HindHuman and organisational factors in operationsight31

SPECIAL SUPPLEMENT EUROCONTROL LEARNING THROUGH COVID-19 LESSONS IN A TIME OF COVID AVIATION AND HEALTHCARE

LEARNING FROM ONLINE TEAM RESOURCE MANAGEMENT By Emmanuelle Gravalon

WHEN EVERYDAY WORK IS NOT SO EVERYDAY By Anders Ellerstrand

CAPTAINING THROUGH COVID-19 By Paul Reuter

IMPACT OF THE COVID-19 PANDEMIC ON AVIATION WORKERS AND THE AVIATION SYSTEM By Paul Cullen

Plus much more on learning through COVID-19 Supplement - Winter 2020-2021 Winter Supplement - HINDSIGHT 31 | SUPPLEMENT WINTER 2020-2021

TABLE OF CONTENTS

3 Welcome 15 HANDLING SMALL PROBLEMS IN A BIG 23 LEARNING FROM EVERYDAY WORK PANDEMIC By Raluca Tilici IN AVIATION: LESSONS IN A TIME OF INVITED FOREWORD: MALTA AIR 4 COVID By Steven Shorrock TRAFFIC SERVICES 16 CAPTAINING THROUGH COVID-19 By Captain Paul Reuter 26 LEARNING FROM EVERYDAY WORK IN WHEN EVERYDAY WORK IS NOT SO 6 HEALTHCARE: LESSONS IN A TIME OF EVERYDAY By Anders Ellerstrand CONNECTING 18 COVID By Steven Shorrock AVIATION AND HEALTHCARE: LET’S WORK TOGETHER By Sebastian 8 PROJECT WINGMAN By Nick Carpenter Daeunert 19 FATIGUE RISK AND THE COVID-19 THE UPS AND DOWNS OF EVERYDAY 11 PANDEMIC By Philippe Cabon and WORK IN THE TOWER DURING Fabrice Drogoul COVID-19 By Shaul Guthrie 21 IMPACT OF THE COVID-19 PANDEMIC LEARNING FROM ONLINE TEAM 13 ON AVIATION WORKERS AND THE RESOURCE MANAGEMENT By AVIATION SYSTEM By Captain Paul Emmanuelle Gravalon Cullen

EDITORIAL TEAM Editor in Chief: Steven Shorrock Graphic Design: inextremis.be Cartoonist: Daniel Avram All HindSight articles are peer-reviewed. Thanks to Tzvetomir Blajev, Svetlana Bunjevac, Radu Cioponea, Anders Ellerstrand, Alexander Krastev, Tony Licu, Alberto Rodríguez de la Flor, and Wolfgang Starke.

Photos: @EUROCONTROL, AdobeStock

2 HindSight 31 | SUPPLEMENT WINTER 2020-2021 CONTACT US HindSight is a magazine on human and organisational factors in operations in air traffic management and related sectors. The success of this publication depends on you. Please tell us what you think. And even more important, please share your experiences with us. We would especially like to hear from front-line personnel (the main readership) with a talent for writing engaging articles.

Please contact: [email protected] EUROCONTROL, Rue de la Fusée, 96 B-1130 Brussels, Belgium

Messages will not be published in HindSight or communicated to others without your permission.

SUBSCRIBE To see HindSight online, or to subscribe to a paper copy or change your subscription address, visit https://www. skybrary.aero/index.php/HindSight_-_ TABLE OF CONTENTS EUROCONTROL WELCOME

Welcome to this HindSight magazine supplement. While the main issue of HindSight 31 concerns learning from everyday work, this supplement concerns the COVID-19 pandemic more specifically. What have we learned about work in this new context? How has the pandemic affected us, and how have we adjusted?

In this supplement you’ll find perspectives from the ground and the air, from aviation staff and healthcare staff.

This will be expanded in the next Issue of HindSight on ‘The New Reality’. How have you and your colleagues adjusted and adapted to work in the context of the COVID-19 pandemic? Let us know, in a few words or more, for Issue 32 of HindSight magazine.

HindSight 31 | SUPPLEMENT WINTER 2020-2021 3 LEARNING THROUGH COVID-19

Kenneth Chircop CEO Malta Air Traffic Services (MATS)

INVITED FOREWORD: MALTA AIR TRAFFIC SERVICES

4 HindSight 31 | SUPPLEMENT WINTER 2020-2021 2020 started as a normal year. The Company contingency plans to adapt to pace. Yet again, new challenges were prospects were of yet another record- the unfolding situation. Operational staff encountered – with an increase in traffic, breaking year both in terms of terminal rosters were modified with the objective rosters needed to be revisited, training and en route traffic in the Malta FIR. The to minimise the complement of personnel had to resume and with the knowledge anticipated challenges were immense, working in close (but necessary) proximity that the virus will be with us for a while executing projects and implementing to each other and limiting to an absolute yet, projects had to be restarted. This time, technology that provides additional air minimum the mixing of staff between however, we knew this day was coming traffic capacity without jeopardising watches, having standby units at home and we had long been preparing for it. A the continuous progress in increasing in case they need to be called in urgently key advantage was also the fact that we safety levels. With the start of a reference and setting arrangements with fumigation had accustomed and adapted ourselves period and a performance regulation companies for emergency call-ins in case and our lives to live with COVID-19. Once mandating highly ambitious cost- of suspected COVID-19 cases, amongst again, we made the necessary changes efficiency targets, this was not going to others. All this was possible with the and we continue learning as we move be an easy year. It turned out, however, minimal traffic that was being serviced along. that 2020 will be remembered as the and it also contributed to much needed year when life as we knew it changed… savings in operational costs. Operational All this was possible with the training was halted. Major cost-cutting professionalism and flexibility of MATS News of the novel coronavirus spreading was achieved through the postponement management and staff. We look forward in Wuhan made the headlines in of all non-essential projects. to the days when COVID-19 is no longer January. Subsequently, all of us in the a concern, when air traffic starts hitting aviation industry were following closely Four months passed, quickly but painfully, records again, when the challenges we what was happening in Asia, horrified and the relaxation of air travel measures were accustomed to return. It will take a with the impact this was causing to air were welcomed. Commercial traffic while, but I am confident that we will get traffic. It did not take long, however, started picking up again, despite a slow there with patience and perseverance! until we started feeling the brunt in Europe. It took only a few weeks, before the European traffic fell to 10% of 2019 levels. The aviation industry had never experienced such a hard-hitting global crisis since World War II. Kenneth Chircop was born in 1982. He studied engineering at the University of Malta and graduated with a Bachelor’s degree in Electrical But what did this mean for Malta Air Engineering in 2004. He started his professional career researching Traffic Services (MATS) Ltd – the small avionics systems at Cranfield University, UK. He moved to the industry in 2005, where he spent more than three years at Hunt Engineering UK ANSP providing air navigation services Ltd., developing high-speed electronic systems for a range of industrial in the Malta FIR? What were the applications. In 2008, Kenneth returned to Malta to join the Department of challenges? Electronics Systems Engineering at the University of Malta, during which time he obtained his Ph.D. in aircraft trajectory optimisation techniques As a small island nation with a single and worked towards the setting up of the Institute of Aerospace airport, Malta’s economy depends Technologies within the same university. In May 2016, Kenneth moved back to the industry to take up the position of Chief Executive Officer of heavily on air connectivity. It was Malta Air Traffic Services (MATS). Kenneth lives in the small village of crucial, therefore, that no matter what Ħaż-Żebbug, a few minutes away from Malta International Airport, with his the situation, MATS needed to ensure wife and their two children. a continuous service. The pandemic, however, brought with it two major challenges: the risk of infection of MATS staff that could compromise continuity of service and the drop in revenue due to the slump in air traffic.

At the start of the pandemic, a crisis management team was quickly set up. The major decisions that were taken at the time were to introduce several measures to minimise the risk of infection and revise

HindSight 31 | SUPPLEMENT WINTER 2020-2021 5 

WHEN EVERYDAY WORK IS NOT SO EVERYDAY

How can we learn from everyday work in the context of an unprecedented pandemic? Using the themes of previous issues of HindSight magazine, Anders Ellerstrand takes a look at human adaptability at work in Sweden.

I work as a Watch Supervisor at the ATC daytime operations resembled old main challenge is Centre in Malmö, Sweden. Using the night-time operations in traffic volumes, to handle a lot of themes from the most recent issues there were other factors. Unlike night- traffic, but suddenly of HindSight, I will give some personal time operations, there were still military that challenge was reflections on how the pandemic has traffic and military activities in restricted gone. I believe a lot affected my everyday work. areas, and there was VFR traffic, of controllers find parachute jumping, etc. In fact, the this worrying; they The HindSight 25 situation was in many ways totally new. wonder if they will theme was ‘Work- The documented procedures, reflecting be able to maintain as-Imagined & the ‘work-as-imagined’ of old, did not their skill when they do not practise Work-as-Done’. cover the new situation, so they had to it. One way to handle this has been Every ANSP has be adapted to a new ‘work-as-done’. to close as many sectors as possible well-documented and to work one controller per sector and comprehensive The HindSight 26 instead of two. Controllers would rather procedures; our theme was ‘Safety work fewer hours in position but have ‘work-as-prescribed’ at the Interfaces: some quality time when they work, to which might also be people’s ‘work-as- Collaboration at still meet a challenge every now and imagined’. When these procedures meet Work’. Outside of the then. To maintain competency is still a reality, there is usually some kind of ANSP, at a state- problem and it will continue to be. The gap, but operational staff adapt to make level, I have seen obvious solution is to use simulators to things work, and the result is ‘work-as- extraordinarily little practise. I believe this will be done in done’. It is considered good if the gap of this. In summary, many places. between these is as small as possible, each country has tried to navigate but it is also realised that there will the pandemic on its own. Suddenly, Crises present problems but there always be a gap. Sweden found borders closed without are usually also opportunities. In this any pre-notification. I did not notice case, one opportunity can be found in As the pandemic hit us, my centre saw any significant change of cooperation relation to the many controllers that traffic volumes drop dramatically. Within between my centre and the centres are not needed in the ops room. Some a few weeks, we had less traffic during bordering to us. The bright shining controllers that work part-time in offices the day than we used to have during exception here is EUROCONTROL. So have been able to spend more time nights. To find guidance for how to far, the EUROCONTROL website has in the office. It has been possible to handle this situation, it seemed natural been my best source of professional take care of a lot of issues that would and made sense to use the procedures information, with frequently updated otherwise have been given lower for night-time work even during the and nicely presented statistics. In a priority. Other controllers that are not daytime. This included reducing the crisis, people want information, to needed in the ops room have been number of open sectors to a minimum understand what is happening and to given the possibility to stay home and and manning each sector with one try and predict what is coming. Thanks increase their competency, e.g., through instead of two controllers. While new to EUROCONTROL, I have been able EUROCONTROL e-learning. to provide such information to my "The documented procedures, controllers in the ops room. The HindSight 28 theme was ‘Change’. I have been an air traffic controller reflecting the ‘work-as-imagined’ In HindSight 27, the theme was for over 38 years. A lot of things have of old, did not cover the new ‘Competency and Expertise’. Controllers happened during these years. I have situation, so they had to be enjoy their work and the challenges seen new technology being introduced, adapted to a new ‘work-as-done’." they meet. For most controllers, the increasing traffic volumes, changes

