59TH ANNUAL CONFERENCE, Singapore, 30 March – 3 April 2020
WP No. 158
Relief from Operational Position after an Occurrence
Presented by PLC
|IMPORTANT NOTE: The IFATCA Annual Conference 2020 in Singapore was cancelled. The present working paper was never discussed at Conference by the committee(s). Resolutions presented by this working paper (if any) were never voted.|
Common practice is that ATCOs are relieved from position immediately after involvement in an occurrence. This can be for safety reasons and to safeguard ATCOs from potential negative emotional and psychological side-effects. However, poor company culture may contribute to the perception on the part of an ATCO that relieving of position following an occurrence is unfair and may contribute to further negative psychological effects on ATCOs. This paper aims to re-evaluate the current policy, determine if policy changes can be made and whether a set of criteria should be introduced to determine the situations in which an ATCO should be relieved from position. This paper concludes that implementing a set of static criteria in such a dynamic workplace may not be suitable. Instead, it is recommended that ATCOs be initially removed from position to determine their mental state and receive basic debriefing. If deemed to not be suffering from traumatic stress or psychological side-effects from the occurrence, ATCOs may resume their control duties.
1.1. It is common practice for all ATCOs involved in an occurrence to be immediately relieved from position for safety reasons and due to the potential negative effects on the emotional and psychological well-being of the ATCOs.
1.2. However, this may in turn have potential negative effects on the ATCOs involved, such as an exacerbated psychological impact of the occurrence and a perception of unfair blame, especially if the cause of the occurrence is perceived as not to be attributable to them. The question may arise as to whether it is fair or appropriate for ATCOs to be relieved after occurrences that are still to be/being investigated.
1.3. Hence this paper aims to re-evaluate the current policy of relieving all ATCOs from position immediately following an occurrence and to determine if any policy changes are necessary or if a set of criteria can be formulated to determine the situations in which an ATCO should be relieved from position.
ICAO Doc 9756, Manual of Aircraft Accident and Incident Investigation, Chapter 1.2 Definitions:
Occurrence: Any accident or incident associated with the operation of an aircraft. ICAO defines 3 event categories (ICAO Annex 13, Aircraft Accident and Incident Investigation, Chapter 1):
Accident: An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which:
i) A person is fatally or seriously injured (as a result of…)
ii) The aircraft sustains damage or structural failure (which…)
iii) The aircraft is missing or is completely inaccessible.
Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.
Serious Incident: An incident involving circumstances indicating that there was a high probability of an accident
For the purposes of this paper, all accidents and incidents shall hereafter be collectively referred to as occurrences.
2.2. IFATCA policy on accident and incident investigation, exemption from duty
IFATCA TPM (2019) – LM 11.2.2 EXEMPTION FROM DUTY at p. 312:
|“When an accident or incident is alleged to have occurred where the actions of an Air Traffic Controller may have had a bearing, the Controller shall have the right to be exempted from control duties until he is physically and psychologically fit again. The removal is without prejudice, and is non- disciplinary.
A Controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an incident / accident.”
The rationale for the above policy is two-fold. Firstly, this policy is in place for the benefit of ATCOs so that they may be safeguarded from the time the occurrence occurred until such time that the occurrence can be fully investigated.
Secondly, it is not always possible for ATCOs to assess their own state of mind after a traumatic situation, hence it is recommended they be relieved from the console. It is important that ATCOs are relieved to fully understand the situation as well as deal with any possible emotional and psychological impacts caused by the occurrence. This aspect of the policy coincides with the principles of Critical Incident Stress Management (CISM) policy which will be discussed below.
Crisis intervention in the form of CISM has been put in place in various organisations to alleviate any psychological impact that occurrences may have on ATCOs and closely follows the principles behind relieving ATCOs from position after an occurrence. It is assumed that there is a risk of high levels of stress immediately following an occurrence, resulting in the mental state of mind of ATCOs not being optimal for work. Hence it is recommended that they be relieved from position. It is also recommended that the ATCOs “take at least the remainder of the shift to “collect” [themselves]” (IFATCA, 2019, p. 307), or seek critical incident stress support services such as CISM where available.
