Also in this issue:

4 CISM
4 Legal issues
4 Interview Prof. S. Dekker
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THE
CONTROLLER
Journal of Air Trafc Control March 2007
4 BRAZILIAN COLLISION SPECIAL
IATA Training &
Development Institute
REFRESHER training
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Ensures that all controllers have full and
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Mechanisms associated with ATC errors
and strategies to identify and manage the
consequences in an operational environ-
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Reduced Vertical Separation
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For en-route controllers handling aircraft
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Phraseology & Safety
for Air Trafc Controllers:
How inappropriate phraseology can con-
tribute to incidents and accidents
ATC Unusual/emergency
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Ways to handle stressful situations with
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ACAS/TCAS training for Air
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How TCAS alerts and advisories are ge-
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Controller Pilot data link
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Analysis of current and future data link
applications, including CPDLC, ADS and
D-FIS.
Air Trafc Flow and
Capacity management *
Overview of ATFCM and how to cope with
future challenges, as the management of
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Satellite Navigation
In depth view of GNSS, the associated
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Contents
THE
CONTROLLER
PUBLISHER
IFATCA, International Federation of
Air Trafc Controllers Associations.
EXECUTIVE BOARD OF IFATCA
Marc Baumgartner
President and Chief Executive Ofcer
Dr Gabriela Logatto
Deputy President
Cedric Murrell
Executive Vice President Americas
Albert Taylor
Executive Vice-President Africa/
Middle East
David K W Cheung
Executive Vice-President Asia/Pacic
Patrik Peters
Executive Vice-President Europe
Dale Wright
Executive Vice-President Finance
Doug Churchill
Executive Vice-President Professional
Dave Grace
Executive Vice-President Technical
Jack van Delft
Secretary/Conference Executive
EDITOR-IN-CHIEF
Philippe Domogala
Editorial address:Westerwaldstrasse 9
D 56337 ARZBACH, Germany
Tel: +492603 8682
email: ed@ifatca.org
Residence: 24 Rue Hector Berlioz
F 17100 LES GONDS, France
CORPORATE AFFAIRS
Kevin Salter (Germany/UK)
CONTRIBUTING EDITORS
Web site: Philip Marien (EGATS)
Chris Stock (UK)
REGIONAL EDITORS
Moetapele D. Matale (Botswana)
Al-Kadur Acosta (Dominican Republic)
Phil Parker (Hong Kong)
Patrik Peters (Europe)
COPY EDITORS
Helena Sjstrm, Stephen Broadbent
and Brent Cash
PRINTING-LAYOUT
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email: info@lithoart-ma.de
Also in this issue:
4 CISM
4 Legal issues
4 Interview Prof. S. Dekker
I N T E R -
NATIONAL FEDERATION OF AIR TRAFFIC CONTROLLERS A S S N S .
THE
CONTROLLER
Journal of Air Trafc Control March 2007
4 BRAZILIAN COLLISION SPECIAL
Photos:
Legacy jet: Embraer
B737 Gol: Andres Contador
Radar picture: C. Gilgen
Label: VEJA
Foreword by Doug Churchill 4
Editorial by Philippe Domogala 5
Brazil Collision 1 Special Feature ... 6
NTSB News Standards for Safety the Language Barrier .. 7
Brazil Collision 2 The Accident Description by the IFATCA Team
by Christoph Gilgen ... 8
Brazil Collision 3 The Collision as Reported by the Media in Brazil
by Philippe Domogala .. 10
Brazil Collision 4 IFATCA Provides CISM to Brazilian Colleagues
by Christoph Gilgen ..... 12
Brazil Collision 5 Brazilian ATC in Turmoil by Christoph Gilgen . 14
Brazil Collision 6 The Collision as Lived by the Brazilian Controllers
by Wellington Rodrigues . 16
Brazil Collision 7 Transponder: What Role did the Transponder play
in this Collision? by Christoph Gilgen ... 18
Brazil Collision 8 Gol Flight 1907 ... 21
Brazil Collision 9 What can IFATCA learn from the Brazil Experience?
by Marc Baumgartner ...... 22
CISM 1 Managing the Other Stress by Doug Churchill .... 24
CISM 2 Explaining how CISM works by Philippe Domogala ... 26
Just Culture Legally speaking by Doug Churchill .. 27
Interview with Sidney Dekker by Marc Baumgartner .. 28
Book Review Critical Incident Stress Management in Aviation
by Joerg Leonhardt and Joachim Vogt .. 29
Legal Issues ATC: One Foot in Court? by Helena Sjstrm . 30
Interview with Gerard Forlin by Patrik Peters .. 31
European Affairs European Regional Meeting Sofia, Bulgaria
by Raf Vigorita ... 32
Europe 1 Europe Tunes 8.33 KHZ above FL 195
by Wolfgang Scheidl .... 33
Europe 2 The Day of the Controller Poster in Italy 33
Spotlight by Kevin Salter .. 34
News Controller in South Africa .. 36
News 17
th
Ama Regional Meeting by El Kadur Acosta.. 36
Asia Controllers The Unsung Heroes of Aviation
by Capt. Elmo Jayawardene . 37
Charlies Column 38
DISCLAIMER: The rules, recommendations and information contained in this document reflects what IFATCA established at time
of the last amendment. Although every effort has been made to ensure accuracy, neither the International Federation of Air Traffic
Controllers Associations (IFATCA), or their Members or Officers or representatives, shall be responsible for loss or damage caused
by errors, omissions, misprints or misinterpretations of the contents hereof. Furthermore IFATCA expressly disclaim all and any
liability to any person whether a purchaser of this publication or not, in respect of anything done or omitted, by any such person in
reliance on the contents of this publication. COPYRIGHT. The materials herein are copyright IFATCA. No part of this document may
be reproduced, recast, reformatted or transmitted in any forms by any means, electronic and mechanical, including photocopying,
recording or any information storage and retrieval system, without the prior written permission from IFATCA.
VISIT THE IFATCA WEB SITES: www.ifatca.org and www.the-controller.net
In this issue:
March 2007
1st quarter 2007 volume 47 ISSN 0010-8073
Foreword from
the Executive Board
4
The Professional Pie
This edition of The Controller magazine
has been dedicated primarily to issues
of a Professional nature. When we think
of professional topics as they relate to us
in the air traffic control world, more than
likely some time-honoured issues will
come immediately to mind: working con-
ditions, industrial relations, hours-of-work,
medical requirements, human factors
and critical incident stress management
among others.
I mention these particular ones because
they form the backbone of much of our
professional policy and will continue to
do so into the future. However important,
they are merely pieces of the professional
pie. Section Four of the IFATCA Manual
lists five principle categories relating to
professional policy: Working Conditions,
Medical Matters, ATC Training, Legal
Matters and Collection and Dissemination
of Information on Professional Matters.
Consider these the crusts of the pie
because within them lies the filling - the
meat - the best and most important part!

On the occasion of this special profes-
sional edition of the magazine, I though it
appropriate to provide an in a nutshell
account of what we in the professional
domain have been up to over the preced-
ing twelve months. You will read of some
of our activities in this edition, but there
are many more. If we look back to the five
main professional categories in the Man-
ual, we see they are further broken down
into twenty-two sub-groups containing
a total of some eighty individual subject
items. The distribution of topics within the
groups is : Working Conditions - 32 items;
Medical Matters - 10 items; Training - 25
items; Legal Matters - 12 and Collection
& Dissemination of Information - 1 item
(IHB). Of these 80 different subjects, we
have been active in addressing nearly 50%
of them within the past 12 to 15 months
or so. They include: Single Person Opera-
tions, Four Eyes Principle, Performance In-
dicators, Social and Labour Aspects, Man-
agement/Controller Relationships, Working
Environments, ATC Systems, Automation -
Human Factors, ATC and Public Relations,
Short Term Conflict Alert - Human Factors,
Duty Rosters, Work and Rest Scheme, Ex-
tra Duty, Remuneration, Language Issue,
Retirement and Pension, Extended duty,
Loss of Licence, Regulatory Framework in
ATM, Normal Operations Safety Survey
(NOSS), Safety Management Systems,
Stress & Stress
Management,
Fatigue in ATC,
Substance
abuse in ATC
and Critical In-
cident Stress
Management. By far, issues in the Work-
ing Conditions category have demanded
the most time and effort, with 21 items
requiring some degree of IFATCA profes-
sional attention. Many times we are able to
address concerns by way of direct corre-
spondence through the Executive Board,
i.e.: letter, telephone call or e-mail, but
there are times when nothing but direct
face-to-face contact is required. We are
very fortunate to have within the Profes-
sional domain representatives who act on
our behalf throughout the year attending
meetings, submitting working papers/
reports and expressing the IFATCA view
to the wider audience.
We are grateful to our representatives of
the Airport Ops Team, Aerodrome Panel,
Human Performance Focus Group, HRT,
our Human Factors Specialist and Single
European Sky & Social Dialogue experts.
They contribute greatly to our success.

Of the remaining four categories, none
had more than six issues where our involve-
ment was needed or requested. Six topics
are the subject of Committee C working
papers at Conference 2007 in Istanbul, fur-
ther illustrating our continued involvement
with, and influence in, a very good cross-
section of our professional domain.
^
Foreword
We are very fortunate to have within the
Professional domain representatives who
act on our behalf throughout the year
P
h
o
t
o
:

D
C
^
by Doug Churchill,
EVP Professional IFATCA
New Controller Layout:
You have all noticed a new format
and a new layout of the magazine.
We have changed printer and design firm and the magazine is
now produced in Mannheim, Germany, by the same firm that also
produces der flugleiter, the German MA magazine. The lady in
charge of the layout is Melanie Fliess, and she brings a refreshing
look into the Controller magazine.
LITHO ART
DRUCKEREI LUFER
PLAKAT-DRUCK MANNHEIM
DIGITALDRUCK MANNHEIM
www.beste-druckqualitaet.de
Editorial
THE
CONTROLLER 5
This issue is a special about the recent Bra-
zilian collision and CISM. You will also find
some legal issues covered and an interview
with Professor Sidney Dekker, the very fa-
mous aviation human factor specialist.
This issue is an attempt to record and
document what happened but also, and
probably foremost, to act as an educative
process for us all. What can we learn from
events such as this, and how can we better
prepare ourselves for the next one?
We should not hide our heads in the sand,
accidents and collisions are likely to oc-
cur at a more frequent rate that what we
have been used to in the past. Simple
mathematics if one takes into account
the tremendous increase in air travel and
current aircraft orders (Boeing and Airbus
have between them over 2000 new aircraft
orders this past year alone and I do not
include the other 1000 or so regional, busi-
ness jets, and the new tendency for the
future: pocket jets)
All of these, or nearly all of these, will fly
IFR and therefore add constraints to our
ATC systems. Some naively thought that
technology such as TCAS or CDTIs (cockpit
display of surrounding traffic) using ADS-B
will take care of the last minute anti-colli-
sion resort.
But as this collision in Brazil showed us: a
transponder, a small piece of 1950s tech-
nology, can fail (or be disconnected) and
then all this last minute collision
avoidance high tech no longer works.

Aircraft can today continue to fly for
days in the busiest class A airspace and
major airport TMAs, with a defective or
inoperative TCAS. Failure in TCAS is not
a no-go item. This is not doomsday, this
is wake-up day, I would say.
One of the roles of IFATCA and this maga-
zine in particular, is perhaps to act as an
alarm clock for this wake up call. It is after
all our business, because it is we control-
lers, who ultimately and generally will win
the legal first prize distributed by the
judges a few years later. Just culture is
important there and there is also an
article about this in this issue.
How to deal with the posttrau-
matic effects of such an ac-
cident for the controllers in-
volved is another important
issue. We have CISM and
now we have IFATCA-
delivered -CISM.
All of this is ex-
plained in this
issue as well.
In my
archives, is
an article
that I wrote
in 1981
for the
Controller,
after
a fact-
finding
visit to Brazil. It is striking to
see, that 25 years later, in fact not many
things have changed with regard to the
controllers situation.
For those interested, this 1981 article is
available on our web site:
www.the-controller.net
I used to end my editorials by saying
Enjoy this issue or Happy reading but
this time that is not appropriate. Be very,
very careful is probably more accurate.
Editorial
About mid-air collisions
^
by Philippe Domogala,
Editor
This is not doomsday,
this is wake up day
I would say
l
READERS LETTERS to the Editor
Reference the collision between a glider and a Business
jet reported in your last Editorial (Dec 06) , although the
NTSB report said the glider was an ASW27, it was in fact an
ASG29, the very last 18m model from Schleicher, a brand
new aircraft.
Jean-Luc Gassmann , Controller Geneva ACC
ed@ifatca.org
Photo: DP
Photo: ifatca
Photo: Alexander Schleicher/M. Mnch
4 Brazil Collision
6
THE
CONTROLLER
The views expressed in the following articles are those of
the authors, and not necessarily IFATCAs ofcial position.
Brazil Collision
Special Feature
What really happened on
29 September 2006 over
the Amazon?
How come, on a beautiful
sunny day, could two brand
new aircraft equipped with the
latest technology and under
surveillance of a relatively mo-
dern radar ATC system (or so
we were told) collide in 2006
like they would have in the
1950s?
Why are the controllers and
the pilots involved almost
always suffering from the
media frenzy looking for
someone to blame?
How can IFATCA help the
controllers involved?
In the next 18 pages, you
will nd some attempts to
answers those questions.
Photo: Embraer
4 Brazil Collision
The September 29, 2006, midair collision
over the Amazon jungle between a Boeing
737-800 (PR-GTD) and an Embraer Legacy
600 business jet (N600XL).
The accident occurred at 4:57 Brasilia stand-
ard time. The Boeing 737 was destroyed, all
154 occupants died. The Legacy sustained
damage to its left wing and left horizontal sta-
bilizer and performed an emergency landing
at Cachimbo Air Base, approximately 60 miles
NW of the collision site.