6 HindSight 31 | SUPPLEMENT WINTER 2020-2021 in training and pandemic has further revealed this as "The pandemic has shown that HindThe ability or opportunity to understand and judge an event or experience after it has occurredight28 in organisation, EUROCONTROL a buzzword. As I mentioned earlier, the people’s ability to adapt and CHANGE but I have never CHANGING TO ADAPT general understanding has been that AND ADAPTING TO CHANGE get the work done in unusual experienced increasing capacity could be a threat

MODE-SWITCHING IN situations is particularly AIR TRAFFIC CONTROL anything like the Zsófi Berkes and Miguel Aulet to safety but reducing capacity is not. CLOSE ENCOUNTERS OF THE LEGAL KIND: A NEED FOR AIRSPACE CHANGE? important. No procedures were situation brought by Marc Baumgartner During the pandemic, the apparent THE JUST CULTURE FOUR MODES OF CHANGE: JOURNEY IN EUROPE: TO, FOR, WITH, BY LOOKING BACK AND Cormac Russell written on how to handle this LOOKING FORWARD the pandemic. It has Roderick van Dam, Maria Kovacova LEARNING FROM conflict between the production and and Tony Licu PSYCHOLOGY AND Plus much more on changing to adapt PSYCHOTHERAPY and adapting to change in aviation and A conversation with David Murphy beyond pandemic." been the quickest 2018-2019 Winter protection has not been a conflict at all. and most dramatic This crisis has been about managing change I have ever seen. production and economy. rather long period. Overall, I believe that most of our staff have been doing "I have never experienced Handling goal conflicts is everyday OK. anything like the situation brought work for the Watch Supervisor, and by the pandemic. It has been the pandemic did not reduce this task. As a summary, the pandemic has the quickest and most dramatic Rather, the opposite emerged. While shown that people’s ability to adapt controllers have been mostly very and get the work done in unusual change I have ever seen." relaxed with few aircraft to handle, situations is particularly important. No supervisors have been rather busy. The procedures were written on how to Through the last two years, the staffing has usually been more than handle this pandemic. Top management recurrent theme for ATM in Europe has enough, which is good from a safety prioritised the economic situation and been ‘the capacity crunch’. Everyone perspective. On the other hand, it is the effects of decisions made at higher was looking for things that could help better if people stay at home, doing levels were dropped to the ops room us increase capacity, of course while e-learning or taking a day off. And manager, the watch supervisor. In an maintaining safety. Then, during March sometimes controllers are needed for extremely dramatic period, with a lack this year, everything changed. We other work, at an office somewhere. of guidance and information, people went from a capacity problem almost Managing staff has been a large part still find ways to manage their work in everywhere to a capacity problem of the supervisors’ work during the a safe and sensible way. And of course, nowhere. Maintaining safety while pandemic: deciding who can do no automation was there to do it for us. increasing capacity is a well-known goal what, informing everyone, updating People made it happen. conflict that we are used to and that paperwork, etc. As most of the normal we can manage. But maintaining safety work (handling airspace, coordinating while reducing capacity? That is not a with the military and so on) has still problem at all, is it? been there, the goal conflicts have been many and trade-offs sometimes We have a safety management system difficult. with different elements to manage safety. One element is the management The HindSight HindThe ability or opportunity to understand and judge an event or experience after it has occurredight30 of change. Whenever we are informed 30 theme was WELLBEING EUROCONTROL QF32 AND POST- TRAUMATIC STRESS Steven Shorrock interviews Captain of a change to our functional system, ‘Wellbeing’. In the Richard Champion de Crespigny MORAL REASONS FOR PROMOTING WELLBEING IN ORGANISATIONS we assess it to understand how it will initial phase of the Suzanne Shale SYSTEM WELLBEING Anders Ellerstrand

THE ENERGY PROJECT affect us, if there are new hazards, and if pandemic, people @MUAC Marinella Leone

BURNOUT IN EMERGENCY we need to mitigate these hazards. With were worried for MEDICINE: HOW DO WE GET BETTER? Shannon McNamara

Plus much more on Wellbeing the pandemic, there was no incoming their own health and in aviation and beyond

mail informing about a coming change. for their family and Spring-2020 I don’t know if there has been a formal friends. In Sweden, safety assessment of the pandemic. As the problems with infection mostly far as I have seen, it just happened, and stayed in the areas around Stockholm. everyone adapted to make things work. My ATC centre is in the far south of Sweden, where we had very few cases, The HindSight 29 so there were fewer worries for health

HindThe ability or opportunity to understand and judge an event or experience after it has occurredight29 theme was ‘Goal after some time. Later came the worries Anders Ellerstrand EUROCONTROL was an ATCO for Conflicts and Trade- GOAL CONFLICTS for the economic effects: will people AND TRADE-OFFS over 35 years and offs’. The classic goal TRADE-OFFS AND TABOOS GOOD JOB, EVERYBODY Jean Pariès Emmanuelle Gravalon lose their jobs? The financial situation INVISIBLE TRADE-OFFS AND CONFLICTS WITHIN AND has an MSc in VISIBLE CONSEQUENCES WITHOUT: LEARNING FROM Erik Hollnagel COSTA CONCORDIA conflict in aviation Nippin Anand was and is particularly worrying. QF32 Plus much more on goal conflicts and Human Factors in An interview with Captain Richard trade-offs in aviation and beyond Champion de Crespigny is that between Recovery is slow, it is obvious that Aviation. He was a ‘production and the money coming in is not enough, Watch Supervisor protection’. The idea and the information about the future in Sweden but has Winter 2019-2020 Winter is that if you increase is not there. Still, the social systems also worked for production you risk losing protection; in Sweden are helping us. Even if the ICAO. that is safety. Of course, most if not all worst comes to the worst, there is good anders.ellerstrand@ ANSPs say ‘safety first’, but I believe the financial back-up that will last for a gmail.com

HindSight 31 | SUPPLEMENT WINTER 2020-2021 7  LET’S WORK TOGETHER

An initiative to learn from everyday work before COVID-19 became even more important as the reality changed, but new questions about work had to be addressed, as Sebastian Daeunert reports.

KEY POINTS

ƒ During the COVID pandemic, we have to consider how to help controllers and trainees maintain an acceptable level of wellbeing and performance. ƒ Maintaining proficiency is a challenge, especially for new controllers who are not getting the practice without a coach. ƒ Learning teams made up of different age groups and perspectives can discuss their wishes and fears, and find solutions for performance and wellbeing. "What do you do as a trainee ƒ We need to plan now for when traffic picks up to help manage short term peaks and longer-term increases. when your runway has turned into an aircraft parking lot for abandoned aircraft?"

“What a sight, what a beautiful sight.” I All of us in aviation have gone through Before Coronavirus am looking out of my office window in rough times during the past months. the early morning. We’ve seen our industry in crisis, Let me explain the situation. Before shattered by an invisible enemy called coronavirus, due to a lack of controllers, And here comes NEO the A320 ‘COVID-19’. And we all carry the big we boosted the number of ATCO trainees glistening in the morning sun. No, we question mark – a mixture of hope and up to what we could handle. Our training are not back to the high traffic numbers fear – on our faces. Being the Safety system, after the theoretical classes and that we used to have at our airport. Manager and Head of Training at our the simulator training at the academy, But the short and medium rangers are tower, I feel lucky to belong to a group comprises three phases of ‘on-the-job coming back, one by one. that has no shortage of work. training’: start, middle, and final phases. Then there is a practical evaluation exam This view would have been nothing out How can this be? It is not the number that finally results in the ATCO licence. of the ordinary during all those years – a of incidents. How could it be, with the common sight. But now, something low amount of traffic that we have? No, Due to the large number of trainees, makes me happy. Finally, my ‘friends’ are a different question has arisen: how some controllers complained that they on the move again. And it makes me to keep my controllers and trainees would not be able to work enough time think about what has happened during at an acceptable level of wellbeing? on their own (without a trainee), fearing the past few months. Not the news, but Sometime soon we will need them at for their proficiency. Young controllers what has happened here and how we their peak again. This is an interesting who had just achieved their licence said made it happen. challenge, but a rewarding one. that they were not getting the practice

8 HindSight 31 | SUPPLEMENT WINTER 2020-2021 integrate new age groups, different views, different needs, and different attitudes into our ATC family? What are the wishes, fears, and requests of controllers, coaches and trainees? What might we learn from ‘new blood’, perhaps in terms of ideas and attitudes?

All that was before COVID-19. Little did we know that our little workgroup would gain such meaningfulness.

After Coronavirus

Then a virus erupted all over the world. Traffic stopped, and then trickled. Suddenly, what we had started to think about became even more important. What do you do as a trainee when your runway has turned into an aircraft parking lot for abandoned aircraft? How do you keep proficient when you drop from 1,600 movements per day to 40? How do you feel when your dream appears to be dying? And what about fear, boredom, distraction, and even a feeling of uselessness?

