Review Accident and Incident Investigation Policies in view of the “Just Culture” Philosophy

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Review Accident and Incident Investigation Policies in view of the “Just Culture” Philosophy

46TH ANNUAL CONFERENCE, Istanbul, Turkey, 16-20 April 2007

WP No. 159

Review Accident and Incident Investigation Policies in view of the “Just Culture” Philosophy

Presented by PLC

Introduction

1.1  The scope of this paper is to review accident and incident investigation policies in light of the Just Culture philosophy and as part of the review of the legal section of the IFATCA Manual.

1.2  Simultaneously the policy document on Accident and Incident Investigation attached to the Legal Section as attachment 1 will be reviewed.

Discussion

2.1 Just Culture Definition

2.1.1  At present the emphasis of the just culture philosophy is apparently put erroneously on safety reporting as stipulated in the IFATCA definition following hereafter. A just culture in Safety Reporting can be defined as follows:

“A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”

2.1.2  It is obvious that the just culture philosophy must cover the complete process of Incident and Accident investigation. This process includes the reporting, the investigation and the outcome of the investigation as well as the data collection and dissemination of the results.

2.1.3  Therefore PLC suggests rephrasing the introduction to the definition as follows. A Just Culture in Accident and Incident Investigation is defined as follows:

“A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”

2.1.4  Additionally, minor editorial changes are suggested to the second paragraph as to read:

“Member Associations shall promote the creation of Air Safety Reporting Systems based on confidential reporting in a just culture among their service provider(s), Civil Aviation Administration(s), National Supervisory Authority(ies) and members.”

2.1.5  These editorials are proposed as there are Member Associations controlling cross- border FIRs under the jurisdiction of different CAAs and NSAs. PLC considers the word “shall” as appropriate rather than “should”.

2.2 IFATCA policy is that:

“When an accident or incident is alleged to have occurred where the actions of an Air Traffic Controller may have had a bearing, the Controller shall have the right to be exempted from control duties until he is physically and psychologically fit again. The removal is without prejudice, and is non-disciplinary.

A Controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an incident/accident.”

 

2.2.1 These policy statements accepted during the Nairobi ’87 and Acapulco ’90 conferences are still valid and in line with the just culture philosophy and as such do not need amending. The heading “Exemption from Duty” has been added to separate the different subjects.

2.3 IFATCA policy is that:

“The Controller has the right to be accompanied by a representative of his choice at any hearing, inquiry or investigation into any Air Traffic Control incident or accident.

The Controller should make no written statements without the advice of a legal representative of his choice, even at pre-investigation board stages.

The circumstances prompting the investigation, and the perceived operational situation immediately prior to the alleged incident/accident, shall be made available to the Controller and his representative prior to any questions being put to the Controller.

When an Investigation Board is convened, it shall be confidential and non- disciplinary in nature. The Board should be comprised of individuals who have operational experience in Air Traffic Control.

The Controller and his representative have the right to make representations and direct questions to the officials in charge of the investigation.

The Controller and his representative have the right, prior to appearing before any investigative Board, to review all relevant video and audio recordings and computer readouts of Air Traffic Control operations where available. In addition, the Controller and his representative shall be provided with copies of transcripts of all relevant audio recordings prior to appearing before any Investigative Board.”

 

2.3.1  This group of policy statements received the heading “Right of Representation”.

2.3.2  There was some concern about the second policy statement. Does this policy also imply the initial occurrence report filed by the controller? PLC is of the opinion that an incident report is factual. The reporter just gives the facts of what happened and therefore the initial report is not considered to be the same as a written statement.

2.4 IFATCA policy is that:

“Member Associations should provide their members with a card containing the basic rights they have and the rules that will be applied in case of incident/accident investigations.

In case of an accident it is recommended that immediate psychological or medical advice is sought.

Protection of the identity(ies) of ATM staff involved in incidents or accidents shall be guaranteed.”

 

2.4.1  These three policy statements are stand-alone statements that cannot be put under a specific heading unless a heading is added for each paragraph.

