IFATCA statement on Russian controllers imprisonment

IFATCA, the International Federation of Air Traffic Controllers’ Associations, is extremely shocked to learn of the final verdict passed by the Russian court where three Air Traffic Controllers were sentenced to 5, 5 ½ and 6 years imprisonment (penal colony). These prosecution and sentencing do nothing to improve aviation safety, well to the contrary, and the consequences of such brutal and unjust treatment cannot yet be assessed. 

Aviation is the safest mode of transport, and accidents are extremely rare. This is thanks to
the continuous effort to learn from incidents and accidents where the stringent aviation
standards may not have been met.

Russia remains amongst a few States that have chosen to deviate from international
standards and recommendations – including those specified in Annexes 13 (Aircraft Accident
and Incident Investigations) and 19 (Safety Management Systems) to the Convention on
International Civil Aviation – when it comes to using safety reports to trigger court cases. To
safeguard the whole aviation system in Russia, the judiciary needs an urgent adjustment in
line with Resolutions 38-3 and 38-4 of the General Assembly of the International Civil
Aviation Organisation, the aviation specialised body of the United Nations. (see Annex 2 for
details)

The Russian judicial system judged and sentenced the three Air Traffic Controllers not for
causing an accident and the death of people, but for failing to prevent an accident with tools
that were not properly set up for the airport. There were no clear rules for operating the
system. The Surface Movement Radar was left on its factory settings and there was no
training provided on the use and operations of the system. (see Annex 1 for details)

It has been reported that during the trial, there was no intention from the judge to listen to
the defence side but only to the prosecution’s side. What makes it worse is that the
prosecution’s opinion, as accepted by the Russian court, was that the Air Traffic Controllers
and not management should have made sure that all the air traffic control equipment was
installed correctly and working according to the requirements.

The official accident report that led to the conviction of the three Air Traffic Controllers
mentions the fact that controllers did not use the voluntary reporting system to identify the
shortcomings that led to the accident. Yet there is a mention that Vnukovo airport had 34
runway incursion reports in the 4 years preceding the accident (2010-2014). Contrary, in the
same period, only one incursion occurred in Sheremetyevo airport and three in
Domodedovo. Both have considerably more traffic than Vnukovo.

Aviation, and in particular Air Traffic Control, is a highly complex industry where the frontend
operator is working as an integral part of the system, interacting with other people,
systems and procedures. Such complex systems are extremely resilient and do not fail only
because of one element of the system: it is the system that fails, not the individual.

Lengthy and costly court cases do not improve aviation safety, nor do they contribute to the
robustness of complex systems. They create a climate of fear amongst aviation professionals
and result in a reluctance to submit reports. The opportunity to learn from these events is
therefore severely compromised. Just Culture is not a carte-blanche for aviation
professionals, including Air Traffic Controllers. It is an essential cornerstone that allows
aviation professionals to actively engage in the process of improving safety.

IFATCA urgently calls upon Russia to align with other States and international standards, to
incorporate the principles of Just Culture into their legal system in order to provide for a
balanced approach between safety and the administration of justice. The international
credibility of the Russian aviation system is at stake.

IFATCA further requests the complete pardon and immediate release of the three Air
Traffic Controllers found guilty and sentenced to imprisonment for the Vnukovo
airport crash on 20 October 2014.

ANNEX 1
TECHNICAL ANALYSIS of Final Accident report of falcon50 in Vnukovo on 20 Oct
2014.

(Analysis Based the final accident report published recently by the Interstate Aviation
Committee and available on: https://mak-iac.org/upload/iblock/e12/Final_Report_eng_FGLSA.
pdf)

INTRODUCTION
The report breaches the Just (Safety) Culture principles promoted by ICAO. Although it
identified an extensive number of shortcomings and systemic failures in the airport and ATC
organisation, it singles out individuals and induces the notion that some illegal operations
were performed by the individual controllers, whereas the report also clearly indicates it was
a systematic organisational failure of a system that led to this accident.

Regarding the ATC operations investigation part of the report, a non-specialist reading the
report can easily be lured into believing the controllers involved mentioned in the report were
partially responsible for the accident, and that could explain the Judicial consequences with
controllers sentenced to very harsh prison sentences.