And then private pilots saw the chance to finally fly from the airport with Cessnas, Catanas, Pipers, even glider parachutes. This may be a dream for many, but it is a nightmare for the sole A320 that sits on the runway while four to ‘swim by themselves’ without a coach, a result, some controllers who had not hobby pilots are meandering around. due to the number of trainees blocking been interviewed appeared with a set of the ‘hot positions’. notes on several pages where they had But most importantly, what happens written down what they thought was when traffic picks up? How do we I did some human factors interviews, important. We gladly listened to what manage short term peaks and longer- trying to find those ‘weak signals’, asking they told us. This was really something. term increases? the same questions but to different peer group members: young trainees, young Now, we were not in a time of crisis. The important part in all of this is to ATCOs, experienced ATCOs, and ATCO Things were working fine. This was keep people as motivated and as happy coaches. A few examples: simply a continuation of our interest as possible as a team, despite the in ‘work-as-imagined and work-as- situation that COVID-19 causes. ƒ “If you were the king of this airport, done’ (see HindSight 25). “Never stop what would you change and why?” monitoring. Never stop improving,” we Many things were done. One was a ƒ “If you put production pressure on thought. safety briefing, a video which was put yourself, what is the motivation?” into the e-learning programme. The ƒ “How do you feel about training and Solutions were soon found and subject? How to cope with boredom coaching?” published. It was made clear and when there is no traffic, keeping up published by our local management the level of attention and maintaining The answers surprised me. I expected that any controller – young or old – situational awareness. each interview to last for 15 minutes. has the right to work on their own if Yet all exceeded one hour, as they required for as long as needed. This was An example we used was a train had so much to say. Try it. It is really not new, but the sense of duty towards accident on a German railway line rewarding, and the information is our trainees had made some ATCOs (Bad Aibling, 12 casualties, 55 injured). valuable. However, I was unable to do forget this. According to the accident report, the interviews with all our people. It would dispatcher had played a game on his have taken up too much time. So, I A learning team was formed, made up mobile phone during a period with tried one person from each group. As of different generations. How do we a lack of traffic on the short line, and

HindSight 31 | SUPPLEMENT WINTER 2020-2021 9 

played a part in causing the accident simulation, at least partly? When can where two trains were approaching we do a checkout, and at what traffic Sebastian Daeunert each other head on, crashing at full level? We do not just try to find ways of is the incident speed on the single-track line. coping with the immediate situation. investigator of We involve those who are affected and Frankfurt Tower. How do you remain attentive when give them a say in the decisions. He was an active there is little to do? How do you react TWR/APP controller when suddenly there is a very serious The Bottom Line: We Care for 15 years before situation that needs full attention? The getting into safety management and safety briefing was appreciated by our Most importantly, we let them know human factors. He controllers, who did not only accept the that we don’t abandon them; we really participates in the content, but also felt that their concerns care. Everyone knows the situation is EUROCONTROL/ were recognised. It also made them a tough challenge. But ‘my controllers’ IFATCA prosecutor think. and ‘my trainees’ know that they are expert scheme and not on their own. They know that we gives occasional are a family that is working together lectures at "What happens when traffic EUROCONTROL to keep this house safe and happy. The Human Factors picks up? How do we manage nightmare has become a collective task. conferences. short term peaks and longer-term This is productive and a major part of [email protected] increases?" wellbeing: feeling safe, warm, needed, and wanted, during the scariest times that I have ever known. And maybe at We gave tasks to the trainees too. We the end of all this we will all come out made sure they knew that they are still stronger. important to us and members of our ‘family’. I wrote a new training concept, Before when things go wrong, as they changing the old system from doing sometimes will "Maybe at the one long checkout to gain all positions And the road you travel, it stays all uphill to one single licence – a ‘one position Let's work together, come on, come on, end of all this we = one licence’ concept. It is currently let's work together will all come out under evaluation with the workers’ You know together we will stand, every stronger." council and the authorities for possible boy, girl, woman and a man approval. Let’s Work Together, Canned Heat (1970) Other questions emerged. Can we substitute on-the-job training with

10 HindSight 31 | SUPPLEMENT WINTER 2020-2021 THE UPS AND DOWNS OF EVERYDAY WORK IN THE TOWER DURING COVID-19

In this brief report, Shaul Guthrie reports on the effects of the COVID-19 pandemic on operations at Haifa Airport in Isreal.

During the first days of March, a commercial flights. The effect was that work needed no more than one active pandemic was something that was traffic fell from 100-170 aircraft a day to ATCO. There was a protocol for how to happening somewhere else. It had 8-16 a day. operate in this ‘slim shift’, and capacity no effect on traffic volume at Haifa was declared so that the slim shift could International Airport. By mid-March, During this time, 30% of ATCOs in the safely operate. there was only a 20% decrease in traffic. unit were sent on unpaid leave. Some On March 27th, a notice to airmen of the shifts were reduced from three or On April 19th, the NOTAM was (NOTAM) was issued prohibiting non- four ATCOs to two ATCOs per shift. The cancelled, and traffic returned. In the

HindSight 31 | SUPPLEMENT WINTER 2020-2021 11 

first 2 days, it was in small bursts of traffic, but on April 21st, we were up to 90% of normal traffic. By April 25th we were at 100% normal summer traffic. To put it into numbers: in the month prior we were working with zero to one plane per hour in the control tower, and within three days we went back to working with 10-23 planes per hour for most of the day.

In response to the rise in traffic, the slim shifts protocol was immediately cancelled. Then, the ATCOs who were on unpaid leave from April 1st were brought back. We had to ascertain their ratings and only then fill the shifts. Luckily, it was ‘only’ one month that they had not worked at the tower, so four hours with a training officer on the first shift was all that was needed.

One of the things that we had to think about was that the ATCOs who had been on unpaid leave were relatively new, with two to five years of experience, including one ATCO who got their rating just a month prior to the COVID-19 crisis.

The way we coped with the sudden return of traffic was to avoid reaching our full capacity in the tower. We controlled that by calling for a coordinator as soon as it was thought From March until June, LLHA was open "We wrote down what we should that traffic could build up. In LLHA, most only during daylight, before that we preserve as standard operating traffic is local flights and circuit training were open for training during the night, procedures so that we can use (pop-ups) and traffic tends to spike from three days a week. At the beginning the collected experience in future two to seven in a matter of minutes. of June, we reopened for two hours training and operations." As far as workload is concerned, traffic once a week for night training. This is not the major issue, but rather created a surge of traffic; in the first four the phone calls and coordination of weeks, we were operating at maximum the role of each team member. We incoming and outgoing traffic. So, capacity of the control tower and the gathered our data, including talking to keep the workload in the tower runway for two hours straight. In these after the shifts, self-reflection and manageable, we split the coordination two hours, we had 70 counted aircraft positive feedback from the team. We to another ATCO. This is considered movements. This is not something we wrote down what we should preserve as normal operation in Haifa, but due to practise in training, keeping maximum standard operating procedures so that the short period that we had minimum capacity for two hours. This required we can use the collected experience in traffic, we tried to keep the workload four ATCOs, which means having all the future training and operations. well away from the ATCOs’ full capacity ATCOs in shift active. After the fourth for the first two months. week, traffic went back to normal operation. Shaul Guthrie In August 2020, traffic was at 110% of is an ATCO at what it was before COVID-19 started in Haifa Airport and Israel. team resource "We learned how to operate as management programme a team at maximum capacity So, what have we learned in the past leader for Israel traffic for long periods of time, five months? We learned how to operate Airports Authority. understanding the role of each as a team at maximum capacity traffic SHAULGU@iaa. team member. " for long periods of time, understanding gov.il

12 HindSight 31 | SUPPLEMENT WINTER 2020-2021 LEARNING FROM ONLINE TEAM RESOURCE MANAGEMENT

As much training has moved online, what might we learn from this for team resource management? Emmanuelle Gravalon reports on the French experience.

In France, team resource management ƒ foster safe individual and collective sociology and ergonomics in order (TRM) courses for ATCOs were behaviour and to improve the to better understand individual and introduced in 2000 as a form of culture of safety through feedback collective behaviours. experience sharing. The stated and experience sharing. objectives were to: The courses are much appreciated To achieve these objectives, the by controllers. Experience sharing ƒ remain vigilant when it comes to TRM facilitators provide theoretical enriches each controller’s experience the ‘human factors’ risks for ATC, in contributions from cognitive science, by exchanging information about order to maintain safe individual and situations and sharing collective behaviours the resolutions. This helps ƒ learn from experience (to better "Experience sharing enriches each to identify problematic understand our own experiences controller’s experience by exchanging situations earlier, and to and those of others) to develop and generate a larger range of improve risk management on a local information about situations and sharing possible resolutions. and national level, and the resolutions."

HindSight 31 | SUPPLEMENT WINTER 2020-2021 13 

Virtual TRM Training two facilitators. This proved pertinent The Future when the first problem with the internet Due to the COVID-19 pandemic, at occurred. When one HF facilitator We will need experience sharing again the beginning of March 2020, DSNA speaks, the other one can keep an to quicken the safe building of the (the French ANSP) decided to stop all eye on the trainees’ reactions or can post-COVID ATC world, which promises ATCO non-operational gatherings, and answer via the chat window. The second new methodologies (free route for thus stopped all continuous training, feedback was that three trainees was a example), new rules, new traffic flows including TRM courses. This was a good number. Each can speak without and new technical systems. We need to problem but also an opportunity. It any problem. This is fewer trainees than share our varied experiences as widely gave us the chance to use our 20 years would be the case in a course. The third and quickly as possible to face all these of experience of TRM differently. We had and perhaps most important feedback simultaneous changes safely and build to come up with new forms of training. is that it was good to meet people from renewed competencies. others’ centres, who wouldn’t have met So, a team of eight TRM facilitators from otherwise. As the Head of the French TRM various centres reviewed and organised facilitators’ network, my hope is to be ‘stress and fatigue management’ The TRM facilitators also appreciated able to retain some of the benefits of materials from different TRM courses working in a team with into an e-learning course for small people from different groups via Zoom. The plan was to have centres, sharing "We need to share our varied experiences as one HF facilitator and three ATCOs from different backgrounds widely and quickly as possible to face all these different centres, with an expected and competences. simultaneous changes safely and build renewed duration of two and a half hours. The They developed new competencies." regulator agreed. facilitation skills. Each time we had We started with a first group of 15 the chance to facilitate TRM sessions virtual TRM. In particular, we need more ATCOs (five groups of three). For each for ATCOs with different backgrounds experience sharing between ATCOs with session, ATCOs from different airports (tower, approach and ACC) we could various professional backgrounds and and ACC were carefully mixed so that experience fruitful exchanges. This was also between other stakeholders, ATSEP, they could exchange their experiences. helpful to get a comprehensive view of managers and pilots, both in-person Test sessions were held beforehand to all the different aspects of the job. and virtually. check connections and hardware used by trainees. The first virtual TRM course This enriched vision of the ATC system was provided by one HF facilitator while facilitates cooperation and interaction two other HF facilitators were there as between the various entities involved in support/observers. air traffic safety, and was more difficult to achieve with in-person TRM. Emmanuelle We validated this new temporary and Gravalon has mandated way of TRM sessions. In total, The negatives been working 138 French ATCOs have attended 45 as an air traffic Zoom sessions between April and July This COVID-forced experiment had controller for over 2020. several advantages, but few trainees 30 years. Formerly wanted to keep this virtual method in in Limoges airport, she is currently an The positives the long term. Most missed the real approach controller meeting with discussions and various in Basel-Mulhouse The feedback has been good, even activities. Some HF facilitators noticed International very good. The HF facilitator team the difficulty in organising such events airport. She is is unanimously praised for their and the technical fragility of the system. an HF facilitator enthusiasm and kindness. The trainees The sharing of more varied experiences for controllers, are happy to try something new (and is counterbalanced by the small number and graduated in Ergonomics & useful for their licences). of participants and covered subjects. HF Basics from The technical fragility of internet Paris Descartes More specifically, the first feedback connections and the use of individual or University. we got from the trainees and the HF private hardware is also a limitation for coordonnateur.fh@ facilitators was that it is better to have more intensive implementation. gmail.com

