Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
ATC834
Initial Report
This is going to prove a very difficult issue to articulate as our unit safety performance remains very good and is arguably better than previous years. Unfortunately this is far from the whole picture. Management decisions and a seaming refusal to invest in core systems is simply poking more holes in our Swiss cheese.
Danger Areas
A report following a danger area (DA) infringement many, many years ago highlighted the need to improve our DA notification process and associated radar mapping – it should have resulted in the implementation of a system called LARA [Local And sub-Regional Airspace management support system]. In its infancy, iFacts, our area controlling tool, was supposed to provide conflict support to DAâs. It seems implementation during iFacts was removed due cost and time constraints. LARA was expected and then seemingly parked in favour of our next system DPER [Deployment Point EnRoute]. This was due into AC [Area Control] in 2019 I believe and is significantly over budget and late. It is likely any DA conflict detection may well be missing when and if it is ever deployed. âOperationalâ date now unknown.
Our Supplementary Information Screen (SIS) is based on 1980/90âs software and is hugely labour intensive to adjust, it is done manually by a human and there are regular mistakes. Attempts have been made to tighten up procedures but there are so many different parties invested from Swanwick Military, Plymouth Military, Qinetic, Swanwick Civil, MABCC or L4M that Iâm not sure we have improved things. Over the last three years we have suffered a significant number of danger area infringements for a variety of reasons but ultimately they can be aligned with the problems above. Human error, poor interpretation of information, poor display of information and lack of tools support. As traffic levels return, so will the mistakes I believe. We will only be lucky so many times before a serious incident occurs.
There is no sign of LARA, no sign of the DPER software thatâs already overdue, not that the latter would have significantly improved things to the best of my knowledge. Senior NATS management believe it will, but my operational colleagues believe the system is significantly âdumberâ than required to improve the current issues. It is an embarrassing mess.
Removal of simulator emergency training.
Over my [numerous] years I have performed [many of] the roles associated with our ART / TRUCE activities. We have improved the range of emergencies trained and also the training of staff behind the scenes who perform pseudo pilot and controller tasks BUT the actual simulator has in my opinion deteriorated year on year. It is, I believe, no longer fit for purpose. We do not resource it appropriately and therefore cannot simulate the full extent of our emergency catalogue and system fall-back scenarios properly. To make matters worse, simulator training has been suspended for the 2023-24 season. All newly valid controllers (of which we now have an increasing number) are expected to undertake simulator ART every year for the first 3 years, I believe this is agreed with the regulator. This yearâs suspension is still awaiting regulator sign off I believe but management are pushing ahead regardless of the overwhelmingly negative response they have received from the operational controllers and competency teams.
We learnt a lot from our handling of BA5390 in June 1990 [G-BJRT explosive decompression with commander partially sucked out of cockpit], but we are rapidly undoing all of the good work we did in the years afterwards to improve the standards of our emergency training. The holes in this particular Swiss Cheese are also growing in my opinion and I have grave concerns about our ability to handle a significant event, fortunately they are very, very rare but this probably exacerbates the problem really.
Finally, the operation at Swanwick seems to be being ignored in many other areas, which impacts morale and dictates operational performance to a degree. Our temporary ops room which we should have vacated in 2019 is a disgrace. Trip hazards from worn out carpet tiles, Radar arms that no longer meet DSE rules and regs, a permanently faulty ops room door that impacts our fire and security, inadequate TEMPORARY rest and kitchen facilities. The list goes on butâŠ. the amount of space here limits further explanation.
NATS Comment
Thank you for the opportunity to respond to the concerns that have been raised, I hope the following helps to correct some of the inaccuracies which may be leading to the frustration shown by the individual and may provide useful information to all with regard to ongoing activities in these areas.
Danger Area infringement is recognised as a significant safety issue across our operation with an increased number of safety reports in recent years. The reporters comments regarding delays to the DPER system are accurate, however, development and implementation of LARA continues with ongoing improvements being made to the existing system. In the last 12 months, updates have been made to the radar mapping system used across upper airspace in the London FIR to improve information displayed on tactical displays. Although this does not provide conflict alert, it has improved the information available to controllers to allow them to make better informed decisions on the availability of direct routes and is part of ongoing works to simplify âflexible use airspaceâ and align procedures across a wide range of external agencies with whom we share these areas. In light of recent changes to the DPER delivery schedule we are in the process of reviewing other alternatives that, whilst not as good as the full DPER integrated solution, may offer an interim step to provide further support to our controllers.
