Japans Opportunity to Improve Aviation Safety

On 29 and 30 January 2009 in Tokyo, the International Federation of Air Traffic Controllers Associations (IFATCA) joined the International Federation of Air Line Pilots Associations, and the Japanese professional aviation associations to promote the cause of aviation safety through the adoption of just culture.
This day was occasioned by the case to be heard by the Japanese Supreme Court in April of the two air traffic controllers convicted as a result of a near miss between two Japan Airlines aircraft over Tokyo in January 2001. The controllers were found guilty of negligence by an Appeal Court which revised the original not guilty verdict of the Tokyo District Court. All groups called upon the Japanese Supreme Court to recognise that the reversal of the findings of the Appeal Court would immediately signal that Japan understands the critical role that just culture would have in ensuring that its citizens are provided with a resilient aviation safety system. As IFATCA noted, the Accident Report into the near miss gave a number of contributing factors to the cause of the incident; these including pilots actions, controllers actions, controllers operational procedures, lack of proper training for the controllers, and lack of definitive procedures for pilots to follow after a TCAS RA. From the current research of highly respected safety experts, it is now accepted that in high reliability organisations that demand a high level of safety, human lapses are a normal part of the system; system failures, however, are not solely due to a single action. System failures are due to systemic problems that emanate from a complex chain of events. The single lapse by a human within that chain is a consequence rather than a cause of the systemic failures, and this lapse may not have materially affected the outcome. In this construct, IFATCA considers that the controllers cannot and should not be singled out to bear complete liability for any incident. We therefore called for the withdrawal of all judicial action against these Japanese controllers. IFATCA explained that there is continued improvement to the international standards of aviation safety so that as aviation travel increases safety will also increase commensurably to reduce the number of accidents, incidents and occurrences so that commercial air travel remains one of the safest means of transport. This can only be achieved if all pilots and controllers provide full and open reports of all potential problems before these develop into serious safety hazards, as well as reports of actual incidents so that others can learn from operational anomalies or oversights. The International Civil Aviation Organisation (ICAO) requires that Japan, along with all States, establish a blame free reporting system as part of its overall aviation safety management. This can only be effective in conjunction with the concept of a Just Culture that promotes reporting whereby pilots and controllers can give details of events and incidents even when they may have made simple errors or mistakes themselves, knowing that the sole purpose of these report are towards enhancing the complete safety information and that they will not be used for retribution or punishment. It is essential that we recognise that human action is not the cause of the system failure human action is a consequence of the failure of the system. The current process in Japan presents the classic LOSE-LOSE situation! Knowing that they are liable to legal action, human nature will now cause pilots and controllers to be reluctant to report vital safety information. By contrast, the ICAO procedure is WIN-WIN. It gives pilots and controllers the confidence to openly report any safety occurrence knowing that they will not be blamed or held liable to prosecution and this in turn benefits world-wide aviation safety thus saving the lives of our citizens. Japan, through the Supreme Court and its aviation authorities, now has a profound responsibility the opportunity to turn a LOSE-LOSE situation into a sustaining WIN-WIN culture.


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