Interesting item in today's
Tages Anzeiger.
http://www.tagesanzeiger.ch/dyn/news...ch/786287.html
To pre-empt complaints about "I can't read German", here a brief translation:
Skyguide apparently incapable of learning
Prior to the mid-air collision over Überlingen, Skyguide’s management had ignored all prior warnings by controllers. Are they now doing enough for safety? Doubts are justified.
Nobody can ever say that the mid-air collision at Überlingen on 1st July 2002 came out of the blue:
On 4th January 2002, air traffic controllers at Geneva write a letter to Skyguide management criticizing the practice at Zurich to allow partial control of air space by only one instead of two controllers. “The consequences are far too serious to be ignored”. On 6th March 2002, Skyguide boss Alain Rossier is the recipient of mail from the Zurich controllers’ association. “We are writing in the face of the desolate situation at Zurich ATC (…). Given the current personnel situation, we are unable to fulfil our mission (…). “ The letter goes on to describe a “Wild West” mentality, with everyone doing their job their own way. On 10th March 2002 a number of controllers warn the head of Zurich ATC, stating, “The daily situation is one of chaos”. Working conditions are said to be “unbearable”. And: “it is hard to imagine that we shall get through summer without trouble”.
Within four months, 71 passengers have to pay for the safety issues at Skyguide with their lives. At the time of the mid-air collision, only one controller is on duty – his colleague is on a break. After the crash, the Swiss civil aviation authority (Bazl) stops this practice and outlaws single man operations.
Prior to the Überlingen crash and even thereafter, a fatal pattern emerges: management implements changes without consultation of its operations staff – often in order to save costs. Some controllers voice concerns about safety implications. Management ignores them out of hand. Complaints are met with pressure tactics; people are discredited or even fired. Bazl only intervenes once matters become public – i.e. when it’s too late. This kind of safety culture may be fine for a shoe factory, but in ATC, even the slightest concerns have to be considered and risks eliminated. This is not happening at Skyguide, as demonstrated by the following four examples:
Example 1: Near Miss due to SMOP
On 13th December 2001, not one but two near misses occur within 90 seconds of each other in Zurich air space, a consequence of controller task saturation. The controller involved has been assigned his sector on the basis of SMOP (single man operation), as there is a shortage of controllers on that day. Despite internal criticism, Skyguide management adheres to this system – until Bazl outlaws it after the Überlingen mid-air collision. Skyguide even today justifies its practice, saying SMOP is a “generally accepted ATC practice” and in use in 14 countries, pointing out that Switzerland is one of only a few countries (if not the only one) where SMOP is prohibited in principle.
Example 2: Chaos with Eastern approaches
On 23rd October 2006, Zurich introduces ILS for Rwy 28. This allows Kloten Airport to be approached not only from the North and South, but also from the East under poor visibility. On 10th October 2006, 36 out of 61 controllers in a letter to management demand that this project be stopped for safety reasons. They raise concerns that the procedure has not been fully reviewed and will provoke dangerously close distances between aircraft to the extreme. Whilst global practice is to disentangle departures and approaches, Zurich is doing the opposite. The new procedure would not allow any controller even the slightest margin of lapse or error.
Management reacts by inviting the sceptical controllers to a meeting. By pure coincidence or not: at the same time, a new code of conduct is issued which lists all kinds of repercussions – right up to dismissal. Article 1 of the new code points out that an investigation may be initiated even for “unacceptable conduct causing disharmony within operations”. According to Skyguide, a meeting with Aerocontrol (the controller’s union) results in having demonstrated that “the concerns voiced in the letter have already been taken into consideration and procedures amended accordingly.” Subsequently, half of the signatories to the letter withdraw their concerns, the others quietly fume.
The position of Aerocontrol becomes more transparent in the days immediately leading up to the Überlingen trial. The union tells its members to shut up. “We wish to remind you that any contact with the media is prohibited (….) we prefer a coordinated strategy in dealing with the media, in which we have control over all statements”.
Example 3: Planning gone wrong and its consequences
Skyguide management plan to concentrate the upper sphere of Swiss air space at a new Upper Airspace Centre (UAC) in Geneva, enabling a reduction in personnel and consequential savings. In October 2004, controllers voice concerns, because 30 jobs are to be axed at Zurich before the new UAC is even opened. The controllers have little confidence in the new project on the one hand, and also believe that the job cuts in Zurich will have serious safety implications if the UAC project cannot be implemented as planned.
The protest by controllers has little effect on Skyguide’s management. However, an anonymous letter is sent to Federal Councillor Mortiz Leuenberger, whose portfolio includes civil aviation. The letter, sent in January 2006, points to “mismanagement and a continuous string of wrong decisions which cause grave concern to its authors”. The writing controllers criticize what they term a “cost intensive and useless exercise” and point to safety issues. “Skyguide cannot afford a second Überlingen”.
Indeed: two days before it is to go online, Bazl intervenes and pulls the plug on UAC, stating that the system is neither fail-safe nor properly tested. In addition, there appears to be any proof of proper training of controllers. In general, Skyguide is accused of awarding sufficient priority to safety. As a direct result of the collapse of the UAC project, there are now only 165 air traffic controllers at Zurich (instead of 206). This blatant shortage can only increase the risk of errors.
Example 4: Firings
Two of the authors of the letter of 10th March 2002 (“it is hard to imagine that we shall get through summer without trouble”) are women. As supervisors of assistant controllers they have often criticized shortcomings in safety and management, for instance in the context of the UAC and of non-adherence to duty rules.
In September 2005, one of the women receives the shocking news from her physician that she is suffering from leukaemia; six months later, Skyguide fires her after 27 years of service and excellent qualifications, citing that she had repeatedly acted without loyalty and against the interests of the Company. Her colleague is fired under the same pretext.
Both women go to court, and the verdict by the Bülach District Court (the same court with jurisdiction over the Überlingen mid-air collision case) is expected this autumn. Skyguide says that the two firings have to be seen against the background of “other issues, which we cannot make public for legal reasons.”
During the Überlingen trial, Prosecutor Bernhard Hecht tore into Skyguide for its “deficient awareness of risk” at management level and its “climate of carelessness” at operations level. Management clearly saw a greater priority in efficiency – read “profit” – than in safety. He called Skyguide’s management poor role models, being “careless, uncritical and uncommunicative.”
Skyguide, however, point out that Bazl are far stricter and more rigorous in any international comparison. In view of the number of aviation accidents in recent Swiss transport history this could be understood and seen as reasonable. But, says Skyguide, the logical consequence of this change in policy means, “that we have to find the common ground between us again”.