IFATCA The Controller - March 2007

THE

CONTROLLER March 2007

Journal of Air Traffic Control

4 BRAZILIAN COLLISION SPECIAL

Also in this issue:

4 Interview Prof. S. Dekker

INTER-

TION OF AIR TRAFF ERA IC C FED

LLERS’ ASSNS. TRO ON

4 Legal issues

NATIO NAL

4 CISM

First ATC Support Tools Implementation Programme

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How inappropriate phraseology can contribute to incidents and accidents

Analysis of current and future data link applications, including CPDLC, ADS and D-FIS.

ATC Team resource Management & Safety Mechanisms associated with ATC errors and strategies to identify and manage the consequences in an operational environment.

Reduced Vertical Separation Minimum (RVSM) For en-route controllers handling aircraft above FL 280.

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Air Traffic Flow and Capacity management * Overview of ATFCM and how to cope with future challenges, as the management of ATC capacity becomes more important.

Satellite Navigation In depth view of GNSS, the associated navigation principles, weaknesses and benefits for civil aviation. *In partnership with Eurocontrol

Visit: www.iata.org/training/ans_safety

Contents

THE

March 2007 1st quarter 2007 volume 47 ISSN 0010-8073

CONTROLLER THE

CONTROLLER March 2007

Journal of Air Traffic Control

4 BRAZILIAN COLLISION SPECIAL

Photos: Also in this issue:

INTER-

TION OF AIR TRAFF ERA IC C FED

LLERS’ ASSNS. TRO ON

4 Legal issues

NATIO NAL

4 CISM 4 Interview Prof. S. Dekker

Legacy jet: Embraer B737 Gol: Andres Contador Radar picture: C. Gilgen Label: VEJA

PUBLISHER IFATCA, International Federation of Air Traffic Controllers’ Associations.

EXECUTIVE BOARD OF IFATCA Marc Baumgartner President and Chief Executive Officer Dr Gabriela Logatto Deputy President Cedric Murrell Executive Vice President Americas Albert Taylor Executive Vice-President Africa/ Middle East David K W Cheung Executive Vice-President Asia/Pacific Patrik Peters Executive Vice-President Europe Dale Wright Executive Vice-President Finance Doug Churchill Executive Vice-President Professional Dave Grace Executive Vice-President Technical Jack van Delft Secretary/Conference Executive EDITOR-IN-CHIEF Philippe Domogala Editorial address:Westerwaldstrasse 9 D 56337 ARZBACH, Germany Tel: +492603 8682 email: ed@ifatca.org Residence: 24 Rue Hector Berlioz F 17100 LES GONDS, France CORPORATE AFFAIRS Kevin Salter (Germany/UK) CONTRIBUTING EDITORS Web site: Philip Marien (EGATS) Chris Stock (UK)

In this issue:

Foreword by Doug Churchill …………………………………………… 4 Editorial by Philippe Domogala ………………………………………… 5 Brazil Collision 1 Special Feature ………………………………………...… 6 NTSB News Standards for Safety the Language Barrier ..………………… 7 Brazil Collision 2 The Accident Description by the IFATCA Team

by Christoph Gilgen …………………….……………………..… 8 Brazil Collision 3 The Collision as Reported by the Media in Brazil

by Philippe Domogala ………..……………………………… 10 Brazil Collision 4 IFATCA Provides CISM to Brazilian Colleagues

by Christoph Gilgen ……….....………………………………… 12 Brazil Collision 5 Brazilian ATC in Turmoil by Christoph Gilgen ………….……… 14 Brazil Collision 6 The Collision as Lived by the Brazilian Controllers

by Wellington Rodrigues ………….…………………………… 16 Brazil Collision 7 Transponder: What Role did the Transponder play in this Collision? by Christoph Gilgen …..….……………… 18 Brazil Collision 8 Gol Flight 1907 ..……………………………………….……… 21 Brazil Collision 9 What can IFATCA learn from the Brazil Experience?

by Marc Baumgartner ..……....……………………………… 22 CISM 1 Managing the “Other” Stress by Doug Churchill ….…...………… 24 CISM 2 Explaining how CISM works by Philippe Domogala ……...……… 26 Just Culture “Legally speaking” by Doug Churchill .………….…………… 27 Interview with Sidney Dekker by Marc Baumgartner .…………….……… 28 Book Review Critical Incident Stress Management in Aviation

by Joerg Leonhardt and Joachim Vogt .………….………… 29 Legal Issues ATC: One Foot in Court? by Helena Sjöström .…………… 30 Interview with Gerard Forlin by Patrik Peters ……………….….……… 31 European Affairs European Regional Meeting Sofia, Bulgaria

by Raf Vigorita .….………….…………………………… 32 Europe 1 Europe Tunes 8.33 KHZ above FL 195

by Wolfgang Scheidl .…..….……………………………… 33 Europe 2 The Day of the Controller Poster in Italy ………… 33 Spotlight by Kevin Salter …………………………..………… 34 News Controller in South Africa ……………..………… 36 News 17th Ama Regional Meeting by El Kadur Acosta.. 36 Asia Controllers – The Unsung Heroes of Aviation

by Capt. Elmo Jayawardene ……….…… 37 Charlie‘s Column ………………… 38

REGIONAL EDITORS Moetapele D. Matale (Botswana) Al-Kadur Acosta (Dominican Republic) Phil Parker (Hong Kong) Patrik Peters (Europe) COPY EDITORS Helena Sjöström, Stephen Broadbent and Brent Cash PRINTING-LAYOUT LITHO ART GmbH & Co. Druckvorlagen KG Friesenheimer Straße 6a D 68169 MANNHEIM, Germany Tel: +49 3 22 59 10 email: info@lithoart-ma.de

DISCLAIMER: The rules, recommendations and information contained in this document reflects what IFATCA established at time of the last amendment. Although every effort has been made to ensure accuracy, neither the International Federation of Air Traffic Controllers Associations (IFATCA), or their Members or Officers or representatives, shall be responsible for loss or damage caused by errors, omissions, misprints or misinterpretations of the contents hereof. Furthermore IFATCA expressly disclaim all and any liability to any person whether a purchaser of this publication or not, in respect of anything done or omitted, by any such person in reliance on the contents of this publication. COPYRIGHT. The materials herein are copyright IFATCA. No part of this document may be reproduced, recast, reformatted or transmitted in any forms by any means, electronic and mechanical, including photocopying, recording or any information storage and retrieval system, without the prior written permission from IFATCA. VISIT THE IFATCA WEB SITES: www.ifatca.org and www.the-controller.net

Foreword

Ph o to :D

Foreword from the Executive Board C

The “Professional” Pie This edition of The Controller magazine has been dedicated primarily to issues of a Professional nature. When we think of professional topics as they relate to us in the air traffic control world, more than likely some “time-honoured“ issues will come immediately to mind: working conditions, industrial relations, hours-of-work, medical requirements, human factors and critical incident stress management among others.

I mention these particular ones because they form the backbone of much of our professional policy and will continue to do so into the future. However important, they are merely pieces of the professional pie. Section Four of the IFATCA Manual lists five principle categories relating to professional policy: Working Conditions, Medical Matters, ATC Training, Legal Matters and Collection and Dissemination of Information on Professional Matters.

Consider these the “crusts” of the pie because within them lies the filling - the meat - the best and most important part!

On the occasion of this special professional edition of the magazine, I though it

New Controller Layout: You have all noticed a new format and a new layout of the magazine.

^

by Doug Churchill, EVP Professional IFATCA

appropriate to provide an “in a nutshell” Management. By far, issues in the Workaccount of what we in the professional ing Conditions category have demanded domain have been up to over the precedthe most time and effort, with 21 items ing twelve months. You will read of some requiring some degree of IFATCA profesof our activities in this edition, but there sional attention. Many times we are able to are many more. If we look back to the five address concerns by way of direct corremain professional categories in the Manspondence through the Executive Board, ual, we see they are further broken down i.e.: letter, telephone call or e-mail, but into twenty-two sub-groups containing there are times when nothing but direct a total of some eighty individual subject face-to-face contact is required. We are items. The distribution of topics within the very fortunate to have within the Profesgroups is : Working Conditions - 32 items; sional domain representatives who act on Medical Matters - 10 items; Training - 25 our behalf throughout the year attending items; Legal Matters - 12 and Collection meetings, submitting working papers/ & Dissemination of Information - 1 item reports and expressing the IFATCA view (IHB). Of these 80 different subjects, we to the wider audience. have been active in addressing nearly 50% We are grateful to our representatives of of them within the past 12 to 15 months the Airport Ops Team, Aerodrome Panel, or so. They include: Single Person OperaHuman Performance Focus Group, HRT, tions, Four Eyes Principle, Performance Inour Human Factors Specialist and Single dicators, Social and Labour Aspects, ManEuropean Sky & Social Dialogue “experts”. agement/Controller Relationships, Working They contribute greatly to our success.

Environments, ATC Systems, Automation Human Factors, ATC and Public Relations, Of the remaining four categories, none Short Term Conflict Alert - Human Factors, had more than six issues where our involveDuty Rosters, Work and Rest Scheme, Exment was needed or requested. Six topics tra Duty, Remuneration, Language Issue, are the subject of Committee C working Retirement and Pension, Extended duty, papers at Conference 2007 in Istanbul, furLoss of Licence, Regulatory Framework in ther illustrating our continued involvement ATM, Normal Operations Safety Survey with, and influence in, a very good cross(NOSS), Safety Management Systems, section of our professional domain. ^ Stress & Stress Management, Fatigue in ATC, We are very fortunate to have within the Substance Professional domain representatives who abuse in ATC act on our behalf throughout the year and Critical Incident Stress

LITHO ART DRUCKEREI LÄUFER PLAKAT-DRUCK MANNHEIM DIGITALDRUCK MANNHEIM

www.beste-druckqualitaet.de

We have changed printer and design firm and the magazine is now produced in Mannheim, Germany, by the same firm that also produces “der flugleiter”, the German MA magazine. The lady in charge of the layout is Melanie Fliess, and she brings a refreshing look into the Controller magazine.

4

Editoriall

Editorial About mid-air collisions ^

by Philippe Domogala, Editor Photo: DP

This issue is a special about the recent Brazilian collision and CISM. You will also find some legal issues covered and an interview with Professor Sidney Dekker, the very famous aviation human factor specialist.

This issue is an attempt to record and document what happened but also, and probably foremost, to act as an educative process for us all. What can we learn from events such as this, and how can we better prepare ourselves for the next one?

We should not hide our heads in the sand, accidents and collisions are likely to occur at a more frequent rate that what we have been used to in the past. Simple mathematics if one takes into account the tremendous increase in air travel and current aircraft orders (Boeing and Airbus have between them over 2000 new aircraft orders this past year alone and I do not include the other 1000 or so regional, business jets, and the new tendency for the future: pocket jets) All of these, or nearly all of these, will fly IFR and therefore add constraints to our ATC systems. Some naively thought that technology such as TCAS or CDTIs (cockpit display of surrounding traffic) using ADS-B will take care of the last minute anti-collision resort.

But as this collision in Brazil showed us: a transponder, a small piece of 1950’s technology, can fail (or be disconnected) and

This is not doomsday, this is wake up day I would say …

Photo: then all this “last minute collision avoidance high tech” no longer works.

Aircraft can today continue to fly for days in the busiest class A airspace and major airport TMAs, with a defective or inoperative TCAS. Failure in TCAS is not a no-go item. This is not doomsday, this is wake-up day, I would say….

One of the roles of IFATCA and this magazine in particular, is perhaps to act as an alarm clock for this wake up call. It is after all our business, because it is we controllers, who ultimately and generally will win the “legal first prize” distributed by the judges a few years later. Just culture is important there and there is also an article about this in this issue.

How to deal with the posttraumatic effects of such an accident for the controllers involved is another important issue. We have CISM and now we have IFATCA-

READER’S LETTERS to the Editor

delivered -CISM. All of this is explained in this issue as well.

In my archives, is an article that I wrote in 1981 for the Controller, after a factfinding visit to Brazil. It is striking to see, that 25 years later, in fact not many things have changed with regard to the controllers’ situation.

For those interested, this 1981 article is available on our web site: www.the-controller.net I used to end my editorials by saying “Enjoy this issue” or “Happy reading” but this time that is not appropriate. “Be very, very careful” is probably more accurate.

ed@ifatca.org

Reference the collision between a glider and a Business jet reported in your last Editorial (Dec 06) , although the NTSB report said the glider was an ASW27, it was in fact an ASG29, the very last 18m model from Schleicher, a brand new aircraft.

Jean-Luc Gassmann , Controller Geneva ACC Photo: Alexander Schleicher/M. Münch

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4 Brazil Collision

Brazil Collision Special Feature

The views expressed in the following articles are those of the authors, and not necessarily IFATCA‘s official position.

What really happened on 29 September 2006 over the Amazon?

How come, on a beautiful sunny day, could two brand new aircraft equipped with the latest technology and under surveillance of a relatively modern radar ATC system (or so we were told) collide in 2006 like they would have in the 1950’s?

Why are the controllers and the pilots involved almost always suffering from the media frenzy looking for someone to blame?

How can IFATCA help the controllers involved?

In the next 18 pages, you will find some attempts to answers those questions.

Photo: Embraer

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4 Brazil Collision

Accident Preliminary Report ^

On November 22, 2006. The NTSB issued a PRELIMINARY REPORT (called UPDATE) on the accident:

The September 29, 2006, midair collision over the Amazon jungle between a Boeing 737-800 (PR-GTD) and an Embraer Legacy 600 business jet (N600XL).

The accident occurred at 4:57 Brasilia standard time. The Boeing 737 was destroyed, all 154 occupants died. The Legacy sustained damage to its left wing and left horizontal stabilizer and performed an emergency landing at Cachimbo Air Base, approximately 60 miles NW of the collision site.

Both aircraft were operating IFR but in VMC Conditions. The B737 was a scheduled domestic flight from Manaus to Brasilia. The Legacy was from, San Jose dos Campos, to Manaus, and eventually continuing to the U.S. This was a delivery flight from the Embraer factory.

The Legacy N600XL departed SBSJ at 2:51.

The filed flight plan included a routing via OREN to POCOS, then UW2 to Brasilia VOR (BRS), UZ6 to Manaus. The cruise altitude filed was FL370, with a planned change to FL360 at BRS, and to FL380 at TERES, 282 miles north of BRS. After takeoff, N600XL was issued a number of interim altitudes. The flight was cleared to proceed direct to ARAXA VOR (on UW2), and at 3:11 was cleared to climb to FL370. At 3:33, the airplane leveled at FL370.

The B737 departed at 3:35, requesting FL370 as a cruise altitude, and a routing via UZ6 to BRS. The airplane reached FL370 at 3:58.

There were no anomalies in communications or radar surveillance of the Boeing 737 throughout the flight.

At 3:51, a controller from Brasilia ACC instructed N600XL to change frequencies to the next sector. N600XL crew reported in on the assigned frequency level at FL370. ATC acknowledged and instructed the crew to ”squawk ident“ Recording show the ident was observed. This was the last two-way communication between N600XL and ATC. At this time the airplane was approximately 40 nautical miles south of BRS.

