It is not too difficult to conclude that a simple transponder failure was the main factor that caused this serious incident.
Nije previše teško zaključiti da je jednostavan kvar transpondera bio glavni faktor koji je izazvao ovaj ozbiljan incident.
Clearly, this was not an “odd” case to be blamed on human factors, although human factors played a significant role in it.
Jasno je da ovo nije bio "neobičan" slučaj u kojem bi se mogli kriviti ljudski faktori, iako su ljudski faktori igrali značajnu ulogu u njemu.
Unfortunately, there are other examples where a similar failure played a major role in incidents or accidents even with catastrophic outcomes (for example, the 2006 mid-air collision over Brazil).
Nažalost, postoje drugi primeri u kojima je sličan kvar imao značajnu ulogu u incidentima ili nesrećama, čak i sa katastrofalnim ishodima (na primer, sudar u vazduhu iznad Brazila 2006. godine).
The question is how a minor and relatively insignificant technical failure can lead to such a big incident.
Pitanje je kako manji i relativno beznačajan tehnički kvar može dovesti do tako velikog incidenta.
Often, reading a magazine article about an event or topic well known to you makes you think this could not be further away from the truth.
Često, kada čitate članak u časopisu o događaju ili temi koju dobro poznajete, pomislite da to ne može biti dalje od istine.
On the other hand, we tend to believe almost everything else we read.
S druge strane, skloni smo da verujemo skoro svemu što pročitamo.
Is it because one could be biased, a different point of view, or something else?
Da li je to zbog pristrasnosti, drugačijeg gledišta, ili nečeg drugog?
It is an interesting “phenomenon”…
To je zanimljiv "fenomen"...
Case Study Comment 5
Komentar slučaja 5
The crew of the 747 could have done more to anticipate potential problems and think of possible actions long before the failure took place.
Posada aviona 747 mogla je da uradi više kako bi predvidela potencijalne probleme i razmislila o mogućim akcijama dugo pre nego što se kvar dogodio.
Having in mind the technical problems before departure, the reaction to the fault transponder light was inappropriate and difficult to understand.
Imajući u vidu tehničke probleme pre polaska, reakcija na signal kvara transpondera bila je neprikladna i teško razumljiva.
The crew should have asked ATC immediately whether their transponder was transmitting or not.
Posada je trebalo odmah da pita kontrolu letenja (ATC) da li njihov transponder šalje signal ili ne.
This would have enabled an early identification of the problem and probably prevented the incident.
Ovo bi omogućilo rano identifikovanje problema i verovatno sprečilo incident.
I have no doubt that an experienced Captain understands the potential consequences of a transponder failure and that you need a “bit” more than just engines to fly an aircraft safely.
Nemam sumnje da iskusni kapetan razume potencijalne posledice kvara transpondera i da vam treba "malo" više od samo motora da biste bezbedno upravljali avionom.
Working for an airline that does not value safety culture, where “cutting corners” here and there is part of daily operations, can probably make professionals act less “professionally” over time and start taking safety for granted.
Rad za avio-kompaniju koja ne vrednuje kulturu bezbednosti, gde je "skraćivanje postupaka" deo svakodnevnih operacija, može verovatno učiniti da profesionalci vremenom postanu manje "profesionalni" i počnu da uzimaju bezbednost zdravo za gotovo.
Controllers learn and practice how to handle flights with transponder failure (with or without primary radar) – we all know it is not a big deal.
Kontrolori uče i vežbaju kako da upravljaju letovima sa kvarom transpondera (sa ili bez primarnog radara) - svi znamo da to nije veliki problem.
But the skill did not get used in this case and ABC654 disappeared from the screen of a busy sector without being noticed.
Ali ta veština nije iskorišćena u ovom slučaju i ABC654 je nestao sa ekrana zauzetog sektora bez da je to primećeno.
You might be thinking that the controllers manning the west sector made a mistake – they should have detected the situation a lot earlier and dealt with it.
Možda mislite da su kontrolori zaduženi za zapadni sektor napravili grešku - trebalo je da ranije primete situaciju i reše je.
True, however, there were a few factors that significantly contributed to this omission that are important to consider.
