Executive summary
The air traffic control safety net fails when human errors go undetected and uncorrected. These operational errors are generally more likely to occur in circumstances such as very high or very low workload situations, or events involving complex coordination. Predisposing or underlying factors relating to the ATC operational environment can influence the frequency, and the consequences, of operational errors. System safety can be improved by the identification and rectification of these predisposing factors.
Information from air traffic controllers from each sector within…