At 3:56 the Legacy passed BRS at FL370.

There is no record of a request from N600XL to the control agencies to conduct a change of altitude, after reaching flight level 370. The airplane made calls, but no communication in which it requested a change of FL. There is also no record of any instruction from Brasilia Center to the aircraft, directing a change of altitude.

When the airplane was 30 NM NW of BRS, at 4:02, the transponder of N600XL was no longer being received by ATC radar.

Between 3:51 and 4:26, there were no attempts to establish radio communications from either the crew of N600XL or ATC. At 4:26 Brasilia ACC made a „blind call“ to N600XL. Subsequently until 4:53, the controller made 6 additional radio calls attempting to establish contact. The 4:53 call instructed the crew to change to frequencies 123.32 or 126.45. No replies were received.

There is no indication that the crew of N600XL performed any abnormal maneuvers during the flight. Flight Data Recorder information indicates that the airplane was level at FL370, on course along UZ6, and at a steady speed, until the collision. Primary (non-transponder) radar returns were received corresponding to the estimated position of N600XL until about 4:30. For 2 minutes, no returns were received, then returns reappeared until 4:38.

After that time, radar returns were sporadic.

Wreckage and damage examination indicates that it is likely the left winglet of the Legacy (which includes a metal spar) contacted the left wing leading edge of the Boeing 737.

The impact resulted in damage to a major portion of the left wing structure and lower skin, ultimately rendering the 737 uncontrollable. Flight recorder information ceased at an approximate altitude of 7,887 feet.

After the collision, the crew of N600XL made numerous further calls to ATC declaring an emergency and their intent to make a landing at the Cachimbo air base. At 5:02 pm, the transponder returns from N600XL were received by ATC. At 5:13 pm, an uninvolved flight crew assisted in relaying communications between N600XL and ATC until the airplane established communication with Cachimbo tower.

The Investigator in Charge estimates a 10-month timeline for the investigation. ^

Beginning at 4:48, the crew of N600XL made a series of 12 radio calls to ATC attempting to make contact. At 4:53, the crew heard the call instructing them to change frequencies, but the pilot did not understand all of the digits, and requested a repeat. No reply from ATC was received. The pilot made 7 more attempts to establish contact. At 4:56:54 the collision occurred at FL370, at a point about 460 NM NW of BRS, on UZ6.

There was no indication of any TCAS alert on board either airplane, no evidence of precollision visual acquisition by any flight crew member on either aircraft, and no evidence of evasive action by either crew.

Photo: FAB

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4 Brazil Collision

The Accident Description by the IFATCA Team

Photo: CG

^

by Christoph Gilgen SKYCONTROL (Swiss ATCA)

Whenever an accident occurs, in particular involving two controlled flights, controllers ask themselves many questions such as: How could two aircraft be at the same altitude and at the same location in a rather remote geographical spot and in a sector that has a relatively low traffic density?

When the IFATCA team arrived in Brasilia, in October 2006, the members started to observe the control sectors. The more we talked to the controllers of the Brasilia ACC, the clearer our view became. The triggering event was without a shadow of doubt the loss of the Mode A and C returns of the Legacy jet, shortly after its passage over Brasilia VOR. This failure occurred at 19.02 UTC at of roughly 25 NM North of Brasilia. The Legacy, was established at FL 370 on the UZ6 airway to Manaus.

In order to understand the subsequent events, it is necessary to explain the configuration of the ATC ground system and the software in place at Brasilia ACC. The ACC software in Brasilia is designed in such a way that controllers have two levels (or altitudes) indicated on their radar labels:

Figure 1:

Figure 1: Normal radar label at Brasilia ACC

Normal radar label at Brasilia ACC In the middle-line of the label are the altitude indications and to the left is the first 390, is the transponder Mode C altitude. The second 390, on the right-hand side shows the system altitude, or ”ATC altitude”. In Brasilia ACC this is most strangely not the cleared level, but the flight plan level (FPL) of the aircraft. It is a mix between an entry level (e.g. from an adjacent unit or sector), the cleared level of the flight, and finally the “flight plan level” that is displayed to the controllers. The controllers have the ability to change this level if they clear an aircraft to a different flight level (controller input). There are some oc-

casions, however when the ATC-system automatically updates and changes this level. For example, if the aircraft passes a waypoint where the FPL in question requires a level change. This was exactly the accident scenario when, due to a change of airway direction, the flight had to change according to the FPL from an odd to an even level. This automatic level change in the system happens without any direct controller input.

Additionally, this automatic change is not shown in any prominent warning colour or special feature, just the “normal colour and fonts”. It is, therefore, rather difficult to see immediately that the ATC-system has changed something. Most ACCs and modern ATC-systems in the world have only one level shown to the controllers working the system (except the Mode C indication) and this is the so-called “cleared FL”, most of the time referred to as “CFL”. This information is very relevant as it is the guarantee that the controllers, the ATM-system on ground, and the crews in the air are working with the same levels and possess the same information.

For the Brasilia ACC, this particular software operation does not normally cause a problem when all runs well, and when Mode C is received by the system. The automatic level changes of the system are sooner or later caught up by the controllers when they scan the flights and detect the discrepancy between the left- and right-hand levels in the aircraft label.

On the 29th of September 2006, however, the situation did not end as described above. As the Legacy continued to be cleared and fly at FL 370 and passed the Brasilia VOR, the automatic level change feature was activated. From this moment, the radar label of the Legacy now showed two different levels, albeit for a short while: FL 370 (Mode C) to the left and FL 360 (system level) to the right as the Legacy’s FPLlevel. Unfortunately the Legacy transponder disappeared at 19.02Z. It appears that the normal “mitigation” of such a discrepancy, however, did not work this time, and from then on

An airborne failure started a fatal chain of events that couldn’t be stopped by a badly designed and weak ATC-system THE

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4 Brazil Collision

Photo: CG

there was a difference of 1000 feet between the level shown by the ATC-system and the aircraft’s actual and cleared flight level.

Due to the loss of the transponder reply, another unusual feature of the Brasilia ACC radar system was activated: the unit’s military primary radar. This is a special radar that specialists call “3-D”. It is not only able to show the geographical position of a blip as all primary radars do (range and azimuth), but has a special feature that permits a calculation of the altitude of the targets. The height detection is based on the measurement of the angle of elevation of the target. This, however, is a rather imprecise process and, as for the azimuth detection, the further the target is away from the radar site the more inaccurate the result will be. Radar specialists have indicated that variations and errors of 4000, or even 5000 feet, at a range of 200 NM from the radar site, are normal.

Shortly after 19.02Z when the Brasilia ACC stopped receiving the Legacy’s SSR-transponder replies, the Brasilia military 3-D radar took over. Based on what we were shown, the call-sign correlation was only lost for a few seconds as a valid primary track was displayed shortly afterwards with full correlation of the call-sign (based on the SSR-track that was previously there). There are, in fact, only two small differences that can be noted on the Legacy’s track indicating that the radar returns of the Legacy are only detected by primary radar. Firstly, the symbol of the radar blip is no longer a + surrounded by a o, but only a +. This symbol (+) indicates to the Brasilia ACC controllers that this is a primary radar blip only.

The following changes in altitude indication then occurred to the Legacy target. Where the Mode C should be shown (to the left) a calculated primary radar altitude is now displayed (the 3-D indication). Next to it, to the right, the erroneous FPL altitude of the label remains the same, at FL360. Between the two numbers, however, there is now a Z shown, meaning Mode C report missing.

Under normal circumstances with a SSR-track present there would be a = (which would mean “maintaining level”). The rest of the label continued to be shown to the control-

lers with the same colour scheme and the same fonts. One of the major problems, also very confusing, is that at several stages of the tracking of N600XL (without SSR-replies) the calculated primary 3-D altitude displayed by the system to the controllers indicated exactly 360. This would indicate, therefore, no discrepancy to the ATM-system FPL-altitude shown to the right of the label.

Figure 2: Reconstructed radar picture (time shown is local) Shortly after the picture was taken, around 19.10 a change of controllers took place at the ACC and a new controller took over. We are still almost 45 minutes before the collision and the Legacy flight is about 40 miles North of Brasilia. It is still established at FL 370, but shown on the labels at FL 360. There was now a period of about 20 minutes where no communication, or attempts to communicate, took place between ATC and the Legacy. The intermediate accident report (see page 7) indicates that as from 19.26 ATC tried to contact N600XL numerous times.

From 19.48 the Legacy crew had also started to make various attempts to contact ATC. There are strong indications that the Legacy was at that moment at the limits, or even outside the VHF-coverage of Brasilia-ACC. At the boundary between Manaus ACC and the ACC-Brasilia both Centres were aware that the Boeing 737-800 of Gol-Airlines was approaching the Legacy-jet in the opposite direction. According to the indications of their ATC-system, however, and the exchanged estimates of the flights a vertical separation of 1000 feet existed. IFATCA team‘s observation indicated that for the controllers of both Aera Control Centres the losses of two-way communication and the bad intermittent radar returns are “normal and frequent occurrences”. We were told that all the operators working the relevant sectors were apparently aware of these difficulties.

The two aircraft, both established on the centreline of Airway UZ 6, hit each other at FL 370 at 19.56.54 UTC in the airspace of Manaus ACC, just North of the line of jurisdiction with Brasilia ACC and close to the waypoint „NABOL“. ^

Figure 2: Reconstructed radar picture (time shown is local)

Photo: VEJA

There was now a difference of 1000 feet between the level shown by the ATC-system, and the aircraft’s actual and cleared flight level.

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The Collision as reported by the Brazilian Media ^

by Philippe Domogala, Editor

Photo: WR

The media [was] looking for and finding someone to blame for the accident

Photos: W.Rodrigues

It is always difficult after a catastrophic event such as this one for the media to remain silent and wait for the official reports to be released.

They want immediate answers. The Brazilian media, (at least the one that we know of, (and was available on line), reported the news like all media do in this situation: with sensationalism and drama –for effect- as well as looking for and finding someone to blame for the accident. We saw this approach clearly in another instance too - the Ueberlingen collision. At first, the focus to find someone to blame was on the Russian pilots, then a few days later it diverted to the controller, and finally concentrated on the Air Navigation Service Provider. (Skyguide in that case).

We are probably seeing a similar pattern here in Brazil. The first thing that the press reported almost immediately after the September collision, was the fact that the Legacy pilots may have voluntarily disconnected their transponder in order to perform some “manoeuvers or stunts” to test their new aircraft. This suggestion of reckless flying put the “blame” of the collision squarely on the two US pilots ...

These “stunts”, it was reported, were apparently documented by some “ radar pictures” showing the Legacy altitude varying from FL310 to 410.

Very soon afterward, when the Legacy Flight Data Recorder was analyzed in Canada, the media reported that the FDR apparently showed that the Legacy was steady at FL 370 the whole time it was under Brasilia ACC area control. (This was confirmed in the preliminary report issued on 22 Nov. (see page 7 of this issue)

There was very little information relating to or about the Gol B737 from either the media or the preliminary report from the National Transportation Safety Board ( see again page 7 )The media did report that the aircraft was normally in contact with CINDACTA-4 (i.e. Manaus ACC) both on R/T VHF and on radar but they continued to report in such a way that led one to believe that the whole cause of the collision lies with the Legacy and perhaps ATC, but not the Gol B737. Then, at the end of November media attention diverted to ATC and the controllers.

An article appeared in titled: “Don‘t Blame Us, But Blind Spots and the Americans, Say Brazil‘s Air Controllers“ In that article, published 22 November 2006, we learn that some controllers allegedly involved in the collision reported a “black hole“ in the interface area between Brasilia and Manaus ACC, exactly where the two aircraft collided. The article which quoted an unidentified lawyer, intimates that controllers were induced to error by defective equipment, and that the issue of a “black hole” or “blind zone” was an old problem that has been presented in the past to the Brazilian air authorities, and that controllers had already told the Air Force about it.

Then on 25 November a Brasília ACC controller gave an interview on Brazilian TV. (o Fantastico) / Globo TV. This controller, with more than 20 years of experience, apparently also confirmed the existence of a “ blind area” in the region where the collision occurred. The controller also alluded to “ flawed” radar and system failures.

Then, two days later on 28 November, we learned that the president of Brazil replaced

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4 Brazil Collision the chief of the country’s Air Traffic Management System. According to Brazil’s largest newspaper, O Globo, “The removal was one of the ways for alleviating the tense relationship between the Air Force and military and civilian controllers.” [...]

On 2 December, two ATCOs who controlled the Legacy in Brasilia ACC gave an interview to Brazil‘s weekly magazine Época.

Both men expressly mentioned a “blind zone” over the Amazon, along with faulty software and communication problems that day due to the fact that VHF transmitter antennas in the Amazon forest do not work properly due to interference.

On 10 December, the two Legacy pilots were back in the USA, and on 17 December they gave an interview to a newspaper in Sao Paulo. In that interview the pilots said the Legacy VHF was working very well at all times, as they could hear transmissions in Portuguese from Brasilia ACC. They indicated they did try to contact Brasilia about 30 times, but could not, and did not attempt contact on other frequencies. It was suggested in this article that the Legacy cockpit voice recorder showed dialogue between the two pilots that would indicate they knew the transponder

was off, but their answer was to the effect that everything was working well.

These articles show a progression of “blaming” that goes from the pilots who were first targeted as being at fault, (held in detention and then released back to the USA), to Air Traffic Control where public opinion then seemed to have shifted its focus, and then to the system itself after controllers have expressed themselves openly to the media and are blaming the system. The next step has yet to materialize.

What we may be witnessing here once again is a high-profile aviation event running a media gauntlet. Many people in many ways for many reasons say many things. The media has a responsibility to provide accurate, factual information to the public but it must also “sell papers”, so a word of caution is advisable.

Another episode of “trial by public opinion” is not what we want to see. We must be patient, un-biased and let the official accident investigation process run its course before reaching conclusions. Sadly, we have already learned the hard way how the mere hint of blame or shadow of doubt cast in a certain direction can have a devastating influence on people and their actions. ^

The Institute of Air Navigation Services (IANS), based in Luxembourg (Grand Duchy), is looking for (m/f) EUROCONTROL, the European Organisation for the Safety of Air Navigation, has as its primary objective the development of a seamless, pan-European air traffic management system that fully copes with the constant growth in air traffic, while maintaining a high level of safety, reducing costs and respecting the environment.

ATM INSTRUCTOR Safety Management and/or Safety Regulation (ref.: LX-2007-AT/027/CO - Closing date: 13.04.07) and

ATM INSTRUCTOR Human Resources (ref.: LX-2007-AT/028/CO - Closing date: 13.04.07) The Institute provides ATM Training for the ATM Service Providers and Regulatory Organisations of its 37 member states. We employ a team of highly professional instructors and provide state-of-the-art training in a multicultural environment.

The IANS ATM courses cover a wide variety of ATM areas, ranging from Airspace Management, Data Processing and Human Factors to Communication, Navigation and Surveillance. For the development and delivery of these courses, modern teaching methods and techniques are used.

The Institute is located in Luxembourg, one of the culturally richest and most diverse areas of Europe.

