After an overload, I was shaking all the way home

Nats One air traffic controller went home shaking after an incident. And a leaked report reveals that problems with technology...

Nats One air traffic controller went home shaking after an incident. And a leaked report reveals that problems with technology can contribute to such incidents. Yet official investigations result in no action. This cultural divide between managers and staff has plagued Nats for years. Here, the second of two articles, Tony Collins looks closely at what has caused divisions in Nats and the company’s efforts to reform itself

 Barry Kirwan thought his employer would want to hear the whole truth about the company’s new technology. He was wrong.

As head of human factors at National Air Traffic Services, he had a particularly important role: helping to ensure that air traffic controllers would be comfortable using new computer systems.

Soon after taking up his post, Kirwan decided to see how Nats’ biggest computer project was shaping up. With two colleagues he visited a 70-acre nature reserve at Swanwick near Southampton, the site of a purpose-built air traffic control centre.

Builder Bovis had completed the futuristic New En Route Centre on time and to budget in 1994. But the building was all but useless without systems to help air traffic controllers handle flights over England and Wales.

At the time of Kirwan’s visit, the Risc-based systems being developed by US suppliers IBM and Lockheed Martin were nearly a year late.

So the pressure on software developers was intense – at one time there were more than 15,000 bugs in the software. Until the systems went live, Nats could not credibly justify the expense of the Swanwick building to its airline customers, or to the government, which had provided a loan.

The total cost of Swanwick, about half of which was for the systems and the rest for the building, was about £623m.

In 1997, Kirwan and his colleagues in the human factors unit  found that Swanwick’s systems were far from ready.

“We very quickly identified a number of problems, including a significant one with the legibility of the text on the screens,” he said.

Main problem
The main problem seemed to be size of text, given the  distance between the controller and the workstation’s screen.

Since this text provided much of the main information available to the controller, including the height levels of aircraft, Kirwan considered clarity to be important.

“There were three sizes of text available, but none seemed adequate.” Using a larger font size caused some of the text to overlap, he said. Kirwan’s team produced a short report. It was not well received.

“There was resistance from our own management to publish the report internally,” he said.

His report was published internally almost two years later, with a narrow distribution list, and many of the issues’ potential implications “toned down”. There was “a trade-off we had to make if it was ever to be published”.

Kirwan spoke informally to the safety regulator to see if it had concerns about the screens, but was told that this matter was not being reviewed.

Nats addressed some of Kirwan’s concerns but the lack of clarity of the screens  remained unresolved. How could he persuade Nats to take his concerns seriously?

Under pressure from the House of Commons transport select committee, the government ordered an audit of Swanwick’s systems. It was carried out by the Defence Evaluation Research Agency (now Qinetiq).

Kirwan said, “I was interviewed by a Dera auditor, but had been instructed beforehand not to offer any information not asked for, and was accompanied by a senior manager to ensure that I did not raise ‘unsolicited observations’.”

The Dera report, in its conclusions, was largely positive about Nats and the systems.

Before leaving Nats in 2000 Kirwan took a number of safety-related concerns to director-level in the company. Still Nats took no action on some key aspects of his advice – a decision that would boomerang on the company.

Going live
As the long-delayed operational date for Swanwick approached, senior managers at Nats wanted nothing to stand in the way of the centre finally going live.

The scheduled date for the opening of Swanwick’s New En Route Centre was 27 January 2002  – nearly five years after Kirwan’s visit to Swanwick, and nearly six years since the centre was supposed to have gone live.

During 2001 air traffic controllers had undergone intensive training on the new systems. Many liked them, but dozens had complained about the clarity of the screens. Their concerns were the same as those highlighted by Kirwan years earlier.

And still their complaints went unaddressed. With safety regulators at the Civil Aviation Authority about to grant Nats an approval to go live with the Swanwick centre, controllers complained about the screens to the Health & Safety Executive. 

Days before Swanwick was due to open, the HSE wrote a letter to Nats saying that the poor legibility of the screens possibly made them illegal. There was even a possible problem for the safety of aircraft if controllers could not read their screens easily, the HSE concluded.

But Nats said the screens raised no issues of safety. The CAA agreed with Nats and approved Swanwick for live operations.

Some controllers complained that the CAA was culturally too close to Nats: the two had at one time been part of the same organisation. The CAA denied that it lacked objectivity when regulating Nats.

Yet the concerns that had been expressed by Kirwan, and by air traffic controllers, proved well founded. During 2002, controllers made operational mistakes reading unclear screens. Still Nats insisted that safety had not been compromised.

Now a report of the Nats safety review committee for the board of directors has revealed that controllers are still experiencing problems with unclear screens and other weaknesses in new technology.

Indeed the report cites a range of difficulties with technology as contributing to a record number of overloads last year. Controllers report an overload when they believe their workload has been excessive to the point where safety was, or could have been, compromised.

Last year there were 68 overloads at Swanwick compared to 28 the previous year when flights over England and Wales were handled by an ageing air traffic control centre at West Drayton, near Heathrow.

