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The Ueberlingen Midair Collision -
Some Lessons Learned
Presentation to the Alias Conference June 15, 2012
Francis SCHUBERT Chief Corporate Officer, skyguide
page 2C/SF/15.09.2011
Outline
• Facts: a reminder• Communication aspects & Crisis Management • Legal aspects:
– Civil liability
– Criminal responsibility
• Conclusions: – Consequences on the system
– Some Lessons learned
page 3C/SF/15.09.2011
page 4C/SF/15.09.2011
OverviewImmediate Response
CommunicationCrisis Management
Safety investigation
CommunicationCrisis Management
ATCO murderer's trial
Skyguide employees'
Criminal Trial
1.7.2002Ueberlingen
Collision
May 2004
Skyguide ATCO
murdered
Feb 2004
Compensation: Out of court settlement
Civil Proceedings
Oct 2005 May 2007 Sep 2007Jul 2003 Nov 2010
page 5C/SF/15.09.2011
Causes (BFU Safety Investigation Report)
• Immediate causes:–Imminent separation infringement not noticed by ATC in time.
Instruction for TU154M to descend given at a time when prescribed separation to the B757-200 could not be ensured anymore.
–TU154M crew followed ATC instruction to descend and continued to do so even after TCAS advised to climb. Manoeuvre performed contrary to the generated TCAS RA.
page 6C/SF/15.09.2011
Causes (BFU Safety Investigation Report)
• Systemic causes:–Integration of ACAS/TCAS II into aviation system was
insufficient and did not correspond with system's philosophy.–Regulations concerning ACAS/TCAS published by ICAO and
as a result, regulations of national aviation authorities, operational and procedural instructions of TCAS manufacturer and the operators not standardised, incomplete and partially contradictory.
–Management and quality assurance of ANS company did not ensure that during the night all open workstations were continuously staffed by controllers.
–Management and quality assurance of ANS company tolerated for years that during times of low traffic flow at night only one controller worked and the other one retired to rest.
page 7C/SF/15.09.2011
Lawyers
Insurance Corporateimage
Gouvern-ment
EmployeesBoard/Manage
ment
Managing conflicts of interest
page 8C/SF/15.09.2011
Theoretical legal channels
• Germany– All claims to be addressed exclusively against the German Republic– No established recourse channel against skyguide
• Switzerland– Skyguide submitted to State liability regime because it performs a
sovereign function on the basis of a State mandate– All claims to be addressed exclusively against skyguide (no direct action
against the State or against individual employees)– Decision in first instance– Federal Supreme Administrative Court acts on recourse and final instance– State subsidiary liability
page 9C/SF/15.09.2011
Criminal liability
• 8 employees prosecuted– 3 Managers– 3 Operational professionals– 2 Engineers
• Claim– Multiple negligent manslaughter– Negligent disturbance of public transportation
• Requisition– 6 to 15 months imprisonment– Suspended sentences with a probation period of 2 years
• 3 Managers + Project Manager condemned to suspended sentences
page 10C/SF/15.09.2011
Internal measures
• Establishment of a high level coordination Task Force– Board of Managers– Legal services– Communication– Safety management– External lawyers
• Mandate– Prepare the trial from a corporate angle and support individual
employees– Follow the trial on a daily basis
page 11C/SF/15.09.2011
Internal measures
• Security:– Personal protection of the employees and of their families– Physical facilities security
• Psychological support of the employees and of their families
• Communication support– Media-Training– External and internal communication
• Legal support– Each employee chose his own attorney– Legal cost borne by skyguide / corporate legal insurance– External specialist hired by skyguide for overall coordination
• Professional support– Dedicated OPS/TEC experts available
page 12C/SF/15.09.2011
Consequences on the system
• Insurance premium?• Regulatory environment
– Possible unwanted side-effects: compliance driven regulatory processes instead of safety oriented practices
• Corporate image• Political instrumentalisation
page 13C/SF/15.09.2011
Some Lessons Learned
• An organisation is never prepared to face a major catastrophe, but basic rules, principles and processes can help an organisation through a crisis
• The adequacy of immediate response is a most critical element:– An early communication / crisis management failure cannot be
recovered later
• There is room to apologise and express sincere regrets for the occurrence of an accident, without jeopardising the legal exposure of the company
• It is possible to accept corporate responsibility without exposing individual employees to personal liability
• The judicialisation of aviation accidents / incidents • Criminal liability is climbing up the corporate ladder
page 14C/SF/15.09.2011
Some Lessons Learned
• Clear rules must be defined and agreed with the staff associations, regarding management measures to be taken in case of criminal proceedings, prior to any accident
• Responsibilities need to be clearly defined and allocated within the organisation:
– Resources & competences need to be allocated accordingly
• Legal framework needs to be certain: e.g. delegation agreements
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