In incidents like this, why does the ‘regulatory’ system always focus on the individual involved at the sharp end? This is a covert blame culture, which usually reflects very limited thinking by the agency concerned. Blame and train.
It is reported that the controller made a mistake. S/he does not have to be below standard or something, or in need of training, or demoted to improve performance; this person is one of us, a human who suffer error, particularly when given opportunity.
“It’s often the good people who make the worst mistakes.” – James Reason
This appears to be a classic incident of the situation – the opportunity for an error to occur. These situations contain latent failures, which are just waiting for the human frailty of forgetting to combine into an accident.
A major principle of threat and error management (TEM) is the identification of such opportunities and then avoiding them.
So what was the compelling reason for cross-runway operations that judges it an acceptable risk, why allow this operation? No doubt the will be some justification, which will/will not stand up in hindsight.
Is there too much dependence on the Airport Movement Area Safety System (AMASS); is this becoming like MSAW – which together with human weaknesses is not a totally effective system -
MSAW.
Why did the controller forget; workload, distraction, fatigue? Again justifiable by regulation; you can’t regulate safety, only participate in it and judge it (usually after the fact).
Thus, another principle of TEM is to actively detect errors. With modern technology there ought to be a means of isolating an active runway, i.e. S-band link from ACAS to ATC such that any aircraft on late final / runway will prevent or warns the controller from issuing a departure clearance on a cross runway. Similarly what external error detection could the flight-crew provide with the use of ACAS.
Flight crews use a human backup – one person decides, the other checks; does this happen with ATC?
I hope that the NTSB can unravel the background factors to this incident (management and equipment) and identify the human issues which contributed to the error.