High court finds air traffic controllers guilty over JAL near miss accident
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High court finds air traffic controllers guilty over JAL near miss accident
Knowing that "the search function is my friend" (thanks Jerrico), I've taken a look around venerable PPRuNe, but have not yet seen this reported...
The Tokyo High Court has found the two ATCers involved in the 2001 JAL near-miss guilty of "professional negligence resulting in injury" and sentenced them to (suspended) jail time.
http://mdn.mainichi.jp/national/news...na013000c.html
I considered posting this in a criminalization or related thread, but thought it might better foster discussion on its own. This sort of reaction to a callsign screw-up cannot bode well for our chosen profession...
Dave
The Tokyo High Court has found the two ATCers involved in the 2001 JAL near-miss guilty of "professional negligence resulting in injury" and sentenced them to (suspended) jail time.
http://mdn.mainichi.jp/national/news...na013000c.html
I considered posting this in a criminalization or related thread, but thought it might better foster discussion on its own. This sort of reaction to a callsign screw-up cannot bode well for our chosen profession...
Dave
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Thanks for sharing this av8boy and shame,shame on the Japanese legal system. Simply outrageous. I wonder when they find out that HE made a mistake in his judgement would HE be sentenced to 3 years in prison!
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Just as we attempt to foster this so called 'just culture', we are hit squarely between the eyes with the old 'hang 'em high' attitude. This judge has a very poor understanding of the profession if he/she thinks that the handing down of such a sentence could ever improve safety standards. All it does is create anxiety and paranoia, traits which do not lend themselves to positive controlling.
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yeah the decision is especially questionable since they were found not guilty in the first trial (2006) and then guilty on appeal hearing.
certainly has me thinking twice about taking any more trainees (8% does not offset the risk of a jail term)
undervalued_ATC.
ps. can anybody explain to me how our profession came to use the phrase "near-miss" for 2 planes in close proximity that don't collide? I mean, if you nearly miss something, does'nt that mean you actually hit it, just?
certainly has me thinking twice about taking any more trainees (8% does not offset the risk of a jail term)
undervalued_ATC.
ps. can anybody explain to me how our profession came to use the phrase "near-miss" for 2 planes in close proximity that don't collide? I mean, if you nearly miss something, does'nt that mean you actually hit it, just?
... most of the time
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Hmm 
Courts have shown themselves time and again not to grasp fully the subtleties of ATC. Maybe there's more to the story but it seems to me that this is the daftest one ever - a trainee gets a suspended sentence!
And for an airprox too. What would he have faced if the aircraft collided?
The gallows?
How is anyone supposed to learn to do the job properly if every mistake carries the threat of jail time?
They won't be queueing up to become OJTI in Japan. And I bet they won't be inundated with replies on the next student controller intake.
It's the kind of short-sighted ruling that could be handed down by a court in any country, however, so we should all take note.
Courts have shown themselves time and again not to grasp fully the subtleties of ATC. Maybe there's more to the story but it seems to me that this is the daftest one ever - a trainee gets a suspended sentence!
And for an airprox too. What would he have faced if the aircraft collided?
The gallows?
How is anyone supposed to learn to do the job properly if every mistake carries the threat of jail time?
They won't be queueing up to become OJTI in Japan. And I bet they won't be inundated with replies on the next student controller intake.
It's the kind of short-sighted ruling that could be handed down by a court in any country, however, so we should all take note.
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I wonder what would happen the next time the JUDGE turned a rapist loose who was guilty, and then they did it again... could we send the judge to prison for his error in judgement?
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What if the student studying law made a mistake during his/her practising at some court ?
Is there a tendency nowadays to think that decisions should be perfect from the beginning?
What is the sentence that should be given to bankers or managers when they
err on behalf of their company so that the company or national economy loses billions?
And as a result some people lose jobs, lose their homes, and ultimately
lose their hope for the future. How many lives will be lost? Who
should be blamed for all this? If there is no criminal activity involved , then
not a single person should EVER be blamed.
Everybody should only be appreciated for doing their best.
Regardless of the outcome. The next time somebody will have learned something.
Should the managers and leaders not make mistakes ever?