2.4.2  Such headings could be Reference Card, CISM and Protection of Identity.

2.4.3  The statement: “In case of an accident it is recommended that immediate psychological or medical advice is sought” is somewhat vague. Who is recommended to seek advice, the controller involved or the member association or the employer or any other colleague?

2.4.4 IFATCA has comprehensive policy on Critical Incident Stress Management on page 4223 saying that:

2.4.4.1  Paragraph 2.4.2:

“Comprehensive and confidential support services should be available at all times for air traffic controllers, support staff and their families.”

 

2.4.4.2  Paragraph 2.4.4:

“Professional critical incident stress support services should be made available to air traffic controllers involved in ATC incidents/accidents if the air traffic controllers so choose.”

 

2.4.5 PLC believes that these policy statements are more accurate and therefore suggests deleting the one stated under 2.1.19 on page 4422. Additionally the CISM policies are subject to review and a separate paper will be presented.


2.5 Additional Policy

2.5.1 PLC examined the need for additional policy and for this purpose explored different documents. One document is the working paper on Just Culture presented by IFATCA at ICAO’s 11th Air Navigation Conference held in autumn 2003 of which the recommendations, listed hereafter, were accepted by that Conference.

2.5.1.1

“Action by the Conference

1. The Conference is invited to task ICAO with developing guidelines promoting the concept of a “just” culture; i.e. a culture in which front line operators are not punished for actions or decisions that are commensurate with their experience and training, but also a culture in which violations and wilful destructive acts by front line operators or others are not tolerated.

2. The Conference is invited to task ICAO to ensure that judicial aspects are adequately addressed in ICAO guidance material on Safety Management Systems for ATS,

3. The Conference is invited to encourage ICAO Member States to:

a) review existing aviation laws with the aim to remove factors that could be deterrents to the collection and analysis of valuable safety-related information; and/or

b) develop legislation that adequately protects all persons involved in the reporting, collection and/or analysis of safety-related information in aviation.”

2.5.2 These recommendations, being subject of an earlier work item of PLC (WP168/2004), are covered by policy statements 2.2.1; 2.2.2 and 2.2.3 edited according 2.4 of this paper and reproduced hereafter:

2.2.1. Member Associations shall promote the creation of Air Safety Reporting Systems based on confidential reporting in a just culture among their service provider(s), Civil Aviation Administration(s), National Supervisory Authority(ies) and members.(Rio 88.C.8, amended Hong Kong 04.C.12).

2.2.2. IFATCA shall not encourage Member Associations to join Incident Reporting Systems unless provisions exist that adequately protect all persons involved in the reporting, collection and/or analysis of safety-related information in aviation (Acapulco 90.C.11, amended Hong Kong 04.C.12).

2.2.3 Any incident reporting system shall be based on the following principles:

a)  in accordance and in cooperation with pilots, air traffic controllers and Air Navigation Service Providers;

b)  the whole procedure shall be confidential, which shall be guaranteed by law;

c)  adequate protection for those involved, the provision of which be within the remit of an independent body (Acapulco 90.C.10, amended Hong Kong 04.C.12).

2.5.3 A second important document is the “Report on ATM Incident Reporting Culture: Impediments and Practices” produced by the SAFREP, Safety Data Reporting and Data Flow Task Force. This task force was installed by the Director General of EUROCONTROL and IFATCA was represented by its President and Chair PLC.

2.5.3.1  The task force produced 12 recommendations that were adopted by the Permanent Commission of EUROCONTROL. These are reproduced in Appendix 2.

2.5.3.2  PLC noticed 2 additional items that are not completely covered by IFATCA policies. Being the collection of safety related information and the dissemination of this information.

2.5.3.3  It speaks for itself that certain rules and/or principles should be applied in the collection and dissemination processes. The SAFREP task force supported the confidentiality in the collection and dissemination of safety related data and formulated strong arguments in favour of de-identification of safety related data both in the collection and dissemination phase. IFATCA, as part of the task force, had a leading role in this.

2.5.3.4  IFATCA policy states that:” The whole procedure shall be confidential, which shall be guaranteed by law,” and “adequate protection of those involved” when referring to the incident reporting system.

