EU authorities seek to promote air safety; risk of prosecution silencing employees

[PJ2]

EU authorities seek to promote air safety

BRUSSELS, Belgium (http://www.iht.com/articles/ap/2008/09/05/europe/EU-FEA-Belgium-Aviation-Safety.php#): The Delta Airlines Boeing 767 was cleared for takeoff and started rolling when the pilots spotted a 747 jumbo jet being towed across their runway. They hit the brakes and turned onto an adjacent taxiway.

The incident in 1998 at Amsterdam's Schiphol Airport caused only a brief departure delay for the Delta jet. Controllers reported the aborted takeoff — later determined to have resulted from poor visibility and a misunderstanding of the position of the towing truck by a trainee controller — and measures were taken to prevent any repeat.

But two years later, Dutch prosecutors brought criminal negligence charges against three controllers. Lengthy legal proceedings led to their eventual conviction, although no sentence was imposed and the controllers later returned to their jobs.

"The immediate result of that prosecution was that voluntary reporting of safety incidents in the Netherlands broke down overnight, and the number of reports dropped by 50 percent," said Fiona McFadden, a spokeswoman for the European Cockpit Association, a pilots' umbrella group.

Analysts say that the prompt identification of errors or hazards and potential or actual incidents are a fundamental element of air safety management. But recent surveys have revealed that in Europe and elsewhere, such incidents are increasingly going unreported because aviation professionals fear prosecution or punishment by management for their supposed mistakes.
Balance of the article at:
EU authorities seek to promote air safety - International Herald Tribune (http://www.iht.com/articles/ap/2008/09/05/europe/EU-FEA-Belgium-Aviation-Safety.php)

[fireflybob]

All I can say is that this trend is a giant leap backwards for aviation safety - all part of the blame culture one suspects.

[Say again s l o w l y]

Yep. A no blame culture to mistakes is what has always been sensible, that way we all learn from the inevitable mistakes that all of us make.

If someone is an incompetent twonk and willfully breaks rules and puts people in danger, then yes prosecution might be an answer, but not for things like this.

It was a potentially very serious incident, but now thanks to it having been reported, it is less likely to happen again and surely that is the point of "safety management". We can never be 100% free of accidents or mistakes all you can do is to try and minimise the impact of them. That only happens by education not by hitting people over the head with the threat of prison.

[manrow]

I don't think it is part of the blame culture.

It has certainly taken us backwards by many years and is a total misunderstanding of the benefit to be gained from individuals concerned being able to tell the exact truth on what happened.

I am reminded of the anon quotation:-

He who never makes a mistake cannot be doing anything!

[WHBM]

A no-blame culture means loss of income for lawyers. Therefore they will never allow it to happen.

[yamaha]

A no blame culture is a ridiculous ideal and has been pushed by those who haven't paid attention.

A just culture is the way forward where one can learn lessons from a genuine mistake without fear of retribution but wilful neglect or incompetence will be punished.

[low n' slow]

Yamaha: isn't that what the no-blame culture has allways been about? It takes for granted that everyone does their best to follow the rules and regulations.

As for incompetence, in our buisness we all risk finding ourselves in situations that are above us and our capacity. In those situations an honest struggle to rectify the situation must be sufficient to avoid being prosecuted?

/LnS

[Piltdown Man]

Unfortunately, there are a minimum of two bodies who investigate incidents and accidents in the Netherlands. The real investigators and the Justice Department. The latter are a bunch of knob-heads who are out to nail anybody. The worse part is that they follow the real investigators and re-use the evidence they assemble and re-interpret it in their own way - even if the real professionals have a contratry opinion. If they determine that they can stiff you, they will. Good system eh!

PM

[6chimes]

All the posts so far seem to refer to an ideal situation where we can report ourselves for the mistakes we make and be absolved from any action against us based on the notion that we are helping to make flying safer for all. On top of that we only use incidents where the implications could of been clearly catastrophic, so it would appear to be a 'no brainer'.

However, what is being overlooked here is this; the commercial pressures that all airlines are under have made safety a 'risk assessment' exercise based upon 'known' factors and the financial cost. When an incident occurs that is outside of the 'known' envelope the airline bosses have evolved a culture that allows there conscience to fall back on the legal minimums given to them from the relevant authorities. Regardless of them being told by the folks that do the job that something is not all as it should be, but because their competitors are operating to lesser and cheaper standards but still not contravening any regulations they have to follow to survive.

This culture leads to micro management and rigorous enforcement by the management. All those little errors that should be reported to monitor trends and pick up indicators go unreported because the employee fears a draconian response to their mistake. Consequently you end up with a culture where people feels that covering something up is the best course of action.

Sorry this reply has got a lot longer than I intended. The point is this, whilst it may seem obvious that major incidents are reported, when you have a culture of fear and therefore silence on the minor stuff. Do not be surprised when it does not happen.

6

[lomapaseo]

This culture leads to micro management and rigorous enforcement by the management. All those little errors that should be reported to monitor trends and pick up indicators go unreported because the employee fears a draconian response to their mistake. Consequently you end up with a culture where people feels that covering something up is the best course of action.

I would like to see a flow chart that identifies where, whom and how critical information is being covered up. As in all critical systems that have filters, there should be a by-pass.

OTOH, maybe the filter is doing its job and letting only the safety critical items get through

[mercurydancer]

6chimes

There is a way to reverse the trend you state... that is to punish covering up far more harshly than the consequences of telling it straight. Everyone has the capability to do something that under scrutiny appears stupid or incompetent and this should be accepted as even the most catastrophic mistakes arent usually made individually but as part of a chain of events.

