JULY DCA ATC INCIDENT REPRESENTS CLASSIC REACTIVE RISK MANAGEMENT STRATEGY

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ARTICLE: FAA suspends operation that led to near-collision

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The FAA has taken action and is barring the use of an air traffic control traffic reversing operation that led to a “close call” event at Reagan National Airport (DCA) on July 31. The action was taken based on preliminary findings and out of an “abundance of caution.” The preliminary incident analysis also revealed that the managers at the regional control center were also performing other administrative-like tasks during complex traffic operations which usually require their undivided attention

The FAA should be commended for taking prompt action to mitigate repeat events which represents a classic SMS reactive risk management approach that has been used for decades:

  1. Hazard identification – a safety event or incident took place and a potential hazard is identified;
  2. Risk Assessment – the hazard is assessed in terms of risk and a determination made as to whether the risk of continuing the operation without intervention is acceptable. If it is not acceptable then the risk mitigation process is engaged;
  3. Risk Mitigation – control measures are taken to prevent further events from happening or to fortify the defenses against the risk of a repeat event.

In this case the ATC system’s level of safety was maintained because an event took place and the FAA implemented corrective action. However, this approach has inherent limitations, one of which is examination of actual failures only. Had a proactive risk management process been in place this type of event would have already been analyzed and the mitigation or corrective action would have been already implemented and the event would never have happened.

A proactive risk management strategy includes identifying hazards before they materialize into incidents or accidents and taking the necessary actions to reduce the safety risks. Components of a proactive safety management strategy include:

  1. Unambiguous safety policy ensuring the senior management commitment to safety;
  2. Hazard identification and risk assessment using state-of-the-art risk assessment methods;
  3. Safety reporting systems used to collect, analyze and share operational safety related data;
  4. Competent investigation of safety occurrences with sole purpose of identifying systemic safety deficiencies;
  5. Safety monitoring and oversight aimed to asses safety performance and eliminate problem areas;
  6. Dedicated safety training for personnel;
  7. Safety lesson dissemination and sharing best practices among operators and service providers;
  8. Building a corporate safety culture that fosters good safety practices and encourages safety communications in a non-punitive environment

This event should serve as a call to action by the FAA to expedite implementation of SMS throughout the Air Traffic Operation organization, so that every aspect of the operation can be proactively reviewed and analyzed per SMS guidelines. This will allow the FAA to uncover latent conditions, conduct risk assessments and move forward with improved programs and procedures that will make the ATC system even safer.

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