Lock up your controllers

A small bunch of people gathered at the Eurocontrol headquarters near Brussels Zaventem airport on 18 December to draw up a programme for persuading countries not to start inquiries into aviation accidents and incidents by initiating a criminal investigation. The most common targets for criminal prosecution are front line operatives like air traffic control officers and pilots.It was not the first time the Eurocontrol team had met to discuss what to do about this state of affairs. They are well down the road to designing an action campaign that – they hope – will persuade states of the benefits to aviation safety of changing the way they do things.

It will be difficult. You can’t – in any country – take away the judiciary’s right to investigate an occurrence in which something obviously went wrong. If someone is found to have deliberately flouted rules, it would be pointless to suggest the judicial system should refrain from meting out punishment. But what of the accident that results from an unintended mistake? At present, most states still rush to prosecute.

A reasonable hope might be to persuade a government that the default air accident investigation sequence should change away from a process that takes this sequence:

Mishap > identify culprit > prosecute > punish > forget

- and move toward

Mishap > identify causes > analyse factors > provide solutions

But to do that requires political and judicial will. What’s needed is a change of judicial culture and priorities rather than a change in the law . The task is to persuade government and the judiciary that they don’t have to surrender their big stick, just wield it more intelligently. Maybe even choose not to pick it up unless the situation calls for it.

Meanwhile anyone trying to change a culture also has a problem with people in my profession: journalists.

Why? Because other people – including politicians and the judiciary – read papers, listen to the radio and watch television. And when an air traffic control incident is in the news, what journalists report and how they report it influences everybody.

Journalists tend to reflect the culture in their country. If the reaction of the judiciary and politicians whenever something goes wrong is to go straight for the throat of whoever looks as if they might be to blame, the journalists do the same.

The worst press in the world in this respect is Italy’s. The British tabloids and many others are pretty judgemental, but not a patch on the Italians.
The worst example of press-led vigilante justice was the series of prosecutions after the Milan Linate runway collision in October 2001. Several industry people were handed jail sentences, but the longest went to the tower controller. He had NOT cleared the errant business jet to enter the active runway, the pilot just did it by mistake and died as a result. And it all happened in a thick fog that prevented the controller from seeing what was happening.

The causes were many, and they were systemic; they inhabited every corner of the Italian aviation system starting with the airport management. Scapegoating was exactly what was NOT needed, but it’s what happened.

So why does Eurocontrol, essentially an organisation whose expertise is in the fields of technology and operational issues, feel it has to do something to persuade states to adopt a “Just Culture” in aviation investigation processes?

Because Eurocontrol sees evidence that the fear of sanctions generated by a punitive culture actively deters individuals from reporting on faults and system weaknesses. In punitive cultures, messengers know they are likely to be shot. So the messages stop coming. The only message that gets through is the one that flows the other way – from the system to individuals: “Cover it up. Sweep it under the carpet. Keep your head below the parapet.”

Eurocontrol is being starved of messages about what’s going on out there. No wonder they want to try to change things, but changing the world is not easy. Good luck trying.

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