14 HindSight 31 | SUPPLEMENT WINTER 2020-2021 HANDLING SMALL PROBLEMS IN A BIG PANDEMIC

In the face of a global pandemic, previously small problems may take us by surprise. In this article, Raluca Tilici reminds of the unseen impacts of factors that affect our performance in a way that we have never seen before.

As experienced in many other ATC In normal times this would have been overcome this ‘stand-by mode’ and this towers, this spring was not only atypical, resolved in seconds. This time, it took took a few minutes for this situation. it was unimaginable. The spring traffic two minutes. So what happened? Why So, how to help ATCOs maintain focus forecast from December for our airport did it take us so long to resolve the and overcome boredom or lack of was a traffic increase of 15%. We were situation, and why did we focus only on vigilance? To improve and better delighted. But then the world changed one problem? These were the questions prepare ourselves, we have to develop with the arrival of COVID-19. All traffic that I asked myself after the aircraft programmes, in the form of online TRM ceased (both international and national). landed safely. Perhaps because I’m part sessions or online group discussion to For a period, we only had humanitarian of the training team in my unit, and also address these issues. and hospital flights, at a maximum of a Human Factors enthusiast, I had to dig one or two flights a day. We are a small deeper. When considering our own airport and we don’t have problems performance, and learning from the with too much traffic, but we never have This was just a simple unusual situation new reality of everyday work, we should problems with monotony either. in COVID-19 low traffic. It was resolved not forget that this pandemic has had safely, and just required an extra time an unseen effect in us as human beings. We didn’t know what to do with all until the solution was implemented. We experience worries and stresses this free time. It was stressful, and felt With learning as our focus, not blaming, uncomfortable, like a bad dream. But we have to understand how this besides the emotional aspect of a pandemic is affecting us as the human "We should not forget that lack of traffic and the world situation, part of the system. this pandemic has had what impact does this have on our an unseen effect in us as performance as ATCOs? I really didn’t ask Until this situation, it didn’t occur to human beings." myself this question until I had to handle me that there could be a problem with an unusual situation in these conditions. staying vigilant as an ATCO during without even perceiving them for what After four hours of no traffic during one COVID-19 traffic. We always perceived they are. And we are each in a different shift, in a row of shifts with no IFR traffic that the problem with vigilance related situation, even though we face the same at all, we received a flight plan for an IFR pandemic. It is a period that may bring technical flight coming to land at our "With learning as our focus, not fear of us or our loved ones getting airport. It was a happy moment but not sick, or worries for our livelihood or blaming, we have to understand stressful at all. We are all experienced income, or of boredom and isolation. controllers and it was only one flight. We how this pandemic is affecting us And then there is the fatigue. While we know our jobs by heart. as the human part of the system." usually think of human factors as most important for busy and stressful work, But things didn’t work as imagined. An to night shifts, where you have to stay here it is especially important. Even aircraft entered our area and did not awake. But we have never dealt with when we are not busy in the usual way, respond to our calls. We presumed that a pandemic before. Our brains had to work and life is particularly stressful. there was a radio communication failure (RCF). We had military traffic in the area, everything was coordinated, and the aircraft followed the local RCF procedure. Raluca Tilici has been working for 10 years as a tower and procedural approach air traffic controller at Bacau Airport, After a few minutes, we discovered Romania. She is an OJTI and Training Manager at her unit. She is that our station was the one with the also a human factors enthusiast, and became a TRM facilitator in problem. We switched to another station, 2019. She holds a BS in Management and in Finance, and a MS in and everything was resolved. Aeronautical Management. [email protected]

HindSight 31 | SUPPLEMENT WINTER 2020-2021 15 

CAPTAINING THROUGH COVID-19

As we cope with the new reality of work during COVID-19, how can captains, supervisors and other team leaders create the right environments for teams to perform well and stay well? Captain Paul Reuter offers some tips from experience.

During the COVID-19 pandemic, "What I feel is missing is a little a strong message is being sent support and advice on how to 1. Acknowledge the Current by the European Union Aviation address and incorporate the Exceptional Situation Safety Authority (EASA) and other realities of the COVID crisis into stakeholder organisations to operators teamwork." The aviation sector, and society at to implement peer support and to give large, faces the biggest challenge proper support to crew members. This in a long time. As individuals, most aims to help crew members to deal with the realities of the COVID crisis into of us have never had to face such the uncertainties and impacts of this teamwork. As I reflect upon this as uncertainties, concerning our crisis. It is also heart-warming to see a captain, I realise that in general, livelihoods and our wellbeing. The aim initiatives such as the European aviation operators give us very little guidance of the crew- or team leader is to help mental wellbeing initiative (EAM-WELL), on how to build a team. Our manuals create an environment where crew the European Aviation Wellbeing are very prescriptive on what to brief members feel psychologically safe Committee, the European Pilot Peer but very short on the relationship side while also clearly setting boundaries Support Initiative (EPPSI), the European of team building. Often, apart from and focusing the team on the mission. Association for Aviation Psychology highlighting the occasional safety topic A quick check-in with your crew or (EAAP) and others that try to stress the or mentioning the odd CRM theme, we team on how everybody is doing importance of ‘wellbeing’ for safe and do not thoroughly address anything will help your crew feel confident resilient crew performance. related to team building at all. that their worries are taken seriously. Sharing that you, as senior members What I feel is missing is a little support There is no silver bullet for achieving of the crew, are also impacted by the and advice to captains, team leaders this but – in trying to learn from my uncertain consequences might help as well as team members in general, own work – here are five thoughts that junior crew members to open up about on how to address and incorporate might help. their worries.

16 HindSight 31 | SUPPLEMENT WINTER 2020-2021 2. Frame the Mission Your team should understand that the aircraft. Still, it is advisable to take you ‘have each other’s back’ – to look two minutes to gather your crew and In these times, rumours such as threats out for and support one another. To to briefly address the topics that you of redundancies and cuts to income be able to do so, people need to feel believe need addressing. will have spread among crews, both psychologically safe to speak up and be in person and via social media. This honest about their feelings. That goes As a captain, you not only hold ultimate will affect everyone, but junior crew for the team leader as well. For your responsibility for your crew. You should members may be more susceptible to team to perform and have your back, also see yourself at the centre of that be overwhelmed by the amount of bad you will need to be honest with them. team, giving support and helping your news and rumours. If such a topic comes Even as a leader, you are allowed to feel team and your team members to learn up during a briefing, acknowledge and unsure, have doubts and voice them. No and grow. A proper debrief after a flight address it. Try to put it into context but one expects you to have all the answers. or even an open discussion on the then refocus your crew on the mission, events of the day and how they were reminding them that we cannot let handled should be seen by everyone as events over which we have no control "Even as a leader, you are allowed an opportunity to learn and improve, affect the way we perform. yourself included. to feel unsure, have doubts and 3. Consider the Challenges that voice them. No one expects you While we may feel that sometimes the Cabin Crew Faces to have all the answers." the challenges and hurdles that this crisis is facing us are huge, we While most operators allow us to leave 5. The Joker Card should acknowledge that there are the mask in the cockpit, cabin crews opportunities as well. One opportunity need to wear the mask both in the cabin In these strange times, some crew might be to refocus our efforts on how, and in the galleys. They have no respite members (especially junior) might feel as a crew, we are a team, bigger than regarding wearing a mask and may also obliged to show up for duties when not the sum of its parts and how important be confronted with additional tense fit to fly. it is to foster relationships within situations associated with compliance the team. with the current hygiene rules. If you have any doubts about the fitness of one of your crew members, find a Whether our team is a small crew of Now, more than ever, it is important way to raise the topic gently. Refusing a regional airline or a department to stress to your cabin crew that any a crew member who is unfit for duty within a larger organisation, we issue they face in the cabin is an issue is in everyone’s best interest. As a might rediscover how empathy, that you will solve as crew, and that team leader, you should help the crew mutual respect and support, as well you as a commander and the cockpit member come to a realistic assessment as transparent communications, can crew will be actively involved in of their fitness and you make it clear make us, as individuals and our teams finding a solution. that you will back up the crew member more resilient, better performing and further down the line if you swap him ultimately bring back some fun and joy Another issue you might want to or her out. Similarly, should your crew to our work. consider is that some of your crew voice concerns concerning your own might be grateful for a little time out or fitness, address it honestly and in a a ‘safe space’ during the duty where they constructive way and if needed, step can relax and recuperate a little. back from your duty.