The selected candidates will be based in Luxembourg and be involved in all aspects of the ATM Training development and delivery.

We would be interested in hearing from you if you are an experienced ATM expert with an interest in training.

For further details on the positions, the candidate profile and the application forms, please consult EUROCONTROL’s website:

www.eurocontrol.int/jobs (click on the position you are interested in).

Closing dates are strictly applied.

The European Organisation for the Safety of Air Navigation.

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4 Brazil Collision

IFATCA provides CISM to Brazilian Colleagues Photo: CG

^

4 Christoph Gilgen

Within hours after the news was received, a first direct contact with the Brazilian MA was established.

4 Virgilio Belo

Photo: VB

by Christoph Gilgen SKYCONTROL (Swiss ATCA) Member IFATCA CISM Team to Brazil

The collision occurred on September 29, 2006, at exactly 17.56 Brasilia time After many hours of confusing and often contradictory news reports the completely destroyed Boeing could finally be located being widely scattered over a large field and almost completely hidden below the dense canopy of the tropical forest. This accident was the worst air-disaster in Brazil history. This explains why the emotional shockwave of the tragic loss of this aircraft and its occupants was so strongly felt throughout the largest South American country. The Brazilian aviation authorities, actually the Ministry of Defence who is responsible for civil and military aviation in Brazil, finally confirmed about 2 days later that a mid-air collision had occurred.

As always when the word “mid-air collision” is heard within IFATCA the whole-wide controller family starts to gather together and makes immediate preparations to help and support the colleagues and controller friends directly involved in this terrible tragedy. The Brazilian mid-air was in this respect no exception. Within hours of the news being received, a first direct contact with the Brazilian MA was established. It was a little bit more difficult to establish direct links with the association representing the military controllers immediatly involved in the ATC-sectors where the terrible collision occurred. But finally this was achieved and IFATCA was able to speak to the Executive Board of ABCTA (Associação Brasileira dos Controladores do Trafego Aereo). This association, founded in 2001, represents the majority of the military air traffic controllers of Brasilia ACC. It’s a fact that they are not yet fully affiliated to our Federation as some legal issues and problems must be solved beforehand. But this is only a question of weeks and, as our official Brazilian MA has always made clear that they desire that IFATCA comes in and tries to help the colleagues in need and distress.

Brasilia ACC, sometimes also called ACC-BS, and in Brazil and in Portuguese it’s named CINDACTA – 1 (Centro Integrado de Defesa Aérea e Controle do Tráfego Aéreo), is traffic-wise amongst the most busiest ACCs of the

world. It controls a large chunk of airspace that is about 6 times the size of France and more than 7 times as big as the territory of the United Kingdom. The ACC and the APP of Brasilia (collocated at the same site) are managed by the FAB (Força Aérea do Brasil) and the Aeronautica, which are both sub-divisions of the Ministry of Defence. They are controlling roughly about 70% of the Brazilian air traffic in three distinct control regions and sectors. These sectors, staffed by controllers having distinct ratings and validations are: the Rio de Janeiro sector, the São Paulo sector and the Northern sector, called “Brasilia sector”. It was in this latter, but already a little bit North of the line jurisdiction (transfer point) with Centro Amazônico, situated in Manaus, where the terrible collision on September 29, 2006 occurred.

Nevertheless it was at ACC-BS where the private Legacy jet was last in contact with ATC before the collision happened. This is also where several Air Traffic controllers were severely affected by the collision, suffering from emotional distress that such an event triggers on those directly involved into an aviation disaster. It became rapidly evident to IFATCA and the EB that the situation was very grave and that our Brazilian friends needed quickly help and support. This was why IFATCA started, in the early days of October, to plan and assess the means and possibilities we had of bring rapidly and efficiently support to Brazil. The initial needs were clearly identified by all: provide professional and technical help, and most of all bring in psychological and professional support to perform CISM (Critical Incident Stress Management) for the operators of Brasilia ACC, and maybe also at Manaus ACC (with whom the Boeing 738 was in contact at the moment it fell).

As language skills and excellent direct verbal communication with the persons involved was deemed to be a crucial factor for the success of this mission, IFATCA immediately decided to ask APCTA, our Portuguese MA, for support.

Most luckily this call for help was immediately accepted and two Portuguese operational staff were dispatched within days for a three-person IFATCA mission to Brazil. The Portuguese staff consisted of the CISM-specialist Dr Isabel

THE

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4 Brazil Collision 4 Brasilia City

Photo: Bruno Puliafito

Cambraia from Lisbon and the active Lisbon approach controller and part-time incident investigator of NAV-Portugal, Virgilio Belo. It was a very lucky coincidence that those two very highly qualified personalities could be readied on short notice and were able to join me for this emergency mission to Brazil. IFATCA and the Brazilian controllers are not only grateful to the two Portuguese controllers for their effort and support given, but also would like to acknowledge the Portuguese airline Air Portugal for having graciously provided two sponsored airfares to Brazil for Isabel and Virgilio. Muito obrigado!

Brazilian Air Force Chief. He expressed his gratitude and the FAB’s appreciation for the gesture of IFATCA to come in to Brazil and help and support the controllers and the FAB in this very grave and difficult moment. From then on a frank and very cooperative spirit reigned between the Brazilian Air Force and the IFATCA and we three delegates were granted free and unlimited access in the ACC-facilities of Brasilia (except the defence part).

During five consecutive days Isabel Cambraia performed dozens of CISM-sessions, either individually (for the more severe cases) or in group sessions according to the personal needs and the gravity of the situation. This work is very taxing, I would even say a very exhausting activity, and everybody that could see and observe Isabel performing her work was awed and stunned by the dedication and effort invested into the tasks. Isabel performed this vital task for several days without any interruption and these were very long days.

During the time Isabel performed her CISMsessions Virgilio Belo and I used the time available to speak to a lot of air traffic controllers in the ACC of Brasilia. Long sessions of observation at the control sectors were made and a lot of facts and points were observed and noted. It’s always very pleasing to see how controllers from different background and different culture are gathering and speaking about their work and the problems at hand and it was more than interesting to speak with the controllers at the sectors and more than one in the rest break rooms where informal gatherings occured. Of course the collision and the perceived problems of the ATC-system in Brazil were the main topics we have discussed.

The IFATCA delegation established through ABCTA contacts to the very high ranking military authorities of the Brazilian Air Force, the owners of the ACCs in Brasilia and Manaus.

A request for full access and a close cooperation was formulated by the Brazilian association on our behalf to perform our mission.

After a cautious first contact on the first day the sky cleared on the second day, on the 10th of October 2006, when I had the honour to be personally received and greeted by the

There is a full report about the technical and operational circumstances or as it is commonly referred to as the “chain events” that led to the terrible and mid-air of September 29, 2006 is described in this special edition of the Controller. To my Brazilian friends we would like to say ”thanks a lot” for your friendship and your warm reception and may we meet again soon in better times and join together forces and to dissimulate the lesson learnt within IFATCA! ^

Photo: IC

On request of the Executive Board of IFATCA I joined my two Portuguese team members and I left home on the 8th of October 2006 bound for Brazil. Our mission was to assess the local situation there and to provide CISM and technical and operational support to the Brazilian controllers friends. Upon arrival in Brazil the gravity of the situation became immediately evident to us: 9 ACC controllers (a whole sector team) had been taken off the control roster and were requiring urgent psychological support by professionals.

Moreover, the whole working shift (of the two remaining CINDATCA-1 sectors), present and witness to the tragedy were also deeply shocked and needed as well close monitoring and psychological attention. In general the whole Brasilia ACC staff was clearly in need of intensive CISM-care as the support offered by the Brazilian Air Force was not at all adapted and adequate for the degree of distress felt by the operators involved.

4 Isabel Cambraia

Isabel performed this vital [CISM] task for several days without any interruption and these were very long days.

THE

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4 Brazil Collision

Brazilian ATC in Turmoil

Photo: Flavio

Photo: CG

4 Passengers queuing in terminal

Brazilian controllers, in particular at the Brasilia ACC, started a work to rule action …

This resulted in huge disruptions.

^

by Christoph Gilgen, SKYCONTROL (Swiss ATCA)

After the accident the two American pilots of the Legacy jet had their passports confiscated

by Brazilian authorities. They were held in a hotel in Rio de Janeiro until the beginning of December when they were finally allowed to leave Brazil. Many international organizations, including IFATCA, pressured the Brazilian authorities to release them immediately after the accident and so to adhere to the “no blame” culture. Furthermore we pressed for a neutral and independent accident investigation so that all facts will come out and that a “lessons learned” process would start. Before the pilots were allowed to leave Brazilian soil, they were officially charged with “endangering of public safety”, and may face trial in the near future and risk a long imprisonment.

At the end of October, just before the prolonged weekend of “finados”, All Souls Day, the Brazilian controllers, in particular at the Brasilia ACC, started a work to rule action.

This action was called “normal operations“ by some or a full strike, depending on who you talked to in Brazil. The fact is that the Brazilian controllers, before the collision, controlled many more aircraft in their sectors than what was determined to be safe by the builders of their ATM-system. In Brasilia ACC the maximum number of aircraft a controller could have safely at the same time per sector is limited to fourteen. Before the accident, however, they were working many more than that. In order to get over the shock of the collision and to guarantee the safety of the

ATC operations, it was decided to adhere strictly to the official limit of 14 aircraft controlled at the same time. This resulted in huge disruptions as all the national airlines schedules fell out of planning. Sometimes the last flights of the day had to be cancelled and this resulted in hours, sometimes even days of delay.

The Brazilian military authorities overseeing the Air Traffic Management System of Brazil reacted as Military normally do, they gave orders and used military discipline to „control the problem“. They ordered the military controllers (all en-route controllers of Brazil still form part of the military) to report to the military quarters and they also cancelled all their leave. They restricted absences severely, even for a justified medical reason and we have seen evidence that they actually prohibited medical absences by ordering military doctors not to issue any sick leave certificates. They started to transfer into Brasilia ACC controllers from other Brazilian locations and let them work alone, at busy and complex ACC-sectors, after only 6 or 7 days of OJT-training.

The press then started to report more and more details of what was wrong with the Brazilian ATC system: miss-management, old equipment lacking sufficient redundancy, poorly trained controllers, many near-misses unreported or not investigated, insufficient staffing levels, low salaries and complete lack of planning. The ATC crisis started to have its own first victims: The chief of Brasilia ACC was replaced and the chief of the Civil Airspace entity DECEA had to leave as well.

THE

14

Guerra

CONTROLLER

4 Brazil Collision The political debate about the demilitarization of Brazil’s ATC system started to make the headlines of the newspapers and IFATCA became a very active player in the media to “discuss this option”. So far IFATCA had remained silent as it had only written to the President of Brazil, Lula da Silva, offering the help and expertise of the Federation to solve the problems of the national ATC-system, after the accident.

The IFATCA President gave a long interview to a Brazilian periodical where he criticized the fact that all of the ATM in Brazil is managed within the hands of the FAB (Brazilian Air Force) and the Aeronautica (Ministry of Defence). According to IFATCA it is essential that the regulator and the ATC-provision be clearly and functionally segregated. The accident and incident investigation body must also be independent. In Brazil this is currently all done under the Ministry of Defence and this is of serious concern to all.

The turmoil entered a new stage on November 21, 2006 when the Commander in Chief of the Brazilian Air Force, and so the Chief of Brazilian ATC declared in a meeting in the Brazilian congress that there had been an ATCcontrol error on September 29, 2006 (when the accident happened). He said that: “two air traffic controllers assumed erroneously that the jet was at FL 360 according to the computer flight plan. But in reality the jet was at FL 370 but I believe they were induced to the conclusions that the flight was at 360 in such a way that the controller passed it at hand-over at that level, and also Manaus was advised of that level. The controller believed that the aircraft was at FL 360. This was false information but he believed that it wasn’t wrong”.

This triggered a long and detailed IFATCA statement released on November 24, 2006 and where a logical accident scenario was described and where the Federation speaks of “non error tolerant system design” and of “system traps in the air and on the ground”. (See page 21 for a longer extract of the IFATCA Statement) This statement was very well received and many articles and blogs were written quoting IFATCA (including 2 articles in Flight International). Several television documentary companies have since contacted IFATCA to conduct interviews in order to contribute to their films. The echo is much less evident in Brazil where the press is still very much controlled by

Photo: Flavio Guerra

Military and so rather scared to make open attacks without having firm evidence. Things are changing quickly, however, and in early 2007 all leading ATC-figures of Brazil are expected to be retired from duty, or substituted.

The Brazilian ATC-system is not yet fully demilitarized but legal texts are currently under discussion in Brasilia, and the President has now a firm proposal in his office to study and decide upon. The military fraction of Brazil still resists this move, as they fear a loss of power and influence. Some structural changes are urgently needed to the Brazilian ATC-system and this appears to be accepted now by the vast majority. The remaining question is just how long the process will take and how far it will go? This depends largely on the decisions that are taken in the coming months, but the transfer to a civilian entity will probably be a rather longer process, lasting many years.

It is therefore more than likely that the Brazilian ATC system will be in a difficult situation for the coming three or four years, i.e. before the structural changes are having their positive effects. What the tragic collision between Gol Flight 1907 and N600XL has again clearly demonstrated is that, for a mid-air to occur, a chain of events is required, where long-standing problems may come to light.

They must align in such an unlucky way that, at the end, all layers of the ATM-system are crossed. This was similar to the Ueberlingen mid-air, that occurred in 2002, another collision that I had experienced firsthand as a Swiss controller. Comparing it today, in 2006, to the Amazon mid-air, it is simply amazing to note that despite many differences and other underlying factors, both collisions can be compared structurally and technically, as basically they are so much alike.

I think the Amazon mid-air has also seen a new IFATCA, growing and acting much more decisively than before. Despite the fact that it is certainly too early to draw quick conclusions, we must start to think how our Federation can contribute, if required.

We need to offer our help, experience and support more systematically to our controller colleagues who are facing such dramatic events and most probably are completely unprepared.

Our Federation should also be more active in press education and information and in offering our expertise to the accident investigation teams. IFATCA has a lot to offer in order that a wider audience gets a full understanding of what contributes to an ATM system and how it functions and, more importantly, to show why it failed at the end.

Unfortunately, seen the current traffic growth, similar accidents are likely to occur again.

We just don’t know when and where and we should get prepared to go in again and help if needed. ^

The Brazilian ATC-system is not yet fully demilitarized but legal texts are currently under discussion in Brasilia.

THE

CONTROLLER

15

4 Brazil Collision

The Collision as seen by the Brazilian Controllers ^

Photo: WR

We were suddenly called “strikers” and “mutineers” without somebody standing up and defending us

by Wellington Rodrigues President of ABCTA (Brazilian Controllers Association)

The 29th of September should have been a normal day, but it will be remembered, forever, in the life of thousands of people as the day of Brazil‘s worst air disaster.

Ironically, earlier that month, our association (ABCTA or Associação Brasileira dos Controladores de Tráfego Aéreo) issued in its bi-weekly internal publication a warning about the risk of a possible collision, but we could not have known that the nightmare of all Air Traffic Controllers would become reality a few days later.