Both aircraft were operating IFR but in VMC
Conditions. The B737 was a scheduled domes-
tic flight from Manaus to Brasilia. The Legacy
was from, San Jose dos Campos, to Manaus,
and eventually continuing to the U.S. This was
a delivery flight from the Embraer factory.
The Legacy N600XL departed SBSJ at 2:51.
The filed flight plan included a routing via
OREN to POCOS, then UW2 to Brasilia VOR
(BRS), UZ6 to Manaus. The cruise altitude
filed was FL370, with a planned change to
FL360 at BRS, and to FL380 at TERES, 282
miles north of BRS.
After takeoff, N600XL was issued a number
of interim altitudes. The flight was cleared
to proceed direct to ARAXA VOR (on UW2),
and at 3:11 was cleared to climb to FL370. At
3:33, the airplane leveled at FL370.
The B737 departed at 3:35, requesting FL370
as a cruise altitude, and a routing via UZ6
to BRS. The airplane reached FL370 at 3:58.
There were no anomalies in communica-
tions or radar surveillance of the Boeing 737
throughout the flight.
At 3:51, a controller from Brasilia ACC in-
structed N600XL to change frequencies to
the next sector. N600XL crew reported in on
the assigned frequency level at FL370. ATC
acknowledged and instructed the crew to
squawk ident Recording show the ident
was observed. This was the last two-way
communication between N600XL and ATC.
At this time the airplane was approximately
40 nautical miles south of BRS.
At 3:56 the Legacy passed BRS at FL370.
There is no record of a request from N600XL
to the control agencies to conduct a change
of altitude, after reaching flight level 370. The
airplane made calls, but no communication in
which it requested a change of FL. There is
also no record of any instruction from Brasilia
Center to the aircraft, directing a change of
altitude.
When the airplane was 30 NM NW of BRS,
at 4:02, the transponder of N600XL was no
longer being received by ATC radar.
Between 3:51 and 4:26, there were no at-
tempts to establish radio communications
from either the crew of N600XL or ATC.
At 4:26 Brasilia ACC made a blind call to
N600XL. Subsequently until 4:53, the control-
ler made 6 additional radio calls attempting
to establish contact. The 4:53 call instructed
the crew to change to frequencies 123.32 or
126.45. No replies were received.
There is no indication that the crew of N600XL
performed any abnormal maneuvers during
the flight. Flight Data Recorder information
indicates that the airplane was level at FL370,
on course along UZ6, and at a steady speed,
until the collision. Primary (non-transponder)
radar returns were received corresponding
to the estimated position of N600XL until
about 4:30. For 2 minutes, no returns were
received, then returns reappeared until 4:38.
After that time, radar returns were sporadic.
Beginning at 4:48, the crew of N600XL made
a series of 12 radio calls to ATC attempting
to make contact. At 4:53, the crew heard the
call instructing them to change frequencies,
but the pilot did not understand all of the
digits, and requested a repeat. No reply from
ATC was received. The pilot made 7 more at-
tempts to establish contact. At 4:56:54 the
collision occurred at FL370, at a point about
460 NM NW of BRS, on UZ6.
There was no indication of any TCAS alert
on board either airplane, no evidence of pre-
collision visual acquisition by any flight crew
member on either aircraft, and no evidence
of evasive action by either crew.
7
THE
CONTROLLER
Accident
Preliminary Report
Wreckage and damage exami-
nation indicates that it is likely
the left winglet of the Legacy
(which includes a metal spar)
contacted the left wing lead-
ing edge of the Boeing 737.
The impact resulted in damage
to a major portion of the left
wing structure and lower skin,
ultimately rendering the 737 un-
controllable. Flight recorder in-
formation ceased at an approxi-
mate altitude of 7,887 feet.
After the collision, the crew of
N600XL made numerous fur-
ther calls to ATC declaring an
emergency and their intent to
make a landing at the Cachimbo
air base. At 5:02 pm, the trans-
ponder returns from N600XL
were received by ATC.
At 5:13 pm, an uninvolved flight
crew assisted in relaying com-
munications between N600XL
and ATC until the airplane es-
tablished communication with
Cachimbo tower.
The Investigator in Charge esti-
mates a 10-month timeline for
the investigation.
^
Photo: FAB
^
On November 22, 2006. The NTSB issued a
PRELIMINARY REPORT (called UPDATE) on the accident:
4 Brazil Collision
The Accident Description
by the IFATCA Team
Whenever an accident occurs, in particular
involving two controlled flights, controllers
ask themselves many questions such as: How
could two aircraft be at the same altitude
and at the same location in a rather remote
geographical spot and in a sector that has a
relatively low traffic density?
When the IFATCA team arrived in Brasilia,
in October 2006, the members started to
observe the control sectors. The more we
talked to the controllers of the Brasilia ACC,
the clearer our view became. The triggering
event was without a shadow of doubt the
loss of the Mode A and C returns of the Leg-
acy jet, shortly after its passage over Brasilia
VOR. This failure occurred at 19.02 UTC at of
roughly 25 NM North of Brasilia. The Legacy,
was established at FL 370 on the UZ6 airway
to Manaus.
In order to understand the subsequent
events, it is necessary to explain the config-
uration of the ATC ground system and the
software in place at Brasilia ACC. The ACC
software in Brasilia is designed in such a way
that controllers have two levels (or altitudes)
indicated on their radar labels:
Figure 1:
Normal radar label at Brasilia ACC
In the middle-line of the label are the altitude
indications and to the left is the first 390, is
the transponder Mode C altitude. The sec-
ond 390, on the right-hand side shows the
system altitude, or ATC altitude. In Brasilia
ACC this is most strangely not the cleared
level, but the flight plan level (FPL) of the air-
craft. It is a mix between an entry level (e.g.
from an adjacent unit or sector), the cleared
level of the flight, and finally the flight plan
level that is displayed to the controllers. The
controllers have the ability to change this lev-
el if they clear an aircraft to a different flight
level (controller input). There are some oc-
casions, however when the ATC-system
automatically updates and changes this
level. For example, if the aircraft passes a
waypoint where the FPL in question requires
a level change. This was exactly the accident
scenario when, due to a change of airway di-
rection, the flight had to change according
to the FPL from an odd to an even level. This
automatic level change in the system hap-
pens without any direct controller input.
Additionally, this automatic change is not
shown in any prominent warning colour or
special feature, just the normal colour and
fonts. It is, therefore, rather difficult to
see immediately that the ATC-system has
changed something. Most ACCs and mod-
ern ATC-systems in the world have only one
level shown to the controllers working the
system (except the Mode C indication) and
this is the so-called cleared FL, most of the
time referred to as CFL. This information is
very relevant as it is the guarantee that the
controllers, the ATM-system on ground, and
the crews in the air are working with the same
levels and possess the same information.
For the Brasilia ACC, this particular software
operation does not normally cause a problem
when all runs well, and when Mode C is received
by the system. The automatic level changes of
the system are sooner or later caught up by
the controllers when they scan the flights and
detect the discrepancy between the left- and
right-hand levels in the aircraft label.
On the 29
th
of September 2006, however, the
situation did not end as described above. As
the Legacy continued to be cleared and fly at
FL 370 and passed the Brasilia VOR, the auto-
matic level change feature was activated. From
this moment, the radar label of the Legacy now
showed two different levels, albeit for a short
while: FL 370 (Mode C) to the left and FL 360
(system level) to the right as the Legacys FPL-
level. Unfortunately the Legacy transponder
disappeared at 19.02Z. It appears that the nor-
mal mitigation of such a discrepancy, how-
ever, did not work this time, and from then on
8
THE
CONTROLLER
An airborne failure started a fatal chain of events that couldnt
be stopped by a badly designed and weak ATC-system
Photo: CG
^
by Christoph Gilgen
SKYCONTROL (Swiss ATCA)
Figure 1:
Normal radar
label at Brasilia
ACC
4 Brazil Collision
9
THE
CONTROLLER
There was now a
difference of 1000 feet
between the level shown
by the ATC-system, and
the aircrafts actual and
cleared ight level.
there was a difference of 1000 feet between
the level shown by the ATC-system and the air-
crafts actual and cleared flight level.

Due to the loss of the transponder reply,
another unusual feature of the Brasilia ACC
radar system was activated: the units military
primary radar. This is a special radar that spe-
cialists call 3-D. It is not only able to show
the geographical position of a blip as all pri-
mary radars do (range and azimuth), but has
a special feature that permits a calculation of
the altitude of the targets. The height detec-
tion is based on the measurement of the an-
gle of elevation of the target. This, however,
is a rather imprecise process and, as for the
azimuth detection, the further the target is
away from the radar site the more inaccurate
the result will be. Radar specialists have indi-
cated that variations and errors of 4000, or
even 5000 feet, at a range of 200 NM from
the radar site, are normal.
Shortly after 19.02Z when the Brasilia ACC
stopped receiving the Legacys SSR-trans-
ponder replies, the Brasilia military 3-D radar
took over. Based on what we were shown,
the call-sign correlation was only lost for a
few seconds as a valid primary track was dis-
played shortly afterwards with full correlation
of the call-sign (based on the SSR-track that
was previously there). There are, in fact, only
two small differences that can be noted on
the Legacys track indicating that the radar
returns of the Legacy are only detected by
primary radar. Firstly, the symbol of the ra-
dar blip is no longer a + surrounded by a o,
but only a +. This symbol (+) indicates to the
Brasilia ACC controllers that this is a primary
radar blip only.
The following changes in altitude indication
then occurred to the Legacy target. Where
the Mode C should be shown (to the left)
a calculated primary radar altitude is now
displayed (the 3-D indication). Next to it, to
the right, the erroneous FPL altitude of the
label remains the same, at FL360. Between
the two numbers, however, there is now a
Z shown, meaning Mode C report missing.
Under normal circumstances with a SSR-track
present there would be a = (which would
mean maintaining level). The rest of the
label continued to be shown to the control-
lers with the same colour scheme and the
same fonts. One of the major problems, also
very confusing, is that at several stages of the
tracking of N600XL (without SSR-replies) the
calculated primary 3-D altitude displayed by
the system to the controllers indicated ex-
actly 360. This would indicate, therefore, no
discrepancy to the ATM-system FPL-altitude
shown to the right of the label.
Figure 2:
Reconstructed radar picture
(time shown is local)
Shortly after the picture was taken, around
19.10 a change of controllers took place at
the ACC and a new controller took over. We
are still almost 45 minutes before the colli-
sion and the Legacy flight is about 40 miles
North of Brasilia. It is still established at FL
370, but shown on the labels at FL 360. There
was now a period of about 20 minutes where
no communication, or attempts to communi-
cate, took place between ATC and the Leg-
acy. The intermediate accident report (see
page 7) indicates that as from 19.26 ATC
tried to contact N600XL numerous times.
From 19.48 the Legacy crew had also started
to make various attempts to contact ATC.
There are strong indications that the Legacy
was at that moment at the limits, or even out-
side the VHF-coverage of Brasilia-ACC.
At the boundary between Manaus ACC and
the ACC-Brasilia both Centres were aware
that the Boeing 737-800 of Gol-Airlines was
approaching the Legacy-jet in the opposite
direction. According to the indications of their
ATC-system, however, and the exchanged
estimates of the flights a vertical separation
of 1000 feet existed. IFATCA teams observa-
tion indicated that for the controllers of both
Aera Control Centres the losses of two-way
communication and the bad intermittent ra-
dar returns are normal and frequent occur-
rences. We were told that all the operators
working the relevant sectors were apparently
aware of these difficulties.
The two aircraft, both established on the cen-
treline of Airway UZ 6, hit each other at FL
370 at 19.56.54 UTC in the airspace of Man-
aus ACC, just North of the line of jurisdiction
with Brasilia ACC and close to the waypoint
NABOL.
^
Photo: VEJA
Photo: CG
Figure 2:
Reconstructed radar picture
(time shown is local)
4 Brazil Collision
The Collision as reported
by the Brazilian Media
It is always difficult after a catastrophic event
such as this one for the media to remain silent
and wait for the official reports to be released.
They want immediate answers. The Brazilian
media, (at least the one that we know of, (and
was available on line), reported the news like
all media do in this situation: with sensational-
ism and drama for effect- as well as looking
for and finding someone to blame for the ac-
cident. We saw this approach clearly in another
instance too - the Ueberlingen collision. At first,
the focus to find someone to blame was on the
Russian pilots, then a few days later it diverted
to the controller, and finally concentrated on
the Air Navigation Service Provider. (Skyguide
in that case).

We are probably seeing a similar pattern here
in Brazil. The first thing that the press reported
almost immediately after the September colli-
sion, was the fact that the Legacy pilots may
have voluntarily disconnected their transpond-
er in order to perform some manoeuvers or
stunts to test their new aircraft. This sugges-
tion of reckless flying put the blame of the
collision squarely on the two US pilots ...
These stunts, it was reported, were apparently
documented by some radar pictures showing
the Legacy altitude varying from FL310 to 410.
Very soon afterward, when the Legacy Flight
Data Recorder was analyzed in Canada, the me-
dia reported that the FDR apparently showed
that the Legacy was steady at FL 370 the whole
time it was under Brasilia ACC area control. (This
was confirmed in the preliminary report issued
on 22 Nov. (see page 7 of this issue)
There was very little information relating to or
about the Gol B737 from either the media or
the preliminary report from the National Trans-
portation Safety Board ( see again page 7 )The
media did report that the aircraft was normally
in contact with CINDACTA-4 (i.e. Manaus ACC)
both on R/T VHF and on radar but they contin-
ued to report in such a way that led one to be-
lieve that the whole cause of the collision lies
with the Legacy and perhaps ATC, but not the
Gol B737. Then, at the end of November media
attention diverted to ATC and the controllers.
An article appeared in
titled: Dont Blame Us, But Blind Spots and
the Americans, Say Brazils Air Controllers
In that article, published 22 November 2006,
we learn that some controllers allegedly in-
volved in the collision reported a black hole
in the interface area between Brasilia and
Manaus ACC, exactly where the two aircraft
collided. The article which quoted an uniden-
tified lawyer, intimates that controllers were
induced to error by defective equipment, and
that the issue of a black hole or blind zone
was an old problem that has been presented
in the past to the Brazilian air authorities, and
that controllers had already told the Air Force
about it.

Then on 25 November a Braslia ACC controller
gave an interview on Brazilian TV. (o Fantastico)
/ Globo TV. This controller, with more than 20
years of experience, apparently also confirmed
the existence of a blind area in the region
where the collision occurred. The controller also
alluded to flawed radar and system failures.
Then, two days later on 28 November, we
learned that the president of Brazil replaced
10
THE
CONTROLLER
The media [was]
looking for and nding
someone to blame for
the accident
Photo: DP
^
by Philippe Domogala,
Editor
Photos: W.Rodrigues
Photo: WR
11
The Institute of Air Navigation Services (IANS), based in Luxembourg (Grand Duchy),
is looking for (m/f)
ATM INSTRUCTOR
Safety Management and/or Safety Regulation
(ref.: LX-2007-AT/027/CO - Closing date: 13.04.07)
and
ATM INSTRUCTOR Human Resources
(ref.: LX-2007-AT/028/CO - Closing date: 13.04.07)
The Institute provides ATM Training for the ATM Service Providers and Regulatory
Organisations of its 37 member states. We employ a team of highly professional instructors
and provide state-of-the-art training in a multicultural environment.
The IANS ATM courses cover a wide variety of ATM areas, ranging from Airspace
Management, Data Processing and Human Factors to Communication, Navigation and
Surveillance. For the development and delivery of these courses, modern teaching
methods and techniques are used.
The Institute is located in Luxembourg, one of the culturally richest and most diverse areas
of Europe.
The selected candidates will be based in Luxembourg and be involved in all aspects of
the ATM Training development and delivery.
We would be interested in hearing from you if you are an experienced ATM expert with
an interest in training.
For further details on the positions, the candidate prole and the application forms,
please consult EUROCONTROLs website:
www.eurocontrol.int/jobs (click on the position you are interested in).
Closing dates are strictly applied.
EUROCONTROL, the European
Organisation for the Safety of
Air Navigation, has as its primary
objective the development of a
seamless, pan-European air trafc
management system that fully copes
with the constant growth in air trafc,
while maintaining a high level of
safety, reducing costs and respecting
the environment.
The European Organisation for the Safety of Air Navigation.
4 Brazil Collision
the chief of the countrys Air Traffic Manage-
ment System. According to Brazils largest
newspaper, O Globo, The
removal was one of the ways for alleviating the
tense relationship between the Air Force and
military and civilian controllers. [...]
On 2 December, two ATCOs who controlled
the Legacy in Brasilia ACC gave an interview to
Brazils weekly magazine poca.
Both men expressly mentioned a
blind zone over the Amazon, along with
faulty software and communication problems
that day due to the fact that VHF transmitter
antennas in the Amazon forest do not work
properly due to interference.