2.4. Current Practises
2.4.1. IFATCA policy on exemption of duty
According to a survey done in Report Writing and ANSP Procedures for Serious Incidents or Accidents (IFATCA, 2019, WP no. 161), all MAs reported that, following an occurrence, ATCOs were relieved of position as soon as possible. This provides some proof that currently, most organisations follow the principles outlined by IFATCA above.
According to a report written by Baumgartner (2004), ATCOs working in New Zealand involved in any occurrence are relieved from their position and are either informed of CISM programs available for them or undergo a defusing session immediately. However, participation is voluntary. On the other hand, CISM is available for all ATCOs involved in any occurrence in the United States, Canada and Germany, while some countries do not subscribe to CISM. Evidently, CISM practices vary internationally.
2.5. Reasons for Immediate Removal of ATCOs
2.5.1. Ensuring Safety
Baumgartner (2004) acknowledges that even if ATCOs are not direct participants in an occurrence, and are rarely confronted with the direct sight of death or serious injury, there is a symbolic confrontation with the unthinkable in the psyche. The impact of this confrontation is an increase in guilt feelings which is not optimal to work with. Therefore, it is recommended for the ATCO to be relieved from position to ensure the safety of all flights in their sector to err on the side of safety.
2.5.2. Traumatic Stress
According to Baumgartner (2004), those who have worked with ATCOs in CISM programmes following a critical incident report that these ATCOs often display symptoms of traumatic stress, for example, “re-living the experience while awake, nightmares and hyper-vigilance, which prevent the ATCO from carrying out any ordinary task in their work without recalling what happened during this incident” (p. 48). Clearly, occurrences that ATCOs are involved in can have an acute impact on their psychological and mental well-being. Hence, ATCOs should be relieved from position immediately following an occurrence not only to ensure safety but also to safeguard their mental well-being which may worsen if not dealt with in the early stages.
2.5.3. Other Psychological Impact – Guilt, Self-Blame and Loss of Confidence
As mentioned above, feelings of guilt and self-blame easily surface immediately following an occurrence. In addition, these feelings are often intense and heightened because of the strong sense of responsibility that ATCOs feel on a day to day basis while performing their duties. Such strong feelings could potentially embed themselves in the psyche of ATCOs and negatively affect their confidence in their professional competence. Such psychological effects could negatively impact future work performance unless time is taken off to deal with these emotions.
2.6. Potential Concerns
2.6.1. Perceived Blame and Prejudice
IFATCA promotes a Just Culture where:
IFATCA TPM (2019) – LM 11.2.1 JUST CULTURE, TRUST AND MUTUAL RESPECT at p. 310:
|“front line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated”|
Poor company culture may mean that immediately relieving an ATCO could be perceived by them as a form of unfair, premature punishment or perceived prejudice before responsibilities for the occurrence have been ascertained. It should be made clear to operational staff that relief after an occurrence is a standard procedure. In case of omission, any perceived negative feelings and prejudice can be mitigated by emphasising that relieve of an ATCO from position after an occurrence is standard practice, it’s done without prejudice and not with the intention of placing blame on any one individual. Line supervisors need to be clear in how they put this message across to ATCOs in addition to maintaining an open channel of communication with ATCOs to ensure they feel understood and supported. Moreover, it should be communicated to ATCOs that this relieve is done to safeguard the interests of all parties involved, especially the ATCO’s own mental, emotional and psychological well-being. It should be made well clear that relieving ATCOs from their position after an occurrence is a standard company safety procedure and in line with Just Culture policy.
