'Just Culture'
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Descent to Jail!
To go further with interesting cases around the World.
Friend of mine living and working in Japan. he sent me an e-mail yesterday with part of original text from Japanese daily newspapers, english language version of course.
Japanese court sentenced one ATCO 12 months plus 3 years of suspension and OJTI ATCO 18 months plus 3 years suspension. They were working on Sector in ACC when air miss occurred a few years ago. They gave wrong descent instruction but STCA and MTCA didn't work properly. Due to lack of investment. Some software malfunction. Everybody knew for it but no one change it.
There are more countries in the world without or with undeveloped safety culture in aviation business than countries with correct approach.
My research told that only Denmark, Oz, NZ ( sorry if I omit someone,but it is not intentionall) have Safety Culture.
@ Divingduck ,
If you again need an explanation or translation,just tell me ,i will arrange something for you.
Friend of mine living and working in Japan. he sent me an e-mail yesterday with part of original text from Japanese daily newspapers, english language version of course.
Japanese court sentenced one ATCO 12 months plus 3 years of suspension and OJTI ATCO 18 months plus 3 years suspension. They were working on Sector in ACC when air miss occurred a few years ago. They gave wrong descent instruction but STCA and MTCA didn't work properly. Due to lack of investment. Some software malfunction. Everybody knew for it but no one change it.
There are more countries in the world without or with undeveloped safety culture in aviation business than countries with correct approach.
My research told that only Denmark, Oz, NZ ( sorry if I omit someone,but it is not intentionall) have Safety Culture.
@ Divingduck ,
If you again need an explanation or translation,just tell me ,i will arrange something for you.
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Just culture helps with bringing the organisation to account, not just the ATCO with the microphone. You pushed the button, it is your fault.... I do have experience in this area and I am providing evidence to defend ATCOs in various cases at the moment.
There are many safety cases around in ATC that are inadequate. The usual failings are those of inadequate risk criteria and risk optimisation criteria, poor hazard identification carried out by unqualified staff, poor quantification with that 5x5 matrix that does not stand-up to any real examination for big ATC related accidents, poor human error analysis, poor equipment reliability analysis, poor procedure design mistake analysis as well as poor risk monitoring. Don't even get started on the lack of safety cases for current operations and ignoring capacity increases as a change to the system.
The barrister's opening question to the author of the safety case of please outline your psychological, engineering and risk management qualifications to be the signatory of this document is a good one.
Beware public expectation!
There are many safety cases around in ATC that are inadequate. The usual failings are those of inadequate risk criteria and risk optimisation criteria, poor hazard identification carried out by unqualified staff, poor quantification with that 5x5 matrix that does not stand-up to any real examination for big ATC related accidents, poor human error analysis, poor equipment reliability analysis, poor procedure design mistake analysis as well as poor risk monitoring. Don't even get started on the lack of safety cases for current operations and ignoring capacity increases as a change to the system.
The barrister's opening question to the author of the safety case of please outline your psychological, engineering and risk management qualifications to be the signatory of this document is a good one.
Beware public expectation!
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There are many safety cases around in ATC that are inadequate. The usual failings are those of inadequate risk criteria and risk optimisation criteria, poor hazard identification carried out by unqualified staff, poor quantification with that 5x5 matrix that does not stand-up to any real examination for big ATC related accidents, poor human error analysis, poor equipment reliability analysis, poor procedure design mistake analysis as well as poor risk monitoring. Don't even get started on the lack of safety cases for current operations and ignoring capacity increases as a change to the system.
But how will that be achieved? People have to learn the skills that will result in good and well documented safety arrangements. This isn't going to happen overnight, it will take time, and a good number of other factors will come into play also.
But what the 'give me everything today' approach is doing is forcing people to try and do things that a book/auditor/condultant tells them they should be doing without understanding why or what the benefit is. Surely it is better to establish the principles in a way that makes sense and then, over time, to develop the processes where a clear benefit can be identified.
It might make you feel good to bandy phrases like 'inadequate risk optimisation criteria' around but unless those to whom you are preaching understand why you think there is a better way you are wasting your breath and, possibly, creating confusion in the minds of those who have yet to learn the basics.
