976-83 BuenosAires is a very diverse,intriguing and ornate vaults and mausoleumsis the Nuestra dictatorship. La Bocais a colourfulneighbourhoodin the vastcity.Wecouldhavespentdaysinvestigating Sef\oradel Pilar - Our Lady of the Column Church- which was built in 1732and is still a southeastcornerof BuenosAires. Knownfor its everythingthat the city had to offer insteadof multi-hued buildings, the area first housed the few short hoursthat we took. beautifulexampleof the neo-baroque style. OnTuesday, we hada nicehot, sunnyday for Italian immigrantsand now is home to many our trip to Tigreandthe ParanaRiverDelta. We left the Sheratonafter lunchand droveto the SanIsidrotrain stationin one of BuenosAires' affluent suburbs. Up-marketspecialtyshops and a selectionof restaurantssurroundthe station. Thetrain line that runs by here was built between1891-94but fell into disusein the 1960s; it is now operating as a scenic railway.Onceoff thetrain, it wasa shorttrip to the dockswherewe boardedboatsfor our tour of the delta. Thereareover5000waterwaysin the delta with approximately3000 people working or living there. The river is a deep brown, owing to the colourof the silt in the water,but we wereassuredthat this colourwas not due to pollution. Thepeoplefrom Buenos Aires,alsoknownas Portefios,usethis areaas a weekenddestination,but somepeople live there full time. Thereare numeroushouses, both humbleand impressive, built on the wellfortified shores. There are also churches, floating shops and a school where children

THE CONTROLLER

The Lighter Side of Conference

arriveand leaveby boat everyday. On a hot, sunnyafternoonit was niceto just cruisealong, enjoyingthe sceneryand watchingthe children playalongthe shore. Wednesday broughtanothergorgeousdayfor our trip to a typical ranchoon the Argentine Pampas. The old houseat the SantaSusana Ranchhad beenusedas the family homeuntil the 1950sand now was set up as a museum chroniclingthe furniture,clothing and utensils used then. On our way to the traditional "asado" or barbeque,we were treated to an empanada(meatpie) and a glassof wine as an appetizer.While we were waiting for lunch, somepeopletook advantageof the time to go horseriding;otherschoseto go for a shorttrip in a horse-drawn cart. Lunchconsistedof saladand varioushelpings of barbequedsausage,beefand chicken,along with all the wine that you could drink (which was a popular feature for many!). This was followed by a show of tango dancing,fancy handwork with boleodoras (stone balls connectedby a thick cord) and then more delicious steak dinner was accompaniedby recruitedfrom the audienceto performon stage dancingwith the crowdjoining in. Afterwards, anotherbottomlessbottleof redwine. Thenthe with thetwin blondsingersandhedid a finejob. therewasanotheropportunityto ride on a horse showbegan- andwhat a show! It lastedclose I've been to many shows in many different or in a wagon- for thosestill mobile enough on two hoursand hadamazingdancersdoingall countriesand I mustsaythat thiswasoneof the kindsof intricatetango steps. TheArgentinean best. after all that redwine!! Congratulations for a job well done to Unfortunately, the tours advertised for tango is quite differentfrom the tango we are Thursday(the Colon Theatre and museums) used to seeing in North America, a lot of GabrielaLogatto,Presidentof the Organizing were no longer being offered so we had to complicatedfootworkby both partners.Thehost Committee.Also,a specialthanksto Santiago content ourselveswith a day of shoppingor for the evening and Seiior Tango himself, Miguensof ZavaletaViajesfor lookingafter us attending the conferencesessions. However, FernandoSoler.was a powerful tenor and an so well on our tours. Thursdayeveningwas well worth waiting for - engaging master of ceremonies.One of our dinnerand a tango showat Se?or Tango. The delegates,OmarAI-Amoushfrom Jordan,was Seeyou in HongKong!