2.6.2. ATCO Psycho-Emotional State
When immediately relieving an ATCO following an occurrence, it may exacerbate the feelings of guilt the ATCO may already feel. This removal, despite guidelines explaining that it is non-prejudicial and non-disciplinary in nature, may cause the ATCO to lose his sense of belonging in the team (Baumgartner, 2004). This loss of sense of belonging may isolate the individual leading ATCOs to feel like they no longer belong to their “family” of work colleagues which may leave lasting effects on their mental state and by extension, their job performance even if they were reinstated in the future. However, these feelings may be temporary following a removal and can be dealt with through CISM if necessary. Not taking a step back to deal with the inherent feelings of guilt that manifest after an occurrence, whether ATCOs are relieved from position or not, is more likely to lead to more entrenched, longer-term negative impacts on the psychological and emotional state of ATCOs. The Baumgartner study stems from 2004. Since then the concept of Just Culture has been developed, the principles of which should help to mitigate or overcome the negative aspects of being relieved from position after an occurrence.
2.7. Circumstances to consider as to whether an ATCO may remain actively controlling after an occurrence
2.7.1. Severity of Occurrence
The Eurocontrol Safety Regulatory Requirement 2 (ESARR2) endorsed the implementation of a consistent and coherent severity classification scheme for all air traffic management-related occurrences. This scheme classifies occurrences into 6 categories in decreasing levels of severity (Appendix A):
b) Serious incident
c) Major incident
d) Significant incident
e) No safety effect
f) Not determined
A significant incident is an incident involving circumstances indicating that an accident, a serious or major incident could have occurred, if the risk had not been managed within safety margins, or if another aircraft had been within the vicinity. ATCOs are known to handle high stake risks on a day to day basis (Simon & Geoff), so it is not surprising that managing risks is part of an ATCO’s day to day job. Air Traffic Control is first and foremost a safety profession, hence it is reasonable to say that all risks managed by an ATCO are within specific safety margins for their particular sector. Where safety is not being compromised, in the case of a significant incident or lower, consideration may be given to allow an ATCO to remain actively controlling.
2.7.2. Role of the ATCO in an occurrence
If it can be determined by a quick radar / audio playback that the ATCO was found not to be a contributing factor to the occurrence (e.g. level bust with correct read back from pilot), consideration may be given to allow the ATCO to remain actively controlling.
2.7.3. Effect of the occurrence on the ATCO (physical/mental condition)
“And yet I told Swissair to stop climbing immediately, but they continued for two rounds of the antenna (24 seconds) to climb against the TWA, which was climbing in the opposite direction.”
This transmission was made by an ATCO from the Geneva ACC and involved in a near-collision between a plane taking off from Zurich and a plane taking off from Geneva, at flight level 220.
As illustrated by this example, even if it was a level bust not caused by the ATCO, the acute experience of loss of control, helplessness and destitution is expressed by the sense of arbitrariness that translates the narcissistic injury related to the individual’s loss, at least the temporary loss, of status (Baumgartner, 2004).
Hence, it is important to ensure that the ATCO is not suffering from traumatic stress or impaired mental and emotional well-being despite not being a contributing factor for any said occurrence.
2.7.4. The ATCO has undergone basic CISM debriefing/defusing (derived form of the Mitchell Method of CISM that is shorter and more flexible than traditional debriefing)
The idea of undergoing a basic CISM defusing session is to enable the ATCO to talk at peer level about what they have experienced during an occurrence before they have time to rethink the event. This may help to avoid a possible negative interpretation of or intense reaction to the occurrence.
2.7.5. To fulfil the requirements above, an initial relief from position is still necessary to be able to determine the initial severity & cause, to ensure that the ATCO does not suffer/develop any form of traumatic stress, and to offer CISM to the ATCO. Special care shall be taken how to organise the whole process in ATM units with temporarily or continuously low numbers of staff.
3.1. General findings mentioned above indicate that ATCOs should be relieved from position immediately after an occurrence for a number of reasons including to ensure safety and to protect the mental, psychological and emotional well-being of the ATCO. In fact, this seems to be the common practice across ANSPs and organisations.
3.2. Nonetheless, there are some concerns that need to be addressed, such as a perception of blame and prejudice as well as potential exacerbation of the negative mental state of ATCOs after an occurrence in some cases. Relieve may not be necessary because the ATCO was clearly not a contributing factor to the occurrences. Moreover, while traumatic stress tends to occur after such occurrences, Le Goff (1998) and Figarol (1997) noted that it does not necessarily always occur after every occurrence and not to every ATCO.