On 10 December, the two Legacy pilots were
back in the USA, and on 17 December they
gave an interview to
a newspaper in Sao Paulo. In that interview the
pilots said the Legacy VHF was working very
well at all times, as they could hear transmis-
sions in Portuguese from Brasilia ACC. They
indicated they did try to contact Brasilia about
30 times, but could not, and did not attempt
contact on other frequencies. It was suggested
in this article that the Legacy cockpit voice re-
corder showed dialogue between the two pilots
that would indicate they knew the transponder
was off, but their answer was to the effect that
everything was working well.
These articles show a progression of blaming
that goes from the pilots who were first target-
ed as being at fault, (held in detention and then
released back to the USA), to Air Traffic Con-
trol where public opinion then seemed to have
shifted its focus, and then to the system itself
after controllers have expressed themselves
openly to the media and are blaming the sys-
tem. The next step has yet to materialize.
What we may be witnessing here once again
is a high-profile aviation event running a me-
dia gauntlet. Many people in many ways for
many reasons say many things. The media has
a responsibility to provide accurate, factual in-
formation to the public but it must also sell
papers, so a word of caution is advisable.
Another episode of trial by public opinion is
not what we want to see. We must be patient,
un-biased and let the official accident investi-
gation process run its course before reaching
conclusions. Sadly, we have already learned
the hard way how the mere hint of blame or
shadow of doubt cast in a certain direction can
have a devastating influence on people and
their actions.
^
4 Brazil Collision
IFATCA provides CISM
to Brazilian Colleagues
The collision occurred on September 29,
2006, at exactly 17.56 Brasilia time
After many hours of confusing and often con-
tradictory news reports the completely de-
stroyed Boeing could finally be located being
widely scattered over a large field and almost
completely hidden below the dense canopy
of the tropical forest. This accident was the
worst air-disaster in Brazil history. This ex-
plains why the emotional shockwave of the
tragic loss of this aircraft and its occupants was
so strongly felt throughout the largest South
American country. The Brazilian aviation au-
thorities, actually the Ministry of Defence who
is responsible for civil and military aviation in
Brazil, finally confirmed about 2 days later that
a mid-air collision had occurred.
As always when the word mid-air collision
is heard within IFATCA the whole-wide con-
troller family starts to gather together and
makes immediate preparations to help and
support the colleagues and controller friends
directly involved in this terrible tragedy. The
Brazilian mid-air was in this respect no ex-
ception. Within hours of the news being re-
ceived, a first direct contact with the Brazilian
MA was established. It was a little bit more
difficult to establish direct links with the as-
sociation representing the military control-
lers immediatly involved in the ATC-sectors
where the terrible collision occurred. But fi-
nally this was achieved and IFATCA was able
to speak to the Executive Board of ABCTA
(Associao Brasileira dos Controladores do
Trafego Aereo). This association, founded in
2001, represents the majority of the military
air traffic controllers of Brasilia ACC. Its a
fact that they are not yet fully affiliated to our
Federation as some legal issues and prob-
lems must be solved beforehand. But this is
only a question of weeks and, as our official
Brazilian MA has always made clear that they
desire that IFATCA comes in and tries to help
the colleagues in need and distress.
Brasilia ACC, sometimes also called ACC-BS,
and in Brazil and in Portuguese its named
CINDACTA 1 (Centro Integrado de Defesa
Area e Controle do Trfego Areo), is traf-
fic-wise amongst the most busiest ACCs of the
world. It controls a large chunk of air-
space that is about 6 times the size of
France and more than 7 times as big
as the territory of the United King-
dom. The ACC and the APP of Brasilia (col-
located at the same site) are managed by the
FAB (Fora Area do Brasil) and the Aeronauti-
ca, which are both sub-divisions of the Ministry
of Defence. They are controlling roughly about
70% of the Brazilian air traffic in three distinct
control regions and sectors. These sectors,
staffed by controllers having distinct ratings
and validations are: the Rio de Janeiro sector,
the So Paulo sector and the Northern sector,
called Brasilia sector. It was in this latter, but
already a little bit North of the line jurisdiction
(transfer point) with Centro Amaznico, situ-
ated in Manaus, where the terrible collision on
September 29, 2006 occurred.
Nevertheless it was at ACC-BS where the
private Legacy jet was last in contact with
ATC before the collision happened. This is
also where several Air Traffic controllers
were severely affected by the collision, suf-
fering from emotional distress that such an
event triggers on those directly involved into
an aviation disaster. It became rapidly evi-
dent to IFATCA and the EB that the situation
was very grave and that our Brazilian friends
needed quickly help and support. This was
why IFATCA started, in the early days of
October, to plan and assess the means and
possibilities we had of bring rapidly and ef-
ficiently support to Brazil. The initial needs
were clearly identified by all: provide pro-
fessional and technical help, and most of all
bring in psychological and professional sup-
port to perform CISM (Critical Incident Stress
Management) for the operators of Brasilia
ACC, and maybe also at Manaus ACC (with
whom the Boeing 738 was in contact at the
moment it fell).
As language skills and excellent direct verbal
communication with the persons involved was
deemed to be a crucial factor for the success of
this mission, IFATCA immediately decided to
ask APCTA, our Portuguese MA, for support.
Most luckily this call for help was immediately
accepted and two Portuguese operational staff
were dispatched within days for a three-per-
son IFATCA mission to Brazil. The Portuguese
staff consisted of the CISM-specialist Dr Isabel
12
THE
CONTROLLER
Within hours after the
news was received,
a rst direct contact
with the Brazilian MA
was established.
P
h
o
t
o
:

C
G

Photo: VB
4 Christoph Gilgen
4 Virgilio Belo
^
by Christoph Gilgen
SKYCONTROL (Swiss ATCA)
Member IFATCA CISM Team to Brazil
4 Brazil Collision
Cambraia from Lisbon and the active Lisbon
approach controller and part-time incident in-
vestigator of NAV-Portugal, Virgilio Belo. It was
a very lucky coincidence that those two very
highly qualified personalities could be readied
on short notice and were able to join me for
this emergency mission to Brazil. IFATCA and
the Brazilian controllers are not only grateful to
the two Portuguese controllers for their effort
and support given, but also would like to ac-
knowledge the Portuguese airline Air Portugal
for having graciously provided two sponsored
airfares to Brazil for Isabel and Virgilio. Muito
obrigado!
On request of the Executive Board of IFAT-
CA I joined my two Portuguese team mem-
bers and I left home on the 8
th
of October
2006 bound for Brazil. Our mission was to as-
sess the local situation there and to provide
CISM and technical and operational support
to the Brazilian controllers friends. Upon ar-
rival in Brazil the gravity of the situation be-
came immediately evident to us: 9 ACC con-
trollers (a whole sector team) had been taken
off the control roster and were requiring ur-
gent psychological support by professionals.
Moreover, the whole working shift (of the
two remaining CINDATCA-1 sectors), present
and witness to the tragedy were also deeply
shocked and needed as well close monitoring
and psychological attention. In general the
whole Brasilia ACC staff was clearly in need of
intensive CISM-care as the support offered by
the Brazilian Air Force was not at all adapted
and adequate for the degree of distress felt
by the operators involved.
During five consecutive days Isabel Cambraia
performed dozens of CISM-sessions, either
individually (for the more severe cases) or
in group sessions according to the personal
needs and the gravity of the situation. This
work is very taxing, I would even say a very
exhausting activity, and everybody that could
see and observe Isabel performing her work
was awed and stunned by the dedication and
effort invested into the tasks. Isabel performed
this vital task for several days without any in-
terruption and these were very long days.
The IFATCA delegation established through
ABCTA contacts to the very high ranking mil-
itary authorities of the Brazilian Air Force, the
owners of the ACCs in Brasilia and Manaus.
A request for full access and a close coop-
eration was formulated by the Brazilian asso-
ciation on our behalf to perform our mission.
After a cautious first contact on the first day
the sky cleared on the second day, on the
10
th
of October 2006, when I had the honour
to be personally received and greeted by the
Brazilian Air Force Chief. He expressed his
gratitude and the FABs appreciation for the
gesture of IFATCA to come in to Brazil and
help and support the controllers and the FAB
in this very grave and difficult moment. From
then on a frank and very cooperative spirit
reigned between the Brazilian Air Force and
the IFATCA and we three delegates were
granted free and unlimited access in the
ACC-facilities of Brasilia (except the defence
part).
During the time Isabel performed her CISM-
sessions Virgilio Belo and I used the time avail-
able to speak to a lot of air traffic controllers
in the ACC of Brasilia. Long sessions of obser-
vation at the control sectors were made and
a lot of facts and points were observed and
noted. Its always very pleasing to see how
controllers from different background and
different culture are gathering and speaking
about their work and the problems at hand
and it was more than interesting to speak with
the controllers at the sectors and more than
one in the rest break rooms where informal
gatherings occured. Of course the collision
and the perceived problems of the ATC-sys-
tem in Brazil were the main topics we have
discussed.
There is a full report about the technical and
operational circumstances or as it is com-
monly referred to as the chain events that
led to the terrible and mid-air of September
29, 2006 is described in this special edition
of the Controller. To my Brazilian friends
we would like to say thanks a lot for your
friendship and your warm reception and may
we meet again soon in better times and join
together forces and to dissimulate the lesson
learnt within IFATCA!
^
13
THE
CONTROLLER
Isabel performed this
vital [CISM] task for
several days without any
interruption and these
were very long days.
Photo: Bruno Puliato
P
h
o
t
o
:

I
C

4 Isabel Cambraia
4 Brasilia City
4 Brazil Collision
Brazilian ATC in Turmoil
After the accident the two American pilots of
the Legacy jet had their passports confiscated
by Brazilian authorities. They were held in a
hotel in Rio de Janeiro until the beginning of
December when they were finally allowed to
leave Brazil. Many international organizations,
including IFATCA, pressured the Brazilian
authorities to release them immediately af-
ter the accident and so to adhere to the no
blame culture. Furthermore we pressed for a
neutral and independent accident investiga-
tion so that all facts will come out and that a
lessons learned process would start. Before
the pilots were allowed to leave Brazilian soil,
they were officially charged with endanger-
ing of public safety, and may face trial in the
near future and risk a long imprisonment.
At the end of October, just before the pro-
longed weekend of finados, All Souls Day,
the Brazilian controllers, in particular at the
Brasilia ACC, started a work to rule action.
This action was called normal operations
by some or a full strike, depending on who
you talked to in Brazil. The fact is that the
Brazilian controllers, before the collision,
controlled many more aircraft in their sectors
than what was determined to be safe by the
builders of their ATM-system. In Brasilia ACC
the maximum number of aircraft a controller
could have safely at the same time per sector
is limited to fourteen. Before the accident,
however, they were working many more than
that. In order to get over the shock of the
collision and to guarantee the safety of the
ATC operations, it was decided to adhere
strictly to the official limit of 14 aircraft
controlled at the same time. This resulted
in huge disruptions as all the national airlines
schedules fell out of planning. Sometimes
the last flights of the day had to be cancelled
and this resulted in hours, sometimes even
days of delay.
The Brazilian military authorities overseeing
the Air Traffic Management System of Brazil
reacted as Military normally do, they gave or-
ders and used military discipline to control
the problem. They ordered the military con-
trollers (all en-route controllers of Brazil still
form part of the military) to report to the mili-
tary quarters and they also cancelled all their
leave. They restricted absences severely, even
for a justified medical reason and we have seen
evidence that they actually prohibited medical
absences by ordering military doctors not to
issue any sick leave certificates. They started
to transfer into Brasilia ACC controllers from
other Brazilian locations and let them work
alone, at busy and complex ACC-sectors, af-
ter only 6 or 7 days of OJT-training.
The press then started to report more and more
details of what was wrong with the Brazilian
ATC system: miss-management, old equip-
ment lacking sufficient redundancy, poorly
trained controllers, many near-misses unre-
ported or not investigated, insufficient staff-
ing levels, low salaries and complete lack of
planning. The ATC crisis started to have its
own first victims: The chief of Brasilia ACC
was replaced and the chief of the Civil Air-
space entity DECEA had to leave as well.
14
THE
CONTROLLER
Brazilian controllers,
in particular at the
Brasilia ACC, started
a work to rule action
This resulted in huge
disruptions.
4 Passengers queuing in terminal
Photo: CG
Photo: Flavio Guerra
^
by Christoph Gilgen,
SKYCONTROL (Swiss ATCA)
4 Brazil Collision
The political debate about the demilitariza-
tion of Brazils ATC system started to make the
headlines of the newspapers and IFATCA be-
came a very active player in the media to dis-
cuss this option. So far IFATCA had remained
silent as it had only written to the President of
Brazil, Lula da Silva, offering the help and ex-
pertise of the Federation to solve the problems
of the national ATC-system, after the accident.
The IFATCA President gave a long interview to
a Brazilian periodical where he criticized the fact
that all of the ATM in Brazil is managed within
the hands of the FAB (Brazilian Air Force) and
the Aeronautica (Ministry of Defence). Accord-
ing to IFATCA it is essential that the regulator
and the ATC-provision be clearly and function-
ally segregated. The accident and incident in-
vestigation body must also be independent. In
Brazil this is currently all done under the Ministry
of Defence and this is of serious concern to all.
The turmoil entered a new stage on Novem-
ber 21, 2006 when the Commander in Chief
of the Brazilian Air Force, and so the Chief of
Brazilian ATC declared in a meeting in the Bra-
zilian congress that there had been an ATC-
control error on September 29, 2006 (when
the accident happened). He said that: two air
traffic controllers assumed erroneously that
the jet was at FL 360 according to the com-
puter flight plan. But in reality the jet was at
FL 370 but I believe they were induced to the
conclusions that the flight was at 360 in such a
way that the controller passed it at hand-over
at that level, and also Manaus was advised of
that level. The controller believed that the air-
craft was at FL 360. This was false information
but he believed that it wasnt wrong.
This triggered a long and detailed IFATCA
statement released on November 24, 2006 and
where a logical accident scenario was described
and where the Federation speaks of non error
tolerant system design and of system traps in
the air and on the ground. (See page 21 for a
longer extract of the IFATCA Statement)
This statement was very well received and
many articles and blogs were written quoting
IFATCA (including 2 articles in Flight Interna-
tional). Several television documentary com-
panies have since contacted IFATCA to con-
duct interviews in order to contribute to their
films. The echo is much less evident in Brazil
where the press is still very much controlled by
Military and so rather scared to make open at-
tacks without having firm evidence. Things are
changing quickly, however, and in early 2007
all leading ATC-figures of Brazil are expected
to be retired from duty, or substituted.
The Brazilian ATC-system is not yet fully de-
militarized but legal texts are currently under
discussion in Brasilia, and the President has
now a firm proposal in his office to study and
decide upon. The military fraction of Brazil still
resists this move, as they fear a loss of power
and influence. Some structural changes are
urgently needed to the Brazilian ATC-system
and this appears to be accepted now by the
vast majority. The remaining question is just
how long the process will take and how far it
will go? This depends largely on the decisions
that are taken in the coming months, but the
transfer to a civilian entity will probably be a
rather longer process, lasting many years.
It is therefore more than likely that the Brazil-
ian ATC system will be in a difficult situation
for the coming three or four years, i.e. be-
fore the structural changes are having their
positive effects. What the tragic collision be-
tween Gol Flight 1907 and N600XL has again
clearly demonstrated is that, for a mid-air to
occur, a chain of events is required, where
long-standing problems may come to light.
They must align in such an unlucky way that,
at the end, all layers of the ATM-system are
crossed. This was similar to the Ueberlingen
mid-air, that occurred in 2002, another col-
lision that I had experienced firsthand as a
Swiss controller. Comparing it today, in 2006,
to the Amazon mid-air, it is simply amazing
to note that despite many differences and
other underlying factors, both collisions can
be compared structurally and technically, as
basically they are so much alike.
15
THE
CONTROLLER
I think the Amazon mid-air has
also seen a new IFATCA, grow-
ing and acting much more deci-
sively than before. Despite the
fact that it is certainly too early to
draw quick conclusions, we must
start to think how our Federa-
tion can contribute, if required.
We need to offer our help, ex-
perience and support more
systematically to our controller
colleagues who are facing such
dramatic events and most prob-
ably are completely unprepared.
Our Federation should also be
more active in press education
and information and in offering
our expertise to the accident in-
vestigation teams. IFATCA has a
lot to offer in order that a wider
audience gets a full understand-
ing of what contributes to an
ATM system and how it func-
tions and, more importantly, to
show why it failed at the end.
Unfortunately, seen the cur-
rent traffic growth, similar acci-
dents are likely to occur again.
We just dont know when and
where and we should get pre-
pared to go in again and help if
needed.
^
The Brazilian ATC-system is not yet fully demilitarized but
legal texts are currently under discussion in Brasilia.
Photo: Flavio Guerra
4 Brazil Collision
The Collision as seen by
the Brazilian Controllers
The 29
th
of September should have been a
normal day, but it will be remembered, for-
ever, in the life of thousands of people as the
day of Brazils worst air disaster.
Ironically, earlier that month, our asso-
ciation (ABCTA or Associao Brasileira dos
Controladores de Trfego Areo) issued in
its bi-weekly internal publication a warning
about the risk of a possible collision, but we
could not have known that the nightmare of
all Air Traffic Controllers would become real-
ity a few days later.
Where is the Gol? This sentence is what
started the fears of the Braslia ACC control-
lers that day. Once the INCERFA phase had
elapsed, the RCC-BR took over to start the
search and rescue actions for flight GOL 1907.
The ACC of Manaus, called Amaznico
Control, informed us that N600XL, a Lega-
cy-jet, had made an emergency landing at
Cachimbo Air Force base and that the pilot
in command of that Legacy had said that
they had hit something in flight.
It was requested that another off duty
controller team should be brought in to re-
place those that were controlling the flight,
and it was also determined that psychologi-
cal support was needed for those that were
most affected. The controller team on duty
was finally released in the very early hours of
the 30th of September, but had to return the
next morning to fill-out the official reports
regarding the accident.
We gratefully accepted the technical and
psychological support offered by IFATCA as
we were totally lost within this completely
unusual situation. Two weeks after the ac-
cident the IFATCA team with Christoph,
Virglio and Isabel (CISM) arrived.
The psychological support that was offered
to the controllers beforehand was deficient: for
example there was no particular attention given
to those that continued to work the traffic as the
management tried to pass the message that
all was OK and that life had to continue. Isabel
could see firsthand in what a bad psychological
shape the Brazilian Air Traffic controllers were:
loss of self-esteem, disillusion, fear, etc.
The situation got worse with time due to
staff shortages. There were suddenly a high
number of medical absences, in addition to
the unavailability of the whole controller team
that was on duty on the day of the accident.
Sectors that were normally manned by a team
of 12 controllers had now to be operated by
a maximum of 6, and even sometimes the
number went down to 4 controllers.
This brought a lot of confusion to the
whole Brazilian ATC-system as the Brasilia
ACC controls 75% of the national air traffic.
There were simply not enough controllers to
meet the traffic demand and those that con-
tinued to work, completely disillusioned by
the lack of recognition by their management,
were encountering serious difficulties in per-
forming their job without having to impose
severe flow control restrictions.
We were suddenly called strikers and
mutineers without somebody standing up
and defending us. At this very moment ABCTA
broke the silence and went public by defend-
ing the controllers and decided to tell the truth
by explaining to the whole country the real
situation of the Air Traffic Controllers in Brazil.
We never asked for anything, it was just
a cry for help to the society and the Brazilian
authorities. The posture adopted by ABCTA
made many controllers start to believe that
positive changes to the structure of the Brazil-
ian Air Traffic Control system were possible.
In particular the end of the military career that
could make a very old dream become true;
that ATC in Brazil would become civilian.
The military high command took the ac-
tions of ABCTA as a rebellion and therefore
put the President of ABCTA, the Director of
Mobilization, and the President of FEBRACTA,
(our Brazilian controllers federation) under of-
ficial inquiry and threatened to fire them.
Another important factor in what was hap-
pening at that time in Brazil was the press fren-
zy surrounding the collision. As expected, they
were in search of any information and keen to
publish it. But what they did to the controllers
that were directly involved in the accident was
very ruthless and made us deeply upset, as
there were pictures taken without permission,
stories of their private life told in a very sen-
sational manner and worse even, some media
declared them guilty without allowing the ac-
cused to defend themselves. There were only a
few journalists really interested in investigating
16
THE
CONTROLLER
We were suddenly
called strikers and
mutineers without
somebody standing up
and defending us
Photo: WR
^
by Wellington Rodrigues President of ABCTA
(Brazilian Controllers Association)
Subscription Form (Valid from June 2006)
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4 Brazil Collision
and publishing the real facts.
In the middle of the Air Traffic Control Sys-
tem crisis the system started to show its defi-
ciencies through various system failures that
occurred. There was a failure of the radar
visualization, followed by an outage of radio
frequencies and also the computer software.
A big storm in Southern Brazil cut an optical
cable of CINDATCA-2 (ACC-CW) disabling
all frequencies of the Curitiba ACC. In addi-
tion, only one week later, a lightning strike
in Campo Grande incapacitated a busy sec-
tor of the same ACC. Finally, on December
5th, 2006 a major communication failure oc-
curred in the Brasilia ACC (a system made by
SITTI of Italy) which created the worst traffic
collapse in the history of Brazil.
On top of the physical and psychologi-
cal stress that we went through, we were
suddenly now also called equipment sabo-
teurs. We asked our management to issue
an official denial of the alleged controller
sabotage, and it was later found out that
human error by a technician responsible for
that equipment led to the failure.
After the first storms had passed, we
went through many days uncertain as to
what would happen to the Brazilian Air Traf-
fic Control system, and most importantly, as
to the future of our friends that were involved
in the tragedy of flight 1907.
17
Where is the Gol?
For ABCTA this will be re-
membered as a big and hard
lesson of how to manage a ma-
jor crisis that hit us unexpect-
edly. We will also keep a never
ending gratitude to our Europe-
an friends that crossed the At-
lantic to help us, and continued
to support us from far away, so
that we can keep on fighting as
strong and focused as possible.
Thanks a lot to the big IFATCA
family, and we look forward to
becoming part of you very soon!
^
P
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C
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4 A Brasilia ACC Sector
4 Brazil Collision
THE
CONTROLLER