THE CONTROLLER

I 00 yearsof PoweredFlight

CELEBRATING 100 YEARSOFFLIGHT, NOWWHATABOUTTHENEXT100 YEARS? Virtualor spaceflights? Philippe Domogala - Europeaneditor In thesetimes of turmoil of USinvolvementin A380 could provide more mass, low cost, transportinggoodsby air, in an automaticway Iraq and Frenchanti-war feelings,it would be transportpossibilitiesin the samemannerthat might be consideredand work successfullyin unwise for me to revive the old controversy the 747 did 30 yearsago.Onthe otherhand,as the not too distantfuture. about who was first - the Wright Brothersor material comfort increases and political Clement Ader, the Frenchengineer who is instability sets us in the "stay at home" Now,for the reallychallengingstuff! I can only supposedto have flown a powered,heavier syndrome,plansmightalter. rememberwhat I reada few yearsagoin Arthur C.Clarke'snovel"3001,the FinalOdyssey"(the than air machinein 1890, 13 yearsbeforethe series)published Wright brothers.In any case,like today with Theglobal Internetweb possibilities,combined lastof the 2001SpaceOdyssey Iraq,it is the marketingandmediacoveragethat with possibly new technological advances, in 1997. Theconceptof "spaceelevators"was countsand the Americanswon the battle on might also reducethe "need to escapefor a unveiled. The idea is to build, in every Continent,a tower300 kilometreshigh. Onthe both cases.SoOrvilleWrightand 1903it is! weekend" from largecities.Orderinggoodsby top of thesetowers,a geo-stationarysatellite Internet might replace shopping trips and with massivesolar panelspowersan elevator The fact that this first flight of the "Flyer"in transporting the ordered goods fast might that could take 100 people into spacein 15 December 2003wasshorterthan the full length increase the alreadylucrativeair parcelbusiness. minutesfor lessthan a US$100Thenlargespace of a Boeing747 indicatesthe advancemadein Therefore,the largestA380might not transport shuttleslink the tops of eachtower togetherat just a century.However, the fact is that the B747 1000peoplebut 200000e-bayparcels! 20.000Km/hr using very little energy. The first flew in 1969,the sameyear mantravelled passengersthen descendedon to the next andwalkedon the MoonandConcordewasfirst I usedto say when I was a kid, and reading continent,at no cost, sincethey are usedas a flown andtested. comicsin the late 50s, early 60s, in the year counterweight for the climbing elevator. 2000 we would see people in shiny overalls, Travellingfrom Australia to the US could be So many technologicaladvancesin aerospace living in glass housesand moving around in done in less than an hour for less than a US$1000return, with hardly any energycosts peakedin the late 60's. personalhelicopters.The reality is somewhat and no pollution. different.Infact, generalaviationtodayusesthe Sadly,the recentSpaceshuttlecrashesand the sameaircraftdesignedin the 1950ssuchas the Theonly drawbackis that no existingpractical currentstate of the Russianeconomyare likely Cessna150 and 172 and they are even still materialexistson earth to build thesetowers. to give a seriousblow to spacetravel for the manufactured... Personalhelicoptersare still a Thestrongestknownnaturalmaterialon earth, foreseeablefuture. The B747is still there, still dreamto all of us,and the few millionairesthat diamond,could possiblysustainthe strength, beingmanufactured,and the Concordewill be do own one arestrugglingamongthe rulesand but you canimaginethe cost! permanentlyretiredby this October. regulationsto find a placeto landthem. Howeverthe recentdiscoveryof anotherformof The military designsremain the technological Jetsreplacedpropellerson the airlinefront (but carbon(C60)with a far greatertensilestrength researchfront, andwhile, in the past,they used not completely, someold goodDC3sanda lot of than diamond,could be the way forward. The to find their way into civil applications, this is no Fokker27s are still flying aroundand probably discovererof that form of carbon,Dr Snelley, longer the case. Tremendous,recent aircraft will continuefor a long time). The numberof won the ChemistryNobelPrizein 1996for this. such as the B2 bomber,the technologically pilots in the cockpithas reducedto 2 from 4 or challengingOspreyTilt-rotor aircraft, or the 5 of fifty yearsago.Will we seethe arrivalof the Now that is a challengingthought! Thefact is Global Hawk unmannedvehiclewill probably singlepilot aeroplane?I think so in somecases, that I do not know if our grandchildren (manyof neverseecivilianapplications. as computerswill take over moreand moreof whom will live to be over a 100 years old the monitoringand alerting roles and become accordingto medical research)are going to Nowwhat will the next100yearsbelike?I think moreand morereliable.But, I do not believein want to go from Paristo Sydneyvia space the glamourof flying hasalreadybeenreplaced automaticaeroplanes.Computershave shown elevators,or if they will have3-D liquid quartz by down-to-eartheconomicsand more and tremendous possibilities in analysing, wall displaysin their homes,equippedwith morepeopleconsideran aeroplaneasa busor a processingand displayingbut not in taking virtual soundsand smells,so that they canvisit train. The recentsuccessof the "no frills low decisions.Theso-called"artificial intelligence" the placewithout leavingtheir homes. cost "airlinesare strengtheningthat trend. One neverreallymaterialisedand I doubtthat it ever of the questionsone might as in a few years will totally. Computersare likely to continue Onething I think is for certain,if theywant to fly could be when is Ryanairgoing to buy British monitoring,warning and managing,but not on Sundayafternoon,theyaremorelikelyto find AirwaysandLufthansa? taking decisionsfor humans,especiallyif the themselvessitting on a Cessna17x, the latest Thearrivalof the largestversionof the Airbus lives of thousandsare at stake. However, versionof the 172designedin 1948...

