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ATC gets criminal sentence for AIRPROX

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ATC gets criminal sentence for AIRPROX

Old 23rd Nov 2018, 06:59
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ATC gets criminal sentence for AIRPROX

Via google translate (sorry could not find an English version online).

The Swiss supreme court upheld the criminal conviction of an air traffic controller who caused - apparently through neglect - an AIRPROX incident in 2013. Apparently a Ryanair pilot was also charged and convinced in the same case but he did not appeal.

Is it common practice to refer ATC to criminal justice in such occurrences ? Anyone knows more about this case ?

Last edited by atakacs; 23rd Nov 2018 at 07:04. Reason: typo
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Old 23rd Nov 2018, 11:30
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I’m not sure but this should be the final report of this particular incident; https://www.sust.admin.ch/inhalte/AV...hte/2211_e.pdf

The only one in 2013 involving TAP and RYR...

From Skyguide regarding Just Culture https://www.skyguide.ch/en/company/safety/

”As has been proven, providing trust and adequate protection for all the individuals involved in aviation (and other safety-relevant fields) encourages them to adopt and maintain the best possible attitude and approach to errors.

Anyone at skyguide who acts in their work to the best of their knowledge and belief need have no fear of disciplinary or legal proceedings as a result of their actions and activities. And everyone is free to report any problems openly and comprehensively – including errors of their own. At the same time, skyguide does not accept deliberate harm, gross negligence or willful damaging behavior.”

I assume they looked at this as “gross negligence”? Mistakes are human and everyone makes them, most are spotted and corrected. If management is, after an incident, deeming something as gross negligence and handing it to the courts that’s an unfortunate development and counterproductive to safety.

The report states that at the time of the incident the volume of traffic was “very high”.


Last edited by SThor; 23rd Nov 2018 at 11:44.
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Old 23rd Nov 2018, 13:07
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Thanks for surfacing the report.

It reads:

The serious incident is attributable to the fact that the crew of a commercial aircraft initiated a climb without clearance, which lead to a dangerous convergence with another commercial aircraft. The following factors were identified as the cause of the serious incident:
  • The crew initiated the climb on the basis of a clearance which had been issued to another commercial aircraft belonging to the same aviation operator.
  • The air traffic controller did not realise that the clearance issued was not read back by the crew for which it had been intended.

The following was identified as a contributing factor to the serious incident:
  • A request by a flight crew for clearance to a higher flight level without specification of their radio callsign;
  • The issue of altitude clearance by air traffic control without verification of the crew which had made the request;
  • Absent reaction of another crew to whom the clearance was addressed to;
  • Insufficient attention was given to the prevailing weather conditions when the decision to combine sectors was made.
Not good but criminal offense ? I'll try to dig up the actual judgment (not all are published).
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Old 7th Dec 2018, 09:31
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Originally Posted by atakacs View Post
.
Not good but criminal offense ?
Clearly Skyguide and the Court are wrong. Not good for ALL involved in aviation. An even more scandalous sentence was handed to that Italian ATCO of that austrian air ambulance that CFITted on a visual approach a few years ago. Sent to jail.

"
  • Insufficient attention was given to the prevailing weather conditions when the decision to combine sectors was made.
Clearly Skyguide has not learned from the Überlingen crash.
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Old 12th Dec 2018, 15:26
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Unfortunately, it's not the only one. Another Zurich controller was sentenced today.

https://www.20min.ch/schweiz/zuerich...otsen-16625770

The incident was the famous close encounter between two simultaneously departing aircraft on crossing runways in March 2011. The controller, who is no longer operational in skyguide, has been sentenced by the Cantonal Court of Zurich to a pecuniary fine of 90 daily rates of 210 swiss francs. The decision, not yet final, overturns the decision of the District Court of Bülach (ZH), which two years ago had come to the conclusion that the ATCO can not be held responsible for an accident that ultimately did not occur.

It's very difficult to accept to all the community here in Switzerland and the ATCO are really sad. It's the second in few months and we also have a third one in judgment for another incident happened in Zurich. (Incident: Darwin SB20 at Zurich on Aug 22nd 2012, close encounter with touch and go on crossing runway

I think that we hitting hard the Just Culture but skyguide can't really do much more.
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Old 13th Dec 2018, 15:40
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These very worrying events have in fact not Just Culture ( more or less applied by the employer) but in fact what I would call " Judiciary Culture" . The Judiciary is totally independent and a prosecutor is free to decide what it considers an offence. Most of them are not educated on how aviation and air traffic control really works and do not really take into consideration that if we enjoy the current levels of safety in aviation today is it because we report our mistakes and learn from them. Unfortunately the Judiciary does not see it that way.
There is also a new tendency for prosecutors to go after cases which will raise their profile in the media , aviation is always a good one .
We need to react strongly to this tendency , which is spreading ( Italy have a similar problem). IFATCA is busy with this right now, and we are getting lots of support, but it will be a long and difficult battle..
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Old 14th Dec 2018, 12:02
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This is indeed problematic and goes against established best practices. I understand there was (is?) a limited strike going on to protest these developments.

I wonder how things are handled in other countries. Is there a specific legislation or is it "just" about the authorities not prosecuting?
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Old 14th Dec 2018, 13:08
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It's not really the first time I hear about, in Italy you have two cases. One very interesting about an accident happened in Cagliari in 2004. Two ATCO's had criminal conviction in 2010.

Incidente di Cagliari 2004: la storia completa

https://aviation-safety.net/database...?id=20040224-0
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Old 14th Dec 2018, 13:38
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Similar situation in other industries and countries of course. Employers create overload /unsafe / out of hours / untrained situations then ‘help’ the prosecutors/ courts to only blame the employees.

Hopefully the debate around these cases would see more “root-cause” investigations as other incidents receive
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Old 15th Dec 2018, 08:59
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ECA ( pilots) and IFATCA issued a joint press release : IFATCA ? One Sky | One Voice
The essence :
Lengthy and costly court cases do not improve aviation safety, nor do they contribute to the robustness of complex systems. They create a climate of fear amongst aviation professionals and result in a reluctance to submit reports. The opportunity to learn from these events is therefore severely compromised.
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Old 28th Dec 2018, 12:10
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Ladies and gents.

I have read this thread with some keen interest and cannot see the benefit of all the emotional threats that are being leveled towards the industry. There are many individual aspects that need to be addressed before this end result is achieved. Two of these that I would like to mention are as follows;

1. Just Culture - This is not an excuse to be used at every opportunity to protect yourself when things go wrong and safety events occur. Just culture is intended to help you and your employer when errors do occur. It it not there to be used as an excuse for misconduct or negligent behavior. I am of the opinion that more and more ATS staff around the world are trying to hide behind the argument of just culture when they find themselves on the wrong side of regulatory conduct through their own misconduct or negligent behavior.
2. Vicarious liability - I would suggest and highly recommend that everybody in the ATS services domain go and read up on this concept. Perhaps we would then all have a different take what that licence you are issued with really means.

In the meantime I suggest that you all put the emotions aside and continue to report all safety events as required by your employers. I have never seen a good outcome from somebody who has tried to hide an event and it has subsequently been found out.

My heart goes out to those who have found themselves involved in these court proceedings.

Festive greetings to all
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Old 28th Dec 2018, 12:48
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Utterly counter-productive to aviation safety. Good for lawyers and judges though.
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Old 28th Dec 2018, 16:18
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Similar situation in other industries and countries of course. Employers create overload /unsafe / out of hours / untrained situations then ‘help’ the prosecutors/ courts to only blame the employees.
And to think we should have learnt the lessons all those years ago from Zagreb.
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