Which role did the trans-
ponder play in this collision?
At the end of 2003 and the start of 2004
the Swiss Air Navigation Service Provider,
Skyguide, noted an emergence of many lost
SSR-tracks and aircraft radar replies that dis-
appeared for several minutes. One particu-
larly worrying case was an Embraer E-145 of
a major European carrier, that, after a Mode
A change, remained invisible for more than
45 minutes before it was identified as an un-
known target by French military control and
the first steps of intercepting the target were
initiated. The worrying fact was that this air-
craft flew for a prolonged period through
busy sectors and airspace without being un-
der positive control and provided with the
required degree of safety .
After a long and tedious inquiry by the techni-
cal and operational departments of Skyguide
the problem was tracked down to a particu-
lar transponder type. A PRIMUS transponder
was identified to have a software problem
that lead to a complete switch-off in flight
and therefore also of the TCAS. In a safety
message published by Eurocontrol on the
13
th
of April 2004 it was written that:
If the flight crew take longer than 5 seconds to
complete a Mode A code change, the trans-
ponder will revert to Standby mode. This
will cause the track to be dropped by radars,
and the TCAS II on board the aircraft will fail
If the ight crew take longer than 5 seconds to complete
a Mode A code change, the transponder will revert to
Standby mode. This will cause the track to be dropped
by radars, and the TCAS II on board the aircraft will fail
(Eurocontrol safety bulletin)
Photo: Embraer
18
^
by Christoph Gilgen,
Skycontrol (Swiss ATCA)
4 Legacy 600 cockpit
4 Brazil Collision
ACC-Brasilia didnt
receive any SSR/Mode-
S transponder replies
from the Legacy-jet for
the last 50 minutes
before the collision.
before the collision. We also know from the
same intermediate report that there were no
TCAS alarms displayed in either of the cock-
pits. This indicates that the transponder of
N600XL, the Legacy jet, was most probably
not operating when the collision occurred.
This also coincided with the ATC radar pic-
ture that the IFATCA delegation was able to
view in Brazil in October 2006.
A ModeS is a basic requirement for any
TCAS-equipped aircraft. Each aircraft carry-
ing TCAS II must have a functioning Mode-S
transponder fitted as part of the TCAS sys-
tem. This capability permits the sending and
receiving of short data link messages and is
essential in order to perform the required
TCAS-TCAS co-ordinations (where evasive
RA-manoeuvres are managed so that com-
plementary RAs are emitted and displayed in
the cockpit). Each TCAS unit with its anten-
nas fitted along the fuselage work in a similar
way to a ground SSR-radar station. A short
and coded active surveillance message
is emitted on 1030 MHz in order to detect
surrounding traffic. Replies are received on
1090 MHz. If there is an aircraft in the area
that is not fitted with a transponder, or has
its transponder selected off or on stand-by,
the system simply cannot detect the intrud-
er, as no replies are received and therefore
no TCAS warnings will be generated.
To fly with the TCAS-unit off or on stand-by
is at the very least worrying. It renders level 3
of conflict management (the anti-collision lay-
er) almost completely ineffective, as not only
TCAS is ineffective but also the safety nets on
ground, such as STCA (Short Term Conflict
Alert) are not able to function as designed.
This fact was known before and was widely
discussed and commented, notably when the
PRIMUS cases were discussed 2004 and 2005
in Europe. Although the phenomena were
considered to be very worrying, the authori-
ties thought, as the source of the problem was
clearly identified, and strong mitigation meas-
ures were put in place. The ATM-system was
deemed to have the required degree of safety
and redundancy.
Further it was written that the operational con-
sequences are high with safety critical impact:
temporary loss of radar contact
degradation of the ACAS-safety net -
the aircrafts TCAS will fail
Authors comment: The word: degradation
is used, but in reality the consequence is that
the ACAS safety net is no longer there.
Fixing
the rst PRIMUS problem
After many controllers had persistently insist-
ed on getting the problem fixed at the source,
stiff warning letters were sent by IFALPA,
IFATCA, the JAA, and the European National
Supervisory Authorities to EASA (European
Aircraft Safety Agency). EASA then took ac-
tion and issued an AD (Airworthiness Direc-
tive) in August 2005 requiring to fix all trans-
ponder units affected within 9 months from
the date of issuance (deadline May 2006).
What was rather worrying was that this directive
was only applicable for all European registered
aircraft and so airframes registered in other
countries and continents were not affected by
this requirement. It is true that several other
States, such as Australia and New Zealand had
issued similar requirements at a later stage, but
the biggest State with the most aircraft affect-
ed, the United States (the FAA was the initial
certifier of the transponder), only published a
directive in October 2006 (less than one month
after the Brazil mid-air). There remains, pos-
sibly, still many of those units flying with this
defect. But that does not seem to be the
case in this collision, as this particular Legacy
transponder, was a newly manufactured unit
with modifications.
Brazil: possibly a new
PRIMUS problem?
But when sifting through the short intermediate
accident report (see page 7) we see that the
Brasilia-ACC failed to receive any SSR/Mode-
S transponder replies from the Legacy-jet for
approximately the last 50 minutes of the flight
Photo: Graf Consulting
Photos: Graf Consulting
19
4 Legacy TCAS display
with transponder on.
4 Legacy trans-
ponder on
stand-by.
4 Legacy RMU with
transponder on.
4 Brazil Collision
20
THE
CONTROLLER
Transponder loss was
at the start of the fatal
chain of events.
This is compounded by the fact that the indi-
cations in the cockpit that the transponder is
currently switched off or on stand-by (and as
a consequence that TCAS is disabled) are ex-
tremely difficult to spot and are not indicated
in the standard failure colours:
there is a small indication in yellow (just
underneath the transponder code select-
ed) saying STANDBY on the RMU (Radio
Management Unit)
on the PFD (Primary Flight Display) to the
left there is a message in white and small
letters indicating TCAS OFF
on the right of the MFD (Multi Flight
Display) the same message is repeated in
small white colours (see above photo)
the Vertical Speed Indicator, also used to
fly the vertical RA escape manoeuvres,
continues to remain green, despite the
fact that the TCAS is not functional.
What is even more worrying to me, is that
back in 2005, when AD-2005-0021 was issued
by EASA it was written as note in European
NOTAM backing issuance of the AD for trans-
ponders that When this reversion to standby
mode occurs, the ATC/TCAS standby mode
is indicated on the RMU and Cockpit Displays
(PFD/MFD), however these indications may
not be apparent to pilots, especially during
periods of high workload.

Outlook
Of course the fact that a transponder ceases
to function or is disabled in flight (being ei-
ther voluntarily or involuntarily) is not yet suf-
ficient to explain a mid-air collision in itself.
It is just a contributing factor but may well
be the start of a chain of events. There must
be more failures or underlying problems oc-
curring simultaneously before this can actu-
ally become so critical that the worst must be
feared, including a mid-air collision.
But we have now indications and hints that
point to the fact that this transponder loss
may very well have been at the start of the
fatal chain of events. It is therefore urgent
to eradicate this problem at the source, as
this will reduce significantly the risk and the
probability that a similar chain of events will
be started again. This is not at all a defence
for a weak or badly designed ATC-system on
the ground, where a lot of decisive actions
are needed as well, but those remedial ac-
tions must be undertaken in parallel.
For me , there are mainly two issues that need
to be addressed with urgency by the regula-
tors and by the transponder manufacturers:
the ability to disable the transponder
in flight by one single key stroke is
unacceptable
the indications that the transponder is off
or stand-by are not visible enough (the
visibility and warning must be improved
significantly)
Let us hope that this accident will finally bring
the required strong and decisive actions by the
stakeholders and regulators. The manufactur-
ers might be restricted in this matter as they are
currently under threat of several law-suits in US
courts that allege their legal liability for this colli-
sion. But common sense should prevail.
^

