29 Aralık 2007 Cumartesi


This is the second of my four articles serie on FALSE SENSE OF SAFETY in the Air Traffic Control systems. The results and advices however not solid,may be considered valid for many large systems,such as nuclear energy reactors, railwaytransport systems etc...

The hardcore large systems guys may considerthese unnecessary or invalid but the developments in the psychology and neurologyin the last ten years have made the oldbooks out-of-date. Even these developmentsalone are precursory to discussthese issues, however subjective or notsolidly founded. The high rate ofmental diseases among people working in the large systems can not be and should not behidden any more... Also, finding thereasons for these mental breakdowns etc...may give us the chance to build evenmore complex systems. We are buildingcomplex systems that can not be controlledhealthily, namely the operator's health andthe mission's healthy success.

In this article, I will compare an internet article named "Night Operations"'s "Disorientation" section with an Air TrafficControl System's safety situation. I willmake a few references to the Swiss ATC accidentthat caused 45 Ukranian chieldren's death also.

"Disorientation, or vertigo, is actually a stateof temporary spatial confusion resulting frommisleading information sent to the brain by various sensory organs."

Every guy, and also the operational responsibleperson in an ATC system assumes that an accidentis inevitable. The technical stuff tries to improve the system so that the possible date ofthis inevitable accident is postponed into thefuture. So, the direction is the directionof the movement of a possible accident on thetime domain.

How can a disorientation happen in the mindsof technical stuff in an ATC system?Just like it happened in Switzerland.It was night, the most appropriate time todo technical changes. Apparently, there weretechnical maintenances on the system. Theoperational management, had considered thatthe changes they made and the operation itselfwould push the inevitable accident a way... But the fact was, telephones not working, short term conflict alert not working on the radar,etc...The operational managementwas fully disoriented...

An accident does not happen easily in a largesystem. There was also an other disorientationin the systems design of conflict alert of the airplane systems. They were designed tohelp the pilots but practically the procedureswere not clear on how to use it. The pilotsgot totally disoriented and one of them acted according to the advise of the controller notto the instrument, which is a typical vertigomistake. The pilot, although died, had actedright according to the rules. The real vertigowas in the minds of the Swiss operational managers.

"The most difficult adjustment that you must make as you acquire flying skill is a willingnessto believe that, under certain condition, yoursenses can be wrong." The fact is many largesystems were state owned and have recently beenprivatized. There is a strong hierarchy inthese organisations. Unfortunately,hierarchy not only gives the operational management the power to make singular individual decisions but also may slow down the information flow coming from the engineers working on the maintenance and enhancement floor.Even Lars Fredholm, from Swedish FireDepartment states "the problem concerns thecapacity to make co-ordinated decision atdifferent levels of the management. In astatic situation you have time to follow thesequence planning, executing, evaluating.In a dynamic situation the sequence is disturbedby the dynamics of emergency. The co-ordination of the decision making at different levels ofmanagement has to be more dynamic and flexible."Report 3111, Lund 1999... That night,the Swiss operation's management was in a dynamicsituation, I believe, according to myexperience at Karlsruhe UIR.

"If the rate of directional change is quitesmall - and not confirmed by eyes - the changewill be virtually on detectable and you willprobably will not sense any motion or whatsoever."When many successive changes are realizedsuccessfully, a sense of false safety forms.Things are going well, we did this, let's addthis modification also... Without reallyevaluating the possibility of falling into a situation where the system fails and must returnback to the backups where not all the modifications may have been done. Moreimportant, the current controller stuff may havedifficulty to remember which version has whichnew functions etc...

"Here's where trouble begins! Inside the airplane,if you are unable to see the ground and establishvisual reference you are just seconds awayfom the famous graveyard spiral."The writer from helicfi.com tells the solution.There must be reference points... There must bemetrics values carefully and insistingly usedin an ATC system. 10 years ago, at Karlsruhe,we only head retrospective reliability measures.In other words, how long the system has workedin the last year, for how long without interruptionit has worked. Nothing prospective... There must be measures as used in spaceshuttle andaerospace companies... to predict possibleproblems... It is a shame if an ATC centeris still not using these measures. I willwrite my next article on this matter whichcould have saved the lives of the Ukranian chieldren.

Metrics values about the ongoing maintenanceand enhancement activities, even the performanceof the controlling and technical personnel cangive a strong indication, and may be the AWARENESSthat could help the operational managementto rise out of their FALSE SENSE OF REALITY,when things seem to be going on routinemanners, in the "automatic processing" of theATC systems using pre-scheduled "schemata"...