“Where is the Gol?“ This sentence is what started the fears of the Brasília ACC controllers that day. Once the INCERFA phase had elapsed, the RCC-BR took over to start the search and rescue actions for flight GOL 1907.

The ACC of Manaus, called Amazônico Control, informed us that N600XL, a Legacy-jet, had made an emergency landing at Cachimbo Air Force base and that the pilot in command of that Legacy had said that they had „hit something“ in flight.

It was requested that another off duty controller team should be brought in to replace those that were controlling the flight, and it was also determined that psychological support was needed for those that were most affected. The controller team on duty was finally released in the very early hours of the 30th of September, but had to return the next morning to fill-out the official reports regarding the accident.

We gratefully accepted the technical and psychological support offered by IFATCA as we were totally lost within this completely unusual situation. Two weeks after the accident the IFATCA team with Christoph, Virgílio and Isabel (CISM) arrived.

The psychological support that was offered to the controllers beforehand was deficient: for example there was no particular attention given to those that continued to work the traffic as the management tried to pass the message that all was OK and that life had to continue. Isabel could see firsthand in what a bad psychological shape the Brazilian Air Traffic controllers were: loss of self-esteem, disillusion, fear, etc.

The situation got worse with time due to staff shortages. There were suddenly a high number of medical absences, in addition to

the unavailability of the whole controller team that was on duty on the day of the accident.

Sectors that were normally manned by a team of 12 controllers had now to be operated by a maximum of 6, and even sometimes the number went down to 4 controllers.

This brought a lot of confusion to the whole Brazilian ATC-system as the Brasilia ACC controls 75% of the national air traffic.

There were simply not enough controllers to meet the traffic demand and those that continued to work, completely disillusioned by the lack of recognition by their management, were encountering serious difficulties in performing their job without having to impose severe flow control restrictions.

We were suddenly called “strikers” and “mutineers” without somebody standing up and defending us. At this very moment ABCTA broke the silence and went public by defending the controllers and decided to tell the truth by explaining to the whole country the real situation of the Air Traffic Controllers in Brazil.

We never asked for anything, it was just a cry for help to the society and the Brazilian authorities. The posture adopted by ABCTA made many controllers start to believe that positive changes to the structure of the Brazilian Air Traffic Control system were possible.

In particular the end of the military career that could make a very old dream become true; that ATC in Brazil would become civilian.

The military high command took the actions of ABCTA as a rebellion and therefore put the President of ABCTA, the Director of Mobilization, and the President of FEBRACTA, (our Brazilian controllers federation) under official inquiry and threatened to fire them.

Another important factor in what was happening at that time in Brazil was the press frenzy surrounding the collision. As expected, they were in search of any information and keen to publish it. But what they did to the controllers that were directly involved in the accident was very ruthless and made us deeply upset, as there were pictures taken without permission, stories of their private life told in a very sensational manner and worse even, some media declared them guilty without allowing the accused to defend themselves. There were only a few journalists really interested in investigating

THE

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4 Brazil Collision curred in the Brasilia ACC (a system made by SITTI of Italy) which created the worst traffic collapse in the history of Brazil.

On top of the physical and psychological stress that we went through, we were suddenly now also called „equipment saboteurs“. We asked our management to issue an official denial of the alleged controller sabotage, and it was later found out that human error by a technician responsible for that equipment led to the failure.

After the first storms had passed, we went through many days uncertain as to what would happen to the Brazilian Air Traffic Control system, and most importantly, as to the future of our friends that were involved in the tragedy of flight 1907.

“Where is the Gol?“

Photo: CG

and publishing the real facts.

In the middle of the Air Traffic Control System crisis the system started to show its deficiencies through various system failures that occurred. There was a failure of the radar visualization, followed by an outage of radio frequencies and also the computer software.

A big storm in Southern Brazil cut an optical cable of CINDATCA-2 (ACC-CW) disabling all frequencies of the Curitiba ACC. In addition, only one week later, a lightning strike in Campo Grande incapacitated a busy sector of the same ACC. Finally, on December 5th, 2006 a major communication failure oc-

For ABCTA this will be remembered as a big and hard lesson of how to manage a major crisis that hit us unexpectedly. We will also keep a never ending gratitude to our European friends that crossed the Atlantic to help us, and continued to support us from far away, so that we can keep on fighting as strong and focused as possible.

Thanks a lot to the big IFATCA family, and we look forward to becoming part of you very soon! ^

4 A Brasilia ACC Sector

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17

4 Brazil Collision 4 Legacy 600 cockpit

Which role did the transponder play in this collision?

Photo: Embraer

^

by Christoph Gilgen, Skycontrol (Swiss ATCA)

At the end of 2003 and the start of 2004 the Swiss Air Navigation Service Provider, Skyguide, noted an emergence of many lost SSR-tracks and aircraft radar replies that disappeared for several minutes. One particularly worrying case was an Embraer E-145 of a major European carrier, that, after a Mode A change, remained invisible for more than 45 minutes before it was identified as an “unknown target” by French military control and the first steps of intercepting the target were initiated. The worrying fact was that this aircraft flew for a prolonged period through busy sectors and airspace without being un-

der positive control and provided with the required degree of safety .

After a long and tedious inquiry by the technical and operational departments of Skyguide the problem was tracked down to a particular transponder type. A PRIMUS transponder was identified to have a software problem that lead to a complete switch-off in flight and therefore also of the TCAS. In a safety message published by Eurocontrol on the 13th of April 2004 it was written that: If the flight crew take longer than 5 seconds to complete a Mode A code change, the transponder will revert to “Standby” mode. This will cause the track to be dropped by radars, and the TCAS II on board the aircraft will fail”

If the flight crew take longer than 5 seconds to complete a Mode A code change, the transponder will revert to “Standby” mode. This will cause the track to be dropped by radars, and the TCAS II on board the aircraft will fail” (Eurocontrol safety bulletin) THE

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4 Brazil Collision Photo: Graf Consulting

Further it was written that the operational consequences are high with safety critical impact: • temporary loss of radar contact • degradation of the ACAS-safety net the aircraft‘s TCAS will fail” Authors comment: The word: “degradation” is used, but in reality the consequence is that the ACAS safety net is no longer there.

„Fixing“ the first PRIMUS problem After many controllers had persistently insisted on getting the problem fixed at the source, stiff warning letters were sent by IFALPA, IFATCA, the JAA, and the European National Supervisory Authorities to EASA (European Aircraft Safety Agency). EASA then took action and issued an AD (Airworthiness Directive) in August 2005 requiring to fix all transponder units affected within 9 months from the date of issuance (deadline May 2006).

What was rather worrying was that this directive was only applicable for all European registered aircraft and so airframes registered in other countries and continents were not affected by this requirement. It is true that several other States, such as Australia and New Zealand had issued similar requirements at a later stage, but the biggest State with the most aircraft affected, the United States (the FAA was the initial certifier of the transponder), only published a directive in October 2006 (less than one month after the Brazil mid-air). There remains, possibly, still many of those units flying with this “defect”. But that does not seem to be the case in this collision, as this particular Legacy’ transponder, was a newly manufactured unit with modifications.

Brazil: possibly a new PRIMUS problem?

But when sifting through the short intermediate accident report (see page 7) we see that the Brasilia-ACC failed to receive any SSR/ModeS transponder replies from the Legacy-jet for approximately the last 50 minutes of the flight

4 Legacy trans-

before the collision. We also know from the same intermediate report that there were no TCAS alarms displayed in either of the cockpits. This indicates that the transponder of N600XL, the Legacy jet, was most probably not operating when the collision occurred.

This also coincided with the ATC radar picture that the IFATCA delegation was able to view in Brazil in October 2006.

A Mode–S is a basic requirement for any TCAS-equipped aircraft. Each aircraft carrying TCAS II must have a functioning Mode-S transponder fitted as part of the TCAS system. This capability permits the sending and receiving of short data link messages and is essential in order to perform the required TCAS-TCAS co-ordinations (where evasive RA-manoeuvres are managed so that complementary RAs are emitted and displayed in the cockpit). Each TCAS unit with it‘s antennas fitted along the fuselage work in a similar way to a ground SSR-radar station. A short and coded active surveillance message is emitted on 1030 MHz in order to detect surrounding traffic. Replies are received on 1090 MHz. If there is an aircraft in the area that is not fitted with a transponder, or has it‘s transponder selected off or on stand-by, the system simply cannot detect the intruder, as no replies are received and therefore no TCAS warnings will be generated.

4 Legacy RMU with transponder on.

ACC-Brasilia didn’t receive any SSR/ModeS transponder replies from the Legacy-jet for the last 50 minutes before the collision.

To fly with the TCAS-unit off or on stand-by is at the very least worrying. It renders level 3 of conflict management (the anti-collision layer) almost completely ineffective, as not only TCAS is ineffective but also the safety nets on ground, such as STCA (Short Term Conflict Alert) are not able to function as designed.

This fact was known before and was widely discussed and commented, notably when the PRIMUS cases were discussed 2004 and 2005 in Europe. Although the phenomena were considered to be very worrying, the authorities thought, as the source of the problem was clearly identified, and “strong mitigation measures were put in place.” The ATM-system was deemed to have the required degree of safety and redundancy.

4 Legacy TCAS display with transponder on.

ponder on stand-by.

Photos: Graf Consulting

19

4 Brazil Collision

When the IFATCA delegation was in Brasilia in early October 2006, some 2 weeks after the collision, the theory of the UScrew having switched off their transponder was still widely debated by the press. It was also discussed at the top-level of the Brazilian Air Force as it‘s commanding officer made remarks to the IFATCA delegation along these lines. First doubts about the theory started to come when we saw the radar recordings and saw the wildly fluctuating altitude indications, but with a steady track flown by the Legacy jet. We started to get the utmost conviction that the aircraft was continuously flying at FL 370 as cleared by ATC. We thought from then on that it simply could not be possible that a professional crew would willingly switch off such an important piece of equipment.

In early November I had a crucial meeting somewhere in Europe where I met a person that had been in Brazil and wanted to talk to me about this midair collision. He asked to check and compare our notes and to show me something important.

I was shown by him how, with one unintentional key-stroke on the RMU (Radio Management Unit) of the avionics fitted on Embraer aircraft, it is possible to put the transponder on stand-by, and disable it.

Transponder loss was at the start of the fatal chain of events.

Photo: Graf consulting

How can a transponder be turned off or put on stand-by and so disable TCAS?

4 TCAS display showing TCAS off and transponder on stand-by on the RMU. This is compounded by the fact that the indications in the cockpit that the transponder is currently switched off or on stand-by (and as a consequence that TCAS is disabled) are extremely difficult to spot and are not indicated in the standard failure colours: • there is a small indication in yellow (just underneath the transponder code selected) saying STANDBY on the RMU (Radio Management Unit) • on the PFD (Primary Flight Display) to the left there is a message in white and small letters indicating TCAS OFF • on the right of the MFD (Multi Flight Display) the same message is repeated in small white colours (see above photo) • the Vertical Speed Indicator, also used to fly the vertical RA escape manoeuvres, continues to remain green, despite the fact that the TCAS is not functional.

What is even more worrying to me, is that back in 2005, when AD-2005-0021 was issued

by EASA it was written as note in European NOTAM backing issuance of the AD for transponders that “When this reversion to standby mode occurs, the ATC/TCAS standby mode is indicated on the RMU and Cockpit Displays (PFD/MFD), however these indications may not be apparent to pilots, especially during periods of high workload”.

Outlook Of course the fact that a transponder ceases to function or is disabled in flight (being either voluntarily or involuntarily) is not yet sufficient to explain a mid-air collision in itself.

It is “just a contributing factor” but may well

be the start of a chain of events. There must be more failures or underlying problems occurring simultaneously before this can actually become so critical that the worst must be feared, including a mid-air collision.

But we have now indications and hints that point to the fact that this transponder loss may very well have been at the start of the fatal chain of events. It is therefore urgent to eradicate this problem at the source, as this will reduce significantly the risk and the probability that a similar chain of events will be started again. This is not at all a defence for a weak or badly designed ATC-system on the ground, where a lot of decisive actions are needed as well, but those remedial actions must be undertaken in parallel.

For me , there are mainly two issues that need to be addressed with urgency by the regulators and by the transponder manufacturers: • the ability to disable the transponder in flight by one single key stroke is unacceptable • the indications that the transponder is off or stand-by are not visible enough (the visibility and warning must be improved significantly) Let us hope that this accident will finally bring the required strong and decisive actions by the stakeholders and regulators. The manufacturers might be restricted in this matter as they are currently under threat of several law-suits in US courts that allege their legal liability for this collision. But common sense should prevail. ^

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IFATCA Statement after the Collision Issued on 24 November 2006 (Extracts)

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Gol Flight 1907

IFATCA believes that Commander Bueno is not well informed and therefore is making incorrect, or only partially correct statements. Facts will show that the Air Traffic Management system in place in the airspace of Brasilia did not register nor correctly detect the true altitude of the American-registered aircraft. […]

IFATCA believes that operators in the air (the pilots), and on ground (the controllers), fell victim to unacceptable systems traps brought on by ‘non-error tolerant’, and ‘bad system design’ of air traffic control and flight equipment in use. We are confident that our statements concerning this equipment are accurate, and said equipment is responsible for starting the fatal chain of events of September 29, 2006, and therefore, contributed to the mid-air collision.

IFATCA urges Brazilian authorities not to engage in a ‘counterproductive’ blame game, but to invest their energies to the undertaking of immediate and decisive remedial actions to eliminate these dangerous safety ‘traps’. If swift action is not forthcoming, the probability of incidents or, a similar type second accident occurring remain high.

END OF STATEMENT

Observations and Areas of Concern (extracts) 1. The software of ACC Brasilia is badly designed in the opinion of IFATCA, and therefore is a major contributor to an unsafe and dangerous ATC system.

2. The Legacy needed to change from an odd level (FL 370) to an even level, being FL 360.

When passing over Brasilia VOR, the Brasilia ACC software did automatically change the coordinated altitude indication to 360 (from 370) on the aircraft label shown on the radar screen. However, the flight was still flying at FL 370 and was not cleared down by ATC to FL 360 as shown on the label.

3. Once a flight is “lost” by SSR in Brasilia ACC (i.e when the transponder shuts off, or goes to ‘stand-by’ mode) , the Brazilian military primary radar kicks in. It continues to show the’ lost’ flight almost immediately in a very similar way as before the failure.

4. A special feature of the Brasilia military radar is that it calculates altitudes (or flight levels) in a 3D-mode. And display this on the label, There is only a small Z between both 360 indicating the missing Mode C report, but this can be easily overseen and not noted.

5. To date IFATCA has not received a convincing explanation of why the software of ACC- Brasilia is tuned in such a strange way. We are also at a loss to understand why the very unreliable 3D-altitude calculations of military primary (3D radars) are shown to civilian controllers.

Final remarks IFATCA is of the opinion that this accident investigation must remain neutral and completely un-biased. The focus should be to bring to light all relevant facts and actions that have led to this terrible tragedy. We must permit the aviation system to learn from this accident and to correct the identified weaknesses in order to strengthen the ATM system.

