NATCA and ATSAP – Leading the Way in Safety Management
Friday, December 17, 2010

Ruth Stilwell, former NATCA executive vice president and current ICAO Air Navigation Commission member, discusses the program's positive effect on global aviation:

The NATCA partnership with the FAA in creating the Air Traffic Safety Action Program (ATSAP) is a model for improving aviation safety around the world. It is exciting to be working with ICAO and see how our work can be used to help shape global policies. As ATSAP-style concepts are adopted by other countries, I have the honor of knowing we have helped lead the way. It is a major change for global aviation as countries shift from the idea of risk management to safety management.

Years ago, one of the first lessons my trainer taught me was that there is no room for secrets in air traffic control; the second lesson was that the FAA didn’t want to hear the truth when it came to safety problems. Like many of my coworkers, I grew up hearing “safety was never compromised,” and we all knew that reporting a problem was more likely to get you in trouble than to get a problem fixed. Contrary to the old adage, what you don’t know cannot only hurt you, but it can get a whole lot of people killed. ICAO has recognized that safety reporting is critical to an effective Safety Management System and NATCA has a lot to be proud of in leading the way.

Our ATSAP program takes the concept of self-reporting, which has been in place for the pilot community for years, a step further by adding a system of cooperative follow-up and corrective action. We have always been advocates of the NASA ASRS program that compiled data and identified trends, but the ATSAP program goes much further to aggressively use the information to make our air transportation system safer for the public we serve.

ICAO is in the process of developing global standards for safety reporting systems that allow for non-punitive reporting of safety information, encourage voluntary participation, and protect safety data from being used for improper purposes (including civil and criminal proceedings). Failure to provide this environment will leave us with a system where safety problems, which can be fixed, are left to develop and worsen simply because there is no mechanism for aviation safety employees to bring the issues to light without fear of reprisal.

Our ATSAP program is a model that will not only help shape ICAO policy, but can also demonstrate that voluntary, non-punitive reporting is a necessary element in a robust Safety Management System. Conversely, traditional blame-based approaches will cause safety concerns to be actively hidden from view. That is a recipe for disaster that we are all working to prevent.

Over the last few months there has been some unsettling news for air traffic controllers around the world. In Japan, the Supreme Court reversed a dismissal from the Appeals court resulting in a criminal conviction for two air traffic controllers. In Italy, the Appeals Court upheld two-year prison sentences for two controllers on duty when a citation on visual approach had a controlled flight into terrain accident. In much of the world, aviation accidents are investigated as criminal events, by criminal authorities.

The problem with this approach is that it seeks to affix blame and does nothing to address the underlying problems that led to the accidents. In fact, in many cases this approach diminishes system safety as fear of reprisal keeps many problems hidden until an accident occurs.

Consider for a moment the JAL near mid-air collision that seriously injured nine people while 91 more sustained minor injuries. The controller issued a descent clearance but had confused the call signs, issuing the descent to JAL907 when he intended to issue it to JAL958. Immediately after, JAL907 received a TCAS RA to climb and JAL958 received a TCAS RA to descend. The pilot of JAL907 followed the controller’s instructions and not the RA, while the pilot of JAL958 followed the RA resulting in both aircraft descending toward one another. The controller was not aware that JAL958 was following an RA or that JAL907 had received conflicting instructions.

ICAO has been criticized for not taking swifter action to establish operating standards when dealing with TCAS Resolution Advisories that are in conflict with ATC clearances following this accident. Even though both crews were operating in their domestic airspace and with the same airline, there were conflicting opinions on how to respond to an RA. While this was a near catastrophe, the fact that it is treated as criminal matter may have been a factor in the ICAO decision to act slowly in addressing a significant underlying problem. Both aircraft were the same Japanese carrier in sovereign airspace under control of the national authority, giving ICAO political cover to say it is not an international matter. But sadly, it was only 18 months later when nearly identical actions with regard to TCAS lead to the tragic midair collision over Uberlingen.

These two accidents were not the first times that differences in training and response to TCAS events created a safety hazard, but without a comprehensive system of safety reporting that puts fixing safety problems ahead of fixing blame, too many systemic problems will go unaddressed until a catastrophe happens. Had the issues been examined as a potentially systemic safety problem instead of a criminal matter, could we have gotten clearer information into the international community to prevent a reoccurrence?

The accident in Italy raises even more concern. Pilots requested a visual approach, and the controllers confirmed that the pilot could and would provide separation from obstacles and terrain, but collided with the side of a mountain in good weather. By all accounts, the controllers followed procedures and regulations, yet the criminal prosecution ensued. As a consequence of the criminal prosecution to affix blame to the controllers, the underlying safety issues including terrain map coloring and marking, crew fatigue and airport lighting may not receive adequate attention to prevent a similar catastrophe.

We are all responsible for our actions, and there is no question that safety is our first priority. Safety reporting allows us to do more than “keep ‘em separated.” It allows us to build a system that is safer every day and meets the needs of our professions and the public.