The report of the committee said, “A number of problems and shortcomings associated with the technology [at Swanwick] used by controllers were cited as creating an environment where overloads were more likely.” It added that, in the view of controllers, “managers did not accept the seriousness of overload incidents”.

This is one of the general themes in the report of safety committee: that of a gulf in perceptions between controllers and managers over what constitutes a risk to the safety of passengers.

And herein lies one of the most serious and enduring problems for Nats: a cultural gap between management and staff that shows few signs of narrowing. There was a “definite gulf in perception” between controllers and managers over, for example, overload incidents, said the committee.

Managers were not worried about last year’s overloads because none led to a loss of legal minimum separation between aircraft. Controllers, however, felt that too many official investigations into an overload concluded with the phrase “Actions: nil”.

Emotional response
For controllers, overloads evoked strong emotional responses, said the report. An overload could lead to a controller losing the ability to control aircraft, which was described in the report as “losing the plot”.

One controller was quoted in the report as saying that, after an overload, he was “shaking all the way home”. Another controller said that overloads were “the stuff that nightmares are made of”.

The report emphasised that the safety performance of Nats last year was “better than in any year since records were first compiled in their present form”. In 2001 and 2002, there were no near-misses in most serious “Category A”.

And some controllers have nothing but praise for the new systems at Swanwick. But others have mixed feelings.

The safety committee’s report referred to difficulties experienced by some controllers in reading information from the displays in the operations room, the lack of clarity on some radio communications between pilots and controllers – including some conversations that were suddenly cut short – and the accuracy of data shown on the screens.

Despite improvements to the legibility of the displays in November 2002, there was still a “garbling” of some data and “out of focus screens”.

This year, said the report, the number of overloads has settled down to “normal” levels, although the summer peak is still some weeks away.

But it is not the number of overloads that is the most worrying aspect of the committee’s report. It is the tacit admission that the “us and them” divide yawns deep and wide despite efforts by competent managers over several years to bridge the gap. This leaves one to wonder whether Nats can ever change its culture.

But unless the culture changes, some specialists doubt that Nats will ever gain acceptance from controllers of new technology.

Major IT projects in the NHS, for example, have shown that a supportive workforce will find ways to overcome the inevitable problems with new systems; and that, conversely, members of a disaffected workforce will find defects with every click of mouse.

The good news for Nats is that it has appointed a new general manager, the affable Paul Louden, who is convinced that the organisation can change its culture.

As a former air traffic controller, he has seen at first hand the different perspectives of staff and managers. And he has strong skills in communication. 

 “There is always a difference between operational controllers and management," he said.

"The controllers sitting at a radar screen will see things in a particularly focused way. Someone standing behind, remote from that particular interface, is bound to see things slightly differently.

"I am trying to create a climate where there is no 'them and us'. We are all part of a company that is trying to get better.”

One wonders whether Louden would find it easier to scale Everest without climbing aids than change Nats’ culture of disaffection among staff and defensiveness among managers.

Controllers say that the chasm between managers and staff is, in part, caused not by the action or inaction of any individual but a history and a culture of denial of serious problems while proclaiming publicly that it is enjoying great success.

For example, Nats told Parliament that Swanwick had gone over budget by only £2.7m. In fact the figure proved to be closer to £150m.
Nats also told Parliament there would be enough controllers to run Swanwick. There has always been and still is a severe shortage.

Despite all the problems Nats chief executive Richard Everitt said on BBC Radio earlier this year, “We have exceeded our safety targets through this year since the opening of Swanwick. Technically it has been very successful. That’s not my words. It’s the words of our independent safety regulator.”

It is unclear how Louden will break the cycle of optimistic statements by Nats to the media and Parliament which incites leaks of internal documents by staff who feel the truth is not being told. Nats then denies some reports in the broadcast or print media that are based on leaked documents, which incites further leaks.

This triggers attacks by management on the workforce for leaking internal information. As the cycle repeats itself, disaffection remains.
The cultural problems are aggravated by a feeling among controllers that Nats has passed to them the responsibility for overcoming weaknesses in the design of the systems.

Staff must note that their screens may display the wrong height of aircraft; they must realise that sometimes information on ghost aircraft may appear on their screens; they must also remember that when they use their mouse to click on overlapping text blocks on the screens, they could in rare cases instantly obliterate key information.

Some controllers claim they receive a plethora of operational notices and supplementary instructions which tell them how to overcome such deficiencies in the systems. And they fear that they will be blamed, should any serious incident arise from human error compounded by confusion over the interface between the system and the controller.

All this has left some controllers distrustful of regulator, the CAA, which approved Swanwick.

No one can doubt the sincerity of senior managers and controllers who believe they are doing their best for the company and their customers, the airlines. But the evidence from the Nats history book is that a large long-established company may never change its culture, even if its senior managers and directors genuinely want to.

“We are trying to work with all the staff to ensure we have the best possible relationship between us. It’s all I can do. It’s the only way the system will work and work well, if we are all working towards the same end,” said Louden as he made his way, unaided, towards the foot of Everest.

The truth, a semblance of the truth and nothing like the truth >>

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