THE CONTROLLER

African Issues

SOCIAL ANDCULTURAL IMPACTON ATCTRAININGIN AFRICA Albert Aidoo Taylor - /FATCAExecutiveVicePresidentAfrica and Middle East INTRODUCTION

necessarythat the right calibre of student be recruited for training.

Safety is crucial in the aviation industry; thereforeeffortsto improvesafetyshouldbe an Selectionprocessinvolves: ongoing process.The introductionof Human Factorsin aviationhashelpedto improvesafety • Suitableage in the industry.Safetydoesnot just happenbut • Academicqualification mustbe createdand nurtured. for careerappreciation It is thereforecrucialto createa safetyculturein • Exposure all areasof the aviation industry.Whilst there areongoingeffortsto addresssafetyconcernsin • Aptitudetest specificallydesignedfor air traffic controllers otherareas,this presentationseeksto highlight other human aspectsthat are yet to receive test adequateattention(at leastin mostAfricanATC • Psychological operations). • Composition of selectionboard ProfessorRobertHelm Reichand his team of researchersfrom TexasUniversityhave done extensiveresearchin the field of culture.The research categorisescultural influence into National,Professional andOrganisational. Many institutions pay some attention to organisational and professional culture. However,very little or no attention is given to impact of national culture on safety critical industriessuchas air traffic control.

• Medicalfitness

An efficientselectionprocessresultsin: • Reduced trainingperiods • Reducedcost • Reduced turnover

memberto assistothermembers. • Oncea familymemberor communityassist anotherperson,it placesa higherexpectation on the beneficiaryto assistor reciprocatethe kind gestureby assistingsiblingsand relationsof the personor communitythat providedthe help.Thisculturalsenseof belonginghasenormousbenefitsto families and communities.However,like all human issuesit alsohasits negativesides. • In additionmanyidentifiableand influential groupsexerta lot of pressureon recruitment processes.

Thesocialgroupsthat imposepressure on the recruitmentprocessare: Unemployed individualsdesperateto havejust anythingto do • Externalfamilyrelations • Traditionalauthoritiesquota • Protocolquota

• Selectionof the right persons • Nationalsecuritypreferences It is not economicallyviable for every ATS providerto establishtheir own training school. There is a 10-15% shortage of Air Traffic Most countrieshaveto sendstudentsto other Controllersin Europe.It is interestingto see •Politicalinfluence countriesto undergoapprovedtraining. widespread advertisements in European • Economic factors countries enticing prospective Air Traffic Bribing (thoseresponsible for selection Culturaldiversityand differences thereforehave Controllersinto ATC.This is done to attract a receivefavoursto recruitunsuitable to be consideredwhen planning training of broadbaseof potentiallysuitablecandidates. trainees) studentsfrom differentbackgrounds. Almost all African ATCunits are understaffed. Aviationis perceivedas luxurywith the Thispresentationseeksto sensitisethe effectof Unlike Europeand North America,all African privilegeof beingableto travelabroadand someAfricansocialnorms,languageand culture countries have very high unemployment.In so attractspeoplewho enroljust to have in the Air TrafficControltrainingprocess. some casesthere are a high percentageof the opportunityof travelling. universitygraduateswhoareunemployed. There ATCtrainingprocesscomprises: is enormouspressureon organisationswith • Affirmativeaction vacanciesto recruit some of the unemployed Genderbalance • Selectionprocess labour. Tribaldistributions • Classroom lessons • Simulatorexercises • On-the-job-training Training of a safe and productive Air Traffic Controller starts with the selection of appropriate trainees. It is therefore really