2.5.3.5  Therefore PLC suggests to amend that policy to state:” Any incident reporting system, including the collection, storage and dissemination of safety related data, shall be based on the following principles:”

2.5.4 For completeness PLC reviewed the latest release of ICAO Annex 13 on Accident & Incident Investigation, effective 23 November 2006. Non-disclosure of records now show under 5.12 e) recordings and transcription of recordings from air traffic control units.

Conclusions

3.1  To put the correct weight on the Just Culture Philosophy, a reassemble of the Accident/Incident pages of the IFATCA Manual is needed.

3.2  Adding subtitles to the different policy statements improves the readability of the document.

3.3  PLC proposes to delete the statement referring to CISM as this topic is covered by IFATCA policy.

Recommendations

Note that this paper is not proposing new Policy. It rather proposes an editorial re-arranging of existing Policy in the Manual. Therefore a paragraph by paragraph approval by Conference is not needed.

4.1 That appendix 1 to this paper be accepted as policy.

References

WP151 – Ottawa, 1994.

WP168 – Hong Kong, 2004.

IFATCA’s ANC 11 working paper 92, The Need For A Just Culture in ATM Management.

EUROCONTROL SAFREP Report, 2005.

ICAO Annex 13, release 23/11/2006.

Appendix 1 – Recommended Policy – IFATCA Manual, pages 4421 and further

2. Accident and Incident Investigation

2.1. Just Culture, Trust and Mutual Respect

A Just Culture in Accident and Incident Investigation is defined as follows:

“A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”

2.1.1.  Member Associations shall promote the creation of Air Safety Reporting Systems based on confidential reporting in a just culture among their service provider(s), Civil Aviation Administration(s), National Supervisory Authority(ies) and members.(Rio 88.C.8, amended Hong Kong 04.C.12).

2.1.2.  IFATCA shall not encourage Member Associations to join Incident Reporting Systems unless provisions exist that adequately protect all persons involved in the reporting, collection and/or analysis of safety-related information in aviation (Acapulco 90.C.11, amended Hong Kong 04.C.12).

2.1.3.  Any incident reporting system, including the collection, storage and dissemination of safety related data, shall be based on the following principles:

a)  in accordance and in cooperation with pilots, air traffic controllers and Air Navigation Service Providers;

b)  the whole procedure shall be confidential, which shall be guaranteed by law;

c)  adequate protection for those involved, the provision of which be within the remit of an independent body (Acapulco 90.C.10, amended Hong Kong 04.C.12).

2.1.4.  Air Navigation Service Providers and their respective employee groups shall develop mechanisms that foster an environment of trust and mutual respect in order to improve the capability to compile, assess and disseminate safety-related information with each other, as well as with other national and international aviation organizations (Hong Kong 04.C.11).

2.2. Exemption from Duty

2.2.1.  When an accident or incident is alleged to have occurred where the actions of an Air Traffic Controller may have had a bearing, the Controller shall have the right to be exempted from control duties until he is physically and psychologically fit again. The removal is without prejudice, and is non-disciplinary (Nairobi 87.C.9, amended Acapulco 90.C.9).

2.2.2.  A Controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an incident/accident (Acapulco 90.C.9).

2.3. Right of Representation

2.3.1.  The Controller has the right to be accompanied by a representative of his choice at any hearing, inquiry or investigation into any Air Traffic Control incident or accident (Nairobi 87.C.12).

2.3.2.  The Controller should make no written statements without the advice of a legal representative of his choice, even at pre-investigation board stages (Acapulco 90.C.9).

2.3.3.  The circumstances prompting the investigation, and the perceived operational situation immediately prior to the alleged incident/accident, shall be made available to the Controller and his representative prior to any questions being put to the Controller (Nairobi 87.C.14).

2.3.4.  When an Investigation Board is convened, it shall be confidential and non- disciplinary in nature. The Board should be comprised of individuals who have operational experience in Air Traffic Control.

2.3.5.  The Controller and his representative have the right to make representations and direct questions to the officials in charge of the investigation (Nairobi 87.C.15).

2.3.6.  The Controller and his representative have the right, prior to appearing before any investigative Board, to review all relevant video and audio recordings and computer readouts of Air Traffic Control operations where available. In addition, the Controller and his representative shall be provided with copies of transcripts of all relevant audio recordings prior to appearing before any Investigative Board (Nairobi 87.C.13).