There is no need to chase the schedule Paul Reuter is a and on turnaround it might be "In these strange times, some crew members (especially junior) Captain Boeing advisable to ensure that your crew gets 737NG for Luxair, a few minutes alone without cleaning might feel obliged to show up for and President of the personnel or passengers in the cabin to duties when not fit to fly. " European Pilot Peer relax and refocus. This will help create Support Initiative. He trust and confidence within your crew In the company I work for, which is is a former president of Luxembourg's and ensuring that you have a dedicated quite small, we have the advantage Airline Pilot and fit crew to operate the next sector. of knowing (almost) everybody, so it Association, former is easier to approach each other than Technical Director 4. Have Each Other’s Backs in a company with thousands of crew of the European members. Cockpit Association, A well-functioning and resilient team and former Chairman is a team where people are not afraid Similarly, we tend to brief together, of ECA's Safety Strategy Task Force. to voice concern or acknowledge providing many opportunities to Paul is an IFALPA vulnerabilities. A team leader needs to incorporate these ideas in our preflight. Accredited Accident foster such an atmosphere. With some operators you might meet Investigator. pr@ your cabin crew only in the shuttle or at eurocockpit.be

HindSight 31 | SUPPLEMENT WINTER 2020-2021 17 

CONNECTING AVIATION AND HEALTHCARE: PROJECT WINGMAN

With many aviation staff losing their jobs or on furlough, a question arises for many: “How can I continue to offer what I have to give?” One answer is to connect aviation with healthcare staff. Nick Carpenter reports on Project Wingman.

I was one of many people to lose my occurred. One well-known company It also raises two rather interesting job during the lockdown in the face told their staff from the outset that questions. First, why has the NHS never of the coronavirus pandemic. As a they would no longer be employed. provided a haven for their staff before? professional pilot, how could I best utilise Another waited until the eleventh hour Some of these individuals work 16-hour my experience? The answer for me, and and then fired many, keeping some in days with only short breaks. They have many other unemployed and furloughed work but on much-reduced terms and little respite from the patients that they colleagues, was Project Wingman. conditions. The difference between treat and nowhere to relax. This is not the two workforces was marked. Those a lot to ask for even in a world where Project Wingman is a charity that helps who have known their fate all along accountants are kings. Second, who airline crew come together to support have continued contributing to Project is going to be lucky enough to add the wellbeing of UK National Health Wingman. Those fired at the last-minute these wonderful characters to their Service (NHS) staff. It provides a haven for have all stopped attending. workforce in the coming months and both medical and non-medical staff away weeks? My admiration for cabin crew from patients, where they can relax with After my first simulator session, I and pilots has grown watching them a drink, snack, and an empathetic ear remember being told to “make a give so much when some of them during the COVID-19 outbreak. decision, any decision, you can always have only unemployment in their near change it later”. Making such decisions future. These people are a credit to the The success at the hospital where is difficult to do and managers, fearing airline industry and the UK workforce. I volunteer has been absolute with the resentment that redundancy Duty is not dead; it perhaps just goes staff enjoying the diversion from announcements cause, can be unrecognised. their exhausting days. My colleagues particularly poor at making them. Having have been amazing. Many of those seen the selfless commitment, pride in Further information: laid off and desperately seeking new the uniform and good-natured strength www.projectwingman.co.uk careers, have wholeheartedly thrown of character of the staff that they have themselves into their new voluntary fired, I can understand why. The terrible roles. Turning up every day in their indecision has had a harmful effect on Nick Carpenter is spotless uniforms, buying snacks out of many of our colleagues with all of us able a military trained incomes that they do not have, baking to see the inequity of those selected for and commercially delicious treats and looking after their work and those discarded. experienced airline pilot guests with a smile, they have been an currently seeking a new example of the best of our industry. career. His interest in "My admiration for cabin crew occupational safety has Many of them have spent weeks and pilots has grown watching inspired him to study for both a Bachelor's and waiting to hear what their companies them give so much when some of a Master's degrees in will do with them and this is where them have only unemployment in Psychology. nickc744@ the interesting daily difference has their future." hotmail.com

18 HindSight 31 | SUPPLEMENT WINTER 2020-2021 FATIGUE RISK AND THE COVID-19 PANDEMIC

The COVID-19 pandemic has a number of implications for human and organisational performance. One of these is fatigue, as Philippe Cabon and Fabrice Drogoul explain.

THE COVID-19 pandemic has deeply and as a result reduced their workforce, COVID-19 impacts many aspects of disturbed ways of working, in all either through furlough or redundancy. personal life which may impact general industries but especially in aviation. For The reduction in working staff has physical and mental fitness for duty. It a few months, aircraft mostly stayed on the potential to leave remaining staff has undoubtedly increased uncertainty, the ground and aviation personnel saw working longer, more intense hours. anxiety and stress for people in general, an unprecedented slowdown of their Many organisations set up longer impacting personnel’s focus and quality activity. In the context of limited hours working hours, including increased of sleep. Increased use of smartphones of work and partial operations, fatigue work hours at night. and longer commute time (due to and associated risk have been largely lack of public transport) perhaps also underestimated. Reductions in staffing levels may lead affected fatigue levels. to more tasks being accomplished per High levels of fatigue impacts air person. These tasks may be unfamiliar If most companies have partly resumed traffic safety as well as the health and are therefore more demanding of their operations, the COVID-19 and wellbeing of the staff. But more individuals, who may not be well suited, pandemic continues to impact staffing focus on information gathering and trained and qualified for the activities levels and air transport organisations monitoring can support organisations they are now performing. must improvise with a lot of uncertainty. in recognising the fatigue levels of their employees. Particular attention needs to be paid to this in the context of reduced job security and increased pressure to Number of Fatigue Reports support the organisation’s survival, even more when resuming operations. 1 000 800 The air transportation industry has 600 paved the way with data collection regarding fatigue monitoring. Fatigue 400 reports sent to Member States are 200 recorded in the European Central 0 Repository. The graphs to the right Jul Number of Occurences Oct Feb Apr Jan Jun Sep Aug Nov Dec Mar compare the number and rate of fatigue May reports in 2020 with the average of 2017-2019 2020 the previous three years. The number of reports has decreased, as might be expected given the reduced air traffic. Rate of Fatigue Reports However, the rate of fatigue reports 1 200 in April and May was higher than the 1 000 three-year average. 800 The analysis of these fatigue reports 600 allowed us to suggest a few reasons for 400 this increased level of fatigue. 200 0 Million IFR Flights Planning schedulers may have Rate of Occurences per Jul Oct Feb Apr Jan Jun Sep Aug Nov Dec Mar insufficiently considered fatigue. Many May organisations experienced a significant 2017-2019 2020 reduction in work from March to June

HindSight 31 | SUPPLEMENT WINTER 2020-2021 19 

We have formed the following principles for managers to increase the focus on their employees’ fatigue in this Philippe Cabon is Fabrice Drogoul is a Human Factors particular context: a Human Factors expert, Associate expert from Professor in Human EUROCONTROL, ƒ Foster your employees to Factors at Université course manager acknowledge and communicate de Paris, co- of the Stress about their fatigue through fatigue founder of Welbees, and Fatigue reporting. a company management course ƒ Analyse fatigue reports to identify specialised in and responsible of Fatigue Risk fatigue management the main area of risk. Management in the OPS room ƒ Assess fatigue risks associated with Systems. initiative. Fabrice duty rosters. www.welbees.com and Philippe started ƒ Inform your employees about these their collaboration increased risks (through normal in 1998 on fatigue communication channels and research In ATM and work together training), highlighting the difficulties on fatigue and imposed by the pandemic. stress training and assessment. fabrice.drogoul@ eurocontrol.int

20 HindSight 31 | SUPPLEMENT WINTER 2020-2021 IMPACT OF THE COVID-19 PANDEMIC ON AVIATION WORKERS AND THE AVIATION SYSTEM

THE COVID-19 pandemic has affected aviation workers and the aviation system more than most could imagine, with a significant impact on wellbeing. Captain Paul Cullen follows up his article in HindSight 30 with feedback on the results of a survey of over 2,000 safety- critical aviation workers.

Over a three-week period in August, have been published, with the following When compared with data recorded in an anonymous online survey was key indicators. 2018 by this research group, an increase conducted, with the objectives of was observed in the number of pilots understanding and evaluating the 1. Those people who have lost suffering with depression at all levels of impact of the COVID-19 pandemic their jobs or are experiencing severity, and this is in line with what is on aviation workers and the aviation mental health difficulties need being observed in the general population. system, and to identify solutions in immediate support. collaboration with stakeholders. 2. Organisations and workers High levels of anxiety were observed, need to manage specific The key issues examined were with 36% of respondents indicating mild sources of stress and anxiety, anxiety, 13% moderate and 11% severe. and the specific impact of ƒ the extent and speed of change In fact, 18% of respondents met the COVID-19. ƒ the probable deterioration in morale threshold for moderate depression, with and wellbeing of safety-critical staff, 7% moderately severe and 5% severe. Overall, 23% of respondents indicated and that their company provided employee ƒ the possible lack or delegation of A clear correlation was found between support to manage wellbeing since safety oversight in the industry. suffering and age, with higher levels COVID, but less than a quarter of these of suffering in younger participants. respondents made use of the support. More than 2,000 safety-critical workers Over half of those working in the responded, with the largest number air traffic control sector reported Almost all respondents (97%) working of responses from pilots (38%), cabin that their wellbeing was negatively in the ATC sector reported being crew (19%), air traffic control (11%) and impacted by the pandemic, with 37% financially affected by COVID-19, and engineering (8%). The data are currently reporting a deterioration in their 55% were worried about meeting being analysed, but preliminary findings mental health. financial obligations.

HindSight 31 | SUPPLEMENT WINTER 2020-2021 21 

3. Roles and responsibilities of 6. There needs to be stronger "The survey showed a stakeholders in relation to regulatory pressure on the managing wellbeing require implementation of the currently variety of concerning rethinking and clarification. deferred regulations in impacts of the relation to the management of pandemic on mental We found that 78% of respondents wellbeing and mental health indicated an unwillingness to disclose of pilots, and also to extend wellbeing." mental health issues to their employer. this to cover all safety-critical Extremely low numbers of respondents workers. reported having ever discussed an issue with either peer support programmes A total of 69% of respondents felt that (PSPs, 3%) or employee assistance changes in morale were negatively programmes (EAPs, 2%). While 79% of impacting on worker engagement ATC respondents would not disclose to and 47% felt that motivation was their employer, 4% reported using Peer deteriorating. Additionally, one in three Support; this was the highest uptake of respondents felt that safety oversight, all staff groups. both within their organisation and from the regulator had deteriorated during 4. Need for peer support the pandemic. One in four respondents programmes for all aviation reported feeling that their competence workers. to do their job safely had deteriorated.