Racialequityand access Social issues relate to society or its organisation, of the mutual relationships of Concerns have been expressedthat some people or classes living in an organised Africancountriesstill havenegligiblenumberof community. blacksas air traffic controllers.Whilst I believe there are many suitable black Africans who • Africanshavea closelylinkedfamily would qualify as potential controllers, it is relationship. importantto stressthat safetyis not negotiable. • Thereis sociala responsibility for everyfamily Effortsshould be made to attract those who

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African Issues meetthe high ATCstandardand encouragedto stay on as controllers.

• Safetyis compromised

• Thereshouldbe no discriminationin gender, tribe or race.

• Moraleis lowered

Effectsof socialgroupson training

• Trainingschoolsmustdevelopeffective methodsof filteringtraineesto ensurethat no unqualifiedpersonspassthroughthe safety • Theselectionrequirementsof age,academic It is impossibleto completelyeliminateendemic net. qualification,aptitudetest, selectionpanel, social and cultural practices.It is importantto etc, are in manycasescompromised. establish control measuresto minimise any • Air TrafficServiceprovidersmustadopt effectivecontrolmeasuresduringOJTto • Selectionpanelsarefilled with peoplewho negativeimpacton safety. ensurethat only qualifiedtraineesreceive are primarilyloyalto authoritiesthat have validations. other interestratherthan ensuringthat the MITIGATING THEIMPACT appropriateATCrequirements are met. In other cases(especiallywhereATCis part of • It is importantto developminimumselection • Air TrafficServiceSafetyManagersand Safety Regulatorsmustestablishpoliciesthat the Civil Service)the ATCadministrations standardand criteria. insulateATSprovidersfrom unduepolitical haveno sayat all in the selectionprocess. and militaryinterference. • Applicantsmustpassminimumselection • Thismodeof employmentallows unsuitable standards • !CAOneedsto educatestateson the dangers traineesto be recruited of undulyinfluencingATCselectionand • ATCOtraineesmustpasspsychological and training process. • It affectsthe trainingprogramme aptitudetests.!CAOshouldco-ordinate • Difficultto enforcediscipline

• It lengthenstrainingperiods • It increasescostof training • Highfailurerate • A latent failureis introducedin the Safetynet • Inabilityto enforceadministrativepolicy

EFFECT ON SAFETY AND ORGANISATION

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certainelementswith visualor oral criteria. • Theselectionboardshall includea psychologist trainedin, or familiarwith, all aspectsof ATCand a controllertrainedin selectionmethodsand procedures. • TrainedATCpersonneltogetherwith assessors shouldmakethe final selectionof prospectivecontrollers. • It is importantto enforceICAOMedical requirements.

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CULTURE is the behaviouror way of doing somethingby a particularpeople or group.

• It is very difficult to changethe cultureof a peopleor group. • Culturehaspositiveand negativesides. • It is importantto monitorits negativeaspects and determinethe impacton safety. • Weare concernedwith buildingstructures that would mitigatethe negativeeffectsof

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African Issues culture.

Language

AssertiveWesterncultureandeffectson organisations training • Westernsocietytendsto be assertive.