2.4. Protection of Identity

2.4.1. Protection of the identity(ies) of ATM staff involved in incidents or accidents shall be guaranteed (Melbourne 05.C.9).

2.5. Reference Card

2.5.1. Member Associations should provide their members with a card containing the basic rights they have and the rules that will be applied in case of incident/accident investigations (Acapulco 90.C.7).

2.6. Use of Recorded data

2.6.1.  Audio, visual and area recordings, together with associated computer data and transcripts of air traffic control communications are intended to provide a record of such communications for use in the monitoring of air traffic control operations, and the investigation of incidents and accidents. Such recordings are confidential and are not permitted to be released to the public. Such recordings are not to be used to provide direct evidence such as in disciplinary cases, or to be used to determine controller incompetence (Nairobi 87.C.17, amended Taipei 97.C.11).

2.6.2.  Except for area recordings, recorded data shall only be used in the following cases:

a) when investigating ATC related accidents and incidents;

b) for search and rescue purposes;

c) for training and review purposes provided all ATCOs affected agree;

d) for the purposes of adjusting and repairing ATC equipment.

(Bournemouth 92.C.13, amended Ottawa 94.C.22)

2.6.3.  Area recordings shall only be used for accident investigation purposes (Ottawa 94.C.24).

2.6.4.  An area recording may generally be defined as any type of recording, audio and/or visual, instituted in an air traffic control operations room that records accurately the conversation of controllers and the environment within an air traffic control operations room on a continuous basis (Ottawa 94.C.23).

2.6.5.  Access to recorded data shall be limited to authorised personnel for the purposes listed in 2.6.2 above. Authorised personnel shall be mutually agreed by the controllers’ representative and the appropriate authority (Bournemouth 92.C.14).

2.6.6.  Recorded data used shall be identical as presented to and/or originated by the controller at the relevant controller’s position (Bournemouth 92.C.15).

2.6.7.  IFATCA is opposed to the use of Visual Area recordings for reasons of invasion of privacy (Ottawa 94.C.25).

2.6.8.  Prior to the installation of Area recorders, legislation shall be in place which prohibits the use of any area recorder information against a controller in any criminal or civil litigation or disciplinary proceedings of any kind. The legislation should provide for substantial penalties for any breach of the legislation (Ottawa 94.C.26).

2.6.9.  Except when an accident occurs, area recordings shall be capable of being erased when a controller is relieved from his position. Controllers shall have prompt confirmation of the erasure. Agreement between the Member Association and the employer on procedures for the erasure of area recordings shall be established prior to the operation of area recorders (Ottawa 94.C.27).


Attachment A – IFATCA Policy on Accident and Incident Investigation

 

MARCH 1992

Amended 2004 and 2006

 

Introduction

The International Federation of Air Traffic Controllers’ Association (IFATCA) lists among its objectives –

“to promote safety, efficiency and regularity in International Air Navigation”.

The basic purpose of any investigative process is to determine what happened, why it happened, and what can be done to prevent a recurrence. The investigative process can be more successful if air traffic controllers are protected from any discipline or legal liability flowing from an investigative process. They are less likely to practice wilfully or otherwise their implicit right to remain silent, if the investigation is confidential and non-punitive.

The International Civil Aviation Organization (ICAO), in Annex 13 to the Chicago Convention, states that

“the sole objective of the investigation of an accident or incident shall be the prevention of accidents or incidents. It is not the purpose of this activity to apportion blame or liability.”

In support this philosophy IFATCA has produced policy on Accident/Incident Investigation in order that air traffic controllers can contribute fully to an investigation. It is necessary to gather all relevant facts that led up to the incident/accident in order that we can continue to use this knowledge to improve the safety of the air traffic control system.

1 Just Culture, Trust and Mutual Respect

IFATCA Policy is that:

“A Just Culture in Accident and Incident Investigation is defined as follows: “A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”

Member Associations shall promote the creation of Air Safety Reporting Systems based on confidential reporting in a just culture among their service provider(s), Civil Aviation Administration(s), National Supervisory Authority(ies) and members.