Common sense tells us that mistakes are a powerfull way of learning.
If mistakes are forbidden by threats of legal actions, then how on earth will
a society go towards the way of a better future then?
If/when the computers do the job for the human (i.e. decisions), the
mistakes most likely will be called programming errors. Who should be
blamed then? The systems designer or the programmer or the user?
Not a single person.
There is most likely a manager who approved the training system for
the Japanese controllers. I think they should only be appreciated for their actions.
Or inactions.
There is a person responsible for designing the structure of how the
controllers are trained.
How about them?
There is somebody responsible for designing an airspace, where
there are possibilities for occurrences.
They should also be free to do their work enhancing safety.
If it is humanly possible to design a flawless air space structure
why has it not been implemented?
If it is humanly possible to do one's work without any mistakes,
why is that person not yet found?
Is it possible to find a student, who does not make errors?
The person who has the courage to take the initiative and make
the daily decisions in the challenging ATC world should only be encouraged.
The person who has the courage to learn by doing should only be appreciared.
Only this way it is in sync with the theories of how human beings learn and implement
effectively the things they learned.
The results that arise from an "Appreciative culture" are far better
than those from a "blamin' and a flamin' culture".
"Appreciative culture" or "Just-Culture" or "AP-Culture" is a working culture where everybody
gives their contribution for the safety and everybody is appreciated for
doing exactly that.
If anyone wants the safety NOT to get better, then the best way of
doing it is to implement a culture with very harsh criticism,
punishments and threats of litigations.
(Does this sound familiar to anybody...)
There is a REASON why "AP-culture" (Appreciative culture) is justified in ATC.
"AP-Culture" leads to FAR BETTER SAFETY.
Is there any way to lobby these legal systems people to think humanly?
If there is a possibility to interpret the laws so that making a mistake
is illegal, then should the laws be written more clearly to prevent this?
All the help should be given to the Japanese ATCOs so that they
can continue their good work for better safety in the skies,
in the spirit of appreciating everyones' work.
Is there a tendency nowadays to think that decisions should be perfect from the beginning?
What is the sentence that should be given to bankers or managers when they
err on behalf of their company so that the company or national economy loses billions?
And as a result some people lose jobs, lose their homes, and ultimately
lose their hope for the future. How many lives will be lost? Who
should be blamed for all this? If there is no criminal activity involved , then
not a single person should EVER be blamed.
Everybody should only be appreciated for doing their best.
Regardless of the outcome. The next time somebody will have learned something.
Should the managers and leaders not make mistakes ever?
Common sense tells us that mistakes are a powerfull way of learning.
If mistakes are forbidden by threats of legal actions, then how on earth will
a society go towards the way of a better future then?
If/when the computers do the job for the human (i.e. decisions), the
mistakes most likely will be called programming errors. Who should be
blamed then? The systems designer or the programmer or the user?
Not a single person.
There is most likely a manager who approved the training system for
the Japanese controllers. I think they should only be appreciated for their actions.
Or inactions.
There is a person responsible for designing the structure of how the
controllers are trained.
How about them?
There is somebody responsible for designing an airspace, where
there are possibilities for occurrences.
They should also be free to do their work enhancing safety.
If it is humanly possible to design a flawless air space structure
why has it not been implemented?
If it is humanly possible to do one's work without any mistakes,
why is that person not yet found?
Is it possible to find a student, who does not make errors?
The person who has the courage to take the initiative and make
the daily decisions in the challenging ATC world should only be encouraged.
The person who has the courage to learn by doing should only be appreciared.
Only this way it is in sync with the theories of how human beings learn and implement
effectively the things they learned.
The results that arise from an "Appreciative culture" are far better
than those from a "blamin' and a flamin' culture".
"Appreciative culture" or "Just-Culture" or "AP-Culture" is a working culture where everybody
gives their contribution for the safety and everybody is appreciated for
doing exactly that.
If anyone wants the safety NOT to get better, then the best way of
doing it is to implement a culture with very harsh criticism,
punishments and threats of litigations.
(Does this sound familiar to anybody...)
There is a REASON why "AP-culture" (Appreciative culture) is justified in ATC.
