ATC868 - Slipping Safety Standards
Initial Report
Report Text (summary): Safety is paramount in aviation however over recent years more and more emphasis is placed upon proving beyond reasonable doubt that an issue is unsafe before some [Air Navigation Service Providers (ANSP)] will actually address the issue. Addressing safety issues is often difficult particularly given the commercial pressures that different companies place upon the safe operation of air traffic sectors. Staff can raise issues, leading to situations where everyone is aware of the problem and yet the problems are not addressed unless incontrovertible proof is available to justify taking action. The burden of proof should be that we have to prove that a situation/procedure is safe, which ensures that we fail safe, not to ignore experienced staffs genuine concerns while we wait for the evidence for controllers to prove that a situation is unsafe.
NATS is without doubt an impressive ANSP with many redeeming features and a genuine desire make safety a priority. Subtle cultural changes have slowly led to changes in the ways in which safety is dealt with, which often considers safety as an inconvenience that is best left to chance. I say this despite having an excellent and determined safety department and a highly professional staff. I suspect that over the next few years that we will find ourselves in situations that could have been avoided and that were completely foreseeable, if not already foreseen! Furthermore, given that staffing is increasingly tighter that possibly this could exacerbate things further.
I would stress that the staff and operational leadership are exceptional on the whole. However, at times genuine safety concerns are ignored. We cannot continue to assume that something is safe until proven to be unsafe. By then it could be too late.
comments
NATS Comment
NATS welcomes the opportunity to respond to the report and highlight some of the areas where we feel that there are sufficient safety checks and reporting lines to assuage the fears of the reporter. Whilst we are not entirely certain of the specific procedures or projects that the reporter is concerned about, we do reemphasise that safety is paramount in the industry and as such we do not take reports like this lightly. We do have a robust reporting process with a proactive approach to risk management, and we believe that all employees are aware of this through various safety initiatives undertaken throughout the year.
From an operational point of view, at our centres we have watch-based safety reps and safety managers that can be approached independently of any reporting process in order to discuss issues and concerns, as well as an entire Centres Safety Improvement Team (CSIT) who proactively monitor the operation to identify trends or issues and lead on necessary changes. In our tower operations we also have safety teams working to ensure the ongoing success of any changes that are made. In our wider programmes and projects, we have embedded safety professionals that carry out bow-tie reviews, hazard analyses etc, leading to safety reports and risk categorisation and mitigations, that need senior management approval before a system/airspace change is deployed into the operation. I have been asked by the highest level of our Safety Management Team to pass on the offer of a direct conversation/interaction in order to share the concerns and discuss any possible changes that may be needed in their eyes. We respect the anonymity of the reporter and therefore ask that you pass on this offer. Should you receive any further comments on this issue then please pass them on straight away so that we can again provide feedback.
CAA Comment
Reg 2017/373 requires Air Navigation Service Providers to have procedures in place to identify hazards associated to its services based on a combination of reactive, proactive and predictive methods of safety data collection. A process that ensures analysis, assessment and control of the safety risks associated with identified hazards and a process to ensure that its contribution to the risk of aircraft accidents is minimised as far as is reasonably practicable. Assured by Safety performance monitoring and measurement processes verifying the safety performance of the organisation and validating the effectiveness of the safety risk controls. Data collected via mandatory or voluntary occurrence reporting should form part of this feedback loop.
CHIRP Comment
This report generated a detailed discussion between the ATC members of CHIRP, and it was agreed that the report itself was raising a philosophical point rather than a specific hazard or notifying CHIRP of a specific situation, such as a near miss. The reporter, having filed the report and received a prompt response from NATS’s senior management of an offer to engage, facilitated by CHIRP involvement, decided to decline the offer. The issue raised could be evidence of a practical drift of attitude in the organisation – that is, a possible example, using Hollnagel’s framework, of “work as done versus work as prescribed”.