IFATCA shall not encourage Member Associations to join Incident Reporting Systems unless provisions exist that adequately protect all persons involved in the reporting, collection and/or analysis of safety-related information in aviation.

Any incident reporting system, including the collection, storage and dissemination of safety related data, shall be based on the following principles:

a)  in accordance and in cooperation with pilots, air traffic controllers and Air Navigation Service Providers;

b)  the whole procedure shall be confidential, which shall be guaranteed by law;

c)  adequate protection for those involved, the provision of which be within the remit of an independent body.

Air Navigation Service Providers and their respective employee groups shall develop mechanisms that foster an environment of trust and mutual respect in order to improve the capability to compile, assess and disseminate safety-related information with each other, as well as with other national and international aviation organizations.”

The aviation industry has accepted that humans cannot be changed but nonetheless are required to make the system work safely. The legal world holds the view that the system is inherently safe and that the humans are the main threat to that safety. Safety improvements in the aviation system will be achieved as a result of an open exchange of information. Human error cannot be avoided by “designing it out of the system” or disciplining operators. Error is a normal component of human performance. This fact must be incorporated into the design, implementation and operation of complex systems where safety is the expected outcome. Air traffic management (ATM) systems are a prime example of such a complex system.

IFATCA proposes that all incident reporting schemes should contain the following principles and criteria:

1. Mutual Trust,

2. Openness of communication,

3. A demonstration of care and concern,

4. A commitment to organisational learning

5. A transparent management commitment to safety,

6. An accountable and open system of information flow, i.e. Staff → Management ATM → Staff.

Specifically, the “Incident Reporting System” must give the possibility to report in confidence rather than anonymously and provide some level of protection/immunity for the controller who is reporting deficiencies or anomalies. There should also be some level of guarantee for a fair hearing and an objective and impartial investigation that any such information given is not used for punitive or enforcement purposes. Reliable and documented follow-up should be provided with a detailed database available to all involved parties.

The Member Associations of IFATCA should play, where necessary, an important role in the process of creating the correct legal framework enabling a “just culture” in Safety Reporting.

2 Exemption from Duty

IFATCA Policy is that:

“When an accident or incident is alleged to have occurred, where the actions of an Air Traffic Controller may have had a bearing, the Controller shall have the right to be exempted from control duties until he is physically and psychologically fit again. The removal is without prejudice, and is non-disciplinary.”

In case of an accident or traumatic incident/event, it is recommended that immediate psychological or medical advice be sought for all parties involved. The time required to obtain this advice and the subsequent return to duty of the controller should be considered part of the investigation for the purpose of protecting the pay and employment benefits of the parties involved. It is not always possible for a controller to assess his own state of mind after a traumatic situation such as an accident/incident. Therefore, it is recommended that the controller take at least the remainder of the shift to “collect” himself. A psychologist or medical professional can be of use in helping one determine a suitable time to return to duty.

“A controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an accident/incident.”

The controller shall not be required to take any type of leave, e.g. sick leave, vacation leave, or any form of leave without pay to cover his absence from work as a result of being exempted from control duties when involved in an accident/incident. A controller may not be able to return to duty during the course of the investigations, which may at times be lengthy. It is not fair then to expect him to take any form of financial or other penalty while he awaits the outcome of the investigation.

3 Right of Representation

IFATCA Policy is that:

“The controller has the right to be accompanied by a representative of his choice at any hearing, inquiry or investigation into any air traffic control incident or accident.”

The controller can be accompanied by an employee or Association representative. He should also have the right to be represented by legal counsel. The choice is his. Justice must be seen to have been served; therefore, the controller should be able to determine who would best serve his interests in the investigation.

“The controller should make no written statements without the advice of a legal representative of his choice, even at pre-investigation board stages.”