"AP-Culture" leads to FAR BETTER SAFETY.
Is there any way to lobby these legal systems people to think humanly?
If there is a possibility to interpret the laws so that making a mistake
is illegal, then should the laws be written more clearly to prevent this?
All the help should be given to the Japanese ATCOs so that they
can continue their good work for better safety in the skies,
in the spirit of appreciating everyones' work.
Last edited by Slo Moe; 28th Apr 2008 at 07:36. Reason: Correcting some thoughts
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Appeals?
Does anybody know, if there is any possibility for the Japanese
ATCO:s to appeal? I am not an expert in legal systems.
All our support might be needed to reverse the verdict.
All ATCO:s that work today or have been working in the past
know that the persons in this case deserve to go free and
continue their work.
ATCO:s to appeal? I am not an expert in legal systems.
All our support might be needed to reverse the verdict.
All ATCO:s that work today or have been working in the past
know that the persons in this case deserve to go free and
continue their work.
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Use of phrase "near miss"...
Hi Undervalued ATC... This is always a bone of contention for me...
Within the centre making use of the term "near miss" nearly ALWAYS results in some sarcastic comment saying, "Well, where did they hit?"
My take on it however is "near" is is more akin to "narrow" and not "almost". To say a "narrow miss" would be completely acceptable...
Sorry, rant over
(Sheepish face)
Back on the topic though, I wish them the best of luck... I see in the article there was some reference to their lawyers appealing the decision again... I'll be holding thumbs
Within the centre making use of the term "near miss" nearly ALWAYS results in some sarcastic comment saying, "Well, where did they hit?"
My take on it however is "near" is is more akin to "narrow" and not "almost". To say a "narrow miss" would be completely acceptable...
Sorry, rant over
(Sheepish face)Back on the topic though, I wish them the best of luck... I see in the article there was some reference to their lawyers appealing the decision again... I'll be holding thumbs
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How to foster collaboration?
Good point Skyjuggler!
Choice of words is actually more important than we might
think. The choice of words actually do contribute to our
processes of thought.
These next contributing questions might need some pondering.
All this is destined to get rid of the unnecessary trials
and unnecessary newspaper stories all because of inadequate
resources etc.
How to get proper tools for the ATCOs, and how to get enough ATCOs ?
How to ignite the will to co-operate across corporate boundaries ?
How to convince the decisionmakers that it is far better for the
business to be proactive and allocate enough resources in time
(more ATCOs on the seats) than the other options?
Most likely the scenario that we want to see managers doing is something like this:
1. Observing the operation environment. (To find spots needing decisive action from managers)
2. A challenge is observed. (For instance changing weather patterns around the world)
3. A solution is devised (E.g. More Atcos, to ensure safe handling of traffic, when weather is more unpredictable)
4. Action is taken (Recruiting more student ATCOs and training them)
5. Go to step 1.
Lo and behold, isn't that actually the way that many ATCOs work?
It is a very very efficient procedure, with good results that's for sure.
That has helped to keep my license, I can tell you that.
Decision making made simple. Might write a book about it...
We can convince the managers/decision makers to follow
the same kind of procedure. What do you think?
The question is:
How can we convince the managers to adapt this decision pattern to their "toolkit"?
(Try something like: it is cost efficient, it is fast,
it keeps the litigations quite quite far away,
which keeps the newspapers writing on something else, which
brings more travellers flying, which keeps the company income healthy,
which makes the company value go up instead of other directions etc...)
The more detailed answers we come up with the merrier.
Choice of words is actually more important than we might
think. The choice of words actually do contribute to our
processes of thought.
These next contributing questions might need some pondering.
All this is destined to get rid of the unnecessary trials
and unnecessary newspaper stories all because of inadequate
resources etc.
How to get proper tools for the ATCOs, and how to get enough ATCOs ?
How to ignite the will to co-operate across corporate boundaries ?
How to convince the decisionmakers that it is far better for the
business to be proactive and allocate enough resources in time
(more ATCOs on the seats) than the other options?
