1 ATM Safety Data Reporting, Analysis and Sharing Where we are and where are we heading by facilitating Just Culture Tony LICU Programme Manager – EUROCONTROL DAP/SAF European Safety Programme for ATM (ESP) April 2006 – Baku/Azerbaijan European Organisation for the Safety of Air Navigation

2 Objective Current Status of Safety Reporting and Analysis Regulations Technical Issues (taxonomy, harmonisation, severity assessment, trend output) A Just Culture definition Actions that ANSPs can do…

3 ICAO Annex 13 First edition September st-3rd edition (04/1973) called “Aircraft Accident Inquiry” 4th-7th edition (05/1988) called “Aircraft Accident Investigation” 8th-9th edition (07/2001) called “Aircraft Accident and Incident Investigation”

4 Findings, Recommendations Severity Assessment Need to know about undesired events that have had or might have had an impact on safety Reported Safety Occurrences Need to determine to what extent ATM has contributed to the occurrences and severity of a safety risk Need to share experiences Reporting systems Requires a common TAXONOMY Data collection Analysis Severity assessment ATM contribution Requires HARMONISED PROCESSES Annual Summary Template Agreements (bilateral or regional) Requires PROCEDURES CONFIDENTIAL ASSURANCE ESARR 2 Trends, KRA, ATM improvements GLOBAL SOLUTIONS

5 What can go wrong ?

6 Accident Definition

What criteria or elements would you consider for the purpose of classifying an occurrence as an accident ? 6 Accident Definition Criteria

8 Persons on board at time of occurrence? NO No Accident NOYES Intention to fly? Accident YES Fatalities? Note 1 NO Serious injuries? Def. YES NO A/c damages, structural Failure req. major repair ? NOYES NO Aircraft missing? or inacessible? Note 2 Accident Criteria

9 Accident Definition cont’d

10 Accident Definition cont’d

11 There is a need for detailed agreed definitions Conclusion

12 “Say…what’s a mountain goat doing way up here in a cloud bank?” CFIT Some Clue…

13 Collision with Ground EVENT TYPE Accident SEVERITY CLASSIFICATION SCHEME No awareness from crew DESCRIPTIVE FACTOR(S) Factual Data BACKGROUND DATA Recommendations RECOMMENDATIONS Human Factors EXPLANATORY FACTOR(S) GLOSSARY HEIDI/ADREP Taxonomy Layout

14 Current Output Trend analysis and statistics on a large number of Safety Performance Indicators: Accidents and the ATM Contribution to accidents Mid-Air Collision, CFIT, Collisions on the ground e.g. Incidents: Separation infringements, Runway Incursions, Near CFIT, Unauthorised penetration of airspace e.g. ATM Specific Occurrences: Provision of ATM services: ATS, ASM, ATFM Failure of ATM Elements: COM, SUR, NAV, FDP

15 Currently Only a Minute Portion of Data is Reported, Analyzed, Used and Disseminated Almost all Data is Lost Forever In reality

16 Why ? - SAFERP TF ReportSeek Solutions

17 JB, FL & GLG mistakesomissionsoptimising violations criminal acts gross negligence Inadequate attitude Repetitive errors Deliberate acts Honest mistakes Management to monitor these and take disciplinary actions as required SMS to address these for the single purpose of improving safety Issue for the competence of justice Just Culture

18 From where in fact safety data comes In the absence of bad outcomes, the best way to sustain a state of intelligent and respectful wariness is to gather the right kinds of data. This means creating a safety information system that collects, analyses and disseminates information from incidents and near misses, as well as from regular proactive checks on the system’s vital signs. prof. J. Reason

19 From where in fact safety data comes Ref – IFATCA survey early 2000

20 Encourage people to report even minor concerns Assess the reporting culture and identify major reporting impediments in your organisation Conduct a survey amongst the totality or part of your staff to assess the reporting culture and main impediments for reporting Involve staff representatives in the survey

21 Improve the trust in the system Trust is the most important foundation of a successful reporting programme, and it must be actively protected, even after many years of successful operation. O’Leary - British Airways & S. L. Chappell -NASA

22 Written reporting policy and procedure People need to know what will happen when they are involved in or witnessed a safety occurrence and submit a report. “Just Culture”, agreed by staff representatives – define the limits Separation of the data-collecting function Involvement of active controller in the process Confidentiality for the reporter

23 Deal with sanctions and Loss of face Ref – IFATCA survey early 2000 LOSS OF FACE 31% ~70%

24 What can we do?

25 The « non-punishment » chart Intentional? (Deliberately endangered others) yes Mental illness? no « normal » Environment? yes Medical case no Criminal case yes Substitution test no Procedures missing or supervision error or Training missing yes Management Issue The environment is not « normal » when the conditions in which operators are required to work were either: Not covered by procedures Or not addressed by training Or the supervision was inadequate (e.g. manning of sectors, traffic flow control etc..) This must be understood as external and internal conditions being covered by procedures, training, and all activities that must be carried out to ensure normality of operations (supervision) Important: non written rules but working habits that are considered « normal » practice at a given unit must be considered as « normal » environment This actually refers to the author of the action(s) or absence of action(s) concerned being conscious of not doing well and potentially endangering others. This includes (gross) negligence The « substitution » test aims at determining whether any other staff with the same experience would have performed in a same way or not. In ATM this can only be achieved by a group discussion of « experts » (experienced staff) which honestly evaluates the performance and decides whether the performance was substandard or not. Care must be taken as experienced staff may have developed their skills in different manners. Individual issue « Disciplinary » Type of sanctions may be Envisaged Rule based Violations Negligence Corrective actions should be Envisaged (training) Knowledge skills Management Issue Revision of procedures Or training Global issue Management issue Lack of Competence verification And/or

26 Train staff to report Training should emphasise that the potential reporters are the only 'expert witnesses' present at the time of the occurrence. An educated witness, a thinking witness, will give a better (more comprehensive, less defensive) overall account of the event.

27 Finally what is JUST CULTURE? Failure Incident Accident

28 Seriously what ANSPs can do? (NAME of organisation) will adopt the following « proportionate blame » policy with regards to incidents with the purpose of making disciplinary measures strictly limited to those acts that do not qualify as « honest mistakes ». 1.Disciplinary measures range from: temporary suspension of payment of shift allowances Down grading …… 2. Disciplinary measures are to be decided upon by the Management who has to consider the advice of the disciplinary committee. (see TORs of disciplinary committee) 3. The disciplinary committee shall also be informed by the Management about acts that need to be reported to the Department of Justice. 4. Safety occurrences that emerge from data derived from automatic reporting activities (STCA and/or AMST) will not mention any names as long as they do not pertain to a reported occurrence (by ATM or pilot)

29 JB, FL & GLG mistakesomissionsoptimising violations criminal acts gross negligence Inadequate attitude Repetitive errors Deliberate acts Honest mistakes Management to monitor these and take disciplinary actions as required SMS to address these for the single purpose of improving safety Issue for the competence of justice In summary

30 Questions? Thank you! ?