IFATCA has concerns regarding some of the content appearing in the intermediate report published by the Centro de Prevenção e Investigação de Acidentes Aeronáuticos (CENIPA) We believe a certain ‘tone’ of language used and points mentioned in the intermediate report are not indicative of a neutral stance, and are an early indication of a certain view and position held by the accident investigation commission.

IFATCA urges the CENIPA and the Brazilian government to report neutrally and consistently, without any distortion, the relevant facts and factors that have led to this terrible accident. Full disclosure is paramount so that we may learn from this tragedy.

The Full statement is available on IFATCA web site at www.ifatca.org

6. The Embraer Legacy cockpit can be a dangerous trap for pilots. The Legacy with its Honeywell custom-built avionics panel can be a hazard in the air. To inadvertently switch off the safety-essential transponder (or to put it on stand-by) in this aircraft is very easy.

IFATCA believes that the pilots, and the controllers, fell victim to unacceptable systems traps brought on by ‘nonerror tolerant’, and ‘bad system design’ of both air traffic control and flight equipment in use

Photo: VEJA

The International Federation of Air Traffic Controllers’ Associations (IFATCA) has noted recent statements attributed to the Chief Commander of the Brazilian Air Force, and Commander of the Aeronautica Tenente-Brigaderio-do-Ar, Senor Luiz Carlos da Silva Bueno. IFATCA is surprised and disheartened to learn that statements to the effect that an air traffic controller from Brasilia ACC made an error when controlling the Legacy flight so that it collided with the Boeing 737-80 of GOL over the Amazon, were made in front of the Brazilian Congress.

Senor Bueno allegedly said that ‘the controller thought that the aircraft was at FL 360, which was erroneous information, but the air traffic controller believed this wrong information’.

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4 Brazil Collision

What can IFATCA learn from the Brazilian experience? ^

Photo: DP

by Marc Baumgartner, President & CEO on behalf of the Executive Board

On the 29th of September a mid-air collision occurred over Brazil. The Executive Board (EB) learned about this unfortunate accident on the 30th of September 2006. This is the second mid-air collision within four years, and we as an organization representing the controllers around the globe decided that we needed to respond. The EB discussed how best to react to this tragic fatal accident.

IFATCA has a Member Association in Brazil and we were able to contact them quite rapidly. Getting to the people concerned was a different story. Our Member Association declares 15 members, however in Brazil there are some 2900 air traffic controllers, most of them are military personnel. Previously IFATCA had tried to find ways of how all the ATCOs could join IFATCA. We had established contacts with the existing Federation of Air Traffic Controller Association of Brazil (FEBRACTA). This association was created in order to give all air traffic controllers (civil and military personnel) the opportunity to join IFATCA in the future. Once we had established the contacts, soon it became very clear, that due to the particular nature of providing ATC in Brazil some support in situ would be required.

With exceptional effort, within a limited timeframe of one week we were able to create, a team of three people capable and willing to give support to our colleagues in Brazil. IFATCA has never done this before. The challenge to create a team (a mental health professional for the Critical Incident Stress Management, a trained accident and incident investigator and an IFATCA ICAO Panel representative who had been involved in the internal Skyguide investigation board after Überlingen) was huge. The team had to be unhindered by unnecessary bureaucracy, knowledgeable with our policies and all this combined with a suf-

ficient level of experience. Within one week after the collision IFATCA had written mission orders, co-ordinated with the individuals and their employers, and our delegation was on its way to Brazil. This would not have been possible without a lot of personal sacrifice by the three individuals, big support from their national member associations, their employers and TAP (Air Portugal). During their visit we needed to consolidate our contacts and obtain feedback. For the EB, the concept of this „crisis intervention team“ was new and therefore a lot of creativity and flexibility was required.

The team acted very professionally and the feedback from the concerned controllers was great and continues to be very positive.

The Brazilian ATCOs were not prepared for such a tragic accident and the support the three individuals have given was outstanding. The EB would like to express its deepest gratitude to them.

After their return we entered a new phase.

What would we do with the debriefing of the team? The information gathered and the feedback received, showed clearly that there were new challenges we were to face, be it on the communication level or optimization of our support to our colleagues in Brazil.

The situation in Brazil was evolving fast and similarities of reactions with other accidents (like Ueberlingen for instance) were very striking. This was (and is) mainly driven by the press and can in general be broken down into three main phases. Theory on crisis communication lists describes this as: (1 Phase one – Consternation: Phase two – Further elaborations: Phase three – Accusation:

Within one week after the collision IFATCA had written mission orders, coordinated with the individuals and their employers, and our delegation was on its way to Brazil THE

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A. Casanova, Risk Symposium 2006, Skyguide

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IFATCA’s continuous support for the Member association in Brazil will be further strengthened once all Brazilian controllers finally become members of the Federation.

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Particularly in phase three, the similarities of reaction were very striking: first the focus of blame the pilots, then the individual ATCOs, then the system (Brazilian Air Force), and then the politicians. During all these phases, the press is omni-present and is asking for improvements in the system and provides the necessary external pressure so that they are implemented.

The next step in Brazil which can be envisaged by IFATCA, will be the start of the legal investigation once the final accident report is published. This will be (as we have seen in other aircraft accidents), a very challenging phase for the ATCOs involved. The EB has written to the Brazilian ATCOs in order they join forces with IFATCA so that we are able to give support as well during this phase.

the correct balance between giving real support (psychological, technical and professional) to the controllers, while keeping the doors open to the Federation to act as a respected stakeholder and interlocutor for Governments, other aviation stakeholder and press.

IFATCA decided to send a letter to the President of Brazil highlighting some of the system deficiencies our team was able to observe during their visit. The letter also addressed the urgent need for improvement of the safety of the traveling public and the economic means required to achieve these goals without delay.

IFATCA will have to carefully analyse this event with all the parties involved and decide if it can play a proactive role when things do go wrong and to give consideration to the experience used in Brazil. One of the main challenges we have learned from the practice so far is to find

IFATCA’s continuous support for the Member association in Brazil will be further strengthened once all Brazilian controllers finally become members of the Federation. ^

Crisis communication basic rules:

The press got hold of this letter, and as could be expected, the individual ATCOs started being accused by their superiors. After discussion within the EB, we decided to give support but to limit it to professional issues.

The reaction of the military authorities was very heavy-handed. The military personnel were placed in barracks and guarded whilst at work. In addition, people that had never worked in the units involved in the mid-air collision were forced to work there. This was clearly a reaction we did not expect to happen. From a professional point of view we thought these actions were completely unacceptable, and would increase the risks taken within the ATM system. The military reaction originated from the reduction of the number of flights handled by the sectors to the number that was actually foreseen at the design stage of the system. This inevitably led to huge delays at all Brazilian airports.

After a serious crisis, these are generally the questions, various players and actors (i.e.: ATC management, Airlines, Politicians, the media… etc.)

Phase one Consternation: The first phase is dealing with the facts.

What has happened? Any impact (collateral damage)? How many deaths? How many injured? Are they being treated?

Is there anything that should be feared? Has rescue been organized? Etc. Phase two Further elaborations: Anything new? One is aware of the facts, what happened and which impact the event had, now starts the research phase? How could something like this have happened? Have some security or safety measures not been dealt with correctly or failed? Could there be any actions to avoid this? Was everything in place to avoid such a situation?

This fact and the intermediate accident report made us go one step further – a new experience in IFATCA history. IFATCA published a statement with some detailed information on the system and its breakdown.

We gave up our natural reservations regarding ongoing accident investigation and took a big risk by publishing the statement. The outcome, however, was very positive as the press and other international organizations(2 were able to better understand how ATM works and what could lead to an accident when the ATM system breaks down.

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Phase three Accusation: Who is responsible? Which consequences will this have? Can somebody be fired or imprisoned? Press starts to judge rapidly and play more and more the role of the judicial system.

(2

common statement with FSF, CANSO, IATA, NBAA, IFALPA and IFATCA

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Managing the “Other” Stress ^

by Doug Churchill, EVP Professional IFATCA

For many years now IFATCA has been active in promoting to our Member Associations the importance of identifying and effectively dealing with stress in the workplace. Due to the dynamic nature of our occupation we have concentrated our efforts for the most part on “critical incidents” and critical incident stress management (CISM) programs and support services. We normally refer to a critical incident as one that has sufficient emotional power to cause an employee to experience a strong and sometimes overwhelming reaction, which could interfere with or hinder their ability to function either on the job or in every-day life.

It is an accepted fact in the medical community that stress is one of the major causes of all illnesses.

Photo : DP

To help guide us in dealing with this form of stress our professional/legal committee has developed policy recommending that… “professional critical incident stress support services should be made available to air traffic controllers involved in ATC incidents/accidents and/or other occurrences that can create critical stress reactions...” Familiar examples are an incident involving loss of life or serious injury, or a near collision between aircraft under the employee’s control.

Our IFATCA Manual includes a section outlining our suggested model for an effective CISM program that includes recommendations for the selection of CISM peers - volunteers trained to support controllers (confidentially) during times of stress and to facilitate referrals to other support services if needed. Working

safely and efficiently in a fast-paced and constantly changing environment day after day can lead controllers to believe they are invincible and could not fall prey to something that allows our normal way of thinking, feeling and acting to be adversely affected … until it happens! We then tend to internalize and not want to talk about these circumstances we find ourselves in.

By behaving this way we allow stress to accumulate, we become more vulnerable and risk shock to our psychological systems that can then result in ‘traumatic’ stress. The difference between so-called normal stress and traumatic stress is the degree of body chemical reaction to the trauma. An opportunity to express our innermost concerns, to re-connect with others and to learn of the potential impact critical incident stress can have on us can be found in interventions such as defusing and debriefings that are designed to encourage us to share our thoughts and feelings resulting from a shocking incident(s).

A peer support program supplemented by professionals can offer not only guidance and education, but a well-balanced strategy for recovery as well. Critical Incident Stress is the type that most readily pops to mind when we think of our work environment but there is another type of stress that we must also be aware of … “ every-day “ stress. We all know what every day stress is, and we all suffer from it at one time or another. It is nothing more than the physical, mental and emotional responses by our minds and bodies in dealing with life and its changes. If it is negative or “bad” stress it wears us down, leaving us feeling drained or burned out.

There is room however for some stress – positive or “good” stress spurs us on and keeps us sharp and alert. But let’s have a closer look at that ‘other’ stress. What is it exactly? How do we recognize it? What does it do to us?

First, I would like to introduce the term “burnout”; a well-worn, perhaps over-used term to describe a physical and/or mental condition we perceive ourselves to be experiencing as a consequence of long-term stress or frustration. Employees who suffer from stressinduced burnout tend to become cynical, indifferent and risk becoming ineffective on the job. They are in an emotional state characterized by an overwhelming and enduring

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4 CISM feeling of exhaustion and/or aggravation that develops gradually into the inability to function productively.

So how do we recognize the onset of stress?

It is not easy, but there are early warning signs that we should be on the lookout for - here are a few: Chronic fatigue (exhaustion, tiredness, physically run down); anger; cynicism; negativity; irritability; frequent headaches; gastrointestinal problems; weight loss or gain; sleeplessness; depression; feelings of helplessness and an increase in risk taking. There are others but these are more easily identifiable by the average person as reactions to highly stressful situations.

It is an accepted fact in the medical community that stress is one of the major causes of all illnesses. As we become more and more stressed, distractions, anxieties and negative thinking occupy our minds. Our concentration suffers, and focus narrows as our brain becomes overloaded. The more our brain is overloaded, the more our performance can suffer. The more our performance suffers, the more new distractions, difficulties, and anxieties flood in. Do we need more convincing for us to realize the need for stress management for air traffic controllers?

So, who if anyone is to blame for these stressdriven phenomena? Historically it has centered solely on the worker, but research has indicated that some causes of burnout may lie in economic trends, technology use and even management philosophy within organizations. Could it be that we are witnessing the demands of the “bottom-line” fuelled by global competition, enticing service providers to “cash in” their human assets for short-term productivity gains? An ugly thought, and a possibility, but in all fairness to our employers we cannot simply lay the blame at their feet and wait for them to eradicate stresses in our lives with one wave a magic wand.

As a group of professionals with a great deal of responsibility resting on our shoulders, and as individuals responsible for our own health and well being, we too must accept that we have a role to play in maintaining our most precious asset - our body - in good working order.

On the professional side of things within IFATCA we have adopted well-thought out policies for the betterment of our health with respect to our working environments (lighting and climate control), hours of work and rest including the effects of shift-work, the effect that medicines, drugs and alcohol have on us, fatigue management and so on. We

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suggest medical standards for controllers, and the identification of causes of stress and methods of prevention as suggested by the ILO Conclusions of 1979(1. We recognize that stress is an increasingly global phenomenon, affecting all categories of workers, all work places and all countries and we acknowledge that considerable levels of occupational stress reactions can and do occur among the air traffic controller population.

Our list of identified occupational stressors contains such items as: Demand (number of aircraft), Operating procedures, Working time(shift and night work), Working tools (limitations and reliability of equipment), Work environment (lighting, rest facilities), and Working organisation (relations with supervisors and colleagues, lack of control over work process, lack of management support).

The Federation recognises the importance of stress management for air traffic controllers and recommends that, at regular intervals, air traffic controllers be provided with up-to-date information on stress management techniques, and that comprehensive and confidential support services should be available at all times for air traffic controllers and their families.

All too often we go to the pub, blot it out and not talk to anyone about it! We fear we will be seen as weak.

If you are experiencing either work-related stress, or stress from outside influences you should seek out others to listen to you and help you find an appropriate solution. Help can come from many sources: your manager, employee representative, CISM counsellor, coworkers, family doctor, friends, HR department and employee assistance programs.

Stress is not a weakness - it can happen to anyone. We need to take all forms of stress seriously, identify its causes and formulate a plan to take control and deal with it. If we do not, our lives and perhaps those of others may be at risk. ^

We urge our Member Associations to bring to their administrations’ attention the stress inducing potential of their work environment in order that particular consideration is given to ensure that the work environment is as stress-free as possible.

We do not take these issues lightly. They are crucial to not only us but to the well-being of the entire system. So why then, is there so little emphasis on us as individuals to protect that most valuable of all assets? We know all too well the devastating consequences prolonged stress can have on our minds and bodies, not to mention the more immediate and serious results that could occur if we are working in an “incapacitated” state of mind and/or body! As employees we have a duty to take care of our health (and safety) not only in the workplace, but away from it as well. We must recognize if and when our personal stress becomes a problem and realize our responsibility to ourselves our families and our employers. If we worry about the symptoms we are experiencing and do nothing about them, we end up in a vicious cycle that makes matters worse.

Photo: DP

If you are experiencing [..] stress […] you should seek out others to listen to you and help you

Simply acknowledging that stress may be responsible for how we feel, is the first step to seeking help. Unfortunately many times our pride gets in the way and we refuse to talk about such personal issues as being “stressed out” due to the social stigma attached to it.