It is not mandatory that a controller obtain advice from a legal representative prior to making written statements. In the case of an incident a controller should obtain advice from a representative (employee, Association, legal). In the case of an accident it is strongly recommended that the controller obtain legal advice. To keep track of the facts during a confusing time immediately after the incident/accident, it is often prudent to make some personal notes of the facts as he remembers them. These personal notes should not be made after he has had a lot of time to reflect on what happened. Notes should be made while the facts have not been coloured by rationalization or interpretation. Caution is suggested when making these notes. In some Member Association countries these personal notes may be admissible as evidence. Therefore, a preface should be included in the notes which state that they are for use of legal counsel only and that they are not an admission of guilt and that the controller reserves the right to change them as more facts become available to the controller.

“The circumstances prompting the investigation, and the perceived operational situation immediately prior to the alleged incident/accident, shall be made available to the controller and his representative prior to any questions being put to the controller.”

The controller and his representative should be granted a reasonable amount of time to peruse this information. The controller should obtain the information dealing with the circumstances prompting the investigation prior to answering any questions. This will allow the controller and his representative to only respond to questions that deal with the alleged incident/accident. This would also ensure time to review what happened in order to arrive at complete and relevant answers to aid the investigation.

“When an Investigation Board is convened, it shall be confidential and non- disciplinary in nature. The Board should be comprised of individuals who have operational experience in air traffic control.”

An Investigation Board is convened, in the case of an incident, to determine if a loss of separation or dangerous situation occurred and if so, what the cause was. Their findings are to be utilized to prevent such a situation occurring in the future. Accurate findings can only be made if all the information is available. Information will be made available when the Board is confidential and non-disciplinary.

If ATC matters are being investigated then it is only logical that the investigators have operational experience in ATC. The facts must not be confused. It is also recommended that another controller, preferably from the same area of responsibility, be on the Investigation Board to ensure impartiality, and to act as an expert advisor on questions that explore practices that may be unique to the facility or sector where the incident allegedly occurred. The same would apply in an accident where the possibility exists of ATC involvement.

“The Controller and his representative have the right to make representations and direct questions to the officials in charge of the investigation.”

One of the objectives of an Investigation Board is to determine all the facts. This can be accomplished by allowing the controller and his representative to make representations and direct questions to members of the Board. This would allow for the opportunity to clear up any misunderstandings or misinterpretations of questions asked. It would also aid in obtaining full cooperation in achieving the common goal – prevention of a similar occurrence.

“The controller and his representative should use the Human Factor checklist in the appendix to this policy to make sure that all Human Factor aspects that might have had an impact on the occurrence being investigated are identified and taken into account.”

See appendix hereafter. This checklist is based on the SHEL Model.

“The controller and his representative have the right, prior to appearing before any investigative Board, to review all relevant audio, visual and area recordings, also any computer readouts of air traffic control operations pertaining to this investigation. In addition, the controller and his representative shall be provided with copies of transcripts of all relevant audio recordings prior to appearing before any investigative Board.”

[…] exempted from control duties until he is physically and psychologically fit again. The removal is without prejudice, and is non-disciplinary.”

In case of an accident or traumatic incident/event, it is recommended that immediate psychological or medical advice be sought for all parties involved. The time required to obtain this advice and the subsequent return to duty of the controller should be considered part of the investigation for the purpose of protecting the pay and employment benefits of the parties involved. It is not always possible for a controller to assess his own state of mind after a traumatic situation such as an accident/incident. Therefore, it is recommended that the controller take at least the remainder of the shift to “collect” himself. A psychologist or medical professional can be of use in helping one determine a suitable time to return to duty.

“A controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an accident/incident.”

The controller shall not be required to take any type of leave, e.g. sick leave, vacation leave, or any form of leave without pay to cover his absence from work as a result of being exempted from control duties when involved in an accident/incident. A controller may not be able to return to duty during the course of the investigations, which may at times be lengthy. It is not fair then to expect him to take any form of financial or other penalty while he awaits the outcome of the investigation.

4 Protection of Identity

IFATCA Policy is that:

“Protection of the identity(ies) of ATM staff involved in incidents or accidents shall be guaranteed.”

The disclosure of personal information details, i.e.: names and addresses of individuals associated/involved with a serious ATC incident or accident have had tragic results for air traffic controllers.

Employers and Service Providers must take firm steps to establish and enforce appropriate legislation that would ensure that identities of air traffic controllers and other ATM staff involved in serious accidents/incidents remains privileged and protected.