Peoplefrom a particularculture tend to have languageand accentpeculiarto them. • Thiscultureseeksto promotethe rightsof Theyalso becomeusedto a particularway of subordinates and hasdisputesresolution hearinganotherlanguage. processes that havethe potentialof offeringa fair judgementto both subordinates and Languageaffects: superiors. • Trainees'levelof understanding of some safetycriticalissues • Subordinates are alsoencouraged to speak againstissuestheydisagreeon and request • Thewaytraineesexpressthemselvesduring explanations whereunderstanding is lacking. training • Subordinates havethe right to petition. • Thewaytraineesanswerexamination questions Submissive Africanculture • Confidence

• Subordinates cannotspeakin front of elders unlessinvited

Medium of instruction and training duration • Theelderis alwayswiserand right • All trainingestablishments (includingthose • Youcannotbe judgedright in a disputewith listedin the ICAOTrainingDirectory)have an elder determinedthe appropriatedurationrequired • Youcannotspeakagainstan organisation you to pursueApprovedCourses. belongto • Althoughcollegesareadvertisetraining • Trainingis considereda privilege studentsfrom differentforeignlands,the impactof languageon trainingis ohen not Effectson training factoredinto determiningthe appropriate trainingduration. Sometrainees: • It is worstwhen studentsfrom different • Are reluctantto askquestionsin class countries,with differentlevelsof understanding and usageof the language • Are unableto askinstructorsto confirm understanding instructions,are lumpedinto one course. This approachto training has a potential for LatentFailureand to affect the successrate of trainees.

RECOMMENDATIONS • It is thereforeimportantfor international trainingestablishments to studythe impactof communication problemsof traineesfrom othercountrieswhendetermining appropriatecourseduration. • Traininginstitutionsshouldtake measures to addresslanguageproblemsof foreign studentsduringtraining. • Traininginstitutionsshouldstudyproblemsof runningclasseswith traineesfrom different languageand culturalbackgrounds and developprogrammes to mitigateadverse effects. • Specifya minimumlevelof language proficiencyrequiredby a traineeto pursue anycourse.

• Research the impactof cultureon aviation training • Educatestatesand otherstakeholders on safetyimplicationsof culturein aviation training

Therole of ATSproviders • ImplementTeamResource programmes that encouragetraineesto be moreassertive • TrainOn-the-Job-Training Instructors • Introducethe role of assessors and ensurean effectiveassessment process • Enforceprocedures for studentfeedback throughouttrainingperiod • Considerlanguageand culturalimpactwhen selectingforeignATCtrainingschoolsand particularlyscrutiniseprogrammes that mitigatelanguageand culturalimpact. • Providefeedbackof languageand cultural impactto trainingschools

Theroleof traininginstitutions • Studyimpactof culturein training • Studyproblemsof runninga classwith traineesfrom differentcultures • Promotebetterinteractionbetweentrainers and trainees

• Unableto voiceannoyancewhen intimidated • Introduceprocesses that encourages trainees by trainerswho bullythem to expresstheir viewson trainingprocessand trainers • Are unsuretheywill receivefair hearingwhen they complainaboutobviousproblemswith • Makeprovisionsfor re-markingof trainingprocess examinations

Impactof aviation

HumanFactorsExperts

• Therecouldbe criticalsafetyissuesthat are not fully understood.

• Shouldintensifyresearchon socialand culturalimpacton ATCtrainingand increase the levelof educationand awareness.

• LatentFailurecouldbe establishedin the safetychain. • It stiflesinitiativesthat arevital for selfevaluationof traininginstitutionsand organisations • It impedesdevelopment effortsby excluding subordinates'inputs

MITIGATION Theroleof ICAOandinternational

CONCLUSION Theeffortsto addresshumanfactorsin aviation must be total. Social, languageand cultural issues in training are becominga gathering danger.Whilst they may be prevalentin other industries,the consequenceto the aviation industrycannot be ignored due to its safety implications.It is thereforeimportantthat ICAO, States,ATS Providers,Human Factorsexperts and Aviation Trainingschoolsto co-operateto minimise the negative impact of language, cultureand societalnormson air transportation

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IFATCA Corporate Members

Air Trafficand NavigationalServicesCo.Ltd. GeraldvanAswegen Executive Ass'tto ManagingDirector knatc@atns.co.za

KrugerMpumalangaInternationalAirport P.O.Box20015,WestAcres1211 SouthAfrica

Tel+27 11 392 4895 Fax+27 11 392 3868

AmbidjiGroupPTYLtd. MikeGahan,GeneralManagerAviation mgahan@ambidji.com.au www.ambidji.com