The reporterâs comments relating to the suspension of simulator training for the next year are inaccurate. Simulator training is being provided for both newly valid and experienced controllers as part of their ongoing emergencies training for 2023-24. As per previous years, a range of options are available to controllers to select from. This includes interaction with pilots and simulator sessions for those who wish to participate â itâs not mandatory for all. Weâre always looking to make improvements to our simulator capability and would be keen to hear from the reporter directly if they feel there are areas which could be improved further. Their comments relating to improvements to pseudo pilot capability and the range of emergencies which can be simulated are welcomed and weâd welcome any further feedback they may wish to share with us in this area. Alongside this plan for the next year, we continue to evolve how we deliver all elements of training whether licence requirements or not. This will see us expand use of other technology to deliver training more flexibly and effectively and in line with modern learning methods. For our emergency training we are consciously moving away from reliance on a single simulator day once per year to regular drops of more interactive material which becomes more topical and timely and offers a mix of simulator, part task trainer, Computer Based Training and other multimedia systems in line with modern thinking on adult learning techniques.
As with many other companies, access to our sites (and specifically operational areas) was quite rightly limited for a significant period of time between 2020 and 2022. A reduction in the number of people allowed on site and the cancellation of works which werenât critical to service delivery has meant that planned works in recent years have been reduced and activities are only now starting to âcatch-upâ with activities that were paused during COVID. The reporterâs comments regarding equipment no longer meeting DSE requirements are a surprise and not something which we recognise; this will be investigated further to ensure any specific concerns which individuals have can be appropriately addressed. We have various routes formally and informally to report and escalate and do not believe this has been raised through any of these. Works have taken place over the last 6 months and a plan is being put in place with our facilities contractor around general replacement and refurbishment of these areas. Although the main door into the Ops room has been out of service for several short periods it was quickly repaired each time and for each event alternative routes used that were both fire and HSE compliant. Having attempted these fixes with the supplier we took the decision that a new door was required and the process put in place to secure a replacement. The nature of the environment means that this needs a bespoke solution meaning long lead times but we expect installation imminently. Works are ongoing across the site as we continue to make improvements for all building users and itâs unfortunate that the reporter doesnât feel that some of the changes already made have had a more positive effect on their own working environment.
We would welcome the opportunity to discuss any of the issues above directly with the reporter should they wish to do so.
CHIRP Comment
Notwithstanding the NATS comments above about ongoing expected improvements, the sub-optimal single-point of display of Danger Area information to controllers does not at present appear to be robust enough. CHIRP has previously commented on this following a similar report about Danger Area handling that we received about 2 years ago (ATC820) and that we had hitherto published in our Air Transport FEEDBACK Edition 140 newsletter (Report 4). After considerable correspondence with NATS at the time, we were advised that the LARA tool was unlikely to be fielded until late 2023 and that the NATS senior leadership had commissioned a âFeasibility & Optionsâ paper to identify potential avenues for improved Danger Area information systems that might provide mitigations in the interim. It seems that we are not much further down the road with Danger Area handling and we welcome NATSâ further comments above about âreviewing other alternatives that, whilst not as good as the full DPER integrated solution, may offer an interim step to provide further support to our controllers.â
With regard to emergencies training and the use of the simulator, it has to be acknowledged that the simulator has also to be prioritised for other activities such as airspace changes and system refreshes. As a result, there is undoubtedly a high demand for simulator time, and NATS has to prioritise its use versus the various risks to operations from all of the demands. But, in this respect, it seems that the simulator is under-resourced to a point that, where possible, all courses or mandatory training are being shifted to other means. NATS say they are pro-actively managing simulator use, and, on the face of it, the move from a single simulator day per year to more regular focused simulator and computer-based training sessions may offer some positive opportunities.
Notwithstanding, CHIRP is told that the licensing-requirement days for simulator emergency training[1] have already been shortened due to lack of simulator staff from 4hrs of simulator time and an hour or two in the classroom facilitating discussion of hot topics, to 2hrs of simulator time (shared amongst 4-6 people so approximately 1hr in the hot-seat) and 4 hours in the classroom (normally hosted by a simulator assistant not a competency examiner as was the case in past). Whereas controllers used to run through five to six different emergency scenarios as tactical controllers during these days, now they are likely handling only one or two. Therefore, because the simulator day is now not offered annually to experienced controllers, they may practise only a couple of emergencies every 3 years. CHIRP believes that the reporterâs concerns about the simulatorâs fitness for purpose and availability need to be addressed, and it is hoped that this report might be a catalyst for doing so.
Finally, many of these issues and NATSâ responses hint at potential, or at least perceived, sub-optimal communication between the management and the workforce. CHIRP lacks sufficient insight into the NATS internal communications channels to make comment ourselves, but there may be a case for reviewing their efficacy, especially with regard to internal company newsletters or associated electronic channels for example.
[1] A simulator every year after validation until 3 years qualified, then once every 3 years (but able to attend annually in place of the alternative annual recurrent training options if desired).