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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 [email protected]
European Organisation for the Safety of Air Navigation
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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…
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ICAO Annex 13
First edition September 1951 1st-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”
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Findings, RecommendationsSeverity Assessment
Findings, RecommendationsSeverity Assessment
Need to know about undesired events that have had or might have had an impact on safety
Reported Safety OccurrencesReported 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
Reporting systems Requires a
common
TAXONOMY
Data collectionAnalysis
Severity assessmentSeverity assessmentATM contribution
Data collectionAnalysis
Severity assessmentSeverity assessmentATM contribution
Requires
HARMONISED PROCESSES
Annual Summary Template
Annual Summary Template
Agreements(bilateral or
regional)
Agreements(bilateral or
regional)Requires
PROCEDURES
CONFIDENTIAL ASSURANCE
ESARR 2ESARR 2
Trends, KRA, ATM improvementsGLOBAL SOLUTIONS
Trends, KRA, ATM improvementsGLOBAL SOLUTIONS
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What can go wrong ?
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Accident Definition
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11 22 33 44 55 77
What criteria or elements would you consider for the purpose of classifying an occurrence as an accident ?
What criteria or elements would you consider for the purpose of classifying an occurrence as an accident ?
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Accident Definition Criteria
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Persons on board at time of occurrence?Persons on board at time of occurrence?
NONO
No AccidentNo AccidentNo AccidentNo Accident
NONO
YESYES
Intention to fly?Intention to fly?
AccidentAccidentAccidentAccident
YESYES
YESYES
Fatalities?Fatalities?Note 1Note 1
NONO
Serious injuries?Serious injuries? Def.Def.
YESYES
YESYES
NONOA/c damages, structural
Failure req. major repair ?A/c damages, structural
Failure req. major repair ?
NONOYESYES
NONO
Aircraft missing? or inacessible?
Aircraft missing? or inacessible?
Note 2Note 2
Accident Criteria
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Accident Definition cont’d
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Accident Definition cont’d
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There is a need for detailed There is a need for detailed agreed definitionsagreed definitions
There is a need for detailed There is a need for detailed agreed definitionsagreed definitions
Conclusion
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“Say…what’s a mountain goat doing way up here in a cloud bank?”
CFIT Some Clue…
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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
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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
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
1999 2000 2001 2002 2003 2004
Runway Incursions(occurrence per million flight hours and severity)
A
B
C
E
D
Not classif ied
0
100
200
300
400
500
600
700
800
900
1999 2000 2001 2002 2003
Total Accidents
Total Fatal ATM Direct
Total Fatal ATM Indirect
Total ATM Direct
Total ATM Indirect
Total Fatal
Total
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Currently Only a Minute Portion of Data is Reported, Analyzed, Used and Disseminated
Almost all Datais Lost Forever
In reality
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Why ? - SAFERP TF Report Seek Solutions
17 JB, FL & GLG
mistakesomissions optimising violations
criminal acts
gross negligence
Ina
de
qua
te a
ttitu
de
Re
pet
itive
err
ors
De
libe
rate
act
s
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
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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
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From where in fact safety data comes Ref – IFATCA survey early 2000
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Encourage people to report even minor concerns
Assess the reporting culture and identify major reporting impediments in your organisationConduct 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
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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
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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
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Deal with sanctions and Loss of faceRef – IFATCA survey early 2000
LOSS OF FACE31%
~70%
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slips
lapses
mistakes
violations
unintended actions
unintended failure to act
intended actions givinga result different from expectations
« Deliberate » and break the assumption of safety management systems:rules will be followed
unintentional non compliancePeople do not know how to apply the rulePeople act as if there is no procedure
routineRules are broken because they are felt irrelevant or because people do not appreciate anymorethe dangers
optimisingIt is sometimes possible to get the job done faster,more conveniently or esperience a thrill by not adhering to the rules
situationalIt is impossible to get the job done by appllying the rules strictly
ExceptionalPeople have to solve the problem for first time and fail to follow good practice
No obvious solutions
No obvious solutions
Training
Behavioral change
Training
No obvious solutions
Question the rules and work place
What can we do?
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The « non-punishment » chartIntentional?
(Deliberately endangered others)
yes
Mental illness?
no
« normal » Environment?
yes
Medical case
no
Criminalcase
yes
Substitution test
no
Procedures missing or
supervision erroror
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
sanctionsmay be
Envisaged
Rule basedViolations
Negligence
Corrective actions
should be Envisaged(training)
Knowledgeskills
Management Issue
Revision of proceduresOr training
Global issue
Managementissue
Lack of Competenceverification
And/or
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Finally what is JUST CULTURE?
Failure
Incident
Accident
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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
mistakesomissions optimising violations
criminal acts
gross negligence
Ina
de
qua
te a
ttitu
de
Re
pet
itive
err
ors
De
libe
rate
act
s
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
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Questions?
Thank you!
?