Level4, 493 St. KildaRoad,Melbourne VIC3004 Australia

Tel+61 26 241 8500 Fax+61 26 241 8577

AMS VincenzoNaddeo vnaddeo@amsjv.it

Via TiburtinaKm12,400 00131,Roma Italy

Tel+39 064 1502765 Fax+39 064 1503057

ArincInc. StephenE. Means VPMarketing& Sales stephen.means@arinc.com

2551RivaRoad,Annapolis Maryland,21401 UnitedStatesof America

Tel+1 410 266 4652

AviationServices TrainingandConsultancy BobPegg ManagingDirector bpegg@astac.org.uk

RudloeCollege,RudloeManor,BoxHill Corsham,WiltshireSN130GT UnitedKingdom

Tel+44 1225 81 7100 Fax+44 1225 81 7101

BARCOORTHOGON AG UweVogele ManagingDirector info@orthogon.de

VaihingerStr.169 70567Stuttgart Germany

Tel+49 711 781960 713 Fax+49 711 781960 711

BreitlingSA TheodoreSchneider

P.O.Box1132,CH-2540 Grenchen Switzerland

Tel+41 32 654 5454 Fax+41 32 654 5401

BritishAirways ColinHume Manager,Air TrafficServices colin.d.hume@british-airways.com

Compass Centre(5734),P.O.Box10 HeathrowAirport,HounslowMiddlesex, TW62JAUnitedKingdom

Tel+44 208 513 0327 Fax+44 208 513 0444

CELLITSAB StigLejon stig.lejon@cellnetwork.com www.cellits.com

Rusthallsgatan 21 SE-25361 Helsingborg Sweden

Tel+46 42 19 8200 Fax+46 42 14 2965

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IFATCA Corporate Members

DiversifiedInternationalSciences Corp. DennisA. Rizzardi Director,Business Development drizzardi@discmd.com

9901-RBusinessParkway, LanhamMD 20706 UnitedStatesof America

Tel+1 301 731 9070 Fax+1 301 731 9074

FR-HiTEMP Ltd N.M.Dickie Business Dev.Manager,S&M

AbbeyPark,Titchfield Fareham,HampshirePO144QA UnitedKingdom

Tel+44120 288 2121 Fax+44 120 288 0096

FrequentisNachrichtentechnik G.m.b.H. ThomasFranzi thomas@fraenzl@frequentis.com

A-1120Wien,Wolfganggasse 58-60 A-1120Vienna Austria

Tel+43 1 811 50 1772 Fax+43 1 811501019

lndra JavierRuano,NationalATMDirectorate jruano@indra.es www.indra.es

CrtraLoeches 9, 28850 Torrejonde Ardoz,Madrid Spain

Tel+31 91 396 8300 Fax+34 91 677 4801

Institutefor InternationalResearch EmmaCollier SeniorConference Producer ecollier@iir-conferences.com

29 Bressenden Place LondonSW1E 5DR UnitedKingdom

Tel+44 (0) 20 7915 5644 Fax+44 (0) 20 7915 5001

Jeppesen& Co GmbH ReinerThamer Director,AviationTechnology & ExternalRei bhonberg@jeppesen.com

FrankfurterStr 233,D-63263 Neulsenburg Germany

Tel+49 610 250 7230 Fax+49 610 250 7249

NASAAMESResearchCenter RobertJacobsen Karl.Grundmann@faa.gov

N 262-1,Moffett Field California94035-1000 USA

Tel+1 650 604 4709 Fax+1 650 604 2698

NiceSystemsLtd. Arik Raviv VPMarketing

8 Hapnina,POB690 Ra'anana43107 Israel

Tel+97 23 645 3777 Fax+97 9 775 3052

NorthropGrummanCorporation ElectronicSensors & Systems, P.O.Box17320 ChristopherM. Francis MSB545, Baltimore, Md 21203 MarketingManager,lnt'I ATMSystems ChristopherM Francis@md.northgrum.com UnitedStatesof America

Tel+1 410 993 3702 Fax+1 410 981 5266

PanAm InternationalFlightAcademy ThomasJones DirectorCivilAviationProgram tjones@netside.net