Despite the low uptake of PSPs and The survey showed a variety of EAPs, 68% of respondents indicated concerning impacts of the pandemic on a willingness to seek help if needed. mental wellbeing. In the coming weeks, Furthermore, 70% were aware of a Peer a thorough analysis of all findings Support Programme and 60% would will be conducted and reported. The use organisational support if provided. evidence will be disseminated to Encouragingly, 79% of ATC workers were support: 1) a recovery roadmap and aware of peer support programmes, strategy; 2) organisational action; and, while the responses suggest that such 3) a policy and regulatory approach. supports are almost non-existent in the A further update will be published engineering/maintenance sector. publicly in the future.

5. Issues pertaining to wellbeing culture need to be addressed.

Wellbeing was not considered a priority for 80% of respondents.

Captain Paul Cullen has been an airline pilot for over 20 years, with over 13,000 hours flying A320, A330 and B737. He has a particular interest in the mental resilience of pilots and is an accident investigator and researcher with the School of Psychology, Trinity College, Dublin. [email protected] | https://www.tcd.ie/cihs/projects/pilot-lived.php The Lived Experience Wellbeing Project is an independent research group based at the Centre for Innovative Human Systems, School of Psychology, Trinity College Dublin. The research team led by Dr Joan Cahill & Captain Paul Cullen examine the effects of work-related stress (WRS) on aviation worker wellbeing and the associated impact on performance and flight safety. Further, the research addresses solutions to WRS both an organisational and employee/worker self-management level. This includes tools to promote stress coping, wellbeing awareness and management and risk assessment for WRS/wellbeing. This research group, although independent, actively collaborates with aviation stakeholders – including the regulator and industry wellbeing and safety working groups.

22 HindSight 31 | SUPPLEMENT WINTER 2020-2021 LEARNING FROM EVERYDAY WORK IN AVIATION: LESSONS IN A TIME OF COVID

Everyday work in aviation COVID-19 pandemic has been affected almost beyond recognition, and with it how we feel about work and the future. HindSight Editor-in-Chief Steven Shorrock asked air traffic controllers and professional pilots about their experiences.

“The current situation presents “The importance of building “ATCOs were affected by a ‘skills fade’ challenge for all relationships and trust in good isolation, loneliness and controllers” times” uncertainty”

Without regular application, the high I’ve learned that no matter how During the COVID period, besides the level of aerobic fitness achieved by confident you are about the path you’re disease anxiety, ATCOs were affected athletes can evaporate in a fraction of on, and how resilient you think you are, by isolation, loneliness and uncertainty. the time that it took to attain. The same managing your resilience over time is Isolated in our control centre, we barely can be said of ATC competency. Those of quite challenging, especially if you are had news or contact with anybody us working in procedural and technical in a situation that has no clear outcome for days. We felt useless: no aim nor roles are acutely aware of the challenge over time. As a leader, it has shown any working perspective during our of maintaining competency despite me the importance of empathy and duty. Used to being ‘in control’ and to periods away from the operation. The compassionate leadership in navigating anticipate, we experienced motivation current situation presents a ‘skills fade’ a team through an already challenging loss, weaker commitment and passive challenge for all controllers. When traffic environment and on the importance of behaviour, including disengagement on levels increase, we must ensure that balancing emotional needs with mission changes integration and on documents we avoid the ‘frog in the pan’ scenario, objective within a team. Finally, it has updating efforts. This wellbeing and and we are working with our training, shown me the importance of building safety drift may create new holes in the technical and competency teams to relationships and trust in good times James Reason Swiss cheese model. ensure we have robust strategies to get that will sustain the team in bad times. back to full ATC fitness. Sebastien Follet, ATCO (TWR/APP), Paul Reuter, Captain (Boeing 737NG), France Ady Dolan, ATM Procedures & Luxembourg Development Controller (Heathrow), UK

HindSight 31 | SUPPLEMENT WINTER 2020-2021 23 

"The sense of community has fact, a few flights in, small things were “We have to take care of our been heart-warming” forgotten. I suppose I began to relax mental wellbeing” more. However, mitigations included Prior to the pandemic, simple keeping things ‘SOP’, taking things The lack of certainty and the scarcity interactions at work were taken for slowly, and ensuring the operation was of tasks let the mind run, while granted. As humans we (mostly) thrive kept as simple as possible. equilibrium is essential. I had never and depend on face-to-face contact. felt anxiety but there were different Needed for our mental health and Ben, Captain (A320), UK and opposite reactions (from panic to wellbeing, it is this aspect which has refusal). Although measures to protect impacted the way I view work in the airport workers from infection were current situation. With no clear idea of taken immediately, the emotional what the short-medium term future “An extra dose of care and impact caused by the pandemic was holds for the industry, I’ve found myself attention…has been necessary” not taken in equal consideration. One cherishing every opportunity to work morning during a break, I was walking and try to really interact with everyone The COVID-19 pandemic has faced us in the airport and the only sound was I come into contact with during the with an unprecedented scenario. Some ambulance sirens and bells announcing course of my duties. The sense of issues have come up strongly. 1) The deaths. I have noted the immediate community has been heart-warming in importance of the team. It has become resilience (mental and logistic) of most these difficult times. The professionalism clear that it does not depend on an of my colleagues. But this exceptional demonstrated with an ever-present individual performance. An extra dose situation has confirmed that if we look threat of redundancy has been nothing of care and attention to each other and for high performance at work, we have short of inspiring. to the operation has been necessary, to take care of our mental wellbeing, as and a strong stress reliever. 2) The well as physical. Pilot, Captain (A350), UK uselessness of ‘the super controller’. Today, the super controller is the one Marcello Scala, ATCO, Italy who knows his or her limits, accepts help, and asks for help. 3) This crisis has “People are willing and capable highlighted the enormous interference to adapt and adjust their work” posed by ‘the ego’, and how it underlies “I learned about adaptive many of the main operational problems. capacity” The pandemic changed everything in a way I have never experienced during David Garcia Hermosilla, ATCO (ACC), Resilience is nothing new in the world almost 40 years as an ATCO. During these Spain of safety science. However, I learned last months, I have learned that even the importance of extrapolating the when conditions change dramatically concept to business strategy and and outside of the system’s normal operations. In fact, it can even be boundaries, people are willing and “My ex-colleagues showed little reduced to the level of household capable to adapt and adjust their work or no degradation in pure piloting or individual resilience. While some so that production can continue, and the skills” organisations like Amazon had business work gets done while maintaining safety. models that were already aligned for And this was done without too much Planning licence revalidations for my ex- success during COVID, I learned more action from management. colleagues after the bankruptcy of our about adaptive capacity watching previous employer, I was little nervous my airline transform their passenger Anders Ellerstrand, ATC Centre Watch the evening before the first check. aircraft into freighters by utilising cargo Supervisor, Sweden What to do, if your colleagues perform netting, seats, and existing anchor insufficiently? The worst would be if you points in a novel way. Innovation like have to fail them. this is driven by front-line field experts collaborating with managers, engineers, “Returning to flying after many Surprisingly, my ex-colleagues showed and regulators to drive change. months off was a daunting little or no degradation in pure piloting prospect” skills. It perhaps took a minute longer to Brian Legge, Training Captain (Boeing get used to the aircraft again after half 777), Hong Kong Returning to flying after many months a year on the ground but flying skills off was a daunting prospect. Would seem to be quite resilient. What definitely I remember everything I needed to? showed degradation was scanning What elements of my skill set would skills and overview in general. These “Problem-solving took place return easily? It became apparent that are the skills required in complex and again during lockdowns” motor skills – the actual flying of the unexpected multiple failure scenarios. aircraft returned very quickly – it was One of the key factors to manage air like I had never left. However, cognitive Wolfgang Starke, Dash8-Q400 traffic is problem-solving, and even processes took a little more time. In Captain, Germany when traffic decreased dramatically,

24 HindSight 31 | SUPPLEMENT WINTER 2020-2021 controllers have to face new challenges. “I wasn’t aware of how important a couple of years (the time it takes to Problem-solving took place again wellbeing is” train a controller). Unless we do this, during lockdowns to keep teams when traffic starts to grow, we will ask working together, despite all limitations. Up until the beginning of the pandemic, ourselves how to deal with the lack of It was incredible how the system I wasn’t aware of how important controllers and the lack of capacity of worked because of the definition of the wellbeing is to personal happiness and the European ATM system, again. system itself: ‘a group of interacting or to those around me. Everyday work interrelated entities that form a unified and family life unfurled in a routine Marcello Di Giulio, ATCO (ACS-RAD, whole’. COVID-19 posed new way of way. Then air traffic stopped. Wellbeing Milano), Italy interacting, but problem solving made it is not something we think of every work again. day, however, through anxiety over competency through lack of traffic, for Oliviero Barsanti, ATCO, Italy the first time worry over job security “Our job as air traffic controllers and potential economic measures, it is is much more akin to that of something that has become important athletes” – much more than I could have “COVID-19 has changed our lives imagined. It is omnipresent, something The current pandemic has reminded as pilots utterly” that we take home, even if we pretend me and my colleagues how our job that these things shouldn’t affect us. as air traffic controllers is much more COVID-19 has changed our lives as akin to that of athletes and sports pilots utterly, mainly for worse, although Jules, ATCO (Geneva TWR/APP), people than to that of office workers. in other ways for better – sleeping in Switzerland Every day, we have to perform to my own bed instead of spending two or the best of our ability, applying the three nights per week in hotel rooms. skills acquired during our training After the initial five weeks without and perfected through experience. flying, I’ve since flown almost weekly, “ANSPs could study the system The drastic reduction in air traffic has enjoying quiet airports and airspace. In to be ready when the traffic brought the problem of skill fading 20 years of flying into Heathrow, I had resumes” to the fore, whose effects we must never before been given “Direct centre- minimise in preparation for when air fix and high speed approved. Let us In the European ATM system of a few traffic returns. In the same way that know when you’re slowing down!” from months ago, the only problem that athletes practise competition scenarios 80 miles out. Then back out early (what’s seemed to exist was the lack of capacity during their training, it will be important a slot?) with pushback to airborne in and the lack of controllers. Then the for air traffic controllers to have access four minutes. (Pity about the pay cut, black swan, COVID-19! Traffic suddenly to simulators so they can hone their though.) dropped from one day to the next by controller skills back to their peak level. 90%. So how does the ATM system Niall Downey, Airbus A320 Captain, react? ANSPs could study the system to Luis Barbero, ATCO (Heathrow Ireland be ready when the traffic resumes, or Approach), United Kingdom could dedicate this time to select new staff and train them to be available in

HindSight 31 | SUPPLEMENT WINTER 2020-2021 25 

LEARNING FROM EVERYDAY WORK IN HEALTHCARE: LESSONS IN A TIME OF COVID

The COVID-19 pandemic has had one of the biggest effects on work- as-done in healthcare in recent memory. So what might we learn about work from the perspectives of frontline workers? HindSight editor-in- chief Steven Shorrock asked a variety of practitioners.