How can a trans-
ponder be tur-
ned off or put on
stand-by and so
disable TCAS?
When the IFATCA delegation
was in Brasilia in early October
2006, some 2 weeks after the
collision, the theory of the US-
crew having switched off their
transponder was still widely de-
bated by the press. It was also
discussed at the top-level of the
Brazilian Air Force as its com-
manding officer made remarks
to the IFATCA delegation along
these lines. First doubts about
the theory started to come
when we saw the radar record-
ings and saw the wildly fluctu-
ating altitude indications, but
with a steady track flown by the
Legacy jet. We started to get
the utmost conviction that the
aircraft was continuously flying
at FL 370 as cleared by ATC.
We thought from then on that
it simply could not be possible
that a professional crew would
willingly switch off such an im-
portant piece of equipment.
In early November I had a cru-
cial meeting somewhere in Eu-
rope where I met a person that
had been in Brazil and wanted
to talk to me about this mid-
air collision. He asked to check
and compare our notes and to
show me something important.
I was shown by him how, with
one unintentional key-stroke
on the RMU (Radio Manage-
ment Unit) of the avionics fitted
on Embraer aircraft, it is possi-
ble to put the transponder on
stand-by, and disable it.
P
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G
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c
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4 TCAS display showing TCAS off and transponder on stand-by on the RMU.
4 Brazil Collision
The International Federation of Air Traffic Con-
trollers Associations (IFATCA) has noted recent
statements attributed to the Chief Command-
er of the Brazilian Air Force, and Commander
of the Aeronautica Tenente-Brigaderio-do-Ar,
Senor Luiz Carlos da Silva Bueno. IFATCA is
surprised and disheartened to learn that state-
ments to the effect that an air traffic controller
from Brasilia ACC made an error when control-
ling the Legacy flight so that it collided with
the Boeing 737-80 of GOL over the Amazon,
were made in front of the Brazilian Congress.
Senor Bueno allegedly said that the controller
thought that the aircraft was at FL 360, which
was erroneous information, but the air traffic
controller believed this wrong information.
IFATCA believes that Commander Bueno is not
well informed and therefore is making incor-
rect, or only partially correct statements. Facts
will show that the Air Traffic Management sys-
tem in place in the airspace of Brasilia did not
register nor correctly detect the true altitude of
the American-registered aircraft. []
IFATCA believes that operators in the air
(the pilots), and on ground (the controllers),
fell victim to unacceptable systems traps
brought on by non-error tolerant, and bad
system design of air traffic control and flight
equipment in use. We are confident that our
statements concerning this equipment are
accurate, and said equipment is responsible
for starting the fatal chain of events of Sep-
tember 29, 2006, and therefore, contributed
to the mid-air collision.
IFATCA urges Brazilian authorities not to en-
gage in a counterproductive blame game,
but to invest their energies to the undertak-
ing of immediate and decisive remedial ac-
tions to eliminate these dangerous safety
traps. If swift action is not forthcoming, the
probability of incidents or, a similar type sec-
ond accident occurring remain high.
END OF STATEMENT
Observations and Areas
of Concern (extracts)
1. The software of ACC Brasilia is badly
designed in the opinion of IFATCA, and
therefore is a major contributor to an un-
safe and dangerous ATC system.
2. The Legacy needed to change from an odd
level (FL 370) to an even level, being FL 360.
When passing over Brasilia VOR, the Brasilia
ACC software did automatically change the
coordinated altitude indication to 360 (from
370) on the aircraft label shown on the radar
screen. However, the flight was still flying at
FL 370 and was not cleared down by ATC to
FL 360 as shown on the label.
3. Once a flight is lost by SSR in Brasilia ACC
(i.e when the transponder shuts off, or goes
to stand-by mode) , the Brazilian military
primary radar kicks in. It continues to show
the lost flight almost immediately in a very
similar way as before the failure.
4. A special feature of the Brasilia military radar
is that it calculates altitudes (or flight levels)
in a 3D-mode. And display this on the label,
There is only a small Z between both 360 in-
dicating the missing Mode C report, but this
can be easily overseen and not noted.
5. To date IFATCA has not received a con-
vincing explanation of why the software
of ACC- Brasilia is tuned in such a strange
way. We are also at a loss to understand
why the very unreliable 3D-altitude calcu-
lations of military primary (3D radars) are
shown to civilian controllers.
6. The Embraer Legacy cockpit can be a dan-
gerous trap for pilots. The Legacy with its
Honeywell custom-built avionics panel can be
a hazard in the air. To inadvertently switch off
the safety-essential transponder (or to put it
on stand-by) in this aircraft is very easy.
21
THE
CONTROLLER
IFATCA Statement after the Collision
Issued on 24 November 2006 (Extracts)
Gol Flight 1907
Final remarks
IFATCA is of the opinion that
this accident investigation must
remain neutral and completely
un-biased. The focus should be
to bring to light all relevant facts
and actions that have led to this
terrible tragedy. We must permit
the aviation system to learn from
this accident and to correct the
identified weaknesses in order
to strengthen the ATM system.
IFATCA has concerns regarding
some of the content appear-
ing in the intermediate report
published by the Centro de
Preveno e Investigao de
Acidentes Aeronuticos (CENI-
PA) We believe a certain tone
of language used and points
mentioned in the intermediate
report are not indicative of a
neutral stance, and are an early
indication of a certain view and
position held by the accident
investigation commission.
IFATCA urges the CENIPA and
the Brazilian government to re-
port neutrally and consistently,
without any distortion, the rel-
evant facts and factors that have
led to this terrible accident. Full
disclosure is paramount so that
we may learn from this tragedy.
The Full statement is available
on IFATCA web site at
www.ifatca.org
IFATCA believes that the pilots, and the controllers, fell
victim to unacceptable systems traps brought on by non-
error tolerant, and bad system design of both air trafc
control and ight equipment in use
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4 Brazil Collision
What can IFATCA learn from
the Brazilian experience?
On the 29
th
of September a mid-air collision
occurred over Brazil. The Executive Board
(EB) learned about this unfortunate accident
on the 30
th
of September 2006. This is the
second mid-air collision within four years,
and we as an organization representing the
controllers around the globe decided that
we needed to respond. The EB discussed
how best to react to this tragic fatal accident.
IFATCA has a Member Association in Brazil
and we were able to contact them quite rap-
idly. Getting to the people concerned was a
different story. Our Member Association de-
clares 15 members, however in Brazil there
are some 2900 air traffic controllers, most
of them are military personnel. Previously
IFATCA had tried to find ways of how all the
ATCOs could join IFATCA. We had estab-
lished contacts with the existing Federation
of Air Traffic Controller Association of Brazil
(FEBRACTA). This association was created
in order to give all air traffic controllers (civil
and military personnel) the opportunity to
join IFATCA in the future. Once we had es-
tablished the contacts, soon it became very
clear, that due to the particular nature of
providing ATC in Brazil some support in situ
would be required.
With exceptional effort, within a limited time-
frame of one week we were able to create, a
team of three people capable and willing to
give support to our colleagues in Brazil. IFATCA
has never done this before. The challenge to
create a team (a mental health professional
for the Critical Incident Stress Management,
a trained accident and incident investigator
and an IFATCA ICAO Panel representative
who had been involved in the internal Sky-
guide investigation board after berlingen)
was huge. The team had to be unhindered by
unnecessary bureaucracy, knowledgeable with
our policies and all this combined with a suf-
ficient level of experience. Within one week
after the collision IFATCA had written mission
orders, co-ordinated with the individuals and
their employers, and our delegation was on its
way to Brazil. This would not have been pos-
sible without a lot of personal sacrifice by the
three individuals, big support from their na-
tional member associations, their employers
and TAP (Air Portugal). During their visit we
needed to consolidate our contacts and obtain
feedback. For the EB, the concept of this cri-
sis intervention team was new and therefore a
lot of creativity and flexibility was required.
The team acted very professionally and the
feedback from the concerned controllers
was great and continues to be very positive.
The Brazilian ATCOs were not prepared for
such a tragic accident and the support the
three individuals have given was outstand-
ing. The EB would like to express its deepest
gratitude to them.
After their return we entered a new phase.
What would we do with the debriefing of
the team? The information gathered and the
feedback received, showed clearly that there
were new challenges we were to face, be it
on the communication level or optimization
of our support to our colleagues in Brazil.
The situation in Brazil was evolving fast and
similarities of reactions with other accidents
(like Ueberlingen for instance) were very
striking. This was (and is) mainly driven by the
press and can in general be broken down
into three main phases. Theory on crisis com-
munication lists describes this as:
(1
Phase one Consternation:
Phase two Further elaborations:
Phase three Accusation:
22
THE
CONTROLLER
(1
A. Casanova, Risk Symposium 2006, Skyguide
Within one week after the collision IFATCA had written
mission orders, coordinated with the individuals and their
employers, and our delegation was on its way to Brazil
Photo: DP
^
by Marc Baumgartner,
President & CEO on behalf of the Executive Board
4 Brazil Collision
Particularly in phase three, the similarities of
reaction were very striking: first the focus of
blame the pilots, then the individual ATCOs,
then the system (Brazilian Air Force), and
then the politicians. During all these phases,
the press is omni-present and is asking for
improvements in the system and provides
the necessary external pressure so that they
are implemented.
IFATCA decided to send a letter to the Presi-
dent of Brazil highlighting some of the system
deficiencies our team was able to observe
during their visit. The letter also addressed
the urgent need for improvement of the safe-
ty of the traveling public and the economic
means required to achieve these goals with-
out delay.
The press got hold of this letter, and as could
be expected, the individual ATCOs started
being accused by their superiors. After dis-
cussion within the EB, we decided to give
support but to limit it to professional issues.
The reaction of the military authorities was
very heavy-handed. The military personnel
were placed in barracks and guarded whilst
at work. In addition, people that had never
worked in the units involved in the mid-air
collision were forced to work there. This
was clearly a reaction we did not expect to
happen. From a professional point of view
we thought these actions were completely
unacceptable, and would increase the risks
taken within the ATM system. The military
reaction originated from the reduction of the
number of flights handled by the sectors to
the number that was actually foreseen at the
design stage of the system. This inevitably
led to huge delays at all Brazilian airports.
This fact and the intermediate accident re-
port made us go one step further a new
experience in IFATCA history. IFATCA pub-
lished a statement with some detailed infor-
mation on the system and its breakdown.
We gave up our natural reservations regard-
ing ongoing accident investigation and took
a big risk by publishing the statement. The
outcome, however, was very positive as the
press and other international organizations
(2

were able to better understand how ATM
works and what could lead to an accident
when the ATM system breaks down.
The next step in Brazil which can be envis-
aged by IFATCA, will be the start of the legal
investigation once the final accident report
is published. This will be (as we have seen in
other aircraft accidents), a very challenging
phase for the ATCOs involved. The EB has
written to the Brazilian ATCOs in order they
join forces with IFATCA so that we are able
to give support as well during this phase.
IFATCA will have to carefully analyse this event
with all the parties involved and decide if it can
play a proactive role when things do go wrong
and to give consideration to the experience
used in Brazil. One of the main challenges we
have learned from the practice so far is to find
23
THE
CONTROLLER
IFATCAs continuous support for the Member association
in Brazil will be further strengthened once all Brazilian
controllers nally become members of the Federation.
(2
common statement with FSF, CANSO, IATA,
NBAA, IFALPA and IFATCA
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the correct balance between
giving real support (psychologi-
cal, technical and professional)
to the controllers, while keep-
ing the doors open to the Fed-
eration to act as a respected
stakeholder and interlocutor for
Governments, other aviation
stakeholder and press.
IFATCAs continuous support
for the Member association in
Brazil will be further strength-
ened once all Brazilian control-
lers finally become members
of the Federation.
^
Crisis communication basic rules:
After a serious crisis, these are generally the questions,
various players and actors (i.e.: ATC management, Airlines,
Politicians, the media etc.)
Phase one
Consternation: The rst phase is dealing with the facts.
What has happened? Any impact (collateral damage)? How
many deaths? How many injured? Are they being treated?
Is there anything that should be feared? Has rescue been
organized? Etc.
Phase two
Further elaborations: Anything new? One is aware of the
facts, what happened and which impact the event had, now
starts the research phase? How could something like this
have happened? Have some security or safety measures
not been dealt with correctly or failed? Could there be any
actions to avoid this? Was everything in place to avoid such
a situation?
Phase three
Accusation: Who is responsible? Which consequences will
this have? Can somebody be red or imprisoned? Press
starts to judge rapidly and play more and more the role of
the judicial system.
4 CISM
Managing the Other Stress
For many years now IFATCA has been active
in promoting to our Member Associations
the importance of identifying and effectively
dealing with stress in the workplace. Due to
the dynamic nature of our occupation we
have concentrated our efforts for the most
part on critical incidents and critical inci-
dent stress management (CISM) programs
and support services. We normally refer to
a critical incident as one that has sufficient
emotional power to cause an employee to
experience a strong and sometimes over-
whelming reaction, which could interfere
with or hinder their ability to function either
on the job or in every-day life.
To help guide us in dealing with this form
of stress our professional/legal committee
has developed policy recommending that
professional critical incident stress support
services should be made available to air traf-
fic controllers involved in ATC incidents/ac-
cidents and/or other occurrences that can
create critical stress reactions... Familiar ex-
amples are an incident involving loss of life
or serious injury, or a near collision between
aircraft under the employees control.
Our IFATCA Manual includes a section out-
lining our suggested model for an effective
CISM program that includes recommendations
for the selection of CISM peers - volunteers
trained to support controllers (confidentially)
during times of stress and to facilitate referrals
to other support services if needed. Working
24
It is an accepted fact
in the medical
community that stress
is one of the major
causes of all illnesses.
safely and efficiently in a fast-paced and con-
stantly changing environment day after day
can lead controllers to believe they are invin-
cible and could not fall prey to something that
allows our normal way of thinking, feeling and
acting to be adversely affected until it hap-
pens! We then tend to internalize and not want
to talk about these circumstances we find our-
selves in.
By behaving this way we allow stress to ac-
cumulate, we become more vulnerable and
risk shock to our psychological systems that
can then result in traumatic stress. The dif-
ference between so-called normal stress and
traumatic stress is the degree of body chemi-
cal reaction to the trauma. An opportunity to
express our innermost concerns, to re-con-
nect with others and to learn of the potential
impact critical incident stress can have on us
can be found in interventions such as defus-
ing and debriefings that are designed to en-
courage us to share our thoughts and feel-
ings resulting from a shocking incident(s).
A peer support program supplemented by
professionals can offer not only guidance
and education, but a well-balanced strategy
for recovery as well. Critical Incident Stress
is the type that most readily pops to mind
when we think of our work environment but
there is another type of stress that we must
also be aware of every-day stress. We
all know what every day stress is, and we all
suffer from it at one time or another. It is
nothing more than the physical, mental and
emotional responses by our minds and bod-
ies in dealing with life and its changes. If it is
negative or bad stress it wears us down,
leaving us feeling drained or burned out.
There is room however for some stress pos-
itive or good stress spurs us on and keeps
us sharp and alert. But lets have a closer look
at that other stress. What is it exactly? How
do we recognize it? What does it do to us?
First, I would like to introduce the term burn-
out; a well-worn, perhaps over-used term to
describe a physical and/or mental condition
we perceive ourselves to be experiencing as
a consequence of long-term stress or frus-
tration. Employees who suffer from stress-
induced burnout tend to become cynical,
indifferent and risk becoming ineffective on
the job. They are in an emotional state char-
acterized by an overwhelming and enduring
THE
CONTROLLER
Photo: D
P
^
by Doug Churchill, EVP
Professional IFATCA
4 CISM
feeling of exhaustion and/or aggravation
that develops gradually into the inability to
function productively.
So how do we recognize the onset of stress?
It is not easy, but there are early warning signs
that we should be on the lookout for - here
are a few: Chronic fatigue (exhaustion, tired-
ness, physically run down); anger; cynicism;
negativity; irritability; frequent headaches;
gastrointestinal problems; weight loss or gain;
sleeplessness; depression; feelings of help-
lessness and an increase in risk taking. There
are others but these are more easily identifi-
able by the average person as reactions to
highly stressful situations.
It is an accepted fact in the medical commu-
nity that stress is one of the major causes of
all illnesses. As we become more and more
stressed, distractions, anxieties and negative
thinking occupy our minds. Our concentra-
tion suffers, and focus narrows as our brain
becomes overloaded. The more our brain is
overloaded, the more our performance can
suffer. The more our performance suffers,
the more new distractions, difficulties, and
anxieties flood in. Do we need more con-
vincing for us to realize the need for stress
management for air traffic controllers?

So, who if anyone is to blame for these stress-
driven phenomena? Historically it has cen-
tered solely on the worker, but research has
indicated that some causes of burnout may
lie in economic trends, technology use and
even management philosophy within organi-
zations. Could it be that we are witnessing
the demands of the bottom-line fuelled by
global competition, enticing service providers
to cash in their human assets for short-term
productivity gains? An ugly thought, and a
possibility, but in all fairness to our employers
we cannot simply lay the blame at their feet
and wait for them to eradicate stresses in our
lives with one wave a magic wand.
As a group of professionals with a great deal
of responsibility resting on our shoulders,
and as individuals responsible for our own
health and well being, we too must accept
that we have a role to play in maintaining
our most precious asset - our body - in good
working order.
On the professional side of things within
IFATCA we have adopted well-thought out
policies for the betterment of our health with
respect to our working environments (light-
ing and climate control), hours of work and
rest including the effects of shift-work, the
effect that medicines, drugs and alcohol have
on us, fatigue management and so on. We
suggest medical standards for controllers,
and the identification of causes of stress and
methods of prevention as suggested by the
ILO Conclusions of 1979
(1
. We recognize that
stress is an increasingly global phenomenon,
affecting all categories of workers, all work
places and all countries and we acknowledge
that considerable levels of occupational
stress reactions can and do occur among the
air traffic controller population.
Our list of identified occupational stressors
contains such items as: Demand (number
of aircraft), Operating procedures, Working
time(shift and night work), Working tools
(limitations and reliability of equipment),
Work environment (lighting, rest facilities),
and Working organisation (relations with su-
pervisors and colleagues, lack of control over
work process, lack of management support).
The Federation recognises the importance of
stress management for air traffic controllers
and recommends that, at regular intervals, air
traffic controllers be provided with up-to-date
information on stress management techniques,
and that comprehensive and confidential sup-
port services should be available at all times for
air traffic controllers and their families.

We urge our Member Associations to bring
to their administrations attention the stress
inducing potential of their work environment
in order that particular consideration is given
to ensure that the work environment is as
stress-free as possible.
We do not take these issues lightly. They are
crucial to not only us but to the well-being of
the entire system. So why then, is there so little
emphasis on us as individuals to protect that
most valuable of all assets? We know all too
well the devastating consequences prolonged
stress can have on our minds and bodies, not
to mention the more immediate and serious
results that could occur if we are working in an
incapacitated state of mind and/or body! As
employees we have a duty to take care of our
health (and safety) not only in the workplace,
but away from it as well. We must recognize if
and when our personal stress becomes a prob-
lem and realize our responsibility to ourselves
our families and our employers. If we worry
about the symptoms we are experiencing and
do nothing about them, we end up in a vicious
cycle that makes matters worse.
Simply acknowledging that stress may be re-
sponsible for how we feel, is the first step to
seeking help. Unfortunately many times our
pride gets in the way and we refuse to talk
about such personal issues as being stressed
out due to the social stigma attached to it.
25
All too often we go to the pub,
blot it out and not talk to any-
one about it! We fear we will be
seen as weak.
If you are experiencing either
work-related stress, or stress
from outside influences you
should seek out others to lis-
ten to you and help you find
an appropriate solution. Help
can come from many sources:
your manager, employee repre-
sentative, CISM counsellor, co-
workers, family doctor, friends,
HR department and employee
assistance programs.
Stress is not a weakness - it can
happen to anyone. We need to
take all forms of stress seriously,
identify its causes and formulate
a plan to take control and deal
with it. If we do not, our lives
and perhaps those of others
may be at risk.
^
THE
CONTROLLER
If you are
experiencing [..] stress
[] you should seek
out others to listen to
you and help you
(1
International Labour Organization Meeting of Experts on
Problems Concerning Air Trafc Controllers, Geneva, 8-16 May 1979
Photo: DP
4 CISM
The new French association FATCOA organ-
ized in the Marseille ACC in South of France a
CISM workshop, mainly to convince their em-
ployer to implement the scheme nationwide.
They invited two speakers, Joerg Leonhardt
from the DFS, the leader in Europe in CISM
training and author of a book on the subject,
(see page 29 for a review of his book), and
IFATCA President Marc Baumgartner, who
explained the benefits of CISM both after
Ueberlingen, and more recently in Brazil.
Emphasis was given to the fact that employ-
ers who introduce such a scheme benefit the
most from their investment as controllers re-
turn to work and remain longer in their jobs
after having experienced the trauma of an
accident or severe incident. We learned that
implementing a CISM scheme has a return
on investment over five years, which exceed
400%. In fact, for European ATM, CISM was
the second most cost-effective program after
RVSM introduction. It is a mystery to many as
to why so many states still are not implement-
ing CISM. Currently less than half the Europe-
an states have a real CISM program in place.
France has local initiatives, like in CDG airport
in Paris, where local management has signed
contracts with psychiatrist units in hospitals
specializing in post accident trauma. But all
CISM specialists including our two speakers,
said that if medically specialized staff help in
the process, they should only do so after the
CISM so called Peers have intervened. CISM
Peers are controllers from the same unit, who
are properly trained to intervene immediately
after an incident or accident and understand
the complexity of ATC and the various rela-
tions one has around ATC, something a pro-
fessional psychiatrist can never do. This early
normalization as they call it (i.e. returning
the controller into normal behavior) has to
be done very quickly (i.e. within hours) and by
people having the necessary ATC background.
They also need to be trusted and accepted by
other fellow controllers. If this is done prop-
erly, over 90% of the controllers will return to
work within three days. The obvious benefit is
of course for the employer. (Another mystery
is why an employer would want to risk loosing
the 500.000 dollars it spent training a control-
ler by denying them such a program.)
The controllers will not only be productive
again much earlier, but by ensuring his or her
well-being the controller is likely to continue
to work for this employer a much longer time.
Marc said that after the Ueberlingen colli-
sion, there were 15 controllers in Skyguide,
who left the OPS room as a direct or indirect
consequence of the collision. Joerg said that
untrained colleague support, although well
meant, can be counter productive. The natural
reaction to comfort someone after an incident
or an accident is to deny it, or say it does not
matter, and this generally make things worse.
Proper Peer selection and training is essential.
For France, the controllers / FATCOA position
is that CISM is a national need that cannot be
left to local initiatives, and it should be Peer
based and not using only outside institutions.
The response of Philippe Bougnoux, the na-
tional CISM coordinator of the French DNSA,
their employer, was disappointing. He said
France was not yet ready to implement CISM
fully and nationwide. He proposed a stepped
approach where the first level would be to ar-
range psychological help support in every unit
(similar to what Paris CDG has done) and a sec-
ond level would be to look for a peer system,
but only in some places. To extend it over the
whole of mainland France, which has five ACCs
and sixty main airports, and the French over-
seas airports and ACCs would be difficult.
It was a pity that after such good presenta-
tions, convincing arguments and debate,
the French DNSA is still not recognizing the
need and the urgency of CISM. The FATCOA
controller Association said they will continue
to fight for CISM implementation and intend
their next step to press their views higher up
in the French administration.
^
THE
CONTROLLER
Explaining how CISM works
A CISM Workshop in Aix en Provence
26
A CISM scheme has a
return on investment
over ve years that
exceed 400%
P
h
o
t
o
:

