The Dec 2018 verdict on an air traffic controller of Zurich airport, who issued simultaneous landing clearances on two crossing runways is a setback for aviation safety in Switzerland. The ‘HRO – high reliability system, aviation’ depends on reliable work of a huge number of specialists. This verdict has the potential to have a negative impact on aviation safety.
In Austria we do not have ‘in depth’ data concerning this case, however we agree with our – well informed – colleagues of Swiss AEROPERS. In a complex aviation system, the safety management depends on voluntary reports by operators (eg. air traffic controllers, pilots).
Procedures and minor events will be reported, to initiate mitigations, long before a real ‘serious danger’ exists. If events have serious consequences for the individual, the willingness to report, will decrease …
Air traffic controllers and pilots are never ‘above the law’, but they deserve fairness under consideration of their working conditions. Negligence and sinister intention are unacceptable and have to be punished. But does anybody believe, an air traffic controller will issue simultaneous clearances on crossing runways on purpose?
High workload, technical restrictions, demanding weather conditions and a high number of other factors have the potential to trigger – rarely – errors. As pilots we prefer to live in a world, where air traffic controllers collaborate without fear, with their respective safety managers and the authorities, to continuously enhance flight safety.
A report: ‘I had almost issued take off clearances to two aircraft on crossing runways, because a telephone call distracted me. The regular line was down and we were working with the standby system. For a moment I was uncertain, whether my telephone partner was hearing me…’ that is the kind of tools to minimize hazard potentials in future.
Like in all complex systems there are always challenges and even minor events that are not foreseen or covered by procedures and regulations. The minor deviations seldom go public.
If a deviation emerges and immediately personal guilt is assigned, the way to punishment is not far. Can anyone have a doubt, this will lead operators to an attitude to cover minor events?
ACA supports the ‘just culture’ principle. Improvements of the system are more important than retribution. In ‘just culture’ there are no sanctions, if operators act according their education/training level and show every effort to do their best. However, ‘no merci’ if ‘intention’ or ‘negligence’ are involved.
The ‘fine line’ between understandable behaviour and negligence can only be drawn by competent specialists. Occasionally judiciary needs counselling by such persons.
ACA is member of an EUROCONTROL program, providing these experts if needed.