“Frontline workers are the solution routinely been included in healthcare “Diverse views were brought to most problems“ teams – such as aerodynamic scientists together” and occupational hygienists – to keep During COVID19 I learned that the workers and patients safe. Many of The potential impacts of COVID-19 need for change is the only thing we these experts are accessible on social required a rapid reconfiguration of the can reliably predict about the future. media, primarily twitter, and have been intensive care unit. This required many Fortunately, frontline workers are the generously sharing their expertise for different teams: ICU clinicians, infection solution to most problems that will the benefit of all. control nurses, biomedical engineers, inevitably arise. They are the most builders, ventilation engineers and valuable resource in healthcare, both Tanya Selak, Anaesthetist, Australia quality improvement specialists. These for delivering the care and for designing @GongGasGirl diverse views were brought together how to do it. Locally, we have seen for the complex, dynamic problems rapid, successful innovation of work we faced. This work leaned heavily on practices through the marriage of the pre-existing relationships built up simulation and human-centred design “Team learning is needed” during a recent volcanic burns disaster. principles. Sadly, though the safety of Additionally, the redesign of clinical our workforce is paramount, it has been Individual adaptations are necessary work was based on four requirements: threatened worldwide. We still haven’t to cope with goal conflicts, but team to be SAFE, SIMPLE, SUSTAINABLE and learned how to put humans at the learning is needed to maximise the ADAPTABLE. The ability to anticipate centre of healthcare. impact and ensure the safety of such potential challenges required adaptations. In my GP practice, daily imagination and a deep understanding Chris Nickson, Intensivist, Australia ‘huddles’ (short meetings) were used to of the realities of everyday work. @precordialthump discuss how we implemented rapidly changing guidance while coping with Carl Horsley, Intensivist, New Zealand varying conditions (e.g., demand and @HorsleyCarl capacity) and competing goals (e.g., “The pandemic has required reducing hospital admissions while groups to leave their silos“ maintaining patient safety). Huddles encouraged sharing of innovative “It is critical that ‘work-as- High trust relationships are critical to practice and increased understanding prescribed’ reflects ‘work-as- safety. Strong bonds within groups of why decisions were made and how done’” develop organically over time. This decisions affected other parts of the social capital has many advantages system. It also supported those making Healthcare has a reputation for particularly during a crisis, but can difficult decisions and ensured people resistance to change, particularly top- have the unintended consequence of did not drift into unsafe practices. down initiated change, with limited excluding others. The pandemic has consultation with clinicians. During the required groups to leave their silos and Duncan McNab, General Practitioner, pandemic, many frontline clinicians to collaborate rapidly on high-stakes Scotland @Duncansmcnab experienced change done ‘to’ them, issues. I have learned that we need to instituted by administrators, particularly call on those who have not previously rationing personal protective

26 HindSight 31 | SUPPLEMENT WINTER 2020-2021 “Looking back, local practice is “Let user-centred and data-driven not ‘work-as-prescribed’” design lead us in rebuilding”

Despite 25 years in the specialty, COVID-19 has shone a light on our the COVID19 pandemic was my first lack of insight into complex system introduction to Personal Protective design. Healthcare is a precarious thing, Equipment (PPE) and a FFP3 mask. Fit balancing on the backs individual and testing achieved and training in PPE team resourcefulness and resilience. donning and doffing undertaken was Emergency medicine, in particular, suffers great preparation to prevent catching a from ‘ad hoc-itis’. Our ability to improvise deadly viral disease. However, this was solutions in the face of massive systemic no preparation for the daily challenges limitations and inefficiencies is practically of working in PPE exacerbated by a professional badge of honour. But it concerns around PPE availability and doesn’t have to be this way. We can build changes in doffing station practice. systems that make sense. We can use The impact of heat, the need for good simulation-informed design, prototype hydration, and the communication testing, multi-source feedback and hazard challenges became stressors – analysis to help manage complexity recognised and managed by great team rather than compel us to work against it. working through adaptations in how we The pandemic has compelled us to tear worked. Looking back, local practice is down and begin again, and therein lies equipment. Other organisations not ‘work-as-prescribed’. a massive challenge and unprecedented have initiated clinician-led processes, opportunity: let user-centred and data- resulting in durable models of care but Alastair Williamson, Anaesthetist, UK driven design lead us in rebuilding. uncovering ‘wicked problems’. COVID-19 @dr_alwilliamson has taught me that engaging clinicians Christopher Hicks, Emergency doing the work increases short-term Physician, Trauma Team Leader, and complexity, but doing otherwise risks Simulation Educator, Canada failure in the long term, losing trust “Work-as-done can be close to @HumanFact0rz on the way. It is critical that ‘work-as- work-as-imagined” prescribed’ reflects ‘work-as-done’ to prevent depletion of the workforce I have learned that some types of through infection and exhaustion. ambulance service work systems that “By starting to address problems would previously have been considered iteratively we could create a Kara Allen, Anaesthetist, Australia very difficult to change, can actually network of actions” @ergopropterdoc be reconfigured at pace and new ways of working can be introduced, which The biggest problem we faced at the led to significantly different system start was the uncertainty and a stream performance. Work-as-done can be of unfiltered information. We had “For the first time, work and its close to work-as-imagined with changes tentative ideas of what needed to be goals were shared” up to a certain size. With larger groups done and what might happen. What of workforce, it can be very difficult we learned subsequently was that by “I know what I’m doing, I don’t need to to influence multiple, often subtle, starting to address problems iteratively be told how to do it” … these are words changes in work-as-done to match with we could create a network of actions I haven’t heard during these months of the more easily changeable work-as- that we could knit together. We rapidly COVID19. This whole experience was new prescribed (and work-as-imagined). This developed a tolerance of failures, using for everyone. For many professionals, was particularly evident in the early them, with active feedback, to modify it has created a touching sense of stages of the response phase when our processes and facilities adaptively, humility, both among frontline actors clinical, logistical and PPE criteria were alongside the new information that and managers. I believe that this humility becoming established. became available. This made it much has facilitated communication and the easier to try and keep pace with a emergence of a shared governance Gary Rutherford, Ambulance Service rapidly evolving situation. between caregivers and administrators Patient Safety Manager, Scotland where I’ve been working. For the first @garyrutherford2 Alex Kazemi, Intensivist, New Zealand time, work and its goals were shared and @KazemiAlex the gap between work-as-imagined and work-as-done was almost zero.

François Jaulin, Anesthesiologist- Intensivist, France @Francois_JAULIN

HindSight 31 | SUPPLEMENT WINTER 2020-2021 27 

“A significant issue…has been “The ability of staff to innovate equipment and personnel removed effective communication” and adapt was remarkable” from the ‘hot-zone’. Limiting opening of doors and wearing of masks and A significant issue for health Without timely clear guidance arriving face shields results in markedly difficult professionals during the coronavirus down the traditional lines, the ability communication – even when that pandemic has been effective of staff to innovate and adapt was communication is critical. Cameras, communication while wearing PPE, remarkable. The constraint of normal microphones, patching of monitors especially for aerosol generating change bureaucracy was temporarily and hand signals are valuable but procedures. Voices are muffled, suspended and essential new ways inadequate. There is certainly greater hearing is compromised and implicit of working arrived in a rapid and appreciation for shared mental models communication through facial remarkably effective way, significantly and planning for complications with expression is lost. This is especially prior to written SOPs. Front-line staff pre-operative briefings than before the a problem for resuscitation teams absorbed the principles and developed pandemic. working under pressure. We provided them in appropriate ways for their own our staff with 5 tools (PRESS) to improve local work, often utilising the skillset Stu Marshall, Anaesthesiologist, communication using PPE: of their staff, e.g., military nurses who Australia @hypoxicchicken had significant experience with PPE P – Pre-transmission pause – think and Ebola. Staff needed guidance in before you speak underlying principles, but then excelled R – Read back – close the loop at translating them into their own “Where you draw the system E – Eye contact – ensure focussed working environment. boundary matters” attention S – Say again – repeat critical Pip Fabb, Consultant Anaesthetist, Where you draw the system boundary information. England @PipCassford matters. I started chairing a theatre S – Shared team mental model with a COVID preparedness group in March. team rally point We quickly transformed the theatre complex to handle a surge in patients Stephen Hearns, Consultant in “My colleagues and I could adapt with COVID, while keeping staff safe. Emergency and Retrieval Medicine rapidly to these new conditions” We liaised with ED, ICU and the wards @StephenHearns1 which are upstream/downstream of Overnight, my job changed from theatres. The teamwork, dynamism and in-person clinical care to online psychological safety of the working telemedicine. Our telemedicine urgent group were excellent. There were times “We were finding solutions from care started seeing hundreds of COVID on the fringes of this system when we the ground up” patients a day, a disease and volume found other systems which benefitted that were totally new to us. I learned from our input. Our system boundary During the start of the pandemic, the that my colleagues and I could adapt did not include the whole hospital rules and guidance we had normally rapidly to these new conditions. The system and that was appropriate, been following were gone. Sometimes, tradeoffs between in-person care other people were focusing on this. rules set out by people that don’t ‘do and online care were challenging for Looking back now I wonder about the the work’ are not the way that the everyone, as patients feared contracting care homes. They were not within my work happens. These rules end up COVID at the hospital. Communicating system and I didn’t give them a second’s being a barrier to do the right thing. clearly with one another and with our thought within my planning. Whose For example, filling a 35-page safety patients about uncertainty and risk were system boundary included care homes? booklet about a newly admitted patient essential, as conditions changed rapidly. What were their working conditions, takes us away from practical tasks demands and constraints? How could such as personal care or administering Shannon McNamara, Emergency we do better next time? medication. Now, no-one knew the best Physician, USA @ShannonOMac way to do things. There was no evidence Michael Moneypenny, Anaesthetist, base to draw from, and no exemplars to Scotland follow. This led to a more collaborative approach. Everyone came up with “Design and processes affect the ideas, and many more came from social normal functioning of a team” media. We openly learned from each other. We were finding solutions from Preparing a new ‘COVID operating the ground up and the senior leadership theatre’ has highlighted the importance team listened. of how design and processes affect the normal functioning of a team. Claire Cox, Former Critical Care To minimise risk, the negative air Outreach Nurse, England pressure of a dedicated COVID theatre @safetynurse999 needs maintaining and non-essential

28 HindSight 31 | SUPPLEMENT WINTER 2020-2021 HindHuman and organisational factors in operations in air traffic managementight

The theme for HindSight 32 will be THE NEW REALITY

HindSight is a magazine for front-line and other practitioners in air traffic management on human and organisational factors in operations.

