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Eurocontrol reveals results of ATC mistake analysis

Eurocontrol says unintentional controller mistakes are the biggest single cause of air traffic management (ATM) reported incidents, but it has also found six other causal categories that, together, caused more incidents than simple mistakes did.

As the agency revealed the first fruits of the Eurocontrol voluntary ATM incident reporting system (EVAIR), its experts confirmed that most - but not all - of the voluntary reports come from pilots, raising the worry that fear of employer reprisal or legal action is inhibiting reporting by controllers at some air navigation service providers (ANSP).

In the hierarchy of analysed contributory factors in voluntarily reported ATM incidents, "mistakes" comes top, closely followed by traffic information, operational communications, ATC clearance instructions and spoken communications. The smallest category was co-ordination.

But the EVAIR system does not halt its analysis at the first level: the mistakes category is broken down into 12 sub-categories, among which the predominant factors were human failings - planning error and mistakes of judgement.

The dominant traffic information failing was providing it late; for operational communications, it was non-standard phraseology; in spoken communication, it was misunderstanding or misinterpretation and language/accent issues.

The most frequent results of incorrect ATC clearance instructions were level busts or runway incursions.

At its Brussels headquarters on 2 April, Eurocontrol, with the International Federation of Air Traffic Controllers' Associations (IFATCA), launched a joint publication, A collaborative approach to the future, which makes it clear that although ATC in the distant future will be more automated, the system will be human-centric as far ahead as can be predicted. Hence the launch of EVAIR and the push for voluntary incident reporting to be supported by a just culture.

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