Most likely the scenario that we want to see managers doing is something like this:
1. Observing the operation environment. (To find spots needing decisive action from managers)
2. A challenge is observed. (For instance changing weather patterns around the world)
3. A solution is devised (E.g. More Atcos, to ensure safe handling of traffic, when weather is more unpredictable)
4. Action is taken (Recruiting more student ATCOs and training them)
5. Go to step 1.
Lo and behold, isn't that actually the way that many ATCOs work?
It is a very very efficient procedure, with good results that's for sure.
That has helped to keep my license, I can tell you that.
Decision making made simple. Might write a book about it...
We can convince the managers/decision makers to follow
the same kind of procedure. What do you think?
The question is:
How can we convince the managers to adapt this decision pattern to their "toolkit"?
(Try something like: it is cost efficient, it is fast,
it keeps the litigations quite quite far away,
which keeps the newspapers writing on something else, which
brings more travellers flying, which keeps the company income healthy,
which makes the company value go up instead of other directions etc...)
The more detailed answers we come up with the merrier.
Last edited by Slo Moe; 10th May 2008 at 10:59. Reason: Some clarifications
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Sloe Moe... May I suggest that you reveal your professional interest? You have written a number of long postings recently, all of which suggest that many more ATCOs are needed. Those of us in the profession have known this for 30+ years, but little has been done about it. What specific interest do you have? Are you a pilot or ATCO? (I seriously doubt either) or are you just an intested passenger?
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H.D.
With all due respect,
since it has been known for 30+ years, it does not imply
that it is a law of nature, does it? (It is an attitude, isn't it?)
The professional interest is that I have noticed same kinds of
trends in several ATC units. I find it something that can be altered.
I have ATC working experience in 2 different countries in
several ATS units. And the postings here indicate same kind of notions
I have made personally in other countries also. My TWR experience is
from so many years ago, that I am very careful posting to those threads.
What more would you like to know ?
Are you referring to the fact that my "handle", the nickname I use
was inadvertently used by some other, or would you please be kind
to elaborate ? (My handle is Slo Moe the other was SloMoe)
My professional interest is to contribute to positive development.
I am also genuinely interested in helping a colleague.
(Sort of "humane" interest, so to say.)
Apologies for the length of my postings, also some of the
thoughts can be interpreted as "off topic" (Sorry for that).
With all due respect,
since it has been known for 30+ years, it does not imply
that it is a law of nature, does it? (It is an attitude, isn't it?)
The professional interest is that I have noticed same kinds of
trends in several ATC units. I find it something that can be altered.
I have ATC working experience in 2 different countries in
several ATS units. And the postings here indicate same kind of notions
I have made personally in other countries also. My TWR experience is
from so many years ago, that I am very careful posting to those threads.
What more would you like to know ?
Are you referring to the fact that my "handle", the nickname I use
was inadvertently used by some other, or would you please be kind
to elaborate ? (My handle is Slo Moe the other was SloMoe)
My professional interest is to contribute to positive development.
I am also genuinely interested in helping a colleague.
(Sort of "humane" interest, so to say.)
Apologies for the length of my postings, also some of the
thoughts can be interpreted as "off topic" (Sorry for that).
Last edited by Slo Moe; 19th May 2008 at 07:13. Reason: Question mark
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The thing I am personally thinking is that
could it be possible, that a major
factor for the incident that started this thread
is lack of ATCOs?
If so, then we would like to have a different
future than the one where ATCOs would be
accused tried and sentenced
for the managerial mistakes, wouldn't we?
That is one trend that I would like to turn to some other
directions. And it can be done. That I am 100% sure of.
There are many calls from time to time
about periodic lack of personnel in many units.
Even on this forum. The reasons vary, but can be traced
quite much back to fiscal reasons (saving money).
Once again I am not in a position to point the finger.
It is clearly a managerial attitude. I have been training
ATCOs so that I might have an opinion that attitudes
can and will be changed, when they are harmful.
could it be possible, that a major
factor for the incident that started this thread
is lack of ATCOs?
If so, then we would like to have a different
future than the one where ATCOs would be
accused tried and sentenced
for the managerial mistakes, wouldn't we?
That is one trend that I would like to turn to some other
directions. And it can be done. That I am 100% sure of.