D
P

Photo: DP
Photo: DP
^
Report by Philippe
Domogala, Editor
4 CISM speaker: Joerg Leonhardt
4 CISM speaker:
Marc Baumgartner
4 Jerome and Cedric
of FATCOA
4 Just Culture
Almost four years have passed since IFATCA
called upon the international aviation com-
munity to develop guidelines promoting the
concept of a just culture.
(1
To be successful, Member States of ICAO
must take action to ensure that national judicial
aspects are adequately addressed (through
ICAO) with respect to their ATS Safety Man-
agement Systems. Specifically, we encouraged
the review of existing national aviation laws
that could deter the collection and analysis of
valuable safety-related information, and have
asked States to develop legislation protecting
persons involved in that reporting.
Much has been written and debated among
Service Providers, safety regulators/investiga-
tors and other international bodies concern-
ing this non-punitive legislation. A major
concern seems to be how to accomplish a just
culture environment and achieve an effective
Safety Management System (SMS), while in-
corporating an acceptable level of just culture
within a non-punitive environment. We have
come to realize the trend of apportioning
blame following accidents, along with a threat
of civil or criminal proceedings has a damaging
effect on the flow of essential information.
That accidents could be prevented and avia-
tion safety enhanced if front-line operators
are protected from punitive action is a popu-
lar notion. This pro-active mindset supported
by the ICAO ANC 11 Recommendation 2/4
(see note
(2
) should encourage States to re-
view their laws and regulations to determine
whether the threat of criminal liability is in-
terfering with the collection of safety-related
information. Criminal prosecution is counter-
productive to improving aviation safety.
The threat of prosecution creates a dont
get caught culture resulting in fewer reports,
thereby yielding little in the way of systemic
improvement(s). IFATCA supports judicial
proceedings meant to determine blame or li-
ability, being completely separate from acci-
dent investigations. An open culture will lead
to systemic improvements, as the sharing
of important data will significantly increase
providing governments have the foresight to
pass legislation decriminalizing those respec-
tive aviation laws within their countries.
The solution may seem an easy one - take a
pill (changes the laws) - the headache (legis-
lative barriers) goes away. It is not that easy.
Criminal law in many countries obligates au-
thorities to investigate aviation occurrences
and to administer justice (read punishment)
for improper behaviour. Non-punitive is in
legal terms, a very strong approach and im-
plies writing a blank cheque.
(3
The time has come to
move forward, but how?
The Eurocontrol Safety Reporting and Data
Flow Task Force (SAFREP TF) may provide
one answer. As identified by the SAFREP TF,
we must stop merely discussing just culture
reporting (we all agree we need it), and focus
on the domestic legal frameworks of States.
Our vision of safety occurrence reporting
will challenge penal, administrative and civil
codes (sometimes even constitutional rights),
of many nations. Changes to national crimi-
nal laws ranks highly in domestic hierarchies,
and as such any amending must involve the
respective Ministries of Justice.
It is the judicial system(s) that must be con-
vinced of the importance of safety reporting
without threat of criminalization. Obviously
this cannot be achieved by simply saying we
THE
CONTROLLER 27
Just Culture
Legally Speaking
want data and we want a just
culture. Multi-party co-operation
is required to bridge the gap be-
tween judicial systems and the
needs of aviation. Engineering
such a reporting culture foster-
ing a high level of trust might not
be easy but its possible.
Introducing Just Culture as part
of a global action plan, along
with certain legal impediments
to progress, need to be singled
out and solutions developed. A
prudent course of action could
be the convening of a series of
workshops developed specifically
for the target audience, i.e., legis-
lators/law makers, specialist legal
representatives, members of par-
liament, civil aviation authorities,
along with representatives from
respected international organiza-
tions (IFATCA, ICAO).
The output from such work-
shops could be a positive con-
tribution to efforts in achieving
the implementation of volun-
tary reporting systems based
on principles of co-operation,
with a guaranteed measure of
legal confidentiality and pro-
tection for those involved.
^
It is the judicial system(s) that must be convinced of the im-
portance of safety reporting without threat of criminalization
(1
a culture in which front line operators are not
punished for actions or decisions that are com-
mensurate with their experience and training,
but also a culture in which violations and wilful
destructive acts by front line operators or others
are not tolerated.
(2
Recommendation 2/4 The protection of sour-
ces of safety information- that ICAO develop
guidelines which will provide support to States
in adopting adequate measures of national law,
for the purpose of protecting the sources and
free ow of safety information, while taking into
account the public interest in the proper admi-
nistration of justice.
(3
In cases where operators are guilty of willful
misconduct perceived to be beyond the limits
of acceptability such as acts of sabotage, gross
negligence or substance abuse, it is necessary
that criminal prosecution will follow.
4 Fear of Blame?
P
h
o
t
o
:

D
P

^
by Doug Churchill, EVP
Professional IFATCA
4 Interview
Interview
With Professor Sidney DEKKER, Ph.D. in Human factors & Aviation safety
The Role of Human Factors in an Accident
Marc: Your are an Human factor expert, how
do you rate ATC knowledge and applica-
tions of Human factors principles compared
to other industries?
Sidney Dekker: I see ATC as pretty involved in
human factors, actually. You seem to take the
issues seriously. Of course, you still carry quite a
large residue of what I would call old-fashioned
approaches, such as HRA (Human Reliability
Analysis) and pretty linear, limited risk assess-
ment methods such as HAZOP. In my opinion
these do not do justice to the complexity of
ATC work and its setting, nor to the resilience
and creativity of people who work within it.
M: How can an Organisation like IFATCA can
tackle the legal issues surrounding Human
performance? IFATCA has no legal expertise
as such and depend on outside help, how
can we get this without having to pay large
sums of money that we do not have?
SD: This is tricky, I understand. One way
(but not always one that is possible, I know)
is to find ways together with the ANSPs to
tackle legal issues. ANSPs have more legal
resources than the unions, probably, and
even though their interests may often di-
verge, when it comes to the problem of the
criminalization of error, for example, that is
good for nobody. Both unions and ANSP suf-
fer there. So in order to tackle legal issues
without bleeding financially for it, I suggest
finding areas of common interest between
ANSPs and unions and partly rely on their
legal expertise thats already paid for.
M: The just culture idea was something every-
one was eager to support a year or two ago.
It would still be a very good thing to have es-
tablished, but it seems to have lost some of its
momentum. How do you see this today and
how can/should it be revived?
SD: The idea of a just culture as you have
tried to sell it in ATC carries the seed of its
own corruption. Just look at the Eurocontrol
definition: a just culture is one in which front
line operators or others are not punished for
actions, omissions or decisions taken by them
that are commensurate with their experience
and training, but where gross negligence,
willful violations and destructive acts are not
tolerated. The idea, of course, is that if just
cultures are to protect people against being
persecuted for honest mistakes, then some
space must be reserved for mistakes that are
not honest (the gross negligence or de-
structive acts in Eurocontrols definition, for
example). You can see all the qualifiers to that
extent as a kind of escape hatch. And building
in an escape hatch means it can be used. It
also means that it can be used to push normal,
honest mistakes into the realm of the negli-
gent, the culpable, the bad. Which is precisely
what has happened in some cases of control-
ler prosecution in Europe recently. This, then,
brings me to the crucial question that nobody
seems to have tackled seriously: who has the
power to draw the line? The line is clearly
negotiable: sometimes we find behavior ac-
ceptable, while others, at another time may
find the very same behavior quite culpable.
So who in your country has the legitimated
authority to draw that line? Can we do some-
thing there? Like putting more domain exper-
tise into the process of drawing the line, and
not leave it to prosecutors or judges or other
people without a clue about what it means to
be a controller and do ATC work.
M: Is your New View being widely accept-
ed by ANSPs over the world?
SD: I actually dont really know! I would hope
so, but I also know that there is still a lot of
old view thinking. People still want to see
human error as the cause of trouble, rather
than as the consequence of trouble deeper
inside their own organizations. There still are
a lot of incident investigations that somehow
say if only the controller had done this or
that, or had tried harder, or not lost situation
awareness, the event would not have hap-
pened. Such language, of course, is use-
less, it is counterproductive even. That said,
I do enjoy the presence of a bunch of ATC
people from all over the world in my classes,
so the word may be spreading. Also, I hope
that one of my recent books, the new Field
Guide to Understanding Human Error is
making its way down to the relevant people
in ANSPs, as it not only shows how to avoid
old-view thinking, but also guides people in
setting up a meaningful safety department,
and how to get their organization to adopt
the new view.
28
THE
CONTROLLER
People still want to
see human error as
the cause of trouble,
rather than as the
consequence of trouble
deeper inside their
own organizations.
Photos: SD
4 Prof. Dekker experiencing
rst hand Human factors
issues on board a Saab 105
Trainer aircraft.
^
Interview by
Marc Baumgartner
4 Prof. Dekker
4 Interview
M: We learned that you have been asked by
Skyguide after the Ueberlingen collision to
make a study on the Human factors surround-
ing that case. This report has not yet been
made public. Did you learn something in that
study that could be of interest to all of us.
SD: I had to sign a non-disclosure agree-
ment, so I cant tell you anything.
M: We could help controllers involved in
collisions, like recently in Brazil, using your
expertise. Would you be prepared to help
IFATCA in such situations?
SD: Of course! But you just told me you dont
have the money ...!
M: Finally, CISM is playing a very important
role after an accident. This is recognized all
over now, but we are still using relatively old
material. Is there anything new on this field?
SD: Oh, there probably is, but I am not an
expert on CISM. Let me say, however, that
independent of the material used, the ideas
of CISM and applying them effectively, are
worth gold. I have seen other industries
(like healthcare) where there is not so much
as even an understanding that helping col-
leagues who were involved in an incident
may be a good idea. More than a good idea
even: the humane, ethical thing to do. CISM
can help ATCOs understand that being in-
volved in an incident is nothing shameful;
that the potential for failure is baked into the
very activity they do successfully every day.
Everybody is vulnerable to get caught up in a
situation that may later be construed as an in-
29
THE
CONTROLLER
BOOK REVIEW
This book describes the various methods
and elements of CISM. The book is based
on Peer Interventions and the so called
Peer model. It also investigates the ben-
efits of CISM, not only for the individual
concerned (i.e. the controllers) but also for
their employer. Because the faster you go
back to work after an incident or an acci-
dent, the better it is for them of course!
But it is all about starting to regain balance
after a critical incident or an accident.
The book is organized around the 3 main
organizations in aviation: Airports, Airlines
and Air traffic Control. But the book concen-
trates a lot on ATC. A complete chapter is
in fact a case study of the CISM application
to controllers after the Ueberlingen collision,
and it is very worth reading. The book de-
scribes how CISM is to be organized, and
answers most questions your management
might have on CISM. Many Specilacists have
also written chapters. For instance proper
Peer Training is shown in a chapter made
by Dr. Victor Welzant, a Psychology Doctor,
who heads CISM services in the US.
Prof. Jeffrey T. Mitchell the founder of
ICISF and the developer of the CISM pro-
gramm has written two chapters and one is
about the history of CISM in Aviation.
For Controllers Associations and Unions,
it gives all the basic answers, and how to
organise a proper CISM scheme in your
own environment, together with your em-
ployer. Ralf Riedle, former controller, Pres-
ident of the German controller association
at some time, and now the Director of
Operations of the DFS, writes in this book
how he had to overcome prejudices to im-
plement CISM in Germany. His experience
and the positive outcome that resulted can
be used by any other Organization, as the
questions raised are inevitably always the
same ones. Getting Controllers back on
their feet after a trauma, as soon as pos-
sible, both psychologically and humanly is
the best we can do to help, both the indi-
vidual controllers and their employers.
The authors are the current experts on
CISM. Joerg Leonhardt is the father of
^
A book by Joerg Leonhardt and Joachim Vogt
Review made by Ph. Domogala, Editor
cident. I think CISM can actually
bolster peoples report-willing-
ness, as they will recognize that
an incident says little about their
competence or professionalism,
and more about the organiza-
tion and operation everybody
works in. CISM, I think, is one
of the ingredients for begin-
ning to build a just culture at
home in your own ANSP. And
for an ANSP as employer itself,
CISM is a smart thing too: you
get operational people back in
the saddle quicker. So whatever
ideas you apply in CISM, keep
doing and developing it.
^
Critical Incident Stress
Management in Aviation
Photo: Ashgate
CISM courses to
train peers and
currently work
in Langen for
the DFS, and
Joachim Vogt is
a well known Psychology
Professor in the Copenhagen University,
specialized in aviation psychology.
Hardback; 194 pages; 978-0-7546-4738-6