Falsehood isnt stupidity or incompetence and as such the cases where people have been disciplined, licences revoked etc have overwhelmingly been cases where there has been dishonesty and not an honest mistake. That principle applies to management enforcing a bad decision too....

[Admiral346]

Unfortunately, there are a minimum of two bodies who investigate incidents and accidents in the Netherlands. The real investigators and the Justice Department. The latter are a bunch of knob-heads who are out to nail anybody.

Well, this happened in BELGIUM, not the NETHERLANDS.



On the other hand, how incidents are handled at BRU seems to be a joke, it is one of the airports making me sit tight in my seat, trying to catch the mistakes made by all the others, not just my own.

Be it an aircraft busting it's altitude, coming straight at me with a mnm of 500' separation and the comment from the controler being "well, I guess he didn't fly his altitude" iso immediate avoidance vectors (does not the short term conflict thing blink and sound at the ATCO's board?), or be it just the fact, that a single controller is doing ALL the arrivals and departures of BRU that provoces my fear and anger when flying into the capital of Europe! Things need to be handled a bit tighter there, it thinks me! So maybe an offical investigation of another seperation bust doesn't really harm the situation, but maybe shakes a few people up, to get their act together!

My tolerance for errors at BRU is depleted, and anything will be brought to the full attention of the authorities.

Nic

[blackboard]

A discussion on this matter was posted here

http://www.pprune.org/rumours-news/343060-aviation-safety-jeopardised-judges.html

[Admiral346]

I have to excuse myself, I did overread the article too fast:

Of course it all happened at AMS, and AMS is an example of a well run airport (at least ATC-wise), I feel safe operating in and out of this field.

Sorry,

Nic

[manrow]

A good post

"Yep. A no blame culture to mistakes is what has always been sensible, that way we all learn from the inevitable mistakes that all of us make.

If someone is an incompetent twonk and willfully breaks rules and puts people in danger, then yes prosecution might be an answer, but not for things like this."

But no-one is listening ............................................. ?

[PJ2]

Flight Safety Foundation (FSF) Calls for Stronger Protection of Volunteered Aviation Safety Information

Oct. 30, 2008, Honolulu, HI – In the wake of recent judicial decisions forcing disclosure of voluntarily supplied aviation safety information, and the use of aviation accident investigation reports in civil litigation and criminal prosecutions, the Flight Safety Foundation (FSF) today announced its support for statutory protection against the release or use of information gathered by voluntary self-disclosure reporting programs.

“We can and must do everything possible to ensure the continued flow of critical safety information that is increasingly coming under assault in courts around the world, ” said FSF President and CEO William R. Voss.

In remarks here before the FSF International Air Safety Seminar, FSF General Counsel Kenneth P. Quinn yesterday noted the increasing tendency to criminalize aviation accidents and said, “Since prosecutors and courts are not protecting the confidentiality of voluntarily supplied safety information, legislatures need to step in to prevent critical sources of safety data from drying up.”

FSF today endorsed the creation of a “qualified exception” from discovery of voluntary self-disclosure reporting programs, similar to the protection already provided in U.S. law against use of cockpit voice recorder (CVR) and surface vehicle recordings and transcripts. Examples of such voluntary self-disclosure reporting programs include the Aviation Safety Action Program (ASAP), the Flight Operational Quality Assurance program (FOQA), and the Aviation Safety Information Analysis and Sharing (ASIAS) system.

Airlines and regulators increasingly are using these and other tools to obtain predictive information that allows preemptive interventions to be developed to mitigate threats revealed by the data instead of relying on forensic evidence after a crash. “We cannot tolerate waiting for a crash to show us there is a safety problem that needs to be fixed,” said Voss.

By most estimates, nearly 98% of safety information currently obtained from voluntary disclosure programs would not be available if program participants are exposed to prosecution and reprisal.

FSF recommends the adoption of stronger protections to shield such information from disclosure in any judicial proceeding, except to allow limited discovery when a court decides that the requesting party has demonstrated a particular need for the information, and that the party would not receive a fair trial if the information is not provided. If discovery is permitted, FSF urged that it only be made available under protective order, and not generally be made available to the public.

The FSF announcement comes on the heels of reports that American Airlines and its pilot union are considering abandoning their 14-year old ASAP program, and a judicial decision concerning the 2006 Comair crash in Lexington, KY, that ordered the release of ASAP reports, saying that Congress had the power to protect the ASAP information, as it had with CVR recordings and transcripts, but had not done so. Further, several recent criminal prosecutions in Europe have sought to establish criminal culpability through the use of information voluntarily provided to accident investigators.

Flight Safety Foundation has published several articles outlining the importance of these reporting programs in AeroSafety World, (http://www.flightsafety.org/asw/july07/asw_july07_p12-21.pdf) and (http://www.flightsafety.org/asw/mar08/asw_mar08_p12-17.pdf), and in news releases defending the confidentiality of these programs (http://www.flightsafety.org/news/nr97-07.pdf). The Foundation was one of the earliest supporters of ASAP programs.

Flight Safety Foundation is an independent, non-profit, international organization engaged in research, auditing, education, advocacy and publishing to improve aviation safety. The Foundation’s mission is to pursue the continuous improvement of global aviation safety and the prevention of accidents. http://www.flightsafety.org