There are many calls from time to time
about periodic lack of personnel in many units.
Even on this forum. The reasons vary, but can be traced
quite much back to fiscal reasons (saving money).
Once again I am not in a position to point the finger.
It is clearly a managerial attitude. I have been training
ATCOs so that I might have an opinion that attitudes
can and will be changed, when they are harmful.
Last edited by Slo Moe; 12th May 2008 at 06:24. Reason: contributing->major, change of place of words of "back" and "to"
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Back to track
P... et al.
High court finds air traffic controllers guilty over JAL near miss accident
I am sorry, but I think this was the topic. So, if you do not mind
I would steer back to this topic. We could think that there is some
importance in this matter. There was another article from the
States on another ruling. So is it a trend or a coincidence?
If it is an international trend, then should we do something about it?
Even small contributions might change the trend at this point.
So I'll print the rest of this posting using a different font.
The choice is yours, if you wish to proceed or contribute.
I chose to contribute and concentrate on this case on FCFF principle
(First Case First Free), and because freedom is important, I think.
This is a lengthy posting, I have done only a couple of courses
in law (aviation law, basic juridical course, and business and
contract laws). So in legal matters I am more or less a layman.
I know that there most likely is an ATCO somewhere with a lawyer
education also.
Somehow we could try to build some facts to help the colleague.
I had to make some speculations on earlier postings also, since
all the background information was not in the articles.
I apologize to defend only the colleague, not the other juridical
entities, had to make some choices. Actually it would be
the best for the company also to help the ATCO be free of charges.
The sentence would most likely make the rest of the ATCOs very very careful
to work very very safe (let's say add some extra to the separation minima,
we're humans for heaven's sake: This will lead to traffic congestion. And
that is not the thing what we want, is it? This kinds of trends we all want to
turn.
We all want to walk free. We all want that traffic flows nice and easy.)
It would be the best for all of us to see the ATCO and the trainee walk
and work free of any charges.
The managerial decisions are partly involved in almost all the incidents that
I know of. The managerial decisions are building the safety net for the
traffic and also behind the chairs on which the ATCOs sit. Those very
decisions are the sole responsibility of the juridical entity called
"the company", where usually this task has been delegated to the DG/CEO
or what ever the title is. He/she might have delegated some tasks to some
other persons.
Usually the laws dictate that the responsiblity can not be delegated, though.
How good is the net then? How wide are the holes on the net?
It is quite easy to pour the sole juridical responsibility on a person, if and
when there are deficiencies in the system. The point is that can this
happen again, if only a person is put away? It might be very wise to
understand that it does not help in building a better system, it does
not help in building or keeping the image of ATC as a profession
(The quality of the material that seeks to the ATC profession might change
to unwanted directions) it does not help in keeping the image of the ANSP
concerned in being a responsible employer.
Quite the contrary.
The ATCO is usually not responsible for designing the work environment.
(E.g. The noises in the background can be distracting, if not taken care of
by local rules and constructional design decisions, how about the lighting
conditions; glares reflecting from the lights on the tubes, when the
instructor is standing by the trainee)
The ATCO is usually not responsible for the rostering.
(How well has the management taken care of the rest periods, if the task
is delegated to someone, then how good training do they have on the
issues concerning fatigue, critical stress management etc...)
Since this incident happened in training, how about the tools and abilities of
the controller? The ATCO is usually not responsible for his/her personal training,
because of the nature of knowledge required in giving training is quite out
of bounds of the ATCO training. This can be clearly evidenced by the
training diaries, that are usually mandatory even on the basic ATC courses
and ACC courses. (Did she have enough training from the employer for the
demanding task of the OJT. E.g. Work psychology, critical stress
management, basic pedagogic training etc.?)
Was the equipment that was used good enough to the task in the ATC facility?
(Does the radar have MTCD or STCA, did the trainee get any training before
entering the OJT, did the trainee get any training about the equipment
before entering the OJT? It is a very demanding and distracting task to do
OJT and equipment training at the same time, in busy traffic it is next to
impossible.)
Let's help them be free. More ideas?