The book is available from Ashgate Pub-
lishing in the UK at a special 25% discount
price to IFACTA members, 41.25 (post-
age extra).
Offer ends 31
st
May 2007. To place your
order email: ashgate@bookpoint.co.uk
or telephone +44 (0)1235 827730
or fax +44 (0)1235 400454.
Important: to obtain the 25% discount
please quote reference IFACTA when
placing your order.
(This discount is only available on direct orders and
not through bookshops or agents. No other dis-
count may be added).
4 Legal Issues
If you work around
a problem and invent
new procedures,
chances are; you will
be held responsible
for an accident.
flight recorder. There is a trend towards
criminal liability lawsuits after accidents. One
reason might be that the public, especially
the families of victims, wants to find some-
one responsible. This is the case not only in
aviation but in all kinds of accidents. In avia-
tion crashes though, the pilots are often no
longer alive. Nadine Pilon, who has done
research on how aviation accidents are re-
ported in newspapers, gave further input to
the issue. As technology makes its advances,
people seem less likely to accept technical
malfunctions as cause of accidents. The same
goes for Human Error.
Controllers are the
experts on safety
Maybe we as controllers have to start ques-
tioning regulations and procedures more.
Even though the regulation says that the wind
information to a landing aircraft shall be the
two-minute wind, we know that in certain con-
ditions the wind can drastically change within
a period of two minutes. Do we then switch
to instant wind and read the wind out as it
changes? The answer is not always. Why?
Because this might not be stated in our regu-
lations. But if we are experts on safety, why
do we not do what is safest, if it does not ex-
plicitly go against the regulations? Why do we
not demand wind shear warning-systems? An-
other example: why do we allow intersection
take-offs? Even if it is not against the rules,
you as a controller might be in serious legal
trouble in the event of an overrun. Defend-
ing the decision to let aircraft take off from
a shorter runway, with because it increases
efficiency, will not be good enough. In a
criminal lawsuit, every single action taken by
the controller will be scrutinized and it will
very likely be pointed out that controllers are
experts on safety. David Gleave talked about
the great importance of incident reporting
and of attitudes in operations: Report things
that are wrong. Always! On paper! If you do,
chances are they will improve. Also, if you
report things that dont work, I can defend
you in court. If you instead work around
the problem and invent new procedures,
chances are; you will be held responsible
for an accident. To achieve an environment
where controllers voluntarily report incidents
as one mean to increase the level of safety, we
need Just Culture. Eurocontrols definition of a
Just Culture is one where ATM personnel and
pilots are not punished for actions, omissions
THE
CONTROLLER 30
ATC: One Foot in Court?
^
by Helena Sjstrm
(Swedish ATCA)
This was the provocative question on the post-
ers for the Legal Issues Workshop on October
20, 2006 at the European Regional Meeting in
Sofia, Bulgaria. Lately we have seen a number of
cases in which ATCOs have been prosecuted,
indicted and even sentenced to prison. Is this
the course of the future? Can we change this?
These and others were the driving questions
when the Executive Vice-President Europe,
Patrik Peters, organized the workshop. For the
first time in the European region, there was an
attendance fee of 30 Euro. The fears that this
might prevent the member associations from
participating were unfounded. More than 80
persons attended.
Speakers specializing
in different legal areas
Patrik Peters had invited speakers with differ-
ent backgrounds: Cesare Ciccorella, defense
attorney in the Linate accident; Ann-Fred-
erique Pothier, legal expert for Eurocontrol;
Radu Ciponea, Eurocontrol Performance Re-
view Unit; David Gleave, chief ATC safety in-
vestigator and Nadine Pilon, media expert for
Eurocontrol. Also invited was Gerard Forlin,
barrister, who unfortunately could not attend.
An attempt was made to make an audio-re-
cording of his presentation but it was techni-
cally not satisfactory. An interview with Gerard
Forlin is presented on the next page. All speak-
ers agreed: Air traffic controllers must initiate
the change. We cannot leave it to lawyers and
legislators. We must start the dialogue, be cre-
ative, think outside of the box.
Media and the public
One paramount issue, in legal proceedings
after an accident or incident, is the media.
Cesare Cicorella, speaking Italian but be-
ing simultaneously translated into English,
stressed the importance of having appro-
priate experts involved at a very early stage
and responding as soon as possible to the
media pressure. This was not the case in the
Linate proceedings and it would prove very
important and indeed detrimental. The in-
vestigators were under heavy pressure from
the media and the defense was not given
full access to the evidence. Four years after
the accident, after around a dozen requests,
the defense for the first time listened to the
Gerard Forlin is a barrister admitted in the
UK, Australia and other jurisdictions. He is an
acknowledged expert on health and safety,
including aviation. He is one of the very few
workplace manslaughter specialists due to
his experience in defence, prosecution and
regulatory work. Gerard Forlin has published
extensively on health and safety law issues,
including corporate manslaughter and he
lectures regularly on these topics
(see www.gerardforlin.com).
Patrik: In the recent past, it has become a
trend to prosecute air traffic controllers for
accidents and incidents related to their pro-
fession. Can you confirm this trend? What
could be possible reasons for this?
Gerard Forlin: It appears that in very re-
cent times there has been a sudden spurt of
prosecutions against individuals in the avia-
tion and the transport sectors in general, for
instance Milano-Linate, berlingen and the
recent mid-air collision in Brazil. There seems
to be a global beefing up of a trend to prose-
cute transport accidents. I am observing this
trend not only in Europe but also in Australia,
the USA and elsewhere. We are living in an
increasingly transparent environment, where
the public demands information about acci-
dent causes. To many in the industry in the
past, blaming frontline operators has been
an expedient way of dealing with the after-
math of a disaster.
P: Responsibilities are not carried solely by
an individual but rather accounted to the sys-
tem itself. What can be done in your point
of view for controllers to not serve as scape-
goats of a weak safety culture?
GF: Most jurisdictions in their criminal law
comprehend that system failure is the re-
sponsibility of management. In my view, in
the absence of real human deviancy e.g.
drugs or alcohol abuse at work, individuals
should not be prosecuted for human error
factors. If they are, then there is a real danger
that safety may be driven underground if for
instance the quantity and/or quality of con-
fidential reporting dries up. In other words,
criminalization of an accident is not an effec-
tive deterrent or in the publics best inter-
est, excluding for example acts of sabotage
or reckless conduct. Controllers have to be
made aware of their role in the safety system.
They need to report deficiencies and irregu-
larities if the system is to be improved.
P: Last September you gave a presentation at
the Worldwide Symposium on Air Navigation
in Montreal. Is there a movement towards a
more fair jurisdictional system for the future?
GF: My speech appears to have acted as a
catalyst to a series of safety groups and bod-
ies formulating a resolution condemning crim-
inalization of accident investigations. I under-
stand that a number of other bodies are also
applauding these statements and the change
of opinion is gathering momentum. We will
have to wait and see!
P: Air Navigation Service Providers and
States have to take their share in forming a
pan-European jurisdictional system. Is this
possible at all or will we, despite working to-
wards a Single European Sky, always have to
face more differences than similarities?
GF: I am doubtful that in the near future,
states will surrender their sovereignty in terms
of their criminal law to any global system.
For instance, many conventions state what
the law should be, but each state prosecutes
according to their own procedures and laws
INTERVIEW
Gerard Forlin, Barrister, on Controllers Prosecution
or decisions taken by them that are commen-
surate with their experience and training but
where gross negligence, willful violations and
destructive acts are not tolerated. Without a
non-punitive work environment, we risk being
drawn into a vicious circle of fewer incident re-
ports, leading to more accidents, maybe lead-
ing to more lawsuits, inducing an even lower
will to report incidents.
THE
CONTROLLER
4 Legal Issues
31
of evidence. Over time, this ap-
proach may change.
P: What can we, IFATCA, do for
our colleagues?
GF: I think you need to continue
to lobby governments and other
organizations. You also need to
financially and emotionally sup-
port the defence of your col-
leagues who are under investi-
gation or who are prosecuted
so that specialized, experienced
lawyers and experts can be en-
gaged on their behalf both at the
police-interview and trial stages.
There may also be disciplinary
and other hearings, where sup-
port will be required.
^
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There seems to be a
global beeng up of
a trend to prosecute
transport accidents.
The future importance of legal issues in ATC
is clear. We need to:
Prepare ATC staff for media scrutiny
Improve public perception of ATC
Learn to better understand the links to the
judicial framework
Work on attitudes and applications of rules
in operations
The evaluation after the work-
shop showed the approval of the
attendants and the wish for fur-
ther efforts in this area. 56 out of
60 replies said that they want a
continuation of the Legal Issues
Workshop. 40 persons said they
would or would probably be will-
ing to pay for future workshops.
^
Interview by Patrik
Peters, European
Regional Editor
4 European Affairs
European Regional Meeting
Sofia, Bulgaria
THE
CONTROLLER
Human Error is and
should not be the con-
clusion of an investi-
gation but it should be
the starting point.
This year, the European Regional Meeting was
held in Sofia, Bulgaria, organized extremely well
by our Bulgarian colleagues of Bulatca. Patrik
Peters, for the first time chairing this event as
EVP-EUR, welcomed Mr. Petar Mutafchiev, the
Bulgarian minister of transport. His speech was
on the lines of those given by politicians in previ-
ous events, praising how his country feels about
safety of air transportation and how important our
job is. He was preceded by a great deal of media
people, anxiously awaiting him. Then Eurocontrol
General Director, Mr. Victor Aguado, gave a very
interesting speech as usual. This time he focused
on performance, which has constantly been in-
creasing despite a considerable traffic-growth.
On September 15, more than 32.000 movements
were recorded in the core part of Europe, which
is the highest ever for a single day. That figure
went together with an average delay of 1, 2 min-
utes for each flight - close to the optimum. He
also underlined that in Europe we experienced
no man-induced accident since 2002. He praised
the ATM system as a whole for dealing with the
planned situations, like the Football World Cup
in Germany but also with the unplanned events,
such as the war in Lebanon and the security alert
in London, with professionalism and commit-
ment. Mr. Aguado also touched on the aspect of
legal issues, a very hot topic this year, by saying
that the good performance recorded stands on
a delicate balance and the separation between
safety analysis and legal issues is not enough yet.
In his words, just culture comes first, because
even in world proven procedures and safety nets,
mid-air collisions can still happen in controlled air-
space. Mr. Aguado continued by saying that effi-
ciency and good results are undermined
by fragmentation. The total cost of this,
annually, is about 1, 4 billion Euros, 40%
of this being ATM costs. In any case, traffic will
double in the next 20 years and a new concept
is needed.
Marc Baumgartner, IFATCA President, made a
valid point in saying that the public opinion only
talks about us if things go wrong and it seems
that the human being has more appetite for bad
rather than for good news. He said, since no-
body else acknowledges us publicly: Be proud of
yourselves. Be proud of what you do, be proud
of your values, be proud of doing such a good
job. But just be aware that when pride comes,
a hard fall could follow. Pride brings arrogance,
so dont be blinded by that. But do be proud
and try to change the communication with the
world by advertising the responsibilities and the
uniqueness of our profession.
Eurocontrols Alexander Skoniezki focused on
the need for a safety culture based on mutual
trust, share of perspectives, preventing measures
and enduring values at every level of an organiza-
tion. I agree with these beautiful dictionary-like
words. However, I would really like to hear them
less and more see them applied, everyday, eve-
rywhere. We are not there yet. Richard Arnold of
the DFS, presented a very interesting movie ti-
tled Human factors in safety management. The
movie explains that the fundamental attribution
of blame leans towards the individual shortcom-
ings. Punishment is primarily a search for closure,
and only thereafter might give a learning ability
to improve. But it has to be noted that Human
Error is not the cause, its the effect, Human Error
is not random, Human Error is and should not be
the conclusion of an investigation but it should be
the starting point. It is necessary to start focusing
Photos: DP
32
^
by Raf Vigorita, Eurocontrol Guild
(EGATS) and Ph. Domogala, Editor
4 Europe
As the IFATCA representative to the Euro-
control 8.33 kHz Drafting Group I would like
to use this opportunity to remind all Euro-
pean controllers that 8.33 kHz channel spac-
ing will be implemented above FL 195 in the
ICAO EUR Region on 15 March 2007.
Europe tunes 8.33 kHz above FL 195 is also
the name of a web based training package
which has been developed to highlight is-
sues that can arise from the implementation
Europe Tunes
8.33 kHz above FL 195
The Day of the Controller Poster in Italy
ANACNA, the Italian controllers association
had a very good idea to celebrate the Day of
the Controller last October.
They produced a very clever poster, based on
the famous smiley figure that can be seen,
depending how you look at it, as a headset
or a smile sign if you turn it. Both placards
were posted everywhere in airports in Italy
during the day of the
controller.
A very interesting
initiative, bringing a
positive representa-
tion of the ATCOs for
the general public.
^
of 8.33 kHz channel spacing. It is aimed at air
traffic controllers, pilots and flight dispatchers
and it uses three comic strip stories.
Further information and the links to the train-
ing package are available on the
Eurocontrol 8.33 kHz website
www.eurocontrol.int/833 under
Awareness and Training.
^
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^
by Wolfgang Scheidl,
Austrian ATCA
on the underlying causes of failure. Dig deeper.
And remember, flexibility is important to cope
with unprecedented events, but that cannot be
confused with breaching the rules, which eventu-
ally is an erosion of safety that mostly goes un-
noticed over time, causing great risks.
Max Bezzina, explained the progress met by the
ELPAC (English Language Proficiency for Aero-
nautical Communication) trials. ELPAC is a test
of proficiency for a target population. More on
http://elpac.info. Many colleagues were con-
cerned about possible failure and retraining. As of
now, there are no procedures for retraining in the
event of failures, but the responsibility for that will
lay with the provider itself, which worried certain
colleagues even more. The target date for ELPAC
introduction should be 17 May 2010. Finally Fre-
deric Deleau of ATCEUC gave a passionate pres-
entation about the MOSAIC project and certainly
caught everyones attention, as he drew a lot of
interest and a lengthy discussion.
The meeting was attended by al-
most 300 participants from nearly
all European MAs and was a great
success. The rest of the meeting
was about discussing members as-
sociations problems, but they were
held in close sessions. The next
Regional meeting will be held in
Prague, 26-28 October 2007.
^
Spotlight
on Corporate Members
34
THE
CONTROLLER
SPOTLIGHT
^
Kevin Salter
Contributing Editor, Corporate Affairs
Welcome to all our readers for the first
Spotlight feature of 2007. For those of you
that are new to our magazine, the aim of
this feature is to introduce ATM topics of
mutual interest that will keep the reader in-
formed on what is happening in our world
of Air Traffic Management. As usual I com-
pile the information based on press releases
and correspondence I receive from our Cor-
porate Members from around the world.
The focus in this issue is, once more, on a
major contributor to Spotlight, THALES.
We start by looking at news from:
TAIWAN:
Thales awarded ATM contract in Taiwan
- New nationwide CNS/ATM* system
Thales ATM Pty Ltd in Australia has been
awarded a contract by the Air Navigation
and Weather Services of the Civil Aeronau-
tics Administration of Taiwan, R.O.C. for
the supply of a fully integrated nationwide
Air Traffic Management System.
Thales will supply its field proven EURO-
CAT air traffic control system for the two
integrated en-route and approach air traf-
fic control centres, simulation capabilities,
a software development environment and
positions in eleven ATC towers. Included
in the contract is the provision of a fully in-
tegrated Aeronautical Information Service
System and a Digital Voice Communica-
tion Switching System.
Under the contract Air Navigation and
Weather Services will receive the latest ATM
system for the management of en-route and
approach air traffic, incorporating integrat-
ed functions to improve air traffic flow and
reduce flight congestion. A spokesperson
for the Air Navigation and Weather Serv-
ices of the Civil Aeronautics Administration
of Taiwan said, The Thales system will lead
to improved safety and security for flights in
our airspace and provide the latest genera-
tion of air traffic management.
Developed in conjunction with controllers
around the world, the new system will in-
clude the capability for multi-sensor tracking
including radar, ADS-B*, and multilateration,
air traffic flow management, air-ground data
link as well as the latest in safety net alerts
and warnings. Air Navigation and Weath-
er Services will benefit from the Thales
policy of continual enhancements to the
EUROCAT product and the recent CMMI*
Level 5 accreditation of the Engineering
Department in Melbourne, Australia where
their system will be developed.
Bachu Murthi, Vice President, Thales Aus-
tralia Air Systems said Thales is proud to
be chosen to provide this new air traffic
management system, which adds to a long
list of systems developed in Melbourne
and installed around the world.
* CNS/ATM: Communication, Navigation, Surveillance /
Air Trafc Management
* ADS-B: Automatic Dependent Surveillance Broadcast ADS
via broadcast from properly equipped aircraft or vehicles
* CMMI: Capability Maturity Model Integration a global
process maturity model of the Carnegie Mellon Software
Engineering Institute
CHINA:
Thales and TEDC create a joint venture
in air traffic control
In Beijing on 20
th
November 2006 Thales
and TEDC (Civil Aviation Air Traffic Con-
trol Technology Equipment Development
Co. Ltd) today signed an agreement for
the creation of a joint venture in the field
of air traffic control. The joint venture will
be owned by TEDC (60%) and the Thales
Group (40%). It will develop, sell and
maintain air traffic control centres derived
from technology inherited from Thales,
predominantly in China.
The creation of this joint venture en-
sures the continuity of the NESACC pro-
grammes, which are aimed at expanding
and modernizing the air traffic control sys-
tems in Beijing, Shanghai, and Guangzhou,
and for which the Civil Aviation Adminis-
tration of China (CAAC) selected Thales
EUROCAT technology. The three centres
are in charge of monitoring the en-route
air traffic control towards eastern China,
i.e. 60% of the total air traffic in the coun-
try. Thales has supplied primary and sec-
ondary radars, navigation aid systems,
and associated training services to China
over the past few years.
With this new joint venture, Thales intends
to strengthen its position in the Asia-Pa-
cific region, and to develop long-term re-
lationships based on excellence with the
stakeholders of the Chinese civil aviation
authorities and industrial partners.
NETHERLANDS:
Thales awarded new PHAROS contract
for the Royal Netherlands Air Force
On 23
rd
November 2006 the Netherlands
Ministry of Defence and Thales signed a
contract for the renovation of PHAROS
III (Plan Handling And Radar Operating
System) the system that has been used
since 1994 by the military air traffic control
centre which is located in Nieuw Milligen,
The Netherlands. PHAROS was initially
supplied to the Royal Netherlands Air
Force (RNLAF) in 1994 by Thomson-CSF,
later renamed Thales. Under the terms of
the new contract, Thales will provide the
RNLAF with state-of-the-art equipment
in replacement of obsolete Data General
equipment and will ensure the migration
^ Alexandre de Juniac, Senior Vice-
President Thales Air Systems (on the
left); Xiaoping Lu, Deputy Director
General Air Trafc Management
Bureau, Civil Aviation Administration
of China (CAAC).
of the operational software. The contract
that includes initial delivery, installation,
testing and maintenance was awarded to
Thales following an international tender.
Although the initial PHAROS project was
commissioned ten years ago, Thales has
maintained the competencies, logistics,
and maintenance services for safety-critical
systems in order to provide customers with
the most efficient migration process. The
same PHAROS functionalities will be main-
tained to enable the Royal Netherlands Air
Force to perform Area Control and to fully
benefit from the new technology. This con-
tract is an illustration of Thales ability to
implement COTS solution in the ATC en-
vironment. Thales already performed such
projects for several international custom-
ers including Denmark, Belgium, Australia,
the Czech Republic, and Slovakia.
INDONESIA:
Indonesia launches airspace safety trial
Technology partners Airservices Austral-
ia, SITA and Thales today congratulated
Indonesia on the successful launch of a
trial to enhance airspace safety across the
archipelago.
The decision to trial ADS-B follows on from a
regional ICAO recommendation adopted in
2003 and demonstrates Indonesias commit-
ment to improving the safety of air travel, the
three companies said in a joint statement.
During the trial the ADS-B traffic data will
be displayed in the Jakarta and Makassar
Air Traffic Control (ATC) Centres where it
may be viewed by air traffic controllers.
This will demonstrate the enhanced sur-
veillance capabilities provided by ADS-B
along a number of key air routes.
Indonesia controls a huge area of airspace,
with very heavy international and domestic
air traffic. The Republics varied terrain and
SPOTLIGHT
equatorial climate mean that a variety of dif-
ferent surveillance technologies are neces-
sary to provide adequate coverage, includ-
ing radars, satellite technology and ADS-B.
Aircraft equipped with ADS-B, including
most modern airliners, emit digital signals
every half second identifying their posi-
tion, height, speed and course. This infor-
mation can be fed into a national air traffic
control system to provide a radar-like pic-
ture of aircraft movements, complimen-
tary to other forms of surveillance.
The trial involves the deployment of
three Thales ADS-B ground receivers - at
Denpasar in Bali, Kupang in Nusa Teng-
gara Timur and Natuna Island in the South
China Sea - which are linked by SITA
communications links and surveillance
processors to Indonesias control centres
in Jakarta and Makassar. Airservices pro-
vides project and technical support and a
remote monitoring capability.
Based on this trial result the Directorate
General Civil Aviation (DGCA) will evalu-
ate the technology before determining
whether to roll out ADS-B nationwide
based on the service model proposed
by the Airservices/SITA ADS-B Alliance.
An important consideration will be the
effectiveness of the system in enhancing
surveillance across international Flight In-
formation Region boundaries.
About Thales
Thales is a leading international electron-
ics and systems group, serving defence,
aerospace and security markets world-
wide, supported by a comprehensive
services offering. The groups civil and
military businesses develop in parallel to
serve a single objective: the security of
people, property and nations.
Leveraging a global network of high-level
researchers, Thales offers a capability un-
matched in Europe to develop and deploy
critical information systems. Thales employs
60,000 people in 50 countries and gener-
ated revenues of 10.3 billion in 2005, with
a record order book of over 20 billion.
Thales in China
Thales has been operating in China for more
than twenty years. As of today, around 500
employees work for the Group in China, in
such fields as electronic components and
equipments, aviation, urban transportation
and security. Over the past three years,
Thales has seen a significant growth in all
its activities, generating an average annual
order intake of 250 million.
Examples of Thales achievements in China:
2008 Olympics Games: On 1st Novem-
ber, Thales International opened Thales
Services Beijing, a new services centre
supporting Thales activities and provid-
ing maintenance and repair services to
Thales customers in China.
The Civil Aviation Air Traffic Control Tech-
nology Equipment Development Co. Ltd.
(TEDC), granted for the establishment
by Civil Aviation Administration of China
(CAAC) in 1998, is a high-tech enterprise
invested by Air Traffic Management Bu-
reau (ATMB) of CAAC and seven local
ATMBs in China. TEDC is a leading na-
tional electronics and systems company,
providing high level operation safeguard
and technology support for Chinas civil
aviation air traffic control (ATC) system.
TEDC employs over 300 people nation-
wide. This team is not only professional,
practical, but also innovative and creative,
endowed with rich enterprising spirit. By
the end of 2005, the company generated
revenues of RMB 60 million. TEDC attach-
es great importance to both the economic
returns and social benefits.
This concludes the first Spotlight feature
for 2007 and I would like to welcome and
thank Mathilde Bouchard my new con-
tact person for Press Relations at Thales,
for supporting Spotlight by providing her
companys contribution.
As I normal say to our corporate mem-
bership readers, dont forget that if you
would like your company to be featured in
`Spotlight, and likewise to any reader, who
would like further information on any topic
that was covered, please do not hesitate to
contact me using the following address:
35
THE
CONTROLLER
^ R.Z. de Ceuninck van Capelle,
Naval Captain (on the left);
and Philippe Rebire, Thales Air
Systems (on the right)
Kevin Salter
IFATCA Contributing Editor
Corporate Affairs
Flugsicherungsakademie
Am DFS-Campus 4 D-63225 Langen
Tel: + 49 (0)6103 707 5202
Fax: + 49 (0)6103 707 5177
E-Mail: kevin-john.salter@dfs.de
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4 News
South African Controller
prosecuted for an
accident is free
At the commencement of the proceedings
in the Regional Court, the State requested a
postponement as they did not complete their
investigations into the accident and requested
that the matter be heard at a later date.
The legal team appointed by ATNS (the
South African ATC Service Provider) on be-
half of the controller, objected to any further
postponement. The Regional Magistrate was
also not happy with the unnecessary delays in
this matter and refused a further postpone-
ment of this case.
The State proceeded to withdraw their
charges against the controller and he was re-
leased of his obligations in terms of his bail
conditions. A good ending!
THE
CONTROLLER
17
TH
AMA Regional Meeting
So Paulo was the host city of the Americas
Regional Meeting, The event took place 25-27
October.
Most of the regions members associations
were present, as well as observers: IFALPA, ITF,
and other Brazilian Air Traffic Controller Asso-
ciations. Pan Am International Flight Academy
and Park Air Systems were the corporate mem-
bers present sponsoring the event.
Cedric Murrell, IFATCA EVP Americas,
chaired the meeting and Marc Baumgartner,
President of IFATCA addressed the meet-
ing via video conference, expressing his
concerns regarding the recent mid air col-
lision and how much this case reminds him
of the Switzerland mid air collision back in
2002. He noted that the federation is work-
ing closely with ICAO to find best ways to
handle conflict management and separation
provision. During the ITF Presentation by Mr.
Gabriel Mocho Rodriguez, a brief introduc-
tion was made about the organization goals,
objectives, area of work and structure; while
a brief explanation about how they work
along with regional associations in their ne-
gotiation process. The Pan Am Academy
explained the services provided by this in-
stitution and concentrated on their English
language programs.
When it comes to member association re-
ports, the issues of main concern are English
language proficiency; privatization; Air Traf-
fic Controller shortage and, of course, labor
relations. Countries such as the United States
and Haiti face their worst air traffic control-
ler shortage ever while Panama expresses
its concern regarding the new government,
which is formed of the same persons that
lead a conflict in the late 1990s, then result-
ing into a major crisis.
The English proficiency issue was discussed
extensively. There, most associations ex-
pressed their concern and some even asked
why their employers are doing little or some-
times nothing to help their staff reach the
minimum Level 4 established by ICAO. It was
agreed that meeting the expectations is eve-
ryones responsibility.
This meeting was a great opportunity to
know the flattering Brazilian hospitality, a
chance to meet new colleagues.
Finally, I would like to express my most sincere
gratitude to ATCAGRU for their warm hospi-
tality and EVP AMA for his support, not only
to me but our Brazilian fellows. Next meeting
will be in Aruba during the fall of 2007.
36
4 Dominican Republic delegates
Photo: EK
^
by El Kadur Acosta,
Americas Regional
Editor
We remember that a South Af-
rican air traffic controller was
prosecuted and threatened
with jail after an accident in
South Africa.
The recent good news was
heard in the Regional Court of
Pretoria on 28 November 2006.
4 Asia
From Orville Wright in a place called Kitty
Hawk to the first step on the moon by Neil
Armstrong, the progress of aviation was phe-
nomenal. The achievement was created by
people - the ordinary, the extraordinary and
the ultra-ordinary. There were the heroes and
the heroines equally matched by the villains
and the vagabonds. There were the dream-
ers and the believers of their dreams. They
all had one thing in common - they were the
fraternity of aviation. Through the years the
public that trotted the sky came to know them
and herald them. They sang their praises and
adored their images. The industry itself en-
sured the celebrity of its prodigy by lavish ad-
vertisement portraying the roles of the pilot,
the engineer, the flight attendant down to
the reservation clerk who booked their seats.
Books were written, movies were made, post-
ers were put up all to glorify and pedestal the
individual who contributed to aviation.
Amidst all this patronising and glorifying, cer-
tain stalwarts of the field were obviously for-
gotten, and paramount among them was the
Air Traffic Controller - the man who controls
the sky. Their poems of praise and credit for
progress were written without a mention of
the man in the Tower, the man sitting away
from everybody in his little pressure cooker
who controlled the skies - the man who en-
sured the safety of so many lives with the
accuracy of his thought and the calmness of
his voice, a lot more lives than the best of us
who fly the machines have ever been respon-
sible for. He was never given the dues he so
richly deserved for his services.
Hence, I write these lines - little lines of ap-
preciation from a creature who has been in
the sky long enough to know what a tremen-
dous contribution the Air Traffic Controller
makes to aviation.
Complications
The intricacies and complications of his exact-
ing profession cannot be penned that simply.
I do not possess the wisdom of words to ad-
equately detail what he means to a pilot - the
quantum of faith the pilot has to have on the
controller is difficult to explain, even more dif-
ficult to understand - a kind of faith that may
not move mountains but would yet get you
home from the storm laden skies when your
skills are taxed to the limit, and the relief and
solace given by the Controller becomes your
solitary source of comfort.
No professional Captain worth his salt would
hesitate in expressing his gratitude to the
Controller, not for once, but for the many
times the Controller guided him to safely
bring him home.