We welcome articles and short contributions, including good practice examples, by Friday 2 April 2021.

We especially welcome articles written by or with front-line operational staff on any aspect of adjusting and adapting to the new reality of work in the context of COVID-19, for example:

• preparation and planning • new or changed risks • managing and handling risk • competency and expertise • collaboration • change • wellbeing.

Articles may include, stories and lessons from operational experience, including what has worked for you, and what has not.

Draft articles (1500 words maximum, but may be around 1000 or 500 words) and short examples of experiences or good practice (that may be helpful to other readers) (200 words maximum) should:

• be relevant to human and organisational factors in operations • be presented in 'light language' keeping in mind that most readers are front- line staff in ATM • be useful and practical.

Please contact [email protected] if you intend to submit an article, to facilitate the process. If you are interested in downloading back issues of the HindSight collection http://www.skybrary.aero/index.php/HindSight_-_EUROCONTROL

8: winteredition’09 “Hindsight” the ability or opportunity to understand and judge an event or experience after it has occurred. EUROCONTROL HindThe ability or opportunity to understand and judge an event or experience after it has occuredight09 N°3 N°4 N°5 N°6 N°7 June 2006 January 2007 June 2007 January 2008 July 2008 Hind ight COLLISION WEATHER Are you responsible “Hindsight” AIRSPACE The ability or opportunity to understand and judge AIRSPACE CONFLICT AVOIDANCE an event or experience after it has occured. Production for safety? “Hindsight” The ability or opportunity to understand and judge INFRINGEMENT DETECTION an event or experience after it has occured. “Hindsight” DETECTION THE RUNWAY AND YOU Putting Safety First The ability or opportunity to understand and judge “Hindsight” A WEATHER Pressure an event or experience after it has occured. The ability or opportunity to understand and judge WORKLOAD By Ian Wigmore in Air Traffi c Management an event or experience after it has occured. WORKLOAD “Hindsight” SeeSee pagepage 2222 GHOST STORY The ability or opportunity to understand and judge THE APPLICATION OF IS AIRSPACE PENETRATION an event or experience after it has occured. By Prof. Sidney Dekker OFFSET TRACKS By Prof. Sidney Dekker Clashing moral values p08 AN ATC PROBLEM OR NOT? ANOTHER SUNNY DAY IN SWEDEN © European Organisation for Safety of Air Navigation See page 8 ANOTHER SUNNY DAY IN SWEDEN IN EUROPEAN AIRSPACE (EUROCONTROL) January 2009. By Professor Sidney Dekker See page 3 BY BENGT COLLIN BY BENGT COLLIN WORKLOAD A STRANGE CONCEPT BY ROLAND RAWLINGS This publication has been prepared by the Safety Improve- See page 5 NEW!ment Sub-Group CASE (SISG) of EUROCONTROL. STUDY: The authors BY PROFESSOR SIDNEY DEKKER See page 8 acknowledge the assistance given by many sources in the Next please p15 “THEpreparation FIRST of this publication. OFFICER IS MY SeeSee pagepage 66 “THE FIRST OFFICER IS MY By Anthony F. Seychell MOTHER-IN-LAW”The information contained herein may be copied in whole MOTHER-IN-LAW”or in part, providing that the copyright notice and disclaimer are included. By Bengt Collin Safety & the cost killers p16 SeeSeeThe pagepage information 1616 contained in this document may not be modifi ed without prior permission from EUROCONTROL. By Jean Paries 50 YEARS AFTER MUNICH A letter to aviation prosecutors WORKLOAD VERSUS BOREDOM The views expressed in this document are not necessarily THE HUMAN FACTOR COLUMN those of EUROCONTROL. See page 39 by Tzvetomir Blajev BY BERT RUITENBERG The consequences of p23 LOSS OF SEPARATION BY PROFESSOR SIDNEY DEKKER EUROCONTROL makes no warranty, either implied or ex- THE BLIND SPOT See page 7 See page 7 pressed, for the information contained in this document; nei- commercial pressure can be fatal THE BLIND SPOT ther does it assume any legal liability or responsibility for the I separate therefore I am safe See page 15 AIRBUS AP/FD TCAS MODE: accuracy completeness and usefulness of this information. By John Barrass AIRBUS AP/FD TCAS MODE: by Bert Ruitenberg NEAR COLLISION INVESTIGATINGINVESTIGATING CONTROLLERCONTROLLER A NEW STEP TOWARDS BLIND SPOTS GET YOUR RUNWAY INCURSIONS - AT LOS ANGELES SAFETY IMPROVEMENT SKYbrary POSTER SeeSee pagepage 2020 See centre page IT WILL NEVER HAPPEN TO ME ... BY DR. BARRY KIRWAN By Paule Botargues Lesson from (the) Hudson SeeSee pagepage 1212 See page 18 See page 25 by Jean Paries CND January ’09

Summer 2009 EUROCONTROL DAP/SAF June 2006 EUROCONTROL DAP/SSH January 2007 EUROCONTROL DAP/SSH June 2007 EUROCONTROL DAP/SSH January 2008 EUROCONTROL DAP/SSH July 2008

EUROCONTROL EUROCONTROL HindThe ability or opportunity to understand and judge an event or experience after it has occuredight10 HindThe ability or opportunity to understand and judge an event or experience after it has occuredight11 HindThe ability or opportunity to understand and judge an event or experience after it has occuredight12

Level Bust... Airspace Infringement - Runway excursion or Altitude Deviation? again?! Controllers and pilots teaming up to prevent runway excursions by Captain Bill de Groh, IFALPA

Some hidden dangers of tailwind by Gerard van Es To see or not to see Level Busts: cause or consequence? by Bert Ruitenberg The role of ATM in reducing by Professor Sidney Decker the risk of runway excursion Let’s get rid of the bad pilots by Jim Burin The ‘Other’ Level Busts by Professor Sidney Dekker by Philip Marien Airbus altitude capture enhancement Air Traffic Controllers do it too! to prevent TCAS RAs by Loukia Loukopoulos by Paule Botargues

Winter 2010 Summer 2010 * Piste - French, 1. (ski) track, 2. runway Winter 2011

EUROCONTROL EUROCONTROL HindThe ability or opportunity to understand and judge an event or experience after it has occuredight17 HindThe ability or opportunity to understand and judge an event or experience after it has occuredight18

Safety versus Cost

Production and safety are not opposites by Professor Sidney Dekker

Defining a Compliant Approach (CA) A joint response to enhance the safety level of approach Justice & Safety and landing by André Vernay

A new just culture algorithm by Professor Sidney Dekker Is justice really important for safety? by Professor Erik Hollnagel Cash is hot and safety is not 'Human error' - the handicap of by Captain Rob van Eekeren human factors, safety and justice by Dr Steven Shorrock

Summer 2013 Winter 2013

HindThe ability or opportunity to understand and judge an event or experience after it has occurredight28 HindThe ability or opportunity to understand and judge an event or experience after it has occurredight29 HindThe ability or opportunity to understand and judge an event or experience after it has occurredight30

EUROCONTROL EUROCONTROL WELLBEING EUROCONTROL QF32 AND POST- GOAL CONFLICTS TRAUMATIC STRESS CHANGE Steven Shorrock interviews Captain CHANGING TO ADAPT Richard Champion de Crespigny AND ADAPTING TO CHANGE AND TRADE-OFFS MORAL REASONS FOR TRADE-OFFS AND TABOOS GOOD JOB, EVERYBODY PROMOTING WELLBEING IN ORGANISATIONS Jean Pariès Emmanuelle Gravalon Suzanne Shale INVISIBLE TRADE-OFFS AND CONFLICTS WITHIN AND VISIBLE CONSEQUENCES WITHOUT: LEARNING FROM SYSTEM WELLBEING Anders Ellerstrand MODE-SWITCHING IN Erik Hollnagel COSTA CONCORDIA AIR TRAFFIC CONTROL Nippin Anand Zsófi Berkes and Miguel Aulet QF32 THE ENERGY PROJECT Plus much more on goal conflicts and @MUAC An interview with Captain Richard trade-offs in aviation and beyond CLOSE ENCOUNTERS OF Champion de Crespigny Marinella Leone THE LEGAL KIND: A NEED FOR AIRSPACE CHANGE? BURNOUT IN Marc Baumgartner EMERGENCY MEDICINE: HOW DO THE JUST CULTURE FOUR MODES OF CHANGE: WE GET BETTER? JOURNEY IN EUROPE: TO, FOR, WITH, BY Shannon McNamara LOOKING BACK AND Cormac Russell Plus much more on Wellbeing LOOKING FORWARD in aviation and beyond Roderick van Dam, Maria Kovacova LEARNING FROM and Tony Licu PSYCHOLOGY AND Plus much more on changing to adapt PSYCHOTHERAPY and adapting to change in aviation and A conversation with David Murphy beyond Winter 2019-2020 Winter Winter 2018-2019 Winter Spring-2020

In the next issue of HindSight:

"THE NEW REALITY" EUROCONTROL

© EUROCONTROL, December 2020

This publication has been prepared under the auspices of the Safety Team of EUROCONTROL.The Editor in Chief acknowledges the assistance given by many sources in its preparation.

The information contained herein may be copied in whole or in part, providing that the Copyright is acknowledged and the disclaimer below is included. It may not be modified without prior permission from EUROCONTROL.

Disclaimer The views expressed in this document are not necessarily those of EUROCONTROL which makes no warranty, either implied or expressed, for the information contained in it and neither does it assume any legal liability or responsibility for its accuracy, completeness or usefulness.