Skyguide comments on safety culture
Skyguide comments on the conviction of an air traffic controller. The conviction sets a precedent for Switzerland and Europe which jeopardises the deeply rooted safety culture in air navigation services.
Skyguide notes the Zurich High Court's ruling against an air traffic controller with incomprehension and disappointment. The conviction calls Swiss air navigation services into question.
Safety culture at risk
In order to be able to continuously improve safety in air traffic, aviation depends on air traffic controllers, technicians and pilots, for example, who work to the best of their knowledge and belief, actively reporting incidents of their own accord without fear.
Only in this way can continuous flight safety be maintained and optimised. The "Just Culture" that has been practised at Zurich Airport to date could suffer a setback as a result of the Zurich High Court's ruling. Skyguide even fears that the high reporting rates that currently exist in Switzerland will decline.
Disproportionate judgment
More than 7 ½ years ago, on March 15, 2011 at 12:40 p.m., two aircraft received clearance at Zurich Airport shortly after each other and took off on the intersecting Runways 16 and 28. The aircraft on runway 16 took off as scheduled, while the aircraft on runway 28 aborted the take-off.
The controller had cleared a southbound aircraft bound for Moscow with 135 people on board on Runway 16. Just one minute later, the controller also cleared an aircraft with 127 people on board and bound for Madrid to take off on Runway 28 westbound. The two runways intersect.
The air traffic controller involved in the incident voluntarily reported this incident, which resulted in neither personal injury nor damage to property, and thus actively contributed to clarifying the background. At the end of November 2018, the Zurich Higher Court reopened the case. Criminal proceedings were initiated against the controller.
He had already been brought before the Bülach District Court in December 2014 and April 2016 on charges of disrupting public transport, but was acquitted there. The internal and external investigation reports had given no cause for disciplinary action against the air traffic controller. On 27 November 2018, the controller then had to appear before the High Court.
The public prosecutor demanded a conditional fine of 18000 Swiss francs for negligently disrupting public traffic. The unusually long duration of the proceedings is a burden for the controller, says Skyguide spokesman Vladi Barrosa (source: NZZ).
Barrosa: "The controller indisputably made a mistake, but noticed it himself and ordered a take-off abort. He therefore acted correctly." Whether there was a threat of damage is a matter for speculation. Skyguide basically criticises the fact that an air traffic controller is legally prosecuted for an inconsequential error. This is absolutely unusual, even by international standards, the spokesman said. Although the man still works for the air navigation service provider, he is no longer employed as a controller, but as a safety expert in the background.
Been supported by alarm systems
Zurich was spared the disaster for several reasons. Firstly, the pilot of the aircraft on runway 28 noticed the aircraft approaching from the right and aborted the take-off. Two seconds later, the controller also gave the order to abort. An electronic alarm system had warned him. Thirdly, the collision would not have occurred, as an animation by the Swiss Safety Investigation Authority (Sust) has shown.
However, the second aircraft taking off would have been exposed to air turbulence from the first, which in the worst case could have led to a crash.
Judgment does not improve safety
Condemnation does nothing to improve aviation safety. The safety culture in aviation is based on voluntary reporting of all types of incidents. If such reports of incidents not caused by negligence or wantonness result in a conviction, the safety culture is weakened with inevitable consequences for aviation safety.
Skyguide itself has introduced various measures to mitigate the risks since the incident of 15 March 2011 as a result of stringent safety reviews at Zurich Airport, "to the extent that the political framework permits," according to the air transport company's latest media release. Skyguide has made major adjustments to its work procedures. At peak times, the shift is double-staffed, with one controller handling approaches and the other departures.
In addition, the necessary measurement flights were shifted to the night hours. In addition, a specially developed safety system designed for intersecting runways has been in operation since 2018.
To the Just Culture
"Just Culture also plays an important role in other areas, such as hospitals and nuclear power plants. Open feedback and feedback are indispensable in these areas for the ongoing improvement of processes, technologies and competencies.