P.O.Box660920 Miami,FL33266-0920 UnitedStatesof America

Tel+1 305 874 6671 Fax+1 305 874 6699

ParkAir SystemsAS TorMagnusOkstad Director,DivisionNova t.okstad@no.parkairsystems.com www.parkairsystems.com

P.O.Box145, 3191 Horten Norway

Tel+47 23 18 02 00 Fax+47 23 12 37 10

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IFATCA Corporate Members

RaytheonCompany RobertW. Meyer RobertW Meyer@Raytheon.com

1001BostonPostRoad,Marlborough MA.,01752 UnitedStatesof America

Tel+1 508 490 3045 Fax+1 508 490 3322

RaytheonSystemsCanadaLtd. AdrienneWhite Communicatons Manager adriennewhite@raytheon.com

150 135 75 Commerce Parkway Richmond,BCV6V2L1 Canada

Tel+1 604 821 5188 Fax+1 604 279 5600

SchmidTelecommunication DanielWeideli,SeniorProductManager daniel.wiedeli@schmid-telecom.ch www.schmid-telecom.com

Binzstrasse 35, CH-8045 Zurich Switzerland

Tel+41 1 456 14 27 Fax+41 1 466 94 27

SensisCorporation FrankMatus InternationalBusinessDevelopment Mgr. frank.matus@sensis.com www.sensis.com

5793WidewatersParkway Dewitt,NewYork13214 UnitedStatesof America

Tel+1 315 445 5050 Tel+1315569 1596 Fax+1 315 446 2209

SercoIALLtd SallyJohnston SeniorOperationsManager loconnor@serco.com

SercoHouse,11 BartleyWoodBusiness Park BartleyWay,Hook,HantsRG279XB UnitedKingdom

Tel+44 (0) 1256 745900 Fax+44 (0) 1256 745970

SocieteD'Etudeset D'Enterprises Electriques Mr. Foenkinos

11 RuePaulBert,F-92240 Malakof France

Tel+331 40 922 000 Fax+331 46 560 816

SolaComTechologies Inc. lria Picanco,MarketingAnalyst ipicanco@solacom.com www.solacom.com

490 St.JosephBlvd,Hull Quebec,J8Y3Y7 Canada

Tel+1 819 770 4049. ext 3 Fax+1 819 770 4222

SwedaviaAB LennartBjork President lennart.bjork@swedavia.lfv.se

S 60179 Norrkoping Sweden

Tel+46 11 192 000 Fax+4611 130 711

TermaA/S IngerThomsen ict@terma.com

Bjarkesvej 2 DK-3450Alleroed Denmark

Tel+45 48 10 55 14 Fax+45 48 10 55 50

ThalesATM LeilaBrown Leila.Brown@thalesatm.com

OakcroftRoad,Chessington, Surrey, KT91QZ UnitedKingdom

UnitedBusiness Media International PaulaMilburn EventManager pmilburn@ubminternational.com

BlenheimHouse,630 ChiswickHigh Road,London,W4 5BG UnitedKingdom

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Tel+44 (0) 208 8987 7832 Fax+44 (O)208 8995 2788

Agenda

AGENDA 2003 Se tember

22 - 3 Oct ICAO11th ANC- Montreal Contact:IFATCA OfficeManager, Tatianalavorskaia

Contact:IFATCA OfficeManager, Tatianalavorskaia 19 - 20 SC4Meeting Trinidadand Tobago Contact:IFATCA OfficeManager, Tatianalavorskaia

October

4 - 6 ExecutiveBoardMeetingMontreal Contact:IFATCA OfficeManager, Tatianalavorskaia 15 - 17 Asia PacificRegionalMeeting Christchurch Contact:IFATCA OfficeManager, Tatianalavorskaia 17 - 19 EuropeanRegionalMeetingPorto

21 - 22 SC1MeetingWashington Contact:IFATCA OfficeManager, Tatianalavorskaia 21 - 23 IFALPA ATS- Washington Contact:IFATCA OfficeManager, Tatianalavorskaia 20 -22 Africa MiddleEastRegional Meeting- Amman Contact:IFATCA OfficeManager, Tatianalavorskaia

30 - 1 NovAmericasRegionalMeeting - SantoDomingo Contact:IFATCA OfficeManager, Tatianalavorskaia