5 Reference Card

IFATCA Policy is that:

“Member Associations should provide their members with a card containing the basic rights they have and the rules that will be applied in case of accident / incident investigation”.

This would educate the members as to their rights/responsibilities, and the steps to follow to protect these rights. This also puts members at ease by ensuring them that no steps in the process were forgotten and that there is a procedure or plan in place to protect and guide them through what can be a traumatic experience they have little knowledge of.

6 Use of recorded data

IFATCA Policy is that:

“Audio, visual and area recordings, together with associated computer data and transcripts of air traffic control communications are intended to provide a record of such communications for use in the monitoring air traffic control operations and the investigation of incidents and accidents. Such recordings are confidential, are not permitted to be released to the public. Such recordings are not to be used to provide direct evidence in disciplinary cases, or to be used to determine controller incompetence.”

Air traffic control recordings are intended to provide a record for the investigation of accidents/incidents and to provide protection for controllers. The protection of these recordings is essential to establishing a credible Accident/Incident Investigation Process.

“Except for area recordings, recorded data shall only be used in the following cases:

a)  when investigating ATC related accidents and incidents;

b)  for search and rescue purposes;

c)  for training and review purposes provided all ATCO5 affected agree;

d)  for the purposes of adjusting and repairing ATC equipment.”

It is recognised that recorded data can be used for more purposes than just the investigation of incidents and accidents.

In connection to SAR its use may be instrumental to determine the last known position of an aircraft.

In relation to ATC training its use is highly effective to allow students to see and/or hear a replay of a traffic situation they handled earlier. In this case prior agreement from all affected ATCOs should be sought, for reasons of courtesy and privacy protection.

Furthermore, there are no objections against the use of recorded data (including computer readouts) by technicians who are adjusting and/or repairing ATC equipment.

“Area recordings shall only be used for accident investigation purposes. An area recording may generally be defined as any type of recording, audio and/or visual, instituted in an air traffic control operations room that records accurately the conversation of controllers and the environment within an air traffic control operations room on a continuous basis.

Access to recorded data shall be limited to authorised personnel for the purposes listed above. Authorised personnel shall be mutually agreed by the Controllers’ representative and the appropriate authority.”

Since there may be differences of opinion as to whom has access to recorded data, it is believed there should be mutual agreement between the Controllers’ representative and the Authorities on what personnel is authorised to use the data. It should be noted that in some countries national legislation may have a bearing on this topic as well.

“Recorded data used shall be identical as presented to and/or originated by the Controller at the relevant controller’s position.”

If recorded data is to be used to reconstruct what happened in a given situation, it is of paramount importance that what is recorded (and replayed) is an exact replica of what was presented to and/or originated by the Controller at his working position. Any omissions or additions in the recording will make a correct reconstruction impossible, and are therefore unacceptable.

“IFATCA is opposed to the use of Visual Area recordings for reasons of invasion of privacy.

Prior to the installation of Area recorders, legislation shall be in place which prohibits the use of any area recorder information against a controller in any criminal or civil litigation or disciplinary proceedings of any kind. The legislation should provide for substantial penalties for any breach of the legislation.

Except when an accident occurs, area recordings shall be capable of being erased when a controller is relieved from his position. Controllers shall have prompt confirmation of the erasure. Agreement between the Member Association and the employer on procedures for the erasure of area recordings shall be established prior to the operation of area recorders.”

7 Summary

In summary, this policy allows for an effective Accident/Incident Investigation Process which will promote aviation safety and efficiency. It provides protection for a controller who has to appear before an Investigation Board which allows him to fully participate in the investigation process. A “just culture” investigative process ensures full disclosure which is conducive to making the correct changes to the system and thus ensuring and improving its safety.

Note: the appendix “CHECKLIST BASED ON THE SHEL MODEL” remains unchanged.


Annex 2 – SAFREP Recommendations

CHAPTER 6 – Recommendations

Just culture is a culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.