High court finds air traffic controllers guilty over JAL near miss accident
I am sorry, but I think this was the topic. So, if you do not mind
I would steer back to this topic. We could think that there is some
importance in this matter. There was another article from the
States on another ruling. So is it a trend or a coincidence?
If it is an international trend, then should we do something about it?
Even small contributions might change the trend at this point.
So I'll print the rest of this posting using a different font.
The choice is yours, if you wish to proceed or contribute.
I chose to contribute and concentrate on this case on FCFF principle
(First Case First Free), and because freedom is important, I think.
This is a lengthy posting, I have done only a couple of courses
in law (aviation law, basic juridical course, and business and
contract laws). So in legal matters I am more or less a layman.
I know that there most likely is an ATCO somewhere with a lawyer
education also.
Somehow we could try to build some facts to help the colleague.
I had to make some speculations on earlier postings also, since
all the background information was not in the articles.
I apologize to defend only the colleague, not the other juridical
entities, had to make some choices. Actually it would be
the best for the company also to help the ATCO be free of charges.
The sentence would most likely make the rest of the ATCOs very very careful
to work very very safe (let's say add some extra to the separation minima,
we're humans for heaven's sake: This will lead to traffic congestion. And
that is not the thing what we want, is it? This kinds of trends we all want to
turn.
We all want to walk free. We all want that traffic flows nice and easy.)
It would be the best for all of us to see the ATCO and the trainee walk
and work free of any charges.
The managerial decisions are partly involved in almost all the incidents that
I know of. The managerial decisions are building the safety net for the
traffic and also behind the chairs on which the ATCOs sit. Those very
decisions are the sole responsibility of the juridical entity called
"the company", where usually this task has been delegated to the DG/CEO
or what ever the title is. He/she might have delegated some tasks to some
other persons.
Usually the laws dictate that the responsiblity can not be delegated, though.
How good is the net then? How wide are the holes on the net?
It is quite easy to pour the sole juridical responsibility on a person, if and
when there are deficiencies in the system. The point is that can this
happen again, if only a person is put away? It might be very wise to
understand that it does not help in building a better system, it does
not help in building or keeping the image of ATC as a profession
(The quality of the material that seeks to the ATC profession might change
to unwanted directions) it does not help in keeping the image of the ANSP
concerned in being a responsible employer.
Quite the contrary.
The ATCO is usually not responsible for designing the work environment.
(E.g. The noises in the background can be distracting, if not taken care of
by local rules and constructional design decisions, how about the lighting
conditions; glares reflecting from the lights on the tubes, when the
instructor is standing by the trainee)
The ATCO is usually not responsible for the rostering.
(How well has the management taken care of the rest periods, if the task
is delegated to someone, then how good training do they have on the
issues concerning fatigue, critical stress management etc...)
Since this incident happened in training, how about the tools and abilities of
the controller? The ATCO is usually not responsible for his/her personal training,
because of the nature of knowledge required in giving training is quite out
of bounds of the ATCO training. This can be clearly evidenced by the
training diaries, that are usually mandatory even on the basic ATC courses
and ACC courses. (Did she have enough training from the employer for the
demanding task of the OJT. E.g. Work psychology, critical stress
management, basic pedagogic training etc.?)
Was the equipment that was used good enough to the task in the ATC facility?
(Does the radar have MTCD or STCA, did the trainee get any training before
entering the OJT, did the trainee get any training about the equipment
before entering the OJT? It is a very demanding and distracting task to do
OJT and equipment training at the same time, in busy traffic it is next to
impossible.)
Let's help them be free. More ideas?
Last edited by Slo Moe; 17th May 2008 at 19:25. Reason: the responsiblity can not be delegated, flow of traffic, FCFF.
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With the vision of the trainee and ATCO concerned walking happily and free.
Their actions are understood to be correct in the circumstances concerned.
Could this help to illustrate what we mean by safety networks?
More ideas?
BTW seems as if the original link is not working at this moment.
Their actions are understood to be correct in the circumstances concerned.
Could this help to illustrate what we mean by safety networks?
More ideas?
BTW seems as if the original link is not working at this moment.
Last edited by Slo Moe; 19th May 2008 at 07:15. Reason: happily, link missing, second line