CAUSES OF THE ACCIDENT
The main cause of the accident is clear: a snow removal vehicle cleaning a closed, nonactive
runway penetrated the active runway at its intersection while an aircraft was
performing its take-off run under poor visibility conditions. The vehicle driver and its
supervisor were both under influence of alcohol, performed the work without a clear plan and
did not inform ATC of that plan. They used a vehicle which was not equipped with VHF so
could not monitor the ATC frequency. The driver had switched the snow remover’s lights off
and penetrated the active runway without asking and obtaining the required authorisation
from ATC.

The accident occurred at night with only 900 meters visibility. Without lights, the vehicle was
not visible from the control tower.

However, it would seem the investigators mentioned that the controllers were obliged to
monitor the take-off run using the newly installed surface movement radar (SMR) and in
doing so could have prevented the accident.

THE SURFACE MOVEMENT RADAR (SMR)
The report says that this Danish-manufactured SMR was introduced one year earlier (Sept
2013) without being configured properly. Only three controllers had been trained to use it,
none of which were on duty that day. Furthermore, the incursion alerts were disabled on the
controller position screens. The audio alert was active but the loudspeakers were not
installed, so not working. The system was never configured for the airport and had been left
on its factory settings. The system was not made for airports with intersecting runways and
configuring the SMR was only possible by system engineers, not by air traffic controllers.

The report acknowledges that the three controllers on duty did not receive training and did
not understand how the system worked. The report acknowledges this clearly: “Being
untrained on the use of the [SMR] system the ground controller was not able to accomplish
its duties properly“ (page 202) and this completely nullify the remark made in the earlier
mentioned conclusion that said: “Failure of the ground controller to comply with standard
operating procedures by not taking actions to prevent the runway incursion though having
radar information and alerts alert on [his Surface movement Radar, SMR ] screen.”

MONITORING TAKE-OFF ROLL ON SMR
The other argument used against the controllers is about monitoring departure during takeoff
roll. The report acknowledges that there are no provisions or regulations that require the
permanent monitoring by controllers of the SMR radar information. The regulations only
mention that the departure controller should “visually” monitor departures until aircraft
reaches 200m (page 209). The fact is repeated later on (page 210) saying: “there are no
requirements to monitor the course of aircraft taking off [using SMR radar” but then goes on
speculating: “the Departing controller could have seen an alert if the mode would have been
activated (it was not) and could have prevented the accident (page 211).

Again, this is reported as an individual “failure” in the report’s conclusions! “Failure of the
[controllers] to detect the runway incursion on the SMR and failure to inform the crew “(page
223).

Vnukovo airport is not equipped with Surface Movement Guidance and Control System
(known as SMGCS). This means it is not equipped with a central guidance lighting system
and stop bars preventing the penetration of active runways that one finds in most large airports
around the world.

On this point the report says (page 228): “There is no system in the Russian Federation for
the planning and implementation of SMGCS.[…] No airport regulation contains a requirement
that there shall be SMGCS system deployed in airports.”

CONCLUSION
From reading the report it appears that the whole Vnukovo airport operation needs to be
brought to safe standards. There are definitely lessons that should be learned from this tragic
accident, but prosecuting and sentencing individual controllers to 5 to 6 years of labour camp
will not resolve the identified shortcomings. On the contrary, it clearly risks creating an
atmosphere of fear amongst the Russian Federation’s controller community that they could
face similar charges while having done nothing wrong. This will not improve safety, but is
likely to have the opposite effect.

ANNEX 2

Extract of the Resolutions adopted at the ICAO 38th Session of the Assembly 2013:
A38-3: Protection of certain accident and incident records

The Assembly:
1. Urges Member States to continue to examine and if necessary adjust their laws,
regulations and policies to protect certain accident and incident records in compliance with
paragraph 5.12 of Annex 13, in order to mitigate impediments to accident and incident
investigations, in consideration of the legal guidance for the protection of information from
safety data collection and processing systems issued by ICAO;

2. Instructs the Council, taking into account the findings and recommendations of the
Safety Information Protection Task Force and further work informed by those findings and
recommendations, to take such steps as may be necessary to ensure meaningful progress
toward the development of new and/or amended provisions in Annex 13, other Annexes as
appropriate and related guidance material before the next ordinary session of the Assembly;
and