The SAFREP Task Force recommends:

1. States to:

a) adopt within their national safety framework, international regulations and requirements for ATM safety data reporting and assessment, taking due account of the need to ensure also compliance with EC Directive 42/2003;

b) adapt their national legal and institutional framework, where required, so that the needs of safety and reporting in the industry are balanced with those of society in general; to this effect, modifications to the domestic legislation may be required to, as far as possible:

i. prevent the misuse of safety information in civil litigations;

ii. ensure appropriate protection against sanctions as a result of submitted safety information;

iii. offer solutions for appropriate protection against penal law proceedings as a result of access to safety information; and

iv. provide protection against inappropriate public disclosure of the submitted safety information; in order to establish a culture that is “just” to all concerned.

2. Creation of awareness of best practices for States, Regulators and ANSPs on incident reporting systems by:

a) the President of the EUROCONTROL Permanent Commission writing to ECAC States, seeking support to remove national judicial impediments to incident reporting;

b) starting an awareness campaign with States to target aviation professionals as well as the media, legislators and judicial experts at both European and National levels to promote the understanding of the importance of a “just culture” for aviation safety. This should facilitate States to open and/or further strengthen communication between the aviation sector and the judicial authorities to reconcile the view on “just culture” and with the media to address the issue of public disclosure and misuse of safety information;

c) EUROCONTROL in coordination with the European Community exploring SES legislation as a potential vehicle to facilitate and promote “just culture”.

3. States to enforce the safety oversight function at national level where required by allocating adequate resources for State NSAs.

4. ANSPs senior management to ensure their commitment on safety and allocation of resources to safety management in general and in particular on safety occurrence reporting and assessment processes. Financial constraints and capacity pressures should not be used to the detriment of safety.

5. Development and establishment of:

a) appropriate guidance material for States to elaborate, and implement at national level, a legal framework supporting the establishment of a “just culture” in ATM;

b) a process for the support of individual States and groups of States, for the implementation, at national level of a legal and institutional framework supporting the establishment of a “just culture” in ATM, where requested;

c) a plan, with clear milestones and reporting deadlines to report regularly to the Provisional Council, regarding the progress of the implementation at domestic level of a legal and institutional framework supporting the establishment of a “just culture” in ATM.

6. Continued encouragement and support for the exchange of voluntary incident and safety risk information, for the purpose of disseminating and sharing safety data and corresponding lessons learned to the widest professional audience by:

a) using the recently agreed CESC policy for risk information sharing between ANSPs and EUROCONTROL as a basis for further intensifying lesson dissemination and identification of any potential urgent mitigation that need to be put in place;

b) using the process for Safety Alerts to ensure a fast and effective follow-up by all parties involved, including ANSPs, regulators and any other interested party when required;

c) enhancing data collection and analysis by including ATM information from airlines’ data repositories such as STEADES.

7. To bring rationalisation in European ATM safety data collation and analysis by:

a) the establishment of a fully coordinated ATM safety information repository through enhancing the EC’s ECCAIRS aviation wide system with the data collected through the current SRC data flow. Merging the current mandatory incident databases into one European ATM repository compatible with ECCAIRS is a long term objective which should now be explored.

b) ensuring that the SRU/SRC as well as the Agency develop the analytical ATM safety expert capabilities for risk analysis, trends and lessons learnt in their respective areas of safety regulation and safety management.

8. The EUROCONTROL Organisation to continue to actively support and cooperate with the relevant ICAO bodies in the implementation of Assembly Resolution A35-17, taking into account the findings and recommendations of this report.

9. The PRC/PRU, SRC/SRU, Agency, States’ Safety Regulators and ANSPs to cooperate further in the development of European Safety KPIs for reporting European ATM Safety levels to the aviation community.

10. The safety roles and responsibilities with respect to the various elements on incident reporting and assessment of the PRU/PRC, SRU/SRC and the Agency as outlined in the Appendix 9 of the SAFREP TF report be accepted.

11. The above recommendations be incorporated into the European Safety Programme and progress of implementation be regularly reported to the Provisional Council.

12.That SAFREP Task Force be put in abeyance and invited by the Provisional Council to consider safety KPIs at an appropriate juncture as that work matures.

Last Update: September 29, 2020  

June 9, 2020   392   Jean-Francois Lepage    2007    

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