2004 Januar:t'll 16 - 18 EBMeeting- Montreal Contact:IFATCA OfficeManager, Tatianalavorskaia March 19 - 20 Pre-Conference EBMeeting HongKong

22 - 26 43rdAnnualConference HongKong 27 Post-Conference EBmeeting HongKong

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Charlie's Column

Morefor lessin the USA

Accordingto the FAA,poor airlinesare actually TheAirlinesreply "Thisis not true, mostof saferto fly . The FAAhead of regulationand our femalecabinstaff AREold". certificationsaidmoneyproblemstendto cause thesepoor airlinesto retire their older aircraft on the R/T and to keeponly their newermachines,which Overheard arein bettershape.Layoffshavealsoresultedin TWR: American1234confirmyou somecaptainsmovingto the righthandseat,so havecapturedthe ILS "what you have on the flight deck is a very Errr,Negative, but we have highly experienced combination of crew Pilot: it surrounded .... members- in essencetwo captains,"the FAA officialtold TheNewYorkTimeslast month. He also said " the FAAhas also been watching R/Texchange on a smallUSfield carefullyairlines in financialtroubleto ensure maintenancestandardsare maintained". So, Controller: Citation22Cyouarenumber the poorairlinesarecheckedmorethanthe rich two behinda Cessna152 ones and are operatedby more experienced presentlyone milefinal. pilotsthan before. Citation: what is the callsignof that Cessna? Interestingconceptbut I am not surethis workseverywhere though.... Controller: N3345D Citation:

UgliestAirlineUniform Recently onthe Internetsomeonelaunched a contestfor the ugliest Airline uniform. Qantasand Unitedcametop. Oneof the jury commented"On United,the uniform makestheir femalecabincrew look much older..

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N3345DI haveyou in sight,do a go around,youareslowingustoo much.

Controller: Citation22Csinceyou are not a controllerandnot God, refrainfrom issuing instructionsand youarestill number2.

Cessnapilot: Thankyou God.....

Andthis onefroma Britishairfield TWR:

N1234taxi via the north Gateto G1for runway24.

Pilot:

Andwhichoneis the north gate?

TWR:

Well,if you are facingSouth it is the onebehindyou....

Thenfrom Heathrow Pilot :

Towerthis is Speedbird Concorde001 with you monitoring118decimal5

TWR:

Rogerspeedbird001, kindly monitorthe frequency silentlylike everyoneelse....

Heardon a recentAer Lingusflight out of Heathrow The standardannouncementon ensuringall mobilephones,CDplayers,etc.areswitchedoff, has beenmadeprior to pushback.Theaircraft hasnow pushedbackand is taxyingfor runway

Charlie's Column 27L, and has practicallyreachedthe holding point. All duringtaxyingthe soundof a mobile phoneringingcan be heardand the cabincrew are runninground desperatelytrying to locate the offendinginstrument. Thenan announcement overthe tannoy: "Thisis the Captain.Will all ownersof mobile phonespleaseensure.... ". Silence "Er... this is the Captain.I was aboutto askall passengers to checkthat their mobile phones wereswitchedoff when I realisedit was MY phone!" Theentireaircraftcollapsedwith hysterics. Thereare two moralsto this story: 1. ALWAYS rememberto switchoff your mobile phonebeforepushback pilotstoo! 2. Pilotsbeware you neverknow who'ssitting downthe back! (guest contribution from Maureen Claysoncopyeditor)

PHOTOS from BUENOS AIRES {IFATCA Conference) 1 ThenaughtyATCfamily : a phototaken duringthe final plenaryat the Buenos Airesconference. It containsOpa, mama,papa,2 childrenand the dog. I leaveit to you to find out who is who.

2 Anotherphototakenduringthe Conference showingthe two

finalistfor the Colgatetoothpaste contest. 3 Uruguayanaviation: An eccentricman with moneyhasdecoratedhisgardenin his homenearMontevideowith a few old carsand the hull of a Fokker27. 4 As he did not havethe engineshejust replacedthe propellersby coolingfans takenfrom a truck.Helovesthe sightof

the planein the morninghe said.

CHARLIE's Philosophy (continuingstory) Neverargue with idiots. They first drag you down to their level, then they beatyou with experience.

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