Voices
On the Controllers part, a good thirty voices
ring in his ears, requesting and requiring in-
structions while everybody is moving at high
speeds through a sky where nobody can be
seen - all converging or diverging from the
same point and all hoping and praying the
Controller will not make a mistake and create
a collision - a kind of scenario where I feel that
for every 400 lives that I am responsible for as
a Captain, the Controller carries 4000 in the
simple accurate commands of his voice.
A voice that through the years all pilots have
learnt to trust in the worst of circumstances, a
voice that merits a lot more recognition and
appreciation in aviation than given at present.
A Controller is a quick thinking man who doesnt
have the privilege to stall. He is like a surgeon,
composed in knowledge, precise in action yet
without the benefit of burying his mistakes. All
his instructions to aircraft are recorded continu-
ously on tape and any instructional error is trace-
able by replay, a tremendous constraint on the
individual - a disturbing yet necessary require-
ment that no other profession entails and no
other professional has to contend with.
THE
CONTROLLER
Controllers the unsung
heroes of aviation
This makes the Controller a man
with a mission of responsibility,
scrutinised constantly, function-
ing to standards of pinpoint ac-
curacy, yet so unrecognised in
his own field of aviation, a field
where he plays a major role for
continued safety - the safety that
you as a passenger enjoy and me
as a Captain is grateful for.
Silent heroes
In any professional field there
are the silent heroes devoid of
credit. In aviation the Air Traffic
Controller is supreme. He will
use his intelligence and pro-
cedural skill to bring the aero-
planes home through the most
adverse conditions - yet he will
continue to remain unheralded -
the unseen and unsung hero of
aviation.
^
A Controller is a quick thinking man who doesnt
have the privilege to stall
Photo: E. J.
37
^
by Capt.
Elmo Jayawardene
(Sri Lanka)
^
Landing on Taxiways
This new method to fight runway congestion
is occurring more and more. First on Octo-
ber 31, a Continental Boeing 757 landed on
the main taxiway in Newark (USA) instead of
the runway. What is interesting is not only
that the taxiway is 70 feet wide, while the
757 has a 155 feet wingspan, but also that
the pilot did not say anything to the TWR,
just taxied normally to the terminal and left
the premises very fast. Unfortunately for
him, the skid landing marks on the taxiway
are still there for everybody to see.
Then on January 6, a Boeing 737 from Ko-
rean Air landed on the taxiway at Akita
Airport (some 450 KM north of Tokyo, Ja-
pan). There is an interesting video running
on the internet where you see passengers
waiting in a terminal reading newspapers
and suddenly the large terminal windows
are full of blue, (the color of the 737) as
the aircraft swiftly passes a few meters
away landing on the taxi way.
(see airport diagram below)
If this tendency continues, we will not have
to bother with inventing new procedures
to increase runway capacity, as each air-
port will automatically have multiple land-
ing capabilities.

Remove before Flight:
This interesting photo was taken in the
USA and is a nicer alternative to the lit-
tle flags used as key rings by aviation
enthusiasts all over the world.
Although, seeing the size of the interior of
my single-engine aircraft, I do not think that
the procedure will be very good for improv-
ing safety (if one is talking about the shirt,
and not the complete lady of course).
Expensive
Retirement Gift
Last December, a well-known United Air-
lines captain about to retire, was having
his last flight on his B777 into Washington
Dulles airport. The airport fire brigade de-
cided to do the same farewell that they
had seen on TV many times i.e. driving the
fire trucks around the aircraft as it taxied
back to the terminal after the flight, and
spray water cannons over it from each side.
This is known as the water canon salute.
Unfortunately, instead of water the trucks
blasted foam fire retardant. As the B777
engines were running, the foam was in-
gested in the engines and stopped them.
Apparently the B777 is totally unservicea-
ble and will probably need 2 new engines.
The story does not say who will finally pay
for the present
Charlies Column
Photo: INT
Charlies Column
Camel Sacrifice:
Last December, a group of Turkish Airlines
technicians were so happy to be rid of the
last of a batch of old planes that they sac-
rificed a camel on the tarmac of Istanbuls
international airport. Apparently it is a tra-
dition in Turkey to sacrifice animals as an
offering to God when wishes come true
We are so happy to be rid of planes which
frequently broke down said a technician.
Unfortunately for them the airline manage-
ment did not approve of the sacrifice and
fired their boss, who had organized the
event. Some local newspapers had run the
story on their front page, and blood on the
tarmac is not a very good public relations
exercise for an airline.
OK, you all want to know now: what were
those bad aircraft that prompted this
antique ceremony? They were first-gener-
ation BAe146, also known as Tonka jets
in Canada, or Jumbolinos in Switzerland,
and Babyjumbos in Africa. (in the UK
when the 146 came out, they were known
as But-why-4-engines?)
Overheard on the
Frequency:
Ground Control:
Midland 123, visual with the
two Virgin Express 737s from
the left?
Pilot:
Afrm.
Ground Control:
Roger, you take position in
between the Virgins.
Pilot:
Ahhh ... Ive always dreamed
of this ...
THE
CONTROLLER
38
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