New FAA Safety Culture Reflected In Operational Error Reporting
"Reducing Emphasis On Blame In Controller Errors
The FAA says it has taken another step toward a new safety culture by
reducing the emphasis on blame in the reporting of operational errors
by air traffic controllers.
"We're moving away from a culture of blame and punishment," said FAA
Administrator Randy Babbitt. "It's important to note that controllers
remain accountable for their actions, but we're moving toward a new
era that focuses on why these events occur and what can be done to
prevent them."
Effective immediately, the names of controllers will not be included
in reports sent to FAA headquarters on operational errors, which occur
when the proper distance between aircraft is not maintained. The
controller's identity will be known at the facility where the event
took place. Necessary training will be conducted and disciplinary
action taken, if appropriate. Both will be recorded in the
controller's record. Removing names on the official report will allow
investigators to focus on what happened rather than who was at fault.
"We need quality information in order to identify problems and learn
from incidents before they become accidents," Babbitt said. "The best
sources of that information are our front-line employees. Our success
depends on their willingness to identify safety concerns."
In order to avoid disrupting operations, controllers will not be
automatically removed from their position following an operational
error unless it is deemed necessary to remove them. Another change
designed to avoid disruptions allows reports to be filed by the close
of the next business day unless the operational error is significant.
Reports previously had to be filed within four hours.
This action is part of the transition to the FAA's new non-punitive
reporting system for controllers. The Air Traffic Safety Action
Program (ATSAP), which now covers one-third of the country, allows
controllers and other employees to report safety problems without fear
of punishment unless the incident is deliberate or criminal in nature.
Today's change in the reporting requirements for operational errors
provides for a more seamless transition as ATSAP is rolled out to the
entire country.
The reporting changes do not alter the investigation and analysis of
operational errors. They also do not change the requirements for
addressing the causal and contributing factors to those events."
FMI:
www.faa.gov
This is a great move in the right direction. The best safety action
programs remove information from individual training jackets after a
short period of time. Humans make errors, especially if the system is
not designed properly and we are trying to manage novel threats, poor
design, organizational factors, fatigue, distraction, whatever the
multitude of contextual factors are at any one point in time or space.
It is good to see the focus shift from "Who" did "What" to "Why?"
Blaming an individual or taking disciplinary action does little,
certainly not in a generative way, to prevent the same person or
another person from experiencing the same lapse, slip or mistake the
next shift. And it certainly does not identify and address hazards to
operational safety in a systematic way.
Information is power. Power + Right Attitude = Performance