International Labour Organization Meeting of Experts on Problems Concerning Air Traffic Controllers, Geneva, 8-16 May 1979

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Explaining how CISM works A CISM Workshop in Aix en Provence 4 Jerome and Cedric of FATCOA

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Photo: DP

4 CISM speaker: Joerg Leonhardt

A CISM scheme has a return on investment over five years that exceed 400% Photo: DP

4 CISM speaker:

Report by Philippe Domogala, Editor

The new French association FATCOA organized in the Marseille ACC in South of France a CISM workshop, mainly to convince their employer to implement the scheme nationwide.

They invited two speakers, Joerg Leonhardt from the DFS, the leader in Europe in CISM training and author of a book on the subject, (see page 29 for a review of his book), and IFATCA President Marc Baumgartner, who explained the benefits of CISM both after Ueberlingen, and more recently in Brazil.

Emphasis was given to the fact that employers who introduce such a scheme benefit the most from their investment as controllers return to work and remain longer in their jobs after having experienced the trauma of an accident or severe incident. We learned that implementing a CISM scheme has a return on investment over five years, which exceed 400%. In fact, for European ATM, CISM was the second most cost-effective program after RVSM introduction. It is a mystery to many as to why so many states still are not implementing CISM. Currently less than half the European states have a real CISM program in place.

France has local initiatives, like in CDG airport in Paris, where local management has signed contracts with psychiatrist units in hospitals specializing in post accident trauma. But all CISM specialists including our two speakers, said that if medically specialized staff help in the process, they should only do so after the CISM so called “Peers“ have intervened. CISM Peers are controllers from the same unit, who are properly trained to intervene immediately after an incident or accident and understand the complexity of ATC and the various relations one has around ATC, something a professional psychiatrist can never do. This early “normalization” as they call it (i.e. returning

the controller into “normal” behavior) has to be done very quickly (i.e. within hours) and by people having the necessary ATC background.

They also need to be trusted and accepted by other fellow controllers. If this is done properly, over 90% of the controllers will return to work within three days. The obvious benefit is of course for the employer. (Another mystery is why an employer would want to risk loosing the 500.000 dollars it spent training a controller by denying them such a program.)

The controllers will not only be productive again much earlier, but by ensuring his or her well-being the controller is likely to continue to work for this employer a much longer time.

Marc said that after the Ueberlingen collision, there were 15 controllers in Skyguide, who left the OPS room as a direct or indirect consequence of the collision. Joerg said that untrained colleague support, although well meant, can be counter productive. The natural reaction to comfort someone after an incident or an accident is to deny it, or say it does not matter, and this generally make things worse.

Proper Peer selection and training is essential.

For France, the controllers / FATCOA position is that CISM is a national need that cannot be left to local initiatives, and it should be Peer based and not using only outside institutions.

The response of Philippe Bougnoux, the national CISM coordinator of the French DNSA, their employer, was disappointing. He said France was not yet ready to implement CISM fully and nationwide. He proposed a stepped approach where the first level would be to arrange psychological help support in every unit (similar to what Paris CDG has done) and a second level would be to look for a peer system, but only in some places. To extend it over the whole of mainland France, which has five ACCs and sixty main airports, and the French overseas airports and ACCs would be difficult.

It was a pity that after such good presentations, convincing arguments and debate, the French DNSA is still not recognizing the need and the urgency of CISM. The FATCOA controller Association said they will continue to fight for CISM implementation and intend their next step to press their views higher up in the French administration. ^

Marc Baumgartner

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4 Just Culture

Just Culture – “Legally Speaking” Almost four years have passed since IFATCA called upon the international aviation community to develop guidelines promoting the concept of a “just” culture.(1 To be successful, Member States of ICAO must take action to ensure that national judicial aspects are adequately addressed (through ICAO) with respect to their ATS Safety Management Systems. Specifically, we encouraged the review of existing national aviation laws that could deter the collection and analysis of valuable safety-related information, and have asked States to develop legislation protecting persons involved in that reporting.

Much has been written and debated among Service Providers, safety regulators/investigators and other international bodies concerning this “non-punitive” legislation. A major concern seems to be how to accomplish a just culture environment and achieve an effective Safety Management System (SMS), while incorporating an acceptable level of just culture within a non-punitive environment. We have come to realize the trend of apportioning blame following accidents, along with a threat of civil or criminal proceedings has a damaging effect on the flow of essential information.

That accidents could be prevented and aviation safety enhanced if front-line operators are protected from punitive action is a popular notion. This pro-active mindset supported by the ICAO ANC 11 Recommendation 2/4 (see note (2) should encourage States to review their laws and regulations to determine whether the threat of criminal liability is interfering with the collection of safety-related information. Criminal prosecution is counterproductive to improving aviation safety.

The threat of prosecution creates a “don’t get caught” culture resulting in fewer reports, thereby yielding little in the way of systemic improvement(s). IFATCA supports judicial proceedings meant to determine blame or liability, being completely separate from accident investigations. An open culture will lead to systemic improvements, as the sharing of important data will significantly increase providing governments have the foresight to

want data and we want a just culture. Multi-party co-operation is required to bridge the gap between judicial systems and the needs of aviation. Engineering such a reporting culture fostering a high level of trust might not be easy but it’s possible.

pass legislation decriminalizing those respective aviation laws within their countries.

The solution may seem an easy one - take a pill (changes the laws) - the headache (legislative barriers) goes away. It is not that easy.

Criminal law in many countries obligates authorities to investigate aviation occurrences and to administer justice (read ‘punishment’) for improper behaviour. ‘Non-punitive’ is in legal terms, a very strong approach and implies “writing a blank cheque”. (3

Introducing Just Culture as part of a global action plan, along with certain legal impediments to progress, need to be singled out and solutions developed. A prudent course of action could be the convening of a series of workshops developed specifically for the target audience, i.e., legislators/law makers, specialist legal representatives, members of parliament, civil aviation authorities, along with representatives from respected international organizations (IFATCA, ICAO).

The time has come to move forward, but how?

The Eurocontrol Safety Reporting and Data Flow Task Force (SAFREP TF) may provide one answer. As identified by the SAFREP TF, we must stop merely discussing just culture reporting (we all agree we need it), and focus on the domestic legal frameworks of States.

Our vision of safety occurrence reporting will challenge penal, administrative and civil codes (sometimes even constitutional rights), of many nations. Changes to national criminal laws ranks highly in domestic hierarchies, and as such any amending must involve the respective Ministries of Justice.

The output from such workshops could be a positive contribution to efforts in achieving the implementation of voluntary reporting systems based on principles of co-operation, with a guaranteed measure of legal confidentiality and protection for those involved. ^

It is the judicial system(s) that must be convinced of the importance of safety reporting without threat of criminalization. Obviously this cannot be achieved by simply saying we

It is the judicial system(s) that must be convinced of the importance of safety reporting without threat of criminalization (1

“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 Recommendation 2/4 — The protection of sources of safety information- “…that ICAO develop guidelines which will provide support to States in adopting adequate measures of national law, for the purpose of protecting the sources and free flow of safety information, while taking into account the public interest in the proper administration of justice.”

(3 In cases where operators are guilty of willful misconduct perceived to be beyond the limits of acceptability such as acts of sabotage, gross negligence or substance abuse, it is necessary that criminal prosecution will follow.

Photo: DP

^

by Doug Churchill, EVP Professional IFATCA

4 Fear of Blame?

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4 Interview

Interview With Professor Sidney DEKKER, Ph.D. in Human factors & Aviation safety

The Role of Human Factors in an Accident

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4 Prof. Dekker

Photos: SD

4 Prof. Dekker experiencing first hand Human factors issues on board a Saab 105 Trainer aircraft.

People still want to see human error as the cause of trouble, rather than as the consequence of trouble deeper inside their own organizations.

Interview by Marc Baumgartner

Marc: Your are an Human factor expert, how do you rate ATC knowledge and applications of Human factors principles compared to other industries?

Sidney Dekker: I see ATC as pretty involved in human factors, actually. You seem to take the issues seriously. Of course, you still carry quite a large residue of what I would call old-fashioned approaches, such as HRA (Human Reliability Analysis) and pretty linear, limited risk assessment methods such as HAZOP. In my opinion these do not do justice to the complexity of ATC work and its setting, nor to the resilience and creativity of people who work within it.

M: How can an Organisation like IFATCA can tackle the legal issues surrounding Human performance? IFATCA has no legal expertise as such and depend on outside help, how can we get this without having to pay large sums of money that we do not have?

SD: This is tricky, I understand. One way (but not always one that is possible, I know) is to find ways together with the ANSP’s to tackle legal issues. ANSP’s have more legal resources than the unions, probably, and even though their interests may often diverge, when it comes to the problem of the criminalization of error, for example, that is good for nobody. Both unions and ANSP suffer there. So in order to tackle legal issues without bleeding financially for it, I suggest finding areas of common interest between ANSP’s and unions and partly rely on their legal expertise that’s already paid for.

M: The just culture idea was something everyone was eager to support a year or two ago.

It would still be a very good thing to have established, but it seems to have lost some of its momentum. How do you see this today and how can/should it be revived?

SD: The idea of a just culture as you have tried to sell it in ATC carries the seed of its own corruption. Just look at the Eurocontrol definition: a just culture is one 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,

willful violations and destructive acts are not tolerated.” The idea, of course, is that if just cultures are to protect people against being persecuted for honest mistakes, then some space must be reserved for mistakes that are not “honest” (the “gross negligence or destructive acts” in Eurocontrol’s definition, for example). You can see all the qualifiers to that extent as a kind of escape hatch. And building in an escape hatch means it can be used. It also means that it can be used to push normal, honest mistakes into the realm of the negligent, the culpable, the bad. Which is precisely what has happened in some cases of controller prosecution in Europe recently. This, then, brings me to the crucial question that nobody seems to have tackled seriously: who has the power to draw the line? The line is clearly negotiable: sometimes we find behavior acceptable, while others, at another time may find the very same behavior quite culpable.

So who in your country has the legitimated authority to draw that line? Can we do something there? Like putting more domain expertise into the process of drawing the line, and not leave it to prosecutors or judges or other people without a clue about what it means to be a controller and do ATC work.

M: Is your “New View” being widely accepted by ANSPs over the world?

SD: I actually don’t really know! I would hope so, but I also know that there is still a lot of “old view” thinking. People still want to see human error as the cause of trouble, rather than as the consequence of trouble deeper inside their own organizations. There still are a lot of incident investigations that somehow say “if only the controller had done this or that, or had tried harder, or not lost situation awareness, the event would not have happened”. Such language, of course, is useless, it is counterproductive even. That said, I do enjoy the presence of a bunch of ATC people from all over the world in my classes, so the word may be spreading. Also, I hope that one of my recent books, the new “Field Guide to Understanding Human Error” is making its way down to the relevant people in ANSP’s, as it not only shows how to avoid old-view thinking, but also guides people in setting up a meaningful safety department, and how to get their organization to adopt the new view.

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4 Interview M: We learned that you have been asked by Skyguide after the Ueberlingen collision to make a study on the Human factors surrounding that case. This report has not yet been made public. Did you learn something in that study that could be of interest to all of us.

SD: I had to sign a non-disclosure agreement, so I can’t tell you anything.

M: We could help controllers involved in collisions, like recently in Brazil, using your expertise. Would you be prepared to help IFATCA in such situations?

SD: Of course! But you just told me you don’t have the money ...!

M: Finally, CISM is playing a very important role after an accident. This is recognized all

over now, but we are still using relatively old material. Is there anything new on this field?

SD: Oh, there probably is, but I am not an expert on CISM. Let me say, however, that independent of the material used, the ideas of CISM and applying them effectively, are worth gold. I have seen other industries (like healthcare) where there is not so much as even an understanding that helping colleagues who were involved in an incident may be a good idea. More than a good idea even: the humane, ethical thing to do. CISM can help ATCO’s understand that being involved in an incident is nothing shameful; that the potential for failure is baked into the very activity they do successfully every day.

Everybody is vulnerable to get caught up in a situation that may later be construed as an in-

cident. I think CISM can actually bolster people’s report-willingness, as they will recognize that an incident says little about their competence or professionalism, and more about the organization and operation everybody works in. CISM, I think, is one of the ingredients for beginning to build a “just culture” at home in your own ANSP. And for an ANSP as employer itself, CISM is a smart thing too: you get operational people back in the saddle quicker. So whatever ideas you apply in CISM, keep doing and developing it. ^

BOOK REVIEW

Critical Incident Stress Management in Aviation ^

Photo:

Ashgate

A book by Joerg Leonhardt and Joachim Vogt Review made by Ph. Domogala, Editor

This book describes the various methods and elements of CISM. The book is based on Peer Interventions and the so called Peer model. It also investigates the benefits of CISM, not only for the individual concerned (i.e. the controllers) but also for their employer. Because the faster you go back to work after an incident or an accident, the better it is for them of course!

But it is all about starting to regain balance after a critical incident or an accident.

The book is organized around the 3 main organizations in aviation: Airports, Airlines and Air traffic Control. But the book concentrates a lot on ATC. A complete chapter is in fact a case study of the CISM application to controllers after the Ueberlingen collision, and it is very worth reading. The book describes how CISM is to be organized, and answers most questions your management might have on CISM. Many Specilacists have also written chapters. For instance proper Peer Training is shown in a chapter made

by Dr. Victor Welzant, a Psychology Doctor, who heads CISM services in the US.

Prof. Jeffrey T. Mitchell the founder of ICISF and the developer of the CISM programm has written two chapters and one is about the history of CISM in Aviation.

For Controllers Associations and Unions, it gives all the basic answers, and how to organise a proper CISM scheme in your own environment, together with your employer. Ralf Riedle, former controller, President of the German controller association at some time, and now the Director of Operations of the DFS, writes in this book how he had to overcome prejudices to implement CISM in Germany. His experience and the positive outcome that resulted can be used by any other Organization, as the questions raised are inevitably always the same ones. Getting Controllers back on their feet after a trauma, as soon as possible, both psychologically and humanly is the best we can do to help, both the individual controllers and their employers.

CISM courses to train peers and currently work in Langen for the DFS, and Joachim Vogt is a well known Psychology Professor in the Copenhagen University, specialized in aviation psychology.

Hardback; 194 pages; 978-0-7546-4738-6 The book is available from Ashgate Publishing in the UK at a special 25% discount price to IFACTA members, £41.25 (postage extra).

Offer ends 31st May 2007. To place your order email: ashgate@bookpoint.co.uk or telephone +44 (0)1235 827730 or fax +44 (0)1235 400454.

Important: to obtain the 25% discount please quote reference ‚IFACTA‘ when placing your order.

(This discount is only available on direct orders and

The authors are “the“ current experts on CISM. Joerg Leonhardt is the father of

not through bookshops or agents. No other discount may be added).

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4 Legal Issues

ATC: One Foot in Court? ^

by Helena Sjöström (Swedish ATCA)

This was the provocative question on the posters for the Legal Issues Workshop on October 20, 2006 at the European Regional Meeting in Sofia, Bulgaria. Lately we have seen a number of cases in which ATCOs have been prosecuted, indicted and even sentenced to prison. Is this the course of the future? Can we change this?

These and others were the driving questions when the Executive Vice-President Europe, Patrik Peters, organized the workshop. For the first time in the European region, there was an attendance fee of 30 Euro. The fears that this might prevent the member associations from participating were unfounded. More than 80 persons attended.

