Eurocontrol: Lack of 'just culture' leads to poor incident reporting, jeopardising aviation safety

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Eurocontrol bemoans reluctance of staff to report lapses

Eurocontrol’s efforts to reduce air traffic management (ATM)-related fatalities are being hampered by the lack of a “just culture” in most member states, leaving risks to go undetected until they are exposed by an accident.

Although Eurocontrol set up a centralised ATM incident reporting and data sharing system several years ago, safety chiefs are convinced it is not working.

They believe the failure of many European countries to protect the safety data reporting systems, and those who submit reports, from the law means that no-one dare use them.

A crucial pillar of Eurocontrol’s European Safety Programme (ESP) is a robust incident reporting and data sharing system, says ESP manager Tony Licu. The fundamental enabler for an effective incident reporting system, he says, is a “just culture data sharing agreement”. According to Dragica Stankovic, who has joined Licu’s team from the International Air Transport Association, this culture is absent from most European countries.

Reporting systems have worked well in the airlines for years, but in a state-controlled sector like ATM there was no such system until Eurocontrol set one up, and even now the reporting rate is low and does not reflect reality, says Dr Erik Merckx, the agency’s head of safety enhancement.

At Eurocontrol a just culture is defined as one in which “front-line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience or training, but where gross negligence, wilful violations and destructive acts are not tolerated”.

Eurocontrol safety regulatory requirements, embodied under European Single European Sky legislation, are supposed to put pressure on states to make the necessary adjustments to their national laws to protect open reporting by removing the fear of punishment or criminal prosecution from those who report on unintentional mistakes, errors, incidents, or on systems that are not working as they should be.

The Danish parliament passed a law in 2002 that facilitated non-punitive, strictly confidential reporting after it had become apparent that there was a failure to report loss of separation incidents in Danish airspace because individuals feared career and legal consequences.

Licu says he is trying to raise awareness of the need for action like this to improve the quantity of ATM incident reporting. Eurocontrol wants the ESP to be fully operational by December 2008, says Licu, but it will be partially disabled unless member states make the changes necessary to support a just culture.