Tačno, međutim, postojalo je nekoliko faktora koji su značajno doprineli ovom propustu i koje je važno razmotriti.
The controllers on the west sector were extremely busy dealing with a lot of weather avoidance due to a thunderstorm and possibly overloaded, while the area controller had very little to do.
Kontrolori u zapadnom sektoru bili su izuzetno zauzeti izbegavanjem lošeg vremena zbog oluje i verovatno preopterećeni, dok je sektor kontrolor imao vrlo malo posla.
Was the sector split done properly?
Da li je podela sektora urađena kako treba?
I would expect that when this is the case, the workload is more evenly spread amongst the various sectors (I know… most of the time it does not feel like that).
Očekivao bih da kada je to slučaj, radno opterećenje je ravnomernije raspoređeno među raznim sektorima (znam... većinu vremena se ne oseća tako).
It also looks like a dangerous culture of not using the restrictions has been introduced even when everybody felt they were needed with the excuse that efficiency measured by the performance indicator mattered most.
Izgleda da je uvedena opasna kultura nepoštovanja ograničenja čak i kada su svi osećali da su potrebna uz izgovor da je najvažnija efikasnost merena indikatorom učinka.
What happened to “safety first”?
Šta se dogodilo sa "bezbednost na prvom mestu"?
The primary radar was removed prior to the incident. Was this another mistake of the management motivated by financial efficiency?
Primarni radar je uklonjen pre incidenta. Da li je ovo bila još jedna greška uprave motivisana finansijskom efikasnošću?
Usually, it is not, if the change is managed properly and if the associated risks are mitigated.
Obično nije, ukoliko je promena pravilno upravljana i ako su povezani rizici ublaženi.
From the story, we cannot tell all details, but it can be expected that the controllers were subject to an awareness campaign about the removal of the primary radar and the effect and changes it might bring to their daily job, the new threats, and how to deal with them.
Iz priče ne možemo saznati sve detalje, ali se može očekivati da su kontrolori prošli kampanju za podizanje svesti o uklanjanju primarnog radara i o efektima i promenama koje bi to moglo doneti u njihov svakodnevni rad, novim pretnjama i kako se sa njima nositi.
The area controller was not busy and had plenty of time. She was working on her own at the time of the incident, but I do not think this had a significant impact.
Kontrolor sektora nije bio zauzet i imao je dovoljno vremena. Radila je sama u trenutku incidenta, ali mislim da to nije imalo značajan uticaj.
Based on the workload described in the story, she could have looked at traffic about to enter the sector and potentially detected an aircraft that was overdue.
Na osnovu radnog opterećenja opisanog u priči, mogla je da pogleda saobraćaj koji je trebalo da uđe u sektor i potencijalno primeti avion koji je kasnio.
Well… probably because this was not part of her daily routine, it did not happen.
Pa... verovatno zato što to nije deo njene svakodnevne rutine, to se nije dogodilo.
Her planner may have had a better chance, but we cannot be absolutely sure about that.
Njen planer je možda imao bolju šansu, ali ne možemo biti apsolutno sigurni u to.
A Recommendation
Preporuka
Most ATC systems have tools that help controllers detect situations like this by initiating a warning when a target correlated with an active flight plan disappears from the screen or when an aircraft about to enter a sector is overdue.
Većina ATC sistema ima alate koji pomažu kontrolorima da otkriju ovakve situacije pokretanjem upozorenja kada cilj povezan sa aktivnim planom leta nestane sa ekrana ili kada avion koji treba da uđe u sektor kasni.
The management of the ANSP should have considered introducing something like this before the decision was taken to remove the primary radar.
Uprava ANSP-a je trebalo da razmotri uvođenje nečeg sličnog pre nego što je doneta odluka o uklanjanju primarnog radara.
Even with primary radar, a tool like this definitely adds another safety barrier – immediate detection of a transponder failure is not always straightforward for controllers.
Čak i sa primarnim radarom, ovakav alat definitivno dodaje još jednu bezbednosnu barijeru – trenutno otkrivanje kvara transpondera nije uvek jednostavno za kontrolore.
Those of you who feel that I have proved the point I made at the beginning of this article, well… in this case it is just a different point of view.