Speakers specializing in different legal areas

If you “work around” a problem and “invent new procedures”, chances are; you will be held responsible for an accident.”

Patrik Peters had invited speakers with different backgrounds: Cesare Ciccorella, defense attorney in the Linate accident; Ann-Frederique Pothier, legal expert for Eurocontrol; Radu Ciponea, Eurocontrol Performance Review Unit; David Gleave, chief ATC safety investigator and Nadine Pilon, media expert for Eurocontrol. Also invited was Gerard Forlin, barrister, who unfortunately could not attend.

An attempt was made to make an audio-recording of his presentation but it was technically not satisfactory. An interview with Gerard Forlin is presented on the next page. All speakers agreed: Air traffic controllers must initiate the change. We cannot leave it to lawyers and legislators. We must start the dialogue, be creative, “think outside of the box”.

Media and the public One paramount issue, in legal proceedings after an accident or incident, is the media.

Cesare Cicorella, speaking Italian but being simultaneously translated into English, stressed the importance of having appropriate experts involved at a very early stage and responding as soon as possible to the media pressure. This was not the case in the Linate proceedings and it would prove very important and indeed detrimental. The investigators were under heavy pressure from the media and the defense was not given full access to the evidence. Four years after the accident, after around a dozen requests, the defense for the first time listened to the

flight recorder. There is a trend towards criminal liability lawsuits after accidents. One reason might be that the public, especially the families of victims, wants to find someone responsible. This is the case not only in aviation but in all kinds of accidents. In aviation crashes though, the pilots are often no longer alive. Nadine Pilon, who has done research on how aviation accidents are reported in newspapers, gave further input to the issue. As technology makes its advances, people seem less likely to accept technical malfunctions as cause of accidents. The same goes for “Human Error”.

Controllers are the experts on safety Maybe we as controllers have to start questioning regulations and procedures more.

Even though the regulation says that the wind information to a landing aircraft shall be the two-minute wind, we know that in certain conditions the wind can drastically change within a period of two minutes. Do we then switch to instant wind and read the wind out as it changes? The answer is “not always”. Why? Because this might not be stated in our regulations. But if we are experts on safety, why do we not do what is safest, if it does not explicitly go against the regulations? Why do we not demand wind shear warning-systems? Another example: why do we allow intersection take-offs? Even if it is not against the rules, you as a controller might be in serious legal trouble in the event of an overrun. Defending the decision to let aircraft take off from a shorter runway, with “because it increases efficiency”, will not be good enough. In a criminal lawsuit, every single action taken by the controller will be scrutinized and it will very likely be pointed out that controllers are experts on safety. David Gleave talked about the great importance of incident reporting and of attitudes in operations: “Report things that are wrong. Always! On paper! If you do, chances are they will improve. Also, if you report things that don’t work, I can defend you in court. If you instead “work around” the problem and “invent new procedures”, chances are; you will be held responsible for an accident.” To achieve an environment where controllers voluntarily report incidents as one mean to increase the level of safety, we need Just Culture. Eurocontrol’s definition of a Just Culture is one where ATM personnel and pilots are not punished for actions, omissions

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4 Legal Issues or decisions taken by them that are commensurate with their experience and training but where gross negligence, willful violations and destructive acts are not tolerated. Without a non-punitive work environment, we risk being drawn into a vicious circle of fewer incident reports, leading to more accidents, maybe leading to more lawsuits, inducing an even lower will to report incidents.

The future importance of legal issues in ATC is clear. We need to: • Prepare ATC staff for media scrutiny • Improve public perception of ATC • Learn to better understand the links to the judicial framework • Work on attitudes and applications of rules in operations

The evaluation after the workshop showed the approval of the attendants and the wish for further efforts in this area. 56 out of 60 replies said that they want a continuation of the Legal Issues Workshop. 40 persons said they would or would probably be willing to pay for future workshops.

INTERVIEW Gerard Forlin, Barrister, on Controllers Prosecution

Gerard Forlin is a barrister admitted in the UK, Australia and other jurisdictions. He is an acknowledged expert on health and safety, including aviation. He is one of the very few workplace manslaughter specialists due to his experience in defence, prosecution and regulatory work. Gerard Forlin has published extensively on health and safety law issues, including corporate manslaughter and he lectures regularly on these topics (see www.gerardforlin.com).

Patrik: In the recent past, it has become a trend to prosecute air traffic controllers for accidents and incidents related to their profession. Can you confirm this trend? What could be possible reasons for this?

Gerard Forlin: It appears that in very recent times there has been a sudden spurt of prosecutions against individuals in the aviation and the transport sectors in general, for instance Milano-Linate, Überlingen and the recent mid-air collision in Brazil. There seems to be a global beefing up of a trend to prosecute transport accidents. I am observing this trend not only in Europe but also in Australia, the USA and elsewhere. We are living in an increasingly transparent environment, where the public demands information about accident causes. To many in the industry in the past, blaming frontline operators has been an expedient way of dealing with the aftermath of a disaster.

P: Responsibilities are not carried solely by an individual but rather accounted to the system itself. What can be done in your point of view for controllers to not serve as scapegoats of a weak safety culture?

GF: Most jurisdictions in their criminal law comprehend that “system failure” is the responsibility of management. In my view, in the absence of real human deviancy e.g. drugs or alcohol abuse at work, individuals should not be prosecuted for human error factors. If they are, then there is a real danger that safety may be driven underground if for instance the quantity and/or quality of confidential reporting dries up. In other words, criminalization of an accident is not an effective deterrent or in the public’s best interest, excluding for example acts of sabotage or reckless conduct. Controllers have to be made aware of their role in the safety system.

They need to report deficiencies and irregularities if the system is to be improved.

P: Last September you gave a presentation at the Worldwide Symposium on Air Navigation in Montreal. Is there a movement towards a more fair jurisdictional system for the future?

GF: My speech appears to have acted as a catalyst to a series of safety groups and bodies formulating a resolution condemning criminalization of accident investigations. I understand that a number of other bodies are also applauding these statements and the change of opinion is gathering momentum. We will have to wait and see!

P: Air Navigation Service Providers and States have to take their share in forming a pan-European jurisdictional system. Is this possible at all or will we, despite working towards a Single European Sky, always have to face more differences than similarities?

GF: I am doubtful that in the near future, states will surrender their sovereignty in terms of their criminal law to any global system.

For instance, many conventions state what the law should be, but each state prosecutes according to their own procedures and laws

of evidence. Over time, this approach may change.

P: What can we, IFATCA, do for our colleagues?

GF: I think you need to continue to lobby governments and other organizations. You also need to financially and emotionally support the defence of your colleagues who are under investigation or who are prosecuted so that specialized, experienced lawyers and experts can be engaged on their behalf both at the police-interview and trial stages.

There may also be disciplinary and other hearings, where support will be required. ^

Photo: Gerard Forlin

^

Interview by Patrik Peters, European Regional Editor

There seems to be a global beefing up of a trend to prosecute transport accidents.

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4 European Affairs

European Regional Meeting Sofia, Bulgaria

^ Human Error is and should not be the conclusion of an investigation but it should be the starting point.

Photos: DP

by Raf Vigorita, Eurocontrol Guild (EGATS) and Ph. Domogala, Editor

This year, the European Regional Meeting was held in Sofia, Bulgaria, organized extremely well by our Bulgarian colleagues of Bulatca. Patrik Peters, for the first time chairing this event as EVP-EUR, welcomed Mr. Petar Mutafchiev, the Bulgarian minister of transport. His speech was on the lines of those given by politicians in previous events, praising how his country feels about safety of air transportation and how important our job is. He was preceded by a great deal of media people, anxiously awaiting him. Then Eurocontrol General Director, Mr. Victor Aguado, gave a very interesting speech as usual. This time he focused on performance, which has constantly been increasing despite a considerable traffic-growth.

On September 15, more than 32.000 movements were recorded in the core part of Europe, which is the highest ever for a single day. That figure went together with an average delay of 1, 2 minutes for each flight - close to the optimum. He also underlined that in Europe we experienced no man-induced accident since 2002. He praised the ATM system as a whole for dealing with the planned situations, like the Football World Cup in Germany but also with the unplanned events, such as the war in Lebanon and the security alert in London, with professionalism and commitment. Mr. Aguado also touched on the aspect of legal issues, a very hot topic this year, by saying that the good performance recorded stands on a delicate balance and the separation between safety analysis and legal issues is not enough yet.

In his words, just culture comes first, because even in world proven procedures and safety nets, mid-air collisions can still happen in controlled airspace. Mr. Aguado continued by saying that effi-

ciency and good results are undermined by fragmentation. The total cost of this, annually, is about 1, 4 billion Euros, 40% of this being ATM costs. In any case, traffic will double in the next 20 years and a new concept is needed.

Marc Baumgartner, IFATCA President, made a valid point in saying that the public opinion only talks about us if things go wrong and it seems that the human being has more appetite for bad rather than for good news. He said, since nobody else acknowledges us publicly: Be proud of yourselves. Be proud of what you do, be proud of your values, be proud of doing such a good job. But just be aware that when pride comes, a hard fall could follow. Pride brings arrogance, so don’t be blinded by that. But do be proud and try to change the communication with the world by advertising the responsibilities and the uniqueness of our profession.

Eurocontrol’s Alexander Skoniezki focused on the need for a safety culture based on mutual trust, share of perspectives, preventing measures and enduring values at every level of an organization. I agree with these beautiful dictionary-like words. However, I would really like to hear them less and more see them applied, everyday, everywhere. We are not there yet. Richard Arnold of the DFS, presented a very interesting movie titled “Human factors in safety management”. The movie explains that the fundamental attribution of blame leans towards the individual shortcomings. Punishment is primarily a search for closure, and only thereafter might give a learning ability to improve. But it has to be noted that Human Error is not the cause, it’s the effect, Human Error is not random, Human Error is and should not be the conclusion of an investigation but it should be the starting point. It is necessary to start focusing

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4 Europe on the underlying causes of failure. Dig deeper.

And remember, flexibility is important to cope with unprecedented events, but that cannot be confused with breaching the rules, which eventually is an erosion of safety that mostly goes unnoticed over time, causing great risks.

Max Bezzina, explained the progress met by the ELPAC (English Language Proficiency for Aeronautical Communication) trials. ELPAC is a test of proficiency for a target population. More on

http://elpac.info. Many colleagues were concerned about possible failure and retraining. As of now, there are no procedures for retraining in the event of failures, but the responsibility for that will lay with the provider itself, which worried certain colleagues even more. The target date for ELPAC introduction should be 17 May 2010. Finally Frederic Deleau of ATCEUC gave a passionate presentation about the MOSAIC project and certainly caught everyone’s attention, as he drew a lot of

interest and a lengthy discussion.

The meeting was attended by almost 300 participants from nearly all European MAs and was a great success. The rest of the meeting was about discussing members associations problems, but they were held in close sessions. The next Regional meeting will be held in Prague, 26-28 October 2007. ^

Europe Tunes 8.33 kHz above FL 195 ^

by Wolfgang Scheidl, Austrian ATCA

of 8.33 kHz channel spacing. It is aimed at air traffic controllers, pilots and flight dispatchers and it uses three “comic strip“ stories.

Further information and the links to the train-

ing package are available on the Eurocontrol 8.33 kHz website www.eurocontrol.int/833 under „Awareness and Training. ^ Photo: Eurocontrol

As the IFATCA representative to the Eurocontrol 8.33 kHz Drafting Group I would like to use this opportunity to remind all European controllers that 8.33 kHz channel spacing will be implemented above FL 195 in the ICAO EUR Region on 15 March 2007.

“Europe tunes 8.33 kHz above FL 195“ is also the name of a web based training package which has been developed to highlight issues that can arise from the implementation

ANACNA, the Italian controllers’ association had a very good idea to celebrate the Day of the Controller last October.

They produced a very clever poster, based on the famous “smiley” figure that can be seen, depending how you look at it, as a headset or a smile sign if you turn it. Both placards were posted everywhere in airports in Italy

during the day of the controller.

A very interesting initiative, bringing a positive representation of the ATCOs for the general public. ^

Photo: ANACNA

The Day of the Controller Poster in Italy

33

SPOTLIGHT

Spotlight on Corporate Members ^

Kevin Salter Contributing Editor, Corporate Affairs

Welcome to all our readers for the first Spotlight feature of 2007. For those of you that are new to our magazine, the aim of this feature is to introduce ATM topics of mutual interest that will keep the reader informed on what is happening in our world of Air Traffic Management. As usual I compile the information based on press releases and correspondence I receive from our Corporate Members from around the world.

The focus in this issue is, once more, on a major contributor to Spotlight, THALES.

We start by looking at news from:

TAIWAN: Thales awarded ATM contract in Taiwan - New nationwide CNS/ATM* system – Thales ATM Pty Ltd in Australia has been awarded a contract by the Air Navigation and Weather Services of the Civil Aeronautics Administration of Taiwan, R.O.C. for the supply of a fully integrated nationwide Air Traffic Management System.

Thales will supply its field proven EUROCAT air traffic control system for the two integrated en-route and approach air traffic control centres, simulation capabilities, a software development environment and positions in eleven ATC towers. Included in the contract is the provision of a fully integrated Aeronautical Information Service System and a Digital Voice Communication Switching System.

Under the contract Air Navigation and Weather Services will receive the latest ATM system for the management of en-route and approach air traffic, incorporating integrated functions to improve air traffic flow and reduce flight congestion. A spokesperson for the Air Navigation and Weather Services of the Civil Aeronautics Administration of Taiwan said, “The Thales system will lead to improved safety and security for flights in our airspace and provide the latest generation of air traffic management”.

Developed in conjunction with controllers around the world, the new system will include the capability for multi-sensor tracking including radar, ADS-B*, and multilateration, air traffic flow management, air-ground data link as well as the latest in safety net alerts and warnings. Air Navigation and Weather Services will benefit from the Thales policy of continual enhancements to the EUROCAT product and the recent CMMI* Level 5 accreditation of the Engineering Department in Melbourne, Australia where their system will be developed.

Bachu Murthi, Vice President, Thales Australia Air Systems said “Thales is proud to be chosen to provide this new air traffic management system, which adds to a long list of systems developed in Melbourne and installed around the world.” * CNS/ATM: Communication, Navigation, Surveillance / Air Traffic Management * ADS-B: Automatic Dependent Surveillance –Broadcast – ADS via broadcast from properly equipped aircraft or vehicles * CMMI: Capability Maturity Model Integration – a global process maturity model of the Carnegie Mellon Software Engineering Institute

CHINA: Thales and TEDC create a joint venture in air traffic control In Beijing on 20th November 2006 Thales and TEDC (Civil Aviation Air Traffic Control Technology Equipment Development Co. Ltd) today signed an agreement for the creation of a joint venture in the field of air traffic control. The joint venture will be owned by TEDC (60%) and the Thales

Group (40%). It will develop, sell and maintain air traffic control centres derived from technology inherited from Thales, predominantly in China.