Yes, the world is not perfect but if we want something useful at the end of all this we need to remember that you can't go for the best on day 1 and not everyone is at the same level of maturity as others. This applies to the establishment of a Just Culture as much as to pretty much every other element of good safety management.
As for
The barrister's opening question to the author of the safety case of please outline your psychological, engineering and risk management qualifications to be the signatory of this document is a good one.
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the case in Japan
IFATCA, FSF and IFALPA issued a joint press release on the Japan case this morning
Front line operators and Flight Safety Foundation criticize the conviction of two Air Traffic Controllers in Japan
http://www.atc-network.com/NewsItem-25459.aspx
Front line operators and Flight Safety Foundation criticize the conviction of two Air Traffic Controllers in Japan
http://www.atc-network.com/NewsItem-25459.aspx
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@ ATC Network,
It is maximum. Strong press release, they do not agree with, it is unacceptable for aviation professional associations, but ATCO and OJTI are still in prison. And they will stay there.
IFATCA has no any power other than to organize meetings at expensive and exotic places.
Do you remember case with Ukrainian ATCos?
It is maximum. Strong press release, they do not agree with, it is unacceptable for aviation professional associations, but ATCO and OJTI are still in prison. And they will stay there.
IFATCA has no any power other than to organize meetings at expensive and exotic places.
Do you remember case with Ukrainian ATCos?
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Yes but I also remeber a case over Zagreb 1976 where something was done. I'm not saying IFATCA can resolve this but it is a start to at least make such a statement.
Better than sitting back and saying '**** happens'.
Better than sitting back and saying '**** happens'.
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To be honest regarding Zagreb case,
ATCO( executive) was sent to jail first,but latter on when State ( ex SFRJ) realized that it would pay to insurance company damage( case is still in court) they released him from prison,and immediately return him to operational duties. Why? because-If he is guilty-than state is also guilty and state must pay for damage. I don't know and there is no comments here that IFATCA has done anything.
By the way,planer and assistant work( maybe some changes in recent times) in Zagreb,while executive died a few years ago in Belgrade, RIP.
ATCO( executive) was sent to jail first,but latter on when State ( ex SFRJ) realized that it would pay to insurance company damage( case is still in court) they released him from prison,and immediately return him to operational duties. Why? because-If he is guilty-than state is also guilty and state must pay for damage. I don't know and there is no comments here that IFATCA has done anything.
By the way,planer and assistant work( maybe some changes in recent times) in Zagreb,while executive died a few years ago in Belgrade, RIP.
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But should we sit back and do nothing? Or at least kick up some noise?
If i was a relative of the Japanese controllers I would hope someone was at least making some noise.
If i was a relative of the Japanese controllers I would hope someone was at least making some noise.
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Yes, But...
I haven't said that we (ATCOs) or IFATCA and unions should sit in chair and doing nothing. I just said that IFATCA had no really power to do anything serious. From my point of view the strongest position lies in ATCOs hand itself.
Read your contact seriously,do your homework before signing contract, find relevant infos about company and authorities ,and the last one you always should aware that sh... happens and in such cases only HIS MAJESTY(if you are religious) may help.
Read your contact seriously,do your homework before signing contract, find relevant infos about company and authorities ,and the last one you always should aware that sh... happens and in such cases only HIS MAJESTY(if you are religious) may help.
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Read your contact seriously,do your homework before signing contract, find relevant infos about company and authorities ,and the last one you always should aware that sh... happens
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My mistake,
I didn't explain it exactly. Point lies at the last part of sentence. Collect infos about company and appropriate authories.
It is always possible that problems(safety related) could happen. It is just question is it in your shift while you are logged in or you are log out. If it happens than it is better to work where Just culture or adequate SMS and critical stres management exist rather than ultra developed and sofisticated Japan.
I hope that now is Ok,
Best regards,
I didn't explain it exactly. Point lies at the last part of sentence. Collect infos about company and appropriate authories.
It is always possible that problems(safety related) could happen. It is just question is it in your shift while you are logged in or you are log out. If it happens than it is better to work where Just culture or adequate SMS and critical stres management exist rather than ultra developed and sofisticated Japan.
I hope that now is Ok,
Best regards,