3. Declares that this resolution supersedes Resolution A37-2.
A38-4: Protecting information from safety data collection and processing systems in
order to maintain and improve aviation safety

The Assembly:
1. Urges all Member States to continue to examine their existing legislation and adjust
as necessary, or enact laws and regulations and introduce supportive policies and practices,
to protect information gathered from all relevant safety data collection and processing
systems based, to the extent possible, on the legal and other guidance developed by ICAO;

2. Urges the Council to cooperate with Member States and appropriate international
organizations regarding the development and implementation of guidance, taking into
account the findings and recommendations of the Safety Information Protection Task Force
and further work informed by those findings and recommendations, to support the
establishment of effective safety-reporting systems, and the achievement of a balanced
environment where valuable information derived from all relevant safety data collection and
processing systems is readily accessible for the purposes of maintaining and improving
aviation safety, while respecting principles of administration of justice and freedom of
information;

3. Instructs the Council to take appropriate steps to ensure that ICAO Standards and
Recommended Practices in Annex 19, other Annexes as appropriate and guidance materials
on the protection of information gathered from safety data collection and processing systems
(SDCPS) are enhanced, taking into account the findings and recommendations of the Safety
Information Protection Task Force and further work informed by those findings and
recommendations, with a view to ensuring and sustaining the availability of safety information
required for the management, maintenance and improvement of safety, taking into account
the necessary interaction between safety and judicial authorities in the context of open
reporting culture; and

4. Declares that this resolution supersedes Resolution A37-3.

Annex 3

TRANSLATION NEWS ARTICLE RUSSIA – Source KOMMERSANT – 29/09/2020.
Source: https://www.kommersant.ru/doc/4511102

The Appeal Moscow City Court has confirmed the verdict against air traffic controllers Alexander Kruglov and Nadezhda Arkhipova. In July this year, the Solntsevsky District Court had found them guilty in the crash of a Falcon 50 business-jet carrying Total President Christophe de Margerie at Moscow Vnukovo airport in 2014. Ms. Arkhipova was released from punishment under amnesty, while Mr. Kruglov will have to present himself to a penal colony. The guilty verdict for the main
defendant, supervisor Roman Dunaev, has not yet been confirmed, since he is on sick leave with suspected coronavirus. It is nevertheless expected that his sentence of six years in a penal colony
will also remain unchanged. Judge Yulia Manerkina dealt with the case rather quickly, deciding to suspend the proceedings on his appeal while ruling on Alexander Kruglov and Nadezhda Arkhipova.

The defendants intend to further appeal the decision, insisting that their arguments were not
heard. According to them, the court was clearly in a hurry because the statute of limitations
on the criminal charges expires in less than a month.

The defence wanted to invite Ms. Svetlana Krivsun, a trainee-controller at the time of the
accident, to testify. Initially, she herself was under criminal investigation, but was later only
considered as a witness. The young woman was directly involved in the tragic event and her
testimony is considered important. Despite this, the lower court did not call on her to present
her testimony. In spite of this, Judge Yulia Manerkina refused all petitions, provoking
indignation from the defence team and a request to challenge the judge, which was
immediately denied. In his argumentation, the prosecutor Dmitry Nadysev explained that
lacking or malfunctioning equipment – including loudspeakers and other alarms at the
controller's workplace, that could warn him/her about the penetration of a vehicle on the
runway – is the controllers' problem: they have a legal obligation to ensure that all their
equipment is fully functional. The defendants again insisted that they had not violated any
instructions and could not be held responsible for the actions of third parties: an intoxicated
driver of a snowplough that collided with the accelerating aircraft and a ground service
engineer, who failed to supervise him. It is worth mentioning here that those two admitted
their guilt and were sentenced accordingly but were subsequently released from their
responsibility under an amnesty measure.

After a short deliberation, Judge Yulia Manerkina ruled to uphold the verdict of the lower
instance court.

The controllers' attorneys immediately indicated that they will continue to fight for the
acquittal of their clients. In their opinion, the court did not consider all the arguments for the
defence and the ruling was clearly rushed to avoid the stature of limitation expiry on October
21st.One of the lawyers, Mr. Oleg Babich explained that, in his opinion, the court refused
"everything" and committed numerous gross violations of the Criminal Procedure Code.