Oni od vas koji smatraju da sam dokazao poentu koju sam izneo na početku ovog članka, pa... u ovom slučaju to je samo drugačiji ugao gledanja.
Controllers learn and practice how to handle flights with transponder failure (with or without primary radar) – we all know it is not a big deal.
Kontrolori uče i vežbaju kako da upravljaju letovima sa kvarom transpondera (sa ili bez primarnog radara) – svi znamo da to nije veliki problem.
But the skill did not get used in this case, and ABC654 disappeared from the screen of a busy sector without being noticed.
Ali ta veština nije iskorišćena u ovom slučaju, i ABC654 je nestao sa ekrana zauzetog sektora bez da je to primećeno.
You might be thinking that the controllers manning the west sector made a mistake – they should have detected the situation a lot earlier and dealt with it.
Možda mislite da su kontrolori zaduženi za zapadni sektor napravili grešku – trebalo je da ranije primete situaciju i reše je.
True, however, there were a few factors that significantly contributed to this omission that are important to consider.
Tačno, međutim, postojalo je nekoliko faktora koji su značajno doprineli ovom propustu i koje je važno razmotriti.
The controllers on the west sector were extremely busy dealing with a lot of weather avoidance due to thunderstorms and possibly overloaded, while the area controller had very little to do.
Kontrolori u zapadnom sektoru bili su izuzetno zauzeti izbegavanjem lošeg vremena zbog oluje i verovatno preopterećeni, dok je kontrolor sektora imao vrlo malo posla.
Was the sector split done properly?
Da li je podela sektora urađena pravilno?
I would expect that when this is the case, the workload is more evenly spread amongst the various sectors (I know… most of the time it does not feel like that).
Očekivao bih da je, kada je to slučaj, radno opterećenje ravnomerno raspoređeno među različitim sektorima (znam... većinu vremena se to ne čini tako).
It also looks like a dangerous culture of not using the restrictions has been introduced even when everybody felt they were needed with the excuse that efficiency measured by the performance indicator mattered most.
Izgleda da je uvedena opasna kultura nepoštovanja ograničenja čak i kada su svi osećali da su ona potrebna, sa izgovorom da je najvažnija efikasnost merena indikatorom učinka.
What happened to “safety first”?
Šta se dogodilo sa "bezbednost na prvom mestu"?
The primary radar was removed prior to the incident. Was this another mistake of the management motivated by financial efficiency?
Primarni radar je uklonjen pre incidenta. Da li je ovo bila još jedna greška uprave motivisana finansijskom efikasnošću?
Usually, it is not, if the change is managed properly and if the associated risks are mitigated.
Obično nije, ukoliko je promena pravilno upravljana i ako su povezani rizici ublaženi.
From the story, we cannot tell all details, but it can be expected that the controllers were subject to an awareness campaign about the removal of the primary radar and the effect and changes it might bring to their daily job, the new threats, and how to deal with them.
Iz priče ne možemo saznati sve detalje, ali se može očekivati da su kontrolori prošli kampanju za podizanje svesti o uklanjanju primarnog radara i o efektima i promenama koje bi to moglo doneti u njihov svakodnevni rad, novim pretnjama i kako se sa njima nositi.
The area controller was not busy and had plenty of time. She was working on her own at the time of the incident, but I do not think this had a significant impact.
Kontrolor sektora nije bio zauzet i imao je dovoljno vremena. Radila je sama u trenutku incidenta, ali mislim da to nije imalo značajan uticaj.
Based on the workload described in the story, she could have looked at traffic about to enter the sector and potentially detected an aircraft that was overdue.
Na osnovu radnog opterećenja opisanog u priči, mogla je da pogleda saobraćaj koji je trebalo da uđe u sektor i potencijalno primeti avion koji je kasnio.
Well… probably because this was not part of her daily routine, it did not happen.
Pa... verovatno zato što to nije deo njene svakodnevne rutine, to se nije dogodilo.
Her planner may have had a better chance, but we cannot be absolutely sure about that.
Njen planer je možda imao bolju šansu, ali ne možemo biti apsolutno sigurni u tom.
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