The creation of this joint venture ensures the continuity of the NESACC programmes, which are aimed at expanding and modernizing the air traffic control systems in Beijing, Shanghai, and Guangzhou, and for which the Civil Aviation Administration of China (CAAC) selected Thales EUROCAT technology. The three centres are in charge of monitoring the en-route air traffic control towards eastern China, i.e. 60% of the total air traffic in the country. Thales has supplied primary and secondary radars, navigation aid systems, and associated training services to China over the past few years.

With this new joint venture, Thales intends to strengthen its position in the Asia-Pacific region, and to develop long-term relationships based on excellence with the stakeholders of the Chinese civil aviation authorities and industrial partners.

NETHERLANDS: Thales awarded new PHAROS contract for the Royal Netherlands Air Force On 23rd November 2006 the Netherlands Ministry of Defence and Thales signed a contract for the renovation of PHAROS III (Plan Handling And Radar Operating System) – the system that has been used since 1994 by the military air traffic control centre which is located in Nieuw Milligen, The Netherlands. PHAROS was initially supplied to the Royal Netherlands Air Force (RNLAF) in 1994 by Thomson-CSF, later renamed Thales. Under the terms of the new contract, Thales will provide the RNLAF with state-of-the-art equipment in replacement of obsolete Data General equipment and will ensure the migration ^ Alexandre de Juniac, Senior VicePresident Thales Air Systems (on the left); Xiaoping Lu, Deputy Director General Air Traffic Management Bureau, Civil Aviation Administration of China (CAAC).

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SPOTLIGHT

^ R.Z. de Ceuninck van Capelle, Naval Captain (on the left); and Philippe Rebière, Thales Air Systems (on the right)

equatorial climate mean that a variety of different surveillance technologies are necessary to provide adequate coverage, including radars, satellite technology and ADS-B. Aircraft equipped with ADS-B, including most modern airliners, emit digital signals every half second identifying their position, height, speed and course. This information can be fed into a national air traffic control system to provide a radar-like picture of aircraft movements, complimentary to other forms of surveillance.

The trial involves the deployment of three Thales ADS-B ground receivers - at Denpasar in Bali, Kupang in Nusa Tenggara Timur and Natuna Island in the South China Sea - which are linked by SITA communications links and surveillance processors to Indonesia’s control centres in Jakarta and Makassar. Airservices provides project and technical support and a remote monitoring capability.

Based on this trial result the Directorate General Civil Aviation (DGCA) will evaluate the technology before determining whether to roll out ADS-B nationwide based on the service model proposed by the Airservices/SITA ADS-B Alliance.

An important consideration will be the effectiveness of the system in enhancing surveillance across international Flight Information Region boundaries.

INDONESIA:

About Thales

Indonesia launches airspace safety trial Technology partners Airservices Australia, SITA and Thales today congratulated Indonesia on the successful launch of a trial to enhance airspace safety across the archipelago.

The decision to trial ADS-B follows on from a regional ICAO recommendation adopted in 2003 and demonstrates Indonesia’s commitment to improving the safety of air travel, the three companies said in a joint statement.

During the trial the ADS-B traffic data will be displayed in the Jakarta and Makassar Air Traffic Control (ATC) Centres where it may be viewed by air traffic controllers.

This will demonstrate the enhanced surveillance capabilities provided by ADS-B along a number of key air routes.

Indonesia controls a huge area of airspace, with very heavy international and domestic air traffic. The Republic’s varied terrain and

Thales is a leading international electronics and systems group, serving defence, aerospace and security markets worldwide, supported by a comprehensive services offering. The group’s civil and military businesses develop in parallel to serve a single objective: the security of people, property and nations.

Leveraging a global network of high-level researchers, Thales offers a capability unmatched in Europe to develop and deploy critical information systems. Thales employs 60,000 people in 50 countries and generated revenues of € 10.3 billion in 2005, with a record order book of over € 20 billion.

Thales in China Thales has been operating in China for more than twenty years. As of today, around 500 employees work for the Group in China, in such fields as electronic components and

equipments, aviation, urban transportation and security. Over the past three years, Thales has seen a significant growth in all its activities, generating an average annual order intake of € 250 million.

Examples of Thales’ achievements in China: 2008 Olympics Games: On 1st November, Thales International opened Thales Services Beijing, a new services centre supporting Thales activities and providing maintenance and repair services to Thales’ customers in China.

The Civil Aviation Air Traffic Control Technology Equipment Development Co. Ltd. (TEDC), granted for the establishment

by Civil Aviation Administration of China (CAAC) in 1998, is a high-tech enterprise invested by Air Traffic Management Bureau (ATMB) of CAAC and seven local ATMBs in China. TEDC is a leading national electronics and systems company, providing high level operation safeguard and technology support for China’s civil aviation air traffic control (ATC) system.

TEDC employs over 300 people nationwide. This team is not only professional, practical, but also innovative and creative, endowed with rich enterprising spirit. By the end of 2005, the company generated revenues of RMB 60 million. TEDC attaches great importance to both the economic returns and social benefits.

This concludes the first Spotlight feature for 2007 and I would like to welcome and thank Mathilde Bouchard my new contact person for Press Relations at Thales, for supporting Spotlight by providing her company’s contribution.

As I normal say to our corporate membership readers, don’t forget that if you would like your company to be featured in `Spotlight´, and likewise to any reader, who would like further information on any topic that was covered, please do not hesitate to contact me using the following address: Kevin Salter IFATCA Contributing Editor Corporate Affairs Flugsicherungsakademie Am DFS-Campus 4 · D-63225 Langen Tel: + 49 (0)6103 707 5202 Fax: + 49 (0)6103 707 5177 E-Mail: kevin-john.salter@dfs.de

Photos: Thales

of the operational software. The contract that includes initial delivery, installation, testing and maintenance was awarded to Thales following an international tender.

Although the initial PHAROS project was commissioned ten years ago, Thales has maintained the competencies, logistics, and maintenance services for safety-critical systems in order to provide customers with the most efficient migration process. The same PHAROS functionalities will be maintained to enable the Royal Netherlands Air Force to perform Area Control and to fully benefit from the new technology. This contract is an illustration of Thales’ ability to implement COTS solution in the ATC environment. Thales already performed such projects for several international customers including Denmark, Belgium, Australia, the Czech Republic, and Slovakia.

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4 News

South African Controller prosecuted for an accident is free We remember that a South African air traffic controller was prosecuted and threatened with jail after an accident in South Africa.

At the commencement of the proceedings in the Regional Court, the State requested a postponement as they did not complete their investigations into the accident and requested that the matter be heard at a later date.

The recent good news was heard in the Regional Court of Pretoria on 28 November 2006.

The legal team appointed by ATNS (the South African ATC Service Provider) on behalf of the controller, objected to any further

postponement. The Regional Magistrate was also not happy with the unnecessary delays in this matter and refused a further postponement of this case.

The State proceeded to withdraw their charges against the controller and he was released of his obligations in terms of his bail conditions. A good ending!

17TH AMA Regional Meeting ^

by El Kadur Acosta, Americas Regional Editor

São Paulo was the host city of the Americas Regional Meeting, The event took place 25-27 October.

Most of the region’s members associations were present, as well as observers: IFALPA, ITF, and other Brazilian Air Traffic Controller Associations. Pan Am International Flight Academy and Park Air Systems were the corporate members present sponsoring the event.

4 Dominican Republic delegates Photo: EK

Cedric Murrell, IFATCA EVP Americas, chaired the meeting and Marc Baumgartner, President of IFATCA addressed the meeting via video conference, expressing his concerns regarding the recent mid air collision and how much this case reminds him of the Switzerland mid air collision back in 2002. He noted that the federation is working closely with ICAO to find best ways to handle conflict management and separation provision. During the ITF Presentation by Mr. Gabriel Mocho Rodriguez, a brief introduction was made about the organization goals, objectives, area of work and structure; while a brief explanation about how they work along with regional associations in their negotiation process. The Pan Am Academy explained the services provided by this in-

stitution and concentrated on their English language programs.

When it comes to member association reports, the issues of main concern are English language proficiency; privatization; Air Traffic Controller shortage and, of course, labor relations. Countries such as the United States and Haiti face their worst air traffic controller shortage ever while Panama expresses its concern regarding the new government, which is formed of the same persons that lead a conflict in the late 1990’s, then resulting into a major crisis.

The English proficiency issue was discussed extensively. There, most associations expressed their concern and some even asked why their employers are doing little or sometimes nothing to help their staff reach the minimum Level 4 established by ICAO. It was agreed that meeting the expectations is everyone’s responsibility.

This meeting was a great opportunity to know the flattering Brazilian hospitality, a chance to meet new colleagues.

Finally, I would like to express my most sincere gratitude to ATCAGRU for their warm hospitality and EVP AMA for his support, not only to me but our Brazilian fellows. Next meeting will be in Aruba during the fall of 2007.

THE

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4 Asia

Controllers – the unsung heroes of aviation ^

by Capt.

Elmo Jayawardene (Sri Lanka)

From Orville Wright in a place called Kitty Hawk to the first step on the moon by Neil Armstrong, the progress of aviation was phenomenal. The achievement was created by people - the ordinary, the extraordinary and the ultra-ordinary. There were the heroes and the heroines equally matched by the villains and the vagabonds. There were the dreamers and the believers of their dreams. They all had one thing in common - they were the fraternity of aviation. Through the years the public that trotted the sky came to know them and herald them. They sang their praises and adored their images. The industry itself ensured the celebrity of its prodigy by lavish advertisement portraying the roles of the pilot, the engineer, the flight attendant down to the reservation clerk who booked their seats.

Books were written, movies were made, posters were put up all to glorify and pedestal the individual who contributed to aviation.

Amidst all this patronising and glorifying, certain stalwarts of the field were obviously forgotten, and paramount among them was the Air Traffic Controller - the man who controls the sky. Their poems of praise and credit for progress were written without a mention of the man in the Tower, the man sitting away from everybody in his little pressure cooker who controlled the skies - the man who ensured the safety of so many lives with the accuracy of his thought and the calmness of his voice, a lot more lives than the best of us who fly the machines have ever been responsible for. He was never given the dues he so richly deserved for his services.

Hence, I write these lines - little lines of appreciation from a creature who has been in the sky long enough to know what a tremendous contribution the Air Traffic Controller makes to aviation.

Complications The intricacies and complications of his exacting profession cannot be penned that simply.

I do not possess the wisdom of words to adequately detail what he means to a pilot - the quantum of faith the pilot has to have on the controller is difficult to explain, even more difficult to understand - a kind of faith that may not move mountains but would yet get you home from the storm laden skies when your skills are taxed to the limit, and the relief and solace given by the Controller becomes your solitary source of comfort.

No professional Captain worth his salt would hesitate in expressing his gratitude to the Controller, not for once, but for the many times the Controller guided him to safely bring him home.

Voices On the Controllers’ part, a good thirty voices ring in his ears, requesting and requiring instructions while everybody is moving at high speeds through a sky where nobody can be seen - all converging or diverging from the same point and all hoping and praying the Controller will not make a mistake and create a collision - a kind of scenario where I feel that for every 400 lives that I am responsible for as a Captain, the Controller carries 4000 in the simple accurate commands of his voice.

This makes the Controller a man with a mission of responsibility, scrutinised constantly, functioning to standards of pinpoint accuracy, yet so unrecognised in his own field of aviation, a field where he plays a major role for continued safety - the safety that you as a passenger enjoy and me as a Captain is grateful for.

Silent heroes In any professional field there are the silent heroes devoid of credit. In aviation the Air Traffic Controller is supreme. He will use his intelligence and procedural skill to bring the aeroplanes home through the most adverse conditions - yet he will continue to remain unheralded the unseen and unsung hero of aviation. ^

A voice that through the years all pilots have learnt to trust in the worst of circumstances, a voice that merits a lot more recognition and appreciation in aviation than given at present.

A Controller is a quick thinking man who doesn’t have the privilege to stall. He is like a surgeon, composed in knowledge, precise in action yet without the benefit of burying his mistakes. All his instructions to aircraft are recorded continuously on tape and any instructional error is traceable by replay, a tremendous constraint on the individual - a disturbing yet necessary requirement that no other profession entails and no other professional has to contend with.

Photo: E. J.

A Controller is a quick thinking man who doesn’t have the privilege to stall THE

CONTROLLER

37

Charlie’s Column

^

Charlie‘s Column Landing on Taxiways This new method to fight runway congestion is occurring more and more. First on October 31, a Continental Boeing 757 landed on the main taxiway in Newark (USA) instead of the runway. What is interesting is not only that the taxiway is 70 feet wide, while the 757 has a 155 feet wingspan, but also that the pilot did not say anything to the TWR, just taxied normally to the terminal and left the premises very fast. Unfortunately for him, the skid landing marks on the taxiway are still there for everybody to see.

Then on January 6, a Boeing 737 from Korean Air landed on the taxiway at Akita Airport (some 450 KM north of Tokyo, Japan). There is an interesting video running on the internet where you see passengers waiting in a terminal reading newspapers Photo: INT

and suddenly the large terminal windows are full of blue, (the color of the 737) as the aircraft swiftly passes a few meters away landing on the taxi way. (see airport diagram below)

If this tendency continues, we will not have to bother with inventing new procedures to increase runway capacity, as each airport will automatically have multiple landing capabilities.

Remove before Flight: This interesting photo was taken in the USA and is a nicer alternative to the little “flags“ used as key rings by aviation enthusiasts all over the world.

Although, seeing the size of the interior of my single-engine aircraft, I do not think that the procedure will be very good for improving safety (if one is talking about the shirt, and not the complete lady of course).

Expensive Retirement Gift Last December, a well-known United Airlines captain about to retire, was having his last flight on his B777 into Washington Dulles airport. The airport fire brigade decided to do the same “farewell“ that they had seen on TV many times i.e. driving the fire trucks around the aircraft as it taxied back to the terminal after the flight, and spray water cannons over it from each side.

This is known as the “water canon salute”.

Unfortunately, instead of water the trucks blasted foam fire retardant. As the B777 engines were running, the foam was ingested in the engines and stopped them.

Apparently the B777 is totally unserviceable and will probably need 2 new engines.

The story does not say who will finally pay for the present …

Camel Sacrifice: Last December, a group of Turkish Airlines technicians were so happy to be rid of the last of a batch of old planes that they sacrificed a camel on the tarmac of Istanbul‘s international airport. Apparently it is a tradition in Turkey to sacrifice animals as an offering to God when wishes come true „We are so happy to be rid of planes which frequently broke down“ said a technician.

Unfortunately for them the airline management did not approve of the sacrifice and fired their boss, who had organized the event. Some local newspapers had run the story on their front page, and blood on the tarmac is not a very good public relations exercise for an airline.

OK, you all want to know now: what were those “bad” aircraft that prompted this antique ceremony? They were first-generation BAe146, also known as “Tonka jets” in Canada, or “Jumbolinos “in Switzerland, and “Babyjumbos “in Africa. (in the UK when the 146 came out, they were known as “But-why-4-engines?)

Overheard on the Frequency: Ground Control: Midland 123, visual with the two Virgin Express 737s from the left?

Pilot: Affirm.

Ground Control: Roger, you take position in between the Virgins.

Pilot: Ahhh ... I‘ve always dreamed of this ...

THE

38

CONTROLLER

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