3.3. Hence, while relieving ATCOs of their position immediately after an occurrence is generally the recommended course of action, a set of criteria as suggested in the discussions above can be created to help supervisors determine if this course of action is truly necessary for the particular occurrence and ATCO. Such decisions should be transparent and not arbitrary. This set of criteria may take into account various concerns, such as an unavoidable initial perceived unfair placement of blame when the ATCO may not have contributed to the occurrence, or in cases where the occurrence was minor and the ATCO was not psychologically or emotionally affected.
3.4. However, due to the dynamism of the work environment of an ATCO, the use of static rule-like criteria may not be suited for all ANSPs, and each ANSP may have different factors unique to them that needs to be taken into account. More importantly is the opportunity for the ATCO involved to be offered basic debriefing to tackle their mental/emotional state. Enhancement of a company culture embedded in Just Culture should be promoted wherever possible. It is also essential that awareness training of operational staff on safety procedures and Just Culture principles be fostered before an occurrence takes place.
Therefore, it is recommended that the IFATCA policy on exemption of duty be amended to:
4.1. IFATCA policy is:
LM 11.2.8 ATTACHMENT: IFATCA POLICY ON ACCIDENT AND INCIDENT INVESTIGATION
2. Exemption from duty
When an accident or incident is alleged to have occurred where the actions of an Air Traffic Controller may have had a bearing, the Controller shall have the right to be exempted from control duties until he is physically and psychologically fit again. The relieve is without prejudice, and is non-disciplinary.
Be replaced with:
In the event of an alleged occurrence, the ATCO(s) shall have the opportunity to be relieved from control duties. IFATCA recommends the ATCO(s) be relieved. The relieve is without prejudice and is non-disciplinary.
When the ATCO(s) are exempted from position, they shall have the opportunity to undergo basic debriefing (e.g. CISM).
If the ATCO(s) agree that they are not suffering from traumatic stress, impaired mental/emotional well-being, they may resume control duties.
4.2 IFATCA policy is:
A controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an incident/accident.
Be replaced with:
A controller thus exempted or removed shall not suffer loss of pay during any period in any way associated with the investigation of an incident/accident occurrence.
Baumgartner M. (2004). Critical Incident Stress Management in Air Traffic Control. Retrieved from Eurocontrol: https://www.eurocontrol.int/sites/default/files/library/028_Critical_Incident_Stress_Management_in_ATC.pdf
Figarol, S. (1997). Le soutien après incident : enjeux et mise en oeuvre. Rapport CENA, Paris.
IFATCA (2019). WP No. 161. Report Writing and ANSP Procedures for Serious Incidents or Accidents. Retrieved from IFATCA: https://www.ifatca.org/wp-content/uploads/2019/07/C.6.10-Report-writing-and-ANSP-procedures-for-serious-incidents-or-accicents.pdf
Le Goff, M. (1998). Stress et contrôle aérien. Université Pierre and Marie Curie –Paris VI, Paris.
Technical and Professional Manual: The permanent record of the Federation’s technical and professional policies, Version 63.0, IFATCA, Montreal (Quebec), Canada, 2019. Available: https://www.ifatca.org/wp-content/uploads/2019/03/IFATCA-TPM_20190328.pdf
ICAO ANNEX 13 Aircraft Accident and Incident Investigation. Retrieved from: https://www.emsa.europa.eu/retro/Docs/marine_casualties/annex_13.pdf
ICAO DOC 9756 Manual of Aircraft Accident and Incident Investigation. Retrieved from: https://www.skybrary.aero/bookshelf/books/3282.pdf
Simon, T & Geoff, T. Risk Type Influence in Air Traffic Controllers. Retrieved from: https://www.psychological-consultancy.com/blog/risk-type-influence-air-traffic-controllers/
Appendix A – ESARR 2 Guidance to ATM Safety Regulators
Severity Classification Scheme for Safety Occurrences in ATM
Last Update: October 2, 2020